Flamur Zendeli

Background: Patients treated with an Ilizarov external fixator often feature risk factors that impair wound healing such as diabetes, peripheral arterial disease, obesity, and renal insufficiency. A 2-staged approach, with initial bony correction (Kirschner wire or hybrid) followed by delayed Ilizarov application by 5 days, is intended to support wound healing by allowing for reduction of soft tissue swelling and enhancing postoperative wound care. We hypothesized that this method is associated with fewer wound complications but increased use of resources. Methods: A retrospective review of 98 cases treated with an Ilizarov fixator (2004-2024) was conducted. Surgical management included 2-stage (n = 53, 54%) and single-stage (n = 45, 46%) procedures. Baseline characteristics and risk factors for compromised wound healing were recorded. Patients were stratified into 3 subgroups to enable comparative analysis: infection-related reconstructions (IRR), Charcot arthropathy (CA) and other applications. Preoperative presence of infection and ulceration was recorded. Primary endpoints were rates of impaired wound healing and wound revisions within 3 months post removal. Secondary endpoints were hospital length of stay after bony fixation, and total hospitalization costs. Results: Wound revision rates were significantly lower in the 2-stage group (9% vs 36%; OR 5.3, 95% CI 1.8-17.9; P = .0025) particularly in the CA subgroup (0% vs 38%; P = .010) or when an infection was present (14% vs 44%; OR 4.6, 95% CI 1.2-22.3, P = .0138). Impaired wound healing was significantly lower in patients with a 2-stage procedure (30% vs 55%; OR 2.9, 95% CI 1.3-6.6, P = .021). As an exploratory secondary outcome, no statistically significant difference in length of hospital stay or total hospitalization costs was observed. Conclusion: Two-stage Ilizarov ring fixator application in high-risk foot and ankle surgery was associated with lower rates of impaired wound healing and wound revisions, particularly in CA and infection cases, without increasing hospital stay or costs.

Background/Objectives: The optimal duration of postoperative antibiotic therapy for bone and orthopaedic implant infections remains undefined. The SALATIO Trials are prospective randomised trials investigating whether shorter antibiotic courses are non-inferior to standard durations across different infection strata. This report presents the second interim analysis. Methods: Two unblinded non-inferiority RCTs were conducted (intention-to-treat population). Primary outcomes were remission, clinical failure, and microbiologically identical recurrence. In SALATIO 1 (material arm), participants with infected implants, retained or replaced during initial surgery, were randomised to short-course (six weeks) or long-course (twelve weeks) targeted systemic antibiotic therapy following debridement. In SALATIO 2 (non-material arm), participants undergoing implant removal or two-stage exchange were randomised to either a short-course (three weeks) or a long-course (six weeks) of antibiotic therapy. Results: We analysed 175 infections with a minimum follow-up period of one-year from October 2022 until July 2025: 69 (39%) in the material arm (38 short-course [55%], 31 long-course [45%]) and 106 (61%) in the non-material arm (44 short-course [42%], 62 long-course [58%]). No significant differences in clinical failure (19% overall) or microbiological recurrence (7%) were observed between treatment arms in either stratum. Multivariate analysis identified diabetes mellitus and number of debridements—but not antibiotic duration—as independent risk factors for clinical failure. Patients receiving short-course therapy experienced significantly fewer adverse events (median 0 versus 1; p = 0.01). Formal non-inferiority has not yet been achieved due to limited statistical power; the current analysis includes 175 of the 280 episodes (62.5%) required for the final analysis. Conclusions: This interim analysis suggests no disadvantage of shorter antibiotic regimens in surgically treated orthopaedic infections, whilst reducing adverse events. Patient comorbidities and surgical factors appear to be more relevant to treatment outcomes than antibiotic duration. The SALATIO Trials are ongoing and may support improved antibiotic stewardship without compromising outcomes. Trials Registration: NCT05499481.

