Ganganalytische Studie zur Entlastungs-Coxa-valga (antetorta) orthetisch und prothetisch versorgter Kinder

Ziel: In der vorliegenden Arbeit sollte in einem ersten Schritt überprüft werden, wie sich bei Kindern, die aufgrund einer nicht behebbaren, einseitigen Beindeformität distal des Kniegelenkes dauerhaft orthetisch oder prothetisch versorgt werden müssen, die primär gesunde Hüfte des betroffenen Beines sekundär verformt. In einem zweiten Schritt sollte mittels Ganganalyse evaluiert werden, welcher Pathomechanismus der diagnostizierten Formstörung zu Grunde liegt. Methodik: Das Patientengut bestand aus zwölf primär hüftgesunden, jedoch einseitig distal des Knies erkrankten, orthesenpflichtigen Kindern und Jugendlichen, deren klinische und radiologische Krankheitsverläufe retrospektiv ausgewertet wurden. Bei zehn der betroffenen Kinder konnte eine verwertbare instrumentelle kinetische und kinematische Ganganalyse mittels des Zebris-Systems durchgeführt werden. Ergebnisse: 1. Grunderkrankungen: Crus varum congenitum oder Tibiapseudarthrosen 5, Fehlbildungsklumpfuß 1, kongenitaler tibialer Längsdefekt 2, kongenitaler fibulärer Längsdefekt 3, Unterschenkeldeformität nach Ewingsarkom 1. 2. Klinische Ergebnisse: Im intraindividuellen Seitvergleich ist die Seite des von der Deformität betroffenen Beines wie folgt verändert: Die Hüftinnenrotation ist durchschnittlich 12,5º signifikant vermehrt (p <0,05), die Hüftaußenrotation um 20-22,5º verkleinert. 3. Radiologische Ergebnisse: Koxales Femurende: Der projizierte CCD-Winkel ist altersabhängig und im Durchschnitt 14,71º signifikant steiler. Die Distanz zwischen Kopfkalotte und Trochanter minor (LTA) ist 1,58 cm signifikant vergrößert. Der Kopfepiphysen-Femurschaft-Winkel (KF) als Beweis der horizontalen Stellung der Kopfepiphysenfuge ist durchschnittlich um 13,52º vergrößert (p <0,05). Hüftpfanne: Der Sharp-Ullmann-Winkel ist 5,01º signifikant vergrößert und der Acetabulumwinkel (AC) ist 3,52º vergrößert (p <0,05). 3. Ganganalytische Ergebnisse: Kinetik: Die Schrittlänge ist um durchschnittlich 7 cm signifikant verlängert (p 0.05). Die Hüftabduktion der entlasteten Hüfte als Hinweis eines konstanten Duchenne-Hinkens ist durchschnittlich um 16,81º vermehrt. Schlussfolgerung: Zusammenfassend kann gesagt werden, dass die einseitig orthetisch/prothetisch versorgten Kinder eine Formstörung der Hüfte aufwiesen, die in der älteren Literatur als Entlastungs-Coxa-valga bzw. Entlastungsdysplasie bezeichnet wird. Erstmals konnten die pathogenetischen Faktoren identifiziert werden, die diese Formstörung hervorrufen. Die Patienten weisen ein Duchenne-Hinken auf und belasten das betroffene Bein weniger stark und mit kürzerer Zeitspanne. Die Untersuchung bestätigt in eindrucksvoller Weise die allgemeinen Wachstumsgesetze des muskulo-skelettalen Organs, die unter dem Merksatz „form follows function“ zusammengefasst werden können. Als praktische Konsequenz für den Klinikalltag ergibt sich die Forderung, die Hüfte orthesenpflichtiger Kinder in größeren Abständen klinisch und bildgebend zu screenen und die Orthesen- bzw. Prothesenaufbau so zu gestalten, dass ein Duchenne-Hinken vermieden wird.Title: Gait analysis study of Unloading-Coxa-Valga (antetorta) in orthoses/prostheses-dependent children Background: During loading cycles, the joints’ geometry is continually modelled. Orthotics/prosthetics-dependent children develop ipsilateral in-toeing gait and Duchenne’s limping due to unilateral severe lower leg or foot deformities. These clinical phenomena are accompanied with an ipsilateral coxa-valga antetorta and hip dysplasia. A practical question is whether these hips are in danger to decompensate. An additional theoretical question is, how the external shape and internal architecture changes, if a primarily healthy hip is underused. Methods: 10 children with healthy hips, who are unilaterally long-term orthotics/prosthetics-dependent, agreed to undergo an instrumental gait analysis. The results were analyzed and correlated with clinical findings, a common activity score and planimetric radiographic data. Results: The intra-individual comparison revealed the following significant changes in the hip of the deformed leg (p <0.05). Clinically, the internal rotation was increased (12.5°), while the external rotation was diminished (20-22.5°). Radiologically, the projected CCD angle, the lesser trochanter to articular surface distance (LTA) and the head-shaft angle (CF) were increased by 14.71°, 1.58 cm and 13.52°, respectively. Both Sharp- and acetabular (AC) angles were increased by 5.01° and 3.52°, respectively. Kinetic gait analysis showed increased stride length (7 cm), shortened stance phase (6.35 %) and reduced forces transmitted to the ground (177.7 N). The kinematic analysis showed increased hip abduction (16.81°) while the pelvic obliquity was not significantly changed (0.08°). Conclusions: Duchenne’s limping and lack of weight-bearing stress are the decisive pathogenic factors of the underuse-coxa-valga and acetabular dysplasia. These changes follow the mechanobiological concept “function modifies design”, that means function influences external shape and internal architecture of bones and joints. As a practical consequence we recommend to perform one pelvic radiograph as a precaution at the end of puberty of the diseased children. Level of evidence: Level II retrospective stud

