Venous thromboembolism (VTE), a disease entity comprising deep vein thrombosis (DVT) and/or pulmonary embolism (PE), represents one of the most frequent and potentially life-threatening complications in orthopaedics and traumatology [1]. The previous Austrian recommendation on VTE prophylaxis in musculoskeletal procedures, dating from 2014 [2], no longer adequately reflects current evidence-based pharmacological and nonpharmacological strategies. Current international interdisciplinary guidelines on VTE prophylaxis, such as those issued by the European Society of Anaesthesiology and Intensive Care (ESAIC) [3] and the Association of the Scientific Medical Societies in Germany (AWMF) [4], were therefore adapted with consideration of Austrian healthcare structures. In particular, clearly defined criteria for a functional early mobilisation concept within the framework of a fast-track programme, as well as structured recommendations on VTE prophylaxis in conservative orthopaedic and traumatological treatments, have been lacking to date. To develop practice-oriented, evidence-based recommendations, an interdisciplinary consensus group comprising representatives of the Austrian medical societies relevant to this topic was convened. The aim was to formulate more structured, risk-adapted recommendations that take the Austrian healthcare context into account.

Venöse Thromboembolien (VTE), eine Krankheitsentität die tiefe Venenthrombosen (TVT) und/oder Lungenembolien (PE) umfasst, gehören in der Orthopädie und Traumatologie zu den häufigsten und potenziell lebensbedrohlichen Komplikationen [1]. Die bislang gültige österreichische Empfehlung zur VTE-Prophylaxe bei muskuloskeletalen Eingriffen aus dem Jahr 2014 [2] bildet die aktuellen evidenzbasierten pharmakologischen und nichtpharmakologischen Strategien nicht mehr adäquat ab. Aktuelle internationale interdisziplinäre Leitlinien zur VTE-Prophylaxe wie von der European Society of Anaesthesiology and Intensive Care (ESAIC) [3] und der Arbeitsgemeinschaft Wissenschaftlich-medizinischer Fachgesellschaften (AWMF) [4] wurden daher unter Berücksichtigung österreichischer Versorgungsstrukturen adaptiert. Insbesondere fehlen bislang klar definierte Kriterien für ein funktionelles Frühmobilisationskonzept im Sinne eines Fast-Track-Programms sowie strukturierte Empfehlungen zur VTE-Prophylaxe bei konservativen orthopädisch-traumatologischen Behandlungen. Zur Erarbeitung praxisorientierter, evidenzbasierter Empfehlungen wurde eine interdisziplinäre Konsensusgruppe aus Vertreter:innen der für dieses Thema relevanten österreichischen Fachgesellschaften einberufen. Das Ziel war, strukturiertere, risikoadaptierte Handlungsempfehlungen unter Berücksichtigung der österreichischen Versorgungsrealität zu formulieren.

PurposeTo provide recommendations for the treatment of patients with first-time patellar dislocation (FTPD). Part I focused on clinical presentation, symptoms, diagnosis, evaluation and imaging.MethodsFifty-four orthopaedic surgeons and one physiotherapist from 20 countries across Europe were involved in the consensus, which was the FTPD. The consensus was performed according to the European Society for Sports Traumatology, Knee Surgery and Arthroscopy consensus methodology. The steering group designed the questions and prepared the statements based on the experience of the experts and the evidence in the literature. The statements were evaluated by the ratings of the peer-review groups before a final consensus was released.ResultsThe consensus consists of 32 questions and statements, 13 of which will be reviewed in Part 1 of the review. There is an inverse correlation between the intensity of trauma leading to FTPD and the underlying pathoanatomic risk factors, meaning that low trauma intensity usually indicates more severe underlying abnormalities. In addition to the clinical investigation, patient age, family history, bilateral symptoms of instability and injury mechanism should be evaluated. However, reliance can be placed not only on clinical examination but also on magnetic resonance imaging scans as soon as possible, which are considered mandatory for evaluating predisposing factors such as trochlear dysplasia and patella alta and for detecting osteochondral lesions, with the exception of asymptomatic patients. Importantly, it must be recognized that in addition to recurrent instability, which affects approximately 25% of patients, a variety of symptoms are experienced by 50% of patients, such as pain, swelling, giving way, functional and psychological limitations, and a reduction in sports participation, all of which reduce their quality of life. The complications after medial patellofemoral ligament reconstruction in patients with FTPD have not yet been established; however, we know from cohorts of heterogeneous patients that the most common complications are patellofemoral pain, a reduced range of motion and patellar fracture. In total, there were 13 statements that were all accepted and achieved, 6 with strong agreements and 7 with relative agreements. The general median agreement was 8 (range 7-9). None were graded A, two were graded B, seven were graded C and 4 were graded D.ConclusionIn relation to the management of patients with first-time patellar luxation, we have worked with 13 questions and based on these we have achieved consensus on 13 statements.Level of EvidenceLevel I, consensus.

