Surgical revision concepts for the treatment of aseptic humeral, femoral, and tibial diaphyseal nonunion were evaluated. It was analyzed if the range of time to bone healing was shorter, and if clinical and radiological long-term outcome was better following application of additional recombinant human Bone Morphogenetic Protein-7 (rhBMP-7) compared to no additional rhBMP-7 use. In a retrospective comparative study between 06/2006 and 05/2013, 112 patients diagnosed with aseptic diaphyseal humerus (22 patients), femur (41 patients), and tibia (49 patients) nonunion were treated using internal fixation and bone graft augmentation. For additional stimulation of bone healing, growth factor rhBMP-7 was locally administered in 62 out of 112 patients. Follow-up studies including clinical and radiological assessment were performed at regular intervals as well as after at least one year following nonunion surgery. One hundred and two out of 112 (humerus: 19, femur: 37, tibia: 47) nonunion healed within 12 months after revision surgery without any significant differences between the cohort groups. According to the DASH outcome measure for the humerus (p = 0.679), LEFS for the femur (p = 0.251) and the tibia (p = 0.946) as well as to the SF-12 for all entities, no significant differences between the treatment groups were found. Aseptic diaphyseal nonunion in humerus, femur, and tibia healed irrespectively of additional rhBMP-7 application. Moreover, the results of this study suggest that successful nonunion healing can be linked to precise surgical concepts using radical removal of nonunion tissue, stable fixation and restoration of axis, length and torsion, rather than to the additional use of signaling proteins. This clinical trial was conducted according to ICMJE guidelines as well as to the approval of the National Medical Board (Ethics Committee of the Bavarian State Chamber of Physicians; TRN: 2016-104) and has been retrospectively registered with the German Clinical Trails Register (TRN: DRKS00012652 ).

Purpose: Although “tension-band wiring” is still commonly used to stabilize patellar fractures, the technique has recently been scrutinized due to biomechanical insufficiency. Consequently, the AO Foundation renamed the principle to compression cerclage wiring (CCW). Several studies propose favorable outcomes when utilizing locked plating (LP). This study aims to compare outcome of CCW and LP for complex patellar fractures. Methods: A retrospective, single-center cohort study was performed on patients who underwent operative treatment for (AO 34 C-Type) patellar fractures between April 2013 and March 2023. Patients with a 12 month follow up were included. We grouped and compared patients based on the applied treatment strategy: group LP vs. group CCW. Primary outcome parameters included implant-related complications and revision surgeries. Secondary outcomes were length of stay, return to work and 12 months functional outcome (Lysholm score). Odd ratios for complications and revisions were calculated using the conditional Maximum Likelihood Estimate. The threshold for statistical significance was set at p < 0.05. Results: Of 145 patients, 63 could be included (group LP: n = 23 and group CCW: n = 40). Fractures in group LP were significantly more complex in regard to AO Classification (p < 0.001), number of fragments (p < 0.001) and degree of comminution (p < 0.001), yet odds of complications were significantly lower in group LP (OR: 0.147; 95%CI: 0.015–0.742; p = 0.009). K-wire migration was the most common complication in group CCW (20%). Odds of revision surgery were significantly lower in group LP (OR: 0.000; 95%CI: 0.000-1.120; p = 0.041). The average Lysholm score at one year was favorable in both groups (89.8; SD: 11.9 in group LP and 90.6; SD: 9.3 in group CCW; n.s.). Conclusion: In our study cohort, LP was routinely chosen for more complex fracture morphologies; nevertheless the data implies that LP may be considered as the superior fixation technique in regard to complications and revision operations. Especially, K-wire migration occurs frequently after CCW. The one year functional outcome was comparable between the groups, with both demonstrating good results. Prospective randomized studies are indicated to validate our findings.

Purpose: Elective implant removal (IR) in the upper extremity remains controversial. Implants in the olecranon and clavicle are commonly removed for prominence, unlike in the distal radius. Patient-reported symptomatic cannot be verified, and nonspecific discomfort remains unquantified. In this study, indications and outcomes of IR at the clavicle, olecranon and distal radius were evaluated, with a focus on postoperative patient satisfaction. Materials and methods: In this retrospective, single-center cohort study, patients, who received elective IR of the clavicle, olecranon and distal radius were included. Patients were followed up at least six weeks after IR. Outcomes included patient satisfaction, symptom resolution, and complications. Results: One hundred and eighty-nine patients were included. Unspecific symptoms of discomfort were the most prevalent indication for IR (48.7%), followed by pain (29.6%) and objective limited range of motion (ROM) (7%). Pain and limited ROM combined was observed in 13.8%. Subjective benefit following IR was described in 54%. Patients with limited ROM (OR 4.7, p < 0.001) or pain (OR 4.1, p < 0.001) were more likely to experience alleviation of complaints. Patients with unspecific symptoms of discomfort, often did not report improvement. Major complications occurred in 2%. Refractures were detected at the clavicle (3.7%) and at the olecranon (2.5%). Minor complication rate was 5%. Conclusion: IR is a safe procedure in the upper extremity. Indications based on unspecific symptoms of discomfort have a significant lower rate of patient satisfaction postoperatively. Elective IR should be considered cautiously, if it is driven primarily by unspecific symptoms of discomfort. Patient education is relevant to prevent dissatisfying outcome.

