Abstract Background There is an vivid, ongoing discussion on whether injuries to the deltoid ligament complex, especially in the setting of ankle fractures, neccessitate surgical treatment. One reason for the conflicting results in literature, could be a missing standard on how acute deltoid ligament injuries are treated. The aim of this systematic review was to analyze the different applied treatment stratagies in studies reporting on the outcome of surgically treated acute deltoid ligament injuries. Methods The herein conducted systematic review was conducted per PRISMA guidelines, the inclusion criteria were framed according to the PICOS criteria. The study was a-priori registered. Three independent reviewers conducted the literature search and data extraction (JS, AMN). The data assessed were study type, level of evidence, included fractures, methods of treating deltoid ligament injuries, differentiation between the superficial and deep layers and associated syndesmotic injuries. Results Per the therapeutic studies (n = 37), the deltoid ligament repair was mostly conducted using suture anchors (n = 29), either placed in the medial malleolus for superficial deltoid ligament (SDL, n = 11)/ deep deltoid ligament (DDL, n = 7) repair and/ or in the medial talus for DDL repair (n = 10). 10 studies used direct sutures for SDL repair (n = 10) and/ or the DDL repair (n = 1). One study each used either a tibialis anterior tendon graft, a temporary arthrodesis of the ankle joint, or augmented the deltoid ligament. Conclusion A missing standard for treating injuries to the deltoid ligament complex was observed. Although most studies used suture anchors, there is a huge heterogeneity regarding the placement, the number of anchors used for repair, and the exact layer(s) that were adressed. Further research is needed to establish evidence-based guidelines on how to treat acute deltoid ligament injuries.

Ankle fractures are among the most common fractures in adults. Despite significant advancements in surgical techniques, the postoperative treatment regimens remain conservative. This study aims to objectively evaluate gait recovery following early mobilization and weight-bearing after surgical ankle fracture treatment using instrumented gait analysis. This prospective, single-armed, longitudinal study enrolled adult patients following surgical treatment for isolated ankle fractures with early pain dependent weightbearing. Gait analysis, utilizing a treadmill integrated with a pressure plate and IMU-based motion capture systems, was conducted at 6 weeks, 3-, 6-, and 12-months post-surgery, assessing spatio-temporal and kinematic parameters. Results were compared longitudinally and against a healthy control group. Longitudinal data were available for 44 patients. Significant (p<.001) improvements of self-paced walking velocity (SPV) were observed from 6 weeks (2.2 ± 1.1 km/h), to 3 (2.9 ± 0.9 km/h) and 6 months (3.4 ± 0.9 km/h). The spatio-temporal parameters showed significant changes between 6 weeks and all further time points only at SPV. Kinematic parameters showed significant longitudinal improvements at SPV for hip, knee, and ankle motion (including all three ankle planes). Patient gait parameters at 6 and 12 months were comparable to healthy controls, except for persistent limitations in ankle sagittal kinematics. Patients undergoing surgical ankle fracture repair with early mobilization and full weight-bearing showed substantial gait recovery within 6 weeks. By 12 weeks, patient gait closely resembled healthy controls, highlighting the efficacy of a pain-adapted postoperative regimen for rapid functional recovery and return to previous activity levels. Level II.

Frakturen der Metatarsale-V-Basis werden häufig falsch eingeschätzt. Einerseits werden viele Frakturen operativ versorgt, obwohl die funktionelle konservative Therapie zu exzellenten Ergebnissen führt. Andererseits erfolgt bei einigen Frakturen eine langwierige Immobilisation, obwohl eine operative Therapie eine viel schnellere Rehabilitation erlaubt, bei deutlich besserer Prognose der Heilung. Die Frakturlokalisation ist entscheidend für die Therapieentscheidung – und den Behandlungserfolg.

