Total Humeral Endoprosthetic Reconstruction: A Systematic Review.

BACKGROUND: Total humeral endoprosthetic reconstruction (THER) is a rare reconstruction option for limb salvage surgery for large humeral neoplasms or bone destruction. MATERIALS AND METHODS: Because of the limited data and need for this procedure, we reviewed the literature surrounding THER and assessed functionality, complications, and revisions using the PubMed, Embase, Ovid, and Scopus databases. RESULTS: Among 29 articles and 175 patients, the most common indication was neoplasm (n=25, 86%), mean follow-up was 61.98 months (SD=55.25 months), and mean Musculoskeletal Tumor Society score was 73.64% (SD=10.69%). Reported complications included 26 (23%) revisions in 7 studies, 35 (36%) cases of shoulder instability in 7 studies, and 13 (13.54%) cases of deep infection in 4 studies. CONCLUSION: THER should be considered with a thorough knowledge of outcomes and potential complications to guide patient and clinician expectations. [Orthopedics. 2024;47(3):e106-e113.].

Intramedullary brachytherapy for the treatment of long bone metastatic disease: A case report.

Case: A 56-year-old woman with metastatic melanoma and femoral lesions with impending pathologic fracture was indicated for intramedullary brachytherapy (IMBT) and intramedullary nail. Conclusions: IMBT + intramedullary nail is a new technique for the treatment of long bone metastases. IMBT maximizes radiation to the tumor and minimizes radiation to surrounding tissues. It allows the patient to resume systemic treatment expediently. Our cadaver model and patient were both treated for femoral metastases; however, this technique allows for the treatment of any long bone. This is a safe technique that minimizes treatment time compared with other standard radiation regimens.

Emerging Minimally Invasive Percutaneous Procedures for Periacetabular Osteolytic Metastases.

➤: Periacetabular osteolytic skeletal metastases are frequently associated with pain and impaired ambulatory function. Minimally invasive techniques allow for the restoration of ambulation without interrupting critical systemic cancer therapy. ➤: The open surgical management of massive periacetabular osteolytic lesions, such as by curettage, internal fixation, or complex total hip reconstruction, is associated with blood loss, hospitalization, rehabilitation, and complications such as infection or delayed wound-healing. ➤: Minimally invasive percutaneous procedures have become increasingly popular for the management of periacetabular osteolytic metastases by interventional oncologists and orthopaedic surgeons before complex open surgical procedures are considered. ➤: Minimally invasive procedures may include various methods of cancer ablation and reinforcement techniques. Minimally invasive procedures may entail cancer ablation, polymethylmethacrylate (PMMA) cement reinforcement, balloon osteoplasty, percutaneous screw fixation, or combinations of the aforementioned techniques (e.g., ablation-osteoplasty-reinforcement-internal fixation [AORIF]).

Case Report of Fibro-Adipose Vascular Anomaly (FAVA) with Activating Somatic PIK3CA Mutation.

Fibro-adipose vascular anomaly (FAVA) is a recently described complex and painful benign lesion found in young adults and the pediatric population composed of intramuscular vascular, fibrous, and adipose tissues. A previous report has identified the presence of somatic mosaic mutations in the gene for the catalytic subunit of phosphatidylinositol 3-kinase (PIK3CA) in cases of FAVA. Herein, we present a case of FAVA found in a 23-year-old male patient who presented with chronic wrist pain associated with a mass, and we identified an associated somatic activating mutation (H1047R) in PIK3CA. We briefly review the relevant literature surrounding the identification and histology of FAVA, the known mutational spectrum, downstream signaling pathways, and relevant treatment modalities. Our case highlights the association between FAVA and somatic mosaic activating PIK3CA mutations.

Multiparametric Evaluation of Soft Tissue Sarcoma: Current Perspectives and Future Directions.

