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Background: Geriatric hip fractures remain associated with significant mortality and morbidity. Identifying factors associated with such outcomes is an important step for improvement of prognostication and supporting individualized care. Sarcopenia is a known risk factor for mortality and thigh muscle measurements on plain radiographs can serve as a proxy measure of sarcopenia. Therefore, the objective was to determine whether radiographic thigh muscle measurements were independently associated with 1-year mortality following hip fracture surgery.

Methods: All consecutive patients aged 70 years or older undergoing operative treatment for an isolated hip fracture at 2 urban Level 1 trauma centers between 2018 and 2020 with preoperative radiographs displaying the distal-and-middle femur were included. Thigh muscle diameter and soft tissue size was measured on anteroposterior and lateral radiographs using standardized anatomical landmarks. Multivariable logistic regression was performed to determine if there were independent associations with 1-year mortality for the variables assessed. Inter-rater reliability for each measurement was evaluated by calculating intraclass correlation coefficients (ICCs).

Results: One hundred ninety-nine patients (median age 85 years, 68% female) were included. One-year mortality was 22%. After adjusting for age, sex, smoking status, preinjury living situation, Charlson Comorbidity Index, frailty, and body mass index, a greater thigh muscle diameter on anteroposterior radiographs was associated with lower odds of 1-year mortality (adjusted odds ratio 0.74, 95% confidence interval 0.56-0.97, p = 0.028). There was no significant association with thigh muscle diameter on lateral radiographs or with total soft tissue diameter on anteroposterior or lateral radiographs. The ICCs demonstrated good-to-excellent reliability for all radiographic measurements.

Conclusion: Greater thigh muscle diameter measured on anteroposterior radiographs was independently associated with decreased 1-year mortality following hip fracture surgery, with each centimeter increase in diameter being associated with an average reduction in odds of 26%. This finding should be interpreted in the context of the limited sample size, homogenous patient population, and range of observed thigh muscle sizes. Overall, these results suggest that radiographic parameters may potentially serve to complement currently used modalities, such as frailty assessment, in supporting individualized care.

Level of evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Acquired and congenital limb length discrepancies often coexist with deformities of the distal femur. Lengthening of the femur along its anatomic axis changes the limb's mechanical alignment. Angular correction and lengthening can be achieved at the same site if a retrograde lengthening nail is used with a specific preoperative planning method ("reverse planning") which permits patient-specific selection of the final mechanical axis.

Methods: A consecutive cohort series of children, adolescents, and young adults (mean 15.6 ± 4.8 years) undergoing retrograde implantable femoral lengthening between the years 2011 and 2024 were analyzed. Surgical details, lengthening parameters, Limb Lengthening and Reconstruction Society (LLRS)-AIM index, accuracy of final correction, and complications were reviewed and classified. Patients were eligible only if the distal femoral physis was closed.

Results: Seventy-three lengthening were eligible in the study period. Average lengthening was 4.2 ± 1.4 cm (range 2.0-8.0 cm), and consolidation index was 39.4 ± 21.9 days/cm. Deformities and length discrepancies were moderately complex, with a mean LLRS AIM score of 6 (range 1-13). Complication rates were similar to previous reports of intramedullary femoral lengthening, comparable between congenital (12 of 31, 39%) and acquired etiologies (16 of 42, 38%). Preoperative coronal alignment ranged from 14° varus to 20° valgus, while final coronal alignment was 0.4° ± 3.4° of neutral (range 7° valgus to 13° varus). Coronal deformities up to 20° and sagittal deformities up to 23° were corrected acutely at the lengthening site.

Conclusions: Retrograde intramedullary femoral lengthening with acute deformity correction at the same site is an alternative to antegrade lengthening with separate osteotomy of the distal femur in children and adolescents. The reverse planning method allows reproducible length and deformity correction at the same location. Specific intraoperative technical adjuncts are used to achieve and maintain the desired alignment.

Level of evidence: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: The aim of this study was to investigate the clinical outcomes and complications of vascularized fibular epiphyseal transfer (VFET) and clavicle pro humero (CPH) for proximal humeral reconstruction after primary sarcoma resection in skeletally immature patients.

