Sacroiliac joint fusion navigation: how accurate is pin placement?

OBJECTIVE: Sacroiliac joint (SIJ) fusion utilizing intraoperative navigation requires a standard reference frame, which is often placed using a percutaneous pin. Proper placement ensures the correct positioning of SIJ fusion implants. There is currently no grading scheme for evaluation of pin placement into the pelvis. The purpose of this study was to evaluate the occurrence of ideal percutaneous pin placement into the posterior ilium during navigated SIJ fusion. METHODS: After IRB approval was obtained, electronic medical records and intraoperative computed tomography images of patients who underwent navigated SIJ fusion by the senior author between October 2013 and January 2020 were reviewed. A pin placement grading scheme and the definition of "ideal" placement were developed by the authors and deemed acceptable by fellow attending surgeons. Six attending surgeons completed two rounds of pin placement grading, and statistical analysis was conducted. RESULTS: Of 90 eligible patients, 73.3% had ideal pin placement, 17.8% medial/lateral breach, and 8.9% complete miss. Male patients were 3.7 times more likely to have ideal placement than females (p < 0.05). There was no relationship between BMI, SIJ fusion laterality, or pin placement laterality and ideal placement. Interobserver reliability was 0.72 and 0.70 in the first and second rounds, respectively, and defined as "substantial agreement." Intraobserver reliability ranged from 0.74 (substantial agreement) to 0.92 (almost perfect agreement). CONCLUSIONS: Nonideal pin placement occurred in 26.7% of cases, but a true "miss" into the sacrum was rare. Ideal pin placement was more likely in males and was not associated with BMI, SIJ fusion laterality, or pin placement laterality. The grading scheme developed has high intraobserver and interobserver reliability, indicating that it is reproducible and can be used for future studies. When placing percutaneous pins, surgeons must be aware of factors that can decrease placement accuracy, regardless of location.

The 2021 Association Research Circulation Osseous Classification for Early-Stage Osteonecrosis of the Femoral Head to Computed Tomography-Based Study.

BACKGROUND: The Association Research Circulation Osseous developed a novel classification for early-stage (precollapse) osteonecrosis of the femoral head (ONFH). We hypothesized that the novel classification is more reliable and valid when compared to previous 3 classifications: Steinberg, modified Kerboul, and Japanese Investigation Committee classifications. METHODS: In the novel classification, necrotic lesions were classified into 3 types: type 1 is a small lesion, where the lateral necrotic margin is medial to the femoral head apex; type 2 is a medium-sized lesion, with the lateral necrotic margin being between the femoral head apex and the lateral acetabular edge; and type 3 is a large lesion, which extends outside the lateral acetabular edge. In a derivation cohort of 40 early-stage osteonecrotic hips based on computed tomography imaging, reliabilities were evaluated using kappa coefficients, and validities to predict future femoral head collapse by chi-squared tests and receiver operating characteristic curve analyses. The predictability for future collapse was also evaluated in a validation cohort of 104 early-stage ONFH. RESULTS: In the derivation cohort, interobserver reliability (k = 0.545) and intraobserver agreement (63%-100%) of the novel method were higher than the other 3 classifications. The novel classification system was best able to predict future collapse (P < .05) and had the best discrimination between non-progressors and progressors in both the derivation cohort (area under the curve = 0.692 [0.522-0.863], P < .05) and the validation cohort (area under the curve = 0.742 [0.644-0.841], P = 2.46 × 10-5). CONCLUSION: This novel classification is a highly reliable and valid method of those examined. Association Research Circulation Osseous recommends using this method as a unified classification for early-stage ONFH. LEVEL OF EVIDENCE: Level III, diagnostic study.

ARCO Consensus on the Pathogenesis of Non-traumatic Osteonecrosis of the Femoral Head.

Osteonecrosis of the femoral head (ONFH) is a devastating disease frequently leading to femoral head collapse and hip arthritis. Specifically, non-traumatic ONFH primarily affects young and middle-aged adults. Although compromised local circulation of the femoral head seems to be pathognomonic for the disease, the pathogenesis is perplexing and continues to be an area of scrutiny and research. Comprehension of the pathogenesis is of crucial importance for developing and guiding treatments for the disease. Therefore, we provide an up-to-date consensus on the pathogenesis of non-traumatic ONFH.

Osteonecrosis of the Femoral Head: an Updated Review of ARCO on Pathogenesis, Staging and Treatment.

Non-traumatic osteonecrosis of the femoral head (ONFH) usually affects adults younger than 50 years and frequently leads to femoral head collapse and subsequent arthritis of the hip. It is becoming more prevalent along with increasing use of corticosteroids for the adjuvant therapy of leukemia and other myelogenous diseases as well as management of organ transplantation. This review updated knowledge on the pathogenesis, classification criteria, staging system, and treatment of ONFH.

