Marc Schmid

Background: With an ever-increasing population of elderly orthopedic patients experiencing co-morbidities and immune suppression, the proportion of postoperatively acquired surgical site infections (SSIs) may increase compared to prior decades, where the majority of SSIs were acquired intraoperatively. A comprehensive overview would aid in allocating resources under these conditions. Methods: We examined a prospective database containing data from four prospective randomized clinical interventional trials and surveillance registers. We concentrated on cases of acute SSIs with complete documentation from the 2019–2024 period, during which the number and proportion of clinically frail patients treated at our tertiary center increased significantly. In this assessment, surgeons and Infectious Physicians specialized in orthopedic infections evaluated each SSI episode clinically by searching medical and nursing notes for postoperative events that could possibly be associated with postoperative surgical site infection. Results: Among 370 SSI cases, we estimated that 241 infections (65%) were acquired intraoperatively and 129 (35%) postoperatively. The three most frequent reasons for postoperative SSIs were skin breakdowns, surgical complications (hematoma; dehiscence), and ischemic necrosis. These (new) risk associations differed significantly from the SSI risk reported in the literature on middle-aged orthopedic patients. Conclusions: According to our prospective evaluation, one-third of acute orthopedic SSIs in the last six years might be associated with a postoperative complication. We need to implement additional preventive measures in the postoperative period.

An 89-year-old man presented with right elbow pain after a low-energy fall. At age 2 years, he sustained an untreated distal humeral fracture dislocation, which resulted in progressive remodeling and formation of a functional pseudoarticulation. Despite permanent deformity, he maintained stable functional motion for decades and performed heavy manual labor. Imaging revealed a displaced distal humeral fracture through the chronically remodeled elbow. Open reduction and internal fixation with a variable-angle locking plate was performed, while the pseudoarticulation was intentionally left untreated. The patient regained his preinjury functional baseline. Conclusion: Fracture treatment should consider the clinical relevance of pre-existing but functional musculoskeletal abnormalities.

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.

Purpose: The role of femorotibial rotation in patellar instability treatment and prognosis remains unclear. This study examines whether increased femorotibial rotation, indicated by a positive winking sign, affects functional outcomes and recurrent instability after patellofemoral stabilizing surgery. Methods: All patients undergoing patellofemoral instability surgery at our institution (2014–2022) with complete rotational imaging (magnetic resonance imaging/computed tomography [MRI/CT]) and functional assessments (Kujala, Tegner) and at least 1‐year follow‐up were included. Patients were grouped based on the presence of a radiological winking sign. Surgical treatment was tailored to individual deformities, including medial patellofemoral ligament reconstruction, trochleoplasty, derotational osteotomy and tibial tuberosity osteotomy. Results: A total of 121 knees (114 patients, mean age 23.5 years) with a mean follow‐up of 2 years were analyzed. Preoperatively, the winking sign was present in 19.8% ( n = 24) and absent in 80.2% ( n = 97). Demographics and preoperative deformity analysis were similar between groups (n.s.) except for increased femorotibial rotation (11.8° ± 7° vs. 8.5° ± 5°; p = 0.031) and patellar tilt ( p = 0.006) in patients with a positive winking sign. Functional outcome scores either improved (Kujala: 68.9 ± 16 to 80.8 ± 19; p < 0.001) or remained unchanged (Tegner: 3.6 ± 1.4 to 3.4 ± 1.6; p = 0.347) from pre‐ to postoperative. Patients with a positive winking sign tended to show less improvement (Δ Kujala: 7.6 ± 18 vs. 13.0 ± 20; p = 0.170; Δ Tegner: 0.0 ± 1.7 vs. −0.1 ± 2.0; p = 0.373). Surgical procedures were evenly distributed between groups (n.s.). One patient (0.8%) with a negative winking sign had a recurrent instability. Complications did not differ between groups (n.s.). Conclusion: Patients with increased femorotibial rotation achieve similar functional outcome following patellofemoral stabilizing surgery without increased complications or persistent instability. A tendency for less functional improvement in these patients raises questions about the need to assess femorotibial rotation as an independent deformity. Further research is needed to investigate this topic more deeply. Level of Evidence: Level III.