Background: This institutional, register-based analysis aimed to evaluate the feasibility of using CT-based sacral Hounsfield units (HUs) for assessing bone density in pelvic fragility fractures and to explore their potential correlation with DEXA measurements and osteological laboratory diagnostics. Methods: Patients aged > 80 years, admitted between 2003 and 2019 with pelvic ring fractures, were analyzed in this retrospective single-center study. CT scans were evaluated according to the classification of fragility fractures of the pelvis (FFPs), which guided treatment decisions (conservative or surgical). The diagnosis of a fragility fracture was based on both fracture morphology and patient history, including the presence of low-energy trauma. Bone health was assessed using standardized laboratory diagnostics including serum calcium, phosphate, alkaline phosphatase, and 25(OH)-vitamin D, in addition to DEXA scans and CT-derived Hounsfield units. Vitamin D levels and bone density evaluations were analyzed to identify possible correlations among these factors and with fracture patterns. Results: A total of 456 patients (mean age 87.3 years, 79.6% female) were included. The CT-based FFP classification identified Type II as the most common fracture type (66.7%). Conservative treatment was the predominant approach (84.9%). Serum 25(OH)-vitamin D deficiency was observed in 62.7% of the patients, while osteopenia and osteoporosis were found in 34.3% and 46.5% of cases, respectively. HU values at S1 showed significant correlation with femoral neck T-scores, highlighting the utility of CT scans for bone density assessment. Conclusions: This study emphasizes the complementary roles of CT-derived HU values and DEXA T-scores in evaluating bone quality and fracture severity in geriatric patients with FFP. While DEXA remains the gold standard, CT imaging offers valuable early insights, supporting the timely initiation of osteoporosis therapy. Given the high prevalence of fragility fractures in this age group, early CT-based screening may facilitate earlier initiation of osteoporosis-specific therapy, including anabolic agents where indicated. Further research is needed to explore the relationships between vitamin D levels, bone density assessments, and fracture types.

Background: Partial or total avoidance of weight-bearing by a lower limb is regularly needed after trauma and surgery. There are approximately 200 such cases per 100 000 persons per year. Forearm crutches have mainly been used in Germany until now to keep these patients mobile. For those who lack the strength or co- ordination needed to use crutches, a wheelchair may become necessary, or they might find themselves forced to continue weight- bearing on the affected limb, with possible impending adverse consequences and complications. Methods: The supplementary use of a new type of orthopedic scooter by patients who must avoid weight-bearing by a lower limb, wholly or in part, was studied in a multicenter randomized controlled trial involving 88 subjects. The endpoints were improvement in quality of life (EQ5D, SF36) and improved abilities in everyday life (retrospective registration: DRKS00032980). Results: Patients who used orthopedic knee scooters (KS) reported a better overall state of health more frequently than those who used forearm crutches (UC) (SF-36 score: 67 [KS group], 95% CI [61; 73]; 59 [UC group], [53; 64]). They also reported less anxiety and depressed mood, greater mobility, and more independence than the patients who used crutches. In addition, they more frequently reported being able to transport themselves 4 x 500 meters in less than 20 minutes (n = 30 [KS], 63.8% [48.5; 77.3]; n = 6 [UC], 14.6% [5.6, 29.2]). Conclusion: The supplementary use of an orthopedic knee scooter can improve these patients' mobility and independence and prolong the distance over which they can transport themselves. For many patients, this form of treatment may well shorten the time of their total or partial inability to work and thus lower the socioeconomic costs of lower limb injuries and surgery.

Long bone non-unions represent a serious clinical and socioeconomical problem due to the prolonged episodes, frequent sequelae, and variable treatment effectiveness. Bone grafts, classically involving the autologous iliac crest graft as the 'gold standard' bone graft, enhance bone regeneration and fracture healing incorporating osteoconductive and/or osteoinductive/osteogenic capacity to the non-union under treatment. Structural alternatives to autologous bone grafts include allografts and bone substitutes, expanding the available stock but loosing biological properties associated with cells in the graft. Biological alternatives to autologous bone grafts include bone marrow concentration from iliac crest aspiration, bone marrow aspiration from reaming of the diaphyseal medullary canal in the long bones, and isolated, expanded mesenchymal stem cells under investigation. When the combination with natural and synthetic bone substitutes allows for larger volumes of structural grafts, the enhancement of the biological regenerative properties through the incorporation of cells and their secretoma permits to foresee new bone grafting solutions and techniques.