Diagnosis and Treatment of Femoral Head Osteonecrosis: A Protocol for Development of Evidence-Based Clinical Practice Guidelines.

INTRODUCTION: There are many treatment options for patients who have osteonecrosis of the femoral head (ONFH) and management strategies vary widely both among and within individual countries. Although many researchers have attempted to elucidate the optimal strategies for managing this disease, the lack of large-scale randomized control trials and the lack of agreement on disease staging have curtailed the development of clear-cut guidelines. MATERIALS AND METHODS: The Association Research Circulation Osseous (ARCO) group sought to address three questions for the management of patients who have ONFH: 1) What imaging studies are most sensitive and specific for the diagnostic evaluation of patients who have ONFH?; 2) What is the best treatment strategy for preventing disease progression in patients who have pre-collapse lesions?; and 3) What is the best treatment strategy for patients who have post-collapse disease? The Patient, Intervention, Comparison, and Outcome (PICO) format was used to formulate the search strategy for each research question. A systematic review will be performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. ARCO participants have been allocated to three groups, each representing one of the PICO questions. After qualitative and quantitative analysis of the data extracted from studies pertaining to each of the three research questions, a set of evidence-based clinical practice guidelines will be proposed for the management of patients who have ONFH. DISCUSSION: It is not always clear which treatment method is optimal for the management of ONFH. Thus, many surgeons have developed and performed various procedures based on patient-specific factors. As there is no consensus on the optimal treatment for various stages of disease, it was clear that developing evidence-based clinical practice guidelines would provide more structure and uniformity to management of these patients. Therefore, the results of this systematic review will lead to the development guidelines that may improve patient-care strategies and result in better outcomes for patients who have ONFH.

The 2019 Revised Version of Association Research Circulation Osseous Staging System of Osteonecrosis of the Femoral Head.

BACKGROUND: The Association Research Circulation Osseous (ARCO) presents the 2019 revised staging system of osteonecrosis of the femoral head (ONFH) based on the 1994 ARCO classification. METHODS: In October 2018, ARCO established a task force to revise the staging system of ONFH. The task force involved 29 experts who used a web-based survey for international collaboration. Content validity ratios for each answer were calculated to identify the levels of agreement. For the rating queries, a consensus was defined when more than 70% of the panel members scored a 4 or 5 rating on a 5-point scale. RESULTS: Response rates were 93.1%-100%, and through the 4-round Delphi study, the 1994 ARCO classification for ONFH was successfully revised. The final consensus resulted in the following 4-staged system: stage I-X-ray is normal, but either magnetic resonance imaging or bone scan is positive; stage II-X-ray is abnormal (subtle signs of osteosclerosis, focal osteoporosis, or cystic change in the femoral head) but without any evidence of subchondral fracture, fracture in the necrotic portion, or flattening of the femoral head; stage III-fracture in the subchondral or necrotic zone as seen on X-ray or computed tomography scans. This stage is further divided into stage IIIA (early, femoral head depression ≤2 mm) and stage IIIB (late, femoral head depression >2 mm); and stage IV-X-ray evidence of osteoarthritis with accompanying joint space narrowing, acetabular changes, and/or joint destruction. This revised staging system does not incorporate the previous subclassification or quantitation parameters, but the panels agreed on the future development of a separate grading system for predicting disease progression. CONCLUSION: A staging system has been developed to revise the 1994 ARCO classification for ONFH by an expert panel-based Delphi survey. ARCO approved and recommends this revised system as a universal staging of ONFH.

Effect of chemotherapy on cancer stem cells and tumor-associated macrophages in a prospective study of preoperative chemotherapy in soft tissue sarcoma.

BACKGROUND: Cancer stem cells (CSC) may respond to chemotherapy differently from other tumor cells. METHODS: This study examined the expression of the putative cancer stem cell markers ALDH1, CD44, and CD133; the angiogenesis marker CD31; and the macrophage marker CD68 in soft tissue sarcomas (STS) before and after 4 cycles of chemotherapy with doxorubicin and ifosfamide in 31 patients with high-grade soft tissue sarcoma in a prospective clinical trial. RESULTS: None of the markers clearly identified CSCs in STS samples. Macrophages represented a prominent component in viable tumor areas in pre-treatment STS biopsies, ranging from < 5 to > 50%. Furthermore, macrophages expressed CD44 and ALDH1. Macrophage density correlated with baseline maximum standardized uptake value (SUVmax) on fluoro-deoxyglucose positron emission tomography (PET) imaging. Pre-chemotherapy CD68 staining correlated positively with the baseline SUVmax, and negatively with the percent of viable tumor cells in post-chemotherapy resection samples. In particular, cases with more CD68-positive cells at biopsy had fewer viable tumor cells at resection, suggesting a better response to chemotherapy. CONCLUSIONS: In conclusion, ALDH1, CD44, and CD133 are not likely to be useful markers of CSCs in STS. However, our observation of infiltrating macrophages in STS specimens indicates that these immune cells may contribute significantly to STS biology and response to chemotherapy, and could provide a potential target of therapy. Future studies should investigate macrophage contribution to STS pathophysiology by cytokine signaling.

