Clinical compatibility of magnetic resonance imaging with magnetic intramedullary nails: a feasibility study.

INTRODUCTION: The use of magnetic resonance imaging (MRI) with a magnetic intramedullary lengthening nail in place is contraindicated per the manufacturer due to the concern of implant activation and migration. A prior in vitro study did not confirm these complications only noting that a 3.0 T MRI weakened the internal magnet. Therefore, a retrospective analysis of patients who underwent an MRI with a magnetic nail in place was performed to determine if any adverse effects occurred in the clinical setting. MATERIALS AND METHODS: A retrospective review of all patients who underwent an MRI with a magnetic lengthening nail in place was performed. The time spent being imaged in the MRI, number of times the patient entered the MRI suite, and the images obtained were recorded. Radiographs were performed before and after the MRI to determine if any hardware complications occurred. The patients were monitored for any adverse symptoms while they were in the suite. RESULTS: A total of 12 patients with 13 nails were identified. Two patients underwent imaging with a 3.0 T MRI while the remaining 10 underwent imaging with a 1.5 T MRI. Each patient entered the MRI suite 2.1 times and spent an average of 84.7 min being imaged in the MRI (range 21-494). No patients noted any adverse symptoms related to the nail while in the suite and no hardware complications were identified. CONCLUSION: MRI appears to be safe with a magnetic nail in place and did not result in any complications. Given the manufacturer's recommendations, informed consent should be obtained prior to an MRI being performed and a 3.0 T MRI should be avoided when possible if further activation of the nail is required.

All-Internal Limb Lengthening with Simultaneous Corrective Osteotomy After Internal Hemipelvectomy: A Case Report.

CASE: A 27-year-old woman with a Grade II chondrosarcoma in the right acetabulum underwent a Type II internal hemipelvectomy with an ischiofemoral fusion. She developed a 7.0-cm functional limb-length discrepancy with adduction of the hip at rest. Four years after surgery, she underwent a corrective osteotomy and limb lengthening with a magnetic lengthening nail. Eleven years after tumor resection and a successful pregnancy, she had symmetric leg lengths and ambulated without an assistive device. CONCLUSIONS: A magnetic lengthening nail is a viable option for correcting limb-length discrepancies after hemipelvectomy. If necessary, a simultaneous corrective proximal femoral osteotomy can be performed.

Outpatient Opioid Prescribing Habits in Pediatric Patients With Bone Sarcomas After Undergoing Primary Tumor Resection.

BACKGROUND: The majority of children with bone sarcomas experience pain. Opioids remain the mainstay treatment of cancer-related pain in children. The patterns of outpatient opioid prescription after surgery for primary bone sarcomas remains unknown. The purpose of this study is to evaluate the patterns of outpatient opioid prescription in patients with bone sarcomas after resection of the primary tumor, and to assess for factors that may lead to increased opioid dosing in these patients. METHODS: A retrospective chart review of 28 patients with bone sarcomas undergoing primary tumor resection was performed. Demographic, medical, surgical, and pharmacological data was collected from all patients. The total morphine milligram equivalents (MMEs) prescribed after patient discharge were compared at 30-day intervals. The MMEs were then stratified by tumor location, presence of metastasis at time of surgery, and preoperative opioid use. Independent predictors of increased 30-day and total 120-day opioid utilization were evaluated. RESULTS: Patients with preoperative opioid use were prescribed significantly more opioids in every 30-day postoperative interval and for the 120-day total. When stratified by tumor location, patients with primary tumors in the pelvis had significantly greater postoperative opioid utilization when compared with patients with tumors located in the lower and upper extremities during postoperative days 61 to 90 (5970 vs. 1060.4 and 0 MMEs, respectively, P=0.048) and during postoperative days 91 to 120 (6450 vs. 829.6 and 0 MMEs, respectively, P=0.015). Older age, diagnosis of osteosarcoma, increased length of stay postoperatively and presence of metastases were associated with a higher 30-day postoperative opioid utilization. CONCLUSION: Multiple factors were associated with increased opioid use including preoperative opioid use, longer postoperative stay in the hospital, metastatic disease, and primary sarcomas in the pelvis. The patient's sex, body mass index, race, type of insurance, type of surgery performed, reoperation during the same admission and use of nonopioid adjuvants had no effect on opioid use. The results of this study can be used to stratify the average opioid requirement of pediatric patients undergoing primary bone sarcoma resection. LEVEL OF EVIDENCE: Level IV.

Robotic assistance for quick and accurate image-guided needle placement.

Computed tomography (CT) image-guided procedures including biopsy, drug delivery, and ablation are gaining increasing application in medicine. Robotic technology holds the promise for allowing surgeons, and other proceduralists, access to such CT-guided procedures by potentially shortening training, improving accuracy, decreasing needle passes, and reducing radiation exposure. We evaluated surgeon learning and proficiency for image-guided needle placement with an FDA-cleared robotic arm. Five out of six surgeons had no prior CT-guided procedural experience, while one had prior experience with freehand CT-guided needle placement. All surgeons underwent a 60-min training with the MAXIO robot (Perfint Healthcare, Redmond, WA). The robot was used to place needles into three different pre-specified targets on a spine model. Performance time, procedural errors, and needle placement accuracy were recorded. All participants successfully placed needles into the targets using the robotic arm. The average time for needle placement was 3:44 ± 1:43 min. Time for needle placement decreased with subsequent attempts, with average third placement taking 2:29 ± 1:51 min less than the first attempt. The average vector distance from the target was 2.3 ± 1.2 mm. One error resulted in the need for reimaging by CT scan. No errant needle placement occurred. Surgeons (attending fellows and residents) without previous experience and minimal training could successfully place percutaneous needles under CT guidance quickly, accurately, and reproducibly using a robotic arm. This suggests that robotic technology may be used to facilitate surgeon adoption of CT image-guided needle-based procedures in the future.

Long-Term Follow-up of High-Dose Chemotherapy with Autologous Stem Cell Transplantation in Children and Young Adults with Metastatic or Relapsed Ewing Sarcoma: A Single-Institution Experience.

Forty-seven patients with metastatic disease at diagnosis or recurrent Ewing sarcoma (EWS) received high-dose chemotherapy (HDC) followed by tandem (n = 20, from February 13, 1997, to October 24, 2002) or single (n = 27, from October 1, 2004, to September 5, 2018) autologous hematopoietic stem cell transplantation (ASCT). To our knowledge, this is the largest single-institution study with sustained long-term follow-up exceeding 10 years. All patients who underwent single ASCT received a novel conditioning regimen with busulfan, melphalan, and topotecan. The overall survival (OS) and disease-free survival (DFS) were 46% and 37% at 10 years and 42% and 37% at 15 years, respectively. Disease status at transplant and the time to disease relapse prior to ASCT were identified as important prognostic factors in OS, DFS, and risk of relapse. At 10 years, patients who underwent transplantation in first complete response (1CR) had an excellent outcome (OS 78%), patients in 1CR/second complete response (2CR)/first partial response (1PR) had an OS of 66%, and patients at third or more complete response, second or more partial response, or advanced disease had an OS of 26%. Ten-year OS for patients without a history of relapse, with late relapse (≥2 years from diagnosis), or with early relapse (<2 years from diagnosis) was 75%, 50%, and 18%, respectively. Selected patients in 1CR, 2CR, 1PR, and with late relapse had excellent, sustained 10- and 15-year OS and DFS.