Is a Cephalomedullary Nail Durable Treatment for Patients With Metastatic Peritrochanteric Disease?

BACKGROUND: Although cephalomedullary nail fixation is often used for metastatic peritrochanteric lesions of the femur, there is concern regarding the durability of the implant in comparison to endoprosthetic reconstruction. Previous studies have reported the proportion of patients who undergo reoperation for loss of stability, but the adequacy of the construct has not been critically evaluated in a competing risk analysis that incorporates death of the patient in the calculation. QUESTIONS/PURPOSES: (1) What is the cumulative incidence of reoperation of cephalomedullary nails with death as a competing risk for metastatic lesions of the proximal femur? (2) What is the survival of patients with metastases to the proximal femur after cephalomedullary nailing? (3) What clinical factors are associated with implant stability in these patients? METHODS: Between 1990 and 2009, 11 surgeons at one center treated 217 patients with cephalomedullary nails for metastatic proximal femoral lesions. This represented 40% (217 of 544) of the patients undergoing surgery for metastases in this location during the study period. In general, we used cephalomedullary nails when there was normal bone in the femoral head, no fracture in the neck, and a moderate-sized lesion; we favored bipolar hemiarthroplasty for femoral neck fractures and disease affecting the femoral head; finally, we used proximal femoral endoprosthetic replacement for large lesions with severe bone destruction. A retrospective study was conducted of 199 patients with cephalomedullary nails for peritrochanteric metastases from 1990 to 2009. Pathologic fracture, defined as a breach in cortex with a clear fracture line either with or without displacement, was present in 61 patients. The most common primary cancers were breast (42 of 199 patients [21%]), lung (37 of 199 patients [18%]), and renal cell (34 of 199 patients [17%]). A competing risk analysis was performed to describe the cumulative incidence of implant revision. Patient overall survival was assessed by Kaplan-Meier survivorship. A univariate analysis was performed to determine whether there was an association between revision surgery and various patient factors, including tumor histology, pathologic fracture, cementation, and radiation. RESULTS: Loss of implant stability necessitating revision surgery occurred in 19 of 199 patients (10%). In a competing risk analysis with death of the patient as the competing event, the cumulative incidence of revision surgery was 5% (95% confidence interval [CI], 3%-9%) at 12 months and 9% (95% CI, 5%-13%) at 5 years. Using Kaplan-Meier analysis, the overall patient survival was 31% (95% CI, 25%-37%) at 12 months and 5% (95% CI, 3%-9%) at 60 months. Patients with lung cancer had the shortest overall survival of 11% (95% CI, 1%-21%) at 12 months, and patients with multiple myeloma had the longest overall survival of 71% (95% CI, 49%-94%) at 12 months (p < 0.001). Duration of patient survival beyond the median 7 months was the only factor associated with a greater likelihood of revision surgery. Factors not associated with revision included tumor histology, pathologic fracture, closed versus open nailing, cementation, gender, age, and postoperative radiation. CONCLUSIONS: The competing risk analysis demonstrates a relatively low cumulative incidence of reoperation and suggests that cephalomedullary nailing is reasonable for patients with moderate-sized proximal femoral metastasis not affecting the femoral head. For the large majority of patients, the construct achieves the goal of stabilizing the femur for the duration of the patient's life. Longer patient survival was associated with greater risk of revision surgery, but no particular tumor histology was found to have a greater cumulative incidence of reoperation. Future work with a larger number of patients and stricter surgical indications may be needed to corroborate these findings. LEVEL OF EVIDENCE: Level III, therapeutic study.

Consideration for Limb Salvage in Place of Amputation in Complex Tibial Fracture With Neurovascular Injury: A Case Report.

High-energy tibial fractures often present with associated soft tissue injuries, including neuro-vascular damage, complicating the treatment decision. A 33-year-old male presented with Gustilo Anderson type IIIA fracture of the left distal tibia and fibula with associated closed calcaneus fracture and tibial nerve transection. Amputation was discussed, but the decision was made for limb salvage with nerve allograft. The patient displayed satisfactory functional recovery at 29 months postoperatively without need for major revision, grafting, arthrodesis, or amputation. This case report provides an example of successful limb salvage utilizing tibial nerve allograft in a complex high-energy lower extremity injury. Level of Evidence: IV.

Use of the Pediatric Outcomes Data Collection Instrument to evaluate functional outcomes in arthrogryposis.

