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Background Limited information exists on nonunion treatment in the elderly. This retrospective study evaluates whether results of operative treatment of nonunion of the humerus or femur in patients aged ≥ 75 years are comparable to those in younger patients. Methods We identified patients age ≥ 75 years with a nonunion of humerus or femur treated with open reduction and internal fixation. The Non-Union Scoring System was calculated. Complications, clinical outcome, and radiographic findings were assessed. Primary endpoint was nonunion healing. A literature review compared time to healing of humeral and femoral nonunion in younger populations. Results We identified 45 patients treated for a nonunion of humerus or femur with > 12 months follow-up. Median age was 79 years (range 75–96). Median time to presentation was 12 months (range 4–127) after injury, median number of prior surgeries was 1 (range 0–4). Union rate was 100%, with median time to union 6 months (range 2–42). Six patients underwent revision for persistent nonunion and healed without further complications. Conclusions Using a protocol of debridement, alignment, compression, stable fixation, bone grafting and early motion, patients aged 75 years or older can reliably achieve healing when faced with a nonunion of the humerus or femur. Level of Evidence: IV.

IntroductionThe incidence of periprosthetic femur fractures is increasing. Multiple treatment methods exist to treat fractures surrounding stable hip arthroplasty implants including locking plate fixation, cable fixation, allograft augmentation, and revision arthroplasty. No consensus regarding optimal treatment has been reached, and significant complications remain. Recently, biomechanical studies have demonstrated the benefits of orthogonal dual-plate fixation, but little clinical data exist. The purpose of the current study was to investigate the clinical and radiographic outcomes of dual-plated periprosthetic femur fractures around stable hip stems.Materials and methodsPatients with periprosthetic femur fractures following hip arthroplasty with a stable femoral stem treated with dual-plate fixation were identified through chart review at a single institution. Fracture classification, fixation characteristics, radiographic outcomes, clinical outcomes and complications including re-operation were recorded.ResultsOver a 12-year period, 31 patients (mean age 77 years at surgery, range 48–94) underwent dual plating by three traumatologists for implant-stable periprosthetic femur fractures surrounding a hip arthroplasty stem. There were 27 Vancouver B1-type and 9 inter-prosthetic fractures. Average follow-up was 2 years. Of the 26 patients with minimum 6-month follow-up, 24 (92%) united after index surgery (mean time to union 6.0 months, range 1.5–14.0). Mean time to full weight-bearing post-operatively was 2.6 months (range 1.5–4.0 months). Two patients required secondary surgery to address nonunion.ConclusionsDual-plating achieved high union rates with an acceptable complication profile for the treatment of periprosthetic femur fractures surrounding a stable hip arthroplasty stem. Our preferred fixation construct involves a lateral plate spanning the entire femur secured with non-locking bicortical screws supplemented with an anteriorly based reconstruction plate. Additional prospective research is required to confirm the results of this study.

Regional periarticular bone mineral density may influence fixation and survivorship in total knee arthroplasty, but its relationship to coronal alignment remains unclear. This study assessed the association between coronal knee alignment and osteoporosis using CT Hounsfield Unit (HU)-based thresholds. Patients aged ≥ 50 years with standing long-leg radiographs and phantomless knee-CT (2008-2025) were retrospectively identified. Exclusion criteria included >12 months between studies, incomplete CT, non-120 kV acquisition, prior fracture or surgery, or metabolic bone disease other than osteopenia or osteoporosis. Mean trabecular attenuation was measured over 15 mm of epiphyseal bone in the distal femur and proximal tibia. Osteoporosis was defined using CT-HU thresholds. Coronal alignment was measured using hip-knee-ankle angle (HKAA) and categorized as varus (<178°), neutral (178-182°), or valgus (>182°). Measurements were performed by a reviewer blinded to osteoporosis classification. Multivariable logistic regression adjusted for age, sex, body mass index, and Kellgren-Lawrence grade. Among 306 patients (mean age 66.9 ± 9.0 years; 51.3% female), 99.3% underwent CT for arthroplasty planning. Osteoporosis prevalence was 34.3% of varus, 58.2% of neutral, and 68.6% of valgus knees. Increasing valgus alignment was associated with higher osteoporosis odds, whereas varus alignment showed lower odds. Female sex (OR 3.06; < 0.001), age (OR 1.06/year; < 0.001), and HKAA (OR 1.05/degree; = 0.042) remained independently associated with osteoporosis, whereas Kellgren-Lawrence grade was nonsignificant. Coronal alignment was associated with CT-defined regional knee osteoporosis. Valgus alignment showed increased odds of osteoporosis, whereas varus alignment showed lower prevalence.

