The effect of timing between preoperative embolization and surgery: A retrospective analysis of hypervascular bone metastases.

BACKGROUND AND OBJECTIVES: The optimal timing between preoperative embolization of hypervascular metastatic bone lesions and surgery has yet to be established. Our analysis sought to evaluate embolization timing impacts blood loss, transfusion risk, and operative time in patients with hypervascular primary tumors. METHODS: We identified patients with renal cell (RCC) or thyroid carcinoma undergoing surgery between 1992 and 2023. Patients were segregated into the following cohorts: (1) no embolization preoperatively, (2) surgery <24 h of embolization, and (3) surgery >24 h after embolization. Multivariate logistic regression analyses were performed to assess the effect of embolization timing while controlling for confounding variables. RESULTS: No differences were seen in all evaluated outcomes between immediate and delayed embolization cohorts. No differences in estimated blood loss were seen between the immediate (OR: 0.685, 95% CI: 0.159-2.949; p = 0.611) and delayed (OR: 0.568, 95% CI: 0.093-3.462; p = 0.539) surgery cohorts compared with patients without embolization. Surgery >24 h after embolization was not associated with a higher risk of prolonged operative time (OR: 13.499, 95% CI: 0.832-219.146; p = 0.067). CONCLUSIONS: These findings suggest that surgery may be safely delayed beyond 24 h from embolization without a higher risk of bleeding. In appropriately selected cohorts, embolization may not be needed preoperatively.

Internal hemipelvectomy: A single institution's learning curve and longitudinal experience.

BACKGROUND AND OBJECTIVES: Wide margin resection for pelvic tumors via internal hemipelvectomy is among the most technically challenging procedures in orthopedic oncology. As such, surgeon experience and technique invariably affect patient outcomes. The aim of this clinical study was to assess how an individual surgeon's experiences and advancements in technology and techniques in the treatment of internal hemipelvectomy have impacted patient outcomes at our institution. METHODS: This study retrospectively examined a single tertiary academic institution's consecutive longitudinal experience with internal hemipelvectomy for primary sarcoma or pelvic metastases over a 26-year period between the years 1994 and 2020. Outcomes were assessed using two separate techniques. The first stratified patients into cohorts based on the date of surgery with three distinct "eras" ("early," "middle," and "modern"), which reflect the implementation of new techniques, including three-dimensional (3D) computer navigation and cutting guide technology into our clinical practice. The second method of cohort selection grouped patients based on each surgeon's case experience with internal hemipelvectomy ("inexperienced," "developing," and "experienced"). Primary endpoints included margin status, complication profiles, and long-term oncologic outcomes. Whole group multivariate analysis was used to evaluate variables predicting blood loss, operative time, tumor-free survival, and mortality. RESULTS: A total of 72 patients who underwent internal hemipelvectomy were identified. Of these patients, 24 had surgery between 1994 and 2007 (early), 28 between 2007 and 2015 (middle), and 20 between 2016 and 2020 (modern). Twenty-eight patients had surgery while the surgeon was still inexperienced, 24 while developing, and 20 when experienced. Evaluation by era demonstrated that a greater proportion of patients were indicated for surgery for oligometastatic disease in the modern era (0% vs. 14.3% vs. 35%, p = 0.022). Fewer modern cases utilized freehand resection (100% vs. 75% vs. 55%, p = 0.012), while instead opting for more frequent utilization of computer navigation (0% vs. 25% vs. 20%, p = 0.012), and customized 3D-printed cutting guides (0% vs. 0% vs. 25%, p = 0.002). Similarly, there was a decline in the rate of massive blood loss observed (72.2% vs. 30.8% vs. 35%, p = 0.016), and interdisciplinary collaboration with a general surgeon for pelvic dissection became more common (4.2% vs. 32.1% vs. 85%, p < 0.001). Local recurrence was less prevalent in patients treated in middle and modern eras (50% vs. 15.4% vs. 25%, p = 0.045). When stratifying by case experience, surgeries performed by experienced surgeons were less frequently complicated by massive blood loss (66.7% vs. 40% vs. 20%, p = 0.007) and more often involved a general surgeon for pelvic dissection (17.9% vs. 37.5% vs. 65%, p = 0.004). Whole group multivariate analysis demonstrated that the use of patient-specific instrumentation (PSI) predicted lower intraoperative blood loss (p = 0.040). However, surgeon experience had no significant effect on operative time (p = 0.125), tumor-free survival (p = 0.501), or overall patient survival (p = 0.735). CONCLUSION: While our institution continues to utilize neoadjuvant and adjuvant therapies following current guideline-based care, we have noticed changing trends from early to modern periods. With the advent of new technologies, we have seen a decline in freehand resections for hemipelvectomy procedures, and a transition to utilizing more 3D navigation and customized 3D cutting guides. Furthermore, we have employed the use of an interdisciplinary team approach more regularly for these complicated cases. Although our results do not demonstrate a significant change in perioperative outcomes over the years, our institution's willingness to treat more complex cases likely obscures the benefits of surgeon experience and recent technological advances for patient outcomes.

