Distal femoral replacement carries higher infection and revision risk than ORIF for distal femoral periprosthetic fractures in elderly patients.

To examine the impact of frailty on 30-day outcomes of open reduction internal fixation (ORIF) alone or ORIF + total hip arthroplasty (THA) (fix-and-replace) for the treatment of acetabular fractures. . Retrospective Cohort. A total of 700 hospitals in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Included were patients aged 60 years or older undergoing ORIF ± THA for OTA/AO type 62 A-C fractures from 2015 to 2020. Preoperative frailty was assessed by the revised Risk Analysis Index (not frail: <21, prefrail: 21-30, frail: 31-40, severely frail: >40) and the 5-Item Modified Frailty Index factor. All outcome measures were in-hospital or within 30 days postoperatively, including the "favorable outcome," defined as no readmission, length of stay (LOS) < cohort median, and no major complication or death. There were 585 patients included [ORIF (88%): mean age-70.5 ± 14.2, sex-41.4% female; ORIF + THA (12%): mean age-77.0 ± 13.4; sex-65.7% female]. Frail patients (n = 353, 65.5%) were more likely to experience a complication [OR: 3.31, CI: (1.83-5.96)] and mortality (3.7% vs. 0.0%). ORIF + THA had higher association with postoperative transfusion [OR: 2.70, CI: (1.63-4.48)] but lower association with LOS >3 days [OR: 0.41, CI: (0.24-0.72)] and nonhome discharge [OR: 0.52, CI: (0.27-0.98)] than ORIF. Prefrail and frail patients undergoing ORIF + THA were more likely to achieve favorable outcomes than those nonfrail or severely frail [OR: 9.69, (3.40-27.57)]. Surgical intervention for acetabular fractures carried a 30-day complication risk of 12%-19% for frail patients. Frailty had similar predictability to age for early morbidity after surgery to treat acetabular fractures. Open reduction and internal fixation with the addition of an acute THA was associated with a higher rate of blood transfusion and shorter hospital LOS in frail patients with acetabular fractures. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

To evaluate soft tissue complications and the incidence of neurovascular bundle (NVB) injury following the modified posteromedial approach (moPMA) for posterior malleolar (PM) fractures, and to describe its indications in clinical practice. Retrospective, observational case-series study. Single center with a dedicated foot and ankle trauma unit. Consecutive adult patients who underwent open reduction and internal fixation (ORIF) of PM fractures (AO/OTA 44 or 43) using the moPMA between 2014 and 2024. Exclusion criteria were open or pathological fractures, prior surgery at other institutions, or incomplete clinical records. Primary outcomes were incidence of soft tissue complications and NVB injuries, graded according to the modified Clavien-Dindo classification for foot and ankle surgery. Secondary outcomes included fracture classification according to AO/OTA and Bartoníček-Rammelt, associated procedures and approaches, surgical staging, fixation type, follow-up, and use of intraoperative imaging. The mean age was 47 years (range 18-83 years), there were 14 male and 40 female patients. The mean time from injury to surgery was 5.9 days. According to the Bartoníček-Rammelt classification, 51.9% were type C, 31.5% type B, and 14.8% type D. Most cases (77.8%) were AO/OTA 44B3. The moPMA was used in the first surgical stage in 77.8% of cases. A second approach was required in 90.7%, most commonly for fibular fixation through a lateral approach (70.4%). Associated procedures were performed in 92.6%, with fibular osteosynthesis being the most frequent (66.7%). Fixation was plate-based in 92.5%. The mean follow-up was 63.1 ± 31.4 months. Hardware removal of the posterior fixation was performed in 37.1%. Soft tissue complications occurred in 4 patients (7.4%), all classified as grade IA. No NVB injuries or tibialis posterior tendon contractures were reported. The modified posteromedial approach for fixation of posterior malleolar fractures demonstrated low complication rates and no neurovascular injuries, supporting its use in a wide range of posterior malleolar fractures. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The influence of the screw configuration of the distal fibular plate on the biomechanics of lateral malleolar oblique fractures.

