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BACKGROUND: Proximal humeral fractures (PHFs) are common injuries that can lead to significant functional impairment. This retrospective cohort study aimed to evaluate the clinical outcomes and complications associated with the use of the Targon PH+ (Fa. Aesculap, Germany) intramedullary nail for the treatment of PHFs. METHODS: A subgroup consisting of 70 patients with a mean follow-up of 4.91 years out of 479 patients who underwent treatment with the Targon PH+ intramedullary nail for PHFs at a single center between 2014 and 2021 were included. Patient-reported outcome measures (PROMs) and health-related quality of life (HRQoL) were assessed using validated German versions of the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, American Shoulder and Elbow Surgeons (ASES) score, Oxford Shoulder Score (OSS), and EuroQol 5-Dimension 5-Level (EQ-5D-5L). Radiographic assessment was performed using pre- and postoperative imaging. RESULTS: Among the 70 patients of the subgroup who completed follow-up, 21.4% experienced complications, including major complications in 15.7% of cases, all of which were revised (revision rate of 15.7%). Anatomical reduction was achieved in 48,5% of cases. The mean DASH, ASES, and OSS scores were 25.4 ± 22.0, 76.2 ± 21.1, and 38.8 ± 10.3, respectively. Significant correlations were observed among the PROMs, indicating their convergent validity. Additionally, a significant correlation of all used PROMs and patient well-being (HRQoL) was observed. Severe complications and revisions were associated with significantly lower ASES scores (-11.1%, p = 0.013). There was a tendency for PROM scores to slightly decline with increasing fracture complexity, although this trend did not reach statistical significance. Our findings indicate that patients over the age of 65 years tend to exhibit lower scores in PROMs and HRQoL measures. CONCLUSION: The use of the Targon PH+ intramedullary nail for the treatment of PHFs resulted in satisfactory clinical outcomes and acceptable complication and revision rates. The PROMs and HRQoL measures indicated varying levels of disability and symptoms, with major complications, revision surgery, and age negatively impacting shoulder function after midterm follow-up.

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PURPOSE: Both dynamic intraligamentary stabilization (DIS) and reconstruction (RECO) are common treatment methods for anterior cruciate ligament (ACL) rupture. We report short term outcomes after DIS (Ligamys, Mathys, Bettlach, Switzerland) and RECO using semitendinosus tendon. We compared postoperative complications, deficits of range-of-motion (ROM), and revision rates between the two treatment options. METHODS: A total of 690 patients (437 male, 253 female), after either DIS or RECO, were included. Of these, 147 patients (21%) received DIS and 543 (79%) underwent RECO. Follow-up examination focused on clinical examination, complications and revision rates. Anteroposterior instability and ROM deficits were analyzed in order to evaluate our policy of early intervention for all cases of ROM restrictions. RESULTS: Relevant ROM restrictions occurred at a significantly higher rate after DIS than after RECO (4.8% vs. 1.3%; p = 0.008). Flexion was more restricted after DIS than RECO (110° vs. 124°, p < 0.001). Extension deficits also occurred more frequently after DIS compared to RECO (49.7% vs. 24.5%; p < 0.001). Total revision surgery rate was 9.1%, with patients after DIS being significantly more frequently affected (20.4% vs. 6.1%; p < 0.001). CONCLUSIONS: Our findings indicate a significantly higher risk for ROM restriction after DIS compared to RECO, resulting in a significantly higher revision rate.

