Elizabeth P. Wellings

Purpose Tibiotalocalcaneal (TTC) arthrodesis is a limb-salvaging procedure for end-stage ankle and hindfoot pathology but carries substantial risks of nonunion and complications. Minimally invasive approaches may reduce surgical morbidity while maintaining fusion outcomes. Methods This was a retrospective case series of patients who underwent TTC arthrodesis with percutaneous joint preparation between January 2020 and March 2025 at a single academic Level II trauma center. The primary outcome was radiographic or clinical fusion at final follow-up. Secondary outcomes included alignment, operative variables, complications, and functional recovery as measured by Patient Reported Outcomes Measurement Information System (PROMIS) domains. Results Thirteen patients (six females) met inclusion criteria with a mean age of 74.0 years and body mass index of 27.1 kg/m². The mean time from injury to surgery in trauma patients was 6.2 days. Fibular fixation was performed in six cases (46.2%), with additional fixation necessary in select patients. Mean clinical follow-up time was 15.0 ± 4.3 months. Most patients advanced to weightbearing in supportive footwear and reported functional improvement. PROMIS Pain Interference averaged 56.8 ± 10.9, Physical Function 37.7 ± 12.2, and Global Pain 38.7 ± 28.9. Radiographs and computed tomography demonstrated moderate fusion rates in this cohort. Complications included wound issues (23.1%), hardware problems (46.2%), and one tibial shaft fracture after a fall; five patients required secondary screw removal. Conclusion Percutaneous TTC arthrodesis demonstrated moderate radiographic fusion rates, functional improvement, and an acceptable complication profile for this cohort of predominantly elderly, medically complex patients.

Summary: Bone defects are among the most challenging problems treated by limb reconstruction surgeons and orthopaedic traumatologists. Bone transport is a biological reconstruction technique which harnesses distraction osteogenesis to create new bone in critical bone defect. This technique has been successfully performed with a variety of internal and external solutions. This work introduces a newly available technology which provides a fully implantable, all-internal solution (eg, without the need for external fixation) for bone transport with the option to simultaneously address residual limb length discrepancy.

Objective: Determine if automated struts can successfully power a balanced cable transport (BCT) during tibial bone transport and thus benefit from the advantages of automation. Design: Retrospective observational case series. Setting: Level 1 trauma center. Patients/Participants: A retrospective analysis of 7 tibial BCTs using automated struts was performed with an average defect size of 102 mm. Outcomes: Union rate, complications, external fixation index, bone healing index, and mechanical alignment. Results: The average bone healing index was found to be 21.9 days/cm in bifocal BCT and 13.7 days/cm in trifocal BCT. Automated struts successfully powered 7 BCTs but were not without complications. Four patients had strut malfunctions necessitating unscheduled return to clinic. Other complications not secondary to the struts included pin tract infections (n = 4) and unplanned return to the operating room (n = 2, docking site nonunion and revision ankle arthrodesis). Conclusions: Automated struts powering BCT is feasible but not without complications. This treatment strategy combines the advantages of automation with the advantages of BCT. Incorporating automation into these complex constructs will allow for ease of use for patient and caregiver during the long process of bone transport, theoretically decrease noncompliance, which otherwise can cause severe complications, and increased segmentation, which may improve quality of regenerate bone formation. Level of Evidence: Level 4.

Background/Objectives: Streptococcus intermedius, a member of the Streptococcus anginosus group, is characterized by a marked propensity for abscess formation but only rarely causes native-joint septic arthritis. Involvement of the acromioclavicular (AC) joint is particularly uncommon. We describe a case of native AC joint septic arthritis due to S. intermedius in a patient with multiple predisposing factors and highlight diagnostic and management considerations. Methods: We report the clinical course of a 72-year-old man with poorly controlled type 2 diabetes mellitus who presented with progressive right shoulder pain, erythema, and swelling following recurrent minor skin abrasions from a newly adopted dog. Initial management for presumed inflammatory shoulder pathology included brief systemic corticosteroids and an ultrasound-guided intra-articular ketorolac injection. Magnetic resonance imaging (MRI) was performed after symptom progression. The patient underwent operative irrigation and debridement with collection of synovial fluid and deep tissue cultures. Blood cultures and transthoracic echocardiography were obtained to evaluate for systemic involvement. Results: MRI demonstrated multiloculated periarticular abscesses and osteolysis centered on the AC joint. Operative cultures yielded high colony counts of S. intermedius from synovial fluid and deep tissues. Blood cultures and echocardiography were negative. The patient required multiple operative debridements with irrigation, adjunctive local antibiotic therapy, and prolonged targeted β-lactam treatment. Clinical and radiographic improvement was achieved following surgical source control and antimicrobial therapy. Conclusions: Native AC joint septic arthritis due to S. intermedius is rare. Older age, uncontrolled diabetes, recent intra-articular intervention, and possible zoonotic inoculation from canine wound licking may represent contributory risk factors. Early imaging, prompt surgical source control, and guideline-concordant antimicrobial therapy are essential when bone and soft tissue involvement is present.