Ganganalytische Studie zur Entlastungs-Coxa-valga (antetorta) orthetisch und prothetisch versorgter Kinder

Ziel: In der vorliegenden Arbeit sollte in einem ersten Schritt überprüft werden, wie sich bei Kindern, die aufgrund einer nicht behebbaren, einseitigen Beindeformität distal des Kniegelenkes dauerhaft orthetisch oder prothetisch versorgt werden müssen, die primär gesunde Hüfte des betroffenen Beines sekundär verformt. In einem zweiten Schritt sollte mittels Ganganalyse evaluiert werden, welcher Pathomechanismus der diagnostizierten Formstörung zu Grunde liegt. Methodik: Das Patientengut bestand aus zwölf primär hüftgesunden, jedoch einseitig distal des Knies erkrankten, orthesenpflichtigen Kindern und Jugendlichen, deren klinische und radiologische Krankheitsverläufe retrospektiv ausgewertet wurden. Bei zehn der betroffenen Kinder konnte eine verwertbare instrumentelle kinetische und kinematische Ganganalyse mittels des Zebris-Systems durchgeführt werden. Ergebnisse: 1. Grunderkrankungen: Crus varum congenitum oder Tibiapseudarthrosen 5, Fehlbildungsklumpfuß 1, kongenitaler tibialer Längsdefekt 2, kongenitaler fibulärer Längsdefekt 3, Unterschenkeldeformität nach Ewingsarkom 1. 2. Klinische Ergebnisse: Im intraindividuellen Seitvergleich ist die Seite des von der Deformität betroffenen Beines wie folgt verändert: Die Hüftinnenrotation ist durchschnittlich 12,5º signifikant vermehrt (p <0,05), die Hüftaußenrotation um 20-22,5º verkleinert. 3. Radiologische Ergebnisse: Koxales Femurende: Der projizierte CCD-Winkel ist altersabhängig und im Durchschnitt 14,71º signifikant steiler. Die Distanz zwischen Kopfkalotte und Trochanter minor (LTA) ist 1,58 cm signifikant vergrößert. Der Kopfepiphysen-Femurschaft-Winkel (KF) als Beweis der horizontalen Stellung der Kopfepiphysenfuge ist durchschnittlich um 13,52º vergrößert (p <0,05). Hüftpfanne: Der Sharp-Ullmann-Winkel ist 5,01º signifikant vergrößert und der Acetabulumwinkel (AC) ist 3,52º vergrößert (p <0,05). 3. Ganganalytische Ergebnisse: Kinetik: Die Schrittlänge ist um durchschnittlich 7 cm signifikant verlängert (p 0.05). Die Hüftabduktion der entlasteten Hüfte als Hinweis eines konstanten Duchenne-Hinkens ist durchschnittlich um 16,81º vermehrt. Schlussfolgerung: Zusammenfassend kann gesagt werden, dass die einseitig orthetisch/prothetisch versorgten Kinder eine Formstörung der Hüfte aufwiesen, die in der älteren Literatur als Entlastungs-Coxa-valga bzw. Entlastungsdysplasie bezeichnet wird. Erstmals konnten die pathogenetischen Faktoren identifiziert werden, die diese Formstörung hervorrufen. Die Patienten weisen ein Duchenne-Hinken auf und belasten das betroffene Bein weniger stark und mit kürzerer