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The recommended first-line treatment for unspecific and degenerative back pain consists of movement exercises and patient education. Using a pragmatic, randomized controlled trial, we evaluated the effectiveness of a digital home exercise program on self-reported pain intensity compared with the standard of care for physiotherapy. Participant recruitment was based on newspaper advertisements and a consecutive on-site assessment for eligibility and enrollment. Participants with unspecific and degenerative back pain aged ≥18 years were randomly assigned in a 1:1 ratio to receive a 12-week stand-alone digital home exercise program or physiotherapy. The digital home exercise program included 4 exercises daily, while physiotherapy included 6 to 12 sessions, depending on the severity of symptoms. The primary outcome was pain, which was assessed using a verbal numerical rating scale. The clinical relevance of pain reduction was assessed using the following thresholds: improvement of at least 1.4 points on the verbal numerical rating scale and a pain reduction of at least 30%. During the study period, 108 participants were assigned to the intervention group and 105 participants to the control group. The mean difference in pain scores between the 2 groups at 12 weeks was -2.44 (95% CI -2.92 to -1.95; P<.01) in favor of the intervention group. The group receiving the digital therapeutic achieved a clinically relevant reduction in pain over the course of the study (baseline vs 12 weeks), with a mean change of -3.35 (SD 2.05) score points or -53.1% (SD 29.5). By contrast, this change did not reach clinical relevance in the control group (mean -0.91, SD 1.5; -14.6%, SD 25.3). Retention rates of 89.9% in the intervention group and 97.3% in the control group were maintained throughout the study. The use of the app-based home exercise program led to a significant and clinically relevant reduction in pain intensity throughout the 12-week duration of the program. The intervention studied showed superior improvement in self-reported pain intensity when compared with the standard of care. Given the great demand for standard physiotherapy for unspecific and degenerative back pain, digital therapeutics are evolving into a suitable therapeutic option that can overcome the limitations of access and availability of conventional modes of health care delivery into this spectrum of indications. However, further independent evaluations are required to support the growing body of evidence on the effectiveness of digital therapeutics in real-world care settings. German Clinical Trials Register DRKS00022781; https://tinyurl.com/hpdraa89.

[This corrects the article DOI: 10.2196/41899.].

Studies that investigated possible associations between the complexity of proximal humeral fractures and patient characteristics are rare. We hypothesized that the grade of fracture complexity may correlate with age and gender of hospitalized, adult patients. Based on the Neer classification, we defined four radiological grades of fracture complexity. The data of adult patients that were treated during a 9-year period at a German hospital serving a town of 80,000 inhabitants was reviewed. Seven hundred and eighty fractures were evaluated [518 female/262 male (66.41/33.59%), average age 64.2years (range 17.4–99.2)]. During the study period, the number of fractures increased to 167%. Almost two-thirds of the patients were females and older than 60years. Of all fractures, 86% were displaced fractures. In patients younger than 60years, 1.99-fold more complex fractures occurred in males (32.4%) than in females (16.2%). In contrast, in patients older than 60years, 1.72-fold more complex fractures occurred in females (54.1%) than in males (31.5%). There was a significant association between low-energy trauma and female gender older than 60years. Our study demonstrated an overall increase of displaced proximal fractures. The vast majority of patients with more complex fractures consisted of female patients older than 60years.

Background and aims The objective of this study was to analyse the incidence and effect on clinical outcome of post-operative Achilles tendon calcifications after open-augmented repair according to the Silfverskjöld technique. Patients/methods This retrospective study presents the results of follow-up examinations on 104 patients with Achilles tendon rupture who were treated according to the Silfverskjöld technique. Post-operative calcifications were identified by means of sonography, and clinical outcome was evaluated using the 100 points Thermann score. The average follow-up examination period was 3.7 years with an average patient age of 42.9 years. Two groups were identified and included those with (Group I) and those without (Group II) calcifications. Clinical outcome was evaluated using the Thermann score for both groups and was compared statistically by means of the two random sample t -test. Results Fifteen patients (Group I) developed tendon calcifications (14.4%) and 89 none (Group II). Group I scored 88.0 points and Group II 88.1 (good to very good outcome). There were no negative effects on clinical outcome ( t  = 0.98). Conclusions The incidence of tendon calcification after open-augmented repair of Achilles tendon rupture was 14.4% with no negative effects on clinical outcome as measured by the Thermann score.