Background: Among the risk factors for nonunion are unchangeable patient factors such as the type of injury and comorbidities, and factors that can be influenced by the surgeon such as fracture treatment and the postoperative course. While there are numerous studies analyzing unchangeable factors, there is poor evidence for factors that can be affected by the physician. This raises the need to fill the existing knowledge gaps and lay the foundations for future prevention and in-depth treatment strategies. Therefore, the goal of this study was to illuminate knowledge about nonunion in general and uncover the possible reasons for their development; Methods: This was a retrospective analysis of 327 patients from 2015 to 2020 from a level I trauma center in Germany. Information about patient characteristics, comorbidities, alcohol and nicotine abuse, fracture classification, type of osteosynthesis, etc., was collected. Matched pair analysis was performed, and statistical testing performed specifically for atrophic long-bone nonunion; Results: The type of osteosynthesis significantly affected the development of nonunion, with plate osteosynthesis being a predictor for nonunion. The use of wire cerclage did not affect the development of nonunion, nor did the use of NSAIDs, smoking, alcohol, osteoporosis and BMI; Conclusion: Knowledge about predictors for nonunion and strategies to avoid them can benefit the medical care of patients, possibly preventing the development of nonunion.

Introduction Since the introduction of e-scooters in Germany in 2019, they are becoming more and more popular and associated injuries have increased significantly. The aim of this study was to assess the injury patterns after e-scooter accidents. Materials and Methods From May 2019 to October 2022, all consecutive patients who presented at our emergency department (ED) following e-scooter accidents were included in our study and retrospectively analyzed. Results A total of 271 patients were included in our study. The mean age was 33 years. 38% of the patients were female and 62% were male. Most common injuries were traumatic brain injuries in 38% of the patients together with fractures affecting the upper limb (17%). An operative treatment was necessary in 40 patients. Most of the patients presented at night and about 30% were under the influence of alcohol. Conclusions Our study shows one of the largest cohort of patients suffering e-scooter accidents in Europe. Compulsory helmet use, stricter alcohol controls and locking periods could contribute significantly to safety.

Osteoporotic proximal femur fractures are on the rise due to demographic change. The most dominant surgical treatment option for per/subtrochanteric fractures is cephalomedullary nailing. As it has been shown to increase primary stability, cement augmentation has become increasingly popular in the treatment of osteoporotic per/subtrochanteric femur fractures. The ultimate goal is to achieve stable osteosynthesis, allowing for rapid full weight-bearing to reduce possible postoperative complications. In recent years, bioresorbable bone cements have been developed and are now mainly used to fill bone voids. The aim of this study was to evaluate the biomechanical stability as well as the micro-structural behaviour of bioresorbable bone cements compared to conventional polymethylmethacrylate (PMMA)-cements in a subtrochanteric femur fracture model. Biomechanical as well as micro-computed tomography morphology analysis revealed no significant differences in both bone cements, as they showed equal mechanical stability and tight interdigitation into the spongious bone of the femoral head. Given the positive risk/benefit ratio for bioresorbable bone cements, their utilisation should be evaluated in future clinical studies, making them a promising alternative to PMMA-bone cements.

BACKGROUND:Gluteal muscle fatty atrophy (gMFA) might impair pelvic stability and negatively influence remobilization in patients with fragility fractures of the pelvis (FFP). This study aimed to investigate the association between gMFA and surgical indication in patients with FFP.METHODS AND MATERIALS:A retrospective analysis of 429 patients (age ≥80) diagnosed with FFP was performed. gMFA of the gluteus maximus, medius, and minimus was evaluated using a standard scoring system based on computer tomography images.RESULTS:No significant difference was found in gMFA between genders or among FFP types. The severity of gMFA did not correlate with age. The severity of gMFA in the gluteus medius was significantly greater than in the gluteus maximus, whereas the most profound gMFA was found in the gluteus minimus. gMFA was significantly more severe in patients who underwent an operation than in conservatively treated patients with type-III FFP, and an independent correlation to surgical indication was found using logistic regression.CONCLUSION:Our findings imply that gMFA is an independent factor for surgical treatment in patients with type-III FFP. Besides focusing on the fracture pattern, the further evaluation of gMFA could be a feasible parameter for decision making toward either conservative or surgical treatment of type-III FFP.