BACKGROUND:Ankle fractures are among the most common types of fracture among adults in Germany, with an incidence of 74 ± 32 cases per 100 000 persons per year. Treatment strategies have changed considerably over the past decade. In this review, we present the current treatment strategies for ankle fractures, aftercare, and long-term results. METHODS:Current treatment strategies for ankle fractures were summarized in the framework of a narrative review and expert consensus of the German Orthopaedic Foot and Ankle Society (Deutsche Assoziation für Fuß und Sprunggelenk, D.A.F.). The current mode of postoperative aftercare for ankle fractures and the long-term results were retrieved from structured literature reviews. RESULTS:Stable, non- or minimally displaced unimalleolar fractures (AO 44A and 44B) can be treated non-operatively with an early return to function. Stability should be verified by bilateral, weight-bearing radiography. Fractures that are unstable or displaced should be treated surgically. Active individuals seem to benefit from anatomic reduction and the stabilization of all fractures and unstable syndesmotic injuries (360° treatment). Minimally invasive techniques are recommended in case of critical soft-tissue conditions or major comorbidity. The benefit of the currently prevailing restrictive postoperative regimens (six weeks of immobilization and reduced or no weight-bearing) has been called into question by the findings of a large number of randomized controlled trials. Early weight-bearing and mobilization improve early functional outcomes without increasing complication rates. Long-term studies have shown that a moderate to poor functional outcome can be expected in up to 20% of cases ≥ 10 years after the operative treatment of an ankle fracture. CONCLUSION:Treatment strategies and aftercare regimens have evolved over the past decade. Future studies will need to determine whether these new strategies yield better long-term clinical outcomes.

Identifizierung und Behandlung von intraartikulären Begleitpathologien, Verifizierung der Syndesmoseninstabilität, bei chronischen Verletzungen Anfrischen der syndesmalen Strukturen, Reposition und Retention der Fibula im distalen Tibiofibulargelenk. Akute und chronische Zwei- oder Dreibandrupturen der Syndesmose bei Patient:innen mit funktionellem Anspruch. Weichteilschäden, allgemeine Risikofaktoren, z. B. Durchblutungsstörungen, diabetisches Fußsyndrom, komplexes regionales Schmerzsyndrom. Durchführung einer diagnostischen Arthroskopie (ASK) des Sprunggelenkes über anterolaterales und -mediales Portal; Identifikation und Behandlung von intraartikulären Begleitpathologien; Verifizierung der syndesmalen Instabilität durch Einführen eine Instrumentes > 4 mm in die Incisura fibularis; bei chronischen Syndesmosenverletzungen Anfrischen der syndesmalen Strukturen und Inspektion ggf. Débridement Deltabandkomplex; Reposition der Fibula in die Incisura fibularis; Retention der Fibula mittels Stellschraube oder Seilzugsystem. Teilbelastung mit 20 kg für 6 Wochen, keine Immobilisation, forcierte Beübung der Beweglichkeit des Sprunggelenkes, Röntgenkontrolle nach 6 Wochen, dann ggf. Belastungssteigerung. Akute Syndesmosenverletzungen: 19 Patient:innen (37 ± 13 Jahre) wurden 38 ± 17 Monate nach arthroskopisch assistierter Versorgung einer akuten Syndesmosenverletzung nachuntersucht. In 53

BACKGROUND:Hallux valgus is a common deformity. Surgical treatment strategies have evolved markedly in recent years. We report on the administrative prevalence of this condition and the available treatments for it. METHODS:The administrative prevalence of hallux valgus and the treatments provided for it in Germany were determined from data supplied by BARMER, a statutory health insurance carrier. The classification and treatment of hallux valgus are outlined in a narrative overview, with particular attention to a meta-analysis. RESULTS:The administrative prevalence of hallux valgus in Germany is nearly 2%; 83% of the affected persons are women. Over a 6-year period, the number of operations declined, and there was a trend toward outpatient treatment. Hallux valgus should be classified as either mild/moderate or severe. The common surgical procedures achieved comparable correction of the bony deformity. The AOFAS score improved by an average of 33.8 points (95% CI: [30.5; 37.0]) across all surgical techniques, reaching average postoperative values that ranged from 81.4±7.7 and 90.1±4.8 points depending on the particular technique used. The choice of technique and the duration of follow-up had no significant effect on the subjective treatment outcome. The overall complication rate after surgical correction was 18.5%. The common complications were metatarsalgia, recurrent deformity, stiffness of the first metatarsal joint, wound-healing disorders, and hallux varus. CONCLUSION:The primary treatment of hallux valgus should be conservative. The various surgical techniques correct the bony deformity with comparable efficacy and good postoperative AOFAS scores. Patients with more severe deformities and greater impairment seem to have a higher potential for improvement in the AOFAS score.