Background Precise indications for computed tomography (CT) in proximal humeral fractures are not established. The purpose of this study was a comparison of conventional radiographic views with different CT reconstructions with 2 D and 3 D imaging to establish indications for additional CT diagnostics depending on the fractured parts. Methods In a prospective diagnostic study in two level 1 trauma centers, 44 patients with proximal humeral fractures were diagnosed with conventional X-rays (22 AP + axillary views, 22 AP + scapular Y-views) and CT (multi-planar reconstruction (MPR) and maximum intensity projection (MIP)) with 2 D and 3 D imaging. 3 observers assessed the technical image quality, the assessment of the relevant anatomical structures (2-sample-t-test) and the percentage of the osseous overlap of the proximal humerus (Welch-test) using a scoring system. The quality of the different diagnostic methods was assessed according to the number of fractured parts (Bonferroni-Holm adjustment). Results There was significantly more overlap of the fractured region on the scapular Y-views (mean 71.5%, range 45–90%) than on axillary views (mean 56.2%, range 10.5–100%). CT-diagnostics allowed a significantly better assessment of the relevant structures than conventional diagnostics (p < 0.05) independently of the fracture severity (two-, three-, and four-part fractures). Conclusion Conventional X-rays with AP view and a high-quality axillary view are useful for primary diagnostics of the fracture and often but not always show a clear presentation of the relevant bony structures such as both tuberosities, the glenoid and humeral head. CT with thin slices technology and additional 3 D imaging provides always a clear presentation of the fractured region. Clinically, a CT should be performed – independently of the number of fractured parts – when the proximal humerus and the shoulder joint are not presented with sufficient X-ray-quality to establish a treatment plan.

Background and aimsAutogenous bone grafting has been used in reconstructing bone defects and in stimulating fracture healing, producing high healing rates in the treatment of infected tibial non-unions. A novel therapeutic alternative is now available known as “vitalised allograft”, a cancellous bone graft procured from femoral heads from living human donors and “vitalised” through the injection of autologous bone marrow. The aim of this study is to summarise the initial results of the fibula and tibia fusion using vitalised cancellous allograft in the treatment of infected tibial non-unions.Patients and methodsWe initiated a follow-up of 15 prospective non-randomized patients who received a vitalised allograft in the treatment of infected tibial non-unions in order to produce bony union. The patients included 13 men and 2 women with an average age of 48 years. All patients received a multi-stage surgical approach. After establishing an infection-free environment, allogenic cancellous bone grafting was performed, intended as the final surgical procedure in fibula and tibia fusion. Our follow-up included a clinical and radiographic investigation of the calf in four planes. We analysed union-rate and time required for bony consolidation, as well as recurrent infections, re-fractures, potential graft-resorption, and time needed for graft and bone remodelling.ResultsWith an average follow-up of 17.1 months, infection control was obtained in 14 of 15 patients, producing an infection arrest rate of 93.3%. Radiographs indicated consolidation in 11 out of 15 cases, with a union rate of 73.3%. Bone union was achieved on average in 17.1 weeks.ConclusionsFibula and tibia fusion with allogenic cancellous bone grafting, vitalised through autogenic bone marrow, could well become an innovative treatment option for infected tibial non-unions. We need, however, to analyse a higher number of cases over a longer follow-up period in order to assess more accurately recurrent infections and re-fractures.

Background The established treatment for bacterial arthritis of the knee joint is arthroscopic surgery with irrigation and debridement. The aim of this article is to summarize the relevant data in treating bacterial arthritis of the knee joint, and based on these findings to present a novel irrigation suction system, tested in a cadaver study, as an additional tool in the postoperative treatment phase of arthroscopic surgery for knee joint infections. Method The novel automated irrigation-suction system presented here was compared to conventional continuous suction irrigation in a total of six knee joints. All knee joints were filled with 80 ml methylene blue stain and rinsed by two different methods. Fluid specimens were taken after ten and twenty minutes to be compared by photometric extinction measurement at a wave length of 500 nm. Results After ten minutes, the average extinction was e 1C = 0.8 for the continuous suction irrigation and e 1N = 0.4 for the novel irrigation-suction system. After twenty minutes, we recorded an average extinction of e 2C = 0.3 for continuous suction irrigation and e 2N = 0.001 for the novel irrigation-suction system. The students t- test revealed superior results after ten and twenty minutes of washing out the knee joints with a p < 0.001 for the novel irrigation-suction system. Conclusion A novel irrigation-suction system may be an effective tool for postoperative knee joint irrigation in arthroscopic therapy for bacterial arthritis of the knee. Further animal studies are needed to verify the effects in vivo.