Reconstruction of the Shoulder and Humerus in Metastatic Bone Disease.

Metastatic disease involving the skeleton most often affects the spine, pelvis, and proximal long bones of the extremities. In the upper extremity, the proximal humerus is frequently affected. Although many of the principles of managing metastatic bone disease are similar, regardless of the metastatic site, the upper extremity has some unique anatomic and functional traits that warrant consideration when making management decisions. The main anatomic differences from the lower extremity pertain to the smaller bone size, rotator cuff function, and proximity to major neurologic structures, and the important functional differences that relate to activities of daily living have a greater dependence on the upper, rather than lower, extremity; greater range of motion of the shoulder; side dominance; limited weight-bearing function; and marked propensity of the elbow to develop stiffness. Clinicians should consider aspects of the shoulder and humerus as they relate to the overall management of metastatic bone disease, either monostotic or polyostotic, when evaluating and managing metastatic lesions at this site.

Etiologic Classification Criteria of ARCO on Femoral Head Osteonecrosis Part 1: Glucocorticoid-Associated Osteonecrosis.

BACKGROUND: Glucocorticoid usage, a leading cause of osteonecrosis of the femoral head (ONFH), and its prevalence was reported in 25%-50% of non-traumatic ONFH patients. Nevertheless, there have been no unified criteria to classify glucocorticoid-associated ONFH (GA-ONFH). In 2015, the Association Research Circulation Osseous addressed the issue of developing a classification scheme. METHODS: In June 2017, a task force was set up to conduct a Delphi survey concerning ONFH. The task force invited 28 experts in osteonecrosis/bone circulation from 8 countries. Each round of the Delphi survey consists of questionnaires, analysis of replies, and feedback reports to the panel. After 3 rounds of the survey, the panel reached a consensus on the classification criteria. The response rates were 100% (Round 1), 96% (Round 2), and 100% (Round 3), respectively. RESULTS: The consensus on the classification criteria of GA-ONFH included the following: (1) patients should have a history of glucocorticoid use >2 g of prednisolone or its equivalent within a 3-month period; (2) osteonecrosis should be diagnosed within 2 years after glucocorticoid usage, and (3) patients should not have other risk factor(s) besides glucocorticoids. CONCLUSION: Association Research Circulation Osseous established classification criteria to standardize clinical studies concerning GA-ONFH.

Etiologic Classification Criteria of ARCO on Femoral Head Osteonecrosis Part 2: Alcohol-Associated Osteonecrosis.

BACKGROUND: Although alcohol is a leading risk factor for osteonecrosis of the femoral head (ONFH) and its prevalence reportedly ranges from 20% to 45%, there are no unified classification criteria for this subpopulation. In 2015, Association Research Circulation Osseous decided to develop classification criteria for alcohol-associated ONFH. METHODS: In June of 2017, Association Research Circulation Osseous formed a task force to conduct a Delphi survey. The task force invited 28 experts in osteonecrosis/bone circulation from 8 countries. Each round of the Delphi survey included questionnaires, analysis of replies, and feedback reports to the panel. After 3 rounds of the survey, consensus was reached on the classification criteria. The response rates for the 3 Delphi rounds were 100% (round 1), 96% (round 2), and 100% (round 3). RESULTS: The consensus on the classification criteria of alcohol-associated ONFH included the following: (1) patients should have a history of alcohol intake >400 mL/wk (320 g/wk, any type of alcoholic beverage) of pure ethanol for more than 6 months; (2) ONFH should be diagnosed within 1 year after alcohol intake of this dose; and (3) patients should not have other risk factor(s). CONCLUSION: ARCO-established classification criteria to standardize clinical studies concerning AA-ONFH.

Drug-induced immune hemolytic anemia associated with anti-vancomycin complicated by a paraben antibody.

BACKGROUND: Drug-induced immune hemolytic anemia (DIIHA) is rare, but potentially life-threatening. A high index of clinical suspicion is required for diagnosis, since the number of medications known to induce DIIHA continues to expand. Additionally, in vitro antibody reactivity against reagent additives has been reported, which may complicate test interpretation. CASE REPORT: A 61-year-old group A, D+ woman with a history of negative antibody detection tests developed hemolytic anemia on Postoperative Day 7 after repeat incision and drainage of a chronically infected right knee prosthesis. She was treated with multiple antibiotics in the postoperative period, including three cephalosporins and vancomycin intravenously as well as vancomycin and gentamicin-containing intraarticular cement spacers. STUDY DESIGN AND METHODS: A workup for possible DIIHA was performed. Testing was performed using vancomycin and cephalosporin antibiotics. Initially, gentamicin injection solution was used for testing, followed by testing with its component ingredients. RESULTS: A vancomycin antibody was detected and anemia resolved after vancomycin was discontinued. Reactivity was seen when gentamicin injection solution was used for testing, raising the possibility of a gentamicin antibody as well. However, testing with purified gentamicin as well as methylparaben and propylparaben demonstrated a paraben antibody that reacted with the paraben-containing gentamicin solution. The patient also demonstrated an anti-N. Neither the paraben antibody nor the anti-N appeared to cause in vivo hemolysis. CONCLUSION: This is the second reported case of DIIHA associated with anti-vancomycin. It is the fourth report describing a paraben antibody.

