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Purpose The economic cost linked to the increasing number of proximal femur fracture and their postoperative care is immense. Mortality rates are high. As early surgery is propagated to lower mortality and reduce complication rates, a 24-h target for surgery is requested. It was our aim to determine the cut-off for the time to surgery from admission and therefore establish a threshold at which the in-house mortality rate changes. Methods A retrospective single-center cohort study was conducted including 1796 patients with an average age of 82.03 years treated operatively for a proximal femoral fracture between January 2016 and June 2020. A single treatment protocol was performed based on the type of anticoagulant, surgery, and renal function. Patient data, surgical procedure, time to surgery, complications, and mortality were assessed. Results In-house mortality rate was 3.95%, and the overall complication rate was 22.7%. A prolonged length of hospital stay was linked to patient age and occurrence of complications. Mortality is influenced by age, number of comorbidities BMI, and postoperative complications of which the most relevant is pneumonia. The mean time to surgery for the entire cohort was 26.4 h. The investigation showed no significant difference in mortality rate among the two groups treated within 24 h and 24 to 48 h while comparing all patients treated within 48 h and after 48 h revealed a significant difference in mortality. Conclusions Age and number of comorbidities significantly influence mortality rates. Time to surgery is not the main factor influencing outcome after proximal femur fractures, and mortality rates do not differ for surgery up to 48 h after admission. Our data suggest that a 24-h target is not necessary, and the first 48 h may be used for optimizing preoperative patient status if necessary.

Background Impact of concomitant fractures on patients sustaining a proximal femur fracture remains unclear. Rising numbers and patient need for rehab is an important issue. The objective of our study was to investigate the impact of concomitant fractures, including all types of fractures, when treated operatively, for proximal femur fractures on the length of hospital stay, in-house mortality and complication rate. Methods Observational retrospective cohort single-center study including 85 of 1933 patients (4.4%) with a mean age of 80.5 years, who were operatively treated for a proximal femoral and a concomitant fracture between January 2016 and June 2020. A matched pair analysis based on age, sex, fracture type and anticoagulants was performed. Patient data, length of hospital stay, complications and mortality were evaluated. Results The most common fractures were osteoporosis-associated fractures of the distal forearm (n = 34) and the proximal humerus (n = 36). The group of concomitant fractures showed a higher CCI than the control group (5.87 vs. 5.7 points; p p N = 20), whilst only 7.1% of complications were recorded for concomitant fractures (p Conclusions A concomitant fracture to a hip fracture increases the length of hospital stay significantly but does not increase the complication rate or the in-house mortality. This might be due to the early mobilization, which is possible after early operative treatment of both fractures.

In past experiments based on 3-D models, medialization of the center of rotation (COR) in total hip arthroplasty (THA) with unilateral hip dysplasia showed a negative influence on the muscle strength of the abductors and the reaction force of the hip joint. The COR displacement was referenced to the healthy non-dysplastic hip and the results therefore might contradict given paradigms, where reduced hip loading forces are claimed to increase functional outcomes. The aim of this study was a clinical evaluation of the COR placement towards the patient’s recovery with respect to daily living ability and mobility using der Barthel index and the Parker mobility score (PMS). 110 patients who underwent THA after a femoral neck fracture between January 2019 and January 2021 were retrospectively evaluated towards their Barthel index on discharge (N = 68). 47 Patients were available for a follow up interview and were interviewed for the Barthel index and Parker Mobility Score (PMS) 6 and 12 months after surgery. COR medialization, superior COR displacement and especially the combination of both (superomedialization) leads to reduced mobility while inferior displacement leads to increased pain. According to our results we recommend an exact vertical COR-restoration, while horizontal medial displacement needs to be avoided.

Introduction The treatment of fragility fractures of the pelvis (FFP) is a challenge. The variations of non-operative- and of operative treatment are manifold and a structured treatment algorithm is lacking. The purpose of this study was to evaluate the outcome of elderly patients with a FFP who were treated with a therapeutic algorithm based on the FFP-classification. Patients and Methods In a prospective cohort study 154 patients (mean age: 81.8 ±.61 (65-96); female: (86.8%; 131/154). BMI: 23.7 ±.34 (15-43)) with a FFP after inadequate mono trauma were treated according to a strict therapeutic algorithm between 04/2016 and 12/2018. According to a classification based on CT-scans either a standardized operative treatment or conservative therapy was induced and the outcome regarding objective measurements of mobility, pain, need for analgesics and mortality during hospital stay and after one year was analyzed. Results 82/154 participants (53.2%) were assigned to the conservative treatment group and 72 participants (46.8%) to the operative treatment group. The overall one-year survival rate was 78.1% (118/151). The survival of the operative treatment group was 90.7% (49/54) and significantly higher than the survival of the conservative treatment group (74.7%; 56/75; p=.023). The one-year follow up showed a high dispersion of the pain level in the operatively treated patients and a significantly higher mean in comparison to conservatively treated patients. Both treatment groups showed increasing numbers of patients with unlimited mobilization but also immobile patients. Overall in 31.0% (18/58) of the operative participants and in 14.9% (14/93) of the non-operatively treated participants complications occurred (p=.04). Conclusion The strict compliance to the presented treatment algorithm of FFP with an operative strategy starting from FFP IIc leads to a significantly lower mortality within one year in comparison to the conservatively treated patients. The worst outcome and the highest mortality was seen in patients who refused the recommendation of operative stabilization. The results of this study justify to proceed with the strict classification dependent treatment algorithm and also support the early switch-over to operative treatment of patients with failed conservative therapy in FFP I to FFP IIb.

Introduction An undislocated fracture of the posterior malleolus is a common concomitant injury in tibial shaft spiral fractures. Nevertheless, these accompanying injuries cannot always be reliably assessed using conventional X-rays. Thus, the aim of the study is to evaluate how often a fracture of the posterior malleolus occurs with tibial shaft fractures (AO:42A/B/C and AO:43A) and which factors—identifiable in conventional X-rays—are predictive. Methods Retrospective evaluation of X-ray and CT images revealed a total of 103 patients with low-energy tibial shaft fractures without direct joint involvement. Proximal fractures and fractures involving the knee were excluded. Basic data on injury, the trauma mechanism, the path of the fracture, bony avulsions of the posterior syndesmosis and the procedures performed were evaluated. Results Thirty-nine fractures were located in the middle third of the tibia, 64 in the distal third. In 65 cases, a spiral fracture (simple or wedge fracture) was found. In 31/103 fractures, an additional osseous avulsion of the posterior syndesmosis could be detected, 5 (16.1%) of them were not recognized preoperatively due to an absence of CT imaging. In three of these patients, a fracture of the posterior malleolus was only recognized postoperatively, and an additional surgery was necessary. The spiral fractures were classified in the a.p. X-ray according to their path from lateral proximal to medial distal (Type A) or from medial proximal to lateral distal (Type B). A Pearson chi-square test and Fisher’s exact test showed a highly significant accumulation of accompanying posterior malleolus fractures for type A fractures (p = 0.001), regardless of the location of the fracture. In addition, the fractures with involvement of the posterior malleolus had a significantly higher proportion in the fractures of the distal third (p = 0.003). There was no statistically significant relationship between the height of the fracture and the path of the fracture (type A or B). These two factors seem to be independent factors for participation of the posterior malleolus. Conclusion In 40.6% of the tibial shaft fractures in the distal third, in 56.9% of the type A spiral fractures and in 67.6% of the type A fractures in the distal third, the ankle joint is involved with bony avulsion of the posterior syndesmosis, which is not always recognized in conventional X-rays. To avoid complications such as additional operations, instability and post-traumatic arthrosis, we recommend preoperative imaging of the ankle using CT for these fractures. Level of evidence III, retrospective cohort study. Trail registration number DRKS00024536.

