Retrospective analysis of treatment decisions and clinical outcome of Lisfranc injuries: operative vs. conservative treatment

Purpose: Lisfranc injuries are rare and often pose a challenge for surgeons, particularly in initially missed or neglected cases. The evidence on which subtypes of Lisfranc injuries are suitable for conservative treatment or should undergo surgery is low. The aim of this study was to retrospectively analyze treatment decisions of Lisfranc injuries and the clinical outcome of these patients within the last ten years. Methods: All patients treated due to a Lisfranc injury in a German level I trauma centre from January 2011 until December 2020 were included in this study. Radiologic images and medical data from the patient files were analyzed concerning the classification of injury, specific radiologic variables, such as the Buehren criteria, patient baseline characteristics, and patient outcome reported with the Foot Function Index (FFI). Results: Ninety-nine patients were included in this study (conservative = 20, operative = 79). The overall clinical outcome assessed by the FFI was good (FFI sum 23.93, SD 24.93); patients that were identified as suitable for conservative treatment did not show inferior functional results. Qualitative radiological factors like the grade of displacement and the trauma mechanism were more strongly associated with the decision for surgical treatment than quantitative radiologic factors such as the distance from the first to the second metatarsal bone. Conclusion: If the indication for conservative or operative treatment of Lisfranc injuries is determined correctly, the clinical outcome can be comparable. These decisions should be based on several factors including quantitative and qualitative radiologic criteria, as well as the trauma mechanism

Correction of severe valgus osteoarthritis by total knee arthroplasty is associated with increased postoperative ankle symptoms

Purpose: The aim of this study was to assess the mid-term clinical outcome of the ankle joint after total knee arthroplasty (TKA) in high-grade valgus osteoarthritis. Methods: In this case–control study, n=36 patients with a preoperative mechanical tibiofemoral angle (mTFA)≥15° who underwent TKA between December 2002 and December 2012 were included. The control group (mTFA<15°) of n=60 patients was created using case matching. Radiological [mechanical tibiofemoral angle (mTFA) and ankle joint orientation to the ground (G-AJLO)] and clinical parameters [Foot Function Index (FFI), Knee Society Score, Forgotten Joint Score, and Range of Motion (ROM)] were analysed. The mean follow-up time was 59 months (IQR [56, 62]). Results: The degree of correcting the mTFA by TKA signifcantly correlated with the postoperative FFI (R=0.95, p<0.05), although the knee and ankle joint lines were corrected to neutral orientations. A cut-of value of 16.5° [AUC 0.912 (0.85–0.975 95% CI), sensitivity=0.8, specifcity=0.895] was calculated, above which the odds ratio (OR) for developing ankle symptoms increased vastly [OR 34.0 (9.10–127.02 95% CI)]. ROM restrictions of the subtalar joint displayed a strong sig nifcant correlation with the FFI (R=0.74, p<0.05), demonstrating that decreased ROM of the subtalar joint was associated with aggravated outcomes of the ankle joint. Conclusions: In this study, higher degrees of leg axis correction in TKA were associated with increased postoperative ankle symptoms. When TKA is performed in excessive valgus knee osteoarthritis, surgeons should be aware that this might trigger the onset or progression of ankle symptoms, particularly in cases of a stif subtalar joint. Level of evidence III