CT-based Structural Rigidity Analysis Is More Accurate Than Mirels Scoring for Fracture Prediction in Metastatic Femoral Lesions.

BACKGROUND: Controversy continues regarding the appropriate assessment of fracture risk in long bone lesions affected by disseminated malignancy. QUESTIONS/PURPOSES: The purpose of this ongoing Musculoskeletal Tumor Society-sponsored, multi-institutional prospective cross-sectional clinical study is to compare CT-based structural rigidity analysis (CTRA) with physician-derived Mirels scoring for predicting pathologic fracture in femoral bone lesions. We hypothesized CTRA would be superior to Mirels in predicting fracture risk within the first year based on (1) sensitivity, specificity, positive predictive value, and negative predictive value; (2) receiver operator characteristic (ROC) analysis; and (3) fracture prediction after controlling for potential confounding variables such as age and lesion size. METHODS: Consented patients with femoral metastatic lesions were assigned Mirels scores by the individual enrolling orthopaedic oncologist based on plain radiographs and then underwent CT scans of both femurs with a phantom of known density. The CTRA was then performed. Between 2004 and 2008, six study centers performed CTRA on 125 patients. The general indications for this test were femoral metastatic lesions potentially at risk of fracture. The enrolling physician was allowed the choice of prophylactic stabilization or nonsurgical treatment, and the local treating oncology team along with the patient made this decision. Of those 125 patients, 78 (62%) did not undergo prophylactic stabilization and had followup sufficient for inclusion, which was fracture through the lesion within 12 months of CTRA, death within 12 months of CTRA, or 12-month survival after CTRA without fracture, whereas 15 (12%) were lost to followup and could not be studied here. The mean patient age was 61 years (SD, 14 years). There were 46 women. Sixty-four of the lesions were located in the proximal femur, 13 were in the diaphysis, and four were distal. Osteolytic lesions prevailed (48 lesions) over mixed (31 lesions) and osteoblastic (15 lesions). The most common primary cancers were breast (25 lesions), lung (14 lesions), and myeloma (11 lesions). CTRA was compared with Mirels based on sensitivity/specificity analysis, ROC, and fracture prediction by multivariate analysis. For the CTRA, reduction greater than 35% in axial, bending, or torsional rigidities at the lesion was considered at risk for fracture, whereas a Mirels score of 9 or above, as suggested in the original manuscript, was used as the definition of impending fracture. RESULTS: CTRA provided higher sensitivity (100% versus 66.7%), specificity (60.6% versus 47.9%), positive predictive value (17.6% versus 9.8%), and negative predictive value (100% versus 94.4%) compared with the classic Mirels definition of impending fracture (≥ 9), although there was considerable overlap in the confidence intervals. ROC curve analysis found CTRA to be better than the Mirels score regardless of what Mirels score cutoff was used. After controlling for potential confounding variables including age, lesion size, and Mirels scores, multivariable logistic regression indicated that CTRA was a better predictor of fracture (likelihood ratio test = 10.49, p < 0.001). CONCLUSIONS: CT-based structural rigidity analysis is better than Mirels score in predicting femoral impending pathologic fracture. CTRA appears to provide a substantial advance in the accuracy of predicting pathological femur fracture over currently used clinical and radiographic criteria. LEVEL OF EVIDENCE: Level III, diagnostic study.

An unusual case of Ewing sarcoma: a middle-aged woman with multiple recurrences over 36 years.

Ewing sarcoma (EWS) is a primary bone tumor that most often occurs in the long bones of young patients. EWS is typically an aggressive tumor that is highly sensitive to radiation therapy; recurrences often occur, usually within a year of treatment. We present a case of EWS that first presented in a patient at the age of 40 with extraosseous disease. The patient was treated initially with radiation and surgery. Over the following 36-year period, the tumor recurred once and metastasized twice. The morphologic, immunohistochemical, and cytogenetic features of this tumor were typical of EWS, and the tumor was highly responsive to radiation therapy. The unusually prolonged course in this patient demonstrates significant heterogeneity in the biological behavior of EWS, and the importance of randomized trials in cancer therapy.

Chemotherapy influences the pseudocapsule composition in soft tissue sarcomas.

