Initial joint stability affects the outcome after conservative treatment of simple elbow dislocations: a retrospective study

Background: Conservative treatment of simple elbow dislocations can lead to complications such as persisting pain and restricted joint mobility. The current aim was to identify patients with deteriorated outcome after conservative treatment and to investigate a possible association with initial joint (in)stability. Methods: Sixty-eight patients (mean age 37.1 ± 17.2 years) with simple elbow dislocations received conservative treatment. After closed reduction, joint stability was tested by varus and valgus stress under fluoroscopy. According to the findings under fluoroscopy, three different groups of instability could be identified: (1) slight instability (joint angulation <10°; n = 49), (2) moderate instability (angulation ≥10°; n = 19) and (3) gross instability. Patients with gross instability (re-dislocation under stability testing) were treated with primary surgical ligament repair and therefore excluded from this study. Additionally, MRIs and radiographs were analysed regarding warning signs of instability such as the drop sign and joint incongruence. Main outcome parameters were the Mayo Elbow Performance Score (MEPS), range of motion (ROM), complications and revision rates. Results: After 40.7 ± 20.4 months, the overall MEPS was excellent (94.2 ± 11.3) with a trend of slightly worse clinical results in group 2 (95.8 ± 9.0 vs. 90.0 ± 15.2 points; p = 0.154). In group 1, significantly more patients achieved an excellent result regarding the MEPS scoring system (77.6 vs. 52.6 %; p = 0.043) and elbow extension was significantly worse in group 2 (5.3 ± 9.9° vs. 1.4 ± 3.0°; p = 0.015). Seven treatment complications occurred in group 2 (36.8 %) compared with two in group 1 (4.1 %, p < 0.0001). Six patients (8.8 %) needed secondary surgery with an 8.4-fold higher risk for revision surgery in group 2 (p = 0.007). The presence of a positive drop sign or joint incongruence led to higher odds ratio (OR) for complications (OR = 15.9) and revision surgery (OR = 10.3). Conclusions: This study demonstrates that patients with moderate joint instability after simple elbow dislocation have a significantly worse clinical outcome, more complications and a higher need for secondary revision surgery following conservative treatment compared to patients with slight elbow instability

A new animal model for delayed osseous union secondary to osteitis

Background: The treatment of infection-related delayed bone unions is still very challenging for the orthopedic surgeon. The prevalence of such infection-related types of osteitis is high in complex fractures, particularly in open fractures with extensive soft-tissue damage. The aim of this study was to develop a new animal model for delayed union due to osteitis. Methods. After randomization to infected or non-infected groups 20 Sprague–Dawley rats underwent a transverse fracture of the midshaft tibia. After intramedullary inoculation with staphylococcus aureus (103 CFU) fracture stabilization was done by intramedullary titanium K-wires. After 5 weeks all rats were euthanized and underwent biomechanical testing to evaluate bone consolidation or delayed union, respectively. Micro-CT scans were additionally used to quantitatively evaluate the callus formation by the score of Lane and Sandhu. Blood samples were taken to analyze infectious disease markers (day 1, 14 and 35). Results: Biomechanical testing showed a significant higher maximum torque in the non-infected group 5 weeks postoperatively compared with the infected group (p < 0.001). According to the Lane and Sandhu score a significantly higher callus formation was found in the non-infected group (p < 0.001). Similarly, the leucocyte count in the infected group was significantly higher than in the non-infected group (p < 0.05). Conclusions: Here we have established a new animal model for delayed osseous union secondary to osteitis. The animal model appears to be appropriate for future experimental studies to test new therapeutic strategies in these difficult to treat bone healing complications

PHTLS ® (Prehospital Trauma Life Support) provider courses in Germany – who takes part and what do participants think about prehospital trauma care training?