Radiolucent implants in orthopedic oncology.

Radiolucent implants in have demonstrated promising results for both extremity and spine oncologic procedures. However, questions persist about whether the superiority in surveillance imaging justify the increased cost and technical challenges. In this review, we present the current body of literature for the use of radiolucent implants in musculoskeletal oncology, with a focus on implant complications, including screw loosening, breakage, malposition, and loss of reduction. We also discuss clinical outcomes, technical considerations, and postoperative radiotherapy.

Comparison of Reconstruction Techniques Following Sacroiliac Tumor Resection: A Systematic Review.

BACKGROUND: Although internal hemipelvectomies with sacroiliac resections are not traditionally reconstructed, surgeons are increasingly pursuing pelvic ring reconstruction to theoretically improve stability, function, and early ambulation. This study aims to systematically compare complications and functional and oncologic outcomes of sacroiliac resection with and without reconstruction. METHODS: PubMed and MEDLINE were queried for studies published between January 1990 and October 2020 pertaining to sacroiliac neoplasm resection with subsequent reconstruction. Patient demographics, histopathologic diagnoses, reconstruction techniques, Musculoskeletal Tumor Society (MSTS) functional scores, and oncologic outcomes were pooled. RESULTS: Twenty-three studies (201 patients) were included for analysis. Reconstruction was performed in 79.1% of patients, most commonly with nonvascularized autografts (45.8%). The overall complication rate was 54.8%; however, resection followed by reconstruction demonstrated significantly higher complication (62.3% versus 25.7%, p < 0.001) and infection rates (13.7% versus 0%, p = 0.020). Mean MSTS functional score trended higher in nonreconstructed patients (82% versus 71.6%). CONCLUSIONS: Reconstruction after sacroiliac resection produced higher complication rates and poorer physical recovery when compared with nonreconstructed resection. This systematic review suggests that patients without spinopelvic junction instability may experience superior outcomes without reconstruction. Ultimately, the need to reconstruct the pelvic girdle depends on tumor size, prognosis, and functional goals.

What is the clinical impact of staging and surveillance PET-CT scan findings in patients with bone and soft tissue sarcoma?

BACKGROUND AND OBJECTIVES: Positron emission tomography-computerized tomography (PET-CTs) are becoming increasingly utilized in sarcoma care, workup, and surveillance. This study aimed to describe additional PET-CT findings as well as subsequent workups and changes in the clinical course due to those results. METHODS: Patient records were retrospectively reviewed, and the additional workups and evaluations triggered by PET-CT findings were qualitatively analyzed to document their results. Additional changes in the clinical course were documented. RESULTS: A total of 183 bone and soft tissue sarcoma patients underwent PET-CT as part of staging or surveillance. Additional workup was performed in 31.5% (n = 41 of 130) patients who had positive PET-CT findings. Among these, 36.6% (n = 15 of 41) patients had clinically significant findings that altered the clinical course. Overall, 14.8% (n = 27 of 183) experienced a change in the clinical course due to PET-CT. CONCLUSION: PET-CT often highlights lesions of potential clinical importance. Additional workup, as well as changes in the clinical course, were not infrequent. Future, multi-institutional studies should address the value of PET-CT in sarcoma care.