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PURPOSE: To evaluate the current practice regarding the prevalence and sequence of x-ray and CT scan in diagnostic algorithms for multiple injured patients. METHODS: All primarily treated patients with ISS ≥ 9 were selected from the TraumaRegister DGU® (years 2008-2015; n = 109,257). Four subgroups of diagnostic algorithm were defined: CT only (group C; n = 63,763), CT before x-ray (group CX; n = 3711), x-ray followed by CT (group XC; n = 33,590), and x-ray only (group X, n = 8193). We analysed the type and sequence of diagnostic procedures and their association with hospital mortality and length-of-stay in the emergency room (ER-LOS). RESULTS: Predominant strategies were CT only (58.4%) and x-ray followed by CT (30.7%). Overall mortality was between 10 and 12% in all subgroups involving CT, and 6.6% in the x-ray only group. Expected mortality was within the 95% confidence of observed mortality except for the CX group (observed 10.0%; CI95 8.9-11.0; expected 11.1%). Mean / median length of stay in the emergency room was shortest in the CT only subgroup: (60 / 50 min). Prior x-ray diagnostic resulted in additional 3 min (group XC). The use of additional x-ray diagnostic decreased from 51.6% (in 2008) to 35.4% (in 2015). CONCLUSIONS: ER-LOS is significantly affected by diagnostic pathway. CT scan alone accelerates ER-LOS, which however was not associated with lower mortality rates. Performing completive x-ray examinations after an initial CT scan seems not to deteriorate mortality rates.

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Sacral fractures in geriatric patients are increasing and form a distinct entity. Clinical findings can be unspecific, which is why they are easily overlooked. It is mandatory to analyze the whole pelvic ring for evaluation of pelvic stability and for making treatment decisions. The primary diagnostics are made using plain X­radiography; however, for assessment of the posterior pelvic ring an examination using sectional imaging is regularly necessary. The fragility fractures of the pelvis (FFP) classification is suitable as a guideline for the surgical treatment to be used. Stable fractures without relevant displacement after initial mobilization should be treated conservatively. Instability, failure of mobilization and persistent pain are, however, common reasons for surgical treatment. Fracture displacement determines if minimally invasive procedures for posterior and anterior pelvic ring stabilization are possible. Otherwise, complex open procedures such as spinopelvic fixation may be necessary.

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OBJECTIVE: The purpose of this study was to compare results of osteochondral fractures (OCF) after first-time lateral patella dislocation, when either refixation or debridement was performed in a mid- to long-term follow-up and to analyze redislocation and reintervention rates. DESIGN: Fifty-three consecutive patients with OCF were included in this retrospective comparative study. Indication for refixation was presence of subchondral bone at the fragment. Thirty-six OCF were located at the patellar surface, and 17 at the lateral condyle of the distal femur. Refixation was performed in 28 patients while 25 patients underwent removal and debridement. Mean follow-up was 8.9 years (±4.4, range 2.0-16.7 years). For assessment of clinical outcome, the International Knee Documentation Committee (IKDC) Score, Knee Injury and Osteoarthritis Outcome Score (KOOS), and Lysholm score were used. Redislocation rate and further surgical interventions within follow-up were evaluated. RESULTS: All clinical scores in the refixation group yielded significantly better results at mid- to long term follow-up (IKDC P < 0.001, KOOS P = 0.006, Lysholm P = 0.001). Significantly more surgical reinterventions were necessary after debridement (48% vs. 7.1%, P = 0.001). The overall redislocation rate in cases with medial reefing as single stabilizing procedure was 43.3%. CONCLUSIONS: Refixation of OCF after lateral patella dislocation shows improved clinical outcome at mid- to long-term follow-up compared with debridement. Therefore, effort to try fragment refixation is recommended. Redislocation rate is high without proper restoration of patellofemoral instability.

