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Background The temporary use of external fixators is an established method for stabilising fractures, particularly for injuries that do not initially allow definitive treatment. Despite its frequent use, it remains unclear whether the interval between fixator application and subsequent definitive fracture treatment affects microbial colonisation of the fixation screws prior to internal fixation. Methods This prospective, single-centre study included patients aged 18 years or older between April 2023 and April 2024 who received a temporary fixator during initial fracture management. During definitive osteosynthesis, two bone-anchored Schanz screws were removed under sterile conditions and processed by sonication; the study was approved by the local ethics committee with written informed consent obtained from all participants. The primary endpoint was the incidence of positive sonication. In cases with microbial detection, the microbial spectrum was assessed, and the influence of fixation time and patient-related factors on colonisation and microbial distribution was analysed. Statistical analyses included chi-square testing, univariate analyses, and multivariable logistic regression with fixation duration modelled both dichotomously and as a continuous variable. Results A total of 271 patients ( n = 542 samples; two screw tips per patient processed together) were included. The median fixation time until definitive osteosynthesis was 8 days. Positive microbial colonisation was observed in 88 patients (32.5%). Patients with an external fixation time > 8 days ( n = 120) showed a significantly higher colonisation rate of 43.3% (odds ratio 2.44, 95% CI 1.46–4.09; p = 0.001) compared with patients with ≤ 8 days ( n = 151; colonisation rate 23.8%; p < 0.001). Frequently detected organisms included Staphylococcus epidermidis, Staphylococcus capitis and Staphylococcus aureus. Pre-existing conditions such as type 2 diabetes mellitus, nicotine abuse and BMI showed no significant impact on colonisation. An ASA score ≥ 3 was associated with a higher colonisation rate in multivariate analysis (OR 1.59; 95% CI 1.01–2.49; p = 0.043). Conclusions Fixation duration showed a significant time-dependent association with microbiologically detected colonisation of Schanz screw tips. When modelled continuously, each additional day of fixation was associated with increased odds of colonisation. An ASA score ≥ 3 was independently associated with colonisation probability.

Background Ankle arthrodesis is an established procedure for end-stage ankle osteoarthritis. Besides the known limited functionality, gait and foot arch changes are accompanying pathologies, which are little investigated. The aim of the present study was to determine the influence of ankle arthrodesis on gait, pedobaropraphy and functional outcome. Methods Thirtyfive patients with unilateral ankle joint fusion after post-traumatic osteoarthritis and a mean follow-up of 60.8 months (SD 18.5, range 32–92) were included. Primary outcome were a 3-D gait analysis including pedobarography. American Orthopaedic Foot and Ankle Society (AOFAS) Score, douleur neuropathique (DN4), EQ-5D-3 L, numeric pain rating scale (NRS), Olerud-Molander Ankle Score (OMAS), painDETECT, short form 36 (SF-36), short musculoskeletal function assessment—German version (SMFA-D) and a clinical examination were secondary outcomes. Results The AOFAS scores showed predominantly fair or poor results (Rearfoot: 48.6% fair, 34.3% poor; Midfoot 42.9% fair, 25.7% poor), while the SMFA tended to reflect mild dysfunction (bother index 31.7, functional index 27.5). Pain-related questionnaires showed a low incidence of pain (DN4 4.1, NRS 2.2, painDETECT 11.6). Kinematic changes were only marginally observed, while the spatio-temporal parameters showed relevant asymmetries between the fused and healthy side. The pedobarography revealed, in addition to other differences, a reduced maximum contact area on the arthrodesis side compared to the healthy side. Conclusions Arthrodesis of the ankle joint results in significant limitation of daily activities with reduced function of the affected limb. The impact of ankle arthrodesis go well beyond the loss of extension and flexion, with changes in spatial and temporal movement, weight bearing profile and contact surface. However, results of pain questionnaires show a good result with regard to the main goal of the arthrodesis, the elimination of pain. Trial registration DRKS, DRKS00033495. Registered 14 March 2024, https://www.drks.de/DRKS00033495 .