Background: The absence of a comprehensive classification system for Achilles tendon (AT) injuries contributes to the lack of consensus regarding optimal treatment strategies, as it hinders accurate differentiation of injury types. Purpose: To evaluate epidemiology of AT ruptures to develop a magnetic resonance imaging–based classification system for rupture location. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A search was conducted for all patients with acute AT injuries between 2016 and 2023. Tear locations were classified as follows: type 1 (musculotendinous junction; MTJ), type 1A (2-cm zone distal to MTJ), type 2 (midsubstance), type 3 (2-cm zone proximal to insertion), type 3A (soft tissue “peel-off”), type 3B (calcaneal bony avulsion). Clinicodemographic data were collected, and rupture gap size, tendon thickness, tibiotalar, and plantarflexion angle were measured. Results: A total of 428 patients were included (age 45 ± 15 years; 17% female). Mean rupture gap size was 30 ± 16 mm in 73°± 8° tibiotalar flexion. AT tear distribution: type 1, 62.7%; type 1A, 16.3%; type 2, 13.8%; type 3, 0.7%; type 3A, 5.8%; and type 3B, 0.7%. Female patients demonstrated lower tendon thickness (P < .001) and a significantly higher prevalence of type 3, 3A, and 3B (P < .001). Multivariate analysis revealed that proximal AT tears were associated with presence of tendinopathy (odds ratio [OR], 2.19; 95% CI, 1.24-3.83), while younger age and larger gap size were significant but with a weak effect size. Midsubstance tears were predicted by older age and increased tendon thickness (OR, 1.02-1.17). Distal tears were associated with absence of tendinopathy (OR, 0.17; 95% CI, 0.07-0.39), while age only had a small effect. Tear location measurements demonstrated substantial to almost perfect interobserver (3 observers; n = 35; Cohen's kappa = 0.93; 95% CI, 0.74-0.99) and intraobserver (1 observer; n = 35; Cohen's kappa = 0.93; 95% CI, 0.86-0.99) reliability. Conclusion: This study introduces an AT tear classification system that demonstrated substantial to almost perfect reliability. AT ruptures at the MTJ were most common (63%). Presence of tendinopathy, age, gap size, and tendon thickness were significant predictors for AT tear type. Female patients exhibited lower tendon thickness and a significantly higher prevalence of distal tear location. Studies with larger cohort sizes are necessary to confirm the current findings.

Purpose Surgical reconstruction is the current standard for ACL rupture treatment in active individuals. Recently, there is renewed interest in primary repair of proximal ACL tears. Despite this, ACL biology and healing potential are currently not well understood. Vascularity is paramount in ACL healing; however, previous ACL vascularity studies have been limited to qualitative histological and dissection-based techniques. The study objective was to use contrast-enhanced quantitative-MRI to compare relative perfusion of proximal, middle, and distal thirds of the in situ ACL. We hypothesized perfusion would be greatest in the proximal third. Methods Fourteen cadaveric knees were studied (8 females, 6 males), age 25–61 years. Superficial femoral, anterior tibial, and posterior tibial arteries were cannulated; without intraarticular dissection. Contrast-enhanced quantitative-MRI was performed using a previously established protocol. ACL regions corresponding to proximal, middle, and distal thirds were identified on sagittal-oblique pre-contrast images. Signal enhancement (normalized to tibial plateau cartilage) was quantified to represent regional perfusion as a percentage of total ACL perfusion. Comparative statistics were computed using repeated measures ANOVA, and pairwise comparisons performed using the Bonferroni method. Results Relative perfusion to proximal, middle, and distal ACL zones were 56.0% ±17.4%, 28.2% ±14.6%, and 15.8% ±16.3%, respectively ( p  = 0.002). Relative perfusion to the proximal third was significantly greater than middle ( p  = 0.007) and distal ( p  = 0.001). No statistically relevant difference in relative perfusion was found to middle and distal thirds ( p  = 0.281). Post-hoc subgroup analysis demonstrated greater proximal perfusion in males (66.9% ± 17.3%) than females (47.8% ± 13.0%), p  = 0.036. Conclusion Using quantitative-MRI, in situ adult ACL demonstrated greatest relative perfusion to the proximal third, nearly 2 times greater than the middle third and 3 times greater than the distal third. Knowledge of differential ACL vascular supply is important for understanding pathogenesis of ACL injury and the process of biological healing following various forms of surgical treatment.

Traumatic injury and surgical intervention about the hip joint place the arterial supply to the femoral head (FH) at risk. Compromised perfusion may lead to FH ischemia, cell death, and osteonecrosis. Progression to FH collapse may lead to pain, functional impairment, and decreased quality of life, especially in younger patients. This review describes the arterial supply to the FH, analyzes the impact of femoral neck fractures on FH vascularity, and explores the vascular implications of various surgical interventions about the hip, offering specific techniques to minimize iatrogenic damage to the vessels supplying the FH. [ Orthopedics . 2019; 42(5):250–257.]