Background: Partial weight-bearing after operatively treated fractures has been the standard of care over the past decades. Recent studies report on better rehabilitation and faster return to daily life in case of immediate weight-bearing as tolerated. To allow early weight-bearing, osteosynthesis needs to provide sufficient mechanical stability. The purpose of this study was to investigate the stabilizing benefits of additive cerclage wiring in combination with intramedullary nailing of distal tibia fractures. Methods: In 14 synthetic tibiae, a reproducible distal spiral fracture was treated by intramedullary nailing. In half of the samples, the fracture was further stabilized by additional cerclage wiring. Under clinically relevant partial and full weight-bearing loads the samples were biomechanically tested and axial construct stiffness as well as interfragmentary movements were assessed. Subsequently, a 5 mm fracture gap was created to simulate insufficient reduction, and tests were repeated. Results: Intramedullary nails offer already high axial stability. Thus, axial construct stiffness cannot be significantly enhanced by an additive cerclage (2858 ± 958 N/mm NailOnly vs. 3727 ± 793 N/mm Nail + Cable; p = 0.089). Under full weight-bearing loads, additive cerclage wiring in well-reduced fractures significantly reduced shear (p = 0.002) and torsional movements (p = 0.013) and showed similar low movements as under partial weight-bearing (shear 0.3 mm, p = 0.073; torsion 1.1°, p = 0.085). In contrast, additional cerclage had no stabilizing effect in large fracture gaps. Conclusions: In well-reduced spiral fractures of the distal tibia, the construct stability of intramedullary nailing can be further increased by additional cerclage wiring. From a biomechanical point of view, augmentation of the primary implant reduced shear movement sufficiently to allow immediate weight-bearing as tolerated. Especially, elderly patients would benefit from early post-operative mobilization, which allows for accelerated rehabilitation and a faster return to daily activities.

ZusammenfassungVorstellung eines 16-jährigen Patienten nach Fahrradsturz beim Mountainbiken 14 Tage nach primärer Versorgung nach offener Epiphysenverletzung. Metaphysär intraossär liegende Steine wurden bei anatomischer Reposition der Fraktur als nebenbefundliches Osteom fehlinterpretiert.

Primary arthroplasty for fractures of the femoral neck is a very common procedure and even the gold standard for the geriatric patient. In contrast, primary arthroplasty for perigenicular fractures is a rare event. On the other hand, it can be a therapeutic option, especially for geriatric patients with prior osteoarthritis or complex fractures and severe osteoporosis.The operative procedure can be complex and requires experience in primary and revision arthroplasty as well as suitable implants and good preoperative planning.There are case series reporting primary arthroplasty in a total of approximately 200 cases of both distal femoral and proximal tibial fractures. Complication rates are between 0 and 90% and mostly concern wound healing problems and infections. From a functional point of view, predominantly good results and a range of motion of 100° can be achieved.Primary arthroplasty can be a therapeutic option for selected cases of perigenicular fractures and gives good functional results. The most frequent complications are wound healing problems and infections.Während die primäre prothetische Versorgung von Schenkelhalsfrakturen ein etabliertes Verfahren und bei geriatrischen Patienten den Goldstandard darstellt, wird die primäre endoprothetische Versorgung bei kniegelenknahen Frakturen deutlich seltener angewendet. Vor allem bei älteren Patienten findet sie Anwendung bei Frakturen mit vorbestehender symptomatischer Gonarthrose oder Frakturen, die aufgrund ihrer Komplexität und vorbestehender reduzierter Knochenqualität nicht osteosynthetisch zu versorgen sind.Die operative Umsetzung ist komplex und bedarf entsprechender Erfahrung in der Primär- und vor allem auch Revisionsendoprothetik, einer Logistik mit Vorhaltung entsprechender Implantate und einer guten präoperativen Planung.Auch wenn hochwertige Studien weitgehend fehlen, gibt es vor allem seit Anfang der 2000er-Jahre immer wieder Berichte und Fallserien zur primären endoprothetischen Versorgung kniegelenknaher Frakturen. Kumulativ liegen Berichte von jeweils gut 200 Fällen nach distalen Femur- und proximalen Tibiafrakturen vor. Die Komplikationsraten werden zwischen 0 und 90% angegeben und betreffen vor allem Wundheilungsstörungen und Infekte. Funktionell können überwiegend sehr gute bis zufriedenstellende Ergebnisse und Bewegungsumfänge von 100° erzielt werden.Die primäre endoprothetische Frakturversorgung kniegelenknaher Frakturen sollte in ausgewählten Fällen als Therapieoption in Betracht gezogen werden. Es lassen sich mit hoher Zuverlässigkeit gute funktionelle Ergebnisse erzielen, Hauptkomplikationen sind Wundheilungsstörungen und Infekte.