Purpose Osteoporosis-related proximal femur fractures continue to increase significantly due to demographic change. This study was designed to evaluate the biomechanical stability of two different fixation methods (cerclage vs. screw) for refixation of a trochanter minor fragment in the pertrochanteric fractures in cadaveric bones. Methods Artificial bones ( n = 14) and human bones ( n = 16) were treated with a DHS and the trochanter minor fragment was reduced by cerclage wiring or direct screw fixation. After preloading the simulated iliopsoas with 10 N, a tensile test was performed, ending with either a 70% loss of strength or avulsion of the fragment. The mean values of the avulsion force and the surface strain were recorded. Results All tensile tests showed no significant differences between refixation using a direct screw or wire cerclage, for both artificial bones and human specimens. Absolute values showed higher avulsion forces after direct screw fixation than refixation with a wire cerclage. The surface tension of specimens treated with direct screw fixation was lower than that of specimens treated with wire cerclage. An opposite effect was seen in artificial bones. Both effects were not statistically significant. Conclusion Based on the equal stability after lag screw placement compared to cerclage wiring, we promote the placement of a lag screw into the lesser trochanter fragment in pertrochanteric femur fractures when using a dynamic hip screw. Level of evidence Level III.

Einleitung Die Verwendung von PMMA-Knochenzement zur Augmentation von Osteosynthesematerial hat in den letzten Jahren vermehrt Verbreitung gefunden und wird am proximalen Femur am häufigsten eingesetzt. Die Vorteile der Augmentation am osteoporotischen proximalen Femur sind eine höhere biomechanische Primärstabilität und eine in Folge verbesserte Mobilisation der Patienten. Bioresorbierbare Zemente vereinen den Vorteil einer hohen Primärstabilität mit der Resorptionsfähigkeit und osteokonduktiven Eigenschaften eines Knochenersatzmaterials und vermeiden Nachteile der klassischen.

Die Kallusdistraktion (KD) ist eine Technik, die erfolgreich zur Behandlung von Beinlängendifferenzen und zur Rekonstruktion langstreckiger Knochendefekte angewandt werden kann. Im Zuge einer graduellen Distraktion der Knochenfragmente um ca. 1 mm/Tag kommt es zur Hypervaskularisierung und zum verstärkten Knochenheilungspotenzial (Wachstumsstimulus). Bisher kommt die KD fast ausschließlich longitudinal zur Anwendung, um neues, biologisch aktives Knochengewebe zu generieren. Chronische Wunden, Ulzera und Osteitiden gerade im Fußbereich stellen für den behandelnden Chirurgen immer wieder eine Herausforderung dar, da die Therapieformen langwierig, unsicher im Ausgang und mit möglichem Verlust der Extremität vergesellschaftet sind. Die transverse Kallusdistraktion (tKD) nutzt translational den Wachstumsstimulus der KD zur Behandlung von distal gelegenen, chronischen Wunden und führt dadurch zu einer Beschleunigung der Wundheilung. Am Ende der 5‑wöchigen Behandlung findet sich das weit proximal der chronischen Wunde gelegene, transvers distrahierte, Fragment wieder an seinem ursprünglichen Ort. Der biologische Stimulus wirkt lange nach – länger als die tKD selbst. Weitere Untersuchungen zu den Wirkmechanismen und Behandlungsergebnissen der tKD sind erforderlich. Sollten sich die bisherigen Ergebnisse bestätigen, kann die tKD zum „game changer“ werden und den Extremitätenerhalt bei einem großen Anteil bisher amputationswürdiger Befunde ermöglichen.