Therapeutic anticoagulation complications in the elderly: a case report

Background: The demographic transition leads to a continuously growing number of elderly patients who receive therapeutic anticoagulation by reason of several comorbidities. Though therapeutic anticoagulation may reduce the number of embolic complications in these patients, major complications such as bleeding complications need to be kept in mind when considering such therapy. However, evidence regarding the choice of anticoagulation agents in chronic kidney disease patients of higher age is limited. In this report, a guideline-based anticoagulation treatment which led to a fulminant atraumatic bleeding complication is discussed. Case presentation: We present the case of an 85-year-old female stage V chronic kidney disease patient who suffered from a diffuse arterial, subcutaneous bleeding in her lower left leg due a therapeutic anticoagulation using low molecular weight heparin (LMWH). Anticoagulation was started in accordance with general recommendations for patients with atrial fibrillation, and the dosage was adapted for the patient's renal function. Nevertheless, the above-mentioned complication occurred, and the bleeding led to a hemorrhagic shock and an acute kidney injury on top of a chronic kidney disease. The hematoma required surgical evacuation and local coagulation in the operating room. In the further course, the patient underwent additional four surgical interventions due to a superinfected skin necrosis, including skin grafting. Furthermore, the patient needed continuous renal replacement therapy, as well as intensive care unit treatment, for a total of 47 days followed by 36 days of geriatric rehabilitation. Afterwards, she was discharged from the hospital to her previous nursing home. Discussion and conclusions: Although therapeutic anticoagulation may sufficiently protect patients at cardiovascular risk, major complications such as bleeding complications may occur at any time. Therefore, physicians need to regularly re-evaluate any prior indication for therapeutic anticoagulation. With this case report, we hope to draw attention to the cohort of geriatric patients and the need for more and well differentiated study settings to preferably prevent any potentially avoidable complications

Comparing Perioperative Outcome Measures of the Dynamic Hip Screw and the Femoral Neck System

Background and Objective: Various fixation devices and surgical techniques are available for the management of proximal femur fractures. Recently, the femoral neck system (FNS) was introduced, and was promoted on the basis of less invasiveness, shorter operating time, and less fluoroscopy time compared to previous systems. The aim of this study was to compare two systems for the internal fixation of femoral neck fractures (FNF), namely the dynamic hip screw (DHS) with an anti-rotation screw (ARS) and an FNS. The outcome measures included operating room time (ORT), dose–area product (DAP), length of stay (LOS), perioperative changes in haemoglobin concentrations, and transfusion rate. Materials and Methods: A retrospective single-centre study was conducted. Patients treated for FNF between 1 January 2020 and 30 September 2021 were included, provided that they had undergone closed reduction and internal fixation. We measured the centrum-collum-diaphyseal (CCD) and the Pauwels angle preoperatively and one week postoperatively. Results: In total, 31 patients (16 females), with a mean age of 62.81 ± 15.05 years, were included. Fracture complexity assessed by the Pauwels and Garden classification did not differ between groups preoperatively. Nonetheless, the ORT (54 ± 26.1 min vs. 91.68 ± 23.96 min, p < 0.01) and DAP (721 ± 270.6 cGycm² vs. 1604 ± 1178 cGycm², p = 0.03) were significantly lower in the FNS group. The pre- and postoperative CCD and Pauwels angles did not differ statistically between groups. Perioperative haemoglobin concentration changes (–1.77 ± 1.19 g/dl vs. –1.74 ± 1.37 g/dl) and LOS (8 ± 5.27 days vs. 7.35 ± 3.43 days) were not statistically different. Conclusions: In this cohort, the ORT and DAP were almost halved in the patient group treated with FNS. This may confer a reduction in secondary risks related to surgery

Outcome Analysis of the Use of Cerament® in Patients with Chronic Osteomyelitis and Corticomedullary Defects

Background: Chronic osteomyelitis (OM) is a progressive but mostly low-grade infection of the bones. The management of this disease is highly challenging for physicians. Despite systematic treatment approaches, recurrence rates are high. Further, functional and patient-reported outcome data are lacking, especially after osseous defects are filled with bioresorbable antibiotic carriers. Objective: To assess functional and patient-reported outcome measures (PROM) following the administration of Cerament (R) G or V due to corticomedullary defects in chronic OM. Methods: We conducted a retrospective study from 2015 to 2020, including all patients who received Cerament (R) for the aforementioned reason. Patients were diagnosed and treated in accordance with globally valid recommendations, and corticomedullary defects were filled with Cerament (R) G or V, depending on the expected germ spectrum. Patients were systematically followed up, and outcome measures were collected during outpatient clinic visits. Results: Twenty patients with Cierny and Mader type III OM were included in this study and followed up for 20.2 +/- 17.2 months (95%CI 12.1-28.3). Ten of these patients needed at least one revision (2.0 +/- 1.3 revisions per patient (95%CI 1.1-2.9) during the study period due to OM persistence or local wound complications. There were no statistically significant differences in functional scores or PROMs between groups. Conclusion: The use of Cerament (R) G and V in chronic OM patients with corticomedullary defects appears to have good functional outcomes and satisfactory PROMs. However, the observed rate of local wound complications and the OM persistence rate may be higher when compared to previously published data

