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Introduction: Dynamization of proximal femoral nailing by removal of distal interlocking is one of the recommended treatment options for nonunions of femur fractures. However, in certain inter-/subtrochanteric fractures, gliding of the nail along the femoral shaft is blocked by lateral femoral cortical support of the lag screw. For these cases, Biber et al. proposed lateral cortical notching (LCN), in which the supporting lateral bone is removed. This study investigates the biomechanical effect of LCN on gliding of proximal femoral nailing and stress distribution at the bone/implant interface., Materials and Methods: In this finite element analysis a three-dimensional model of an unstable intertrochanteric fracture with proximal femoral nailing without distal interlocking was simulated using the FebioStudio software suite. To simulate LCN, the lag screw hole was lengthened to 15.34 mm at the lateral cortex. Displacement of the nail along the femoral shaft axis and von Mises stress distribution were compared between LCN model and standard implantation model., Results: Displacement of the nail along the femoral shaft axis was higher in the LCN model than in the standard implantation model (0.48 mm vs. 0.07 mm). Highest von Mises stresses of 176-178 MPa at the implant and of 52-81 MPa at the proximal femur were detected. Maximum von Mises stresses of the implant were comparable at all sides, except for a reduced von Mises stress at the lateral inferior side in the LCN model (80 vs. 102 MPa). At the inferior lateral screw hole and the anterior/posterior lateral screw hole maximum von Mises stress was reduced in the LCN model (2 vs. 49 MPa and 52 vs. 81 MPa), whereas the maximum von Mises stress at the inferior medial screw hole was higher in the LCN model than in the standard implantation model (53 vs. 27 MPa)., Conclusions: Lateral cortical notching facilitates gliding of a distally dynamized proximal femoral nail along the femoral shaft axis in intertrochanteric fractures. Additionally, the lack of lateral cortical bone support at the lag screw reduces von Mises stress at the bone/implant interface and thus could lower the risk for implant breakage and peri‑implant fractures., Competing Interests: Declaration of Competing Interest KS and CL are employees of Swemac Innovation (Germany) GmbH. The authors have no competing interests to declare that are relevant to the content of this article., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: The Masquelet technique is a surgical procedure for the reconstruction of bone defects. During the first step, an osteosynthetically stabilized defect is filled with a cement spacer. The spacer induces a foreign body membrane, called a Masquelet membrane. In a follow-up procedure, the spacer is replaced by a bone graft, which ossifies in the subsequent phase., Material and Methods: A total of 171 patients with 195 septic bone defects on the extremities that had been treated with the Masquelet procedure at the BG Klinikum in Hamburg, Germany, from 2011 to 2021 were retrospectively analysed, comparing patients who reached full weight and load bearing on the affected extremity to those who failed to do so. Defect size and configuration, microbiological results and treatment methods as well as comorbidities and epidemiologic data were analysed for factors influencing the treatment outcome., Results: In all, 113[66%] of the patients were male, and 58[34%] were female, with an age distribution of 52 +/-16 years. Out of 171 patients, 24 patients had two defects. The number of patients that reached full weight bearing was 152[89%], the follow-up period was 2 +/-1 years (median +/- SD). Full weight bearing capability was negatively by the defect size as defects >62 mm tended to be less likely to reach full weight bearing than smaller defects. A secondary stabilization with an internal stabilization was applied in 58[34%] of all patients and positively influenced the attainment of full weight and load bearing., Discussion: With 171 patients and 195 septic bone defects treated at a single centre with the Masquelet Technique, this study represents a comparably large cohort. Demographics, defect characteristics and treatment outcomes did not differ from those of other cohorts described in the literature. Defects larger than 62 mm showed lower chances to reach full weight bearing and can be defined as "critical defect size" for the Masquelet technique based on our data., Competing Interests: Declaration of Competing Interest None of the authors declare any conflicts of interest., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Aim: To describe demographic findings, typical injuries and functional neurological outcomes in patients with cervical trauma and tetraplegia sustained after diving into shallow water., Patients and Methods: A retrospective study was performed including all patients treated in