Zusammenfassung Einleitung Die Therapie der Humerusschaftfraktur ist vielfältig und oft problematisch. Neben der konservativen Therapie konkurrieren Marknagel- und Plattenosteosynthese miteinander; bislang existiert kein Goldstandard. Aus biomechanischen Überlegungen bieten sich für die Versorgung von Spiralfrakturen additive Cerclagen an. Die Argumente gegen deren Verwendung sind zum einen die Gefahr von Radialisläsionen, zum anderen eine mutmaßliche Störung der Fragmentdurchblutung. Ziel dieser Studie ist die Analyse sekundärer Radialisläsionen bei der Anwendung additiver, limitiert invasiver Cerclagen bei der antegraden Nagelosteosynthese von Humerusschaftfrakturen. Methodik In dieser retrospektiven Studie erfolgen die klinische und die neurologische Untersuchung von 102 Patienten, welche im Zeitraum von 5 Jahren bei einer Humerusschaftfraktur operativ versorgt wurden. Insgesamt wurden zur Marknagelosteosynthese 193 Cerclagen durch einen limitiert invasiven Zugang eingebracht. Ergebnisse und Schlussfolgerung Bei 4 Patienten (3,9 %) zeigte sich eine sekundäre Radialisläsion im Rahmen der operativen Stabilisierung. Die neurophysiologische und neurosonographische Untersuchung zeigten in keinem Fall eine Kompromittierung des Nerven durch Einschlingen oder gar Durchtrennung durch die additive Cerclage. Zwei Nervenläsionen erholten sich innerhalb von 3 bzw. 6 Monaten spontan. In den anderen 2 Fällen konnte der Verlauf aufgrund eines Exitus letalis nicht über 12 Monate dokumentiert werden. Mit 3,9 % der iatrogenen Radialisläsionen liegt die Rate an Nervenläsionen im unteren Bereich dessen, was in der Literatur für die operative Therapie von Humerusschaftfrakturen beschrieben wird (3–12 %). Durch die limitiert invasive, additive Cerclage ergibt sich somit kein erhöhtes Risiko für die iatrogene Schädigung des N. radialis.

Zusammenfassung Einleitung Die Verwendung von Cerclagen zur Osteosynthese ist ein kontrovers diskutiertes Thema. Als Gegenargument gelten negative Effekte auf die periostale Blutzirkulation. In der vorliegenden Arbeit soll die vorhandene Evidenz geprüft werden, ob Cerclagen tatsächlich zu einer relevanten Reduktion der periostalen Durchblutung führen. Methodik In einer systematischen Literaturrecherche wurde nach experimentellen Studien gesucht, die sich mit dem Einfluss von Cerclagen auf die periostale Blutversorgung befassen. Ergebnis Es existiert keine experimentelle Studie, die die Auswirkung von Cerclagen auf die Durchblutung von frakturierten Knochen untersucht. Es konnten 7 experimentelle Arbeiten identifiziert werden. Hierunter befanden sich 2 Arbeiten an menschlichen Kadaver-Femora, die keine relevante Reduktion der Blutversorgung zeigten. Die übrigen 5 Untersuchungen wurden im Tiermodell an lebenden Versuchstieren durchgeführt. Hier wies eine Studie an Kaninchen-Femora szintigraphisch eine postoperativ um 45–56 % reduzierte Perfusion nach. Eine Studie an Pferde-Radii sowie drei Studien an Hunde Femura ergaben hingegen mikroangiographisch keine relevante Einschränkung der Blutversorgung. Eine Studie wurde hierbei am osteotomierten, die anderen an unverletzten Knochen durchgeführt. Diskussion Im Tiermodell konnte lediglich in einer Studie direkt postoperativ eine relevante Reduktion der Blutversorgung durch Cerclagen belegt werden. In 4 anderen Untersuchungen am Tiermodell über längere postoperative Zeiträume zeigte sich die Durchblutung der Knochen hingegen nicht beeinträchtigt. Auch in 2 Versuchsreihen an menschlichen Kadaver-Femora ließen sich keine relevanten negativen Effekte nachweisen. Zumindest in mittel- bis langfristigem Verlauf lässt sich somit die Befürchtung einer relevanten Beeinträchtigung der Blutversorgung durch Cerclagen für unverletzte oder osteotomierte Knochen nicht durch experimentelle Studien belegen. Zu frakturierten Knochen existieren keine experimentellen Studien.

Purpose The prevalence of proximal femur fractures is increasing with rising population age. Patients are presenting with more comorbidities. Anticoagulants create a challenge for the necessary early surgical procedure (osteosynthesis or arthroplasty). Our aim was to investigate the influence of anticoagulants on in-house mortality after surgical treatment of proximal femoral fractures. Methods A retrospective single-centre study was conducted including 1933 patients with an average age of 79.8 years treated operatively for a proximal femoral fracture between January 2016 and June 2020. One treatment protocol was performed based on type of anticoagulant, surgery, and renal function. Patient data, surgical procedure, time to surgery, complications and mortality were assessed. Results On average, patients with anticoagulants had a delay to surgery of 41.37 hours vs 22.1 hours for patients without (p p p p p Conclusions Pre-existing anticoagulant therapy in patients with proximal femur fractures is associated with a higher mortality rate, risk of complications and prolonged hospital stay. Further influential factors are age, gender, BMI and time to surgery.

Introduction Blood loss after proximal femoral fractures is an important risk factor for postoperative outcome and recovery. The purpose of our study was to investigate the total blood loss depending on fracture type and additional risks, such as anticoagulant use, to be able to recognize vulnerable patients depending on planned surgery and underlying comorbidities. Materials and methods A retrospective single center study including 1478 patients treated operatively for a proximal femoral fracture between January 2016 and June 2020 at a level I trauma center. Patient data, surgical procedure, time to surgery, complications and mortality were assessed. Lab data including hemoglobin and transfusion rates were collected. The Mercuriali formula was implemented to calculate total blood loss. Linear regression was performed to identify influencing factors. Results One thousand four hundred seventy-eight mainly female patients were included in the study (mean age: 79.8 years) comprising 667 femoral neck fractures, 704 pertrochanteric- and 107 subtrochanteric fractures. Nearly 50% of the cohort were on anticoagulants or anti- platelet therapy. At time of admission average hemoglobin was 12.1 g/l. Linear regression proved fracture morphology, age, BMI, in-house mortality and anticoagulant use to have crucial influence on postoperative blood loss. Femoral neck fractures had a blood loss of 1227.5 ml (SD 740.4 ml), pertrochanteric fractures lost 1,474.2 ml (SD 830 ml) and subtrochanteric femoral fractures lost 1902.2 ml (SD 1,058 ml). Conclusions Hidden blood loss is underestimated. Anticoagulant use, fracture type, gender and BMI influence the total blood loss. Hemoglobin levels should be monitored closely. Within 48 h there was no increased mortality, so adequate time should be given to reduce anticoagulant levels and safely perform surgery.