PURPOSE:To provide recommendations for the treatment of patients with first-time patellar dislocation (FTPD). Part 2 focused on nonoperative treatment, bracing, rehabilitation, indications for surgery and surgical strategies. METHODS:The consensus was performed according to the European Society for Sports Traumatology, Knee Surgery and Arthroscopy consensus methodology. RESULTS:The consensus comprised 32 questions and statements, 19 of which will be presented in this part. Eight statements achieved strong agreement (median 9; range 7-9), and 11 statements achieved relative agreement (median 9; range 5-9). None were Grade A, 2 were Grade B, 11 were Grade C and 5 were Grade D. In summary, treatment decisions for FTPD should prioritize individualized care, balancing patient-specific risks and demands. Surgical options are increasingly considered for skeletally immature patients and those with increased recurrence risk. Medial patellofemoral ligament (MPFL) reconstruction is the preferred surgical technique for addressing medial soft tissue stabilizers, offering better outcomes than repair methods. Combining MPFL reconstruction with corrections of relevant bony risk factors might further reduce the risk of recurrence and revision surgery, although specific thresholds for intervention remain debated. Physical therapy is recommended as an essential complement to both operative and nonoperative treatments, but bracing offers no clear long-term benefit. Chondral or osteochondral lesions should be repaired when the defect is at least 1 cm² in the patellofemoral joint contact area. Fragment refixation or other cartilage restoration techniques are preferred, and delayed repair is favoured over fragment removal when immediate surgery is not needed. CONCLUSION:The consensus consists of recommendations for evaluation and treatment strategies for managing FTPD. High levels of agreement were reached by experts throughout Europe. In areas without clear scientific evidence, this consensus aimed at providing recommendations and guidance on the basis of expert opinion and pointed out areas where further studies are necessary. LEVEL OF EVIDENCE:Level I, consensus.

