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Introduction: Open and closed fractures of the tibial shaft or distal tibia can be challenging for surgeons to treat if the fractures are accompanied by aggravating conditions, such as various accompanying diseases, pronounced soft tissue injuries, osteomyelitis, and/or noncompliance. The aim of this retrospective study was to present our approach and results with the Ilizarov fixator as a treatment option for such individually complex cases., Materials and Methods: Between 2005 and 2018, 20 patients were treated with the Ilizarov fixator for fractures of the tibial shaft/distal tibia. The indication for this was a 2nd- to 3rd-degree open fracture in 10 patients, a 1st-degree open fracture in one patient, and closed fractures in 9 patients. Aggravating conditions included soft tissue injuries, osteomyelitis, leg deformities, multiple traumas, smoking, alcohol/drug abuse, and obesity (BMI > 60). In addition to demographic data, the time of fixator treatment, complications, and the endpoint of consolidation were evaluated retrospectively., Results: The mean time of fixator treatment was 29 (range 15-65) weeks. Complete fracture consolidation was achieved in 13 patients (65%) with the Ilizarov fixator. The mean follow-up period after fixator removal was 36 (range 2-186) months in 14 patients. Five patients with complete consolidation were lost to further follow-up. One patient was amputated. In six patients without union, internal osteosynthesis was carried out., Conclusion: The use of the Ilizarov fixator is a treatment option for individual high-risk patients with complicating courses but should be seen as a salvage procedure due to the high complication rate and long treatment process., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Posttraumatic osteomyelitis and the ensuing bone defects are a debilitating complication after open fractures with little therapeutic options. We have recently identified potent osteoanabolic effects of sphingosine-1-phosphate (S1P) signalling and have now tested whether it may beneficially affect bone regeneration after infection. We employed pharmacological S1P lyase inhibition by 4-deoxypyrodoxin (DOP) to raise S1P levels in vivo in an unicortical long bone defect model of posttraumatic osteomyelitis in mice. In a translational approach, human bone specimens of clinical osteomyelitis patients were treated in organ culture in vitro with DOP. Bone regeneration was assessed by μCT, histomorphometry, immunohistology and gene expression analysis. The role of S1P receptors was addressed using S1PR3 deficient mice. Here, we present data that DOP treatment markedly enhanced osteogenesis in posttraumatic osteomyelitis. This was accompanied by greatly improved osteoblastogenesis and enhanced angiogenesis in the callus accompanied by osteoclast-mediated bone remodelling. We also identified the target of increased S1P to be the S1PR3 as S1PR3 -/- mice showed no improvement of bone regeneration by DOP. In the human bone explants, bone mass significantly increased along with enhanced osteoblastogenesis and angiogenesis. Our data suggest that enhancement of S1P/S1PR3 signalling may be a promising therapeutic target for bone regeneration in posttraumatic osteomyelitis., (© 2023 The Authors. Journal of Cellular and Molecular Medicine published by Foundation for Cellular and Molecular Medicine and John Wiley & Sons Ltd.)

Background: Distal femur nonunions are well-recognized contributors to persistent functional disability, with limited data regarding their treatment options. In the current study, we asked whether additional medial augmentation plating is a feasible treatment option for patients with aseptic distal femoral nonunion and intact lateral implants., Methods: We conducted a single-center, retrospective study including 20 patients treated for aseptic distal femoral nonunion between 2002 and 2017. The treatment procedure included a medial approach to the distal femur, debridement of the nonunion site, bone grafting and medial augmentation plating utilizing a large-fragment titanium plate. Outcome measures were bone-related and functional results, measured by the Hospital for Special Surgery Knee Rating Scale (HSS) and the German Short Musculoskeletal Function Assessment questionnaire (SMFA-D)., Results: Eighteen of 20 nonunions showed osseous healing at 8.16 ± 5.23 (range: 3-21) months after augmentation plating. Regarding functional results, the mean HSS score was 74.17 ± 11.12 (range: 57-87). The mean SMFA-D functional index was 47.38 ± 16.78 (range 25.74-71.32) at the last follow-up. Index procedure-associated complications included two cases of persistent nonunion and one case of infection., Conclusions: According to the assessed outcome measures, augmentation plating is a feasible treatment option, with a high proportion of patients achieving bony union and good functional outcomes and a few patients experiencing complications., (© 2023. The Author(s).)

Introduction: Only few and inconsistent data about the impact of articular congruity and tolerable residual intraarticular steps and gaps of the joint surface after tibial plateau fractures exist. Therefore, aim of this study was to investigate the correlation between OTA type B and C tibial plateau fracture outcomes and postoperative articular congruity using computed tomography (CT) data., Materials and Methods: Fifty-five patients with a mean age of 45.5 ± 12.5 years and treated for 27 type B and 28 C tibial plateau fractures with pre- and postsurgical CT data were included. Primary outcome measure was the correlation of postoperative intraarticular step and gap sizes, articular comminution area, the postoperative medial proximal tibial angle (MPTA), and the Lysholm and IKDC score. Receiver-operating characteristic (ROC) curves were used to determine threshold values for step and gap heights according to the following outcome scores: IKDC > 70; Lysholm > 80. Secondary outcome measures were the correlation of fracture severity, the number of complications and surgical revisions and the outcome scores, as well as the Tegner activity score before injury and at final follow-up., Results: After a mean follow-up of 42.4 ± 18.9 months, the mean Lysholm score was 80.7 ± 13.3, and the mean IKDC score was 62.7 ± 17.6. The median Tegner activity score was 5 before the injury and 4 at final follow-up (p < 0.05). The intraarticular step height, gap size, comminution area and MPTA deviation were significantly negatively correlated with the IKDC and Lysholm scores. The cutoff values for step height were 2.6 and 2.9 mm. The gap size threshold was 6.6 mm. In total, an average of 0.5 ± 0.8 (range 0-3) complications occurred, and on average, 0.5 ± 1.1 (range 0-7) surgical revisions had to be performed. The number of complications and surgical revisions also had negative impacts on the outcome. Neither fracture severity nor BMI or patient's age was significantly correlated with the IKDC or Lysholm score., Conclusions: Tibial plateau fractures are severe injuries, which lead to a subsequent reduced level of patient activity. Precise reconstruction of the articular surface with regard to intraarticular step and gap size, residual comminution area and joint angle is decisive for the final outcome. Complications and surgical revisions also worsen it., Level of Evidence: III., (© 2022. The Author(s).)