Background/Objectives: The optimal duration of postoperative antibiotic therapy for bone and orthopaedic implant infections remains undefined. The SALATIO Trials are prospective randomised trials investigating whether shorter antibiotic courses are non-inferior to standard durations across different infection strata. This report presents the second interim analysis. Methods: Two unblinded non-inferiority RCTs were conducted (intention-to-treat population). Primary outcomes were remission, clinical failure, and microbiologically identical recurrence. In SALATIO 1 (material arm), participants with infected implants, retained or replaced during initial surgery, were randomised to short-course (six weeks) or long-course (twelve weeks) targeted systemic antibiotic therapy following debridement. In SALATIO 2 (non-material arm), participants undergoing implant removal or two-stage exchange were randomised to either a short-course (three weeks) or a long-course (six weeks) of antibiotic therapy. Results: We analysed 175 infections with a minimum follow-up period of one-year from October 2022 until July 2025: 69 (39%) in the material arm (38 short-course [55%], 31 long-course [45%]) and 106 (61%) in the non-material arm (44 short-course [42%], 62 long-course [58%]). No significant differences in clinical failure (19% overall) or microbiological recurrence (7%) were observed between treatment arms in either stratum. Multivariate analysis identified diabetes mellitus and number of debridements—but not antibiotic duration—as independent risk factors for clinical failure. Patients receiving short-course therapy experienced significantly fewer adverse events (median 0 versus 1; p=0.01). Formal non-inferiority has not yet been achieved due to limited statistical power. Conclusion: This interim analysis suggests no disadvantage of shorter antibiotic regimens in surgically treated orthopaedic infections, whilst reducing adverse events. Patient comorbidities and surgical factors appear to be more relevant to treatment outcomes than antibiotic duration. The SALATIO Trials are ongoing and may support improved antibiotic stewardship without compromising outcomes. Trials Registration: NCT05499481.

Background: Accurate hindfoot alignment (HA) assessment is essential for surgical planning of foot and ankle procedures, as measurement errors may lead to inappropriate indication. Weight-bearing computed tomography (WBCT) enables HA assessment through coronal images, typically aligned perpendicular to the second ray. However, this forefoot-based reference may not be appropriate in all clinical scenarios, particularly when isolated hindfoot evaluation is required. This exploratory study sought to evaluate how 3 anatomical reference axes affect HA measurements in patients with different foot deformities. Methods: This retrospective cohort study examined 136 WBCT and standard foot radiographs of patients older than 18 years. HA was measured as hindfoot alignment angle (HAA) in coronal images perpendicular to (1) second ray, (2) ankle mortise (bisection of medial and lateral malleoli), and (3) forefoot midpoint (bisection of first and fifth metatarsal heads). Meary, Sgarlato, hallux valgus, and intermetatarsal I-II and I-V angles assessed foot morphology. Spearman correlation analysis was performed to assess relationships between 2-dimensional (2D) parameters and HAA measurements. Results: Median age was 50.3 years and 64% were female. HAA showed significant variations across different reference systems (second ray: 10.0 degrees, ankle mortise: 15.2 degrees, forefoot midpoint: 12.7 degrees; P < .01), with 20.6% of feet showing a discrepancy exceeding 10 degrees between the second ray and ankle mortise. Spearman correlation analysis showed correlation between HAA and Meary angle across all reference axes (ρ = −0.58 to −0.49, P < .01), and between HAA and Sgarlato angle with second ray referencing (ρ = −0.41, P < .01). Conclusions: Reference axis selection substantially influences 2D HA measurements on WBCT. The ankle mortise reference could provide isolated measurement of HA regardless of concurrent forefoot deformities. When using 2D measurement methods, reference system selection could be tailored to whether surgical planning requires comprehensive foot alignment assessment or isolated hindfoot evaluation. Level of Evidence: Level III, retrospective cohort study.

Background/Objectives: Almost all orthopedic infections require a combination of surgical debridement with targeted antimicrobial treatment. The number of debridement procedures may vary considerably between infection episodes. The case mix is large, and so-called “second looks” are frequent. We investigate which bacteria are associated with second looks to achieve local infection control. Methods: We used a composite database stemming from three prospective randomized controlled trials (RCTs) from 2019 to 2025 with protocoled surgical debridement (initial debridement). In these RCTs, we allowed additional debridement only in the case of persistent or progressive local infection. Results: Overall, 201/1067 (18.8%) orthopedic infections required multiple debridement procedures. The median number of additional debridement procedures was two across all pathogen groups, with a range of 2–8 interventions. Gram-negative pathogens revealed the highest risk for “second looks” (28.2%), followed by implant-related infections (25.4%). Cutibacteria yielded the lowest risk (11.7%). In the multivariable logistic regression model, Gram-negative infections (OR 2.04, 95%CI 1.20–3.47) and infected implants (OR 2.18, 95%CI 1.56–3.03) were independently associated with multiple interventions, in contrast to Staphylococcus aureus, Enterococci, or Streptococci. Conclusions: Gram-negative pathogens were significantly associated with the need for second looks in orthopedic infections. The findings support preoperative counseling, antibiotic stewardship, and operative planning for staged management in infection cases with a high risk of clinical failure. Trials registrations: NCT04048304, NCT04081792, NCT05499481.

