Introduction: Periprosthetic joint infection (PJI) is a major cause of failure after total hip arthroplasty (THA) and total knee arthroplasty (TKA). While primary PJI treatment costs are increasingly recognized, the economic burden of septic re-revision surgery remains poorly defined. This study estimated septic re-revisions and the reimbursement burden across Europe. Methods: A payor-perspective health-economic model was applied to 30 European countries, combining 2023 Eurostat arthroplasty data with published infection rates to estimate PJIs and septic re-revisions (including after aseptic revisions), categorized as DAIR (debridement, antibiotics, and implant retention), one-stage, or two-stage procedures. Reimbursement used 13-country survey data plus GDP-based extrapolation; sensitivity analyses varied key parameters by ± 20 %. Results: In 2023, 2.29 million primary arthroplasties were performed in Europe, resulting in an estimated 22 794 PJIs and 8629 septic re-revisions. Total reimbursement costs were estimated at EUR 123.6 million (EUR 74.1 million THA; EUR 49.5 million TKA), split into EUR 111.6 million after primary PJI treatment and EUR 12.0 million after initially aseptic revision. Two-stage exchanges accounted for 82.8 % of expenditures and were the main cost driver; Germany had the highest national costs. A Monte Carlo probabilistic sensitivity analysis yielded a 95 % credibility interval of EUR 102.0-156.2 million. Conclusion: Septic re-revision surgery after arthroplasty represents a substantial economic burden in Europe, largely driven by two-stage exchange procedures. Reducing infection and treatment failure rates may provide major clinical and financial benefits: a 25 % reduction in PJI incidence could save EUR 27.9 million annually (22.6 %), and shifting half of two-stage cases to one-stage a further EUR 22.6 million (18.3 %).

OBJECTIVE:Lower limb amputation profoundly impairs health related quality of life (HRQoL), yet comparative data across indications and amputation levels are scarce. This study evaluated EQ-5D-3L outcomes in patients with and without ischaemia undergoing major vs. minor lower extremity amputations. METHODS:In this retrospective cohort at a German level 1 trauma centre, patients (during 2010 - 2020) were classified by indication (ischaemia vs. trauma, tumour, and or infection) and amputation level (major vs. minor). Between 2023 and 2024, EQ-5D-3L interviews assessed five HRQoL dimensions. Multivariable linear regression identified independent predictors of EQ-5D index scores. RESULTS:Of 1 075 eligible patients, 276 (25.7%) completed EQ-5D: 176 with ischaemia (124 minor and 53 major) and 100 with other indications (55 minor and 44 major). Mobility limitations were more frequent in major vs. minor amputees for both ischaemia (71.7% vs. 62.1%) and other indications (75.0% vs. 41.8%). Self care was least affected (ischaemia majors 47.2% no problems; minors 60.5%; other majors 51.2%; minors 80.0%). Pain or discomfort was reported by 77.4% of ischaemia majors and 52.8% of ischaemia minors, and by 68.2% and 58.2% of other majors and minors, respectively. Anxiety or depression impairment was intermediate across groups. In patients with ischaemia, higher American Society of Anesthesiologists (ASA) score (β = -6.05, p = .001) and dialysis status (β = 3.47, p = .15) strongly predicted EQ-5D, whereas amputation level did not (β = -2.50, p = .32). In patients without ischaemia, coronary heart disease (β = -10.47, p < .001) and major amputation (β = -8.47, p = .006) were key negative predictors. CONCLUSION:HRQoL impairments after lower limb amputation vary by indication and level, with comorbidity burden, especially ASA score and coronary disease, exerting greater influence than amputation level alone. These findings support multidisciplinary optimisation of systemic health in amputation care.