Syndesmotic instability or malreduction is an independent risk factor for an impaired patient-rated outcome. If a syndesmotic injury is suspected, a stepwise diagnostic approach including plane radiographs, MRI, and bilateral stress radiographs should be conducted to differentiate stable from latent unstable and frank diastasis cases. The basic requirement for any surgical treatment approach is a stable and anatomically reduced DTFJ. Any avulsion fracture of the syndesmosis should be addressed by open reduction and internal fixation, whenever possible. The best treatment approach for a 2-ligament injury (AiTFL + IOL) seems to be a single suture-button system. For a 3-ligament injury (AiTFL + IOL + PiTFL), either 2 suture-button systems or a suture-button system and a syndesmotic screw should be used. A bilateral CT imaging must be conducted postoperative to assess the quality of DTFJ reduction. In case of malreduction, the postoperative CT image must be analyzed in detail and a rigid fixation technique facilitated.

Ankle fractures often involve intra-articular pathologies, which can only be addressed by additional arthroscopy. This systematic review aims to compare the outcomes of arthroscopically assisted open reduction and internal fixation (AORIF) with traditional open reduction and internal fixation (ORIF) for ankle fractures. A systematic literature search adhering to PICOS and PRISMA guidelines was conducted across the following databases: MEDLINE (PubMed), Scopus, Central and EMBASE. Studies that compared AORIF and ORIF of ankle fractures and focused on patient-reported outcome measures (PROMs) as the primary outcome were included. Excluded were studies on non-acute or non-isolated fractures, pilon fractures, concomitant injuries outside the ankle, biomechanical or computational studies, and those lacking objective outcome data. A total of 7089 studies were screened, 12 of which met the inclusion criteria for qualitative synthesis. The level of evidence was I-III with a mean MINORS Tool score of 19.17. Among the included studies, six studies focused on unimalleolar fractures, with four demonstrating significantly better PROMs for the AORIF group. Five studies addressed bimalleolar and/or trimalleolar fractures, with one showing significantly better PROMs for AORIF. Seven studies reported on intra-articular pathologies, with a detection rate of up to 88.89

IntroductionThe demographic shift leads to a tremendous increase in age-related diseases, which are often chronic. Therefore, a focus of chronic disease management should be set on the maintenance or even improvement of the patients’ quality of life (QoL). One indicator to objectively measure QoL is the EQ-5D questionnaire, which was validated in a disease- and world region-specific manner. The aim of this study was to conduct a systematic literature review and meta-analysis on the QoL across the most frequent chronic diseases that utilized the EQ-5D and performed a disease-specific meta-analysis for treatment-dependent QoL improvement.Materials and methodsThe most common chronic disease in Germany were identified by their ICD-10 codes, followed by a systematic literature review of these ICD-10 codes and the EQ-5D index values. Finally, out of 10,016 independently -screened studies by two persons, 538 studies were included in the systematic review and 216 studies in the meta-analysis, respectively.ResultsWe found significant medium to large effect sizes of treatment effects, i.e., effect size >0.5, in musculoskeletal conditions with the exception of fractures, for chronic depression and for stroke. The effect size did not differ significantly from zero for breast and lung cancer and were significantly negative for fractures.ConclusionOur analysis showed a large variation between baseline and post-treatment scores on the EQ-5D health index, depending on the health condition. We found large gains in health-related quality of life mainly for interventions for musculoskeletal disease.Systematic review registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020150936, PROSPERO identifier CRD42020150936.

Introduction In recent years, there has been an increasing demand for patient-reported outcome measures (PROMs) to assess the outcome following orthopedic surgery. But, we are lacking a standard set of PROMs to assess the outcome of hallux valgus surgery. The aim of this study was to analyze the chosen patient rated outcome scores used in studies reporting on hallux valgus surgery. Materials and methods The study was based on a previously published living systematic review. Included were prospective, comparative studies of different surgical procedures or the same procedure for different degrees of deformity. Four common databases were searched for the last decade. Study selection, data extraction, and risk of bias assessment were made by two independent reviewers. Data assessed were the individual PROMs used to assess the outcome of hallux valgus surgery. Results 46 studies (30 RCTs and 16 non-randomized prospective studies) met the inclusion criteria. The most commonly used clinical outcome measures were the AOFAS (55%) and the VAS (30%). No differences were found between frequency of the individual scores per the level of evidence or the type of osteotomy. Conclusion Based on a systematic literature review, the AOFAS and VAS are the most frequently used outcome tools in studies assessing the outcome following hallux valgus surgery. Based on the literature available, the MOXFQ is a more valid alternative. Level of evidence Level I; systematic review of prospective comparative (level II) and randomized controlled trials (level I).