The multilayer coatings on polylactic acid implants spatiotemporally regulates the microenvironment to enhance antibacterial and osseointegration capacity.

Transcervical femoral neck fractures (TFNFs) are among the most devastating fragility fractures in theelderly. TFNF are associated with excess 1-year mortality rates ranging from 15% to 30%. Treatments include conservative methods, internal fixation, and arthroplasty (partial or total hip arthroplasty). This study aims to analyze the changes in incidences of TFNF in the Italian population between 2001 and 2023 and the evolution of the choices of treatment. Using hospital discharge record (HDR) data from 2001 to 2023, records with ICD9-CM codes for femoral neck fractures (820.0 and 820.1) among diagnoses were selected and categorized into four treatment groups: totalarthroplasty,partial arthroplasty, fixation, and conservative. Time series were analyzed with stratification by sex and age. The extracted data included 1,120,724 records of TFNFs, with 871,161 cases treated surgically (total or partial arthroplasty or internal fixation) and 249,563 treated conservatively; the average patient age was 79.1years, with a higher proportion of women (72.8%). Partial hip arthroplasty was the preferred treatment overall. For younger patients, in the age classes < 45 and 45-54 years, fixation was the most chosen treatment. Over time, the use of the conservative treatment decreased from 27.5% in 2001 to 14.6% of cases in 2023. The use of partial and total hip arthroplasty increased from 40% and 13.3% in 2001 to 44.5% and 24.3% in 2023, respectively. Over the past two decades, Italy experienced declining age-adjusted incidence rates of TFNF despite persistent crude numbers (approximately 50,000 cases per year) owing to demographic aging. Partial hip arthroplasty (PHA) remained the preferred treatment, while total hip arthroplasty (THA) went from being the least used to the second-most performed treatment through the 23 observed years. Level of evidence level 1, population-based study.

Femoral neck fracture (FNF) is a common type of hip fracture, for which cannulated screw fixation is a primary internal fixation method. The optimal configuration for cannulated screw fixation remains controversial, with debate primarily focused on two approaches: parallel fixation configuration (PFC) versus non-parallel fixation configuration (NFC). The objective of this study was to compare the efficacy and safety of two configurations in the treatment of femoral neck fractures. Following PRISMA guidelines, we systematically searched PubMed, Embase, the Cochrane Library, and CNKI for studies comparing PFC and NFC in FNF fixation. Study quality was assessed using the Cochrane risk-of-bias tool and MINORS scale. Outcomes included femoral head necrosis, nonunion, femoral neck shortening, and fixation failure. Meta-analysis was conducted in RevMan 5.3, employing a fixed-effects model unless heterogeneity (I² > 50%) warranted an alternative approach. A total of 20 studies involving 1,508 patients were included in the meta-analysis. The meta-analysis showed that the NFC group had significantly better outcomes, including lower rates of femoral head necrosis (OR 0.50, 95% CI 0.34-0.74, P = 0.0005), nonunion (OR 0.41, 95% CI 0.26-0.65, P = 0.0001), femoral neck shortening (OR 0.40, 95% CI 0.28-0.57, P < 0.00001), and internal fixation failure (OR 0.34, 95% CI 0.22-0.52, P < 0.00001). Our findings indicate that NFC is more effective than traditional PFC for internal fixation of FNFs. Level of evidence Level III.

Response to the Letter to the Editor Regarding "Proton Pump Inhibitors Are Associated With Increased Risk of Site-Specific Nonunion After Open Reduction Internal Fixation".

The impact of conversion arthroplasty for failed femoral neck or intertrochanteric fractures on complication and mortality rates: A "second-hit" effect?