Introduction The purpose was to compare the arthroscopic rod technique to stress ultrasound in the dynamic assessment of lateral elbow instabilities. Materials and methods Fifteen elbows of eight specimen with a mean age of 66.4 ± 13.3 years were assessed in a prone position following a defined dissection setup. After evaluation of the native status, an arthroscopic dissection of the radial collateral ligament (RCL) or lateral ulnar collateral ligament (LUCL), and finally of entire capsuloligamentous structures was performed. Three raters examined each state (native, RCL or LUCL lesion, complete lesion) with the arthroscopic rod technique in 90° flexion and with stress ultrasound in 30 and 90° flexion. The intra-class correlation coefficient (ICC) was calculated to assess the interrater reliability as well as test–retest reliability for each testing modality (arthroscopy and ultrasound). Results The arthroscopic rod technique showed a superior interrater and test–retest reliability of 0.953 and 0.959 (P P 6 mm humero-ulnar or > 7 mm humero-radial was indicative for a lateral collateral ligament lesion. However, a differentiation between an isolated RCL or LUCL tear was not possible. A lateral joint opening of ≥ 9 mm was only observed in complete tears of the lateral capsuloligamentous complex. Conclusions The arthroscopic rod technique showed a superior interrater and test–retest reliability when compared to stress ultrasound. Arthroscopic assessment for radial elbow instability was found to be reliable and reproducible. A joint gapping ≥ 9 mm in the arthroscopic evaluation is a sign for a complete insufficiency of the radial capsuloligamentous complex. However, it is not possible to precisely distinguish between a lesion of the RCL or LUCL by arthroscopy. On the basis of our results, dynamic ultrasound testing may be inappropriate to objectify lateral elbow instability.

Purpose Literature shows that orthogeriatric co-management improves the outcomes of patients with hip fractures. Corresponding research with more diverse fragility fracture groups is lacking. Therefore, an examination was performed prospectively as a 2 year-follow-up on an orthogeriatric co-managed ward, comparing relevant outcome parameters for major and minor fragility fractures. Methods All patients treated on an orthogeriatric co-managed ward from February 2014 to January 2015 were included and their injuries, orthogeriatric parameters such as the Barthel Index (BI), Parker Mobility Score (PMS) and place of residence (POR). Patients were separated into two groups of either immobilizing major (MaF) or non-immobilizing minor (MiF) fractures. 2 years later, a follow-up was conducted via telephone calls and questionnaires mailed to patients and/or their relatives. Results 740 (574 major vs. 166 minor injuries) patients were initially assessed, with a follow-up rate of 78.9%. The in-house, 1-year, and 2-year-mortality rates were 2.7, 27.4, and 39.2%, respectively. Mortality was significantly higher for MaF in the short term, but not after 2 years. On average, during the observation period, patients regained their BI by 36.7 points (95% CI: 33.80–39.63) and PMS was reduced by 1.4 points (95% CI: 1.16–1.68). No significant differences were found in the readmission rate, change in BI, PMS or POR between the MaF and MiF groups. Conclusion The relevance of orthogeriatric treatment to improving functional and socioeconomic outcomes was confirmed. The similarity of the results from both fracture groups emphasizes the need for a multidisciplinary approach also for minor fractures.

Background Hip fractures are well researched in orthogeriatric literature. Equivalent investigations for fragility-associated periprosthetic and periosteosynthetic femoral, ankle joint, pelvic ring, and rib fractures are still rare. The purpose of this study was to evaluate mortality, functional outcome, and socioeconomic parameters associated to the upper-mentioned fragility fractures prospectively in a 2-year follow-up. Methods Over the course of a year, all periprosthetic and periosteosynthetic femoral fractures (PPFF), ankle joint fractures (AJ), pelvic ring fractures (PR), and rib fractures (RF), that were treated on a co-managed orthogeriatric ward, were assessed. Parker Mobility Score (PMS), Barthel Index (BI), place of residence, and care level were recorded. After 2 years, patients and/or relatives were contacted by mailed questionnaires or phone calls in order to calculate mortality and reevaluate the mentioned parameters. Results Follow-up rate was 77.7%, assessing 87 patients overall. The relative mortality risk was significantly increased for PR (2.9 (95% CI: 1.5–5.4)) and PPFF (3.5 (95% CI: 1.2–5.8)) but not for RF (1.5 (95% CI: 0.4–2.6)) and AJ (2.0 (95% CI: 0.0–4.0)). Every fracture group except AJ showed significantly higher BI on average at follow-up. PMS was, respectively, reduced on average for PR and RF insignificantly, but significantly for PPFF and AJ in comparison to pre-hospital values. 10.0–27.3% (each group) of patients had to leave their homes permanently; care levels were raised in 30.0–61.5% of cases. Discussion This investigation provides a perspective for further larger examinations. PR and PPFF correlate with significant increased mortality risk. Patients suffering from PPFF, PR, and RF were able to significantly recover in their activities of daily living. AJ and PPFF conclude in significant reduction of PMS after 2 years. Conclusion Any fragility fracture has its impact on mortality, function, and socioeconomic aspects and shall not be underestimated. Despite some fractures not being the most common, they are still present in daily practice.

Introduction In spiral fractures of the tibia, the stability of an osteosynthesis may be significantly increased by additive cerclages and, according to biomechanical studies, be brought into a state that allows immediate full weight bearing. As early as 1933, Goetze described a minimally invasive technique for classic steel cerclages. This technique was modified, so that it can be used for modern cable cerclages in a soft part saving way. Method After closed reduction, an 8 Fr redon drain is first inserted in a minimally invasive manner, strictly along the bone and placed around the tibia via 1 cm incisions on the anterolateral and dorsomedial tibial edges using a curette and a tissue protection sleeve. Via this drain, a 1.7 mm cable cerclage can be inserted. The fracture is then anatomically reduced while simultaneously tightening the cerclage. Subsequently, a nail or a minimally invasive plate osteosynthesis is executed using the standard technique. Using the hospital documentation system, data of patients that were treated with additional cerclages for tibial fractures between 01/01/2014 and 06/30/2020 were subjected to a retrospective analysis for postoperative complications (wound-healing problems, infections and neurovascular injury). Inclusion criteria were: operatively treated tibial fractures, at least one minimally invasive additive cerclage, and age of 18 years or older. Exclusion criteria were: periprosthetic or pathological fractures and the primary need of reconstructive plastic surgery. SPSS was used for statistical analysis. Results 96 tibial shaft spiral fractures were treated with a total of 113 additive cerclages. The foregoing resulted in 10 (10.4%) postoperative wound infections, 7 of which did not involve the cerclage. One lesion of the profundal peroneal nerve was detected, which largely declined after cerclage removal. In 3 cases, local irritation from the cerclage occurred and required removal of material. Conclusion In the described technique, cerclages may be inserted additively at the tibia in a minimally invasive manner and with a few complications, thus significantly increasing the stability of an osteosynthesis. How this ultimately affects fracture healing is the subject of an ongoing study.

Zusammenfassung Zur knöchernen Defektauffüllung wird regelhaft Knochen vom vorderen Beckenkamm entnommen. Typische Komplikationen sind postoperatives Hämatom, Nervenverletzungen, Infektionen oder Schmerzen an der Entnahmestelle. Wir beschreiben einen Fall, in dem es nach Knochenentnahme am rechten Beckenkamm bei einem jungen Patienten als Koinzidenz zu einer akuten Appendizitis kam. Durch die durchgeführte Knochenentnahme kam es zu einer erschwerten Diagnosestellung, die nur durch eine differenzierte klinische Untersuchung und daraufhin eingeleitete laborchemische und apparative Diagnostik möglich war.