Septic nonunion of the pilon region with ankle joint infection is challenging for orthopedic surgeons to treat and is associated with a high risk of limb loss. Therefore, the aim of this study was to evaluate the effectiveness of bone transport for ankle arthrodesis in salvaging the limp after septic ankle destruction of the pilon region. We conducted a single-center, retrospective study including 21 patients treated for septic pilon nonunion with accompanying septic ankle destruction via Ilizarov bone transport between 2004 and 2018. In all cases, the complete excision of the nonunion and the resection of the ankle joint were carried out, followed by treating the bone and joint defect with a bone transport into the ankle arthrodesis. In 12/21 patients an additional flap transfer was required due to an accompanying soft tissue lesion. The overall healing and failure rate, final alignment and complications were recorded by the patients’ medical files. The bone-related and functional results were evaluated according to the Association for the Study and Application of Methods of Ilizarov (ASAMI) scoring system and a modified American Orthopedic Foot and Ankle Society (AOFAS) scale. After a mean follow-up of 30.9 ± 15.7 months (range 12–63 months), complete bone and soft tissue healing occurred in 18/21 patients (85.7%). The patients had excellent (5), good (7), fair (4), and poor (3) results based on the ASAMI functional score. Regarding bone stock, 6 patients had excellent, 7 good, and 6 fair results. The modified AOFAS score reached 60.6 ± 18 points (range, 29–86). In total, 33 minor complications and 28 major complications occurred during the study period. In 2 cases, a proximal lower leg amputation was performed due to a persistent infection and free flap necrosis with a large soft tissue defect, whereas in one case, persistent nonunion on the docking side was treated with a carbon orthosis because the patient refused to undergo an additional surgery. Bone transport for ankle arthrodesis offers the possibility of limb salvage after septic ankle destruction of the pilon region, with acceptable bony and functional results. However, a high number of complications and surgical revisions are associated with the treatment of this severe complication after pilon fracture.

Background Distal femur nonunions are well-recognized contributors to persistent functional disability, with limited data regarding their treatment options. In the current study, we asked whether additional medial augmentation plating is a feasible treatment option for patients with aseptic distal femoral nonunion and intact lateral implants. Methods We conducted a single-center, retrospective study including 20 patients treated for aseptic distal femoral nonunion between 2002 and 2017. The treatment procedure included a medial approach to the distal femur, debridement of the nonunion site, bone grafting and medial augmentation plating utilizing a large-fragment titanium plate. Outcome measures were bone-related and functional results, measured by the Hospital for Special Surgery Knee Rating Scale (HSS) and the German Short Musculoskeletal Function Assessment questionnaire (SMFA-D). Results Eighteen of 20 nonunions showed osseous healing at 8.16 ± 5.23 (range: 3–21) months after augmentation plating. Regarding functional results, the mean HSS score was 74.17 ± 11.12 (range: 57–87). The mean SMFA-D functional index was 47.38 ± 16.78 (range 25.74–71.32) at the last follow-up. Index procedure-associated complications included two cases of persistent nonunion and one case of infection. Conclusions According to the assessed outcome measures, augmentation plating is a feasible treatment option, with a high proportion of patients achieving bony union and good functional outcomes and a few patients experiencing complications.

Background This study analysed changes in gait and pedobarography and subjective and functional outcomes after isolated Chopart joint injury. Methods The results of 14 patients were reviewed. Kinematic 3D gait analysis, comparative bilateral electromyography (EMG) and pedobarography were performed. Results On the injured side, the 3D gait analysis showed a significantly increased internal rotation and decreased external rotation of the hip and significantly decreased adduction and decreased range of motion (ROM) for the ankle. On the healthy side, the pedobarography revealed a significantly increased mean force in the forefoot, an increased peak maximum force and an increased maximum pressure in the metatarsal. When standing, significantly more weight was placed on the healthy side. The EMG measurements showed no significant differences between the healthy and injured legs. Conclusions After isolated Chopart injuries, significant changes in gait and pedobarography can be seen over the long term.

