Increasing incidences for fragility fractures of the pelvis (FFP) have been reported and surgical treatment remains demanding. While conventional screw osteosynthesis is a common method, complications may arise due to altered bone morphology in the osteoporotic pelvic bone. The iFuse implant system is a novel implant, first introduced for treatment of degenerative sacroiliac joint dysfunction, which offers promising biomechanical characteristics with potential benefits for treatment of FFP. Yet data on the use for FFP is limited. The objective of this study is to compare early postoperative mobility of patients treated with screw osteosynthesis only versus patients treated with additional iFuse stabilization based on insole force sensor gait analysis. We hypothesized that additional iFuse implantation leads to superior postoperative mobility. In the prospective observational study, 37 orthogeriatric patients with FFP types II-IV were included. Postoperative mobility of patients treated with conventional screw osteosynthesis only (group 1) and patients with additional iFuse implantation (group 2) was compared. Mobility was examined using insole force sensors (Loadsol®, Novel GmbH). Postoperative comparison of gait analysis showed no significant difference in average (APF) and maximum peak force (MPF) between group 1 (n = 19, APF 64.9

Background Ankle fractures are one of the most common fractures in adults but due to their complexity, often result in inferior treatment outcomes. One reason could be undiagnosed concomitant ligamentous and (osteo)chondral injuries.Material and methods The preoperative diagnosis of these injuries is only possible to a limited extent, even by magnetic resonance imaging (MRI). Additive arthroscopy during the operative treatment of ankle fractures enables the diagnosis and treatment of chondral lesions, latent instability of syndesmoses as well as superficial and deep ruptures of the deltoid ligament. Within the operative workflow arthroscopy should be performed initially as well as at the end of surgery. The initial lax situs enables a complete overview of the joint and facilitates the treatment of chondral lesions. After complete osseous and ligamentous stabilization, the final arthroscopy enables verification of the reduction, removal of residual free intra-articular fragments and resection of interposing soft tissue components.Results Based on the available study situation, additive arthroscopy slightly increases the operative time and costs without increasing the complication rate. In the context of unimalleolar ankle fractures, several studies have shown an advantage for arthroscopically assisted fracture treatment. For more complex ankle fractures, comparative high-quality studies are lacking. A consistent superiority compared to open reduction alone has not yet been demonstrated for complex ankle fractures.

Frakturen des Sprunggelenks gehören zu den häufigsten Brüchen im Erwachsenenalter, resultieren jedoch aufgrund ihrer Komplexität oft in schlechten Behandlungsergebnissen. Eine Ursache könnten die ligamentären und (osteo)chondralen Begleitverletzungen sein. Die präoperative Diagnose dieser Verletzungen ist selbst mittels Magnetresonanztomographie (MRT) nur eingeschränkt möglich. Die additive Arthroskopie im Rahmen der operativen Versorgung von Sprunggelenkfrakturen erlaubt die Diagnose und Therapie von chondralen Läsionen, latenten Syndesmoseninstabilitäten sowie oberflächlichen und tiefen Deltabandrupturen. Im Rahmen des operativen Workflows sollte die Arthroskopie initial sowie zum Abschluss der Operation durchgeführt werden. Der initial laxe Situs erlaubt eine vollständige Übersicht des Gelenks und erleichtert die Therapie von Knorpelschäden. Nach vollständiger ossärer und ligamentärer Stabilisierung erlaubt die finale Arthroskopie die Repositionskontrolle, Entfernung verbleibender freier Gelenkkörper sowie die Resektion von einschlagenden Kapsel-Band-Anteilen. Basierend auf der vorhandenen Studienlage, erhöht die additive Arthroskopie die Operationszeit und Kosten geringfügig, ohne dabei die Komplikationsrate zu steigern. Für unimalleolare Sprunggelenkfrakturen konnten mehrere Studien einen Vorteil der arthroskopisch assistierten Frakturversorgung zeigen. Bei komplexeren Frakturen fehlen vergleichende, qualitativ hochwertige Studien. Eine konstante Überlegenheit im Vergleich zu der alleinigen offenen Reposition konnte für komplexe Sprunggelenkfrakturen noch nicht belegt werden.