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BACKGROUND: American football is known for its high risk of injury, especially in the professional field. Although the number of players in the German football league (GFL) has risen in recent years, data concerning the injury rates of German amateur players in American football are scarce. OBJECTIVE: Analysis of the injury rates in league games and training sessions in amateur football according to playing positions and body region. MATERIAL AND METHODS: Injuries of 123 American football players in a club playing in the second GFL (first and second team) were prospectively recorded over a period of 4 seasons (2014-2018). A complete history of injuries was obtained from 72 players. The injuries were classified using the Orchard sports injury classification system 10.1 (OSICS 10.1). The injury rates were calculated per 1000 athlete exposures (AE) for training as well as for league games with respect to the playing position and for each body region. RESULTS: Overall 142 injuries were recorded. On average there were 35.5 injuries per season and 1.9 injuries per player. Of the injuries 54.7% occurred during training and 46.1% during games. The risk of injury was significantly increased during league games (15.6 ± 16.3) compared to training (3.1 ± 2.7, p < 0.0001). While wide receivers and cornerbacks had the highest overall injury rates, running backs had the highest injury risk during games (p = 0.046). Injuries to knees (27.3%) and shoulders (20.1%) were the most frequent. The shoulder was the body region injured most frequently during games (p = 0.002). Regarding the injury pattern, distorsions (30.9%) and contusions (22.5%) occurred more often compared to fractures (12.6%) and dislocations (16.1%). Concussion only contributed to 2.9% of the injuries. CONCLUSION: American football is a contact sport with high injury rates even in the German amateur field, especially during league games. Regarding body regions, shoulders and knees were predominantly affected while regarding the playing position, wide receivers and cornerbacks were particularly jeopardized. Therefore, a continuous close medical supervision during games and an intensive position-specific training seem to be necessary even in the amateur field in order to reduce the injury rate.

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INTRODUCTION: Based on a novel simple frontal view classification, a comprehensive concept for systematic management of intramedullary fixation of distal tibial fractures is introduced. Even the usage of thin (unreamed) nails allows for anatomic reduction and stable fixation if applied in combination with transmedullary support (TMS) screws. Our classification system guides the placement of the TMS screw (medial or lateral) and suggests whether to fix the fibula or not. PATIENTS AND METHODS: The fixation concept of the classification was applied to 67 distal tibial fracture cases. Patients were followed up until nail removal after at least 12 months. RESULTS: All fractures united. Besides 5 cases of slight external malrotation (<5 degrees) no axial malunion was found. Two infections were encountered, but both were treated effectively by exchange nailing, antibiotic therapy until wound healing and C-reactive protein normalization. Final functional assessment according to Olerud/Molander Score was 85 pts (100 pts. possible, range 50-100 pts). DISCUSSION: The stability we achieved even with single screw interlocking was high due to anatomic reduction with interfragmental compression in the lowest fracture line. In cases of fracture extension into the ankle joint, interfragmental compression screws were applied before nail insertion. In more comminuted fracture types additional screws are advisable. CONCLUSIONS: The frontal view classification has proven to be a reliable guideline for effective intramedullary fracture fixation by minimally invasive means, allowing for optimized soft tissue protection.

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Upper extremity fractures in the elderly are very frequent and second only to hip fractures in the group of fragility fractures. Their impact on mobility and functional decline seems to be underestimated especially when they occur in combination with lower extremity fractures. Fractures of the proximal humerus and the distal radius can often be treated conservatively; however, the indications for operative treatment must not be based on fracture morphology alone and due consideration should be given to all concomitant circumstances affecting functional aspects of patients. Operative treatment of proximal humeral fractures may aim either at preserving the humeral head or at prosthetic replacement. There is broad agreement that this decision should depend on the condition of the humeral head fragment (degree of damage, perfusion). Fixation of distal radial fractures is commonly performed with angular volar stable plates. The more complex the fracture, the more likely conservative treatment will fail.

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MAGNEZIX® CS (Syntellix AG, Hanover, Germany) is a bioabsorbable compression screw made of a magnesium alloy (MgYREZr). Currently there are only two clinical studies reporting on a limited number of elective patients who received this screw in a hallux valgus operation. We applied MAGNEZIX® CS for fixation of distal fibular fracture in a trauma patient who had sustained a bimalleolar fracture type AO 44-B2.3. Clinical course was uneventful, fracture healing occurred within three months. Follow-up X-rays showed a radiolucent area around the implant for some months, yet this radiolucent area had disappeared in the 17-months follow-up X-ray.

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MAGNEZIX® (Syntellix AG, Hanover, Germany) is a biodegradable magnesium-based alloy (MgYREZr) which is currently used to manufacture bioabsorbable compression screws. To date, there are very few studies reporting on a limited number of elective foot surgeries using this innovative implant. This case report describes the application of this screw for osteochondral fracture fixation at the humeral capitulum next to a loose radial head prosthesis, which was revised at the same time. The clinical course was uneventful. Degradation of the magnesium alloy did not interfere with fracture healing. Showing an excellent clinical result and free range-of-motion, the contour of the implant was still visible in a one-year follow-up.

