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Background Negative Pressure Wound Therapy (NPWT) is being increasingly used to treat postoperative infections after osteosynthetic fracture fixation. The aim of the present study was to analyze the influence of epidemiological and microbiological parameters on outcome. Methods Infections following operative fracture fixation were registered in a comprehensive Critical Incidence Reporting System and subsequently analyzed retrospectively for characteristics of patients including comorbidity, bacteria, and clinical factors. The influence of the investigated parameters was analyzed using logistic regression models based on data from 106 patients. Results Staged wound lavage in combination with NPWT allowed implant preservation in 44% and led to successful healing in 73% of patients. Fermentation characteristics, load and behavior after gram staining revealed no statistically significant correlation with either healing or implant preservation. Infecting bacteria were successfully isolated in 87% of patients. 20% of all infections were caused by bacterial combinations. We observed a change in the infecting bacterial species under therapy in 23%. Age, gender, metabolic diseases or comorbidities did not influence the probability of implant preservation or healing. The delayed manifestation of infection (>4 weeks) correlated with a higher risk for implant loss (OR 5.1 [95% CI 1.41–17.92]) as did the presence of bacterial mixture (OR 5.0 [95% CI 1.41–17.92]) and open soft-tissue damage ≥ grade 3 (OR 10.2 [CI 1.88–55.28]). Wounds were less likely to heal in conjunction with high CRP blood levels (>20 mg/l) at the time of discharge (OR 3.6 [95% CI 1.31–10.08]) or following a change of the infecting bacterial species under therapy (OR 3.2 [95% CI, 1.13–8.99]). Conclusions These results indicate that the delayed manifestation of infection, high CRP blood levels at discharge, and alterations in the infecting bacterial species under therapy raise the risk of NPWT failure.

Purpose The aim of the present study was to assess the changes in rotational alignment introduced by total knee arthroplasty (TKA) and the reproducibility of pre- and postoperative CT measurements of rotational limb alignment. Methods For this purpose we analyzed data from 196 consecutive cruciate-retaining, fixed bearing Columbus TKA procedures. Both pre- and postoperative scans torsion difference CT scans were available for measurements in 89 cases. Using these CT scans the neck-malleolar angle (NMA), the femoral posterior condylar angle (fPCA), the tibial posterior condylar axis (tPCA) and the tibial torsion angle (TTA) were independently assessed by three raters. CT scans were re-evaluated 8 weeks later by the most experienced rater for assessment of intraobserver agreement. Results Measurements of all angles were prone to high standard deviations reflecting interindividual variability. Mean fPCA changed from 1.3° to 2.7° internal rotation preoperatively to 0.1°–1.9° internal rotation postoperatively. Based on a relative external rotation of the tibial base plate as compared to the preoperative situation, we found a relative internal rotation of the postoperative NMA and tibial torsion of 3°–5.4° and 6°–7.5°, respectively. Intra- and interobserver agreement was strong for all angles assessed (ICCs 0.7–1.0) except for fPCA (ICC 0.2–0.6). However, mean absolute measurement differences for fPCA were clinically acceptable (1.2°–2.6°). Conclusions Reproducibility of CT rotational limb alignment measurements was found to be clinically acceptable. Rotational alignment of the femoral and even more so of the tibial component will ultimately affect the rotational alignment of the entire limb—at least when fixed bearings are used. Level of evidence Diagnostic study, Level III.

Background Precise indications for computed tomography (CT) in proximal humeral fractures are not established. The purpose of this study was a comparison of conventional radiographic views with different CT reconstructions with 2 D and 3 D imaging to establish indications for additional CT diagnostics depending on the fractured parts. Methods In a prospective diagnostic study in two level 1 trauma centers, 44 patients with proximal humeral fractures were diagnosed with conventional X-rays (22 AP + axillary views, 22 AP + scapular Y-views) and CT (multi-planar reconstruction (MPR) and maximum intensity projection (MIP)) with 2 D and 3 D imaging. 3 observers assessed the technical image quality, the assessment of the relevant anatomical structures (2-sample-t-test) and the percentage of the osseous overlap of the proximal humerus (Welch-test) using a scoring system. The quality of the different diagnostic methods was assessed according to the number of fractured parts (Bonferroni-Holm adjustment). Results There was significantly more overlap of the fractured region on the scapular Y-views (mean 71.5%, range 45–90%) than on axillary views (mean 56.2%, range 10.5–100%). CT-diagnostics allowed a significantly better assessment of the relevant structures than conventional diagnostics (p < 0.05) independently of the fracture severity (two-, three-, and four-part fractures). Conclusion Conventional X-rays with AP view and a high-quality axillary view are useful for primary diagnostics of the fracture and often but not always show a clear presentation of the relevant bony structures such as both tuberosities, the glenoid and humeral head. CT with thin slices technology and additional 3 D imaging provides always a clear presentation of the fractured region. Clinically, a CT should be performed – independently of the number of fractured parts – when the proximal humerus and the shoulder joint are not presented with sufficient X-ray-quality to establish a treatment plan.