Radial styloid fractures may occur in isolation or as part of complex intra-articular distal radius injuries. Fixation can be achieved using either a cannulated screw or a radial plate. This study aimed to compare these two fixation techniques with respect to surgical time, fracture union, and postoperative complications in patients with isolated radial styloid fractures, thereby eliminating confounding factors related to associated injuries. Between 2024 and 2025, a retrospective study was conducted involving 20 patients (mean age, 37.6 ± 6.9 years) with isolated radial styloid fractures. Patients were assigned to undergo open reduction and internal fixation using either a cannulated screw (group A, n = 10) or a radial plate (group B, n = 10). All patients were followed for 6 months. The primary outcomes included surgical time, fracture union, and postoperative complications. Group A demonstrated a markedly shorter surgical time than group B (34.4 ± 2.4 minutes vs 50.6 ± 3.9 minutes; P < 0.05) and achieved faster fracture union (6.7 ± 0.7 weeks vs 7.6 ± 1.0 weeks; P < 0.05). Temporary extensor tendinitis and implant irritation occurred slightly more frequently in group B (10% vs 0%), although this difference was not statistically significant. The incidence of transient superficial radial neuritis was similar between the groups (10%). Cannulated screw fixation for isolated radial styloid fractures is a reliable and efficient alternative to radial plate fixation. It provides shorter surgical time, earlier fracture union, and comparable complication rates while minimizing soft-tissue dissection.

Objective: To investigate the distribution patterns of vertebral bone density in degenerative lumbar scoliosis (DLS) patients with different coronal imbalance classifications. Methods: A retrospective study was conducted on 154 patients with DLS who underwent long-segment spinal fusion surgery at Nanjing Drum Tower Hospital between January 2017 and December 2022. The patients were classified according to the Nanjing Drum Tower coronal imbalance classification of DLS: Type A, coronal balance distance (CBD) <3 cm; Type B, CBD ≥3 cm and C7 plumb line (C7PL) located on the concave side; Type C, CBD ≥3 cm and C7PL located on the convex side. The major curve Cobb angle and CBD were measured on preoperative standing full-spine radiographs. Preoperative assessments also included L1-4 T-scores and femoral neck T-scores obtained from dual-energy X-ray absorptiometry (DXA). Additionally, overall vertebral body bone density and Hounsfield unit (HU) values on the concave and convex sides were measured using preoperative CT scans. The patients with L1 HU value <110 were diagnosed with osteoporosis (OP). Comparative analyses included OP prevalence and coronal plane bone mass distribution patterns among the different coronal classifications. Results: A total of 154 patients were included in this study, comprising 21 males and 133 females, with an average age of (62.9±6.6) years. Among them, 99 patients were classified as Type A, 30 as Type B, and 25 as Type C. The prevalence of OP was 48.7% (75/154), with the prevalence in Type C (72.0%, 18/25) patients being higher than that in Types A (44.4%, 44/99) and B (43.3%, 13/30) (both P<0.05). The mean HU value of the S1 vertebra for all patients was 140.8±63.1, it was the lowest in Type C patients (108.2±53.4), which was statistically significantly lower than that in Types A and B patients (150.2±66.0 and 137.1±52.0, respectively, both P<0.05). For all the patients, the HU values on the concave side of the main curve were all greater than those on the convex side (all P<0.005), with the greatest asymmetry observed at the apex vertebra. The asymmetry ratios of the concave to convex sides of the S1 vertebra in Type B and Type C patients were higher than those in Type A patients (1.25±0.24, 1.23±0.24, and 1.11±0.22, respectively; P<0.01). Conclusions: Patients with DLS exhibit a high prevalence of OP, with Type C patients showing the highest OP prevalence and the lowest bone density at the S1 vertebral body. Based on these findings, it is recommended that, for type C patients, distal internal fixation be performed using iliac screws or S2 sacroiliac screws to reduce the risk of internal fixation failure.