Background: The Ilizarov fixator is a popular device for treating arthrodesis of the ankle joint in complex situations. However, the therapy can fail, with nonunion or partial union that might not be load stable. There is the possibility of follow-up surgery or extended wearing of the fixator. Full weight bearing with a carbon orthosis remains another treatment option, which has not yet been investigated.The aim of the study was to determine the rate of progress that can be obtained with a carbon orthosis in cases of partial union or nonunion after fixator removal., Methods: In this retrospective observational study thirty-three patients received a carbon orthosis after fixator removal due to nonunion or partial union. All patients were allowed to walk with the orthosis under full load. The consolidation rate was determined radiologically and compared with the imaging data obtained during the last follow-up. In addition to demographic data, the Foot and Ankle Ability Measure and pain using a numeric rating scale were determined. Nine patients had to be excluded due to insufficient follow-up, and finally n = 24 patients were included in the study., Results: The average duration of fixator use was 21 weeks (range 15-40 weeks), and the total average follow-up after removal of the fixator was 16 months (range 4- 56). For 14 (58.33%) patients, there was a further increase in consolidation with the orthosis after the fixator was removed., Conclusion: The results show that if there is only partial union or nonunion, further consolidations can be achieved after the application of a carbon orthosis. In a difficult patient population, using an orthosis should therefore be attempted to avoid unnecessary revision operations., (© 2023. The Author(s).)

Background: The posterior quadrants of the tibial plateau are frequently involved in OTA type C tibial plateau fractures. The biomechanical influence of a residual articular step-off of the posterolateral-central (PLC) segment, which is difficult to visualize intraoperatively, remains unclear. Therefore, aim of this study was to investigate the contact area and stress of the tibial plateau in cases of different articular step-offs of the PLC segment., Methods: Seven human cadaveric knees were used to simulate articular impressions of the PLC segment with step-offs of 1 mm, 3 mm, and 5 mm. The knees were axially loaded up to 150 N during a total of 25 dynamic cycles of knee flexion up to 90°. Pressure mapping sensors were inserted into the medial and lateral joint compartments beneath the menisci to measure articular contact area and stress., Results: Between 60° and 90° of knee flexion, increasing PLC segment impressions of the tibial plateau led to increasing contact stress and a significantly reduced contact area. The largest decrease in the contact area was 30 %, with an articular step-off of 5 mm (0.003). An increase in contact stress, especially from a 3-mm step-off, was measured, with a doubling of the mean contact stress at 3-mm and 5-mm step-offs and 90° knee flexion (p = 0.06/0.05)., Conclusion: From a biomechanical point of view, posterior impressions of the PLC segment greater than a 1-mm step-off should be addressed as anatomically as possible, especially in active patients with the need for higher knee flexion angles., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: In clinical practice, even when the fixator is locked, a noticeable laxity of the construct can be observed. This study was designed to measure the stiffness of the fixator and to analyze the movements of the osteotomy site. Furthermore, the effect of three additional longitudinal rods on the locking of the construct was analyzed., Methods: Five synthetic tibia/fixator models (Model A) were tested under rotational torque (40 Nm) and axial compression (700 N). Three additional rigid rods were subsequently mounted, and the tests were repeated (Model B). The movements of the fixator as well as the osteotomy site were registered by a digital optical measurement system. Load- deformation curves, and so stiffness of the models, were calculated and compared., Findings: Under rotational and axial loadings, Model A was found to be less rigid than Model B (p = 0.034; p = 0.194). Notably, Model A showed a region of laxity around neutral rotational (ΔF = 5 Nm) and axial (ΔF = 16.64 N) loading before a linear deformation trend was measured. Concomitantly, greater osteotomy site movement was measured for Model A than for Model B under full loading (p = 0.05) and within the region of increased laxity (p = 0.042)., Interpretation: The fixator showed an element of laxity around neutral axial and rotational loading, which transferred to the bone and led to a notable amount of osteotomy gap movement. Mounting three additional rods increased the stiffness of the construct and therefore reduced the movement of the osteotomy site., Competing Interests: Declaration of Competing Interest The authors report that they have no conflicts of interest in the authorship and publication of this article. All work, including writing, was done by the authors., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Purpose: At the lower leg, soft tissue defects with exposed bones, tendons, or hardware require flap coverage. In this retrospective study, we analyzed combined bone and soft tissue reconstructions compared to amputations of the lower leg in a civilian setting., Materials and Methods: Patients who underwent combined bone and flap reconstruction (LR) or amputation (LA) of the lower leg were eligible for the study. Bone conditions included fractures and bony defects due to posttraumatic osteomyelitis and non-union. Besides the analysis of the medical history, the study included clinical examination including extremity functional scale (LEFS) and SF-36-questionnaire., Results: LEFS score was significantly higher in the LR group compared to the LA group. Importantly, 42% in the LR group as opposed to 80% in the LA group could not return to their occupation. Mean hospitalization was 119 in the LR and 49 days in the LA group. SF-36 body item scores were significantly higher in the LR group as compared to LA., Conclusions: Patients undergoing complex extremity reconstructions, including flap transfer to the lower leg have better functionality and higher quality of life than amputated patients. These data emphasize the advantages of these procedures and justify reconstructive efforts for limb salvage. Level of Evidence III.Implications for RehabilitationAmputation and combined bone and flap reconstruction in severe injuries of the lower leg can imply functional disabilities even after successful treatment.Albeit longer hospitalizations, patients with complex reconstructions showed better functional outcomes and had a higher quality of life.Limb salvage showed better functional outcomes and a higher rate in reintegration to work as compared to limb amputation.These data emphasize the importance of complex bone and soft tissue reconstruction in this patient cohort.