Background Different stand-alone cerclage configurations and their optimal twisting techniques have been investigated over the years. This study tests for the stabilizing effect of different supplemental cerclage materials in combination with locked plating of distal tibia fractures. Methods Locking plate fixation of a distal tibial spiral fracture was tested as stand-alone and with supplemental cerclage materials (one cable, two cables, wire, fiber tape). Construct stiffness and fracture gap movements were investigated under quasi-static and dynamic loads and compared to the stand-alone locking plate. Results With each of the tested cerclages, stiffness was significantly higher than for a solitary plate osteosynthesis. Most reduction in fracture gap movement was achieved by cable cerclages, followed by double-looped wire and double-looped fiber tape cerclages. Under dynamic loading an additional cable cerclage reduces excessive gap movement. Conclusion Compared to solitary plate osteosynthesis all supplemental cerclage materials were generally superior with reduced fracture gap movements whereas cable cerclages showing the greatest stabilizing effect.

Introduction The humeral shaft fracture is a rare fracture of the long bones with various treatment options. Dreaded complications such as lesions of the radial nerve or non-unions make the decision for what kind of therapy option more difficult. Biomechanically the upper arm is mostly exposed to rotational forces, which affect intramedullary nail osteosynthesis. Additive cerclage may compensate for these in spiral fractures. The aim of this study is to investigate what effect a combination of intramedullary nail osteosynthesis and limited invasive cerclage has on the rate of healing. In addition, this study addresses the question if complications arise as a result of cerclage. Methods In this retrospective study, 109 patients were evaluated, who, during a period of 6 years, underwent operative treatment of a humerus shaft fracture with a combination of intramedullary nail osteosynthesis and additive cerclage. The primary end point was to establish the rate of healing. A secondary end point was to evaluate complications such as infections and damage to the nerve. This was followed by an examination of patient files and X-ray images and a statistical analysis with SPSS. Results and conclusion The healing process shows a non-union rate of 2.6%, and complications such as secondary radial nerve lesions of 4.6%. The antegrade intramedullary nail osteosynthesis with limited invasive, additive cerclage reduces the risk of non-union and does not lead to an increased risk of iatrogenic damage to the radial nerve. Wound healing was not impaired and there were no infections through the cerclage in our patient cohort.

Osteoporotic vertebral compression fractures (VCF) are a common injury among older patients. The optimal treatment option (operative or conservative) is still discussed. The literature describes a reduced mortality following operative augmentation of VCF compared to conservative treatment. We examined our orthogeriatric patient cohort to find out whether there is a positive correlation between surgical treatment of VCF and the survival rate.We performed an assessment of all patients with an osteoporotic spinal fracture who were treated on an orthogeriatric care unit due to VCF between 1 February 2014 and 31 January 2015. The treatment associated-mortality was examined in a 2-year follow-up, with a special focus on the influence of the treatment.A total of 74 patients (74% follow-up) with an average age of 83.2 years were included, 40 having been treated conservatively and 34 surgically. Overall, the 1‑year and 2‑year mortalities were 29.7% and 35.1%, respectively. Surgical treatment was associated with 1‑year and 2‑year mortalities of 20.6% and 23.5% compared to 37.5% and 45%, respectively, after conservative treatment (p = 0.113 and 0.086, χAlthough no statistically significant difference between the treatment groups could be detected (possibly due to the small sample size), the analysis showed a tendency towards an improved survival after surgical treatment. This is in accordance with international studies. Further investigations in the literature suggest that the reduction of kyphosis by surgery could represent an important causal association.HINTERGRUND: Osteoporotische Wirbelkörperfrakturen sind eine häufige Verletzung alter Menschen, deren optimale Behandlung (konservativ oder operativ) diskutiert wird. Die Literatur beschreibt nach Wirbelkörperaugmentationen geringere Mortalitäten als nach konservativer Therapie. Ob eine positive Korrelation des operativen Vorgehens mit dem Überleben nach oben genannten Verletzungen besteht, soll im eigenen alterstraumatologischen Patientenkollektiv überprüft werden.Es erfolgte die Erfassung aller Patienten, die mit einer osteoporotischen Wirbelkörperfraktur vom 01.02.2014 bis 31.01.2015 auf einer alterstraumatologischen Station behandelt wurden. Im Rahmen eines 2‑Jahres-Follow-up wurden diese auf die assoziierte Sterblichkeit untersucht, wobei insbesondere der Einfluss der Therapie untersucht wurde.Insgesamt konnten 74 Patienten (Rücklauf 74 %) mit einem durchschnittlichen Alter von 83,2 Jahren eingeschlossen werden, davon wurden 40 konservativ und 34 operativ versorgt. Die gesamte Ein- und Zweijahresmortalität betrugen 29,7 % bzw. 35,1 %, nach operativer Versorgung 20,6 % bzw. 23,5 % und nach konservativer Therapie 37,5 % bzw. 45 % (p = 0,113 bzw. 0,086, Chi-Quadrat-Test). Die um Störfaktoren bereinigte „hazard ratio“ betrug 2,0 (95 %-KI: 0,686–6,100) DISKUSSION: Auch wenn möglicherweise wegen der eher geringen Fallzahl kein signifikantes Ergebnis nachgewiesen werden konnte, zeigen die Analysen eine Tendenz des verbesserten Überlebens nach operativem Vorgehen. Dies steht im Einklang mit internationalen Studien. Bestehende Untersuchungen lassen vermuten, dass die Reduktion der Kyphosierung durch die Operation einen wichtigen kausalen Zusammenhang darstellen könnte.

Purpose Distal tibial fractures generally require post-operative weight-bearing restrictions. Especially geriatric patients are unable to follow these recommendations. To increase post-operative implant stability and enable early weight-bearing, augmentation of the primary osteosynthesis by cerclage is desirable. The purpose of this study was to identify the stabilizing effects of a supplemental cable cerclage following plate fixation of distal tibial spiral fractures compared to solitary plate osteosynthesis. Methods In eight synthetic tibiae, a reproducible spiral fracture (AO/OTA 42-A1.1c) was stabilized by angle stable plate fixation. Each specimen was statically loaded under combined axial and torsional loads to simulate partial (200 N, 2 Nm) and full (750 N, 7 Nm) weight-bearing. Tests were repeated with supplemental cable cerclage looped around the fracture zone. In a subsequent stepwise increased dynamic load scenario, construct stiffness and interfragmentary movements were analyzed. Results With supplemental cable cerclage, construct stiffness almost tripled compared to solitary plate osteosynthesis (2882 ± 739 N/mm vs. 983 ± 355 N/mm; p p = 0.001) and shear movement (− 83%; p p = 0.001) compared to a solitary plate under partial weight-bearing. Under dynamic loads supplemental cerclage significantly reduced axial (p = 0.005) as well as shear movements (p Conclusion Supplemental cable cerclage significantly increases fixation stiffness and reduces shear movement in distal tibial spiral fractures. This stabilizing effect enables from a biomechanical point of view immediate mobilization without any weight-bearing restrictions, which may improve the quality of care of orthopedic patients and may trigger a change towards early weight-bearing regimes, especially geriatric patients would benefit from.