Management of severe distal tibia pilon fractures (AO/OTA 43-C3) in older adults is exceptionally challenging. Open reduction and internal fixation is associated with a high incidence of posttraumatic arthritis, whereas primary arthrodesis results in significant functional limitations. We investigated primary total ankle replacement (TAR) as a definitive, single-stage, motion-preserving solution. We retrospectively reviewed 29 older adult patients (age ≥60 years) treated with primary TAR since 2016 for comminuted pilon fractures. Inclusion required severe articular destruction (AO/OTA 43-C2/C3) but a reconstructable metaphyseal cortical shell. We evaluated surgical timing, adjunctive fixation, bone grafting, and clinical and radiographic outcomes. The primary outcome was the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score at ≥6 months. At 6 months post-surgery, the mean AOFAS score was 85.2 ± 7.5. Metaphyseal fracture union was achieved in all cases at an average of 17.4 ± 2.1 weeks. Postoperative alignment was excellent, with a mean medial distal tibial angle (MDTA) of 89.2° ± 1.8°. No deep infections, insert dislocations, or component overhang were observed. Three patients (10.3%) developed progressive valgus deformity, with MDTA increasing by an average of 3.4° at 1 year. In this retrospective level IV series with short-term follow-up, primary TAR may be a feasible option for carefully selected older adult patients with comminuted pilon fractures and a preserved metaphyseal cortical shell, demonstrating encouraging early functional outcomes. Longer term follow-up is required to determine implant survivorship and revision risk.

Medial tibial plateau fractures are frequently due to high-energy injuries, and can be difficult to manage and associated with a significant rate of postoperative complications. The goal of the study was to evaluate the epidemiology and results of management of medial tibial plateau fractures, and ascertain the factors influencing its outcomes. The patient cohort comprised 143 patients with medial tibial plateau fractures treated over a period of six years. The groups were divided into medial tibial plateau fractures (B-type) and bicondylar tibial plateau fractures (C-type), according to the AO/Orthopaedic Trauma Association (OTA) classification and Schatzker classification. Patient information, including basic demographic details, duration of follow-up, mechanism of injury, comorbidities, management, and postoperative complications, was recorded. Analysis of these data was performed to evaluate outcomes and compare both fracture groups. Among 143 patients, C-type fractures (43%) were more often linked to high-energy trauma and comorbidities, though not statistically significant (p = 0.051). Both groups were primarily managed with open reduction and internal fixation (ORIF; C-type: 88.5%, B-type: 85.4%, p = 0.582), with 7% managed conservatively. Complications were comparable, but deep infections (13.1% vs 4.9%, p = 0.079) and compartment syndrome (3.3% vs 0%, p = 0.099) were more frequent in C-type. Although C-type fractures demonstrated a trend towards higher complication rates and more complex management, none of the observed differences reached statistical significance. The overall risk of complications did not vary significantly between the two groups (p = 0.639). Logistic regression revealed no significant predictors of fracture type (R² = 0.050). The outcomes of isolated medial tibial plateau fractures are comparable with those of bicondylar tibial plateau fractures, with similar complication rates. Although C-type fractures tended to be associated with higher-energy trauma and increased risks of deep infection and compartment syndrome, these differences were not statistically significant. While medial plateau fractures are often assumed to be less severe, they can be considered injuries of similar complexity to bicondylar patterns.

Background: Fingertip injuries, particularly unstable distal phalanx fractures and open mallet-type extensor tendon injuries, impose a significant socioeconomic burden, especially on working-age adults in precarious employment. While internal fixation is often required to preserve alignment and function, the gold standard—Kirschner wire (K-wire) fixation under fluoroscopic guidance—is frequently inaccessible in emergency settings or for patients with limited financial resources. Methods: We present two patients presenting to the emergency department with unstable distal phalanx injuries. In the absence of intraoperative fluoroscopy and orthopedic power drills, stabilization was achieved using standard sterile hypodermic needles (18–21 gauge) as intramedullary or transarticular fixation devices. Results: Successful immediate stabilization was achieved in both cases. The needle fixation technique effectively reduced fracture displacement and, in the tendon injury case, restored the continuity of the extensor mechanism. At the final follow-up, all patients demonstrated maintained alignment and clinical fracture union. Functional outcomes were favorable, with patients regaining a pain-free range of motion at the distal interphalangeal joint and returning to daily manual labor without significant delay. Conclusion: Hypodermic needle osteosynthesis is a safe, accessible, and highly cost-effective technique for damage-control fixation of selected fingertip injuries.