Introduction: The use of forklift trucks during work has a high accident potential. The aim of this study is to describe injury patterns, treatment and outcome after forklift truck accidents in the context of the employers' liability insurance association., Methods: Retrospective data collection of all cases between 2004 and 2019. Excluded were patients < 18 years, without follow-up or with definitive external treatment. Trauma mechanism, injury patterns and distribution, treatment, complications, time of incapacity for work, return to work and impairment of earning capacity were recorded., Results: Of 109 patients with 110 injuries, 52.7% showed isolated injuries and 47.3% combined injuries, which affected the lower extremity in 95 cases. There were fractures in 85.5%, including 32.7% in open form. The mean length of stay was 29.1 days (range 1 - 129); an indication for surgery was seen in 80.9%. Surgical treatment required an average of 3 interventions, with significantly more operations for soft tissue closure than for the fractures (p ≤ 0.023). Amputations were necessary in 8 cases; complications occurred in 29.1%. Return to work was possible in 90%, after a mean period of incapacity for work of 33.6 weeks. A total of 40% showed a pensionable impairment of earning capacity., Conclusion: Accidents with forklift trucks result in complex lower extremities injuries with the need of multi-stage treatment and show relatively high complication rates. A return to work is often possible after a long period of convalescence, and a pensionable impairment of earning capacity often persists., Competing Interests: The authors declare that they have no conflict of interest./Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Purpose: Treatment of joint destruction of the tibiotalar and subtalar joints caused by acute or chronic infections in compromised hosts is a challenging problem. In these cases, simultaneous septic arthrodesis with the use of the Ilizarov external fixator represents a possible alternative to amputation. This case series presents the results and complications of patients with acute or chronic infection of the tibiotalar and subtalar joints., Methods: Between 2005 and 2015, 13 patients with acute or chronic infections were treated by simultaneous single-stage debridement/arthrodesis of the tibiotalar and subtalar joints. In seven patients, there was a florid infection with fistula formation and soft tissue defects, and in six patients, there was chronic osteomyelitis with closed soft tissue. In addition to the demographic data, the time spent in the fixator, the major and minor complications and the endpoint of consolidation were reviewed., Results: The mean time spent in the fixator was 18 (min 15, max 26) weeks. The mean follow-up time for nine patients was 100 (min 3, max 341) weeks. Complete osseous consolidation of both the tibiotalar and subtalar joints was achieved in 10 patients (77%). In three (23%) patients, there was complete consolidation of one of the joints and partial consolidation of the other joint., Conclusion: The Ilizarov external fixator allows for simultaneous arthrodesis of the tibiotalar and subtalar joints in septic joint destruction. However, the healing rates are below the rates reported in the literature for isolated tibiotalar or tibiocalcaneal arthrodesis in comparable clinical situations., (© 2021. The Author(s).)

Introduction: Salvage of joint destruction of the tibiotalar and subtalar joint with necrosis or infection of the talus in compromised hosts is a challenging problem. In these cases, tibiocalcaneal arthrodesis using the Ilizarov external fixator represents a possible alternative to amputation. This retrospective study presents the results and complications of this salvage procedure., Materials and Methods: Between 2005 and 2015, 19 patients were treated with tibiocalcaneal arthrodesis using the Ilizarov external fixator. Ten patients received tibiocalcaneal arthrodesis due to an acute or chronic infection with joint destruction. The other nine patients presented posttraumatic necrosis of the talus or Charcot arthropathy. In addition to demographic data, the time spent in the fixator, the major and minor complications and the endpoint of the consolidation were evaluated retrospectively. Furthermore, clinical outcomes were measured using the modified American Orthopedic Foot and Ankle Society (AOFAS) score., Results: The average time spent in the fixator was 22 (range 14-34) weeks. The average follow-up in 17 patients was 116 (range 4-542) weeks. Two patients were lost to follow-up. Complete osseous consolidation was achieved in 14 out of 19 patients. One patient presented partial consolidation, and in four patients, pseudarthrosis could be detected. The mean modified AOFAS score at the final follow-up was 53 out of 86 possible points., Conclusion: Tibiocalcaneal arthrodesis using the Ilizarov fixator is a possible salvage procedure even in compromised hosts. However, the healing rates are below the rates reported in the literature for tibiotalar arthrodesis in comparable clinical situations., (© 2021. The Author(s).)