BACKGROUND: The Pediatric Outcomes Data Collection Instrument (PODCI) is a subjective measurement tool designed to provide a standardized method of assessing outcomes in pediatric musculoskeletal conditions. It has earlier been shown to be useful in several pediatric musculoskeletal conditions, but there is currently no widely accepted subjective outcome measurement tool for children with arthrogryposis. METHODS: The PODCI was administered to parents of 74 children diagnosed with amyoplasia. The score distributions were compared with values published earlier for children without musculoskeletal disorders. For those patients with repeated PODCI administrations over time, the initial score was compared with the most recent score. Comparisons were made using the Student t test. RESULTS: PODCI scores in children with amyoplasia were significantly lower than those for typically developing children in all 6 domains. The scores were also more normally distributed than those for typically developing children in all 6 domains. Over an average follow-up period of approximately 3 years, children with amyoplasia had a statistically significant increase in scores for upper extremity function, sports participation, and global functioning. CONCLUSIONS: These results show that the PODCI is useful in evaluating functional outcomes of children with amyoplasia, and is sensitive to change in function over time. The PODCI shows promise as a tool to evaluate long-term outcomes of surgical management in amyoplasia. LEVEL OF EVIDENCE: Diagnostic Study, Level III.

Leveraging Scarce Resources With Bone Health TeleECHO to Improve the Care of Osteoporosis.

Osteoporosis is a common condition with serious consequences because of fractures. Despite availability of treatments to reduce fracture risk, there is a large osteoporosis treatment gap that has reached crisis proportions. There are too few specialists to provide services for patients who need them. Bone Health Extension for Community Health Care Outcomes (TeleECHO) is a strategy using real-time ongoing videoconferencing technology to mentor health care professionals in rural and underserved communities to achieve an advanced level of knowledge for the care of patients with skeletal diseases. Over the first 21 months of weekly Bone Health TeleECHO programs, there were 263 registered health care professionals in the United States and several other countries, with 221 attending at least 1 online clinic and typically 35 to 40 attendees at each session at the end of the reported period. Assessment of self-confidence in 20 domains of osteoporosis care showed substantial improvement with the ECHO intervention (P = 0.005). Bone Health TeleECHO can contribute to mitigating the crisis in osteoporosis care by leveraging scarce resources, providing motivated practitioners with skills to provide better skeletal health care, closer to home, with greater convenience, and lower cost than referral to a specialty center. Bone Health TeleECHO can be replicated in any location worldwide to reach anyone with Internet access, allowing access in local time zones and languages. The ECHO model of learning can be applied to other aspects of bone care, including the education of fracture liaison service coordinators, residents and fellows, and physicians with an interest in rare bone diseases.

Bone Health ECHO: telementoring to improve osteoporosis care.

Extension for Community Healthcare Outcomes creates knowledge networks that enable a transition from centralized specialty care at academic institutions to empowerment of primary care providers to provide more highly skilled care closer to home.

Chondroblastoma of the knee treated with resection and osteochondral allograft reconstruction.

Case. This case report describes the operative management of 16-year-old male with a symptomatic chondroblastoma of the distal femur with breach of the chondral surface. Following appropriate imaging and core needle biopsy, the diagnosis was confirmed histologically. The patient then underwent intralesional curettage and osteochondral allograft reconstruction of the defect. At one-year follow-up the patient was pain-free and has obtained excellent range of motion. There is radiographic evidence of allograft incorporation and no evidence of local recurrence. Conclusion. Osteochondral allograft reconstruction is an effective option following marginal resection and curettage of chondroblastoma involving the chondral surface of the distal femur.

Bizarre parosteal osteochondromatous proliferation: a new cytogenetic subgroup characterized by inversion of chromosome 7.

Bizarre parosteal osteochondromatous proliferation (BPOP) is a rare, benign osteocartilaginous lesion characterized by a mixture of immature bone, bland spindle cells, and irregular, hypercellular cartilage undergoing calcification. A t(1;17)(q32;q21) has been reported as a unique recurring translocation identified in seven cases. Inversion of chromosome 7, inv(7)(q22q32), has also recently been described in one case of BPOP. We report an additional case of inv(7) in a BPOP occurring on the distal radius in a 36-year-old woman who presented with a slow-growing mass on the right wrist. Metaphase karyotype analysis of fresh tissue from tumor taken at resection revealed an inv(7)(q22q32). A review of the literature identified two additional cases of inv(7) (q21.1q31.3 and q22.1q31.3), both paired with inv(6)(p25q15), bringing the total number of cases of inv(7) in BPOP to four. These data suggest inv(7) may be another characteristic cytogenetic abnormality associated with and possibly contributing to the development of BPOP.