Artificial intelligence in predicting early-onset adjacent segment degeneration following anterior cervical discectomy and fusion.

PURPOSE: Anterior cervical discectomy and fusion (ACDF) is a common surgical treatment for degenerative disease in the cervical spine. However, resultant biomechanical alterations may predispose to early-onset adjacent segment degeneration (EO-ASD), which may become symptomatic and require reoperation. This study aimed to develop and validate a machine learning (ML) model to predict EO-ASD following ACDF. METHODS: Retrospective review of prospectively collected data of patients undergoing ACDF at a quaternary referral medical center was performed. Patients > 18 years of age with > 6 months of follow-up and complete pre- and postoperative X-ray and MRI imaging were included. An ML-based algorithm was developed to predict EO-ASD based on preoperative demographic, clinical, and radiographic parameters, and model performance was evaluated according to discrimination and overall performance. RESULTS: In total, 366 ACDF patients were included (50.8% male, mean age 51.4 ± 11.1 years). Over 18.7 ± 20.9 months of follow-up, 97 (26.5%) patients developed EO-ASD. The model demonstrated good discrimination and overall performance according to precision (EO-ASD: 0.70, non-ASD: 0.88), recall (EO-ASD: 0.73, non-ASD: 0.87), accuracy (0.82), F1-score (0.79), Brier score (0.203), and AUC (0.794), with C4/C5 posterior disc bulge, C4/C5 anterior disc bulge, C6 posterior superior osteophyte, presence of osteophytes, and C6/C7 anterior disc bulge identified as the most important predictive features. CONCLUSIONS: Through an ML approach, the model identified risk factors and predicted development of EO-ASD following ACDF with good discrimination and overall performance. By addressing the shortcomings of traditional statistics, ML techniques can support discovery, clinical decision-making, and precision-based spine care.

Tumors and Tumorlike Conditions of Which Every Orthopaedic Surgeon Should Be Aware.

All orthopaedic surgeons during the course of their career will likely encounter both benign and malignant musculoskeletal neoplasms. Given the rarity of these entities and the stress conferred by diagnosing a tumor or tumorlike condition, many orthopaedic surgeons may benefit from a review of the contemporary treatment of such patients. Whether in the outpatient clinic or following a high-energy trauma, special attention should be given to concerning signs and symptoms that will aid in the workup of children and adults with a possible tumor. A thorough and logical workup in this manner will often lead to a definitive diagnosis such as metastatic bone disease or perhaps a benign lesion. In these instances, the informed general orthopaedic surgeon or subspecialist may choose to treat the patient independently. However, if the workup is inconclusive or if the diagnosis is even questionably malignant, referral to an orthopaedic oncologist should be sought as to avoid pitfalls in diagnosis and treatment.

Indication for Proximal Femoral Replacement Is Associated With Risk of Failure.

BACKGROUND: Proximal femoral replacement (PFR) is reserved as a salvage procedure after failed total hip arthroplasty (THA) or after wide margin resection of tumors involving the proximal femur. Although failure of the PFR construct remains a significant problem, indication has not previously been investigated as a risk factor for failure. METHODS: This study retrospectively evaluated patients who underwent PFR over a consecutive 15-year period for primary sarcoma or metastatic disease of the proximal femur, compared with conversion to PFR after failed THA. PFR failure was defined as recurrent prosthetic dislocations, periprosthetic fracture, aseptic loosening, or infection that ultimately resulted in revision surgery. RESULTS: Overall, 99 patients were evaluated, including 58 in the neoplasm and 41 in the failed THA cohorts. Failed THA patients were older (P < .001), with a greater proportion having comorbid hypertension (P = .008), cardiac disease (P = .014), and history of prior ipsilateral and intracapsular surgeries (P < .001). The failure rate was significantly higher in failed THA patients (39.0% vs 10.3%; P < .001) with significantly shorter implant survivorship on Kaplan-Meier analysis (P = .003). A multivariate Cox proportional hazards model showed that THA failure was the only independent predictor for PFR failure (hazard ratio: 4.26, 95% confidence interval: 1.66-10.94; P = .003). CONCLUSION: This study revealed significantly worse PFR implant survivorship in patients undergoing PFR for the indication of failed THA compared with neoplasm. Although the underlying etiology of this relationship remains to be explicitly outlined, poor bone quality and soft tissue integrity, multiple prior surgeries, and comorbid conditions are likely contributing factors.