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.

Despite the high union rate of femoral shaft fractures treated with intramedullary nailing (90% to 100%), the annual incidence of femoral shaft nonunion ranges from 2% to 6%. Although less common than tibial nonunions, femoral shaft nonunions remain a clinical problem in orthopaedic surgery. Proper treatment begins with appropriate diagnosis, workup, and identification of risk factors followed by a multidisciplinary approach to treatment. This article provides current evidence-based guidance for providers on the diagnosis and management of femoral shaft nonunions.

Case: A 42-year-old African-American woman sustained a type IIIA open pilon fracture requiring open reduction internal fixation complicated by wound dehiscence. Acute shortening for primary wound closure was performed followed by relengthening in a circular frame. Owing to the patient's intolerance to the circular frame, pre-existing osseous deformity, large body habitus, and soft tissue compromise, conversion to intramedullary stabilization with standard nailing was deemed exceedingly difficult. We describe the use of a photodynamic bone stabilization system allowing for percutaneous entry and implant flexibility for the purpose of early circular frame removal. Conclusion: This case demonstrates successful protection of immature regenerate using a photodynamic bone stabilization system, offering another tool to minimize time spent in a circular frame.

This article describes a technical trick for obtaining appropriate imaging of the anterior column of the acetabulum when in the lateral decubitus position. Surgical fixation of acetabular fractures can be done in the supine, prone, or lateral decubitus position or a combination of these can be done depending on the fracture type, body habitus, and surgeon preference. Imaging of osseous corridors in the supine and prone positions have been well described, but imaging in the lateral position can be more difficult due to limitations in C-arm positioning. This article provides technical guidance for obtaining accurate orthogonal anterior column radiographs while in the lateral decubitus position.

The tibia is the most common long bone at risk for nonunion with an annual incidence ranging from 12% to 19%. This topic continues to be an area of research as management techniques constantly evolve. A foundational knowledge of the fundamental concepts, etiology, and risk factors for nonunions is crucial for success. Treatment of tibial shaft nonunions often requires a multidisciplinary effort. This article provides guidance based on the most recent literature that can be used to aid the treating provider in the diagnosis, workup, and management of tibial shaft nonunions.

Purpose Chondrosarcomas are common primary bone tumours in adults, often affecting the flat bones. Oncologic outcomes are often tied to tumour grade; however, grade is only a factor in the aggressiveness of a tumor. Extracompartmental extension, or tumor stage, has been found to be predictive of a poor outcome in other flat bone chondrosarcomas; however, this relationship has not been identified in the scapula. The purpose of the current study was to analyze the impact of tumour stage on the outcome of patients with scapular chondrosarcoma. Methods Thirty-nine patients (26 males:13 females) with a mean age of 46 ± 17 undergoing surgical resection of a scapular chondrosarcomas were reviewed. Most patients had grade 1 (n = 24) tumors, with 26 (67%) having extracompartmental extension. The mean follow-up was eight years. Results The ten year disease-specific survival was 77%. High-grade tumours (HR 18.15, p < 0.01) were associated with death due to disease. The ten year local recurrence- and metastatic-free survival were 77% and 74%. Positive surgical margins (HR 8.85, p < 0.01) were associated with local recurrence, and local recurrence was associated with metastatic disease (HR3.37, p = 0.04). All disease recurrences and death due to disease occurred in patients with extracompartmental extension (p < 0.05). Conclusion Extracompartmental extension was associated with a worse oncologic outcome in patients with scapular chondrosarcomas. Positive margins were associated with local recurrence, which was associated with metastatic disease; wide local excision with negative margins should be a goal for all patients, regardless of tumour grade.