The purpose of this study was to analyze radiographic signs of carpal bone instability in patients with an acutely injured wrist. There were 80 patients (52 women and 28 men) with a fall on the outstretched hand. Fifty patients had a fracture of the distal radius, and eight had a scaphoid fracture. The patients with a bone fracture showed a larger scapholunate angle than those without a fracture (P less than 0.001, t-test). However, only four of them showed true carpal bone instability: two patients with a scaphoid fracture and one with a radius fracture had dorsiflexion instability of the wrist and one patient with a radius fracture had dorsal subluxation of the wrist. In addition, one patient without any bone fracture had scapholunate dissociation, one form of carpal bone instability. Although carpal bone instability is not frequent in an acutely injured wrist, its signs should be remembered in the radiographic analysis of the traumatic wrist to prevent subsequent articular disorders.

Short‐stem humeral implants in reverse total shoulder arthroplasty (rTSA) are increasingly adopted because they preserve bone stock and reduce stress shielding. However, their shorter length raises the risk of malalignment, and outcomes may be further affected by osteoporosis, which is common in rTSA patients. This study investigated how humeral stem alignment (neutral, varus, valgus) and bone mineral density simultaneously influence stress distribution in the proximal humerus using finite element (FE) analysis. FE models were developed from computed tomography scans of one normal and one osteoporotic humerus. A curved short stem was virtually implanted in three alignments, and physiological loading was applied. Von Mises stress was examined in cortical and trabecular bone, subdivided into medial/lateral and proximal/distal regions. Varus alignment produced the largest stress reduction in the proximal‐lateral region, particularly in osteoporotic bone (up to −55.5%). Valgus alignment reduced stress primarily in the proximal‐medial region (up to −55.9%) but also affected the proximal‐lateral region. These results confirm that malalignment induces stress shielding patterns consistent with clinically observed bone resorption. Specifically, varus alignment was associated with shielding in the proximal‐lateral region, whereas valgus alignment contributed to reductions in both proximal‐medial and lateral regions. In osteoporotic bone, malalignment exacerbated stress shielding, with varus demonstrating the most detrimental effect.

A bursa is a thin sac filled with viscous fluid to facilitate friction and gliding. In the human body, there are two types of bursae: synovial bursae in well-defined positions and adventitial bursae, which develop in sites where friction or pressure increases. This case study is on a young woman with an old distal radial extremity fracture, with occupational exposure to pressure on distal ulnar forearm. She noticed a small and painful mass, with some mobility on the above-mentioned site. Sonography was used to detect a small fluid accumulation with features of adventitial bursitis. This case presents a rare localization of an adventitial bursitis. It is believed to have developed over the distal ulnar epiphysis, with a small bone malalignment, after an old and consolidated fracture, of the distal radial extremity.

PurposeMeniscal allograft transplantation (MAT) is a well-established option for young, active patients with symptomatic functional meniscal deficiency, aiming to restore knee function and delay the progression of degenerative changes. This review provides an overview of available root fixation techniques and contextualizes their clinical outcomes to help surgeons select the most suitable method for individual patients.Recent FindingsMultiple fixation approaches, including all–soft-tissue, bony fixation (bone plug or bone bridge), and hybrid techniques have demonstrated significant improvements in patient-reported outcomes and pain reduction. Bony fixation may reduce or equalize graft extrusion relative to soft-tissue methods, though the clinical significance of extrusion remains uncertain. While functional outcomes and long-term survivorship appear similar across techniques, soft-tissue fixation may carry a slightly higher rate of graft tears and complications. Long-term follow-up reveals that osteoarthritis progression and graft degeneration can still occur. Hybrid fixation techniques combine bony and all-soft-tissue root fixation to leverage the advantages of both methods. It is important to address related conditions such as bone malalignment and ligament instability.SummaryOverall, MAT provides durable improvements in knee function and quality of life regardless of fixation method. Optimal results depend not only on the fixation technique but also on addressing concomitant pathologies, such as ligamentous instability and malalignment, with osteotomy playing a key role in protecting the graft when necessary. As no single fixation method has proven superior, further research is required to clarify the ideal strategy and the true clinical impact of graft extrusion.

Purpose. To assess the results of concurrent intramedullary nailing plus plate osteosynthesis for fractures of the distal tibia and fibula. Methods. 15 men and 10 women (mean age, 35 years) with concurrent fractures of the distal tibia and fibula underwent intramedullary nailing (for the tibia) and plate osteosynthesis (for the fibula). 17 fractures were type A1, 6 type A2, and 2 type A3. Compound type IIIB or more extensive fractures were excluded. Results. The mean follow-up duration was 2 years. The mean time to bone union was 20 weeks. Six patients underwent dynamisation and 4 bone grafting. Two patients had malalignment (angulation of >5° in any plane), but none was rotational. No patient had shortening, hardware breakdown, or deep-seated infection. Two patients had superficial cellulitis at the site of the distal locking screws. Conclusion. Concurrent intramedullary nailing and plate osteosynthesis for fractures of the distal tibia and fibula is effective in preventing malalignment. Plate osteosynthesis for the fibula provides additional stability even when a single distal locking bolt is used to fix the intramedullary nail to the tibia.