PURPOSE:Modifying interference screw composition may ensure better osteoconductive properties in order to reduce tunnel enlargement after anterior cruciate ligament (ACL) reconstruction. The primary and secondary purposes were to evaluate tunnel and screw volume changes in poly-L-lactide acid (PLLA) and poly-D-lactic acid + hydroxyapatite + β-tricalcium phosphate (PLDLA+) screws. The tertiary purpose was to compare patient reported- and functional outcomes between PLLA and PLDLA+ group. It was hypothesised that PLLA group would show more tunnel enlargement and a lower rate of resorption than PLDLA+ group with similar clinical results. METHODS:Patients were treated with ACL reconstruction using hamstring autograft with femoral and tibial interference screw fixation (PLLA or PLDLA+). Tunnel volume changes were assessed after 0, 24 and 36 months on computed tomography (CT) scans. Screw volume changes were analysed after 0, 3, 6, 12, 24 and 36 months on magnetic resonance imaging (MRI). Patient reported outcome scores (PROMS) and knee laxity were analysed after 12 and 36 months. Data were evaluated using analysis of variance (ANOVA) with Bonferroni correction. Significance was set at <0.05. RESULTS:Femoral/tibial tunnel volume enlarged 10.7 ± 46.6%/3.8 ± 14.4% (PLLA, n = 9) and 2.6 ± 30.8%/19.0 ± 20.5% (PLDLA +, n = 13) after 36 months on CT scans (p = 0.063/p = 0.070). Using MRI scans, femoral/tibial screw volume decreased -53.8 ± 6.9%/-48.8 ± 9% (PLLA) and -88.2 ± 8.9%/-80.6 ± 3.4% (PLDLA+) (p ≤ 0.001/p ≤ 0.001). No difference was found between the two groups (PLLA, n = 17; PLDLA+, n = 19) in PROMS and knee laxity (n.s. and/or minimal clinically important difference (MCID) not reached). CONCLUSIONS:Tunnel volumes remained slightly enlarged, screw degradation was significantly higher in the PLDLA+ group while clinical outcomes led to good short-term results. Comparable tunnel enlargement for both screws can be expected in revision ACL reconstruction. LEVEL OF EVIDENCE:Level I randomised controlled trial.

Despite the availability of clinical guidelines for hip fracture patients, adherence to these guidelines is challenging, potentially resulting in suboptimal patient care. The goal of this study was (1) to evaluate and benchmark the adherence to recently established quality indicators (QIs), and (2) to study clinical outcomes, in fragile hip fracture patients from different European countries. This observational, cross-sectional multicenter study was performed in 10 hospitals from 9 European countries including data of 298 consecutive patients. A large variation both within and between hospitals were seen regarding adherence to the individual QIs. QIs with the lowest overall adherence rates were the administration of systemic steroids (5.4

Background: Functional recovery after intramedullary nailing of distal tibial fractures can be monitored using ipsilateral vertical ground reaction forces (vGRF), giving insight into recovery of patients' gait symmetry. Previous work compared patient cohorts to healthy controls, but it remains unclear if these metrics can identify treatment-based differences in return to function post-surgery. Research question: Is treatment of a distal tibial fracture with intramedullary nailing with an angle stable locking system (ASLS) associated with higher ipsilateral vGRF and improved symmetry compared to conventional intramedullary nailing at an early time point? Methods: Thirty-nine patients treated with ASLS intramedullary nailing were retrospectively compared to thirtynine patients with conventional locking. vGRFs were collected at 1, 6, 12, 26, and 52 weeks post-surgery during standing and gait. Discrete metrics of ipsilateral vGRF (maximal force, impulse) and asymmetry were compared between treatments at each time point. Time-scale comparisons of ipsilateral vGRF and lower limb asymmetry were additionally performed for gait trials. Mann-Whitney Test or a two-way analysis of variance tested discrete comparisons; statistical non-parametric mapping tested time-scale data between treatment groups. Results: During gait, ASLS-treated patients applied more load on the operated limb (17-38% stance, p = 0.015) and consequently loaded limbs more symmetrically (8-37% stance, p = 0.008) during the loading response at 6 weeks post-surgery compared to conventional IM treatment. Discrete measures of symmetry at the same time point identified treatment-based differences in maximal force (p = 0.039) and impulse (p = 0.012), with ASLStreated patients exhibiting more symmetry. No differences were identified in gait trials at later time points nor from all standing trials. Significance: During the initial loading response of gait, increased ipsilateral vGRF and improved weightbearing symmetry were identified in ASLS patients at 6 weeks post-surgery compared to conventional IM nailing. Early and objective metrics of dynamic movement are suggested to identify treatment-based differences in functional recovery.

