Alberto Alfieri Zellner

Background: Hand osteomyelitis is an uncommon but potentially devastating infection associated with prolonged treatment, repeated surgical interventions, and risk of amputation. Owing to its rarity, evidence regarding prognostic factors and optimal management remains limited. This study aimed to evaluate the clinical characteristics, microbiological findings, treatment strategies, and outcomes of patients with hand osteomyelitis, with particular emphasis on the association of admission inflammatory markers, immunosuppression, and preoperative magnetic resonance imaging (MRI). Methods: A retrospective single-center cohort study was performed over a 11-year period at a tertiary referral hospital. Patients with clinically and/or histopathologically confirmed hand osteomyelitis were identified using ICD-10-GM codes. Demographic characteristics, etiology, microbiological and histopathological findings, laboratory parameters, imaging, surgical treatment, antibiotic therapy, and length of hospital stay were reviewed. Correlations between admission C-reactive protein (CRP), leukocyte count, number of surgical procedures, and hospital stay were analyzed using Pearson’s correlation coefficient. Results: Fourteen patients were included (mean age, 53.7 years; 64.3% female). Osteomyelitis predominantly affected the distal phalanx (92.9%). Immunosuppression or immunocompromising comorbidities were present in 64.3% of patients. Staphylococcus aureus, methicillin-resistant Staphylococcus aureus, and Streptococcus pyogenes were the most frequently isolated pathogens, while immunosuppressed patients exhibited more polymicrobial infections. The mean admission CRP was 87.8 mg/L and was markedly higher in immunosuppressed than in non-immunosuppressed patients (128.5 vs. 14.6 mg/L). Amputation was required in 78.6% of patients, with a mean of 3.3 surgical procedures per patient. Admission CRP is associated with both length of hospital stay (r = 0.61) and number of surgical procedures (r = 0.73), whereas leukocyte count showed only weak correlations. Patients who underwent MRI had a shorter mean hospital stay than those without MRI (13.4 vs. 19.6 days). The mean duration of antibiotic therapy was 29.3 days. Conclusions: In this small cohort, admission CRP showed a potential association with disease severity in hand osteomyelitis, with higher levels observed in patients requiring more extensive surgical treatment and longer hospitalization. MRI was associated with a shorter hospital stay, suggesting a possible role of early advanced imaging in facilitating timely diagnosis and treatment planning. Immunosuppressed patients tended to exhibit higher inflammatory markers and more frequently polymicrobial infections, although these findings should be interpreted cautiously given the limited sample size. Overall, these observations are exploratory and require confirmation in larger, preferably prospective studies.

Background: While modern third-generation cementation techniques have optimized outcomes for cemented fixation, cementless acetabular fixation is currently the widely preferred cup option in Germany. In elderly patients, however, international registry data suggest a potential advantage for cemented acetabular fixation strategies. Given the rising volume of total hip arthroplasties (THA) and an ageing population, we performed a registry-based analysis to evaluate revision risk associated with the type of acetabular fixation in elderly patients. Methods: A registry-based cohort analysis of 330,910 primary THAs was performed. The overall median follow-up was 3.48 years (IQR 1.52–5.82), with a mean follow-up of 3.79 years (SD 2.60) and a maximum follow-up duration of 11.38 years. Statutory health insurance billing data, implant manufacturer product database, and hospital electronic case report forms were evaluated. Longitudinal follow-up was conducted for all-cause revisions and mortality. Estimated risk of revision for any reason at eight years was assessed using Kaplan–Meier, adjusting for age and femoral stem fixation (cemented vs cementless). Furthermore, multivariable Cox proportional hazard regression analyses were performed. Results: Age-stratified analyses showed higher revision rates in patients < 75 years for cemented polyethylene (PE) and highly-cross-linked polyethylene (XPE) cups (both 7.7%) compared to patients ≥ 75 years (5.1% for PE; 4.5% for XPE). In patients ≥ 75 years, the combination of a cemented XPE cup with a cemented stem achieved, together with hybrid THA, the lowest eight-year revision rate (4.1%). Among patients ≥ 80 years ( n = 63,278), cemented PE/XPE cups had the highest eight-year revision-free survival (95.5%), compared to hemispherical press-fit cups (94.6%) ( p = 0.015), independent of the type of femoral fixation. Within the ≥ 80-year subgroup with cemented stems, no significant differences were observed between cup types ( p = 0.100). However, in multivariable Cox regression analyses, cemented XPE cups were associated with revision risks comparable to those of hemispherical cups in patients aged ≥ 75 years with no significant differences (HR 0.98, 95% CI 0.84–1.14; p = 0.80) and ≥ 80 years (HR 0.98, 95% CI 0.81–1.19; p = 0.80). Within the cemented (X)PE cups subgroup, larger head size, ceramic-on-polyethylene, lower comorbidity burden, and a BMI of ≤ 30 were all significantly associated with improved revision-free survival. Conclusion: The German arthroplasty registry indicates that, although cementless hemispherical press-fit cups remain the predominant acetabular fixation method used for THA across all age groups, cemented XPE cups have no clinically relevant survivorship differences in selected elderly subgroups (≥ 75-year-old; ≥ 80-year-old patients). For < 75-year-old patients, hemispherical press-fit cups remain the most favorable option. Future studies should focus on prospective analyses of patient-reported outcomes, complication profiles, and long-term cost-effectiveness for acetabular fixation in THA to further define the optimal fixation strategy for different age and risk groups.