Abstract Purpose While predominant blood supply to the adult patella enters inferomedially, little is known about skeletally immature patellar perfusion. Improved knowledge of immature patella vascularity can further understanding of osteochondritis dissecans, dorsal defects of the patella and bipartite patella, and help ensure safe surgical approaches. We hypothesized that the immature patella would exhibit more uniform blood flow. The study purpose was to quantify immature patella regional perfusion in comparison with adults. Methods Ten cadaveric knees were utilized (five immature, five mature). The superficial femoral artery was cannulated proximally. Signal enhancement increases were compared from pre- to post-contrast MRI to assess relative arterial contributions to patella regions (quadrants, anterior/posterior, superior/inferior, medial/lateral, and outer/inner). Results Quantitative-MRI analysis revealed similar distribution of enhancement between the immature and mature patella. The inferior pole exhibited significantly higher arterial contribution versus superior pole in both immature and mature groups (p = 0.009; both groups), while the inferomedial quadrant had the highest arterial contribution of all quadrants in both groups. The superolateral quadrant demonstrated the lowest arterial contribution in the immature group and second lowest in the adult group. The patella outer periphery had significantly greater arterial contribution than the inner central region in both immature (p = 0.009) and mature (p = 0.009) groups. Conclusion Distribution of arterial contributions between the immature and mature patella was similar. Our results highlight the importance of inferior and inferomedial blood supply in both immature and mature patellas. These findings have implications for paediatric and adult patients; surgical damage to inferior patellar vessels should be avoided to prevent associated complications.

Category: Trauma; Ankle Introduction/Purpose: The native sagittal plane alignment of the distal tibia has not been well-described and has implications during the fixation of tibia fractures. Cavovarus foot alignment has been previously thought to influence gastrocsoleus tightness and the potential for anterior talar escape in the setting of an osseous injury in this region. However, the relationship between midfoot alignment and sagittal distal tibia morphology is undescribed. Characterization of this osseous anatomy may be helpful to achieve adequate sagittal alignment during the reduction of distal tibia fractures. The purpose of this study was primarily to characterize distal tibia sagittal morphology and ankle radiographic parameters, determine whether symmetry exists from side-to- side, and secondarily to identify any differences based on midfoot alignment. Methods: 112 patients (60 females, mean age 45.8 years) with bilateral lateral weight-bearing ankle radiographs were retrospectively evaluated (224 ankles). Midfoot morphology was classified as normal, planus, or cavus using Meary's angle (MA) (Planus: MA <-4°, Normal: MA -4°≤x≤4°, Cavus: MA>4°). The angle between the proximal diaphyseal (Line 1) and distal tibia (Line 2) axes was measured, and the location of the center of rotation of angulation (CORA) relative to the plafond was recorded (Figure 1). The horizontal distance (via a line parallel to the floor) from the distal tibia axis (Line 2) to the lateral talar process was measured, as well as the anterior distal tibial angle, and the plafond radius of curvature (ROC). Bilateral ankles and midfoot morphologies were compared using a Mann-Whitney U test and ANOVA, respectively. Correlation was assessed using linear regression. Results: The average distal tibia had 2° of apex posterior angulation with the CORA located 8.0 cm proximal to the plafond. There was no difference by laterality in magnitude of the angulation (p=.358) or distance from the plafond to the CORA (p=.901). The angulation increased as foot alignment transitioned from cavus (1.25°), to normal (1.89°), to planus (3.05°) alignment (r=.32; R2=.102; p<.001). The angulation was larger in men (2.8°) than in women (1.4°) (p<.001) and decreased with increasing patient age (r=.279, R2=.078, p<.001). The lateral talar process was on average 5.9 mm anterior to the distal tibia axis (Line 2), more anterior with cavus versus planus alignment (6.7mm vs. 4.8mm) (p<.001). The average anterior distal tibial angle and plafond ROC were 83.6° and 22.9 mm, respectively, with no significant differences by laterality or midfoot morphology (p>.05 for both). Conclusion: The distal tibia has a consistent apex posterior bow that is symmetric from side-to-side, but variable from patient- to-patient. Distal tibia osseous morphology is related to midfoot alignment, sex, and age. Cavus alignment is additionally correlated with anterior translation of the lateral talar process relative to the distal tibia axis. Surgeons treating distal tibia fractures may consider the use of contralateral imaging as a reduction template to help restore patient-specific sagittal alignment. A tibial nail that ends anterior in the distal segment of a distal tibia fracture should prompt the surgeon to carefully evaluate whether sagittal alignment has been restored.