Imaging plays an essential role in diagnosing and managing musculoskeletal soft tissue masses. It provides anatomic details and aids in the characterization and prognostication of tumors. Advanced imaging is also essential for assessing treatment response and post-treatment surveillance. Several novel imaging techniques are now available that provide additional functional and metabolic information about these tumors. This additional information may be used to predict the biological behavior of the tumors and effectively assess the treatment response for optimizing their management. This article focuses on multiparametric imaging evaluation of soft tissue masses with a discussion of advancements in the domains of ultrasound, MRI, and CT imaging and how these may be helpful in pre- and post-treatment assessment of soft tissue tumors. Current perspectives on the role of diffusion imaging, perfusion imaging, and MR spectroscopy have been highlighted, and future directions of metabolic imaging are briefly outlined. As these advances hold a promising role in the multidisciplinary management of soft tissue sarcomas, it is important for the radiologist to be familiar with the latest advances and developments in imaging soft tissue tumors.

Fever and Systemic Inflammatory Response Syndrome After Wide Resection of Pediatric Bone Sarcomas.

BACKGROUND: While postoperative fever is common and thought to be physiological, data is limited in pediatric patients with bone sarcomas. Understanding the predictive value of postoperative fever and systemic inflammatory response syndrome (SIRS) in this population is essential to guide further workup and avoid delays in adjuvant therapy. The aim of this study is to characterize the prevalence of postoperative fever and SIRS in pediatric patients undergoing wide resection of bone sarcomas and to determine whether these signs are associated with wound or infectious complications. METHODS: A retrospective chart review of cases performed by a single surgeon between January 2018 and December 2020 was performed. RESULTS: Twenty-two patients were identified. All patients had pathology-confirmed diagnoses of osteosarcoma (77.3%) or Ewing sarcoma (22.7%). Before discharge, 68.2% developed a fever >38°C and 90.9% met SIRS criteria. The rate of wound and infectious complications during the first 6 weeks after surgery was 27.3%. The positive predictive values (PPV) of fever and SIRS were low at 26.7% and 31.0% respectively. No association between complications and fever [dds ratio (OR): 0.91, 95% confidence interval (CI): 0.12-6.72] or SIRS (OR: 2.24, 95% CI: 0.78-46.14) was identified. High fever >39°C had a better PPV of 50.0%. However, the association between high fever and complications did not reach significance (OR: 6.00, 95% CI: 0.78-46.14). Age, tumor size, days from chemo to surgery, duration of surgery, estimated blood loss, number of packed red blood cells units transfused, and length of stay were not associated with the development of postoperative fever or complications. CONCLUSION: Pediatric patients undergoing wide resection of bone sarcomas frequently mount a robust SIRS response after surgery. However, fever and SIRS are both poor predictors of infection and wound complications. Patients with postoperative fever or SIRS should not undergo an extensive infectious workup unless there are clear signs or symptoms to suggest an infectious etiology. LEVEL OF EVIDENCE: Level II-prognostic retrospective study.

Osseous Tumor Reporting and Data System-Multireader Validation Study.

OBJECTIVE: To develop and validate an Osseous Tumor Reporting and Data System (OT-RADS) with the hypothesis that the proposed guideline is reliable and assists in separating benign from malignant osseous tumors with a good area under the curve, and that could assist further patient management. METHODS: In this multireader cross-sectional validation study, an agreement was reached for OT-RADS categories based on previously described magnetic resonance imaging features and consensus of expert musculoskeletal radiologists. World Health Organization classification was used, and a wide spectrum of benign and malignant osseous tumors was evaluated. Magnetic resonance imaging categories were as follows: OT-RADS 0-incomplete imaging; OT-RADS I-negative; OT-RADS II-definitely benign; OT-RADS III-probably benign; OT-RADS IV-suspicious for malignancy or indeterminate; OT-RADS V-highly suggestive of malignancy; and OT-RADS VI-known biopsy-proven malignancy or recurrent malignancy in the tumor bed. Four blinded readers categorized each tumor according to OT-RADS classification. Intraclass correlation (ICC) and Conger κ were used. Diagnostic performance measures including area under the receiver operating curve were reported. Osseous Tumor Reporting and Data System was dichotomized as benign (I-III) and malignant (IV and V) for calculating sensitivity and specificity. RESULTS: Interreader agreement for OT-RADS (ICC = 0.78) and binary distinction of benign versus malignant (κ = 0.67) were good to excellent, while agreement for individual tumor feature characteristics were poor to fair (ICC = 0.25-0.36; κ = 0.16-0.39). The sensitivities, specificities, and area under the receiver operating curve of the readers ranged from 0.93-1.0, 0.71-0.86, and 0.92-0.97, respectively. CONCLUSIONS: Osseous Tumor Reporting and Data System lexicon is reliable and helps stratify tumors into benign and malignant categories. It can be practically used by radiologists to guide patient management, improve multidisciplinary communications, and potentially impact outcomes.