IntroductionHeterotopic ossifications (HOs) commonly occur following total hip arthroplasty. Data regarding the appearance of HO after periprosthetic joint infection (PJI) of the hip are rare. Therefore, the aim of this study was to analyze the incidence and potential risk factors for the development of HO in patients with PJI of the hip.Materials and methodsWe performed a single-center, retrospective study including patients treated with a two- or multistage operation and patients undergoing salvage procedure in cases of PJI of the hip with a minimum follow-up of 6 months. A total of 150 patients were included in the analysis. The Brooker-scale was used to classify HO. Patients were divided in three groups: (1) No HO, (2) HO Brooker type 1–4, and (3) high-grade HO (HO Brooker type 3 and 4). In each group, we checked possible risk factors for the development of HO for statistical significance.ResultsPatients included in our study had a mean age of 70.4 ± 12.1 years. Of all patients, 75 were women (50%). HOs could be found in 70 patients (46.7%). Twenty-seven patients showed HO Brooker type 1, 23 type 2, 15 type 3 and 5 type 4. Male gender [odds ratio (OR) 2.14; p = 0.022], smoking (OR 5.75; p = 0.025) were significant risk factors for HO. A chronic infection (OR 3.54; p = 0.029) and a higher number of procedures (p = 0.009) were significant risk factors for the development of high-grade HO.ConclusionsHOs often occur following surgical care of PJI. Male gender, smoking, a chronic infection and high number of operations are risk factors for developing HO after PJI.

BackgroundThe Ilizarov fixator is a popular device for treating arthrodesis of the ankle joint in complex situations. However, the therapy can fail, with nonunion or partial union that might not be load stable. There is the possibility of follow-up surgery or extended wearing of the fixator. Full weight bearing with a carbon orthosis remains another treatment option, which has not yet been investigated.The aim of the study was to determine the rate of progress that can be obtained with a carbon orthosis in cases of partial union or nonunion after fixator removal.MethodsIn this retrospective observational study thirty-three patients received a carbon orthosis after fixator removal due to nonunion or partial union. All patients were allowed to walk with the orthosis under full load. The consolidation rate was determined radiologically and compared with the imaging data obtained during the last follow-up. In addition to demographic data, the Foot and Ankle Ability Measure and pain using a numeric rating scale were determined. Nine patients had to be excluded due to insufficient follow-up, and finally n = 24 patients were included in the study.ResultsThe average duration of fixator use was 21 weeks (range 15–40 weeks), and the total average follow-up after removal of the fixator was 16 months (range 4- 56). For 14 (58.33%) patients, there was a further increase in consolidation with the orthosis after the fixator was removed.ConclusionThe results show that if there is only partial union or nonunion, further consolidations can be achieved after the application of a carbon orthosis. In a difficult patient population, using an orthosis should therefore be attempted to avoid unnecessary revision operations.

Background: Tendinopathies of the long head of the biceps (LHB) are a common issue in shoulder surgery. Purpose/Hypothesis: The purpose of this study is to determine whether the red discoloration observed in the LHB and synovial rotator cuff interval during arthroscopy invariably indicates significant inflammation, which is frequently used to guide therapeutic decisions about LHB tenotomy or tenodesis. Red coloration of the LHB and the surrounding rotator cuff interval would not necessarily be related to the clinical symptoms of the patient. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Patients undergoing arthroscopy for symptomatic LHB pathology were included in the study if they met the inclusion criteria. Images of patients who were undergoing arthroscopy for other shoulder pathologies, but who did not exhibit LHB symptoms, were designated as the control group. Standardized imaging and video techniques were employed to identify the LHB and to calculate an objective measure of the total red component of the respective LHB. Machine learning (ML) was utilized to enumerate the respective red component in pixel count for each LHB, along with the redness of the synovial rotator cuff interval. The extent of effusion within the bicipital groove (as evident from axial slides of preoperative magnetic resonance imaging) was noted and subsequently correlated. The ranges into which the red hue of the LHB and the surrounding rotator cuff interval were divided included >60%, 60% to 31%, 30% to 11%, and <10%. Results: A total of 124 patients (men = 84, women = 40) were included, with a collective sum of 36,941 arthroscopy images (both standalone images and video frames). A total of 31 superior labral lesions, from anterior to posterior lesions, and 10 pulley lesions were detected. Moreover, 46 lesions were subjectively assessed by the surgeon as having LHB tendinitis based on LHB red “inflammation” staining intraoperatively. ML-based quantification revealed >60% LHB redness in 17 instances, between 60% to 31% in 22, between 30% to 11% in 33, and <10% in 52 instances. However, it could not be established that a significant statistical correlation exists between the intensity and extent of LHB redness, or the associated redness in the rotator interval, and their corresponding clinical symptoms related to LHB pathologies. In addition, there was no positive correlation between the effusion area and the LHB red staining, the surrounding sulcus bicipitalis area, or indications of pain. Conclusion: No positive correlation was found between the redness/intensity of the LHB on arthroscopy and the clinical symptoms within the LHB tests. The assessment of visually detectable “inflammation” of the LHB within arthroscopy as a therapeutic criterion must be questioned.