Zusammenfassung Hintergrund Osteoporotische Wirbelkörperfrakturen sind eine häufige Verletzung alter Menschen, deren optimale Behandlung (konservativ oder operativ) diskutiert wird. Die Literatur beschreibt nach Wirbelkörperaugmentationen geringere Mortalitäten als nach konservativer Therapie. Ob eine positive Korrelation des operativen Vorgehens mit dem Überleben nach oben genannten Verletzungen besteht, soll im eigenen alterstraumatologischen Patientenkollektiv überprüft werden. Methodik Es erfolgte die Erfassung aller Patienten, die mit einer osteoporotischen Wirbelkörperfraktur vom 01.02.2014 bis 31.01.2015 auf einer alterstraumatologischen Station behandelt wurden. Im Rahmen eines 2‑Jahres-Follow-up wurden diese auf die assoziierte Sterblichkeit untersucht, wobei insbesondere der Einfluss der Therapie untersucht wurde. Ergebnisse Insgesamt konnten 74 Patienten (Rücklauf 74 %) mit einem durchschnittlichen Alter von 83,2 Jahren eingeschlossen werden, davon wurden 40 konservativ und 34 operativ versorgt. Die gesamte Ein- und Zweijahresmortalität betrugen 29,7 % bzw. 35,1 %, nach operativer Versorgung 20,6 % bzw. 23,5 % und nach konservativer Therapie 37,5 % bzw. 45 % (p = 0,113 bzw. 0,086, Chi-Quadrat-Test). Die um Störfaktoren bereinigte „hazard ratio“ betrug 2,0 (95 %-KI: 0,686–6,100) Diskussion Auch wenn möglicherweise wegen der eher geringen Fallzahl kein signifikantes Ergebnis nachgewiesen werden konnte, zeigen die Analysen eine Tendenz des verbesserten Überlebens nach operativem Vorgehen. Dies steht im Einklang mit internationalen Studien. Bestehende Untersuchungen lassen vermuten, dass die Reduktion der Kyphosierung durch die Operation einen wichtigen kausalen Zusammenhang darstellen könnte.

Key summary points Aim To determine differences in mortality between hip-, vertebral- and upper extremity fractures of orthogeriatric inpatients and mortality’s respective age dependence. Findings All fracture-related death rates were comparable and not significantly different. Age stratification showed a reduction in relative death risk at higher age in all groups. Message The fracture event was an indicator of higher susceptibility of death in relatively younger orthogeriatric patients independent of fracture entity., Purpose The most common osteoporotic fragility fractures are hip, vertebral and upper extremity fractures. An association with increased mortality is widely described with their occurrence. Fracture-specific associated death rates were determined in a 2-year follow-up for patients treated on an orthogeriatric ward. These were compared amongst each other, examined for changes with age and their impact on the relative mortality risk in relation to the corresponding population. Methods We assessed all patients that were treated in the course of a year on an orthogeriatric ward and suffered from the following injuries: hip (HF), vertebral (VF) and upper extremity fractures (UEF). In a 2-year follow-up it was possible to determine the month of death in the case of the patient’s decease. Pairwise comparisons of the three fracture type death rates were performed through Cox-Regression. We stratified the fracture-dependent absolute mortality and age-specific mortality risk (ASMR) for age groups 71–80, 81–90 and 91–95. Results Overall, we assessed 240 patients with HF, 96 with VF and 127 with UEF over the span of a year. 1- and 2-year-mortality was: HF: 29.6% a.e. 42.9%, VF: 29.2% a.e. 36.5%, UEF: 20.5% a.e 34.6%. Pairwise comparisons of these mortality values revealed no significant differences. In association with HF and VF, we observed a significant increase of 2-year mortality for the oldest compared to the youngest patients (HF: 60.4% vs. 22.5%; p = 0.028) (VF 70% vs. 14.3%; p = 0.033). The analogue comparison for UEF revealed no relevant difference in age-dependent mortality (40.9% vs. 31.1%; p = 0.784). Common for all fracture types ASMR’s were more elevated in the younger patients and decreased with higher age. Conclusion The fracture-related mortality in the 2-year follow-up was comparable. We observed a reduction of relative mortality risk in the oldest patients. While a direct influence of fracture on mortality must be supposed, we support the thesis of the fracture rather being an indicator of higher susceptibility of timely death.

ZusammenfassungDistale Humerusfrakturen zeigen im geriatrischen Patientenkollektiv eine zunehmende Inzidenz. Aufgrund der häufig vorbestehenden osteoporotischen Knochenverhältnisse ist der Chirurg regelhaft mit komplexen intraartikulären mehrfragmentären Frakturen konfrontiert. Der Erhalt der Selbstständigkeit und das Vermeiden von Pflegebedürftigkeit ist ein Dogma in der Versorgung geriatrischer Patienten. Gerade beim betagten Patienten ist folglich eine stabile postoperative Situation und eine frühfunktionelle Nachbehandlung anzustreben. Die offene anatomische Reposition und stabile Retention mittels Doppelplattenosteosynthese ist der osteosynthetische Versorgungsstandard. Moderne anatomische, winkelstabile Implantate sollen die stabile Retention erleichtern und die Operationsdauer verkürzen. Die wenigen zur Verfügung stehenden Daten mit modernen Plattensystemen zeigen beim geriatrischen Patienten zwar gute funktionelle Ergebnisse, jedoch auch hohe Komplikationsraten. Wie an anderen großen Gelenken hat sich auch am Ellenbogen die Frakturendoprothetik aufgrund der direkten Primärstabilität als wertvolle therapeutische Alternative beim älteren Patienten etabliert. So zeigen die Register in den letzten Jahrzehnten eine Vervielfachung der Implantationszahlen. Das Standardimplantat in der Frakturendoprothetik des geriatrischen Patienten ist die zementierte „semi-constrained“ Prothese. Als Nachteile einer primär endoprothetischen Versorgung werden die lebenslange Belastungsrestriktion sowie potenzielle prothesenassoziierte Langzeitkomplikationen wie aseptische Lockerung und periprothetische Frakturen genannt. Vergleichende Studien mit kurz- und mittelfristigen Nachuntersuchungszeiträumen zeigen gegenüber der Osteosynthese vergleichbare funktionelle Ergebnisse, jedoch weniger Komplikationen und Revisionen sowie eine verkürzte Operationsdauer. Langzeitergebnisse, die potenzielle prothesenassoziierte Komplikationen suffizient erfassen, fehlen jedoch. In der rekonstruierbaren und für eine frühfunktionelle Beübung stabil retinierbaren Fraktursituation des distalen Humerus bleibt die Osteosynthese folglich auch beim geriatrischen Patienten das Verfahren der ersten Wahl.