Introduction: Bone infections are one of the main reasons for impaired bone regeneration and non-union formation. In previous experimental animal studies we could already demonstrate that bone defects due to prior infections showed a markedly reduced healing capacity, which could effectively be enhanced via application of Wnt3a and Adipose-derived stromal cells (ASCs). For a more in-depth analysis, we investigated proliferation and mineralization of cultured osteoblasts infected with staph aureus and sought to investigate effects of Wnt3a and ASCs on infected osteoblasts., Materials and Methods: Primary murine osteoblasts were isolated from calvariae and infected with staph aureus. Infected osteoblasts received treatment via application of recombinant Wnt3a, ASC conditioned medium and were furthermore cocultured with ASCs. Osteoblasts were evaluated by Alamar blue assay for metabolic activity, TUNEL-assay for apoptosis, ALP and Alizarin Red staining for mineralization. In addition, immunoflourescent staining (IF) and qRT-PCR analyses were performed., Results: Infected osteoblasts showed a markedly reduced ability for mineralization and increased apoptosis, which could be restored to physiological levels by Wnt3a and ASC treatment. Interestingly, metabolic activity of osteoblasts seemed to be unaffected by staph aureus infection. Additional analyses of Wnt-pathway activity revealed effective enhancement of canonical Wnt-pathway activity in Wnt3a-treated osteoblasts., Conclusions: In summary, we gained further osteoblast-related insights into pathomechanisms of reduced bone healing capacity upon infections., (© 2021. The Japanese Society Bone and Mineral Research.)

Septic nonunion of the pilon region with ankle joint infection is challenging for orthopedic surgeons to treat and is associated with a high risk of limb loss. Therefore, the aim of this study was to evaluate the effectiveness of bone transport for ankle arthrodesis in salvaging the limp after septic ankle destruction of the pilon region. We conducted a single-center, retrospective study including 21 patients treated for septic pilon nonunion with accompanying septic ankle destruction via Ilizarov bone transport between 2004 and 2018. In all cases, the complete excision of the nonunion and the resection of the ankle joint were carried out, followed by treating the bone and joint defect with a bone transport into the ankle arthrodesis. In 12/21 patients an additional flap transfer was required due to an accompanying soft tissue lesion. The overall healing and failure rate, final alignment and complications were recorded by the patients' medical files. The bone-related and functional results were evaluated according to the Association for the Study and Application of Methods of Ilizarov (ASAMI) scoring system and a modified American Orthopedic Foot and Ankle Society (AOFAS) scale. After a mean follow-up of 30.9 ± 15.7 months (range 12-63 months), complete bone and soft tissue healing occurred in 18/21 patients (85.7%). The patients had excellent (5), good (7), fair (4), and poor (3) results based on the ASAMI functional score. Regarding bone stock, 6 patients had excellent, 7 good, and 6 fair results. The modified AOFAS score reached 60.6 ± 18 points (range, 29-86). In total, 33 minor complications and 28 major complications occurred during the study period. In 2 cases, a proximal lower leg amputation was performed due to a persistent infection and free flap necrosis with a large soft tissue defect, whereas in one case, persistent nonunion on the docking side was treated with a carbon orthosis because the patient refused to undergo an additional surgery. Bone transport for ankle arthrodesis offers the possibility of limb salvage after septic ankle destruction of the pilon region, with acceptable bony and functional results. However, a high number of complications and surgical revisions are associated with the treatment of this severe complication after pilon fracture., (© 2021. The Author(s).)

Purpose: The aim of this study was to analyze the outcomes of anatomical repair and ligament bracing for Schenck III and IV knee dislocation (KD)., Methods: The results of 27 patients (15 and 12 cases of Schenck III and IV KD, respectively) after a mean follow-up of 18.1 ± 12.1 months (range 6-45 months) were retrospectively reviewed. Twenty-two patients suffered high-kinetic-energy accidents, whereas five patients suffered ultralow-velocity (ULV) trauma due to obesity. The outcome measures were the Lysholm score, Hospital for Special Surgery (HSS) knee score, Knee Society Score (KSS), Knee Injury and Osteoarthritis Outcome Score (KOOS) and Short Form 36 (SF-36) score. A kinematic 3D gait analysis with five walking trials was performed to compare the patients and healthy controls., Results: The mean KSS, HSS score, Lysholm score, and KOOS were 77.4 ± 14.4, 84.6 ± 11.2, 81.5 ± 10.4, and 67.3 ± 16.8, respectively. No intra- or postoperative complications occurred. The mean range of motion deficiency compared to the healthy side was 24.4 ± 18.5°. Ten patients had first-degree residual laxity of the anterior cruciate ligament; 12 and 2 patients had first- and second-degree residual laxity of the collateral ligament, respectively. Five patients underwent additional arthroscopic arthrolysis due to arthrofibrosis at an average of 6.2 ± 1.9 months (range 4-9 months) after the initial surgery. The 3D gait analysis showed no major differences in joint stability or movement between the patients and healthy controls. Only the ULV trauma patients had significantly lower outcome scores and showed larger kinematic deviations in joint movement during the gait analysis., Conclusion: Anatomical repair with ligament bracing is a suitable surgical procedure in the treatment of KD and provides evidence in clinical practice with the benefit of early, definitive repair and preservation of the native ligaments. Patients reach acceptable subjective and objective functional outcomes, including mainly normalized gait patterns during short-term follow-up, with only minor changes in kinematics and spatial-temporal characteristics. Obese patients who suffered ULV trauma showed significantly inferior outcomes with larger deviations in joint kinematics., Level of Evidence: Level III., (© 2021. The Author(s).)