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Osteoporotic spinal fractures are typical age-related fragility fractures. Their impact on the quality of life is often underestimated; therefore, anti-osteoporotic drug treatment according to the current guidelines is essential. Occult vertebral fractures may be difficult to detect and a differentiation between fresh and old fractures is often only possible with magnetic resonance imaging (MRI) to reveal cancellous bone edema. Treatment recommendations are predominantly based on traumatic fractures in younger adults and are thus not applicable in orthogeriatrics. A new classification currently under validation and presented in this article was developed in order to aid decision-making for operative interventions. Minimally invasive treatment options include vertebroplasty, kyphopasty and internal fixation. The application of cement provides additional stability but can be accompanied by cement-specific complications, such as extravasation and embolism.

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The aim of the study was to evaluate the use of incisional negative pressure wound therapy (iNPWT) in wound healing after femoral neck fracture (FNF) treated with hip hemiarthroplasty (HA) and its influence on postoperative seromas, wound secretion, as well as time and material consumption for dressing changes. The study is a prospective randomised evaluation of iNPWT in patients with large surgical wounds after FNF. Patients were randomised either to be treated by iNPWT (group A) or a standard wound dressing (group B). Follow-up included ultrasound measurements of seroma volumes on postoperative days 5 and 10, duration of wound secretion, and time and material spent for wound dressing changes. For comparison of the means, we used the t-test for independent samples, P > 0·05 was considered significant. There were 21 patients randomised in this study. Group A (11 patients, 81·6 ± 5·2 years of age) developed a seroma of 0·257 ± 0·75 cm(3) after 5 days and had a secretion of 0·9 ± 1·0 days, and the total time for dressing changes was 14·8 ± 3·9 minutes, whereas group B (ten patients, 82·6 ± 8·6 years of age) developed a seroma of 3·995 ± 5·01 cm(3) after 5 days and had a secretion of 4·3 ± 2·45 days, and the total time for dressing changes was 42·9 ± 11·0 minutes. All mentioned differences were significant. iNPWT has been used on many different types of traumatic and non-traumatic wounds. This prospective, randomised study has demonstrated decreased development of postoperative seromas, reduction of total wound secretion days and reduction of needed time for dressing changes.

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To evaluate the clinical use and economic aspects of negative pressure wound therapy (NPWT) after dorsal stabilisation of spinal fractures. This study is a prospective randomised evaluation of NPWT in patients with large surgical wounds after surgical stabilisation of spinal fractures by internal fixation. Patients were randomised to either standard wound dressing treatment (group A) or NPWT (group B). The wound area was examined by ultrasound to measure seroma volumes in both groups on the 5th and 10th day after surgery. Furthermore, data on economic aspects such as nursing time for wound care and material used for wound dressing were evaluated. A total of 20 patients (10 in each group) were enrolled. Throughout the whole study, mean seroma volume was significantly higher in group A than that in group B (day 5: 1·9 ml versus 0 ml; P = 0·0007; day 10: 1·6 ml versus 0·5 ml; P <0·024). Furthermore, patients of group A required more wound care time (group A: 31 ± 10 minutes; group B 13·8 ± 6 minutes; P = 0·0005) and more number of compresses (total number; group A 35 ± 15; group B 11 ± 3; P = 0·0376). NPWT reduced the development of postoperative seroma, reduced nursing time and reduced material required for wound care.

