Moritz F. Lodde

Pilon-tibiale-Frakturen stellen aufgrund der häufig komplexen Frakturmorphologie sowie des zumeist schweren Weichteilschadens eine chirurgische Herausforderung dar. Um ein bestmögliches Therapieergebnis zu erreichen, sind neben dem Ausmaß der knöchernen Verletzung die Beurteilung und das therapeutische Management des Weichteilschadens sowie die Auswahl des OP-Zeitpunkts und des OP-Verfahrens von großer Bedeutung. Pilon tibial fractures are intra-articular fractures of the distal tibial metaphysis, typically resulting from high-energy axial trauma. Accurate classification using AO/OTA type 43-C and advanced imaging, including CT with 3D reconstruction, is essential for preoperative planning. Initial management of displaced fractures includes prompt reduction and temporary immobilization, often with a spanning external fixator. Definitive treatment follows a staged protocol based on soft tissue status and involves open reduction and internal fixation via approach-specific surgical access. Conservative management is reserved for stable, non-displaced fractures. Anatomical reduction is critical for favorable long-term outcomes. Postoperative care includes early physiotherapy, individualized weight-bearing, and close radiological monitoring. Article published online: 23 September 2025 © 2025. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

Zusammenfassung Die knöcherne Konsolidierung nach einer Fraktur hängt von verschiedenen Faktoren ab. Unter optimalen Bedingungen erfolgt sie innerhalb von wenigen Wochen. Grundvoraussetzung für die Frakturheilung ist die Wiederherstellung der adäquaten biomechanischen Stabilität mit möglichst idealer interfragmentärer Bewegung. Die distale Femurfraktur stellt, insbesondere bei ausgeprägtem Weichteilschaden, mehrfragmentärer Fraktursituation und Gelenkbeteiligung eine besondere Herausforderung dar. Aktuell angewandte operativen Verfahren – isolierte laterale Platten‑, Doppelplatten- und Marknagelosteosynthese sowie Kombinationsverfahren – gehen mit einer relativ hoher Komplikationsrate einher. Das Prinzip der Biphasic Plate beruht auf der in der Platte befindlichen quer und längs verlaufenden Spalten, der bei Belastung eine „kontrollierte Instabilität“ ermöglicht. Dieser sorgt für eine relativ hohe interfragmentäre Bewegung schon bei geringer Belastung (flexible Phase) und eine geringe Bewegung bei hoher Belastung (steife Phase). Das Implantat wird also bei höherer mechanischer Beanspruchung rigider. In biomechanischen Tests erwiesen sich die Stressverteilung des Implantats, die Zahl der Zyklen bis zum Versagen und die maximale Belastung gegenüber der Locking Compression Plate – Distal Femur (LCP-DF) vorteilhaft. Zukünftige Studien müssen die mögliche klinische und wirtschaftliche Überlegenheit zu den derzeit etablierten Verfahren vergleichen. Die bisherigen präklinischen Studien konnten die Sicherheit und Anwendbarkeit des Implantats und des innovativen Prinzips der kontrollierten Instabilität in der Frakturheilung nachweisen.

Introduction: Current literature lacks recommendations regarding proper fixation of comminuted coronal plane fractures of the posterior femoral condyles (Hoffa fractures). Therefore, the aim of this study was to compare the biomechanical characteristics of different plate-augmented constructs to isolated posteroanterior screw fixation in comminuted lateral Hoffa fractures. Materials and methods: Comminuted Letenneur type IIb lateral Hoffa fractures were simulated in 24 human cadaveric distal femora. The fractures were fixed with either isolated crossed posteroanterior screws or additionally with either a posterior plate, a lateral locking plate, or combined posterior and lateral locking plates. All specimens were biomechanically tested under progressively increasing cyclic loading until failure, while capturing the interfragmentary movements of the Hoffa and intercalary fragments via motion tracking. Results: Plate-augmented posteroanterior screw fixation of the Hoffa fragment exhibited higher cycles to failure, higher failure loads ( p < 0.05) and less axial displacements ( p < 0.05) compared to isolated posteroanterior screw fixation. Both additional lateral locking and double plate fixations of the intercalary fragment provided higher cycles to failure, higher failure loads ( p < 0.05) and less axial displacement ( p < 0.05) than isolated posteroanterior screw fixation, whereas additional posterior plate fixation did not significantly increase cycles to failure, failure loads and axial displacement (n.s.). Fracture gap twisting and opening did not differ significantly between the four constructs for the Hoffa fragment, while plate-augmented constructs provided less fracture opening of the intercalary fragment compared to isolated posteroanterior screw fixation ( p < 0.01). Conclusions: Plate-augmented posteroanterior screw fixation of comminuted Letenneur type IIb Hoffa fractures provided greater biomechanical stability than isolated posteroanterior screw fixation. While additional lateral or double plate fixation improves the stability of both the intercalary and Hoffa fragment, posterior plating stabilized only the Hoffa fragment.