Frakturen der Metatarsale V Basis gehören zu den häufigsten Brüchen des Fußes. Einige dieser Frakturen heilen unter konservativer Therapie schnell und unkompliziert, während andere häufig zu symptomatischen Pseudarthrosen führen. Entsprechend ist die richtige Klassifizierung entscheidend für den Behandlungserfolg. Die beste Therapie der Pseudarthrose ist deren Vermeidung. Frakturen am distalen Ende der Artikulation der MT IV und V (Meta-Diaphysäre Frakturen) weisen unter konservativer Therapie ein hohes Risiko für Pseudarthrosen auf. Die operative Therapie mittels intramedullärere Schraubenosteosynthese (CRIF) führt zu reproduzierbar guten Ergebnissen. Entsprechend sollte diese Therapie empfohlen werden. Kommt es zur Ausbildung einer Pseudarthrose, ist dies in den allermeisten Fällen die Folge einer konservativen Therapie. Behandlungspflichtig ist lediglich die symptomatische Pseudarthrose. Initial kann hier eine Stoßwellen-Therapie erwogen werden. Operativ empfehlen die meisten Autoren die isolierte intramedulläre Schraubenosteosynthese mit Aufbohren des Markraums. Ein offenes Anfrischen der Pseudarthrose oder gar eine Spongiosaplastik scheinen nicht erforderlich zu sein.

The two most commonly instrumented gait analysis tools used are Optical Motion Capture systems (OMC) and Inertial Measurement Units (IMU). To date, OMC based gait analysis is considered the gold-standard. Still, it is space-, cost-, and time-intense. On the other hand IMU systems are more cost- and time effective but simulate the whole foot as a single segment. To get a more detailed model of the foot and ankle, a new 2-segment foot model using IMU was developed, comparable to the multi-segment foot models assessed by OMC. Can an IMU based 2-segment foot model be developed to provide a more detailed representation of the foot and ankle kinematics? To establish a 2-segment foot model, in addition to the previous 1-segment foot model an IMU sensor was added to the calcaneus. This allowed the differentiation between the hindfoot and forefoot kinematics. 30 healthy individuals (mean age 27 ± 7 years) were recruited to create a norm data set of a healthy cohort. Moreover, the kinematic data of the 2-segment foot model were compared to those of the traditional 1-segment foot model using statistical parametric mapping. The 2-segment foot model proved to be applicable. Furthermore, it allowed for a more detailed representation of the foot and ankle joints, similar to other multi-segment foot model. The healthy cohort’s norm data set showed a homogeneous motion pattern for gait. The 2-segment foot model allows for an extension of IMU-based gait analysis. Futures studies must prove the reliability and validity of the 2-segment foot model in healthy and pathologic situations. Level II.

INTRODUCTION:Hallux valgus deformity severity is one determent for the surgical procedure for hallux valgus (HV) correction. HV deformities are usually classified into mild/moderate/severe. The aim was to investigate the cut-off criteria used to classify HV deformity. MATERIALS AND METHODS:The study was based on a previous living systematic review. Four common databases were searched for the last decade. All review-steps were conducted by two reviewers. Data assessed were the individual cut-off values used to classify HV deformity into mild/moderate/severe, and the referenced classification systems. RESULTS:46 studies were included. 21/18 studies grade deformity based on the intermetatarsal angle (IMA)/ hallux valgus angle (HVA) with great heterogeneity throughout the different cut-off values. The most referenced classification systems were the Coughlin and Mann's and the Robinson classification. CONCLUSIONS:The currently used classification systems are heterogenic, and no standard could be defined. The community should define a uniform classification system. LEVEL OF EVIDENCE:Level I, systematic review of randomized controlled trials and prospective comparative studies.

Syndesmosenverletzungen können isoliert oder in Kombination mit Sprunggelenksfrakturen auftreten. Traditionell werden diese in stabile, latent-instabile und instabile Verletzungen untergliedert. Bis dato fehlen einheitliche Diagnosealgorithmen und Klassifikationen.Im Rahmen dieser Übersichtsarbeit stellen die Autoren die aktuell vorhandene Literatur zu Diagnose und Klassifikation von isolierten, akuten Syndesmosenverletzungen vor. Basierend auf dieser Datengrundlage wird ein „best-evidence“ Diagnose- und Klassifikationsalgorithmus vorgestellt.Die Diagnose sollte schrittweise erfolgen und die strukturierte klinische Untersuchung, eine MRT-Bildgebung sowie ggf. dynamische bildgebende Untersuchung umfassen. Die Klassifikation sollte anatomisch, entsprechend der rupturierten Bandanteile erfolgen. Verletzungen des Deltaband-Komplexes sollten separat klassifiziert werden.