Abstract Background Musculoskeletal disorders, including chronic back pain, osteoarthritis, rheumatoid arthritis, and fibromyalgia, are leading causes of chronic pain and reduced quality of life. Standard treatment approaches often focus on physical symptoms, while psychosomatic factors are sometimes overlooked. This study aims to evaluate the effectiveness of adjunct psychosomatic interventions—guided meditation and aromatherapy—on pain perception, stress levels, and quality of life in patients with musculoskeletal disorders. Methods This is a three-arm, prospective, randomized controlled trial conducted in Germany. A total of 90 participants aged 18 to 90 with chronic musculoskeletal disorders will be randomized into one of three groups: (1) guided meditation, (2) aromatherapy, or (3) control receiving standard care. The intervention groups will receive either body-scan meditation (23 min, twice weekly) or aromatherapy (5–10 min daily) for one week. The primary outcomes include pain intensity (measured using the Numerical Rating Scale), perceived stress (measured using the Perceived Stress Questionnaire), and quality of life (measured using the EQ-5D). Secondary outcomes will include pain medication consumption. Follow-up assessments will be conducted at 3-, 6-, and 12-month post-intervention. Data will be analyzed using an intention-to-treat approach with ANCOVA for primary endpoints. Discussion This trial will provide valuable insights into the effectiveness of psychosomatic interventions as adjunct therapies for managing chronic pain and stress in musculoskeletal disorders. If successful, these interventions could be implemented as cost-effective and non-invasive strategies to improve quality of life and pain management for patients with musculoskeletal conditions. The findings may also inform future studies on integrative treatment approaches for chronic pain conditions. Trial registration The trial is registered at the German Clinical Trials Register ( https://www.drks.de ), registration number DRKS00034506.

Introduction: Septic arthritis (SA) is an orthopaedic emergency; delayed treatment endangers joint function and survival. Unlike periprosthetic infections, diagnostic criteria for native joints are poorly standardized. This study aimed to (1) evaluate diagnostic parameters including synovial white blood cell (sWBC) count, neutrophil percentage, serum C-reactive protein (CRP), and leukocyte count and (2) assess a new evaluation score combining these parameters. Methods: In a retrospective cohort study, cases of knee and shoulder SA treated at a German university hospital (2013-2022) were analysed. Parameters included synovial fluid analysis (sWBC, neutrophils), blood samples (CRP, leukocytes), and intraoperative cultures. Cut-offs for sWBC and neutrophils were determined using receiver-operating characteristic (ROC) analysis and the Youden index, comparing SA patients with non-infected controls. A new evaluation score for SA (Septic Arthritis Evaluation Score, SAES) was created: 2 points each for sWBC and neutrophils and 1 point each for CRP and leukocytes. Results: Complete data were available for 45 patients (71.4 % male, mean age 64.3 years). Knees were affected in 73.7 %, and shoulders were affected in 26.3 %. Median values were as follows: leukocytes - 11/nl, CRP - 158 mg L-1, sWBC - 42 910/ µ L, and neutrophils - 93.6 %. ROC analysis identified an optimal sWBC cut-off of 35 650/ µ L (sensitivity of 64.4 %, specificity of 87.8 %). The SAES showed higher discriminatory performance; with a threshold ≥ 3 points, sensitivity was 95.6 %, and specificity was 70.7 %. Conclusions: In this retrospective cohort, commonly used laboratory parameters for native joint SA showed limited discriminatory ability when applied individually. A newly developed composite score combining synovial and serum markers demonstrated higher sensitivity within this dataset. Prospective validation in larger cohorts is required before clinical application.

Introduction Fractures represent a major clinical and socioeconomic burden; however, existing epidemiological data in Germany are largely based on inpatient cohorts and may underestimate the true incidence by omitting conservatively managed cases. This study aimed to quantify the national burden of fractures using nationwide outpatient statutory health insurance data.Methods A retrospective analysis of nationwide outpatient billing data from the Central Institute for Statutory Health Insurance Physicians (ZI) was conducted, covering approximately 90% of the German population. All ICD-10 fracture diagnoses recorded between 2015 and 2022 were included. To avoid double-counting, repeated documentation of identical diagnoses within four consecutive quarters was excluded. Incidence rates were calculated per 100 000 inhabitants using population data from the Federal Statistical Office. Fractures were analysed by anatomical site, age and sex using descriptive epidemiological methods.Results A total of 18 171 815 fractures were identified between 2015 and 2022. In 2022, 2 400 606 fractures were recorded, corresponding to an incidence of 2845.71 per 100 000 inhabitants. Overall fracture incidence increased by 7.5% during the study period, with a temporary decline in 2020 followed by a rebound in subsequent years. The most frequent fracture sites were the distal radius, toes, fingers, ribs and lumbar spine. The largest relative increases were observed for distal femur (+38.7%), pelvic ring (+37.1%) and cervical spine fractures (+36.9%). Fracture incidence was higher in females than in males and increased markedly with age, particularly in individuals aged ≥65 years.Conclusions This nationwide analysis demonstrates a growing fracture burden in Germany, particularly among older adults. Outpatient data provide a comprehensive perspective on fracture epidemiology beyond surgically treated cases. These findings highlight the need for improved strategies in fracture prevention and outpatient care, and underline the importance of integrating inpatient and outpatient data for future health policy planning.