Pediatric Back Pain: A Scoring System to Guide Use of Magnetic Resonance Imaging.

BACKGROUND: The prevalence of back pain in the pediatric population is increasing, and the workup of these patients presents a clinical challenge. Many cases are selflimited, but failure to diagnose a pathology that requires clinical intervention can carry severe repercussions. Magnetic resonance imaging (MRI) carries a high cost to the patient and health care system, and may even require procedural sedation in the pediatric population. The aim of this study was to develop a scoring system based on pediatric patient factors to help determine when an MRI will change clinical management. METHODS: This is a retrospective cohort analysis of consecutive pediatric patients who presented to clinic with a chief complaint of back pain between 2010 and 2018 at single orthopaedic surgery practice. Comprehensive demographic and presentation variables were collected. A predictive model of factors that influence whether MRI results in a change in management was then generated using cross-validation least absolute shrinkage and selection operator logistic regression analysis. RESULTS: A total of 729 patients were included, with a mean age of 15.1 years (range: 3 to 20 y). Of these, 344 (47.2%) had an MRI. A predictive model was generated, with nocturnal symptoms (5 points), neurological deficit (10 points), age (0.7 points per year), lumbar pain (2 points), sudden onset of pain (3.25 points), and leg pain (3.75 points) identified as significant predictors. A combined score of greater than 9.5 points for a given patient is highly suggestive that an MRI will result in a change in clinical management (specificity: 0.93; positive predictive value: 0.92). CONCLUSIONS: A predictive model was generated to help determine when ordering an MRI may result in a change in clinical management for workup of back pain in the pediatric population. The main factors included the presence of a neurological deficit, nocturnal symptoms, sudden onset, leg pain, lumbar pain, and age. Care providers can use these findings to better determine if and when an MRI might be appropriate. LEVEL OF EVIDENCE: Level III-diagnostic study.

The prognostic significance of lymphovascular tumor invasion in localized high-grade osteosarcoma: Outcomes of a single institution over 10 years.

BACKGROUNDS AND OBJECTIVES: Lymphovascular invasion (LVI) has shown evidence of an association with worse survival in high-grade osteosarcoma patients. The purpose of this investigation was to prognosticate LVI as a predictor of survival. METHODS: This was a retrospective review of high-grade, localized osteosarcoma patients over a consecutive 10-year period. Proportional hazards regression was used to identify prognostic factors. Cumulative mortality incidence was estimated with recurrence as a competing risk. RESULTS: Forty-two cases with a median follow-up of 64 months (range, 6-158 months) were reviewed. LVI was present in 21.4% (n = 9) cases. The five- and ten-year survivals in LVI (+) were 40% and 20%, compared to 93% and 81% in LVI (-), respectively (p < .001). After controlling for confounders, advanced age (hazards ratio [HR], 1.134; 95% confidence interval [CI], 1-1.2; p = .01) and LVI (HR, 21.768; 95% CI, 3-135; p = .001) were negative prognosticators. The cumulative incidence of recurrence was no different between LVI (+) and LVI (-) (p = .811), though the incidence of mortality was significantly higher in LVI (+) (p = .003). CONCLUSION: The presence of LVI in the setting of high-grade, localized osteosarcoma is associated with greater rates of mortality and appears to portend a dismal prognosis.

Pelvic ring reconstruction with segmental spinal instrumentation after complete type I pelvic resection.