Zeitspanne. Die Untersuchung bestätigt in eindrucksvoller Weise die allgemeinen Wachstumsgesetze des muskulo-skelettalen Organs, die unter dem Merksatz „form follows function“ zusammengefasst werden können. Als praktische Konsequenz für den Klinikalltag ergibt sich die Forderung, die Hüfte orthesenpflichtiger Kinder in größeren Abständen klinisch und bildgebend zu screenen und die Orthesen- bzw. Prothesenaufbau so zu gestalten, dass ein Duchenne-Hinken vermieden wird.Title: Gait analysis study of Unloading-Coxa-Valga (antetorta) in orthoses/prostheses-dependent children Background: During loading cycles, the joints’ geometry is continually modelled. Orthotics/prosthetics-dependent children develop ipsilateral in-toeing gait and Duchenne’s limping due to unilateral severe lower leg or foot deformities. These clinical phenomena are accompanied with an ipsilateral coxa-valga antetorta and hip dysplasia. A practical question is whether these hips are in danger to decompensate. An additional theoretical question is, how the external shape and internal architecture changes, if a primarily healthy hip is underused. Methods: 10 children with healthy hips, who are unilaterally long-term orthotics/prosthetics-dependent, agreed to undergo an instrumental gait analysis. The results were analyzed and correlated with clinical findings, a common activity score and planimetric radiographic data. Results: The intra-individual comparison revealed the following significant changes in the hip of the deformed leg (p <0.05). Clinically, the internal rotation was increased (12.5°), while the external rotation was diminished (20-22.5°). Radiologically, the projected CCD angle, the lesser trochanter to articular surface distance (LTA) and the head-shaft angle (CF) were increased by 14.71°, 1.58 cm and 13.52°, respectively. Both Sharp- and acetabular (AC) angles were increased by 5.01° and 3.52°, respectively. Kinetic gait analysis showed increased stride length (7 cm), shortened stance phase (6.35 %) and reduced forces transmitted to the ground (177.7 N). The kinematic analysis showed increased hip abduction (16.81°) while the pelvic obliquity was not significantly changed (0.08°). Conclusions: Duchenne’s limping and lack of weight-bearing stress are the decisive pathogenic factors of the underuse-coxa-valga and acetabular dysplasia. These changes follow the mechanobiological concept “function modifies design”, that means function influences external shape and internal architecture of bones and joints. As a practical consequence we recommend to perform one pelvic radiograph as a precaution at the end of puberty of the diseased children. Level of evidence: Level II retrospective stud