BACKGROUND: Soft tissue sarcomas are a heterogeneous group of malignant tumors. Standard treatment for soft tissue sarcoma of the extremity is surgical excision and adjuvant therapy; however, the role of neoadjuvant chemotherapy is controversial. QUESTIONS/PURPOSES: We sought to (1) define the histologic characteristics of the pseudocapsule in soft tissue sarcomas; (2) compare the appearance of this structure in chemotherapy-treated versus untreated soft tissue sarcomas; and (3) evaluate the effect of chemotherapy on the presence and viability of tumor cells at the host-sarcoma interface. METHODS: Twenty-eight patients with biopsy-proven, deep, high-grade extremity soft tissue sarcomas greater than 5 cm (AJCC stage III) treated with chemotherapy and surgical excision were compared histologically with 47 matched control subjects treated with surgery alone. RESULTS: A pseudocapsule was identifiable in the majority of tumors and consisted of two identifiable layers, each with specific histological characteristics suggesting the biologic processes occurring in these layers are different. The pseudocapsule was more frequently observed in the group treated with chemotherapy and it was more frequently continuous, thicker, and better developed in this group. Chemotherapy decreased the number of tumors with malignant cells identified within and beyond the pseudocapsule. CONCLUSIONS: Neoadjuvant chemotherapy contributed to the development of a pseudocapsule and decreased the number of tumors with malignant cells identified within and beyond the pseudocapsule. CLINICAL RELEVANCE: These findings may provide a histological explanation for the clinical effect of chemotherapy in soft tissue sarcoma. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Arthroscopic Lysis of Adhesions for the Stiff Total Knee Arthroplasty.

Background: Arthroscopic lysis of adhesions is a treatment option for patients with painful, stiff knees as a result of arthrofibrosis following knee arthroplasty, in whom prior manipulation under anesthesia (MUA) has failed. Typically, nonoperative treatment in these patients has also failed, including aggressive physiotherapy, stretching, dynamic splinting, and various pain-management measures or medications. Range of motion in these patients is often suboptimal, and any gains in flexibility will likely have hit a plateau over many months. The goal of performing lysis of adhesions is to increase the range of motion in patients with knee stiffness following total knee arthroplasty, as well as to reduce pain and restore physiologic function of the knee, enabling activities of daily living. Description: This is a straightforward surgical technique that can be performed in a single stage. The preoperative range of motion is documented after induction of general anesthesia. The procedure begins with the establishment of standard medial and lateral parapatellar arthroscopic portals. A blunt trocar is introduced into the knee, and blunt, manual lysis of adhesions is performed in the suprapatellar pouch and the medial and lateral gutters with use of a sweeping motion after piercing and perforating the scarred adhesive bands or capsular tissue. Next, the arthroscope is inserted into the knee, and a diagnostic arthroscopy is performed. Bands of fibrous tissue are released and resected with use of electrocautery and a 4.0-mm arthroscopic shaver. Next, the posterior cruciate ligament (PCL) is visualized in full flexion. If PCL tightness is observed, the PCL can be released from its femoral origin until the flexion gap is increased. This portion of the procedure can include either partial or full release of the PCL, as indicated. Next, the arthroscope is removed and the ipsilateral hip is flexed to 90° for a standard MUA. Gentle force is applied to the proximal aspect of the tibia, and the knee is flexed. After completing the MUA, immediate post-intervention range of motion of the knee is documented, and the patient is provided with a continuous passive motion (CPM) machine set to the maximum flexion and extension achieved in the operating room. Alternatives: Nonoperative treatment of a stiff knee following total knee arthroplasty is well documented in the current literature. Range of motion has been shown to increase in patients undergoing proper pain management, aggressive physical therapy, and closed MUA in the acute postoperative setting. Additionally, more severe cases of established arthrofibrosis despite prior MUA can be treated with an open lysis of adhesions1-3. Rationale: Arthroscopic lysis of adhesions with PCL release versus resection has been well described previously. This procedure has been shown to benefit patients in whom initial nonoperative treatment has failed. Additionally, this procedure is not limited to the immediate acute postoperative period like standard MUA3. To our knowledge, no technique video has been published outlining arthroscopic lysis of adhesions for a stiff knee following total knee arthroplasty. Expected Outcomes: This procedure has been shown to provide an immediate and lasting improvement in the flexion and extension arc of the knee, as well as improved functional outcomes. Patients should be educated that improvements gained in the operating room must be sustained through physical therapy. In a study of 32 patients who underwent arthroscopic lysis of adhesions for moderately severe arthrofibrosis following a total knee arthroplasty, Jerosch and Aldawoudy reported a mean postoperative flexion of 119° in the operating room and 97° at the time of the latest follow-up. Eight patients with extensor lag showed improvement from 27° to 4°. Average Knee Society scores improved from 70 points preoperatively to 86 points at the time of the latest follow-up4. Their article showed that arthroscopic treatment of stiffness following total knee arthroplasty is a safe and effective form of treatment. Important Tips: Perform manual lysis of adhesions with a trocar prior to inserting the arthroscope in order to improve visualization and access.Utilize all portals and accessory portals interchangeably in order to improve access.Prescribe physical therapy with or without CPM machine immediately following surgery in order to maintain correction.Utilize pump inflow in order to help distend the tightened capsule.Protect the prosthetic surface from scratches during portal establishment.Loss of flexion implies scarring in the suprapatellar pouch and/or intercondylar notch, or PCL tightness.Loss of extension implies a tight posterior capsule, posterior osteophytes, or scarring of the PCL stump.A motorized shaver is the best tool for treatment of dense fibrous tissue, but be sure not to scratch metal total knee components. Acronyms and Abbreviations: TKA = total knee arthroplastyROM = range of motionCT = computed tomographyMRI = magnetic resonance imagingESR = erythrocyte sedimentation rateCRP = C-reactive protein.