BACKGROUND AND OBJECTIVES: Internal hemipelvectomy is a complex procedure used to treat malignancy that involves the pelvis. Reconstruction of the pelvis after type I or type I/IV resection remains controversial due to high complication rates and debatable functional benefit. Modern reconstruction options may provide a rapid, intuitive, and reliable way to reconstitute the pelvic ring. METHODS: This is a retrospective case series of four patients who underwent a novel reconstruction method involving computer navigation and segmental spinal instrumentation applied to the pelvis after type I or type I/IV pelvic resection for malignancy between 2015 and 2020. RESULTS: Time to ambulation postoperatively ranged from 1 to 7 days, and median length of hospital stay was 8.5 (7.5, 10.5) days. Complications included wound necrosis in two patients that did not require reoperation and wound infection in one patient that required irrigation and debridement. There was no radiographic evidence of hardware loosening or failure on follow-up. Three patients remain alive and two remain disease-free. At most recent follow-up, all patients were able to ambulate and perform activities of daily living. CONCLUSIONS: The technique for pelvic reconstruction described allows for rapid fixation intraoperatively with few complications and satisfactory functional results in this limited series.

Sacroiliac joint cut accuracy: Comparing new technologies in an idealized sawbones model.

BACKGROUND AND OBJECTIVES: The anatomical complexity of the pelvis creates challenges for orthopaedic oncologists to accurately and safely resect tumors involving the sacroiliac joint. Current technology may help overcome these obstacles. METHODS: Four fellowship-trained orthopaedic oncologists performed 22 all-posterior sacroiliac cuts using freehand, computerized navigation, and patient-specific cutting guides on a Sawbones male pelvis model. Cut accuracies to preoperative planned margins were analyzed via a high-resolution optical scanner. Soft tissue damage was determined by visually inspecting the Sawbones foam placed on the far side of the cut. RESULTS: Within 5 mm of the margins, the freehand technique resulted in 67.0% cut accuracy, the navigation technique had 71.1%, and the patient-specific cutting guide technique had 85.6% (P = .093). Within 2 mm, the techniques showed an accuracy of 25.8%, 32.5%, and 47.5%, respectively (P = .022). Regarding soft tissue damage, the freehand technique exhibited minimal penetration damage for 16.7% of the cuts, while navigation and patient-specific guide techniques exhibited 25.0% and 75.0%, respectively (P = .046). Years of surgical experience of the operator (1-7) did not influence the cut accuracy for any method. CONCLUSIONS: Under ideal conditions, patient-specific guide technology possesses the same or better accuracy as other cutting techniques as well as the circumvention of soft tissue damage.

What are the functional results and complications from allograft reconstruction after partial hemipelvectomy of the pubis?

BACKGROUND: In patients undergoing hemipelvectomies including resection either of a portion of the pubis or the entire pubis from the symphysis to the lateral margin of the obturator foramen while sparing the hip (so-called Dunham Type III hemipelvectomies), reconstructions typically are not performed given the preserved continuity of the weightbearing axis and the potential complications associated with reconstruction. Allograft reconstruction of the pelvic ring may, however, offer benefits for soft tissue reconstruction of the pelvic floor and hip stability, but little is known about these reconstructions. QUESTIONS/PURPOSES: (1) What is the postoperative functional status after allograft reconstruction of Type III pelvic defects? (2) What are the rates of hernia, infection, and hip instability? METHODS: In this case series, we reviewed all patients with Type III pelvic resections (with or without anterior acetabular wall resections) who underwent allograft reconstruction between 2005 and 2013 at one center (N = 14). During the period in question, reconstruction was the general approach used in patients undergoing these resections; during that time, three other patients were treated without reconstruction as a result of either surgeon preference or the patient choosing to not have reconstruction after a discussion of the risks and benefits. Of the 14 patients treated with reconstruction, complete followup was available at a minimum of 1 year in 11 (other than those who died before the end of the first year; median, 19 months; range 16-70 months among those surviving), one was lost to followup before a year, and two others had partial telephone or email followup. Patient demographics, disease status, functional status, and complications were recorded. For a portion of the cohort (four patients) later in the series, we used a novel technique for anterior acetabular wall reconstruction using the concave cartilaginous surface of a proximal fibula allograft; the others received either a long bone (humerus or femur) or hemipelvis graft. Seven patients died of disease; two had local recurrence, and five died of metastatic disease. RESULTS: All patients remained ambulatory Pain at 12 months after surgery was reported as none in five, mild in two, moderate in two, and severe in one. Operative complications included infection in two, symptomatic hernia in one, hip instability in one, dislocated total hip arthroplasty on the first postoperative day in one, and graft failure in one. CONCLUSIONS: Allograft reconstruction after Type III pelvic resections can provide functional reconstruction of the pelvic ring, pelvic floor, and, in certain patients with partial anterior acetabular resections, the resected anterior acetabulum. This has implications in preventing the occurrence of hernia and hip instability in this patient population that is classically not reconstructed, although longer-term outcomes in a larger number of patients would help to better delineate this because infection, hernia, hip instability, and graft nonunion still remain concerns with this approach. The most important unanswered question remains whether, on balance, any benefits that may accrue to these patients as the result of reconstruction are offset by a relatively high likelihood of undergoing secondary or revision surgery.