Patients and methods: This retrospective case-control study included 29 skeletally immature patients (18 male patients, 11 female patients) with primary bone sarcomas who were treated between January 2009 and June 2023 at Beijing Jishuitan Hospital. The average age was 9.4 ± 2.8 years (range, 5-14), and the pathological type included osteosarcoma (25) and Ewing sarcoma (4). We compared the graft survival, function, and complication rate between the VFET group and the CPH group.

Results: The 2-year and 5-year overall survival rates for the VFET group and CPH group were 94%, 75%, 86%, and 55%, respectively. The 2-year and 5-year revision-free survival for the VFET group and CPH group were 77%, 61%, 75%, and 37%, respectively. At the final follow-up, the mean MSTS-93 score in the VFET group was 82% (67%-97%), while the mean MSTS-93 score in the CPH group was 79% (73%-96%, p > 0.05). The incidence of mechanical complications was significantly higher in the CPH group (88%, 7/8) than that in the VFET group (52%, 11/21) (p = 0.036). The mean difference in upper limb length in the VFET group was 5.0 ± 2.9 cm and 10.2 ± 4.2 cm in the CPH group (p = 0.003).

Conclusions: We suggest that vascularized fibular epiphyseal transfer may be considered as a promising biological reconstruction option for pediatric patients with proximal humeral osteosarcoma who have a longer life expectancy. For institutions lacking the necessary microsurgical techniques, clavicle pro humero reconstruction remains a relatively simple and feasible alternative reconstruction option.

Level of evidence: Level III Case-control study. See Instructions for Authors for a complete description of levels of evidence.

» Dual mobility cup (DMC) implants reduce dislocation rates in both primary and revision total hip arthroplasty (THA), particularly in high-risk patients with neuromuscular disorders, cognitive impairment, or obesity. » The dual articulation mechanism enhances joint stability by increasing jump distance and the head-to-neck ratio, without compromising range of motion. » Incorporation of highly cross-linked polyethylene and vitamin E-infused liners improves wear resistance, supporting broader use in younger, more active patients. » Long-term survivorship of modern DMCs is comparable or superior to fixed-bearing implants, with a lower revision burden and durable fixation when appropriately selected and implanted. » Systemic metal ion levels remain low in well-functioning modular DMCs, though continued monitoring is recommended in younger patients and those with reproductive potential.

Background: As the global population ages, an increasing number of older individuals reside in nursing homes, underscoring the need to include this group in discharge outcome analyses. The aim of this study was to assess the effect of early surgical intervention (defined as surgery within 48 hours of injury) on ambulatory function at discharge and the likelihood of returning to the preinjury residence, including discharge to nursing homes, among patients with hip fractures.

Methods: We retrospectively analyzed 455 patients who underwent open reduction and internal fixation (ORIF) for hip fractures at our institution between April 2017 and March 2023. Patients were categorized into 2 groups based on the timing of surgery: the "early group" (within 48 hours) and the "delayed group" (after 48 hours).

Results: The early group included 338 patients, while the delayed group included 117 patients. The mean functional independence measure (FIM) (locomotion) score at discharge was 5.35 in the early group and 4.68 in the delayed group (p = 0.04). Spearman correlation coefficient between early surgical intervention and FIM (locomotion) at discharge was 0.097 (p < 0.05). Multiple regression analysis revealed a regression coefficient of 0.63 (p = 0.02) for early surgical intervention with respect to FIM (locomotion) at discharge. Furthermore, logistic regression analysis indicated that the higher FIM (locomotion) score at discharge was associated with an increased likelihood of returning to the preinjury residence (regression coefficient = 0.30, p < 0.001).

Conclusions: Early surgical intervention was associated with improved FIM (locomotion) scores at discharge. Higher FIM (locomotion) scores at discharge were correlated with an increased likelihood of returning to the preinjury residence. These findings underscore the importance of early functional recovery in older patients undergoing ORIF for hip fractures, as surgical delays can hinder the restoration of activities of daily living. Therefore, where feasible, early ORIF should be prioritized to optimize patient outcomes.

Level of evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Introduction: We aimed to identify a new biomarker using ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography (PET)/computed tomography (CT) parameters to identify osteosarcoma patients with standard response after neoadjuvant chemotherapy (NAC).