PURPOSE:Ruptures of the anterior cruciate ligament (ACL) are among the most common orthopaedic diagnoses with severe short- and long-term consequences for patients. The aim of the study was to analyze trends of inpatient and outpatient treatment of ACL injuries in Germany. MATERIALS AND METHODS:All ACL reconstructions in Germany in public health insurance patients between 2019 and 2024 were included. The data of the Institute for the hospital remuneration system (InEK) were used for inpatient cases, while data of the Central Institute for Statutory Health Insurance Physicians in Germany (ZI) were used for outpatient treatments. RESULTS:Between 2019 and 2024, a total of 242,423 operatively treated ACL ruptures were identified in Germany, corresponding to an overall annual incidence of 48.39 ± 6.63 per 100,000 inhabitants. While the overall incidence declined slightly by 5.5% over the study period, substantial shifts in treatment setting were observed: outpatient cases increased by 70.8%, whereas inpatient cases decreased by 26.8%. Across all age groups, inpatient incidence rates declined, especially among younger and middle-aged adults, while outpatient incidence increased significantly, most notably in working-age populations (18-65 years). The relative difference between inpatient and outpatient care narrowed over time (RR 4.99 in 2019 vs. 2.35 in 2024), indicating a pronounced shift towards outpatient management. CONCLUSION:This nationwide move towards outpatient ACL reconstruction signifies a fundamental change in care delivery, offering potential benefits in efficiency and resource use. However, it also emphasizes the importance of careful patient selection, standardized perioperative protocols and ongoing outcome monitoring to make sure clinical safety and effectiveness are maintained. LEVEL OF EVIDENCE:Level IV.

Aims Fracture-related infections (FRIs) are a major concern for patients and healthcare systems, yet their impact on mental health has been largely overlooked. This study aimed to assess the longitudinal impact of FRI on patients’ quality of life. Methods A prospective study was conducted at a level 1 trauma centre between January 2020 and December 2022. In total, 56 patients participated, with quality of life assessed at five timepoints: one week preoperatively, and one, three, six, and 12 months postoperatively. Statistical analysis was performed using repeated measures analysis of variance (ANOVA) with adjusted post-hoc analysis. Results The preoperative Physical Component Summary score on the 36-Item Short-Form Health Survey questionnaire (SF-36) was 26.71, increasing to 30.40 at one month, remaining stable at three months. A modest increase was observed at six months (32.45, p = 0.003), but it decreased to 29.72 at 12 months. The preoperative Mental Component Summary score (SF-36) was 46.48, decreasing to 39.89 at one month (p = 0.027) and to 36.03 at three months (p ≤ 0.001). However, it improved at six (42.74) and 12 months (44.05). Positive changes were seen in EuroQol five-dimension questionnaire (EQ-5D) subdimensions, such as mobility, self-care, usual activities, and pain/discomfort, while anxiety/depression scores decreased over time. The EQ-5D visual analogue scale (VAS) score increased to 62.79 at six months (p ≤ 0.001) and decreased to 58.2 at 12 months (p = 0.011). Conclusion FRIs substantially affect mental health and quality of life, particularly during the initial three months of treatment. This study emphasizes the importance of addressing psychological aspects early in FRI management, advocating for holistic care encompassing both physical and psychological aspects of treatment. Cite this article: Bone Joint Res 2025;14(2):136–142.