Sliding Hip Screw and Side Plate for Intertrochanteric Hip Fractures.

For stable intertrochanteric hip fractures, treatment commonly involves the use of a sliding hip screw. Intertrochanteric hip fractures are increasingly common as the population ages and lives longer. More than 250,000 hip fractures occur per year in the United States1. The mortality rate within the first year following operative treatment ranges from 14% to 27.3%2,3. Early surgical repair within 48 hours of injury is associated with a lower risk of mortality2,4,5. The goals of surgical treatment are restoration of coronal plane alignment without varus angulation and early patient mobilization. Description: The sliding hip screw procedure can be divided into (1) preoperative planning; (2) patient positioning; (3) C-arm setup; (4) closed reduction of fracture; (5) sterile preparation and draping; (6) lateral hip approach; (7) guide pin insertion; (8) triple-reaming the proximal aspect of the femur; (9) sliding hip screw insertion into the femoral neck and head; (10) side plate insertion, engaging the sliding hip screw, and fixation to the femur; (11) lag compression screw insertion (if appropriate); and (12) final fluoroscopic images and wound closure. Alternatives: Intertrochanteric hip fractures must be surgically treated to avoid morbidity and increased risk of mortality. Nonoperative treatment is occasionally indicated in nonambulatory patients or those with high perioperative risk. If treated surgically, a common alternative implant option includes the intramedullary nail. Finally, for severely comminuted fractures or failed internal fixation, total hip arthroplasty may be necessary. Rationale: Sliding hip screws are as effective as intramedullary nails and often less costly6. In general, the quality of fracture reduction is more critical than the choice of implant7. A prospective study found no significant difference in walking ability with either sliding hip screws or intramedullary nails for stable intertrochanteric fractures8. Expected Outcomes: By 6 months, the majority of fractures will have healed; according to a prospective randomized study, 91% of stable fractures and 85% of unstable fractures had achieved radiographic union by that time9. Another study showed radiographically healed fractures in all 106 patients treated with sliding hip screws at median follow-up of 13.6 months8. Important Tips: Watch out for comminution of the greater or lesser trochanter, which may require supplemental fixation.Prior to completely reflecting the vastus lateralis muscle, control the bleeding from any perforators with use of 2-0 silk ties. This prevents recurrent bleeding, which often occurs if only cautery is utilized to coagulate these vessels.Utilize a 4.5-mm drill hole in the lateral cortex of the femur in order to allow for minor adjustments of the anterior femoral neck guide pin; otherwise, the pin will be held tightly and continue to be bound in the same direction by the lateral cortex on repeated attempts.If the guide pin is inadvertently withdrawn along with the reamer after reaming, a lag screw may be placed backward in the newly reamed hole and the guide pin passed back through the lag screw to reposition it.Extracapsular hip fractures should be carefully scrutinized for signs of instability, such as lateral wall comminution or reverse obliquity. The fracture may displace posteriorly when the patient is supine on the fracture table.While placing the guidewire, multiple entry attempts can weaken the lateral cortex and propagate the fracture into the subtrochanteric region.Superior placement of the lag screw results in poor tip-apex distance and a higher chance of screw cut-out.Be careful to prevent guidewire penetration into the hip joint.Loss of reduction or femoral head malrotation may occur during lag screw insertion. Acronyms & Abbreviations: AP = anteroposteriorfx's = fracturesIMN = intramedullary nailIV = intravenousPDS = polydioxanone sutureSHS = sliding hip screwTFL = tensor fascia lata.

Extensile Anterior and Posterior Knee Exposure for Complete Synovectomy of Diffuse Tenosynovial Giant Cell Tumor (Pigmented Villonodular Synovitis).