Zusammenfassung Der „AGA Therapiealgorithmus der Patellainstabilität“ (ATAPI) basiert auf der klinischen Untersuchung, der Bildgebung und dem daraus resultierenden Risikoprofil. Im ersten Schritt wird eine mögliche Flake-Fraktur mittels Bildgebung detektiert. Im zweiten Schritt wird das individuelle Risiko einer Reluxation in Abhängigkeit der vorliegenden anatomischen und epidemiologischen Parameter erfasst. Bei niedrigem Risikoprofil ohne Flake-Fraktur wird primär die konservative Therapie empfohlen. Bei vorhandener Flake-Fraktur wird eine Refixation des Fragments angestrebt. Eine zusätzliche Rekonstruktion des medialen patellofemoralen Ligaments (MPFL) senkt das Reluxationsrisiko deutlich und wird auch als Grundpfeiler der operativen Therapie gesehen. Je nach Risikoprofil werden weitere Zusatzeingriffe in Erwägung gezogen. Somit besteht auch bei Patellaluxation ohne Flake-Fraktur aber hohem Risikoprofil die Indikation zur Operation.

Purpose Even though hip fracture care pathways have evolved, mortality rates have not improved during the last 20 years. This finding together with the increased frailty of hip fracture patients turned hip fractures into a major public health concern. The corresponding development of an indicator labyrinth for hip fractures and the ongoing practice variance in Europe call for a list of benchmarking indicators that allow for quality improvement initiatives for the rapid recovery of fragile hip fractures (RR-FHF). The purpose of this study was to identify quality indicators that assess the quality of in-hospital care for rapid recovery of fragile hip fracture (RR-FHF). Methods A literature search and guideline selection was conducted to identify recommendations for RR-FHF. Recommendations were categorized as potential structure, process, and outcome QIs and subdivided in-hospital care treatment topics. A list of structure and process recommendations that belongs to care treatment topics relevant for RR-FHF was used to facilitate extraction of recommendations during a 2-day consensus meeting with experts (n = 15) in hip fracture care across Europe. Participants were instructed to select 5 key recommendations relevant for RR-FHF for each part of the in-hospital care pathway: pre-, intra-, and postoperative care. Results In total, 37 potential QIs for RR-FHF were selected based on a methodology using the combination of high levels of evidence and expert opinion. The set consists of 14 process, 13 structure, and 10 outcome indicators that cover the whole perioperative process of fragile hip fracture care. Conclusion We suggest the QIs for RR-FHF to be practice tested and adapted to allow for intra-hospital longitudinal follow-up of the quality of care and for inter-hospital and cross-country benchmarking and quality improvement initiatives.

Background: The operative therapy of patellofemoral arthritis requires an individual approach depending on the underlying injury. However, the literature lacks recommendations for its course of action. Purpose: To generate an expert recommendation of therapy for different patellofemoral abnormalities in patients suffering from isolated patellofemoral arthritis. Study Design: Consensus statement. Methods: To generate recommendations, the AGA Patellofemoral Committee performed a consensus process using the Delphi method based on the available literature on isolated patellofemoral arthritis. Results: In most statements and recommendations, a high percentage of consensus could be found. However, also in the expert group of the AGA Patellofemoral Committee, some controversies on the treatment of patellofemoral arthritis exist. Conclusion: The operative therapy of isolated patellofemoral arthritis is a challenging topic that leads to controversial discussions, even in an expert group. With this consensus statement of the AGA Patellofemoral Committee, recommendations on different operative treatment options were able to be generated, which should be considered in clinical practice.