Aims Periprosthetic joint infections (PJIs) pose significant challenges to patients and healthcare systems worldwide. The aim of this study was to estimate the health-economic burden of reimbursement payment in Europe for PJIs following primary hip and knee arthroplasty. Methods The calculation was based on health-economic modelling using data on primary hip and knee arthroplasties for the year 2019 from the Statistical Office of the European Union (Eurostat) and published infection rates to estimate the total number of hip and knee PJIs in 30 European countries. Revision procedures were stratified into: 1) debridement, antibiotics, and implant retention (DAIR); 2) one-stage exchange; and 3) two-stage revision procedures. The cases were then multiplied by the respective healthcare system reimbursement payments. Payment data were acquired from a survey of 13 countries (Austria, Croatia, France, Germany, Italy, Lithuania, Netherlands, Norway, Portugal, Slovenia, Switzerland, Turkey, and the UK) and extrapolated for the remaining countries. Results In 2019, a total of 2,048,778 primary total joint replacements were performed (total hip arthroplasty (THA) = 1,147,316 and total knee arthroplasty (TKA) = 901,462), with an estimated 20,416 cases of PJIs (11,131 hip and 9,285 knee) in Europe. This results in an estimated total reimbursement burden of 346,262,026 for European healthcare systems. The breakdown for hip PJI reimbursement was 197,230,953 (9,751,962 for DAIR procedures, 45,135,894 for one-stage revisions, and 142,343,097 for two-stage revisions). For knee PJIs, the analysis yielded a total reimbursement of 149,031,073 (9,335,075 for DAIR procedures, 48,058,479 for one-stage revisions, and 91,637,518 for two-stage revisions). Conclusion This is the first study to evaluate the health-economic burden of PJIs in Europe, revealing a substantial impact on healthcare systems with an estimated case load of 20,414 cases and overall reimbursement of 346,262,026 for primary THAs and TKAs performed in 2019.

Background:. Fracture-related infections (FRIs) pose significant clinical and economic challenges in trauma surgery. Despite advancements in treatment modalities, the economic burden of managing FRIs remains substantial. However, cost analyses are scarce. Therefore, the aim of this study was to analyze the direct healthcare costs associated with FRI treatment compared with initial fracture treatment across various fracture types in a level 1 trauma center in Germany. Methods:. A retrospective analysis of 95 patients treated for fractures and FRIs between 2013 and 2020 was conducted. Patients were categorized based on the fracture location: femur, tibia, ankle, and foot. Data collected included fracture characteristics, and costs related to both initial fracture treatment and FRI management. Costs were analyzed using diagnosis-related group (DRG) reimbursement data. The mean DRG reimbursement for initial fracture treatment and FRI treatment was compared to determine the economic impact of FRIs. Results:. The study revealed significant increases in costs for FRI treatment across all fracture types. For femur fractures, the mean reimbursement for initial treatment was €17,617.66, while FRI treatment costs were €31,731.49, resulting in a difference of €14,113.83 and a 1.8-fold increase in costs. Tibia fractures showed an increase from €10,327.70 to €28,024.38 (difference of €17,696.68, 2.7-fold increase of costs). Ankle fractures had a cost increase from €3,790.38 to €17,940.90 (difference of €14,150.52, 4.7-fold increase of costs), and foot fractures showed an increase from €6,557.95 to €23,272.48 (difference of €16,714.53, 3.5-fold increase of costs). Conclusions:. The costs for FRI treatment are substantially higher than those for initial fracture management across all fracture types studied. These findings emphasize the need for effective preventive measures and efficient management protocols to reduce the incidence and financial impact of FRIs. Level of Evidence:. Level III. See Instructions for Authors for a complete description of levels of evidence.

Civilian firearm violence is a significant healthcare burden and particularly fractures after gunshot injuries are at risk for fracture related infection (FRI). This risk has been reported between 3.6 and 22 % in different retrospective case series. A central question is how to prevent this complication after ballistic injuries. Antibiotic prophylaxis - or better preemptive antibiotic therapy - should be applied early and recent data do not show benefits for long duration. A recent paper demonstrated that prophylactic antibiotic administration for ≥48 h is unwarranted for patients with ballistic fractures to the extremities and may even be associated with a higher infection risk. Three days of preemptive antibiotic therapy or even 24 h was not inferior compared to longer-duration therapy in the development of infectious sequelae after gunshot fractures to the pelvis. The microbiological profile of FRIs following gunshot injuries is diverse, though Gram-positive pathogens dominate but also polymicrobial infections are of significance. Narrow-spectrum agents, such as cefazolin or clindamycin, showed comparable effectiveness compared to extended gram-negative coverage in uncomplicated case in the absence of visceral involvement or gross contamination. However, in cases with bowel injuries or other high-risk features, broader-spectrum therapy may still be justified. A further important question is whether or not retained bullied fragments should be removed. Recent data showed a statistically significant increased risk of FRI when retained bullied fragments are not removed at the time of internal fracture fixation. Treatment of FRI after gunshot injuries should be based on the recently developed diagnostic, classification and treatment principles of FRI in general. This includes a straight forward diagnostic approach using suggestive and confirmatory criteria. Treatment strategy should rely on a multidisciplinary approach, including all relevant disciplines, e.g. plastic surgery, microbiology, infectious disease etc. Treatment goal is the infection free consolidation of the fracture with good function of the limb with restoration of quality of life, including psycho-social health of the patient.