Background: Despite advances in surgical techniques, implant technology, and biological augmentation, one innate limitation to meniscus healing is lack of vascularity. Ability to quantify meniscal vascularity has been limited with previous techniques, and minimal data exists describing differential vascular zones in the skeletally immature meniscus. Purpose/Hypothesis: The objective of this study is to use quantitative contrast-enhanced magnetic resonance imaging (MRI) to compare meniscal vascularity in pediatric cadaveric specimens to adults. We hypothesize that the developing meniscus has greater and more uniform vascularity throughout all zones. Methods: We utilized 10 fresh-frozen human cadaveric knees (5 immature knees, age 0-6 months; 5 mature knees, age 34-67 years). Gadolinium-enhanced MRI was performed using a previously established vascularity quantification protocol. Regions of interest corresponding to peripheral and central zones of the meniscus were identified on pre-contrast coronal images, and signal enhancement (normalized against background tissue) was compared between pre-and post-contrast images (Figure 1). Results: Quantitative MRI demonstrated increased perfusion in the peripheral zones compared to the central zones (2.3:1 in immature knees and 3:1 in mature knees) in the medial and lateral menisci separately, and both menisci aggregated. Overall, the medial and lateral menisci had similar levels of perfusion in all specimens (45.9% ± 8.3% medial vs. 54.1% ± 8.3% lateral in immature knees; 50.5% ± 11.3% medial vs. 49.5% ± 11.3% lateral in mature knees). Immature specimens demonstrated greater overall normalized meniscal signal uptake, with the 0-month specimen demonstrating the greatest proportional signal enhancement. Conclusion: While blood flow to peripheral zones is greater than to central zones in both immature and adult menisci, younger menisci receive proportionally greater overall blood flow compared to adults, including greater blood flow to the inner zone, challenging the conventional wisdom of the central zone being avascular. As younger patients become increasingly active in sports, thorough understanding of the immature meniscus is required. Greater overall vascularity, including centrally, to the developing meniscus suggests improved healing potential following injury, and further encourages meniscal preservation when possible. Figure 1. Analysis of meniscal vascularity using contract-enhanced magnetic resonance imaging. A:Schematic drawing of peripheral and central zones of the medial and lateral menisci used for quantification.B:Mid-coronal images showing pre-and post contract images with ROIs delineated in adult and pediatric specimens; there is significatly increased perfusion to the epiphysis in the immature knee. Figure 2. Quantification of mensical vascularity in each specimen Comparsion of relative vascularity of peripheral versus central zones shows significantly greater blood flow to outer zone across all specimens.Quantification of total vascular contribution from the medial and lateral menisci aggregated showed a trend towards greater proportional blood flow in younger specimens.

Background: Although vascularity plays a critical role in healing after ulnar collateral ligament (UCL) reconstruction, intraosseous blood flow to the medial epicondyle (ME) and sublime tubercle remains undefined. Purpose: To quantify vascular disruption caused by tunnel drilling with the modified Jobe and docking techniques for UCL reconstruction. Study Design: Controlled laboratory study. Methods: Eight matched pairs (16 specimens) of fresh-frozen cadaveric upper extremities were randomized to 1 of 2 study groups: docking technique or modified Jobe technique. One elbow in each pair underwent tunnel drilling by the assigned technique, while the contralateral elbow served as a control. Pregadolinium and postgadolinium magnetic resonance imaging were performed to quantify intraosseous vascularity within the ME, trochlea, and proximal ulna. Three-dimensional computed tomography (CT) and gross dissection were performed to assess terminal vessel integrity. Results: Ulnar tunnel drilling had minimal impact on vascularity of the proximal ulna, with maintenance of >95% blood flow for each technique. Perfusion in the ME was reduced 14% (to 86% of baseline) for the docking technique and 60% (to 40% of baseline) for the modified Jobe technique (mean difference, 46%; P = .029). Three-dimensional CT and gross dissection revealed increased disruption of small perforating vessels of the posterior aspect of the ME for the modified Jobe technique. Conclusion: Although tunnel drilling in the sublime tubercle appears to have a minimal effect on intraosseous vascularity of the proximal ulna, both the docking and modified Jobe techniques reduce flow in the ME. This reduction was 4 times greater for the modified Jobe technique, and these findings have important implications for UCL reconstruction surgery. Clinical Relevance: As the rate of revision UCL reconstructions continues to rise, investigation into causes for failure of primary surgery is needed. One potential cause is poor tendon-to-bone healing due to inadequate vascularity. This study quantifies the amount of vascular insult that is incurred in the ME during UCL reconstruction. While vascular insult is only one of many factors that affects the surgical success rate, surgeons performing this procedure should be mindful of this potential for vascular disruption.