Die Zahl der Patienten mit Sprunggelenkarthrosen, die mit einer Endoprothese versorgt sind, hat in den letzten Jahren stetig zugenommen. Die Standzeit der Implantate liegt weit unter den bekannten Ergebnissen aus der Hüft- und Kniegelenkendoprothetik. Es wird teilweise von einer jährlichen rund 1 %gen Versagensrate bzw. einer Überlebensrate von 70 % nach 10 Jahren berichtet. Die häufigsten Revisionsgründe einer Prothese des oberen Sprunggelenks (OSG) sind die aseptische Lockerung, technische Einbaufehler und persistierende Schmerzen. Bei der Revision der Sprunggelenkprothese gibt es grundsätzlich 2 Optionen in der Versorgung. Lange Zeit galt die Sprunggelenkarthrodese als Goldstandard nach gescheiterter Prothese. Seit den letzten Jahren besteht aufgrund neuer Revisions-Prothesen, auch die Möglichkeit der Re-Implantation einer OSG-Prothese. Je nach Genese des Versagens und der Größe des Knochendefekts muss zwischen einer einzeitigen Operation und einem zweizeitigen Verfahren mit Knochenaugmentation entschieden werden. Der vorliegende Beitrag stellt die Vor- und Nachteile einer Arthrodese sowie einer Revisionsendoprothese nach gescheiterter primärer OSG-Endoprothese dar und beleuchtet die operativen Besonderheiten.

Abstract Background Posttraumatic shoulder stiffness remains a problem after proximal humerus fracture (PHF) despite good healing rates. The aim of this pilot study was to determine whether the implant material and overlying soft tissue have an effect on shoulder range of motion (ROM) before and after implant removal (IR). Methods 16 patients (mean age 55.2 ± 15.3 (SD) years; 62.5% female) were included who underwent operative treatment with locking plates of either carbon fiber reinforced Polyetheretherketone (PEEK) (PEEKPower® humeral fracture plate, Arthrex, Naples, Florida, USA, n = 8) or titanium alloy (Ti) (Philos®, DePuy Synthes, Johnson & Johnson Medical, Raynham, Massachusetts, USA, n = 8) for PHF. All patients presented with a limited ROM and persistent pain in everyday life after the fracture had healed, whereupon IR was indicated. ROM before and after IR were compared as well as the Constant Score (CS) and the CS compared to the contralateral shoulder (%CS) 1 year after IR. Results In group PEEK, elevation was 116.3° ± 19.2° pre- and 129.4° ± 23.7° post-IR (p = 0.027). External rotation was 35.0° ± 7.6° pre- and 50.6° ± 21.8° post-IR (p = 0.041). External rotation with the humerus abducted 90° was 38.8° ± 18.1° pre- and 52.5° ± 25.5° post-IR (p = 0.024). In group Ti, elevation was 110.0° ± 34.6° pre- and 133.8° ± 31.1° post-IR (p = 0.011). External rotation with the humerus at rest was 33.8° ± 23.1° pre- and 48.8° ± 18.7° post-IR (p = 0.048). External rotation with the humerus abducted 90° was 40.0° ± 31.6° pre- and 52.5° ± 22.5° post-IR (p = 0.011). Comparison of the two implant materials showed no significant difference. The overall CS was 90.3 ± 8.8, the %CS was 91.8% ± 14.7%. Conclusion There was no significant difference in ROM, CS and %CS with respect to plate materials, although lower cell adhesion is reported for the hydrophobic PEEK. However, all patients showed improved functional outcomes after IR in this pilot study. In patients with shoulder stiffness following locked plating for PHF, implants should be removed and open arthrolysis should be performed, independently from the hardware material. Level of evidence II

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.