The complication rate after trauma-associated spine surgery remains unknown because of the rarity of this injury and the polymorphism of treatment methods. We report the complication rates recorded at one center after treatment of unstable vertebral body fractures according to a single, uniform procedure. The aim of this analysis was to identify the typical complications associated with this surgical procedure and, consequently, to contribute to critical deliberations on the introduction of technical innovations such as navigation, intraoperative three-dimensional imaging, and neuromonitoring. Perioperative complications related to surgery of 208 consecutive patients, operated on for unstable vertebral body fractures were analyzed. First, stabilization was performed through an open, posterior, nonnavigated approach. This was followed, in all patients, by reconstruction of the anterior column form with a tricortical iliac crest graft during a second operation. In regard to posterior stabilization, at least one pedicle screw in six patients (3%) was placed incorrectly; furthermore, there were five patients with general complications, all of which required revision surgery. After anterior spondylodesis, there were also nine general complications and five neurological complications, one of them in a patient with persistent paraplegia. At the graft donor site, three patients experienced an avulsion fracture of the anterosuperior iliac crest. Overall, at least one complication occurred in 13% of patients (confidence interval 0.08–0.18). With regard to early complications, two-stage anteroposterior stabilization of unstable spinal fractures of the thoracolumbar spine is a reliable procedure.

Purpose. Anderson type III odontoid fractures have traditionally been considered stable and treated conservatively. However, unstable cases with unfavorable results following conservative treatment have been reported. Methods. We present the cases of two patients who sustained minimally displaced Anderson type III fractures with a characteristic fracture pattern that we refer to as “oblique type axis body fracture.” Results. The female patients aged 90 and 72 years, respectively, were both diagnosed with minimally displaced Anderson type III fractures. Both fractures had a characteristic “oblique type” fracture pattern. The first patient was treated conservatively with cervical spine immobilization in a semirigid collar. However, gross displacement was noted at the 6-week follow-up visit. The second patient was therefore treated operatively by C1–C3/4 posterior fusion and the course was uneventful. Conclusions. Oblique type axis body fractures resemble a highly unstable subtype of Anderson type III fractures with the potential of severe secondary deformity following conservative treatment, irrespective of initial grade of displacement. The authors therefore warrant a high index of suspicion for this injury and suggest early operative stabilization.

Purpose The aim of this study was to determine how well pre-operative size selection for total knee and hip arthroplasties based on the digital imaging with and without additional referencing correlated with the size actually implanted. Methods Size selection planning of total knee arthroplasty by digital templating was documented in 46 cases with reference ball (group A) and in 48 cases without ball (group B). In addition, prospective analysis of pre-operative planning was conducted for 52 acetabular components with reference ball (group C) and 69 without ball (group D) as well as stem planning in 38 cases with ball (group E) and 54 cases without ball (group F). The data were analysed and compared with the size of the final component selected during surgery. Results The correlation between planned and implanted size for total knee arthroplasty in group A resulted in femoral anteroposterior (AP) r = 0.8622 and lateral r = 0.8333 and in group B AP r = 0.4552 and lateral r = 0.6950. Tibial in group A was AP r = 0.9030 and lateral r = 0.9074 and in group B AP r = 0.7000 and lateral r = 0.6376. For the acetabular components, the results in group C were r = 0.5998 and group D r = 0.6923. For stems, group E was r = 0.5306 and group F r = 0.5786. No correlation between BMI and the difference between planned and implanted size was found in any of the groups. Conclusion In the case of total hip arthroplasty there was a relatively low correlation between planned and implanted sizes with or without reference ball. For total knee arthroplasties the already high precision of size planning was further improved by the additional referencing with a reference ball.

Purpose Relatively little is known about the extent to which periprosthetic joint infections (PJI) affect the patient’s long-term quality of life (QoL). Our study aim was to assess the effect of a periprosthetic infection on our patients’ QoL. Methods We collected data retrospectively of patients who had undergone surgery in our institution between 2006 and 2011. To capture their overall QoL, we telephoned the patients who could be reached and asked them the questions on the SF-12 questionnaire. Results In 84 patients (53 male, 31 female, 43 TKA and 41 THA), 88 % of the hip infections and 62 % of the knee infections had been successfully treated. The hip infections’ cure rate was significantly higher than that of the knee joint infections. The average SF-12 score was 36.2 points on the physical scale and 52 on the mental scale. The difference in QoL between patients with and without successful infection therapy was not significant, nor did the site of the infection (knee or hip) influence QoL significantly. Comparison of our patients’ QoL data to that from the general population revealed a significant difference in the physical scale but not the mental scale. Conclusion From these results QoL is substantially reduced after a prosthetic infection. We did however observe that post-Girdelstone procedure patients or those with an arthrodesis attained an acceptable QoL, and that those methods remain therapeutic alternatives as far as patient-perceived QoL is concerned.

The demographic shift is expected to lead to a further increase in the number of hip joint replacements. Accordingly, as has already been observed in recent years, a further increase in periprosthetic femoral fractures (PPF) is to be expected. PPF is now the third most common reason for revision surgery after hip arthroplasty. Taking into account the known risk factors for PPF, fracture treatment strategies are evaluated based on current evidence in order to make recommendations for practice. Narrative review. Overall, the literature is very heterogeneous and evidence is lacking for many aspects. Numerous recommendations are based on non-randomized studies with low patient count. Mortality after PPF is high regardless of the treatment chosen. Age and bone quality influence the partly heterogeneous results and play a role in the treatment strategy. The use of both cemented and uncemented stems in revision surgery due to proximal PPF is frequently described in the literature. There are no significant differences in terms of outcome. The advantage of uncemented modular stems is currently not supported by the literature. An individualized approach to the treatment of PPF is recommended, considering environmental factors and comorbidities. In geriatric patients, full weight-bearing of the lower extremity should be aimed for postoperatively to avoid complications.