Septic arthritis (SA) presents a complex clinical challenge, often resulting in significant morbidity and mortality. This study aimed to (1) assess overall mortality rates and (2) identify potential factors contributing to increased mortality risk in patients with SA. This retrospective study on SA patients treated at a German university hospital between January 1, 2011, and December 31, 2021. Patients were identified using International Classification of Diseases (ICD)-10 codes for septic arthritis, specifically “M00.-”. The study evaluated mortality rates and analyzed comorbidities, pathogens, and other potential risk factors. Kaplan–Meier survival curves and odds ratios (OR) were calculated to assess mortality risk. In a cohort of 192 patients diagnosed with SA, 64 patients (33.3

Purpose With the aging population and rising life expectancy the incidence of trauma-related injuries, particularly proximal femur fractures, is expected to increase. Complications such as fracture-related infections (FRI) significantly impede the healing process and pose substantial risks to patients. Despite advancements in understanding, diagnosing, and treating FRI, challenges persist in achieving optimal outcomes. This review addresses the significance of FRI following proximal femur fractures, emphasizing diagnostic methodologies and therapeutic modalities to enhance clinical care. Findings Notably, a consensus definition for FRI has been established, providing clarity for accurate diagnosis. Diagnostic criteria encompass confirmatory and suggestive elements, facilitating precise identification of FRI. Therapeutic strategies for FRI in proximal femur fractures include a spectrum of surgical and antimicrobial approaches. Surgical interventions, ranging from debridement with implant retention over implant removal/exchange to staged conversions to arthroplasty, are tailored based on fracture stability, individual patient factors, and infection characteristics. The intricate decision-making process is elucidated, highlighting the importance of individualized treatment plans and multidisciplinary collaboration. Antimicrobial therapy plays a pivotal role in FRI management, with empirical regiments targeting common pathogens and local delivery systems offering sustained antibiotic release. Microbiological analysis and collaboration with infectious disease specialists should guide antimicrobial treatment and ensure optimal therapy efficacy. Conclusion Managing FRI following proximal femur fractures requires a tailored, multidisciplinary approach. Treatment strategies should be guided by diagnostic precision, patient-specific considerations, and collaboration among surgical, infectious disease, and clinical teams. Implementing comprehensive therapeutic approaches is essential for mitigating the impact of FRI and improving patient outcomes.

The implantation rate of knee arthroplasty and, in particular of unicondylar knee arthroplasty (UKA), is increasing, and revision is a feared complication. The aim of this study was to identify factors influencing aseptic and septic revision that are of high interest for establishing preventive measures. Data were collected using the German Arthroplasty Registry (EPRD). Patients with UKA were analyzed using the multiple Log-rank test with Holm’s method. Septic and aseptic revisions were calculated using Kaplan–Meier estimates. In total, 300,998 cases of knee arthroplasty were identified in the registry, and 36,861 patients with UKA were analyzed with a maximum follow-up of 7 years. The primary reason for UKA revision surgery was aseptic loosening (32.5