Combined immune checkpoint blockade and radiotherapy induces durable remission in relapsed natural killer/T-cell lymphoma: a case report and review of the literature.

BACKGROUND: Extranodal natural killer/T-cell lymphoma is a rare, aggressive non-Hodgkin lymphoma that is treated upfront mostly with L-asparaginase containing regimens. Relapsed extranodal natural killer/T-cell lymphoma is associated with a poor prognosis, and there is no established standard of care. CASE PRESENTATION: We report the case of a 72 year-old white male with a distant extranasal relapse of extranodal natural killer/T-cell lymphoma that has been managed successfully with a combination of radiation and immune checkpoint blockade with pembrolizumab. Pseudoprogression with new skin and bone lesions on positron emission tomography imaging was encountered during this Caucasian patient's immunotherapy and was successfully managed with supportive care and continuation of immune checkpoint blockade. CONCLUSIONS: The patient has been in complete clinical, radiologic, and molecular remission for close to 3 years and has not had any immune-related adverse effects. Pseudoprogression is a clinical challenge that can be encountered while patients are treated with immunotherapy, and astute clinical acumen is needed for accurate management. We believe this is the longest duration of response to immune checkpoint blockade in relapsed extranodal natural killer/T-cell lymphoma reported to date in literature. There is a strong biologic rationale in combining radiation with immunotherapy. The optimal timing, dose, and duration of radiation combined with immunotherapy in extranodal natural killer/T-cell lymphoma need to be prospectively evaluated.

Thirty-day Outcomes After Surgery for Metastatic Bone Disease of the Extremities: An Analysis of the NSQIP Database.

INTRODUCTION: Metastatic bone disease of the extremities is a notable cause of morbidity and mortality. Surgical management is not curative; therefore, risks and benefits of surgery must be carefully considered. Previous studies of surgical outcomes are limited by small sample sizes because of the rare incidence of these procedures. In this study, we aim to describe the rates of complications and mortality in the first 30 days after surgical treatment of metastatic bone disease of the femur and humerus. METHODS: A retrospective review of patients in the National Surgical Quality Improvement Program database who underwent surgery between 2005 and 2016 was performed. Demographics, comorbidities, preoperative factors, surgical parameters, and postoperative complications were extracted. The cohort was also partitioned by surgical site and surgical modality. RESULTS: One thousand one hundred fifty-four patients were identified, 13.1 percent of patients experienced one or more complications within 30 days of surgery. The most common complications were urinary tract infection (2.9%), deep vein thrombosis (2.5%), pneumonia (2.4%), pulmonary embolism (2.0%), and surgical site infections (1.9%). In addition, intraoperative or postoperative bleeding requiring transfusion occurred in 32.9% of cases. The rates of unplanned readmission and unplanned revision surgery were 12.7% and 4.1%, respectively. The 30-day mortality rate was 7.1%. Femur and arthroplasty cases were associated with a higher risk of bleeding requiring transfusion. Prophylactic stabilization was associated with a lower risk of unplanned revision surgery (P = 0.015) and a lower overall complication rate (P < 0.0001). CONCLUSION: Our study demonstrates a higher 30-day mortality rate than previously reported. In additon, prophylactic stabilization of impending pathologic fractures may be associated with a lower risk of complications and unplanned revision surgery. The National Surgical Quality Improvement Program or other large database reports can help surgeons counsel patients appropriately regarding the risks and benefits of surgery.

Thirty-Day Outcomes after Surgery for Primary Sarcomas of the Extremities: An Analysis of the NSQIP Database.