BACKGROUND: The goal of this study was to examine PHTLS Provider courses in Germany and to proof the assumption that formation of physicians and paramedics in prehospital trauma care can be optimized. METHODS: PHTLS participants were asked to fill out standardized questionnaires during their course preparation and directly after the course. There were some open questions regarding their professional background and closed questions concerning PHTLS itself. Further questions were to be answered on an analog scale in order to quantify subjective impressions of confidence, knowledge and also to describe individual levels of education and training. RESULTS: 247 questionnaires could be analyzed. Physicians noted significant (p < 0.001) more deficits in their professional training than paramedics. 80% of the paramedics affirmed to have had adequate training with respect to prehospital trauma care, all physicians claimed not to have had sufficient training for prehospital trauma care situations at Medical School. Physicians were statistically most significant dissatisfied then paramedics (p < 0.001). While most participants gave positive feedback, anesthetists were less convinced of PHTLS (p = 0.005), didn’t benefit as much as the rest (p = 0.004) and stated more often, that the course was of less value for their daily work (p = 0.03). After the course confidence increased remarkably and reached higher rates than before the course (p < 0.001). After PHTLS both groups showed similar ratings concerning the course concept indicating that PHTLS could equalize some training deficits and help to gain confidence and assurance in prehospital trauma situations. 90% of the paramedics and 100% of the physicians would recommend PHTLS. Physicians and especially anesthetists revised their opinions with regard to providing PHTLS at Medical School after having taken part in a PHTLS course. CONCLUSION: The evaluation of PHTLS courses in Germany indicates the necessity for special prehospital trauma care training. Paramedics and physicians criticize deficits in their professional training, which can be compensated by PHTLS. With respect to relevant items like confidence and knowledge PHTLS leads to a statistically significant increase in ratings on a visual analogue scale. PHTLS should be integrated into the curriculum at Medical School

Development and validation of a novel questionnaire for self-determination of the range of motion of wrist and elbow

Background: The aim of this study was to develop and validate a novel self-administered questionnaire for assessing the patient’s own range of motion (ROM) of the wrist and the elbow. Methods: In a prospective clinical study from January 2015 to June 2015, 101 consecutive patients were evaluated with a novel, self-administered, diagram-based, wrist motion assessment score (W-MAS) and elbow motion assessment score (E-MAS). The questionnaire was statistically evaluated for test-retest reliability, patient-physician agreement, comparison with healthy population, and influence of covariates (age, gender, affected side and involvement in workers’ compensation cases). Results: Assessment of patient-physician agreement demonstrated almost perfect agreement (k > 0.80) with regard to six out of eight items. There was substantial agreement with regard to two items: elbow extension (k = 0.76) and pronation (k = 0.75). The assessment of the test-retest reliability revealed at least substantial agreement (k = 0.70). The questionnaire revealed a high discriminative power when comparing the healthy population with the study group (p = 0.007 or lower for every item). Age, gender, affected side and involvement in workers’ compensation cases did not in general significantly influence the patient-physician agreement for the questionnaire. Conclusion: The W-MAS and E-MAS are valid and reliable self-administered questionnaires that provide a high level of patient-physician agreement for the assessments of wrist and elbow ROM. Level of evidence: Diagnostic study, Level I

Characteristics of bone turnover in the long bone metaphysis fractured patients with normal or low Bone Mineral Density (BMD).

The incidence of osteoporotic fractures increases as our population ages. Until now, the exact biochemical processes that occur during the healing of metaphyseal fractures remain unclear. Diagnostic instruments that allow a dynamic insight into the fracture healing process are as yet unavailable. In the present matched pair analysis, we study the time course of the osteoanabolic markers bone specific alkaline phosphatase (BAP) and transforming growth factor β1 (TGFβ1), as well as the osteocatabolic markers crosslinked C-telopeptide of type-I-collagen (β-CTX) and serum band 5 tartrate-resistant acid phosphatase (TRAP5b), during the healing of fractures that have a low level of bone mineral density (BMD) compared with fractures that have a normal BMD. Between March 2007 and February 2009, 30 patients aged older than 50 years who suffered a metaphyseal fracture were included in our study. BMDs were verified by dual energy Xray absorptiometry (DXEA) scans. The levels of BTMs were examined over an 8-week period. Osteoanabolic BAP levels in those with low levels of BMD were significantly different from the BAP levels in those with normal BMD. BAP levels in the former group increased constantly, whereas the latter group showed an initial strong decrease in BAP followed by slowly rising values. Osteocatabolic β-CTX increased in the bone of the normal BMD group constantly, whereas these levels decreased significantly in the bone of the group with low BMD from the first week. TRAP5b was significantly reduced in the low level BMD group. With this work, we conduct first insights into the molecular biology of the fracture healing process in patients with low levels of BMD that explains the mechanism of its fracture healing. The results may be one reason for the reduced healing qualities in bones with low BMD

Responsabilité des associations sportives : dernier essai

<p>Statistics were performed using the software SPSS 11.0.0 (IBM Germany, Munich, Germany), P≤0.05 was considered to be significant, p≤0.01 as very significant, and p≤0.001 as highly significant. Different levels of significance are marked by one to three stars.</p