Periprosthetic joint infections (PJIs) pose significant challenges to patients and healthcare systems worldwide. The aim of this study was to estimate the health-economic burden of reimbursement payment in Europe for PJIs following primary hip and knee arthroplasty. The calculation was based on health-economic modelling using data on primary hip and knee arthroplasties for the year 2019 from the Statistical Office of the European Union (Eurostat) and published infection rates to estimate the total number of hip and knee PJIs in 30 European countries. Revision procedures were stratified into: 1) debridement, antibiotics, and implant retention (DAIR); 2) one-stage exchange; and 3) two-stage revision procedures. The cases were then multiplied by the respective healthcare system reimbursement payments. Payment data were acquired from a survey of 13 countries (Austria, Croatia, France, Germany, Italy, Lithuania, Netherlands, Norway, Portugal, Slovenia, Switzerland, Turkey, and the UK) and extrapolated for the remaining countries. In 2019, a total of 2,048,778 primary total joint replacements were performed (total hip arthroplasty (THA) = 1,147,316 and total knee arthroplasty (TKA) = 901,462), with an estimated 20,416 cases of PJIs (11,131 hip and 9,285 knee) in Europe. This results in an estimated total reimbursement burden of €346,262,026 for European healthcare systems. The breakdown for hip PJI reimbursement was €197,230,953 (€9,751,962 for DAIR procedures, €45,135,894 for one-stage revisions, and €142,343,097 for two-stage revisions). For knee PJIs, the analysis yielded a total reimbursement of €149,031,073 (€9,335,075 for DAIR procedures, €48,058,479 for one-stage revisions, and €91,637,518 for two-stage revisions). This is the first study to evaluate the health-economic burden of PJIs in Europe, revealing a substantial impact on healthcare systems with an estimated case load of 20,414 cases and overall reimbursement of €346,262,026 for primary THAs and TKAs performed in 2019. Cite this article: Bone Jt Open 2025;6(3):298–311.

Purpose Standard operating procedures aim to achieve a standardized and assumedly high-quality therapy. However, in orthopaedic surgery, the aspect of temporal urgency is often based on surgical tradition and experience. At a time of evidence-based medicine, it is necessary to question these temporal guidelines. The following review will therefore address the most important temporal guidelines in orthopaedic surgery and discuss their practical relevance and potential need for optimization. Methods The systematic review features a literature review by database search in “PubMed” (https://pubmed.ncbi.nlm.nih.gov) for time to surgery in terms of (1) “proximal femoral fractures”, (2) “femoral neck fractures”, (3) “proximal humeral fractures”, (4) “ligament and tendon injuries”, (5) “spinal cord injuries”, (6) “open fractures” and (7) “fracture-related infections”. For every diagnosis, hypotheses on timing were set up and checked for evidence. Results There is solid clinical evidence supporting the initiation of treatment within 24 h for specific conditions like the surgical treatment of proximal femur fractures and prompt decompression of spinal cord injuries. However, for other scenarios such as the 6-hour rule for open fractures, joint-preserving femoral neck fractures, timing of ligament injuries, humeral head fractures and fracture-related infections there is currently no reliable evidence to guide prompt surgical treatment. Conclusion Based on the current data, resource-adapted surgical planning seems reasonable. Further research in these areas is necessary to determine the best timing of treatment and address existing doubts.

BACKGROUND:Fractures are a major public health problem, especially in older people. A better understanding of epidemiological trends and risk factors is essential for the development of prevention strategies. METHODS:We analyzed ICD-10 data provided by the German Federal Statistical Office and the Central Institute for Health Care (Zi) on inpatient and outpatient treatments for fracture in the year 2022. The frequency and distribution of fractures were examined according to anatomical site, sex, and age. The prevalence of inpatient cases was standardized to the German population and compared with figures from 2019. RESULTS:In 2022, there were 683 185 recorded fracture treatments in the inpatient setting, 1% fewer than in 2019. 63% of fractures were in women, and 71% in persons over age 65. The most common types were femoral neck fractures (129 per 100 000 population), pertrochanteric femur fractures (115/100 000), and distal radius fractures (106/100 000). Compared to 2019, there were more fractures of the femoral neck (+8%), femoral shaft (+7%), and distal humerus (+7%), and fewer fractures of the scaphoid bone (-31%), carpal and metacarpal bones (-30%), and ribs (-29%). 2 400 606 fractures were treated in the outpatient setting in 2022, corresponding to a prevalence of 2845.71/100 000. The most common types were distal radius fractures (210.76/100 000), finger fractures (186.1/100 000), and rib fractures (156.51/100 000 population). CONCLUSION:Although the overall fracture prevalence declined slightly between 2019 and 2022, certain fracture types remained prevalent or even increased in frequency. This highlights the continued need for targeted preventive strategies, particularly for older adults.