Percutaneous Acetabuloplasty Compared With Open Reconstruction for Extensive Periacetabular Carcinoma Metastases.

For destructive metastatic periacetabular disease, options include open acetabular reconstruction or percutaneous cement acetabuloplasty (PA). We reviewed 28 consecutive patients with Harrington grade II or III lesions, 17 who underwent Harrington-type or anti-protrusio reconstruction and 11 who underwent PA. Primary outcome measures were performance status (PS), ambulatory status (0=unassisted ambulation, 1=assisted ambulation, 2=nonambulatory), and 10-point VAS score. The surgery group had better pain reduction than the PA group at 3 months (3.6 vs. 1.5 points, P=0.04), and a trend at final follow-up (3.8 vs. 1.4 points, P=0.06). Improvement in ambulatory status was better in the surgery group at 3 months only (0.53 vs. -0.14, P=0.03). Thus compared with PA, open reconstruction may provide improved pain relief and ambulation.

Evaluation of Absolute Neutrophil Count in the Perioperative Setting of Sarcoma Resection.

Introduction: Limb salvage surgery (LSS) is the preferred surgical treatment for bone sarcomas. Preoperatively, many patients receive chemotherapy and may develop neutropenia. No study has evaluated the effect of a low preoperative absolute neutrophil count (ANC) on postoperative outcomes following LSS. Methods: This was a retrospective review of 114 patients who underwent LSS for bone sarcoma from 2010 to 2020. Preoperative lab values were analyzed by logistic regression to identify the risk of developing surgical complications within 30 days, surgical site infection (SSI), and reoperation. Results: Three (2.6%) patients experienced a surgical complication within 30 days. Twelve (10.53%) patients experienced postoperative SSI. Twenty-nine (25.4%) required reoperation. Preoperative ANC was not a significant predictor of surgical complications within 30 days, SSI, or reoperation. The only independent predictor of worse overall survival was the presence of a pathologic fracture at the time of surgery. Conclusion: This is the first study to evaluate preoperative ANC on postoperative outcomes following LSS. We report no significant differences in surgical complications within 30 days, SSI, or reoperation with low preoperative ANC. Future studies with larger cohorts of neutropenic patients are needed to evaluate these outcomes, as our cohort had very few neutropenic patients due to selection bias.

Rare Dedifferentiated Periosteal Chondrosarcoma with 11-Year Metastatic Relapse: A Case Report.

A 50-year-old man presented for evaluation of a periscapular mass. Biopsy suggested a low-grade chondrosarcoma; however, the resected specimen revealed a grade 2 chondrosarcoma with a low-grade dedifferentiated mesenchymal component. The mass multiply recurred as chondrosarcoma without a dedifferentiated component before the patient developed lung metastases of chondrosarcoma without a dedifferentiated component 11 years after the initial diagnosis and died of disease. This is one of the first reported cases of a dedifferentiated chondrosarcoma with low-grade dedifferentiated component. While overall prognosis may be better than in typical dedifferentiated chondrosarcoma, this tumor demonstrated numerous local recurrences as well as metastasis.

Hip Arthroplasty Outcomes in Patients with Metastatic Bone Disease.