Purpose:The aim was to conduct a systematic literature review and meta-anaylsis to analyze the diagnostic accuracy of the external rotation stress test (ERST) for syndesmotic injuries.Methods:The systematic review was conducted according to the PRISMA-P guidelines (Prospero ID: CRD42021282457). Four common databases were searched from inception to September 29, 2021. Eligible were any studies facilitating the ERST under fluoroscopy in a defined state of syndesmotic instability. Syndesmotic ligament-specific rupture must have been proven by MRI, arthroscopy, or controlled dissection (cadaver study). Two reviewers independently conducted each step of the systematic literature review. The risk of bias was assessed by the Quality Appraisal for Cadaveric Studies Score scale. The data analysis was performed qualitatively and quantitatively.Results:Eight studies were eligible for a qualitative analysis, and six studies were eligible for a quantitative analysis. All studies included were cadaver studies. The qualitative analysis comprised 94 specimens and revealed considerable heterogeneity. Six studies allowed for a quantitative analysis of the tibiofibular clear space (TFCS) and five studies for the medial clear space (MCS) during the ERST. The quantitative analysis of the TFCS revealed no significant differences between intact and any stage of syndesmotic injury. The MCS was able to differentiate between intact and 2-ligament- (Z = 2.04, P = 0.02), 3-ligament- (Z = 3.2, P = 0.001), and 3-ligament + deltoid ruptures (Z = 3.35, P < 0.001).Conclusion:The ERST is the only noninvasive test to assess syndesmotic instability and can be conducted bilaterally. The uninjured contralateral side can serve as a baseline reference. Based on the conducted quantitative analysis, the MCS seems to be able to differentiate between stable (intact/1-ligament) and unstable (2-ligament/3-ligament) lesions.

To firstly examine the pain levels during distraction osteogenesis (DO) with lengthening nails (LN) in a large sample. A total of 168 cases underwent DO of the tibia or femur with five different models of LN. Under a standardized medical regime, daily pain levels were noted as nominal rating scale (NRS) score (0–10) during the distraction phase. NRS scores and several potential influence factors (LN model, bone, approach, side, age, gender) were evaluated. The mean distraction length was 39.1 ± 14.4 mm. The average NRS score decreased from postoperative day 1 with 2.84 nonlinearly by 1.03 points (36.3

Purpose The purposes of the study were to (1) analyze the shape of the distal fibula at the location of syndesmotic stabilization and to (2) define safe zones at the distal-lateral fibula for three different drilling tunnel orientations: anteriorly-, posteriorly angulated and center-center. Methods Postoperative, bilateral CT images of adult patients that underwent syndesmotic stabilization (suture-button system) for an acute, unilateral ankle injury were analyzed. Manual axial CT reconstructions of the uninjured side were generated. First, the axial shape of the distal fibula was classified. The aspect ratio between the anterio-lateral and the posterior-lateral surfaces of the fibula was calculated to assess symmetry. Second, the same axial planes were used to define the safe zones. Each drilling-tunnel orientation (anterior, central, posterior) comprised a fixed medial tibial anchor point and a safe zone on the lateral fibula. For each of the three orientations, the most anteriorly and posteriorly drilling tunnel location was simulated. Next to a cumulative visual analysis, a quantitative analysis of the most anterior and posterior point on the anterio- and posterior-lateral surfaces was calculated. Results A total of 96 CT datasets were analyzed. (1) 81% of fibulae revealed a triangular convex-, 10% an irregular-, and 8% a quadrilateral shape. The lateral surface ratio was 1.0 ± 0.2 (range: 0.7–1.5), not differing between the fibula types (n.s.). (2) The safe corridor on the lateral surface of the fibula for an anteriorly angulated drilling tunnel was − 8% to − 41%, for a posteriorly angulated drilling tunnel was 0% to 46%, and for a center-center alignment − 7 ± 11% (range: − 28 to 18%). Conclusion The meta-diaphyseal region of the distal fibula revealed a homogeneous crosssectional shape. The lateral apex of the fibula can serve as a landmark defining safe zones to place the drilling tunnels correctly. Applying these safe zones in clinical practice could help to avoid the misplacement of the syndesmotic fixation device. Level of evidence Level III, retrospective radiographic study.

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.