BackgroundThis study aims to evaluate the efficacy and potential advantages of full-endoscopic unilateral laminotomy with bilateral decompression (FE-ULBD) for degenerative cervical myelopathy (DCM) as a minimally invasive posterior decompression technique.MethodsWe retrospectively reviewed 123 patients treated between January 2020 and January 2025. Procedures were selected based on predefined clinical/imaging indications and shared decision-making. FE-ULBD was primarily applied to 1–2-level posterior compression, whereas multilevel disease underwent laminoplasty or laminectomy with internal fixation. Patients were assigned to Group A (FE-ULBD, n=28), Group B (single-door laminoplasty, n=60), and Group C (laminectomy with internal fixation, n=35). Baseline characteristics, perioperative parameters (operative time, blood loss, length of stay), clinical outcomes (mJOA at multiple time points and modified MacNab criteria), and complications were compared among groups. In Group A, intervertebral height, C2–C7 Cobb angle, and dural sac cross-sectional area (DSCA) were evaluated pre- and postoperatively. Outcomes were assessed preoperatively, at 3 months postoperatively, and at final follow-up (mean 8.07 ± 2.24 months).ResultsGroup A had significantly shorter operative time, reduced blood loss, and a shorter hospital stay compared to Groups B and C (all P<0.05). mJOA improved significantly from baseline in all groups at 3 months and at final follow-up (within-group P<0.05). No significant between-group differences were observed in absolute mJOA or ΔmJOA at either time point (all P>0.05). The excellent/good rate by modified MacNab criteria at final follow-up was 89.3% in Group A, 76.7% in Group B, and 77.1% in Group C (P>0.05). The overall complication rate was lower in Group A (P<0.05). In Group A, intervertebral height and C2–C7 Cobb angle showed no significant postoperative change, whereas DSCA increased significantly (P<0.05).ConclusionIn this retrospective cohort, FE-ULBD was associated with less perioperative morbidity and fewer complications while providing neurological recovery comparable to conventional posterior approaches in selected DCM patients.

Introduction: Failed internal fixation of proximal femoral fractures is associated with significant morbidity, mortality, and financial burden. Conversion total hip arthroplasty (THA) is a technically demanding salvage procedure associated with high risks of periprosthetic joint infection and instability. Methods: Independent searches of MEDLINE, EMBASE, and the Cochrane library were performed for studies published from 1990 onwards regarding conversion THA in adults following failed proximal femur fixation. Following screening, 34 studies were included in this review. Results: Predictors of failure include female sex, smoking, and tip-apex distance &gt;25 mm. Preoperative screening for occult, extra-articular infection is vital, as pathogens often reside near hardware rather than within the joint. CT, ultrasound, and SPECT-CT are essential for assessing bone stock and identifying fluid collections. Dual-mobility cups effectively reduce dislocation rates to 0–3%. Functional scores improve significantly, though 10-year survivorship is approximately 86%. Discussion: Conversion THA provides substantial functional recovery but carries a 7-fold higher infection risk than primary THA. Success requires meticulous screening tailored to previous hardware sites and selecting femoral fixation based on bone quality and cortical defects. Specialised implants are essential for optimising long-term outcomes in this high-risk population.