Objective: Traumatic dislocation and fracture–dislocation of the hip are rare and severe injuries often associated with high-energy trauma. Early recognition and rapid, stable reduction are essential for successful treatment; otherwise, this type of injury is associated with poor functional outcomes and high rates of complications such as avascular necrosis. This retrospective study aims to describe and analyze long-term outcomes and survival rates after a hip dislocation. Methods: Between 2008 and 2021, all patients with traumatic hip dislocation who were treated in a Level I Trauma Center were retrospectively assessed and analyzed. During the follow-up examination, two experienced surgeons carried out a clinical follow-up examination and evaluated the available X-ray images. Anterior and posterior fracture–dislocations and femoral head fractures were classified according to Stewart and Milford’s and Pipkin’s classification system, respectively. All patients were followed up using the Harris Hip Score (HHS) and Lequesne score. Results: Forty-four (38 male and 6 female) patients with a mean age of 46.02 (±19.48) years were included. The average follow-up period was 45.69 (±45.69) months. Traffic accidents were the main cause of traumatic dislocation in this series, accounting for 75% of all cases. Associated injuries were noted in 28 cases. Twenty-three and 21 patients were treated with closed and open reduction, respectively. Isolated hip dislocations without bony involvement according to Stewart and Milford type 1 occurred in five cases. Type 3 injuries were most common, followed by type 4 injuries. This study found that the type of reduction and the trauma mechanism are not significant factors in long-term prognosis (p = 0.463). Thirteen patients had subjective excellent or good results in the HHS and Lequesne score. Late post-traumatic osteoarthritis of the hip developed in 10 patients (22.7%). Patients received a hip replacement at 20.7 months (1–102) months. Thus, after 2 years, implantation of a hip prosthesis due to post-traumatic coxarthrosis was necessary in 22.7% of all cases. The type of hip dislocation classified according to Stewart and Milford had no significant influence on the implantation of a hip prosthesis. Conclusions: Excellent or good results in HHS were obtained in patients with early, stable, and accurate reduction by closed or open methods. After 2 years, 22.7% of the patients needed a total hip replacement.