Patients and materials: Fifty-four patients with conventional osteosarcoma (age ≤39 years) were included in this study. All patients underwent ¹⁸F-FDG PET/CT before (PET1) and after NAC (PET2). We measured PET parameters, including maximum, average, and peak standardized uptake value (SUVmax, SUVave, and SUVpeak); metabolic tumor volume (MTV); and total lesion glycolysis (TLG). Their changes (ΔPET = PET2/PET1) were also examined. The patients were classified into 4 groups based on the histological tumor necrosis rate (TNR): G0 (<50%), G1 (50 to < 90%), G2 (90 to < 100%), and G3 (100%). G0 and G1 patients were enrolled in the standard responder (SR) group (n = 35), while G2 and G3 patients were enrolled in the good responder (GR) group (n = 19). We examined the correlation between changes in each ¹⁸F-FDG PET/CT parameter and TNR as well as overall survival (OS) and progression-free survival (PFS) among the 4 groups. In the SR group, the median value of ΔSUVmax was calculated and correlated with prognostic stratification.

Results: The changes in each PET parameter were correlated with TNR, with SUVpeak showing the strongest correlation. Moreover, in the SR group, there were no differences in OS or PFS between G0 and G1. Patients in the SR group were stratified into 2 groups according to the median ΔSUVmax value (0.62). Patients with ΔSUVmax < 0.62 had significantly better OS (P < 0.01) and PFS (P = 0.02) in comparison with patients with ΔSUVmax ≥ 0.62. In multivariate analyses, ΔSUVmax showed a correlation with OS in the SR group.

Discussion: This study revealed that ΔSUVmax may confirm the preoperative stratification of the prognosis be a predictive biomarker for patients in the SR group. Moreover, the preoperative identification of patients with a worse prognosis in the SR group has a significant impact on improving the clinical outcomes of patients with osteosarcoma.

Level of evidence: Prognostic studies, Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Musculoskeletal pathology (MSP) develops in the lower limbs of the majority of children with cerebral palsy (CP) with time and growth. The aims of this study were to investigate the epidemiology of MSP in the lower limbs, of a large population-based sample of children with CP, at long-term follow up.

Methods: An inception cohort was generated from the Victorian Cerebral Palsy Register for the birth years 1990 through 1992 inclusive. Children had regular clinical and radiographic examinations from infancy until after skeletal maturity. Cerebral palsy was classified using the Gross Motor Function Classification System (GMFCS) and a Topographical Classification System (TCS), devised for this study. MSP was classified using the Musculoskeletal Pathology Classification System, which has good reliability.

Results: A full dataset was available for 292 individuals, 78% of the inception cohort (170 males, 122 females). Mean age at final follow-up was 20 years (SD 4.5, range 6-31 years). MSP type changed with age. Hypertonia (MSP 1) was present in 77% of children at age 5 years, contractures (MSP 2) in 22% of children at 10 years, contractures combined with bony torsion (MSP 3) in 31% of teenagers at age 15 years, and decompensation (MSP 4) in 15% of young adults at age 25 years. There were moderate to strong associations between GMFCS and MSP and TCS and MSP (Kendall's tau 0.36-0.55, p < 0.001).

Conclusions: The prevalence of MSP in children with CP who were born between 1990 and 1992 and followed into the third decade was high and was related to age and CP severity by GMFCS.

Level of evidence: Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: Cementless total knee arthroplasty (TKA) offers several conceptual benefits over cemented TKA. However, the effect of the cam-post interaction of posterior-stabilized (PS)-TKA on implant osseointegration remains uncertain.

Methods: Data were obtained from the UK National Joint Registry (UK NJR), on patients who underwent primary PS-TKA for osteoarthritis using the Stryker Triathlon system between January 1, 2010, and December 31, 2019. Patients were excluded if they had an implausible body mass index (BMI) or where there was use of bone graft, revision implants, or hybrid cementation. A local cohort of patients were similarly identified, with additional postoperative radiographic analysis performed. The primary outcome for both cohorts was all-cause survivorship.

Results: There were 18,824 relevant PS-TKA: 1,068 (5.7%) cementless and 17,756 (94.3%) cemented. The cementless group had a higher proportion of men (48.7% vs. 41.9%), a lower median age (70 vs. 71 years), a higher median BMI (31 vs. 30 kg/m²), and shorter median duration of exposure to risk of revision (5.5 vs. 6.9 years, p < 0.01). All-cause revision rates were similar between the cementless and cemented groups (2.4% vs. 2.8%, p = 0.49). The second cohort of 875 patients had no statistical difference in all-cause revision rates for cementless and cemented PS-TKA (2.9% vs. 1.3%, p = 0.22), and radiographic analysis of those with cementless implants revealed that revision was more likely if there was radiographic loosening within the first 30 months postoperatively (33.3% vs. 2.1% if absent).