BACKGROUND: Primary bone and soft tissue sarcomas are rare tumors requiring wide surgical resection and reconstruction to achieve local control. Postoperative complications can lead to delays in adjuvant therapy, potentially affecting long-term oncologic outcomes. Understanding postoperative complication risks is essential; however, past studies are limited by small sample sizes. PURPOSE: This study uses a large national registry to characterize the incidence of complications and mortality in the first thirty days following surgical management of primary bone and soft tissue sarcomas of the extremities. METHODS: A retrospective review of patients in the National Surgical Quality Improvement Program database was performed. Cases were identified using diagnosis codes for malignant neoplasm of soft tissue or bone and procedure codes for amputation and radical resection. The cohort was subdivided by bone versus soft tissue sarcoma, upper versus lower extremity, and amputation versus limb salvage. RESULTS: One thousand, one hundred eleven patients were identified. The most frequent complications were surgical site infections, sepsis, and venous thromboembolism. The overall incidence of complications was 14.0%. Unplanned readmission and reoperation occurred after 7.0% and 8.0% of cases, respectively. Thirty-day mortality was 0.3%, with one intraoperative death. Patient factors and complication rates varied by tumor location and surgical modality. Lower extremity cases were associated with higher rates of wound complications and infectious etiologies such as surgical site infections, urinary tract infections, and systemic sepsis. In contrast, patients undergoing amputation were more likely to experience major medical complications including acute renal failure, cardiac arrest, and myocardial infarction. CONCLUSION: Approximately 1 in 7 patients will experience a complication in the first thirty days following surgery for primary bone and soft tissue sarcomas of the extremities. The unique risk profiles of lower extremity and amputation cases should be considered during perioperative planning and surveillance.

Thirty-Day Outcomes following Pediatric Bone and Soft Tissue Sarcoma Surgery: A NSQIP Pediatrics Analysis.

BACKGROUND: Pediatric bone and soft tissue sarcomas are rare; therefore, national registries are essential tools for orthopedic oncology research. Past studies provide excellent data on long-term prognosis and survival trends but fail to examine treatment-specific morbidity. The aim of this study is to use a national registry to describe patient demographics, comorbidities, and adverse events in the first thirty days following surgical management of pediatric bone and soft tissue sarcomas. METHODS: A retrospective review of patients in the American College of Surgeons National Surgical Quality Improvement Program-Pediatrics database (NSQIP-P) was performed. The cohort was partitioned by tumor origin (bone versus soft tissue) and tumor location (axial versus appendicular). RESULTS: One-hundred ninety-two patients were identified. Bone sarcomas were more common (71.9%) and predominately appendicular (62.3%), while soft tissue sarcomas were predominately axial (77.8%). The overall complication rate was 8.9%. The most frequent etiologies were wound dehiscence (3.6%) and infectious complications such as surgical site infections (2.6%), pneumonia (1.6%), urinary tract infections (1.6%), and C. diff colitis (1.0%). Twenty-four percent of patients experienced bleeding requiring transfusion. The unplanned readmission rate was 12.5% (3.6% related to principle procedure), and the unplanned reoperation rate was 4.7% (4.2% related to principle procedure). The mortality rate was 1.0%. Neoadjuvant chemotherapy was associated with higher rates of wound dehiscence and infectious complications. There were no differences in adverse events with respect to tumor origin or location. CONCLUSION: Approximately 1 in 11 pediatric patients will experience a complication in the first thirty days following surgery. However, perioperative mortality remains low. This study represents the first comprehensive review of pediatric bone and soft tissue sarcoma surgery in the NSQIP-P database. As the case volume of NSQIP-P continues to grow, NSQIP-P has the potential to become a powerful tool for pediatric orthopedic oncology research.

Total Tibial Allograft Reconstruction for Adamantinoma: A Case Report With 2-Year Follow-up.

CASE: A 47-year-old woman with adamantinoma of the entire left tibia and distal fibula underwent resection and reconstruction using a total tibia allograft-prosthetic composite with rotating hinged knee replacement and ankle fusion. She is ambulating without tumor recurrence with 2-year follow-up. CONCLUSION: This case report offers a unique reconstruction option for extensive tibia bone primary malignancy. To our knowledge, this is the longest survival for total tibia allograft prosthetic composite reconstruction.

Over-utilization of computed tomography angiography in extremity trauma.