Introduction: According to the expected demographical changes, the number of elderly trauma patients will increase exponentially over the next decades. Different models of an interdisciplinary orthogeriatric care have been developed. But there is only limited evaluation of their benefit without clear and evidence-based results. In 2011, we monitored the results of our orthogeriatric combined management by conducting a 1-year follow-up. Methods: We treated 231 patients presenting a proximal femoral fracture on our orthogeriatric ward. We obtained the epidemiological data and the geriatric assessments from all these patients. One year after discharge, we sent them a written questionnaire. Primary end points were the mortality and the functional outcome, measured by Barthel score, the requirement of care, and the residential status. Results: One hundred sixty-seven (72%) of the 231 patients completed the follow-up. The average age at admission was 81.5 years (70-99 years). The mortality rate was 2.4% during hospital stay and 31.4% after 1 year. The average Barthel score was 44 points at the time of admission, 55 points at discharge, and 72 points after 1 year. Forty-five percent of the patients were in requirement of care at the time of their admission. At the 1-year follow-up, 63% of the patients had some form of care, thus showing an increase of 18%. At the moment of the fracture, 77% of the patients were living in their own home and 23% in a nursing home. After 1 year, the surviving patients show nearly unchanged conditions (75% own home vs 25% nursing home). Eighty-six percent of the patients coming from their own home were able to continue living there independently. Conclusion: The orthogeriatric care is successful in reducing the short-time mortality without showing any effect on 1-year mortality. But the surviving patients seem to benefit from an improved functional outcome.

Introduction: Pneumonia, thromboembolic and ischemic events, urinary tract infections (UTI), delirium and acute kidney injury (AKI) are common complications during the treatment of fragility fractures. In a 2 years-follow-up we determined the according incidence and risk factors of these and other complications in orthogeriatric inward patients, as well as the respective associated mortality. Methods: All patients treated on an orthogeriatric co-managed ward over the course of a year were included. Besides injury, therapy and geriatric assessment parameters, we evaluated the inward incidence of common complications. In a 2 years-follow-up the associated death rates were aquired. SPSS (IBM) was used to determine the importance of risk factors predisposing to the respective occurrence of a complication and accordingly determine it’s impact on the patients’ 1- and 2-years-mortality. Results: 830 orthogeriatric patients were initially assessed with a remaining follow-up cohort of 661 (79.6%). We observed very few cases of thrombosis (0.6%), pulmonary embolism (0.5%), apoplex (0.5%) and myocardial infarction (0.8%). Pneumonia was seen in 42 (5.1%), UTI in 85 (10.2%), delirium in 186 (22.4%) and AKI in 91 (11.0%) patients. Consistently ADL on admission was found to be a relevant risk factor in the development of each complication. After adjustment only AKI showed a significant increased mortality risk of 1.60 (95%CI:1.086-2.350). Discussion: In our fracture-independent assessment of complications in the orthogeriatric treatment of inward patients we’ve seen very rare cases of cardiac and thrombotic complications. Typical fragility-fracture associated common events like pneumonia, UTI, delirium and AKI were still more incidental. No complication except AKI was associated to significant increased mortality risk. Conclusions: The relevance of orthogeriatric care in prevention and outcome of inward complications seems promising, needing still more controlled studies, evaluating not just hip fracture patients but more diverse groups. Consensus is needed in the scholar evaluation of orthogeriatric complications.

Introduction The objective of this study was to assess the clinical outcome of displaced proximal humerus fracture treated with a new locking blade nail. Materials and methods This prospective study included a series of 92 patients with acute fracture of the proximal humerus treated in one hospital level I trauma centre with locking blade nail between December 2010 and December 2013. According to the Neer classification, all fractures were two- to four-part fractures. Age adopted Constant score, DASH and visual analogue scores were used as outcome measures. Results A total of 92 patients were enrolled in the study. However, 29 patients were excluded due to loss to follow-up and death. Ultimately, 63 patients were available for final follow-up and data analysis. The mean duration of follow-up was 22 months (range 16–48 months). On average at 1 year, all fractures had united. The mean weighted Constant score was 84.2 % and the median disabilities of the arm, shoulder and hand (DASH) score was 26, the range of elevation was 115 and range of abduction was 97. The head shaft angle was 130, and pain visual analogue was 1.6. We found that 5 of the 63 patients (8 %) demonstrated complications. Two patients (3 %) displayed secondary displacement and require device removal. Two patients (3 %) had impingement due to prominent metal work, and one patient had a superficial wound infection which was treated with a course of antibiotics. Conclusion Our study shows excellent results with new locking blade nail for displaced proximal humerus fractures. We think the locking blade nail offers stiff triangular fixation of the head fragment and support of the medial calcar region to prevent secondary varus collapse. Level of evidence III.

Hintergrund Obwohl suprakondylare Humerusfrakturen die haufigsten kindlichen Ellbogenfrakturen sind, besteht Uneinigkeit uber die optimale operative Versorgung mit lediglich schwacher Empfehlung fur ein rein radiales Einbringen der Kirschner-Drahte. An unserer Klinik ist die gekreuzte Kirschner-Draht-Osteosynthese nach wie vor das Standardverfahren.

Die demografische Entwicklung unserer Gesellschaft bringt Veranderungen mit sich, auf die sich die Traumatologie einstellen muss. Vielerorts sind in den vergangenen Jahren spezialisierte Alterstraumazentren entstanden, in denen in interdisziplinarer und interprofessionaler Zusammenarbeit die Behandlung geriatrischer Traumapatienten erfolgt. Wissenschaftlich konnte der Nutzen solcher Zentren gegenuber der Standardbehandlung in der Zwischenzeit nachgewiesen werden. Abgeleitet vom § 1 des SGB VII mussen die gesetzlichen Unfallversicherungstrager damit darauf drangen, dass ihre Versicherten in eben solchen Einrichtungen behandelt werden, die uber ein entsprechendes Zertifikat verfugen. Das Zertifikat selbst sollte von den beiden Fachgesellschaften fur Unfallchirurgie und Geriatrie gemeinsam erarbeitet werden, da die Zusammenarbeit der beiden Facher eben solche Alterstraumazentren ausmacht. Die Moglichkeit zur Beteiligung an einem stationaren Heilverfahren fur geriatrische Traumapatienten sollte dabei unabhangig von der dreistufigen Einordnung DAV (Durchgangsarztverfahren) – VAV (Verletzungsartenverfahren) – SAV (Schwerstverletzungsartenverfahren) moglich sein. Allerdings muss auch eine adaquate Finanzierung fur diese kostenintensive Behandlung sichergestellt werden.