Background/Objectives: Hand phlegmons are rapidly progressive bacterial soft-tissue infections that may lead to severe functional impairment, repeated surgical interventions, and prolonged hospitalization if diagnosis and treatment are delayed. Although Gram-positive skin flora are considered the predominant pathogens, microbiological findings and clinical severity may vary considerably depending on the extent of infection and host factors. Methods: This single-center retrospective study analyzed 100 patients surgically treated for hand phlegmons at a university hospital between 2020 and 2025. Clinical data included demographics, portal of entry, microbiological findings, inflammatory markers, antibiotic therapy, number of surgical procedures, and length of hospital stay. Pathogens were classified according to Gram stain characteristics, and statistical analyses were performed using nonparametric methods and correlation analyses. Results: The cohort consisted of 69 male and 31 female patients with a mean age of 50.5 ± 20.9 years. Mean hospital stay was 12.9 days (range 1–77), and patients underwent an average of 2.18 surgical procedures (range 0–11). Wounds and bite injuries represented the most common portals of entry, although many cases lacked a clearly identifiable cause. Microbiological cultures were negative in 62% of cases. Among positive cultures, Gram-positive organisms predominated (84.2%), with Staphylococcus aureus and Streptococcus pyogenes representing the most frequent pathogens. MRSA was detected in three patients and was associated with significantly more surgical procedures (p = 0.04) and a tendency toward prolonged hospitalization. Admission CRP levels differed significantly according to Gram stain classification (p = 0.008) and correlated positively with both length of hospital stay (r = 0.431, p < 0.001) and number of surgical interventions (r = 0.272, p = 0.006). Patients with microbiologically confirmed infections required significantly more operative procedures than patients without pathogen detection (p < 0.001). Empiric antibiotic therapy primarily consisted of ampicillin/sulbactam, cefuroxime, and clindamycin, followed by oral therapy with amoxicillin–clavulanate or clindamycin. Conclusions: Hand phlegmons remain clinically challenging infections characterized by heterogeneous presentation, frequent culture-negative findings, and substantial surgical burden. Gram-positive pathogens continue to predominate, while resistant organisms such as MRSA may be associated with more complex clinical courses. Elevated inflammatory markers at admission correlate with prolonged hospitalization and increased operative requirements, suggesting their potential value as indicators of disease severity. Early diagnosis, prompt surgical debridement, and individualized antimicrobial therapy remain essential for infection control and preservation of hand function.

Objective: Femoral head fractures are rare and severe injuries often associated with high-energy trauma. Early recognition and rapid, stable reduction are essential for successful treatment to prevent complications and morbidity. This retrospective study aims to describe and analyze long-term outcomes and survival rates of the femoral head after a Pipkin fracture. Methods: Between 2012 and 2021, all patients with a femoral head fracture who were treated in a Level I Trauma Center were assessed and analyzed. Two examiners performed a physical examination and radiological control of patients and called the patients for a final follow-up. Anterior and posterior fracture-dislocations and femoral head fractures were classified according to Pipkin’s classification system. The functional outcome was assessed using the Harris Hip Score (HHS). Results: Over a 10-year period, n = 15 patients were diagnosed with a femoral head fracture. All patients were male; the average age at admission was 41.3 years. The mean follow-up was 43.7 months ± 46 months. No complications occurred in three patients (20%). Twelve patients had complications. The most common complications were nerve lesions and posttraumatic osteoarthritis. Regarding the outcome, no data were available for two patients; one patient died, and two of four patients remained with a Girdlestone resection arthroplasty at the follow-up. The mean score in HHS was 76.69 ± 20.3 (mean ± standard deviation). Conclusions: An overall complication rate of 80% was observed; however, functional outcomes were generally moderate at final follow-up. These findings highlight the considerable risk of complications associated with femoral head fractures, particularly nerve injury and posttraumatic osteoarthritis. Notably, six of 15 patients no longer retained their native hip joint at the time of assessment. The study is a Level 2b study.

Background: The German congress for orthopedics and trauma surgery is the largest congress of this specialty in Europe. It reflects the latest scientific achievements and thus has a lasting impact on both, clinical practice and research. Understanding what is currently moving the specialist groups therefore helps to understand where orthopedics and trauma surgery is heading. Methods: Contribution titles, topics, authors, and cities were extracted from the German Medical Science database ( https://www.egms.de/ ) and using three distinct network analyses: an author network, a city network, and an entity network. Internal ratings were obtained from the congress committee for further elaboration. Results: The congress comprised 696 accepted papers, most of which were presented in German (72.41%) and in the form of lectures (57.61%), focusing on topics such as “spine,” “basic research” and “polytrauma.” The city network revealed geographical clusters, with Berlin, Munich and Dresden forming the most closely networked nodes. In the entity network, three major communities emerged, focusing on clinical care, fracture research and joint-related studies. Of the 1232 submissions, 85.80% received a majority favorable review, and 56.49% were accepted, with the acceptance rate increasing in proportion to the review score. Conclusion: The analysis of the DKOU 2021 revealed a broad scientific focus and research communities centered on clinical care, fracture studies and joint-related research. Transparent evaluation processes and global longitudinal comparisons are recommended to align research with the global burden of disease, taking into account the limitations of congress-based analyses and the influence of external factors such as the Covid-19 pandemic.