Originally founded by three renowned orthopedic masters, Bauer, Kerschbaumer, and Poisel, this atlas has enjoyed a longstanding reputation for the exceptional quality of its surgical, topographic anatomical illustrations. Considerable advances in minimally invasive, endoscopic, and arthroscopic surgery during the last few decades necessitated this updated edition.Special FeaturesThe addition of more than 40 new surgical procedures, including soft tissue preservation techniques used in trauma surgery.More than 700 color illustrations drawn directly from cadavers or documentation from the operating room.The authors provide a unique operative guide, gleaned from years of evidence-based, clinical experience. From the cervical spine to the foot and ankle, each part of the body is divided into detailed subsections. Multiple approaches are included to treat common and rare musculoskeletal injuries, conditions, and diseases. The concise descriptions are complemented by meticulously crafted, labelled anatomical drawings illustrating each step of the procedure, from the skin incision to the targeted region to incision closure. Associated indications, patient positioning and preparation, precautions, and dangers are also summarized for each approach.This comprehensive, state-of-the-art atlas is an invaluable surgical resource for all orthopedic surgeons, residents, and medical students.

IntroductionThe purpose of this prospective study was to assess the Constant score and radiographic outcome in 66 patients (mean age 58.7 years/mean follow-up 51 months) with a minimally displaced and/or impacted fracture of the proximal humerus treated with early mobilization.MethodSpecial attention was paid to analyze the specific intrinsic parameters (age, gender, ASA grade and length of physiotherapy), injury-related parameters (classification, osteoporosis) and therapy-related parameters (initial fracture displacement, residual bony-deformity after healing, secondary fracture displacement during healing period, non-union, humeral head necrosis and omarthrosis) that may influence the final score.PatientsThere were 31 A (47%), 22 B (33%) and 13 C-fractures (19%). The median Constant score for the fractured shoulder was 89 points.ResultsAll fractures healed without non-union. The radiological assessment showed in 80% a fracture-displacement with <15° angulation and/or <5-mm displacement of the greater tuberosity. At time of follow-up, the residual bony-deformity was perfect and good in 88% of cases. There was a significant association between the final Constant score and the age, ASA classification, AO (ABC) classification and initial fracture displacement.ConclusionEarly physiotherapy, with a short period of immobilization is a sufficient therapy for management of minimally displaced and/or impacted fractures of the proximal humerus.

Purpose Restoration of the anterior spinal profile and regular load-bearing is the main goal treating anterior spinal defects in case of fracture. Over the past years, development and clinical usage of cages for vertebral body replacement have increased rapidly. For an enhanced stabilization of rotationally unstable fractures, additional antero-lateral implants are common. The purpose of this study was the evaluation of the biomechanical behaviour of a recently modified, in situ distractible vertebral body replacement (VBR) combined with a newly developed antero-lateral polyaxial plate and/or pedicle screws and rods using a full corpectomy model as fracture simulation. Methods Twelve human spinal specimens (Th12–L4) were tested in a six-degree-of-freedom spine tester applying pure moments of 7.5 Nm to evaluate the stiffness of three different test instrumentations using a total corpectomy L2 model: (1) VBR + antero-lateral plate; (2) VBR, antero-lateral plate + pedicle screws and rods and (3) VBR + pedicle screws and rods. Results In the presented total corpectomy defect model, only the combined antero-posterior instrumentation (VBR, antero-lateral plate + pedicle screws and rods) could achieve higher stiffness in all three-movement planes than the intact specimen. In axial rotation, neither isolated anterior instrumentation (VBR + antero-lateral plate) nor isolated posterior instrumentation (VBR + pedicle screws and rods) could stabilize the total corpectomy compared to the intact state. Conclusions For rotationally unstable vertebral body fractures, only combined antero-posterior instrumentation could significantly decrease the range of motion (ROM) in all motion planes compared to the intact state.