OBJECTIVES: Widespread availability of computed tomography angiography (CTA) for diagnosing arterial injury in injured extremities has created the possibility of overuse. The objective of this study was to evaluate CTA utilization, indications, ordering personnel, and rate of significant findings for blunt or penetrating extremity trauma at a level I trauma center. METHODS: We performed a retrospective chart review of 1440 consecutive CTAs of upper and lower extremities from 2010 to 2012 at a large level I trauma center, and included only those done for acute trauma. Data were collected with regard to injury, initial exam, reason given for ordering a CTA, specialty of physician ordering CTA, results, and vascular interventions needed. CTAs were categorized as appropriately ordered based on if there was a documented abnormal distal pulse or ankle-brachial index (ABI). Study indication was classified as inconclusive if no vascular exam was documented or physical exam varied. RESULTS: A total of 481 CTAs were performed after blunt or penetrating trauma in the emergency room with 31.0% appropriately indicated, 48.0% without indication, and 21.8% inconclusive. Mechanism of injury was most commonly a gunshot wound (40.3%), followed by motor vehicle accidents (39.5%). Overall, 61.5% of the studies had normal arterial flow and only 15.8% of CTAs required vascular operative intervention. Of the studies appropriately indicated, 76.5% had positive findings, with 43% needing operative intervention compared to the inappropriately indicated studies only 11.6% had positive findings, with 0.4% needing operative intervention (P < .0001). CONCLUSION: CTA for blunt or penetrating trauma at a level I trauma center may be over-utilized. Often, this advanced imaging is ordered prior to orthopaedic evaluation or limb reduction, without exam-based indication, and most do not affect patients' treatment. From our study, CTA utilization based on more stringent exam findings at our hospital could eliminate 48% of all CTA studies for trauma.

Conventional MR and diffusion-weighted imaging of musculoskeletal soft tissue malignancy: correlation with histologic grading.

AIM: To evaluate proven soft tissue musculoskeletal malignancies blinded to their Fédération Nationale des Centres de Lutte Contre le Cancer histologic grades to identify the predictive values of conventional MR findings and best fit region of interest (ROI) apparent diffusion coefficient (ADC) measurements. MATERIALS AND METHODS: Fifty-one consecutive patients with different histologic grades were evaluated by four readers (R1-4) of different experience levels. Quantitatively, the maximum longitudinal size, tumor to muscle signal intensity ratios, and ADC measurements and, qualitatively, the spatial location of the tumor, its signal alterations, heterogeneity, intralesional hemorrhage or fat, and types of enhancement were assessed. Intraclass correlation, weighted kappa, ANOVA, and Fisher exact tests were used. RESULTS: There were 22/51 (43%) men (mean age ± SD = 52 ± 16 years) and 29/51 (57%) women (mean age ± SD = 54± 17 years), with the majority of tumors 38/51 (75%) in the lower extremities. Histologic grades were I in 8/51 (16%), II in 17/51 (33%), and III in 26/51 (51%), respectively. The longitudinal dimensions were different among three grades (p = 0.0015), largest with grade I. More central enhancements and deep locations were seen in grade III tumors (p = 0.0191, 0.0246). The ADC mean was significantly lower in grade III than in grade I or II (p < 0.0001 and p = 0.04). The ADC min was significantly lower in grade III than in grade I (p = 0.02). Good to excellent agreements were seen for T1/T2 tumor/muscle ratios, longitudinal dimension, and ADC (ICC = 0.60-0.98). CONCLUSION: Longitudinal tumor dimension, central enhancement, and ADC values differentiate histology grades in musculoskeletal soft tissue malignancy with good to excellent inter-reader reliability. KEY POINTS: • The longitudinal tumor dimension of grade III malignancy is smaller than that of grade I (p < 0.0001), and higher-grade tumors are located deeper (p = 0.0246). • The ADC mean is significantly lower in grade III than in grade I or grade II (p < 0.0001 and p = 0.04). • The ADC minimum is significantly lower in grade III than in grade I (p = 0.02).

Deep Spine Infection After Acupuncture in the Setting of Spinal Instrumentation.