Conclusions: This study, the largest of its kind, reports equivalent revision rates between cementless and cemented fixation of PS-TKA in the medium term, suggesting that either fixation option was reasonable for PS-TKA. This work complements existing NJR reports by providing a comparison not readily available, for the PS design of what is currently the most used TKA system in the United Kingdom.

Level of evidence: Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: For adolescent idiopathic scoliosis, whether the Proximal Femur Maturity Index (PFMI) can guide brace-wear weaning remains unknown. The aim of this study was to investigate whether PFMI gradings at brace weaning were related to curve progression after brace treatment and to evaluate the postweaning curve progression risk associated with PFMI gradings.

Methods: This prospective study included 137 patients who were advised to wean from underarm bracing with adequate compliance. They were followed up for at least 2 years. Data collection included bodily growth parameters, curve magnitude, and skeletal maturity status at weaning as assessed by PFMI, distal radius and ulna classification, and Risser and Sanders staging. Curve progression was defined as >6° major curve increase at postweaning 2 years. Relationships between PFMI and other skeletal maturity gradings, and whether parameters at weaning were associated with curve progression were investigated.

Results: There were 59.1% (n = 81) of patients who weaned bracing at PFMI grade 5, 39.4% at grade 6, and 1.5% at grade 4. PFMI gradings correlated with radius (G = 0.596, p < 0.001), ulnar (G = 0.700, p < 0.001), and Sanders (G = 0.689, p < 0.001) stages. 11.7% of the patients experienced curve progression. Curve progression rate was 0% for those who weaned at PFMI grade 6, or PFMI grade 5 with Risser stage 5 or ≥ R10 U9 for <30° curves. Compared with PFMI grade 4 or 5, weaning at grade 6 reduced progression risk by 29.7% (95% Confidence Interval [CI] 13.3-43.0, p = 0.023) for curves ≥30°, while relative risk reduction was 10.9% (95% CI 1.4-19.4, p = 0.037) for <30° curves.

Conclusions: For patients who were prescribed bracing for their 25° to 40° curves with adequate compliance, PFMI grade 6 can serve as an independent indicator for guiding brace weaning with minimal curve progression risk.

Background: Nonunion of an osteotomy site is one of the most reported complications following periacetabular osteotomy (PAO). Identification of risk factors for nonunion is an important area of research as hip preservation has an increasing presence in orthopaedic surgery.

Methods: We retrospectively identified patients who underwent PAO between March 2018 and May 2023 with a minimum of 1-year follow-up. Twelve-month postoperative radiographs were reviewed to determine the prevalence of nonunion. Descriptive statistics and mixed-effects logistic regression models were run.

Results: Ninety-four hips (84 patients) were included. 84.5% of patients (n = 71) were female, average age was 28.2 (±9.8) years and body mass index (BMI) was 25.4 (±4.3) kg/m². 15 of 94 hips (16.0%) were nonunited at the superior ramus osteotomy, and 2 of these hips (2.1%) also had an ischial nonunion. All nonunions occurred in female patients. The mean age of healed hips was 26.7 ± 9.5 years compared with 35.7 ± 8.1 years for nonunion (p = 0.016). BMI was higher in the nonunion group (healed 24.8 ± 4.0, nonunion 27.7 ± 4.3 kg/m²; p = 0.048). Hounsfield unit at the femoral neck on preoperative computed tomograpy was 220.7 ± 77.3 in healed hips and 167.6 ± 49.6 for nonunion (p = 0.047). Average distance from the ilioischial line to the most medial aspect of the femoral head was 5.6 ± 5.7 mm in healed hips and 1.7 ± 5.2 mm for nonunion (p = 0.047).

Conclusions: Risk factors of nonunion include older age, lower bone mineral density at the femoral neck, greater acetabular fragment medialization, and higher BMI. Our findings reinforce the importance of preoperative risk assessment and patient counseling, particularly for older, higher BMI, female patients. Intraoperative modifications, including making a more lateral superior ramus osteotomy and minimizing excessive acetabular fragment medialization, may help mitigate nonunion risk.

Level of evidence: Level III. See Instructions for Authors for a complete description of levels of evidence.