Transforming the German ICD-10 (ICD-10-GM) into Injury Severity Score (ISS)—Introducing a new method for automated re-coding

Background: While potentially timesaving, there is no program to automatically transform diagnosis codes of the ICD-10 German modification (ICD-10-GM) into the injury severity score (ISS). Objective: To develop a mapping method from ICD-10-GM into ICD-10 clinical modification (ICD-10-CM) to calculate the abbreviated injury scale (AIS) and ISS of each patient using the ICDPIC-R and to compare the manually and automatically calculated scores. Methods: Between January 2019 and June 2021, the most severe AIS of each body region and the ISS were manually calculated using medical documentation and radiology reports of all major trauma patients of a German level I trauma centre. The ICD-10-GM codes of these patients were exported from the electronic medical data system SAP, and a Java program was written to transform these into ICD-10-CM codes. Afterwards, the ICDPIC-R was used to automatically generate the most severe AIS of each body region and the ISS. The automatically and manually determined ISS and AIS scores were then tested for equivalence. Results: Statistical analysis revealed that the manually and automatically calculated ISS were significantly equivalent over the entire patient cohort. Further sub-group analysis, however, showed that equivalence could only be demonstrated for patients with an ISS between 16 and 24. Likewise, the highest AIS scores of each body region were not equal in the manually and automatically calculated group. Conclusion: Though achieving mapping results highly comparable to previous mapping methods of ICD-10-CM diagnosis codes, it is not unrestrictedly possible to automatically calculate the AIS and ISS using ICD-10-GM codes

Differential Influence of Levodopa on Reward-Based Learning in Parkinson's Disease

The mesocorticolimbic dopamine (DA) system linking the dopaminergic midbrain to the prefrontal cortex and subcortical striatum has been shown to be sensitive to reinforcement in animals and humans. Within this system, coexistent segregated striato-frontal circuits have been linked to different functions. In the present study, we tested patients with Parkinson's disease (PD), a neurodegenerative disorder characterized by dopaminergic cell loss, on two reward-based learning tasks assumed to differentially involve dorsal and ventral striato-frontal circuits. 15 non-depressed and non-demented PD patients on levodopa monotherapy were tested both on and off medication. Levodopa had beneficial effects on the performance on an instrumental learning task with constant stimulus-reward associations, hypothesized to rely on dorsal striato-frontal circuits. In contrast, performance on a reversal learning task with changing reward contingencies, relying on ventral striato-frontal structures, was better in the unmedicated state. These results are in line with the “overdose hypothesis” which assumes detrimental effects of dopaminergic medication on functions relying upon less affected regions in PD. This study demonstrates, in a within-subject design, a double dissociation of dopaminergic medication and performance on two reward-based learning tasks differing in regard to whether reward contingencies are constant or dynamic. There was no evidence for a dose effect of levodopa on reward-based behavior with the patients’ actual levodopa dose being uncorrelated to their performance on the reward-based learning tasks

Validation of reference genes for expression analysis in a murine trauma model combining traumatic brain injury and femoral fracture