Background/Objectives: Almost all orthopedic infections require a combination of surgi-cal debridement with targeted antimicrobial treatment. The number of debridement may vary considerably between infection episodes. The case-mix is enormous and so-called "second looks" are frequent. We investigate which bacteria are associated with second looks to achieve local infection control. Methods: We used a composite database stem-ming from three prospective randomized-controlled trials (RCTs) 2019-2025 with proto-colled surgical debridement (initial debridement). In these RCTs, we allowed additional debridement only in case of persistent (during several days) or progredient local infection. Results: Overall, 201/1,067 (18.8%) orthopedic infections required multiple debridement (median two second looks, range 2–8 surgeries). Gram-negative pathogens revealed the highest risk for "second looks" (28.2%), followed by implant-related infections (25.4%). Cutibacteria yielded the lowest risk (11.7%). In the multivariable logistic regression model, Gram-negative infections (odds ratio 2.04, 95%CI 1.20-3.47) and infected implants (OR 2.18, 95%CI 1.56-3.03) were independently associated to multiple interventions, in con-trast to Staphylococcus aureus, enterococci or streptococci. Conclusions: When analyzing orthopedic infections included in prospective RCTs, Gram-negative pathogens groups significantly associate with the need for second looks, which matches our own experience. Today findings support preoperative counseling, antibiotic stewardship, and operative planning for a staged management in infection cases with a high risk of clinical failure. Trials registrations: NCT04048304, NCT04081792, NCT05499481.

Background: Reverse total shoulder arthroplasty (RTSA) is a well-established treatment option for complex proximal humeral fractures in older patients, with greater tuberosity (GT) healing being critical for achieving optimal clinical outcomes. We compared the clinical and radiological outcomes between 2 GT fixation techniques: the “cow hitch” (CH) cerclage suture fixation technique and conventional suture fixation technique. Methods: This retrospective cohort study compared 20 consecutive patients who underwent RTSA using the CH cerclage suture fixation technique (CH group) with 29 consecutive patients who underwent RTSA using the conventional suture fixation technique (control group). Radiological healing of the GT was defined as the primary outcome parameter and assessed using standard radiographs at the last follow-up visit. Clinical outcomes were assessed as secondary outcome parameters and measured using the absolute and relative Constant-Murley scores (aCS and rCS), Subjective Shoulder Value (SSV), range of motion (ROM), and patient-reported outcome satisfaction (PROS). Results: At a mean follow-up at 47 ± 30 (range, 24-120) months, the radiographic findings revealed a 95% healing rate of the GT in the CH group compared with a 66% healing rate in the control group (p = 0.03). No secondary displacement was observed in the CH group, whereas 5 cases (17%) were observed in the control group (p = 0.14). Overall, aCS, rCS, SSV, ROM (flexion, abduction, external rotation), and PROS were significantly higher in the CH group than in the control group (p-values: 0.03, 0.002, 0.004, 0.03, 0.01, 0.01, 0.047, respectively). Conclusion: Compared with the conventional suture GT fixation technique, the CH cerclage suture fixation technique in RTSA performed for complex proximal humerus fractures resulted in higher healing rates with no secondary displacement of the GT, improved clinical outcomes, and enhanced patient satisfaction. Level of Evidence: Level III (Retrospective cohort study). See Instructions for Authors for a complete description of levels of evidence.

Background: Several demographic and clinical risk factors for recurrent ankle instability have been described. The main objective of this study was to investigate the potential influence of morphologic characteristics of the ankle joint on the occurrence of recurrent instability and the functional outcomes following a modified Broström-Gould procedure for chronic lateral ankle instability. Methods: Fifty-eight ankles from 58 patients (28 males and 30 females) undergoing a modified Broström-Gould procedure for chronic lateral ankle instability between January 2014 and July 2021 were available for clinical and radiological evaluation. Based on the preoperative radiographs, the following radiographic parameters were measured: talar width (TW), tibial anterior surface (TAS) angle, talar height (TH), talar radius (TR), tibiotalar sector (TTS), and tibial lateral surface (TLS) angle. The history of recurrent ankle instability and the functional outcome using the Karlsson Score were assessed after a minimum follow-up of 2 years. Results: Recurrent ankle instability was reported in 14 patients (24%). The TTS was significantly lower in patients with recurrent ankle instability (69.8 degrees vs 79.3 degrees) ( P < .00001). The multivariate logistic regression model confirmed the TTS as an independent risk factor for recurrent ankle instability (OR = 1.64) ( P = .003). The receiver operating characteristic curve analysis revealed that patients with a TTS lower than 72 degrees (=low-TTS group) had an 82-fold increased risk for recurrent ankle instability ( P = .001). The low-TTS group showed a significantly higher rate of recurrent instability (58% vs 8%; P = .0001) and a significantly lower Karlsson score (65 points vs 85 points; P < .00001). Conclusion: A smaller TTS was found to be an independent risk factor for recurrent ankle instability and led to poorer functional outcomes after a modified Broström-Gould procedure. Level of Evidence: Level IV, retrospective cohort study.