(1) Background: The incidence of fragility fractures of the pelvis (FFP) has increased significantly over the past decades. Unilateral non-displaced fractures, defined as FFP II, are the most common type of fracture. When conservative treatment fails, surgical treatment is indicated. We hypothesize that the use of bilateral SI screws (BSIs) or a transsacral screw (TSI) is superior compared to a unilateral screw (USI) because of a significant reduction in the risk of adjacent fractures and a reduction in fracture progression. (2) Methods: A finite element model of a female pelvic ring was constructed. The ligaments were simulated as tension springs. The load was applied through the sacrum with the pelvis fixed to both acetabula. An FFP IIc was simulated and fixed with either a USI or BSI or TSI. The models were analyzed for a quantitative statement of stress and fracture dislocation. (3) Results: The BSI and TSI resulted in less dislocation compared to the USI. The stress distribution on both sides of the sacrum was favorable in the BSI and TSI groups. The BSI resulted in a higher rotational stability compared to the TSI. (4) Conclusions: The use of either a BSI or TSI for fixation of unilateral FFP is biomechanically favorable compared to the use of a USI. In addition, the use of a BSI or TSI reduces the stress on the contralateral uninjured side of the sacrum. This may reduce the risk of an adjacent fracture or fracture progression.

Background and purpose: The treatment of acetabular fractures remains technically demanding. In the case of reduced bone quality or fracture morphology reducing the amount of bone available for fixation, locking plates should provide considerable advantages. The aim of the present study was to compare conventional and locking plate fixation. It was hypothesized that locking plate fixation provides less displacement and higher construct stiffness.Methods: A T-shaped acetabular fracture was simulated in 16 synthetic pelvic models. The fracture was addressed with a biplanar 10-hole 2-column plate buttressing the medial acetabular wall. Optical markers were attached to the fracture sites for motion tracking. Standardization of the acetabulum loading mechanism was performed using a unipolar hemiarthroplasty. The primary outcome measure was displacement at the fracture sites. The secondary outcome measure was the construct stiffness (N/mm).Results: Fracture displacement was less in the group of angular stable implants compared with the group fixed with conventional non-locking implants. Under cyclic loading displacement was less in the group of locking plate fixation. No differences in mean initial axial stiffness were detected between locking plate fixation (407 N/mm) and conventional plating (308 N/mm, ∆ 99 N/mm, 95% confidence interval –48 to 245).Conclusion: We showed that locking plate fixation buttressing the medial acetabular wall achieved less fracture displacement but showed no differences in axial stiffness compared with conventional plating.

(1) Background: High-energy injuries of the pelvic ring are rare. The wide application of iliosacral screw fixation of the posterior pelvic ring is relatively new. The aim of the present study was to evaluate the long-term quality of life. (2) Methods: All patients treated with an iliosacral screw for a posterior pelvic ring stabilization after high-energy trauma at a level 1 trauma center between 2005 and 2015 were included. Pelvic ring injuries were classified according to the Tile classification adapted by AO/ASIF. The clinical evaluation included the patient-oriented questionnaires surveys of the Majeed Score, Iowa Pelvic Score (IPS), Work Ability Index (WAI), SF-36, EQ5D-5L. (3) Results: A total of 84 patients were included with a median follow-up of 130.1 months (IQR 95.0–162.0 months). The median ISS was 22.5 (IQR 16.0–29.0), mean Majeed Score 83.32 (SD ± 19.26), IPS 77.88 (SD ± 13.96), WAI 32.71 (SD ± 11.31), SF-36 PF 71.25 (SD ± 29.61) and EQ5D-5L 0.83 (SD ± 0.21). There was a notably difference between uni- and bilateral pelvic fractures (p = 0.033) as well as a correlation with the ISS (p = 0.043) with inferior functional outcome measured by IPS. (4) Conclusions: Long-term follow-up of iliosacral screw fixation of unstable pelvic ring fractures showed a good quality of life and functional outcome with equal EQ5D-5L results and inferior SF-36 physical functioning compared to the German population.