Unipolar versus bipolar hemiarthroplasty for displaced femoral neck fractures: A pooled analysis of 30,250 participants data

PURPOSE: To assess the clinical outcomes of unipolar versus bipolar hemiarthroplasty for displaced intracapsular femoral neck fractures in older patients and to report whether bipolar implants yield better long-term functional results. METHODS: We searched PubMed, Scopus, EBSCO, and Cochrane Library for relevant randomized clinical trials (RCTs) and observational studies, comparing unipolar and bipolar hemiarthroplasty. Data were extracted from eligible studies and pooled as relative risk (RR) or mean difference (MD) with corresponding 95% confidence intervals (CI) using RevMan software for Windows. RESULTS: A total of 30 studies were included (13 RCTs and 17 observational studies). Analyses included 30,250 patients with a mean age of 79 years and mean follow-up time of 24.6 months. The overall pooled estimates showed that bipolar was superior to unipolar hemiarthroplasty in terms of hip function, range of motion and reoperation rate, but at the expense of longer operative time. In the longer term the unipolar group had higher rates of acetabular erosion compared to the bipolar group. There was no significant difference in terms of hip pain, implant related complications, intraoperative blood loss, mortality, six-minute walk times, medical outcomes, and hospital stay and subsequently cost. CONCLUSIONS: Bipolar hemiarthroplasty is associated with better range of motion, lower rates of acetabular erosion and lower reoperation rates compared to the unipolar hemiarthroplasty but at the expense of longer operative time. Both were similar in terms of mortality, and surgical or medical outcomes. Future large studies are recommended to compare both methods regarding the quality of life

The effect of type of femoral component fixation on mortality and morbidity after hip hemiarthroplasty:A systematic review and meta-analysis

Background: Hip hemiarthroplasty is a well-established treatment of displaced femoral neck fracture, although debate exists over whether cemented or uncemented fixation is superior. Uncemented prostheses have typically been used in younger, healthier patients and cemented prostheses in older patients with less-stable bone. Also, earlier research has suggested that bone cement has cytotoxic effects and may trigger cardiovascular and respiratory adverse events. Questions/Purposes: The aim of this systematic review and meta-analysis was to compare morbidity and mortality rates after cemented and uncemented hemiarthroplasty for the treatment of displaced femoral neck fractures in elderly patients. Methods: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched seven medical databases for randomized clinical trials and observational studies. We compared cemented and uncemented hemiarthroplasty using the Harris Hip Score (HHS), as well as measures of postoperative pain, mortality, and complications. Data were extracted and pooled as risk ratios or standardized mean difference with their corresponding 95% confidence intervals in a meta-analysis model. Results: The meta-analysis included 34 studies (12 randomized trials and 22 observational studies), with a total of 42,411 patients. In the pooled estimate, cemented hemiarthroplasty was associated with less risk of postoperative pain than uncemented hemiarthroplasty. There were no significant differences between groups regarding HHS or rates of postoperative mortality, pulmonary embolism, cardiac arrest, myocardial infarction, acute cardiac arrhythmia, or deep venous thrombosis. Conclusions: While we found that cemented hemiarthroplasty results in less postoperative pain than uncemented hemiarthroplasty in older patients with femoral neck fracture, the lack of significant differences in functional hip scores, mortality, and complications was surprising. Further high-level research is needed

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Medical Students’ Perception of a Newly Implemented Objective Structured Clinical Examination (OSCE) in Orthopedic Surgery and Trauma: A Mixed-Method Study