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INTRODUCTION: Humeral head necrosis (HHN) remains a major problem in fracture care. Neither its occurrence, its extend, nor its impact on clinical outcomes is predictable on the long term. This study was designed to evaluate clinical and radiological outcomes in patients depending on the influence of HHN. PATIENTS AND METHODS: 32 patients with a 3-6 year follow up participated in this study. Their humeral fractures had been stabilized with a standard Targon PH nail (Aesculap, Tuttlingen, Germany) for an acute humeral head fracture. Constant score (CS), DASH score, UCLA shoulder rating scale, and Neer score were assessed. Range of motion (ROM) as well as pain during exercise was documented (VAS). HHN was detected radiologically and graded in stages 0-5. RESULTS: All fractures had healed. HHN was found in 10 cases (31.3%). 4 patients (12.5%) showed interlocking screw perforation as part of the head collapse caused by HHN. Median CS was 73 (range: 24-85). There was no association detectable between number of fracture fragments and CS (p ≥ 0.631). The median DASH score was 16.4 (range: 0-74.1), UCLA score 30 (range: 9-35), Neer score 80 (range: 29-100). Three (37.5%) of the patients with a stage IV or V osteonecrosis reported about pain (twice VAS grade 4, once VAS grade 5). All patients suffering from pain were affected by high grade HHN and screw perforation. CS was nonsignificantly affected by HHN (75.5 vs. 63.5; p = 0.12), however massively diminished if additional implant protrusion was present (63.5 vs. 25; p = 0.02). Findings for normalised CS, relative CS, DASH score, UCLA shoulder rating scale, Neer score, and ROM were analogous. DISCUSSION: Whereas HHN itself seems to contribute only mildly to functional outcome, we identified screw protrusion as major predictor for bad clinical results. The high rate of HHN found in our study (31.3%) may be attributed to the inclusion of mild HHN and our long follow-up period, as it is known that late-onset HHN may occur more than 3 years after trauma. CONCLUSIONS: HHN may lead to screw perforation, resulting in poorest outcomes. We recommend regular clinical and radiographic follow-up for at least five years in order to detect impending screw perforation and plan screw removal in time.

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The name of Ender is primarily associated with the Ender nails, which were popular for trochanteric fracture fixation more than thirty years ago. However, Ender's concepts were not limited to the implant. Ender developed a unique classification system for trochanteric and subtrochanteric fractures, which provided the theory for closed reduction maneuvers that made the method so successful in his hands. While Ender's nails have become history in the meantime, his principles of fracture reduction can be readily applied on surgery with modern implants such as proximal femoral nails. This article reflects the classification and the principles published by Hans Georg Ender in some print work hardly available nowadays.

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INTRODUCTION: Intramedullary nailing is a common procedure for the treatment of proximal humeral fractures. In practical resident training this standardized operation plays an important role in the introduction to osteosynthesis. Our aim was to investigate whether assisting this operation to residents influences the surgical complication rate both in-house and on re-admission. METHODS: All 1134 patients who received a proximal humeral Targon PH nail (Aesculap) for proximal humeral fractures were included between 2000 and 2013. Several age groups (≤60 years, 61-70 years, 71-80 years, 80-90 years, and over 90 years) were analyzed separately. Complications including screw/nail protrusion, displacement, infection, humeral head necrosis, nonunion, stiffness, hematoma, impingement, screw loosening, implant failure, dislocation were recorded. 803 (70.7%) of the patients were female. Mean patient age was 71.7 years (standard deviation: 14.0 years). For detection of significantly different complication frequencies between operations performed by residents or attending physicians, we used the χ2 test in cases with all expected values greater than five, otherwise we used the two-sided Fisher's exact test. RESULTS: Supervised residents performed 204 operations. Overall complication rate was 12.6% (95% CI: 10.7-14.5%). The complication rate of the attending operations was 13.2% while it was 9.8% for resident operations. The difference was not significant. No statistically significant relation between age group and complication rate was found. In all patients older than 80 years the complication rate was higher when operated by residents compared to those operated by consultants, whereas in younger patients it was lower. Whereas the difference was not significant in patients younger than 60 and older than 80, we found significantly less complications in the group of patients between 61 and 80 years of age. On the other hand patients between 81 and 90 years displayed a 1.46 fold higher risk after training operations. No significant differences in the frequency of the different complications were found. CONCLUSION: We conclude that proximal humeral nailing is an operation suitable for teaching purposes. However, patients between 81 and 90 years of age seem to be at an increased risk for complications if operated by a resident.