Purpose. To assess the outcome of unreamed intramedullary nailing through the lateralised entry point using oblique proximal and biplanar distal interlocking screws. Methods. 15 men and 3 women aged 25 to 58 (mean, 37) years underwent unreamed intramedullary nailing with oblique proximal and biplanar distal interlocking screws for proximal third metaphyseal tibial fractures. The entry point was kept proximal to the tibial tuberosity and slightly lateral to midline. Proximal locking was at 45° to the coronal and sagittal planes. Biplanar distal locking was in the coronal and sagittal planes. Results. 16 patients had bone union within 20 (mean, 17; range, 14–27) weeks; 2 underwent dynamisation for delayed union. Three patients had valgus angulation of <5°; 2 had a loss of terminal knee flexion; 3 had a loss of ankle dorsiflexion; and 3 had shortening of >0.5 cm. Functional outcomes were excellent in 13, good in 4, and fair in one patient. No patient endured neurovascular injury, compartment syndrome or implant failure. Conclusion. Unreamed intramedullary nailing with oblique proximal and biplanar distal interlocking screws for proximal third tibial fractures was effective in preventing malalignment.

PurposeSagittal spinal malalignment often leads to surgical realignment, which is associated with major complications. Low bone mineral density (BMD) and impaired bone microstructure are risk factors for instrumentation failure. This study aims to demonstrate differences in volumetric BMD and bone microstructure between normal and pathological sagittal alignment and to determine the relationships among vBMD, microstructure, sagittal spinal and spinopelvic alignment.MethodsA retrospective, cross-sectional study of patients who underwent lumbar fusion for degeneration was conducted. The vBMD of the lumbar spine was assessed by quantitative computed tomography. Bone biopsies were evaluated using microcomputed tomography (μCT). C7-S1 sagittal vertical axis (SVA; ≥ 50 mm malalignment) and spinopelvic alignment were measured. Univariate and multivariable linear regression analysis evaluated associations among the alignment, vBMD and μCT parameters.ResultsA total of 172 patients (55.8% female, 63.3 years, BMI 29.7 kg/m2, 43.0% with malalignment) including N = 106 bone biopsies were analyzed. The vBMD at levels L1, L2, L3 and L4 and the trabecular bone (BV) and total volume (TV) were significantly lower in the malalignment group. SVA was significantly correlated with vBMD at L1–L4 (ρ = -0.300, p < 0.001), BV (ρ = − 0.319, p = 0.006) and TV (ρ = − 0.276, p = 0.018). Significant associations were found between PT and L1–L4 vBMD (ρ = − 0.171, p = 0.029), PT and trabecular number (ρ = − 0.249, p = 0.032), PT and trabecular separation (ρ = 0.291, p = 0.012), and LL and trabecular thickness (ρ = 0.240, p = 0.017). In the multivariable analysis, a higher SVA was associated with lower vBMD (β = − 0.269; p = 0.002).ConclusionSagittal malalignment is associated with lower lumbar vBMD and trabecular microstructure. Lumbar vBMD was significantly lower in patients with malalignment. These findings warrant attention, as malalignment patients may be at a higher risk of surgery-related complications due to impaired bone. Standardized preoperative assessment of vBMD may be advisable.

Patellar malalignment [The Journal of Bone and Joint Surgery 2000;82-A(11):1639-50]

IntroductionMalalignment of the Total Ankle Replacement (TAR) has often been postulated as the main reason for the high incidence of TAR failure. As the ankle joint has a small contact area, stresses are typically high, and malalignment may lead to non-homogeneous stress distributions, including stress peaks that may initiate failure. This study aims to elucidate the effect of TAR malalignment on the contact stresses on the bone-implant interface, thereby gaining more understanding of the potential role of malalignment in TAR failure.MethodsFinite Element (FE) models of the neutrally aligned as well as malaligned CCI (Ceramic Coated Implant) Evolution TAR implant (Van Straten Medical) were developed. The CCI components were virtually inserted in a generic three-dimensional (3D) reconstruction of the tibia and talus. The tibial and talar TAR components were placed in neutral alignment and in 5° and 10° varus, valgus, anterior and posterior malalignment. Loading conditions of the terminal stance phase of the gait cycle were applied. Peak contact pressure and shear stress at the bone-implant interface were simulated and stress distributions on the bone-implant interface were visualized.ResultsIn the neutral position, a peak contact pressure and shear stress of respectively 98.4 MPa and 31.9 MPa were found on the tibial bone-implant interface. For the talar bone-implant interface, this was respectively 68.2 MPa and 39.0 MPa. TAR malalignment increases peak contact pressure and shear stress on the bone-implant interface. The highest peak contact pressure of 177 MPa was found for the 10° valgus malaligned tibial component, and the highest shear stress of 98.5 MPa was found for the 10° posterior malaligned talar model. High contact stresses were mainly located at the edges of the bone-implant interface and the fixation pegs of the talar component.ConclusionsThe current study demonstrates that TAR malalignment leads to increased peak stresses. High peak stresses could contribute to bone damage and subsequently reduced implant fixation, micromotion, and loosening. Further research is needed to investigate the relationship between increased contact stresses at the bone-implant interface and TAR failure.