&lt;strong&gt;Introduction:&lt;/strong&gt; Objective Structured Clinical Examination (OSCE) is a well-known, widespread method of assessment of clinical skills. It is being widely used in Egyptian medical schools. This study aimed to explore the perception of the fifth-year medical students on the attributes, quality, validity, reliability and organization of the end-of-rotation Orthopedics Surgery and Trauma OSCE held at FOM-SCU in two academic years (2017-2018 and 2018-2019). It also aimed to assess the students rating of OSCE in relation to the other available assessment methods in clinical rotations. &lt;strong&gt;Material and Methods:&lt;/strong&gt; This is a cross-sectional mixed-method study that was conducted at Suez Canal University Hospital. A convenient sample of the fifth-year medical students, who underwent the OSCE at the end of their Orthopedic Surgery and Trauma rotation during both academic years 2017-2018 and 2018-2019 were involved (n = 254). Quantitative data were collected through a validated questionnaire consisting of 32 items. Focus group discussions of students were conducted and qualitative data were recorded, coded, and thematically analyzed. &lt;strong&gt;Results:&lt;/strong&gt; More than half of the students (55.5%) believed that the exam was fair and covered a wide range of knowledge (63.8%) and clinical skills (72.4%). Considerable percentages of students were doubtful regarding the standardization of OSCE scores (62.6%) and whether those scores provided a true measurement of their clinical skills (65%) and more than half of them were not sure whether gender, personality, or ethnicity affected their exam scores (55.5%) and whether OSCE provides them practical and useful experience (53.5%). OSCE and portfolio were reported as the easiest method among 55.5% and 63.8% of students, respectively, and 31.1% rated MCQs as the most difficult form of assessment. Qualitative analysis identified two themes; namely: “Challenges of implementing OSCE” and “Ways to overcome identified challenges”. &lt;strong&gt;Conclusion:&lt;/strong&gt; Medical students positively perceived and provided good perception on the organization and implementation of the Orthopedics OSCE, although some of them were doubtful regarding its validity and reliability in assessing their clinical skills in Orthopedics and Trauma. The challenges regarding the OSCE can be overcome by more well-structured, practical training and orientation sessions for the examiners, students, and simulated patients.</jats:p

The underused hip in ipsilaterally orthotics-dependent children

Background The aim of this investigation is the development of primarily healthy hips in children who have required orthoses/protheses over the long term due to ipsilateral distally located deformities of the leg. These children show ipsilateral in-toeing gait and Duchenne's limping followed by a coxa valga antetorta and facultative hip decentration. A practical question is whether these hips are in danger of decompensation. An additional theoretical question is how the external shape and internal architecture changes if a primarily healthy hip is underused. Methods Ten children with healthy hips who are unilaterally long-term orthotics/prosthetics-dependent agreed to undergo an instrumental gait analysis. The results were analyzed and correlated with clinical findings, a common activity score and planimetric radiographic data. Results The intra-individual comparison revealed a number of significant changes in the hip of the deformed leg ( p &lt; 0.05). Clinically, the internal rotation was increased (15° ± 4.2°), while the external rotation was diminished (13° ± 1.3°). Radiologically, the projected caput–collum–diaphyseal angle, the lesser trochanter to articular surface distance and the head–shaft angle were increased by 11.1° ± 15.4°, 5.8 ± 4.2 mm and 11.9° ± 0.6°, respectively. Both the Sharp and acetabular angles were increased, the former by 3.6° ± 0.6° and the latter by 3.2° ± 0.6°. Kinetic gait analysis showed increased stride length (6.8 ± 3.7 cm), shortened stance phase (6.6 ± 1.6 %) and reduced forces transmitted to the ground (92.2 ± 34.3 N). The kinematic analysis showed increased hip abduction (14.0° ± 8.2°), while the pelvic obliquity was not significantly changed (0.01° ± 0.01°). Conclusions Duchenne's limp and lack of weight-bearing stress are the decisive pathogenic factors of the underused coxa valga and acetabular dysplasia. These changes follow the mechanobiological concept of “function modifies design”, which means function influences external shape and internal architecture of bones and joints. As a practical consequence we recommend that one pelvic radiograph be performed as a precaution at the end of puberty of children with these conditions. Level of evidence Level II retrospective study. </jats:sec