BG Klinikum Hamburg suffering from tetraplegia after jumping into shallow water between 1st June 1980 and 31st July 2018., Results: One hundred and sixty patients with cervical spinal injuries and tetraplegia following a dive into shallow water were evaluated. Of these, 156 patients (97.5%) were male. The mean age was 24.3 years ± 8.1 and the accidents occurred most often in inland waters (56.2%) and mostly between May and August (90.6%). In all cases there was one vertebra fractured, whereas in 48.1% of cases, two vertebrae were severed. In the majority of cases (n = 146), a surgical procedure was performed. Overall, the mean hospital stay was 202 days (±72, range: 31-403) and one patient died. On admission, 106 patients (66.2%) showed a complete lesion according to AIS A, with incomplete lesions in the remaining 54 patients (AIS B: n = 25 [15.6%], AIS C: n = 26 [16.3%], AIS D: n = 3 [1.9%]). In two thirds of the patients, the level of paralysis on admission was at the level of segments C4 (31.9%) or C5 (33.7%). Seventeen patients (10.6%) needed prehospital resuscitation. In 55 patients (34.4%), the neurological findings improved during the course of inpatient treatment and rehabilitation. Sixty-eight patients (42.5%) developed pneumonia, of which 52 patients (76.5%) were ventilated. In addition, 56.5% of patients with paralysis levels C0-C3 required ventilation, whereas only 6.3% of patients with paralysis levels C6-C7 were affected. Three patients (1.9%) were discharged from hospital with continuous ventilation. Overall, 27.4% of all AIS A patients, 56% of all AIS B patients and 46.2% of all AIS C patients improved neurologically, with 17% of all patients being able to walk., Conclusions: The consequences of a cervical spine injury after diving into shallow water are severe and lifelong. Functionally, patients may benefit from care in a specialised centre, both in the acute phase and during rehabilitation. The more incomplete the primary paralysis, the greater the possibility of neurological recovery., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023. Published by Elsevier Ltd.)

Introduction: The annual incidence of proximal femoral fractures is 100-150/100,000 and continues to increase with an aging population. Cut-out of hip screws after fracture fixation has been quoted as 8% in the literature. The tip-apex distance (TAD) is the strongest predictor for cut-out after operative fracture stabilisation. The aim of this study was to evaluate the novel ADAPT system (Adaptive Positioning Technology, Stryker, USA), a navigation device for intramedullary nailing of trochanteric fractures and its effect on optimising the TAD. This is the first clinical study to evaluate this new technology., Methods: The study group of 36 consecutive patients with a pertrochanteric fracture underwent intramedullary nailing for fracture fixation using ADAPT technology, while the matched control group underwent conventional Gamma-3-nailing. Matching criteria included fracture classification, gender and age. We measured the operative time and the postoperative TAD in anteroposterior (AP) and lateral radiographs of the 72 patients., Results: The mean TAD using ADAPT was 16.9 mm (range 8.4-33.7 mm) compared with 24.9 mm (range 14.6-40.2 mm) in the reference group treated without ADAPT. Using the ADAPT system significantly improved (p < 0.0005) the accuracy of lag screw placement but had no effect on operating time in fixation of femoral pertrochanteric fractures., Conclusion: Working with the novel ADAPT system for positioning the lag screw using the Gamma-3-nail led to a statistically highly significant reduction of the TAD compared to the reference group (p < 0.001). The ADAPT system proved to be a very useful device in achieving higher surgical standards for the treatment of trochanteric fractures with intramedullary nailing. It enables higher accuracy in screw positioning and therefore better placement of the implant., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Only a minority of sternal fractures require osteosynthesis. Unstable non-union of the sternum is a very disabling condition which often requires treatment. The method most often used is tension-wiring. Due to loosening of the tensile strength or wire cut-out, this method often fails. We report the results of locked plate osteosynthesis of sternal non-union and displaced fractures. Over a five-year period, 12 patients have been treated using this method in a multicentre trial. Mean age at trauma was 32.8 years, the implant used in all cases was an 8-hole titanium plate, the fixation of the screws is based on the principles of angular stable fixation.In all cases the index procedure was possible, in all cases there was bony healing at follow-up examination.Multidirectional locked plating offers a reliable method for the successful treatment of sternal nonunion and displaced fractures., (2010 Elsevier Ltd. All rights reserved.)