Extremity injuries appear to have less impact on the mortality of multiple trauma patients (ISS ≥ 16). The Primary Survey of the Advanced Trauma Life Support (ATLS) only lists pelvic and femur fractures among the extremity injuries. The aim of this study was to evaluate the role of multiple extremity injuries in terms of lethality, progression, and complications in multiple trauma patients and the actual influence of concomitant blood loss. The Extremity Severity Score (ESS) was developed as a central instrument for this purpose. This investigation is a retrospective single center study at a Level I trauma center over the period 2008–2019. The study cohort was identified as patients who met an Injury Severity Score (ISS) of at least 16. People who were < 16 years old at the time of the accident, patients who were primarily treated in other hospitals or transferred directly from the trauma bay, and cases without a Revised Injury Severity Classification Score 2 (RISC2) were excluded. Similar to the calculation of the ISS or NISS, the three most severe limb injuries (including the bony pelvis, corresponding to the ISS region of the extremities) were squared and added together to calculate the ESS. The study cohort was divided into the groups ESS ≥ 16 and ESS < 16 and these were examined with regard to the primary endpoint of lethality and several secondary endpoints. In addition to the univariate analysis of the data set, a logistic regression model was calculated. Out of 3.101 cases 1.227 patients and 5.824 extremity injuries met the inclusion criteria. Both unadjusted lethality and Standardized Mortality Rate (SMR) were not significantly different for the EES < 16 vs. ESS ≥ 16 group overall (22.5

Fracture-related infections (FRIs) are complex challenges in orthopedic and trauma surgery, driving ongoing advancements in diagnostics, therapeutics, and management strategies. This scoping review examines recent progress and future directions in FRI management. Diagnostic enhancements encompass standardized definitions, improved biomarkers, advanced microbiological techniques, and innovative imaging modalities. Promising future diagnostics may include point-of-care testing, advanced imaging with enhanced specificity, and machine learning algorithms. Advancements in implant technology emphasize materials science, surface modifications, and personalized 3D printing, enhancing durability and antimicrobial efficacy. Immunomodulatory therapies targeting T cell dysfunction offer potential in addressing FRI chronicity. Enzybiotics and phages present promising alternatives to combat antibiotic resistance, with enzybiotics demonstrating effectiveness against biofilm-associated infections. Patient optimization, multidisciplinary approaches and specialized reference centers play vital roles in comprehensive FRI management, particularly crucial in resource-constrained settings. Collaboration and investment in research and technology are imperative for harnessing the full potential of these advancements and improving global FRI management outcomes. Addressing these complexities necessitates a multifaceted approach integrating clinical expertise, technological innovation, and global cooperation to optimize patient care and mitigate the burden of FRI worldwide.

Aims:This study aimed to evaluate the clinical application of the PJI-TNM classification for periprosthetic joint infection (PJI) by determining intraobserver and interobserver reliability. To facilitate its use in clinical practice, an educational app was subsequently developed and evaluated. Methods:A total of ten orthopaedic surgeons classified 20 cases of PJI based on the PJI-TNM classification. Subsequently, the classification was re-evaluated using the PJI-TNM app. Classification accuracy was calculated separately for each subcategory (reinfection, tissue and implant condition, non-human cells, and morbidity of the patient). Fleiss' kappa and Cohen's kappa were calculated for interobserver and intraobserver reliability, respectively. Results:Overall, interobserver and intraobserver agreements were substantial across the 20 classified cases. Analyses for the variable 'reinfection' revealed an almost perfect interobserver and intraobserver agreement with a classification accuracy of 94.8%. The category 'tissue and implant conditions' showed moderate interobserver and substantial intraobserver reliability, while the classification accuracy was 70.8%. For 'non-human cells,' accuracy was 81.0% and interobserver agreement was moderate with an almost perfect intraobserver reliability. The classification accuracy of the variable 'morbidity of the patient' reached 73.5% with a moderate interobserver agreement, whereas the intraobserver agreement was substantial. The application of the app yielded comparable results across all subgroups. Conclusion:The PJI-TNM classification system captures the heterogeneity of PJI and can be applied with substantial inter- and intraobserver reliability. The PJI-TNM educational app aims to facilitate application in clinical practice. A major limitation was the correct assessment of the implant situation. To eliminate this, a re-evaluation according to intraoperative findings is strongly recommended.