The Morel-Lavallée lesion (MLL) is an internal degloving injury typically associated with high-energy trauma and is suspected to be underdiagnosed in a majority of cases. Here, we illustrate the typical clinical and radiological characteristics of an extensive peripelvic MLL in a 50-year-old patient presenting to our trauma outpatient clinic with peripelvic pain, bruising and swelling six weeks after severe spine trauma caused by a high-energy car accident. Using this case study as an example, current therapeutic approaches are discussed. Therapeutic decisions should be based on clinical symptoms, lesion size, severity, age and co-morbidities. Extensive, symptomatic and chronic lesions should be addressed with early débridement, irrigation and drainage in order to prevent complications like infection or soft tissue necrosis.

Due to the demographic change towards an older society, osteoporosis-related proximal femur fractures are steadily increasing. Intramedullary nail osteosyntheses are available in different lengths, where the field of application overlaps. The aim of this study was to investigate whether subtrochanteric fractures can also be treated stably using a short femoral intramedullary nail in cadaveric bones. A short PFNA and a long PFNA were implanted in both seven artificial bones and osteoporotic human specimens. A standardized AO 31-A3 (reverse-oblique) fracture was placed in the specimens with a lateral fracture spur 2 cm proximal to the distal locking screw (short PFNA) and embedded. The simulated iliotibial tract was preloaded to 50 N. The force was applied at 10 mm/min up to a force of 200–800 N (artificial bones) and 200–400 N (human specimens). The dislocation of the fracture gap, the axial bone stiffness of bone construct and the force curve of the tractus iliotibialis were measured. There is no difference in the use of a short versus long PFNA in terms of stiffness of the overall construct and only a slight increase in dislocation in the fracture gap results with short PFNA compared to a long intramedullary nail. In summary of the available literature, the present study supports the thesis that there is no clinical difference between long versus short nails in A3 femur fractures. Furthermore, the present study defines a safe biomechanical range of fracture extension above the locking screw of the short intramedullary nail. III

BACKGROUND:Surgical treatment of unstable syndesmotic injuries is not trivial, and there are no generally accepted treatment guidelines. The most common controversies regarding surgical treatment are related to screw fixation versus dynamic fixation, the use of reduction clamps, open versus closed reduction, and the role of the posterior malleolus and of the anterior inferior tibiofibular ligament (AITFL). Our aim was to draw important conclusions from the pertinent literature concerning surgical treatment of unstable syndesmotic injuries, to transform these conclusions into surgical principles supported by the literature, and finally to fuse these principles into an evidence-based surgical treatment algorithm.METHODS:PubMed, Embase, Google Scholar, The Cochrane Database of Systematic Reviews, and the reference lists of systematic reviews of relevant studies dealing with the surgical treatment of unstable syndesmotic injuries were searched independently by two reviewers using specific terms and limits. Surgical principles supported by the literature were fused into an evidence-based surgical treatment algorithm.RESULTS:A total of 171 articles were included for further considerations. Among them, 47 articles concerned syndesmotic screw fixation and 41 flexible dynamic fixations of the syndesmosis. Twenty-five studies compared screw fixation with dynamic fixations, and seven out of these comparisons were randomized controlled trials. Nineteen articles addressed the posterior malleolus, 14 the role of the AITFL, and eight the use of reduction clamps. Anatomic reduction is crucial to prevent posttraumatic osteoarthritis. Therefore, flexible dynamic stabilization techniques should be preferred whenever possible. An unstable AITFL should be repaired and augmented, as it represents an important stabilizer of external rotation of the distal fibula.CONCLUSIONS:The current literature provides sufficient arguments for the development of an evidence-based surgical treatment algorithm for unstable syndesmotic injuries.