Background/Objective: The hip is a common location for metastatic bone disease (MBD) and surgical intervention is often indicated to relieve pain and improve function. MBD of the hip is usually treated with hemiarthroplasty or with total hip arthroplasty if there are acetabular lesions. As treatment for metastatic disease evolves and patients may expect to live longer after diagnosis, further evaluation of the complications and functional outcomes associated with hip arthroplasty for MBD are necessary. Methods: This was a retrospective review of patients who underwent hip arthroplasty for MBD at a single institution between 2007 and 2021. Outcomes included rates of reoperation, complications, and overall survival. Results: Ninety-three cases in 91 patients were included. Total hip arthroplasty (THA) was performed in 52 cases (55.9%), hemiarthroplasty in 15 (16.1%), and complex arthroplasty, including proximal femur replacement or THA with complex acetabular reconstruction, was performed in 26 (28%). There were 11 reoperations in five patients and six dislocations. Median survival was 10.4 months and one-year overall survival was 53.3%. There was a significant increase in the proportion of patients who were able to ambulate independently (35.2% vs 17.6%; p=0.02) and a significant decrease in patients confined to a wheelchair (18.7% vs 3.3%; p=0.045) after surgery. Conclusions: Hip arthroplasty for MBD leads to relatively low rates of complications and reoperations in this population known to have high postoperative morbidity and mortality. Hip arthroplasty provides the majority of MBD patients with a durable reconstruction that exceeds their lifespan and enables them to return to an acceptable level of function.

Preoperative diagnosis of mental health disorder and dysphagia following anterior cervical spine surgery.

OBJECTIVE: Mental health disorders (MHDs) have been linked to worse postoperative outcomes after various surgical procedures. Past studies have also demonstrated a higher prevalence of dysphagia in both acute and community mental health settings. Dysphagia is among the most common complications following anterior cervical spine surgery (ACSS); however, current literature describing the association between an established diagnosis of an MHD and the rate of dysphagia after ACSS is sparse. METHODS: All patients who underwent ACSS between 2014 and 2020 with a minimum of 6 months of follow-up were retrospectively evaluated at a single institution. Patients were divided into cohorts depending on an established diagnosis of an MHD: the first had no established MHD (non-MHD); the second included patients with a diagnosed MHD. Outcomes were measured using pre- and postoperative patient-reported outcome scores, which included the Swallowing Quality of Life survey for dysphagia, as well as physical and mental health questionnaires. Postoperative dysphagia surveys were obtained at final follow-up for both patient cohorts. RESULTS: A total of 68 and 124 patients with and without a diagnosis of a MHD were assessed. The MHD group reported significantly worse baseline Patient-Reported Outcomes Measurement Information System depression scale scores (p < 0.001), 12-Item Short-Form Health Survey (p < 0.001), and Veterans RAND 12-Item Health Survey (p = 0.001) mental health components compared to non-MHD group. This group continued to have worse mental health status in the postoperative period, as reported by Patient-Reported Outcomes Measurement Information System depression scale scores (p = 0.024), 12-Item Short-Form Health Survey (p = 0.019), and Veterans RAND 12-Item Health Survey (p = 0.027). Postoperative assessment of Swallowing Quality of Life scores (expressed as the mean ± SD) also showed worse dysphagia outcomes in the MHD cohort (80.1 ± 12.2) than in the non-MHD cohort (86.0 ± 12.1, p = 0.001). CONCLUSIONS: ACSS is associated with significantly higher postoperative dysphagia in patients diagnosed with an MHD when compared to patients without an established mental health diagnosis. Given the high prevalence of MHDs in patients with spinal pathology, it is important for spine surgeons to take note of the increased incidence of dysphagia faced by this patient population.

An Unusual Case of Clear Cell Chondrosarcoma With Early Metastatic Recurrence.

We present a case of a 58-year-old male who presented following 4 months of progressively worsening right upper extremity pain. Initial pathology demonstrated pleomorphic chondroblasts with increased mitotic activity indicating an intermediate grade (Grade 2) clear cell chondrosarcoma of the proximal humerus. Following surgical resection, the primary lesion demonstrated aggressive behavior and early metastasis to the cervical and thoracic spine. The patient unfortunately expired 30 months after initial presentation. Although clear cell chondrosarcoma has been historically regarded as low grade, we present a unique example of an aggressive clinical course of clear cell chondrosarcoma.