BACKGROUND: Acupuncture can be used to manage chronic pain. The most common complications related to acupuncture include pain, bruising, bleeding, or symptom exacerbation. Rarely, more serious adverse events occur, including infection, pneumothorax, septic arthritis, and peripheral nerve injury. To our knowledge, there are no reports of complications associated with acupuncture following spinal instrumentation. PURPOSE: To report a case of deep infection as a rare complication of acupuncture following posterior spinal fusion for adolescent idiopathic scoliosis. STUDY DESIGN: Case report. METHODS: Case report. RESULTS: A 15-year-old female presented 21 months after spinal arthrodesis for idiopathic scoliosis with a deep spine infection. The patient had recently been receiving a variation of acupuncture (dry needling therapy) in her medial periscapular region to manage chronic back and shoulder pain. She underwent serial irrigation and debridement with implant removal. Intraoperative cultures revealed pseudomonas and aerobic diptheroids. Two weeks later, the patient developed a periscapular abscess requiring additional operative debridement; cultures from this abscess were negative. After an 8-week course of antibiotics, the patient remains infection free with normalized inflammatory markers 2 years postoperatively. CONCLUSIONS: Acupuncture is sometimes pursued as part of a multimodality pain management program for back pain, but it is not without risk and can lead to infection. Deep infection from acupuncture may contaminate existing spinal instrumentation and require operative debridement, implant removal, and long-term antibiotic therapy. Accordingly, there is an increased risk for deformity progression in this scenario related to the implant removal.

Length-Preserving Intramedullary Femoral Fixation for Traumatic Leg Amputation.

CASE: We present the case of a twenty-one-year-old woman with a traumatic left leg amputation, substantial proximal skin degloving, and an ipsilateral femoral fracture treated with revision amputation distal to the fracture site and retrograde femoral nailing through the amputation site. CONCLUSION: A short retrograde femoral nail is a surgical option to fix a femoral shaft fracture proximal to a traumatic amputation in order to preserve limb length for effective prosthetic fit and ambulation.

Length-Preserving Intramedullary Femoral Fixation for Traumatic Leg Amputation: A Case Report.

CASE: We present the case of a twenty-one-year-old woman with a traumatic left leg amputation, substantial proximal skin degloving, and an ipsilateral femoral fracture treated with revision amputation distal to the fracture site and retrograde femoral nailing through the amputation site. CONCLUSION: A short retrograde femoral nail is a surgical option to fix a femoral shaft fracture proximal to a traumatic amputation in order to preserve limb length for effective prosthetic fit and ambulation.

On-Call Communication in Orthopaedic Trauma: "A Picture Is Worth a Thousand Words"--A Survey of OTA Members.

OBJECTIVES: To quantify the effects of varying clinical communication styles (verbal and pictorial) on the ability of orthopaedic trauma surgeons in understanding an injury and formulate an initial management plan. METHODS: A Research Electronic Data Capture survey was e-mailed to all OTA members. Respondents quantified (5-point Likert scale) how confident they felt understanding an injury and establishing an initial management plan based on the information provided for 5 common orthopaedic trauma scenarios. Three verbal descriptions were created for each scenario and categorized as limited, moderate, or detailed. The questions were repeated with the addition of a radiographic image and then repeated a third time including a clinical photograph. Statistical evaluation consisted of descriptive statistics and Kruskal-Wallis analyses using STATA (version 12.0). RESULTS: Of the 221 respondents, there were a total of 95 who completed the entire survey. Nearly all were currently taking call (92/95 = 96.8%) and the majority were fellowship trained (79/95 = 83.2%). Most practice at a level I trauma center (58/95 = 61.1%) and work with orthopaedic residents (62/95 = 65.3%). There was a significant increase in confidence scores between a limited, moderate, and detailed description in all clinical scenarios for understanding the injury and establishing an initial management plan (P < 0.05). There was a significant difference in confidence scores between all 3 types of evidence presented (verbal, verbal + x-ray, verbal + x-ray + photograph) in both understanding and managing the injury for limited and moderate descriptions (P < 0.001). No differences were seen when adding pictorial information to the detailed verbal description. When comparing confidence scores between a detailed description without images and a limited description that includes radiographs and a photograph, no difference in confidence levels was seen in 7 of the 10 scenarios (P > 0.05). CONCLUSIONS: The addition of images in the form of radiographs and/or clinical photographs greatly improves the confidence of orthopaedic trauma surgeons in understanding injuries and establishing initial management plans with limited verbal information (P < 0.001). The inclusion of x-rays and photographs raises the confidence for understanding and management with limited verbal information to the level of a detailed verbal description in most scenarios. Mobile technology allows for easy secure transfer of images that can make up for the lack of available information from limited verbal descriptions because of the knowledge base of communicating providers.