Purpose Corrective midfoot resection arthrodesis is the standard treatment of Charcot arthropathy type Sanders 2 and 3 with severe dislocation. In order to critically evaluate the effect of surgical correction, a retrospective analysis of our patient cohort was performed. Hereby, special emphasis was set on the analysis of the pre- and post-operative equinus position of the hindfoot. Methods Retrospectively, all patients ( n = 82) after midfoot resection arthrodesis in Charcot type Sanders 2 or 3 were included. Complications were recorded, and the mean complication-free interval was calculated. Additionally, the calcaneal pitch as well as Meary’s angle were measured pre- and post-operatively and in case of complications. Results Overall complication rate was 89%. Revision surgery was necessary in 46% of all patients. The mean complication-free interval was 285 days (0–1560 days). Calcaneal pitch and Meary’s angle significantly improved after operation but returned to pre-operative values after onset of complications. Achilles tendon lengthening showed no significant effects on the mean complication-free interval. Conclusion Operative treatment of Charcot arthropathy remains a surgical challenge with high complication rates. Surgical correction of equinus position has been highlighted for successful treatment but was not able to prevent complications in this study, which is demonstrated by the recurrent decrease of the calcaneal pitch in cases of reoperation. Therefore, as a conclusion of our results, our treatment algorithm changed towards primarily addressing the equinus malpositioning of the hindfoot by corrective arthrodesis of the hindfoot.

Orthoses are designed to achieve immobilization or off-loading of certain regions of the foot. Yet, their off-loading capacity for the specific regions has not yet been studied. Therefore, the aim of this study was to analyze the plantar pressure distribution of five commonly applied orthoses for foot and ankle in a healthy population. Five orthoses (postoperative shoe, forefoot relief shoe, short walker boot, high walker boot, and calcaneus fracture orthosis) were compared pedobarographically using insoles on a treadmill to a ready-made running shoe in eleven healthy subjects (median age 29 years). Peak pressure, maximum force, force–time integral, contact time, and contact area were evaluated separately for the forefoot, midfoot, and hindfoot. The forefoot relief shoe, the short- and high walker boot significantly reduced the peak pressure at the forefoot with no significant differences between these orthoses. None of the five orthoses off-loaded the midfoot, but the calcaneus fracture orthosis and the short walker boot instead increased midfoot load. For the hindfoot, the calcaneus fracture orthosis was the only device to significantly reduce the peak pressure. This is the first study to investigate the specific off-loading capacities of different orthoses for specific foot regions in a healthy collective. The knowledge of absolute and relative load shifts for the different orthoses is of fundamental interest for targeted clinical decision-making of physicians.

Objective: While long standing radiographs (LSR) represent the gold standard for preoperative alignment assessment and planning of lower limb deformity corrections, there is no consensus about the intraoperative alignment assesments (IAC) due to various limitations of the common methods. The present study introduces a radiolucent X-ray grid with integrated radiopaque lines explicitly designed for fluoroscopic IAC and evaluates its reliability in comparsion to the LSR. Methods: Patients with posttaumatic and congenital lower limb deformity surgery and preoperative LSR as well as fluoroscopic IAC utilizing the X-ray grid were retrospectively included to the study. The me-chanical axis deviation (MAD) in percentage of the maximum tibial width from the medial to the lateral in comparison between the image pairs was set as primary outcome parameter. Multiple rater and measurements determined intra- and interobserver reliabilit of both imaging methods. In addition, the effects of age, gender, body mass index (BMI), etiology, joint line convergence angle (JLCA), and extent varus or valgus deformity were analysed. Results: A total of 84 patients were finally included. The mean absolute difference of MAD between the two techniques was 7.2 +/- 0.8%. MAD between the LSR and IAC correlated at a high level (R = 0.96, p < 0.001). The agreement decreased with increasing extent of deformity (p < 0.01) and with higher devia-tion of JLCA between LSR and IAC (p < 0.01). Intra-and interobserver concordance correlation coefficient (CCC) for MAD measurements were 0.99 for both imaging techniques. Conclusion: Fluoroscopy combined with the X-ray grid method is a valid tool for intraoperative assess-ment of lower limb alignment in deformity correction surgery, and the correlation between LSR and IAC is better than in other similar techniques described in the literature. However, in case of severe coronal alignment deformity and highly divergent JLCA, the agreement between both imaging techniques decreases significantly. (C) 2022 Published by Elsevier Ltd.