Systemic and local posttraumatic responses are often monitored on mRNA expression level using quantitative real-time PCR (qRT-PCR), which requires normalisation to adjust for confounding sources of variability. Normalisation requests reference (housekeeping) genes stable throughout time and divergent experimental conditions in the tissue of interest, which are crucial for a reliable and reproducible gene expression analysis. Although previous animal studies analysed reference genes following isolated trauma, this multiple-trauma gene expression analysis provides a notable study analysing reference genes in primarily affected (i.e. bone/fracture callus and hypothalamus) and secondarily affected organs (i.e. white adipose tissue, liver, muscle and spleen), following experimental long bone fracture and traumatic brain injury. We considered tissue-specific and commonly used top-ranked reference candidates from different functional groups that were evaluated applying the established expression stability analysis tools NormFinder, GeNorm, BestKeeper and RefFinder. In conclusion, reference gene expression in primary organs is highly time point as well as tissue-specific, and therefore requires careful evaluation for qRT-PCR analysis. Furthermore, the general application of Ppia, particularly in combination with a second reference gene, is strongly recommended for the analysis of systemic effects in the case of indirect trauma affecting secondary organs through local and systemic pathophysiological responses

Polymorphisms in the Hsp70 gene locus are genetically associated with systemic lupus erythematosus

Background Heat shock proteins (Hsps) play a role in the delivery and presentation of antigenic peptides and are thought to be involved in the pathogenesis of multifactorial diseases. Objective To investigate genes encoding cytosolic Hsp70 proteins for associations of allelic variants with systemic lupus erythematosus (SLE). Methods Case-control studies of two independent Caucasian SLE cohorts were performed. In a haplotype-tagging single-nucleotide polymorphism approach, common variants of HspA1L, HspA1A and HspA1B were genotyped and principal component analyses were performed for the cohort from the Oklahoma Medical Research Foundation (OMRF). Relative quantification of mRNA was carried out for each Hsp70 gene in healthy controls. Conditional regression analysis was performed to determine if allelic variants in Hsp70 act independently of HLA-DR3. Results On analysis of common genetic variants of HspA1L, HspA1A and HspA1B, a haplotype significantly associated with SLE in the Erlangen-SLE cohort was identified, which was confirmed in the OMRF cohort. Depending on the cohorts, OR ranging from 1.43 to 1.88 and 2.64 to 3.16 was observed for individuals heterozygous and homozygous for the associated haplotype, respectively. Patients carrying the risk haplotype or the risk allele more often displayed autoantibodies to Ro and La in both cohorts. In healthy controls bearing this haplotype, the amount of HspA1A mRNA was significantly increased, whereas total Hsp70 protein concentration was not altered. Conclusions Allelic variants of the Hsp70 genes are significantly associated with SLE in Caucasians, independently of HLA-DR3, and correlate with the presence of autoantibodies to Ro and La. Hence, the Hsp70 gene locus appears to be involved in SLE pathogenesis

The effect of dopamine agonists on adaptive and aberrant salience in Parkinson's disease

Clinical evidence suggests that after initiation of dopaminergic medications some patients with Parkinson's disease (PD) develop psychotic symptoms, such as hallucinations and delusions. Here, we tested the hypothesis that the neurocognitive basis of this phenomenon can be defined as the formation of arbitrary and illusory associations between conditioned stimuli and reward signals, called aberrant salience. Young, never-medicated PD patients and matched controls were assessed on a speeded reaction time task in which the probe stimulus was preceded by conditioned stimuli that could signal monetary reward by color or shape. The patients and controls were re-evaluated after 12 weeks during which the patients received a dopamine agonist (pramipexole or ropinirole). Results indicated that dopamine agonists increased both adaptive and aberrant salience in PD patients, that is, formation of real and illusory associations between conditioned stimuli and reward, respectively. This effect was present when associations were assessed by means of faster responding after conditioned stimuli signaling reward (implicit salience) and overt rating of stimulus-reward links (explicit salience). However, unusual feelings and experiences, which are subclinical manifestations of psychotic-like symptoms, were specifically related to irrelevant and illusory stimulus-reward associations (aberrant salience) in PD patients receiving dopamine agonists. The learning of relevant and real stimulus-reward associations (adaptive salience) was not related to unusual experiences. These results suggest that dopamine agonists may increase psychotic-like experiences in young patients with PD, possibly by facilitating dopaminergic transmission in the ventral striatum, which results in aberrant associations between conditioned stimuli and reward