Background Patellar instability has a high incidence and occurs particularly in young and female patients. If the patella dislocates for the first time, treatment is usually conservative. However, this cautious approach carries the risk of recurrence and of secondary pathologies such as osteochondral fractures. Moreover, there is also risk of continuous symptoms apparent, as recurrent patella dislocation is related to patellofemoral osteoarthritis as well. An initial surgical treatment could possibly avoid these consequences of recurrent patella dislocation. Methods A prospective, randomized-controlled trial design is applied. Patients with unilateral first-time patella dislocation will be considered for participation. Study participants will be randomized to either conservative treatment or to a tailored patella stabilizing treatment. In the conservative group, patients will use a knee brace and will be prescribed outpatient physical therapy. The surgical treatment will be performed in a tailored manner, addressing the pathologic anatomy that predisposes to patella dislocation. The Banff Patellofemoral Instability-Instrument 2.0, recurrence rate, apprehension test, joint degeneration, and the Patella Instability Severity Score will serve as outcome parameters. The main analysis will focus on the difference in change of the scores between the two groups within a 2-year follow-up. Statistical analysis will use linear mixed models. Power analysis was done for the comparison of the two study arms at 2-year follow-up with regard to the BPII Score. A sample size of N = 64 per study arm (128 overall) provides 80% power (alpha = 0.05, two-tailed) to detect a difference of 0.5 standard deviations in a t-test for independent samples. Discussion Although several studies have already dealt with this issue, there is still no consensus on the ideal treatment concept for primary patellar dislocation. Moreover, most of these studies show a unified surgical group, which means that all patients were treated with the same surgical procedure. This is regarded as a major limitation as surgical treatment of patella dislocation should depend on the patient’s anatomic pathologies leading to patellar instability. To our knowledge, this is the first study investigating whether patients with primary patella dislocation are better treated conservatively or operatively with tailored surgery to stabilize the patella. Trial registration The study will be prospectively registered in the publicly accessible database www.ClinicalTrials.gov .

The aim of this study was to investigate the association of femoral (FT), tibial (TT), and knee torsion (KT) on the patella tilt (PT), the axial engagement index (AEI), and the tibial tuberosity–trochlear groove distance (TTTG). Femoral torsion, tibial torsion, knee torsion, patella tilt, the axial engagement index, the TTTG, and trochlear dysplasia were retrospectively evaluated on 59 patients suffering from recurrent patella instability or anterior knee pain with 118 torsional lower limb magnetic resonance imaging studies. FT and TT did not show any significant associations with TTTG, PT, and AEI (n.s.). KT was significantly associated with a higher TTTG, higher PT, and lower AEI (all, p < 0.001). Higher grade trochlear dysplasia was associated with a higher PT and lower AEI (both, p < 0.001). The Dejour classification showed no significant association with FT, TT, KT, and TTTG (n.s.). All measurement parameters showed an excellent interrater agreement (ICC 0.89–0.97). Static patella tilt and patellofemoral axial engagement in knee extension are mainly influenced by knee torsion, TTTG, and trochlear dysplasia but not by femoral or tibial torsion. These findings help to understand the underlying reasons for the patella position in knee extensions in CT and MRI investigations in patients suffering from patella instability and patellofemoral pain syndrome. III.

K norpelschäden im Bereich des pa­ tellofemoralen Gelenks (PFG) gel­ ten als schwierig zu behandeln. Bei viertgradiger Arthrose mit komplett auf­ gebrauchtem Gelenkspalt ist die Ent­ scheidung oft einfach: Patellofemorale Prothesen zeigen heute gute Ergebnisse. Was aber kann jüngeren Patienten ange­ boten werden, beziehungsweise welche Operationen können bei früher Degene­ ration sinnvoll eingesetzt werden? Dabei sind die vielfältigen Ursachen der Dege­ neration ebenso wie die komplexe Bio­ mechanik in diesem Gelenk unbedingt zu berücksichtigen. Wann immer mög­ lich, sollte die Stabilität und ein verbes­ serter Lauf der Kniescheibe („tracking“) wieder hergestellt werden.