Study Design: Retrospective, monocentric, observational study in a tertiary health care center., Objectives: To analyze prehospital and clinical findings, complications, neurological improvement and follow-up in a young person cohort with spinal cord injury (SCI) and tetraplegia according to the American Spinal Injury Association (ASIA) Impairment Scale (AIS) A to D after diving into shallow water., Methods: Included were all persons younger than 50 years with SCI after head-first diving into shallow water between June 2001 and June 2019. All persons with SCI were divided into complete tetraplegia (AIS A) and incomplete tetraplegia (AIS B, C, and D) to test differences., Results: A total of 59 males (98.7%) and 1 female with a mean age of 27.7 years suffered an SCI. Alcohol use was documented in 25 cases (41.7%). At the time of admission, 33 people (55%) showed a complete tetraplegia (AIS A) and 27 showed an incomplete tetraplegia with 8 AIS B (13.3%), 15 AIS C (25%), and 4 AIS D (6.7%). At the time of discharge, people with initially complete tetraplegia showed a significant improvement from admission to discharge ( P ≤ .004). Persons with incomplete tetraplegia were more likely to improve their neurological status compared with complete tetraplegia patients ( P ≤ .001). Especially persons with complete tetraplegia suffered from typical SCI-related problems and complications., Conclusions: People with SCI and tetraplegia at the time admission show neurological improvement in 50% of the cases with an overall better outcome in persons with incomplete tetraplegia. The surgical treatment of SCI within 24 hours seems to be associated with a better neurological outcome and a lower level of tetraplegia. The incidence of SCI caused by diving into shallow water remains stable without a significant change, especially in high-risk groups. More education and prevention programs are necessary to avoid these injuries.

Introduction: Among the few techniques described for the treatment of coronoid fractures, osteosynthesis techniques include screw osteosynthesis from anterior to posterior (AP) or from posterior to anterior (PA) and plate osteosynthesis. The aim of this study was to test the biomechanical stability of screw osteosynthesis and plate osteosynthesis using anatomical plates in coronoid process fractures., Materials and Methods: On a total of 25 biomechanical synthetical ulnae, a coronoid shear fracture including 70% of the coronoid height was simulated. Osteosynthesis was then performed using two 2.7 mm screws from anterior, posterior and with use of three different anatomical plates of the coronoid process. For the biomechanical testing, axial load was applied to the fragment with 1000 cycles from 5 to 250 N, load to failure and load at 100 µm displacement. Displacements were measured using a point-based three-dimensional motion analysis system., Results: Osteosynthesis using the PA-screw showed significant more displacement during cyclic loading compared with all other osteosyntheses (0.99 mm), whereas AP-screw showed the smallest displacement (0.10 mm) during cyclic loading. The PA-screw technique showed a significant lower load to failure compared to all other osteosynthesis with the highest load in AP-screw osteosynthesis. The load for 100 µm displacement was the smallest in PA-screw with a significant difference to the AP-screw and one plate osteosynthesis., Conclusion: Osteosynthesis of large coronoid shear fractures with two small-fragment screws from anterior allows stable fixation that is not inferior to anterior plate osteosynthesis and might be an alternative in specific fracture types. Posterior screw fixation was found as the weakest fixation method., Level of Evidence: Basic science study., (© 2020. The Author(s).)

Objectives: To evaluate the results of a series of septic tibial bone defects treated with the Masquelet technique and external ring fixation as a standardized treatment procedure., Design: Retrospective study., Setting: Level one trauma center., Patients/participants: All patients 18 years of age or older with septic diaphyseal bone defects of the tibia who underwent induced membrane treatment with ring fixation at our institution between June 1, 2012, and November 31, 2017., Intervention: Staged management as described by Masquelet using an external ring fixator for definitive fixation., Main Outcome Measurements: Bony healing at the last follow-up and the time to healing in months. Functional results were assessed according to the scoring system of the Association for the Study and Application of Methods of Ilizarov. The secondary outcome measures were treatment failure and complications., Results: Thirty-one patients were treated, with a mean follow-up period of 33 months (range, 13-69 months). Overall, among 14 patients assessed as having achieved bone healing, an average of 3.7 surgical revisions were required. The mean healing time was 15.5 months (range, 6-49 months). According to the Association for the Study and Application of Methods of Ilizarov criteria, 7 patients were rated as "excellent" and 6 patients were rated as "good"; one patient showed "poor" functional results. A total of 17 cases of treatment failure and 36 complications were detected., Conclusions: The combination of the Masquelet technique and external fixation yielded a low healing rate and was associated with a significant number of cases of treatment failure., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Segmental tibia defects remain challenging for orthopedic surgeons to treat. The aim of this study was to demonstrate bone-related and functional outcomes after treatment of complex tibial bone defects using Ilizarov bone transport with a modified intramedullary cable transportation system (CTS)., Patients and Methods: We conducted a single-center, retrospective study including all 42 patients treated for tibial bone loss via Ilizarov bone transport with CTS between 2005 and 2018. Bone-related and functional results were evaluated according to the Association for the Study and Application of Methods of Ilizarov (ASAMI) scoring system. Complication and failure rates were determined by the patients' medical files., Results: Patients had a mean age of 45.5 ± 15.1 years. The mean bone defect size was 7.7 ± 3.4 cm, the average nonunion scoring system (NUSS) score was 59 ± 9.5 points, and the mean follow-up was 40.8 ± 24.4 months (range, 13-139 months). Complete bone and soft tissue healing occurred in 32/42 patients (76.2%). These patients had excellent (10), good (17), fair (2), and poor (3) results based on the ASAMI functional score. Regarding bone stock, 19 patients had excellent, 10 good, and 3 fair results. In total, 37 minor complications and 62 major complications occurred during the study. In 7 patients, bone and soft tissue healing occurred after CTS failure with either an induced membrane technique or classic bone transport; 3 patients underwent lower leg amputation. Patients with treatment failure were significantly older (57.6 vs. 41.8 years; p = 0.003). Charlson score and treatment failure had a positive correlation (Spearman's rho 0.43; p = 0.004)., Conclusion: Bone transport using both intramedullary CTS and Ilizarov ring fixation is viable for treating patients with bone loss of the tibia and complex infection or soft tissue conditions. However, a high number of complications and surgical revisions are associated with the treatment of this severe clinical entity and should be taken into account., Competing Interests: Declaration of Competing Interest None., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Nonunion after medial opening-wedge high tibial osteotomy (OWHTO) is a rare but serious complication with very limited data regarding its treatment. The aim of this study was to analyze the healing rate after operative treatment of nonunion after OWHTO., Methods: We performed a single-center, retrospective study that included 14 patients with nonunion after OWHTO between 2010 and 2018. The treatment for all patients consisted of local debridement and cancellous bone grafting at the osteotomy gap. Revision osteosynthesis due to a loss of correction/loosening of the locking screws or plates was performed in 5 patients. In 7 patients, lateral hinge fractures were treated with additional lateral plating. Union was confirmed using the modified "Radiographic Union Score for Tibial fractures". Outcome measure was the Lysholm Knee Score at final follow-up., Results: The mean age of the patients included in our study was 48.4 ± 6.7 years. Three patients were female (21.4%). The mean follow-up period was 20.8 ± 12.8 months. Union was achieved in 12/14 patients (85.7%) after a mean of 6 months (range, 3-13). The mean Lysholm Knee Score at the final follow-up was 83.2 ± 11.6. Two patients did not reach definitive union during the follow-up. In one patient, an infection of the nonunion following bone grafting was successfully treated with a two-stage procedure. Two patients needed additional cancellous bone grafting 6 and 8 months after the first revision surgery. All patients showed pain-free full weight bearing after union was achieved., Conclusions: Nonunions after OWHTO can generally be treated successfully with cancellous bone grafting. For patients who have loss of correction, loosening of the osteosynthetic material or fracture of the lateral hinge, an additional revision or additive osteosynthesis may be required., Level of Evidence: Grade III.