Diffuse tenosynovial giant cell tumor (TGCT), also known as pigmented villonodular synovitis, is a benign, neoplastic disease of the synovium that can lead to joint destruction, osteoarthritis, and long-term morbidity1,2. Often, there is extra-articular involvement in the intercondylar notch and posterior soft tissues. A complete anterior and posterior synovectomy of the knee is indicated for treating diffuse TGCT when the anterior and posterior compartments of the knee joint are involved. Additionally, either an anterior or posterior synovectomy may be performed when the TGCT is limited to 1 compartment of the knee. Although an anterior synovectomy is relatively straightforward technically, a posterior synovectomy is challenging because of the presence of the neurovascular and muscular structures, which limit access, and because of the infrequency of the procedure. Description: The surgical technique for open anterior and posterior knee synovectomy is performed under 1 anesthetic via separate exposures with the patient initially supine and then prone. In cases of focal TGCT, in which both the anterior and posterior compartments are involved, either an anterior or posterior approach can be utilized in isolation to target the affected compartment. The anterior approach is performed via anteromedial parapatellar arthrotomy, with care to preserve the meniscal attachments and ligaments. Once the suprapatellar pouch is visualized, all tissue deep to the quadriceps muscle and tendon, extending around to the femoral periosteum, is excised en bloc. Attention is then turned to the undersurface of the patella, fat pad, distal aspect of the femur, and proximal aspect of the tibia. The tumor may be embedded within the fat pad and must be removed. Any tumor remnants within the medial or lateral gutter or beneath the menisci are excised with use of a standard or pituitary rongeur or curets. The quadriceps tendon, subcutaneous tissue, and skin are closed over a deep drain, and the patient is turned prone and re-prepared for the posterior approach. The posterior synovectomy utilizes an S-shaped incision either superolateral to inferomedial or superomedial to inferolateral, depending on the location of the TGCT. The popliteal artery and vein and the tibial and common peroneal nerves are identified, mobilized, and protected during retraction. This step requires ligating the geniculate and other small branches of the popliteal artery and vein. To expose the posterior femoral condyle, the medial and/or lateral heads of the gastrocnemius must be tagged and released by dividing the myotendinous origin from the posterior aspect of the femur at the proximal extent of the condyle. Alternatives: Although surgical resection is the primary treatment for TGCT, nonsurgical alternatives include radiation therapy (either external beam or radiosynoviorthesis) and the use of pharmacologic agents. Radiation therapy is associated with complications such as irreversible skin changes, arthrofibrosis, arthritis, osteonecrosis, and radiation-induced sarcoma1,2. Systemic agents such as tyrosine kinase inhibitors (e.g., nilotinib and imatinib) or agents targeting the CSF-1 (colony-stimulating factor-1) pathway (e.g., pexidartinib and emactuzumab) are active against TGCT. The agents are typically employed in recurrent, advanced, and unresectable situations in which surgical morbidity would outweigh the therapeutic benefit2. Aside from open synovectomy, arthroscopic synovectomy-usually anterior-has been utilized by some centers. Rationale: To our knowledge, there is no Level-I study indicating the superiority of 1 surgical technique over the other treatments for diffuse TGCT. Anterior arthroscopic synovectomy, in isolation, for diffuse TGCT has demonstrated recurrence rates as high as 92% to 94%1. Recent studies comparing anterior and posterior open and arthroscopic synovectomy have demonstrated mixed results, are limited by being retrospective, and are subject to selection bias because of the open synovectomy being selected for more extensive disease2,3. The mixed results may a result of variation in both tumor size and location about the knee joint2. The benefit of an open anterior and posterior synovectomy is that it can provide optimal exposure for large and extra-articular tumor masses that would not be accessible using an arthroscopic approach and allows for complete, gross total excision without morsellization of the tumor. The surgeon must be familiar and facile with vascular dissection techniques, even if the soft tissues surrounding the vascular structures are preserved as much as possible, in an effort to minimize postoperative edema4. Expected Outcomes: Open anterior and posterior synovectomy provides improved exposure for large and extra-articular tumor masses and has a 5-year recurrence-free survival of 29% to 33%5-7. Pain associated with diffuse TGCT has been demonstrated to improve in 59% of cases, with swelling reported to improve by 72% in patients following surgical intervention7. No significant difference has been reported when comparing open versus arthroscopic synovectomy in terms of arthritic progression, with 8% of patients progressing to a total knee arthroplasty at a mean follow-up of 40 months3. Important Tips: Careful preoperative planning is crucial: note all locations of posteriorly located tumor on magnetic resonance imaging and in relation to anatomic landmarks and neurovascular structures in order to guide dissection.It can be advantageous to have multiple blunt retractor options available when dissecting in tight spaces.Be prepared for vessel ligation with free ties, vessel clips, and additional clamps.The technical ability to dissect and mobilize the popliteal vessels is essential, but this step can be tedious.At the time of incision, preserve the integrity of the popliteal fascia to facilitate a good closure later, as this step avoids the herniation of tissues in the popliteal fossa. Because this fascial tissue is fragile, the use of a monofilament rather than braided suture in addition to the placement of far-near-near-far-type figure-of-8 sutures minimizes the risk of tearing the fascia during reapproximation.To ease retraction of the soft tissues, slightly flex the knee to relax the hamstring and other muscles and neurovascular structures. This will also reduce the risk of a postoperative nerve palsy.Although separate instruments for the anterior and posterior portions of the procedure are not necessary, separate drapes, gown, and gloves and other preoperative preparation should be readied in advance for the second portion of the procedure in order to save operative time. Acronyms & Abbreviations: PVNS = pigmented villonodular synovitisROM = range of motionMRI = magnetic resonance imagingGastroc = gastrocnemiusPDS = polydioxanone sutureCAM = controlled ankle motionASA = acetylsalicylic acid (aspirin).