Background: We investigated the spinopelvic parameters of lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT) and sacral slope (SS) in patients with fragility fractures of the pelvis (FFPs). We hypothesized that these parameters differ from asymptomatic patients. Methods: All patients treated for FFPs in a center of maximal care of the German Spine Society (DWG) between 2017 and 2021 were included. The inclusion criteria were age ≥ 60 years and the availability of a standing lateral radiograph of the spine and pelvis in which the spine from T12 to S1 and both femoral heads were visible. The baseline characteristics and study parameters were calculated and compared with databases of asymptomatic patients. The two-sample t-Test was performed with p < 0.05. Results: The study population (n = 57) consisted of 49 female patients. The mean age was 81.0 years. The mean LL was 47.9°, the mean PT was 29.4°, the mean SS was 34.2° and the mean PI was 64.4°. The mean value of LLI was 0.7. LL, LLI and SS were significantly reduced, and PI and PT were significantly increased compared to asymptomatic patients. Conclusions: The spinopelvic parameters in patients with FFPs differ significantly from asymptomatic patients. In patients with FFPs, LL, LLI and SS are significantly reduced, and PI and PT are significantly increased. The sagittal spinopelvic balance is abnormal in patients with FFPs.

Background and Objectives: The stability of the pelvic ring mainly depends on the integrity of its posterior part. Percutaneous sacroiliac (SI) screws are widely implanted as standard of care treatment. The main risk factors for their fixation failure are related to vertical shear or transforaminal sacral fractures. The aim of this study was to compare the biomechanical performance of fixations using one (Group 1) or two (Group 2) standard SI screws versus one SI screw with bone cement augmentation (Group 3). Materials and Methods: Unstable fractures of the pelvic ring (AO/OTA 61-C1.3, FFP IIc) were simulated in 21 artificial pelvises by means of vertical osteotomies in the ipsilateral anterior and posterior pelvic ring. A supra-acetabular external fixator was applied to address the anterior fracture. All specimens were tested under progressively increasing cyclic loading until failure, with monitoring by means of motion tracking. Fracture site displacement and cycles to failure were evaluated. Results: Fracture displacement after 500 cycles was lowest in Group 3 (0.76 cm [0.30] (median [interquartile range, IQR])) followed by Group 1 (1.42 cm, [0.21]) and Group 2 (1.42 cm [1.66]), with significant differences between Groups 1 and 3, p = 0.04. Fracture displacement after 1000 cycles was significantly lower in Group 3 (1.15 cm [0.37]) compared to both Group 1 (2.19 cm [2.39]) and Group 2 (2.23 cm [3.65]), p ≤ 0.04. Cycles to failure (Group 1: 3930 ± 890 (mean ± standard deviation), Group 2: 3676 ± 348, Group 3: 3764 ± 645) did not differ significantly between the groups, p = 0.79. Conclusions: In our biomechanical setup cement augmentation of one SI screw resulted in significantly less displacement compared to the use of one or two SI screws. However, the number of cycles to failure was not significantly different between the groups. Cement augmentation of one SI screw seems to be a useful treatment option for posterior pelvic ring fixation, especially in osteoporotic bone.

Background: Fractures of the four anterior pubic rami are described as “straddle fractures”. The aim of this study was to compare biomechanical anterior plating (group 1) versus the bilateral use of retrograde transpubic screws (group 2). Methods: A straddle fracture was simulated in 16 artificial pelvises. All specimens were tested under progressively increasing cyclic loading, with monitoring by means of motion tracking. Results: Axial stiffness did not differ significantly between the groups, p = 0.88. Fracture displacement after 1000–4000 cycles was not significantly different between the groups, p ≥ 0.38; however, after 5000 cycles it was significantly less in the retrograde transpubic screw group compared to the anterior plating group, p = 0.04. No significantly different flexural rotations were detected between the groups, p ≥ 0.32. Moreover, no significant differences were detected between the groups with respect to their cycles to failure and failure loads, p = 0.14. Conclusion: The results of this biomechanical study reveal less fracture displacement in the retrograde transpubic screw group after long-term testing with no further significant difference between anterior plating and bilateral use of retrograde transpubic screws. While the open approach using anterior plating allows for better visualization of the fracture site and open reduction, the use of bilateral retrograde transpubic screws, splinting the fracture, presents a minimally invasive and biomechanically stable technique.