Background: The aim of this study was to analyze the long-term outcomes of extensor tendon ruptures of the knee using exact measuring tools., Methods: The results of patients treated for extensor tendon rupture with a minimum follow up of 10 years were reviewed. Electromyography (EMG) and three-dimensional (3D) gait analyses were performed and compared with the healthy side of each patient and with the gait patterns of 20 healthy controls. Functional outcome scores were assessed using the Lysholm score and Knee Injury and Osteoarthritis Outcome Score (KOOS)., Results: After a mean of 13.4 ± 3 years, 23 patients were available for follow up. The mean Lysholm score was 86.6, and the KOOS averaged 78.1. Gait analysis showed no major kinematic differences between these patients compared with healthy controls. In the squat test, the mean peak amplitude of the rectus femoris muscle was significantly smaller on the injured side than on the healthy side (140.21 ± 66.13 μV vs. 168.25 ± 91.77 μV; P = 0.01). The mean peaks of the vastus lateralis and medialis EMG signals were also lower on the injured side (P = 0.63; P = 0.08). Correspondingly, the thigh girth at 20 cm and 10 cm above the knee was significantly lower on the injured side. One patient had re-rupture after patella tendon repair., Conclusion: At long-term follow up the patients reached good clinical outcomes and exhibited mainly physiological gait patterns after rupture of knee extensor tendons. However, the thigh muscles showed hypotrophy and a significantly smaller EMG signal amplitude during a high-intensity task on the formerly injured side., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Introduction: Nonunions of trochanteric femoral fractures are uncommon due to a good blood supply of the cancellous bone of the trochanteric region. Nevertheless, if a nonunion occurs, complex revision procedures usually become necessary. The purpose of this study was to evaluate a series of aseptic trochanteric nonunions in patients aged 60 years or older, looking at outcomes regarding healing rate, implant-related complications and secondary surgeries., Material and Methods: We conducted a retrospective chart review of patients with aseptic femoral trochanteric nonunions aged over 60 years. Nonunion treatment consisted of implant removal, debridement of the nonunion, and restoration of the neck shaft angle, followed by DCS plating. An additional 4.5-mm limited contact dynamic compression plate was placed in twelve patients anteriorly. The primary outcome measure was bony healing and time to healing in months. Secondary outcome measures included postoperative complications related to the index procedure, range of motion of the affected hip and postoperative mobility., Results: A total of 21 patients with a mean age of 69.1 years met the inclusion criteria. After a mean follow-up of 21.62 months, 17 of the 21 nonunions healed successfully. The mean healing time was 6.59 months. A total of six of the 21 patients needed secondary revision surgery. At the final follow-up, a full range of motion of the hip was seen in 17 of the 21 hips., Conclusions: DCS treatment and preservation of the patient's femoral head can be successful for patients aged over 60 years with a well-preserved femoral head and acetabulum. However, preservation of the hip joint and revision plating might be associated with higher revision rates., Competing Interests: Declaration of Competing Interest This study was not funded. The authors report that they have no conflicts of interest in the authorship and publication of this article. All work, including writing, was done by the authors., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Knee joint infections with pronounced joint destruction, soft tissue and bone involvement are serious diseases in which not only the joint but also the entire extremity are directly endangered. What results can be achieved with the Ilizarov external fixator for septic knee arthrodesis?, Patients and Methods: Between 2005 and 2017, 13 patients (4 women and 9 men, mean age 46 years) with acute joint and concomitant bone and soft-tissue infections were treated with Ilizarov knee joint arthrodesis. In addition to demographic data, the time spent in the fixator, major and minor complications were retrospectively evaluated., Results: The average time spent in the Ilizarov external fixator was 27 weeks (min. 13, max. 68). Arthrodesis and infection repair were primarily achieved in 12 out of 13 patients. In one patient, a delayed healing of the arthrodesis zone could be cured by iliac crest bone grafting, so that eventually a bony knee arthrodesis was achieved in all patients. Pin infects as a minor complication during the time spent in the fixator were common and could be treated by stab incision and antibiotics. Major complications occurred in 3 cases (2 femoral fractures peri-implant, 1 nonunion in the arthrodesis area), which were treated by dilatation of the Ilizarov external fixator and finally plate osteosynthesis or by resection of the pseudarthrosis and iliac crest bone grafting., Conclusion: The knee joint arthrodesis with the Ilizarov external fixator is a salvage procedure for limb preservation in fulminant knee joint and concomitant soft tissue infections. The advantages lie in the possibility of osteosynthesis in the acute infection and/or chronic osteomyelitis and the direct full load capacity. Disadvantages are long and complicated treatment times in the fixator with limited patient comfort., Competing Interests: The authors declare that they have no conflict of interest.The author has not received any benefit for personal or professional use from a commercial party related directly or indirectly to the subject of this article./Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Intraoperative periprosthetic fractures (IPF) are a well-described complication following hip hemiarthroplasty. Our aims were to identify risk factors that characterize IPF and to investigate postoperative mobility., Methods: We retrospectively reviewed 481 bipolar hemiarthroplasties for displaced femoral neck fractures; of which, 421 (87.5%) were performed without cement, from January 2013 to March 2018. Data on the patients' demographics, comorbidities, femoral canal geometry (Dorr canal type, Canal Flare Index), surgeon's experience (junior vs. senior surgeon), and timing of surgery (daytime vs. on-call duty) were obtained. In patients with intraoperative fractures, further information was obtained. Patient mobility was assessed using matched-pair analysis. Mobility was classified according to the NHFD mobility score. The chi-square test, Fisher's exact test, and Fisher-Freeman-Halton exact test were used for comparison between categorical variables, while the Mann-Whitney U test was used for continuous variables. The data analysis was performed using SPSS., Results: Of 481 procedures, 34 (7.1%) IPFs were encountered. The Dorr canal type C was identified as a significant risk factor (p = .004). Other risk factors included female sex (OR 2.30, 95% CI .872-6.079), stovepipe femur (OR 1.749, 95% CI .823-3.713), junior surgeon (OR 1.204, 95% CI .596-2.432), and on-call-duty surgery (OR 1.471, 95% CI .711-3.046), although none showed a significant difference. Of 34 IPFs, 25 (73.5%) were classified as Vancouver type A. The treatment of choice was cerclage wiring. Within the 12 matched pairs identified, the postoperative mobility was slightly worse for the IPF group (delta = .41)., Conclusions: IPF is a serious complication with bipolar hemiarthroplasty. The identification of risk factors preoperatively, in particular femur shape, is crucial and should be incorporated into the decision-making process.