Geriatric trauma is expected to increase due to the lifestyle and activity of the aging population and will be among the major future challenges in health care. Therefore, the aim of this study was to investigate differences between polytraumatized geriatric and non-geriatric patients regarding mortality, length-of-stay and complications with a matched pair analysis. We included patients older than 17 years with an Injury Severity Score (ISS) of 16 or more admitted to our level 1 trauma center between January 2008 and December 2015. The cohort was stratified into two groups (age < 70 and ≥ 70 years). One-to-one matching was performed based on gender, ISS, mechanism of injury (penetrating/blunt), Glasgow coma scale (GCS), base excess, and the presence of coagulopathy (international normalized ratio (INR) ≥ 1.4). Outcome was compared using the paired t-test and McNemar-test. A total of 1457 patients were identified. There were 1022 male (70%) and 435 female patients. Three hundred and sixty-four patients (24%) were older than 70 years. Matching resulted in 57 pairs. Mortality as well as length-of-stay were comparable between geriatric and non-geriatric polytraumatized patients. Complication rate (34% vs. 56%, p = 0.031) was significantly higher in geriatric patients. This indicates the possibility of similar outcomes in geriatric polytraumatized patients receiving optimal care.

Purpose: Soft tissue injury and soft tissue injury as risk factors for nonunion following trochanteric femur fractures (TFF) are marginally investigated. The aim of this study was to identify risk factors for impaired fracture healing in geriatric trauma patients with TFF following surgical treatment with a femoral nail. Methods: This retrospective cohort study included geriatric trauma patients (aged > 70 years) with TFF who were treated with femoral nailing. Fractures were classified according to AO/OTA. Nonunion was defined as lack of callus-formation after 6 months, material breakage, and requirement of revision surgery. Risk factors for nonunion included variables of clinical interest (injury pattern, demographics, comorbidities), as well as type of approach (open versus closed) and were assessed with uni- and multivariate regression analyses. Results: This study included 225 geriatric trauma patients. Nonunion was significantly more frequently following AO/OTA 31A3 fractures (N = 10, 23.3%) compared with AO/OTA type 31A2 (N = 6, 6.9%) or AO/OTA 31A1 (N = 3, 3.2%, p < 0.001). Type 31A3 fractures had an increased risk for nonunion compared with type 31A1 (OR 10.3 95%CI 2.2 to 48.9, p = 0.003). Open reduction was not associated with increased risk for nonunion (OR 0.9, 95%CI 0.1 to 6.1. p = 0.942) as was not the use of cerclage (OR 1.0, 95%CI 0.2 to 6.5, p = 0.995). Factors such as osteoporosis, polytrauma or diabetes were not associated with delayed union or nonunion. Conclusion: The fracture morphology of TFF is an independent risk factor for nonunion in geriatric patients. The reduction technique is not associated with increased risk for nonunion, despite increased soft tissue damage following open reduction.

Purpose: Removal of symptomatic hardware after fracture fixation is common, especially in patients with clavicle fracture. Yet, refracture after hardware removal is a relatively common complication in those patients. The aim of this study was to identify risk factors for clavicle refractures that could be influenced by the surgical treatment provided. Methods: All patients from a level one trauma center from 2017 to 2022 were screened for eligibility. Inclusion criteria included hardware removal after plate osteosynthesis of the clavicle, age ≥ 18 years, and signed informed consent. Groups were stratified according to occurrence of refracture: no-refracture (NR) vs. refracture (R). Nearest-neighbor matching in a ratio of 5:1 was performed. Parameter investigated included baseline demographics, fracture characteristics and surgical treatment details. A subgroup analysis of only clavicle shaft fractures was performed. Results: Sixty patients were included with 50 patients in Group NR and 10 in Group R. Baseline characteristics were comparable between the groups. A subgroup analysis on shaft fractures revealed that a significantly larger working length (number of empty screw holes adjacent to the fracture site) in Group NR (1.94 ± 0.85) compared to the refracture group (1.20 ± 0.92) (p = 0.042). Logistic regression yielded an inverse correlation with the number of empty screw holes to the fracture site and the occurrence of refractures (OR 0.369, 95% CI 0.132–0.873; p = 0.035). Time in situ, lag screw application, plate positioning and the total amount of screws did not affect either of the groups. Conclusion: An increased working length in patients with clavicle shaft fractures might be a protective measure for occurrence of refractures after hardware removal.