In recent years robotic devices became part of rehabilitation offers for patients suffering from Spinal Cord Injury (SCI) and other diseases. Most scientific publications about such devices focus on functional outcome. The aim of this study was to verify whether an improvement in physiological gait can be demonstrated in addition to the functional parameters after treatment with neurological controlled HAL® Robot Suit. Fifteen subjects with acute (<12 months since injury, n = 5) or chronic (>12 months since injury, n = 10) incomplete paraplegia (AIS B, n = 0/AIS C, n = 2/AIS D, n = 8) or complete paraplegia (AIS A, n = 5) with zones of partial preservation participated. Subjects underwent a body weight supported treadmill training for five times a week over 12 weeks using HAL®. At baseline and at the end of the study a gait analysis was performed and additional functional parameters such as 10-Meter-Walk-Test, Timed-Up-and-Go-Test, 6-Minutes-Walk-Test, and WISCI II score were collected. Results were evaluated for whole group and individually for acute and chronic subgroups. All functional parameters improved. Differences were also found in physiological parameters such as phases of gait cycle and accompanied by significant improvement in all spatiotemporal and gait phase parameters. The presented study shows signs that an improvement in physiological gait can be achieved in addition to improved functional parameters in patients with SCI after completing 12-week training with HAL®. Trial Registration: DRKS, DRKS00020805. Registered 12 February 2020—Retrospectively registered, https://www.drks.de/DRKS00020805 .

Background Septic arthritis of the elbow joint is a rare condition. Limited data is available on infections of the elbow joint following trauma or prior surgery on this joint. The aim of this study was to describe the etiology, comorbidities, bacterial spectrum and therapy of secondary purulent elbow infections. Methods Patients treated in our hospital were selected through retrospective chart review between 2006 and 2015. We included all patients with an empyema of the elbow after a trauma or surgical intervention on this joint. 30 patients between 26 and 82 years (mean: 52.47) were included. Results Seven patients (23.3%) were female, 23 (76.7%) male. 22 patients (73.3%) had a history of trauma, eight (26.7%) had prior elective surgeries on their elbow. Between one and 25 surgeries (mean: 5.77) were necessary for treatment. In nine patients, debridement and synovectomy were sufficient, eight patients (26.7%) received resection of the elbow joint. One patient was treated with a chronic fistula. In 18 patients (60%), cultures of aspiration/intraoperative swabs were positive for Staphylococcus aureus , four of these were methicillin-resistant. Four patients (13.3%) had positive cultures for Staphylococcus epidermidis , in five patients (16.7%) no bacteria could be cultured. Conclusions Secondary infections of the elbow joint are a rare disease with potentially severe courses, requiring aggressive surgical treatment and possibly severely impacting elbow function. Staphylococcus aureus was the most common bacteria in secondary infections and should be addressed by empiric antibiotic treatment when no suspicion for other participating organisms is present.