ZusammenfassungFrakturen des distalen Humerus sind die häufigsten Verletzungen am kindlichen Oberarm. Im überwiegenden Teil handelt es sich hierbei um eine suprakondyläre Humerusfraktur. Prinzipiell muss man diese rein metaphysären Frakturen und die ebenfalls extraartikulär liegenden Frakturen im epikondylären Bereich von den intraartikulären Frakturen im kondylären Bereich bez. der Behandlungsstrategie und der Prognose unterscheiden. Die Wachstumspotenz und damit das Korrekturpotenzial sind am distalen Humerus selbst bei sehr jungen Kindern gering, dies muss daher bei der Behandlungsstrategie beachtet werden. Undislozierte und stabile Frakturen können immer konservativ behandelt werden. Ziel der operativen Therapie bei den dislozierten und instabilen Frakturen ist die anatomische Reposition und wenn möglich bewegungsstabile Frakturfixation, wobei Osteosynthesen mittels K-Drähten einer zusätzlichen Ruhigstellung bedürfen. Bei Beachtung der grundlegenden therapeutischen Prinzipien kommt es in aller Regel zu exzellenten funktionellen Ergebnissen. Durch übersehene Fehlstellungen oder unzureichend reponierte Frakturen können selten durch Pseudarthrosenbildung, häufiger durch Wachstumsstörungen vor allem kosmetisch störende Fehlstellungen (Cubitus valgus oder varus), aber auch Bewegungseinschränkungen, Schmerzen und Nervenirritationen resultieren, die das Outcome dieser Verletzungen deutlich verschlechtern.

ZusammenfassungDie aktuelle Bevölkerungsentwicklung mit gestiegener Lebenserwartung und zunehmender Überalterung der Bevölkerung ist eine der größten Herausforderungen in der Medizin allgemein und ganz speziell auch in der Unfallchirurgie. Diese Entwicklung ist keineswegs abgeschlossen, sondern wird sich in Zukunft noch fortsetzen. Um die Behandlung von geriatrischen Patienten mit Frakturen zu optimieren, werden nicht nur in Deutschland immer mehr Alterstraumazentren gebildet. In diesen spezialisierten Zentren soll nicht nur die operative Behandlung an die sog. „fragility fractures“ angepasst werden, sondern vielmehr der Patient mit allen seinen Komorbiditäten in einem interdisziplinären Gesamtkonzept therapiert werden. Dies erfordert neben dem interdisziplinären Team aus Unfallchirurgen, Geriatern, spezialisierter Pflege, Physio-, Ergotherapie und Sozialdienst auch entsprechende strukturelle Voraussetzungen wie z. B. gemeinsame Visiten und Besprechungen oder angepasste Patientenzimmer, Therapie- und Gruppenräume. Auch wenn bis dato keine harte Evidenz vorliegt, zeigen sich in den vorliegenden Studien zunehmend die Vorteile von Alterstraumazentren gegenüber der konventionellen rein unfallchirurgischen Behandlung z. B. in Hinblick auf Komplikationen, Krankenhausmortalität oder das funktionelle Outcome.

Objective Minimally invasive surgical stabilization of ankle fractures allowing postoperative full weight bearing. Indications Unstable ankle fractures type Weber B and C in the geriatric patients or with a critical soft tissue situation. Contraindications Ankle fractures in young patients and patients with high demands (relative contraindication). Surgical technique Closed reduction, retrograde insertion of the intramedullary nail into the fibula via a small incision, insertion of up to four locking screws using an aiming device and small incisions. Postoperative management Full weight bearing in an ankle joint orthosis. Results In 34 patients who were treated with a retrograde fibula nail, a 6-month follow-up was possible in 18 patients. Osseous consolidation was achieved without any soft tissue complications or infections in all 18 cases. The patients regained their preoperative level of mobility (Parker Mobility Score 4.2 preoperative vs 4.3 postoperative).

Surgical treatment of anterior pelvic fragility fractures is indicated to improve stability of the pelvic ring after fixation of the posterior pelvis. In order to achieve durable fixation in weakened bone, implants should realize optimal anchoring as well as improved load distribution and transfer. Plates provide the strongest mechanical fixation for the pelvic bone. Major disadvantage is the requirement for extended and lengthy surgical dissection around vital neurovascular and visceral structures that in turn may lead to significant perioperative morbidity. A standard surgical approach to the symphysis and rami is carried out through a transverse suprapubic Pfannenstiel incision. In case fixation of lateral rami fractures is needed, the modified Stoppa approach can be performed. The subcutaneous pedicle screw-rod crossover fixator and the pelvic bridge can also be useful for fixation of anterior pelvic ring fractures. Disadvantages include lower mechanical strength of fixation, compared to conventional plating, and possible need for removal of the construct. Indications include unstable unilateral or bilateral pubic rami fractures, isolated or in combination with posterior lesions where load-bearing stability is required for ambulatory rehabilitation. The anterior subcutaneous cross-over internal pelvic fixator consist of two large diameter long pedicle screws inserted into the supraacetabular regions and interconnected by a curved rod. Data is favorable, demonstrating adequate healing at the average of 3 months after the surgery. The implants were routinely removed after 4–6 months. The most notorious complication was lateral femoral cutaneous nerve palsy. Heterotopic ossification around the screw heads was noted. The anterior pelvic bridge represents a subcutaneously placed internal fixator to interconnect the ipsilateral iliac crest to an ipsilateral or contralateral pubic tubercle and spans a fracture of the anterior pelvic ring. The pelvic bridge provides quick pain relief and the opportunity of rapid postoperative mobilization. Complications related to the pelvic bridge include superficial wound infection, pubic fracture; asymptomatic nonunion and temporary lateral femoral cutaneous nerve palsy. The anterior subcutaneous three-point pelvic fixator is a minimally invasive stabilization frame for the anterior pelvic ring using the internal fixator system of the implants for spinal fusion. A pedicle screw is positioned into the iliac wing just below the anterior superior iliac spine on both sides. One or two additional screws are positioned into the pubic bone close to the symphysis. The three to four screws are connected by a curved rod which runs parallel to the inguinal ligament on both sides. This rod is positioned epifascial to prevent direct pressure on neural or vascular structures of the inguinal region. The main disadvantage is the restricted comfort for the patient because the rod is palpable in the subcutaneous layer. Experience of anterior internal fixators with the treatment of fragility fractures of the pelvis is sparse yet promising. Plating and subcutaneous internal constructs provide appropriate stability of the anterior pelvic ring, with improved patient satisfaction, nursing care and diminished perioperative morbidity.