Background: Fractures of the humeral shaft represent 2-4% of all fractures. Fractures of the humerus have traditionally been approached posteriorly for open reduction and internal fixation. Reports of treating midshaft fractures with an open anterolateral approach and anterior plating are limited. The purpose of this study was to evaluate a series of humeral shaft fractures treated with plate osteosynthesis regarding the effect of the approach and plate location on the healing rate and occurrence of complications., Methods: We conducted a retrospective chart review of patients aged over 18 years with humeral midshaft fractures treated with anterior or posterior plate fixation. Selection of the approach to the humerus was based on the particular pattern of injury and soft tissue involvement. The minimum follow-up duration was set at six months. The outcomes included the rate of union, primary nerve palsy recovery, secondary nerve damage, infection and revision surgery., Results: Between 2006 and 2014, 58 patients (mean age, 59.9; range, 19-97 years) with humeral midshaft fractures were treated with anterior (n = 33) or posterior (n = 25) plate fixation. After a mean follow-up duration of 34 months, 57 of 58 fractures achieved union after index procedure. Twelve fractures were associated with primary radial nerve palsy. Ten of the twelve patients with primary radial palsy recovered completely within six months after the index surgery. In total, one patient developed secondary palsy after anterior plating, and three patients developed secondary palsy after posterior plating. No significant difference in the healing rate (p = 0.4), primary nerve palsy recovery rate (p = 0.6) or prevalence of secondary nerve palsy (p = 0.4) was found between the two clinical groups. No cases of infection after plate fixation were documented., Conclusions: Open reduction and internal fixation using an anterior approach with plate fixation provides a safe alternative to posterior plating in the treatment of humeral shaft fractures. An anterior approach allows supine positioning of the patient and yields union and complication rates comparable to those of a posterior approach with plate fixation for the treatment of humeral shaft fractures.