Core Decompression and Bone Marrow Aspiration Concentrate Grafting for Osteonecrosis of the Femoral Head.

BACKGROUND: Core decompression (CD) with bone marrow aspiration concentrate (BMAC) is a technique that may improve outcomes in osteonecrosis of the femoral head (ONFH). The primary aim of this study was to evaluate the radiographic progression free survival (PFS) of CD augmented with BMAC. Secondary aims were to determine the survivorship with conversion (CFS) to total hip arthroplasty (THA) as an endpoint, determine prognostic factors, and characterize the cellular quality of the BMAC. METHODS: A retrospective cohort study of 61 femoral heads (40 patients) was performed. Patient demographics, comorbidities, BMI, smoking status, etiology, location and extent of ONFH were recorded. The primary endpoint was radiographic progression of ONFH and secondarily, conversion to THA. Additional aims were to determine predictive factors for progression and report the cellular characteristics of the BMAC. Data obtained were compared to the results of a prior randomized controlled trial comparing CD alone versus CD with polymethylmethacrylate cement (PMMA) augmentation. RESULTS: Radiographic PFS of CD with BMAC at 2 and 5 years was 78.3% and 53.3%, respectively. The risk of progression was lower in the CD with BMAC group compared to CD alone (HR0.45, p = 0.03), however this difference no longer remained statistically significant on multivariate analysis. Conversion to total hip arthroplasty free survival (CFS) of CD with BMAC at both 2 and 5 years was 72.1% and 54.6%, respectively with no differences compared to the control groups (CD alone, CD and PMMA). The predictive factors for progression were obesity (BMI ≥ 30) and the extent of the disease as quantified by either percentage involvement, necrotic index or modified necrotic index. CONCLUSIONS: No differences in PFS or CFS between CD with BMAC compared to CD alone or CD with PMMA were identified. Independent statistically significant predictors of progression-free survival or conversion to THA are BMI ≥ 30 and the extent of ONFH. Further research with an adequately powered randomized controlled trial is needed. LEVEL OF EVIDENCE: 3.

Prospective Trial of Monocyte Count as a Biomarker of Hand-Foot Syndrome Among Patients With Soft Tissue Sarcomas Treated With Pegylated Liposomal Doxorubicin and Ifosfamide.

Pegylated liposomal doxorubicin (PLD) is widely used and can be used for prolonged periods, with the limiting toxicity usually being hand-foot syndrome (HFS). The pharmacokinetics of PLD is variable between patients, leading to variability in the risk of developing HFS. Dosing based on body surface area does not decrease variability in PLD clearance; thus, other predictive markers could be useful. The peripheral blood absolute monocyte count (AMC) has been suggested as a possible marker of both reticuloendothelial system function and PLD pharmacokinetics. The present study examined the AMC as a potential predictive biomarker in a prospective trial of pre-operative PLD combined with ifosfamide in soft tissue sarcomas (STSs). While our results suggest a relationship between pre-treatment AMC and PLD-induced HFS, the association did not reach statistical significance. The clinical utility of the AMC as a predictor of PLD-induced HFS appears limited, at least when given with ifosfamide.

Prospective Trial of Neutrophil/Lymphocyte Ratio and Other Blood Counts as Biomarkers of Survival among Patients with High-Grade Soft Tissue Sarcomas Treated with Pegylated Liposomal Doxorubicin and Ifosfamide.

Several studies have reported an association between levels of circulating blood cells, in particular the neutrophil to lymphocyte ratio (absolute neutrophil count (ANC)/absolute lymphocyte count (ALC)) and outcomes in patients with cancer. In the current study, the association between lymphocyte, neutrophil, monocyte, and platelet counts and survival was examined in a prospective trial of preoperative pegylated-liposomal doxorubicin and ifosfamide for high-grade soft-tissue sarcomas. A statistically significant association between overall survival, but not progression free-survival, was observed with the ANC/ALC ratio at a cutoff value of ≥2 and a statistically significant trend using a cutoff of ≥5. Our results suggest that a balance between the lymphocyte count and the number of circulating myeloid cells that can suppress lymphocyte function may be predictive of survival in patients with soft-tissue sarcomas. Future research should therefore examine the role of lymphocyte-myeloid cell balance in sarcoma biology.