Die Patellaluxation ist ein häufiges Krankheitsbild und bei vielen Patienten mit Rezidivereignissen, patellofemoralen Schmerzen, Knorpelschäden, Einschränkungen der sportlichen Aktivität und des sozialen Lebens sowie langfristig mit dem Risiko einer Femoropatellararthrose verbunden. Obwohl viele Studien die Ergebnisse unterschiedlicher Behandlungsmodalitäten nach erstmaliger Patellaluxation untersuchten, gibt es bislang kein Konsensmanagement höherer Evidenz. Ein pragmatischer Ansatz besteht darin, die Risikofaktoren der Patellainstabilität zu erfassen sowie den Patienten einer individuellen Risikostratifizierung zu unterziehen und dadurch die Entscheidungsfindung hinsichtlich einer konservativen oder operativen Therapie treffen zu können. In diesem Übersichtsartikel wird, basierend auf spezifischen Risikofaktoren und veröffentlichten Scores, ein Algorithmus zur Behandlung von Erst- und Rezidivluxationen der Patella vorgestellt.

Dislocation of the patella is a frequent occurrence and for many patients is associated with recurrent instability episodes, patellofemoral pain, cartilage damage, limitations in sport activities and social life as well as the risk of patellofemoral osteoarthritis in the long term. Although many studies investigated the results of different treatment modalities after primary patellar dislocation, there is so far no higher evidence consensus management. A pragmatic approach consists of collating the risk factors of patellar instability, to subject the patient to an individual risk stratification and in this way to be able to make a decision with respect to conservative or surgical treatment. As such this review article presents a treatment algorithm for primary and for recurrent patellar dislocations, based on specific risk factors and published scores.

in den vergangenen 10 Jahren wurden für viele patellofemorale Pathologien neue Behandlungsstrategien entwickelt, die teilweise sehr stark vom Althergebrachten abweichen. Aufgrund der speziellen anatomischen Voraussetzungen dieses Gelenks, des einzigartigen Zusammenspiels von aktiven und passiven Stabilisatoren sowie einer großen Zahl an zusätzlichen Einflussfaktoren fehlen nach wie vor klinische und experimentelle Studien mit größeren Fallzahlen, hohem Evidenzlevel und direkter Vergleichbarkeit. Sehr unterschiedliche Herangehensweisen in Europa und den USA machen die Datenlage nicht übersichtlicher.

ZusammenfassungDie Röntgenuntersuchung ist der Goldstandard für die Frakturdiagnostik. Mit den verschiedenen Projektionen können außerdem Operationsplanung, intraoperative Kontrolle, Verlaufsbeurteilung und Funktionsprüfung durchgeführt werden. Dieser Beitrag beschreibt die gängigsten Röntgenprojektionen am Knie, deren Indikationen samt Einstelltechniken. Weiterführende Schnittbilddiagnostik (CT, MRT) wird ebenso besprochen.

PURPOSE:To investigate whether temporary postoperative compartment-unloading therapy after arthroscopic partial meniscectomy (APM)-with either knee braces or wedge insoles-leads to superior clinical outcome as compared to controls. This difference in clinical outcome was tested in the form of two knee scores, physical activity and general health outcome over the first postoperative year.METHODS:Sixty-three patients who underwent arthroscopic partial meniscectomy (APM) were randomized to one of the following three groups: 12 weeks postoperative knee compartment-unloading therapy with either a knee brace (brace group) or wedge insoles (insole group) or no specific postoperative therapy (control group). Patient-reported outcome was assessed with the International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC Score), the Knee Injury and Osteoarthritis Outcome Score (KOOS), the MARX score (physical activity) and the SF-12 (general health).RESULTS:Sixty-three patients were available for analysis. Except for the SF-12 mental score, all other scores showed significant improvement over time. With regard to the hypotheses proposed, no significant group * time interactions were observed for any of the outcome parameters. This means that the group (i.e. the type of postoperative treatment) was not related to the degree of improvement of any of the scores.CONCLUSIONS:It was concluded that 12 weeks of compartment-unloading therapy-with either a knee brace or wedge insoles-is ineffective with regard to clinical outcome after APM. This applies to the knee score outcome, physical activity and general health outcome over the first year following APM.LEVEL OF EVIDENCE:Randomized controlled trial, Level I.