Introduction: Heterotopic ossifications (HOs) commonly occur following total hip arthroplasty. Data regarding the appearance of HO after periprosthetic joint infection (PJI) of the hip are rare. Therefore, the aim of this study was to analyze the incidence and potential risk factors for the development of HO in patients with PJI of the hip., Materials and Methods: We performed a single-center, retrospective study including patients treated with a two- or multistage operation and patients undergoing salvage procedure in cases of PJI of the hip with a minimum follow-up of 6 months. A total of 150 patients were included in the analysis. The Brooker-scale was used to classify HO. Patients were divided in three groups: (1) No HO, (2) HO Brooker type 1-4, and (3) high-grade HO (HO Brooker type 3 and 4). In each group, we checked possible risk factors for the development of HO for statistical significance., Results: Patients included in our study had a mean age of 70.4 ± 12.1 years. Of all patients, 75 were women (50%). HOs could be found in 70 patients (46.7%). Twenty-seven patients showed HO Brooker type 1, 23 type 2, 15 type 3 and 5 type 4. Male gender [odds ratio (OR) 2.14; p = 0.022], smoking (OR 5.75; p = 0.025) were significant risk factors for HO. A chronic infection (OR 3.54; p = 0.029) and a higher number of procedures (p = 0.009) were significant risk factors for the development of high-grade HO., Conclusions: HOs often occur following surgical care of PJI. Male gender, smoking, a chronic infection and high number of operations are risk factors for developing HO after PJI.

Purpose: The number of total knee arthroplasties (TKA) increased rapidly. In conjunction with higher implantation rates, periprosthetic femur fractures following TKA are also gradually increasing. Purpose of this study was to evaluate polyaxial locking plate treatment of periprosthetic femoral fractures with retained total knee replacement using polyaxial locking plates in regard to quality of life, functional outcome and complications., Methods: The Study design is a single-center retrospective cohort analysis. Included were patients with periprosthetic supracondylar femoral fractures with a well-fixed knee prosthesis initially treated with NCB plate (Non-contact bridging plate, Zimmer Inc., Warsaw, IN). Primary outcome was measured including quality of life and functional status using the SMFA-D score (German short musculoskeletal function assessment questionnaire), the mortality rate and union rate. Formerly published SMFA-data presenting representative randomly chosen cross-sectional data from general population of the USA and Dutch population was used as historic control group., Results: In total, 45 patients with a mean age of 74 years were included (10 males; 35 females). Body mass index averaged 27.4 kg/m 2 . Follow-up averaged 52 months. Comparison of the SMFA-D scores showed higher scores according to bother index (41.5 vs. 15.7/13.8) and function index (42.5 vs. 14.5/12.7). Mortality rate was 26.7%. The CCI was directly related to the mortality rate (p = 0.033). Union was achieved in 35 of 45 fractures (78%) six months after the index procedure. The ultimate union rate including following procedures at last follow-up was 95.6%., Conclusion: Besides already highlighted limitations in range of motion, we quantified patient-related limitations in daily living. A large number of patients after surgery are not self-reliant mobile or on orthopedic aids. A high CCI was directly related to the mortality rate and can be used as a predictive factor for postoperative mortality.

Background: Nonunions of the subtrochanteric region of the femur after previous intramedullary nailing can be difficult to address. Implant failure and bone defects around the implant significantly complicate the therapy, and complex surgical procedures with implant removal, extensive debridement of the nonunion site, bone grafting and reosteosynthesis usually become necessary. The purpose of this study was to evaluate the records of a series of patients with subtrochanteric femoral nonunions who were treated with dynamic condylar screws (DCS) regarding their healing rate, subsequent revision surgeries and implant-related complications., Methods: We conducted a retrospective chart review of patients with aseptic femoral subtrochanteric nonunions after failed intramedullary nailing. Nonunion treatment consisted of nail removal, debridement of the nonunion, and restoration of the neck shaft angle (CCD), followed by DCS plating. Supplemental bone grafting was performed in all atrophic nonunions. All patients were followed for at least six months after DCS plating., Results: Between 2002 and 2017, we identified 40 patients with a mean age of 65.4 years (range 34-91 years) who met the inclusion criteria. At a mean follow-up period of 26.3 months (range 6-173), 37 of the 40 (92.5%) nonunions healed successfully (secondary procedures included). The mean healing time of the 37 patients was 11.63 months (± 12.4 months). A total of 13 of the 40 (32.5%) patients needed a secondary revision surgery; one patient had a persistent nonunion, nine patients had persistent nonunions leading to hardware failure, two patients had deep infections requiring revision surgery, and one patient had a peri-implant fracture due to low-energy trauma four days after the index surgery., Conclusions: The results indicate that revision surgery of subtrochanteric femoral nonunions after intramedullary nailing with dynamic condylar screws is a reliable treatment option overall. However, secondary revision surgery may be indicated before final healing of the nonunion.

Objective: Trauma-related spinal cord injury (SCI) leads to a loss of motor, sensory and vegetative functions and is disproportionately associated with respiratory complications. SCI has a significant impact on respiratory muscle function and can lead to respiratory dysfunction or severe lung failure., Participants: Between 2008 and 2014, 7 patients with severe lung failure following SCI received veno-venous extracorporeal membrane oxygenation (ECMO) n = 5 and interventional lung assist (iLA) n = 2., Results: The median duration of extracorporeal lung support was 8 (5.7-17.6) days. All 5 of the ECMO-supported patients were successfully weaned, and one of the two patients treated with iLA was weaned from the device. The median intensive care unit (ICU) stay was 35 (8.5-44.5) days. The mean hospital stay was 81 (8.5-120.7) days, and the average ventilation time was 817 (206-1,225) hours. Five (71.4%) of the 7 patients were discharged from the ICU and hospital., Conclusions: In patients with SCI, serious complications include microatelectasis, infection, ventilation-perfusion mismatching and aspiration (special case: salt-water aspiration after jumping into shallow water). In patients with SCI with post-traumatic lung failure, ECMO is a feasible and life-saving procedure. After surviving spinal shock, a long rehabilitation period with intensive follow-up in specialized centers is required.