Mobility patterns of western societies have been changing due to ongoing demographic change. Therefore, continuously updated epidemiological data on fracture morphology and treatment strategies are needed. This retrospective single-center study included all tibial plateau fractures (TPF) between January 2011 and December 2020 in a level-I trauma center in Central Europe. Epidemiology, trauma mechanism and fracture morphology were analyzed. Age- and sex-specific differences regarding fracture classification (Schatzker, AO/OTA, Moore) and changes during the study period are highlighted. A total of 607 patients (55.2

Distraction osteogenesis (DO) is a technique that can be successfully used to treat leg length discrepancies and to reconstruct long defects of bone. By gradual distraction of the bone fragments by approximately 1 mm per day, hypervascularization and an increased bone healing potential (growth stimulus) occur. So far, DO has almost exclusively been used longitudinally to generate new biologically active bone. Chronic wounds, ulcers and osteitis, especially in the region of the foot, are always a challenge for the treating surgeon, since treatment is tedious, the outcome uncertain and associated with possible loss of the extremity. Transverse distraction osteogenesis (tDO) now uses the growth stimulus of the DO translationally to treat distally located, chronic wounds and thus leads to accelerated wound healing. At the end of the 5-week treatment, the transversely distracted fragment, located far proximal to the chronic wound, is back in its original location. The biological stimulus has a long-lasting effect, longer than the tDO itself. Further investigations into the mechanisms of action and treatment outcomes of tDO are required. If the previous results are confirmed, tDO may become a game changer and enable the limb salvage for a large proportion of findings that previously required amputation.

Background: Various risk factors affecting outcome of elderly patients after proximal femur fracture have been identified. The present study aims to evaluate the impact of the fracture pattern in trochanteric fractures on postoperative mobility and complications. Methods: Ninety-two patients with a mean age of 84 years were included. According to the revised AO/OTA classification, fractures were divided into stable (AO 31A1) and unstable (AO 31A2/3) patterns. A follow-up examination was performed 12 months after cephalomedullary fixation to assess outcome parameters for mobility/activities of daily living (Parker Mobility Score (PMS)/Barthel Index (BI)) and complications (increase in requirement of care, hospital readmission, mortality rate). Results: At follow-up, patients with unstable trochanteric fracture patterns presented with lower PMS and BI compared to stable fractures (p < 0.05). Further, higher requirement of care and higher readmission rates compared to stable patterns were observed. Conclusion: Unstable trochanteric fractures presented inferior outcome compared to simple fracture patterns. This might be explained by the increasing surgical trauma in unstable fractures as well as by the mechanical impact of the lesser trochanter, which provides medial femoral support and is of functional relevance. Subsequent studies should assess if treatment strategies adapted to the specific fracture pattern (refixation of lesser trochanter) influence outcome in unstable trochanteric fractures.

Surgical treatment of jumper’s fractures is a highly demanding situation for the surgeon due to its rareness and frequent association with severe concomitant injuries. There is no current consensus regarding a standard treatment approach, thus reducing quality of care. Our objectives were to describe, apply and assess a novel surgical technic. The presented research is an observational retrospective study of patients who underwent the described novel surgical intervention in a level 1 trauma center. We conducted analyses of the patient cohort using patient-related outcome measures at least 1 year after surgery, as well as investigating pain, quality of life and the clinical effectiveness of the procedure. A total of 24 patients (17 male and 7 female) with an average age 47 ± 16.3 years were included. ISS scores ranged from 9 to 66 with a mean ISS of 40 ± 15. Clinical scores exist of 15 out of 24 patients (62.5%). The mean VAS score was 53.7 ± 12.9. The mean EQ-5D index was 0.68 ± 0.22. Significant negative correlation existed between the ISS value and the EQ-5D index (r =  − 0.704; p < 0.005) and EQ-5D VAS (r =  − 0.809; p < 0.001). Anatomical reduction was achieved in all patients (n = 24). Radiological follow-up was performed in 58%. We present one of the largest studies with operatively treated jumper’s fractures of the sacrum. The technique is capable of reproducibly restoring the physiological anatomy of the patient and allows pain-adapted mobilization.