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We examined the relationship between postoperative dietary intake (DI) of geriatric hip fracture (HF) patients and their functional and clinical course until 6 months after hospital discharge. In eighty-eight HF patients ≥ 75 years, postoperative DI was estimated with plate diagrams of main meals over four postoperative days. DI was stratified as >50, >25-50, ≤ 25 % of meals served. Functional status according to Barthel index (activities of daily living) and patients' mobility level before fracture, postoperatively, at discharge and 6 months later were assessed and related to DI levels. In-hospital complications were recorded according to clinical diagnosis. Associations were evaluated using χ2 and Kruskal-Wallis tests, and repeated-measures ANOVA and ANCOVA. Postoperatively, 28 % of participants ate >50 %, 43 % ate >25-50 % and 28 % ≤ 25 % of meals served. Irrespective of pre-fracture functional status, patients with DI ≤ 25 % had significantly lower Barthel index scores at all times after surgery (all P50 % more often had regained their pre-fracture mobility level than those with DI ≤ 25 % at discharge (>50 %: 36 %; >25-50 %: 10 %; ≤ 25 %: 0 %; P= 0·001) and 6 months after discharge (88; 87; 68 %; P= 0·087) and had significantly less complications (median 2 (25th-75th percentile 1-3); 3 (25th-75th percentile 2-4); 3 (25th-75th percentile 3-4); P= 0·012). To conclude, geriatric HF patients had very low postoperative voluntary DI and thus need specific nutritional interventions to achieve adequate DI to support functional and clinical recovery.

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OBJECTIVES: Hip fractures (HFs) in old age frequently cause severe functional impairment and deteriorating autonomy in everyday life. Many older patients with HFs are malnourished or at risk of malnutrition. In this study, we examined the relationship between nutritional status of geriatric patients before HF and their functional and clinical course up to 6 months after hospital discharge. DESIGN: Observational study with follow-up after 6 months. SETTING: Four wards of the department of trauma and orthopedic surgery of a large urban maximum care hospital (Klinikum Nürnberg, Nuremberg, Germany). PARTICIPANTS: Geriatric patients aged ≥75 years with surgically repaired proximal femoral fracture. MEASUREMENTS: Prefracture nutritional status was determined by Mini Nutritional Assessment (MNA). Comorbidities and complications during hospital stay were obtained from medical documentation. Functional status before HF, postoperatively, at hospital discharge, and 6 months later was assessed by Barthel Index for activities of daily living (ADL) and patients' mobility level and related to MNA categories. Associations were evaluated using χ(2), Fisher exact, Kruskal-Wallis, Mann-Whitney-U, Jonckheere-Terpstra, and Cochrane-Armitage tests as appropriate, as well as analysis of covariance with repeated measures. RESULTS: Of 97 included patients, 17% were malnourished and 38% at risk of malnutrition before HF. Participants with (risk of) malnutrition were equally mobile but more dependent in ADL prior to HF than well-nourished patients (P < .001). Independent of nutritional status, after 6 months 68% of participants had not regained their prefracture level of independence in ADL. According to analysis of covariance, the ADL development over time until follow-up 6 months after hospital discharge did not depend on nutritional status. However, at follow-up malnourished patients more often suffered from remaining losses in ADL ≥25% of initial Barthel Index points (P = .033) and less often had regained their prefracture mobility level (P = .020) than well-nourished patients. Clinical course did not differ significantly between the groups with different nutritional status. CONCLUSIONS: In this study with geriatric HF patients from all functional and cognitive levels, worse prefracture nutritional status was associated with worse functional status and more frequent remaining functional loss, whereas the trajectory of ADL recovery and clinical course did not differ significantly. Further studies with sufficient statistical power are needed to substantiate these inconclusive results. In order to clarify the association of nutritional status with functional and clinical course in geriatric patients after HF, they should preferably focus on the role of nutritional management during the hospital stay.

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