PURPOSE-Limb reconstruction system (LRS) fixators have been used in the management of complex tibial fractures with severe soft tissue injuries, compound tibial fractures, and infected tibial non-union for which conventional internal fixation cannot be contemplated. Fracture union and distraction osteogenesis can be done simultaneously with these external fixators , allowing early weight bearing. Thus, a prospective observational study was done to evaluate the union rate, functional outcome and limb length discrepancy in compound segmental tibial fractures managed primarily by LRS fixators. METHODOLOGY-A prospective observational study was conducted at Agartala Government Medical College &amp; GBP Hospital, Tripura, India and included two patients with compound segmental tibial fracture. The patients underwent LRS fixation and followed up at 1 month, 3 months, 6 months and 1 year. Functional and radiological outcomes were assessed using the Association for the Study and Application of Methods of Ilizarov (ASAMI) criteria. RESULTS-Union was achieved and radiological outcome was found excellent. Functional result was satisfactory. Post operative evaluation showed no pin-tract infection, loosening of pin, breakage of pin, assembly loosening, knee stiffness, ankle stiffness, neurovascular complication, limb length discrepancy, chronic osteomyelitis and delayed union. The patients achieved full range of motion at knee (0 to 135 degree), plantar flexion (0 to 45 degree) and dorsi flexion (0 to 20 degree). CONCLUSION-In this assessment, LRS fixators showed a favorable result in terms of fracture union and functional outcome with good healing of the soft tissues and maintenance of the limb length.

EXPRESS: Morphometric description of the feline tibia using three - dimensional computed tomography.

Periprosthetic humeral fractures are becoming an increasingly more relevant complication due to the growing number of shoulder arthroplasties being performed. The management of these fractures is complex and influenced by multiple factors. This article provides astructured overview of current classification systems, discusses therapeutic challenges and outlines contemporary treatment strategies for periprosthetic humeral fractures. Anarrative literature review was conducted focusing on the etiology, classification and treatment options of periprosthetic humeral fractures. Particular attention is given to the classification systems of Wright and Cofield and the classification system of Sanchez-SoteloPF with an emphasis on their relevance to surgical decision making. The management of periprosthetic humeral fractures requires an individualized approach. Nondisplaced fractures with astable implant can be treated conservatively, whereas displaced fractures or those associated with implant loosening typically necessitate surgical intervention. Surgical options include open reduction and internal fixation (ORIF), revision arthroplasty and, in selected cases, the use of custom-made implants. Early mobilization combined with interdisciplinary management is critical to achieving favorable functional outcomes. Periprosthetic humeral fractures continue to represent ademanding complication in shoulder surgery. Acomprehensive understanding of classification systems and modern treatment strategies is essential for accurate treatment planning and improved patient outcomes.

Periosteal entrapment (PE) in displaced distal tibial Salter-Harris (S-H) II fractures is considered a risk for growth disturbances, but causality is debated. To investigate whether PE is an independent risk factor for growth disturbances in distal tibial S-H II physeal fractures and to compare the clinical efficacy of different treatment methods. Retrospective analysis of 27 patients (2015 to 2024) with distal tibial S-H II fractures and confirmed PE [magnetic resonance imaging (MRI): n=21; follow-up radiograph: n=6]. Patients received conservative treatment, closed reduction and percutaneous fixation (CR-PF), or open reduction internal fixation (ORIF). Functional outcomes were assessed with the American Orthopaedic Foot and Ankle Society (AOFAS) questionnaire. Correlations (phi coefficient) and risk factors (univariable/multivariable regression) were assessed between PE and growth disturbances. Patients (19 boys and 8 girls; mean age 9.99y or younger) were followed for a mean of 22.13 months. Overall incidence of growth disturbances was 14.8%, and the difference in the proportion of growth disturbances among the 3 groups was not significant (P>0.05). No independent risk factors were identified in univariable or multivariable analysis (all P>0.05). All fractures healed, and all groups showed an excellent AOFAS score (100%) at 6 months postinjury and comparable functional recovery (all P>0.05). The only case of premature physeal closure (PPC) occurred in the ORIF group, with the bony bridge appearing at the distal tibial Kump's bump, subsequently leading to an ankle valgus deformity. PE is not independently correlated with growth disturbances following distal tibia SH II fractures, challenging the traditional mainstream view of its causal role in causing growth disturbances. In addition, the therapeutic effects of different treatment methods are comparable. Conservative treatment should be preferred when closed reduction achieves good alignment, and routine periosteal stripping may be unnecessary. Level III.