Open fractures are severe injuries in which bone is exposed due to soft tissue damage or skin perforation. They account for approximately 3% of all fractures, with a high prevalence in the tibia (around 25%). In addition to significant functional and psychological burden, they carry a high risk of infection, particularly osteomyelitis. Due to the compromised soft tissue barrier, preemptive antibiotic prophylaxis plays a key role.Inadequate treatment duration carries risks: if this is too short, it prevents complete eradication of pathogens, while if too long this increases adverse effects and the development of resistance. In order to develop recommendations, a systematic PubMed search (last five years) was conducted, which identified 82 relevant studies.Antibiotic therapy is essential in open fractures, as the disrupted skin barrier substantially increases infection risk. Critical factors include drug selection, timing, and duration. Administration should begin immediately after trauma, ideally within 3 h.For Gustilo-Anderson type I/II fractures, a single dose of a cephalosporin (e.g., cefuroxime) is generally sufficient. In cases of allergy, clindamycin is recommended; for MRSA carriers, vancomycin is indicated.Type III fractures require therapy of up to 72 h but not longer than 24 h after wound closure. The standard regimen is a combination of a cephalosporin with gentamicin; alternatively, piperacillin/tazobactam may be used. In penicillin allergy, gentamicin or tobramycin is indicated.Thus, preemptive antibiotic therapy significantly reduces the risk of infection and is an essential component of open fracture management.

The management of shoulder injuries resulting from epileptic seizures presents a particular challenge. These injuries often present complex patterns, ranging from dislocations and fractures to damage to the rotator cuff. Recurrent seizures can significantly impact the outcome and must be considered a central risk factor when choosing the therapeutic approach. Accordingly, these injuries require close multidisciplinary cooperation between orthopaedics/trauma surgery, neurology/epileptology and physiotherapy, both in diagnosis and treatment. Despite their clinical relevance, standardised treatment algorithms are currently lacking, and the available scientific evidence remains limited. This review article addresses the specific characteristics of seizure-related shoulder injuries within a multidisciplinary approach. Epidemiological aspects, including pathomechanical principles, diagnostic challenges, and current conservative and surgical treatment options, are discussed.

Objective: The current gold standard for detection of implant-related infections is the intraoperative collection of tissue samples. However, false-negative results frequently occur, particularly in infections caused by biofilm-forming bacteria. As a complementary method, sonication has therefore been established for detecting implant-associated infections, especially in periprosthetic joint infections. In trauma surgery, this technique is still rarely used. The aim of this study is to evaluate the diagnostic significance of sonication after osteosynthesis. Methods: A retrospective single-center analysis was conducted on all patients who underwent plate osteosynthesis removal between 1 January 2019, and 1 May 2021, with both sonication and intraoperative tissue sampling performed. Patients with inlying arthroplasties or nail-less osteosynthesis systems were excluded. Pre- and postoperative infection parameters (leukocytes, CRP) were recorded, and preoperative clinical findings were used to classify suspected infection. Results: A total of 57 patients (30 men, 27 women; mean age 57.6 years, range 12–91) were included. The mean treatment duration was 20.1 days (range 1–152). Sonication was positive in 33 patients, tissue samples in 28, with 31 cases (54%) showing concordant results. In cases with preoperative suspicion of infection, sonication was positive in 21 of 26 cases (80.7%) and tissue samples in 18 of 26 (69.2%), whereas without suspicion, positivity rates were 38% and 31%, respectively. Sonication and tissue results matched in 14 of 26 cases; in the remainder, results were different or incomplete. Preoperative CRP elevation and the presence of an infection membrane influenced sensitivity: sonication generally detected more bacteria (59–81%) than tissue samples (49–73%), though discrepancies remained. Conclusions: Sonication represents a valuable complementary method for detecting implant-related infections. Due to its high sensitivity but limited specificity, it should not be used as a standalone diagnostic method.