Treatments and Sequelae of Pediatric Pathologic Proximal Femur Fractures Due to Benign Bone Cyst.

BACKGROUND: The proximal femur is a common location for pathologic fractures in children, yet there is little published information regarding this injury. The purpose of this study was to investigate the outcomes of pediatric pathologic proximal femur fractures due to benign bone tumors. METHODS: A retrospective review of patients treated for pathologic proximal femur fractures from 2004 to 2018 was conducted. Inclusion criteria were age below 18 years and pathologic proximal femur fracture secondary to a benign bone tumor. Patients were excluded if they had <1 year of follow-up. Medical charts and serial radiographs were reviewed for fracture classification, underlying pathology, treatment, complications, and time to fracture healing. RESULTS: A total of 14 patients were included. Mean age was 6±3 (3 to 11) years, and mean follow-up was 44±21 (22 to 86) months. Index treatment was spica casting in 9/14 (68%) patients, while 5/14 (32%) were treated with internal fixation. Of the 9 patients initially treated with casting, 22% (2/9) required repeat spica casting at a mean of 0.6 months after index treatment, 67% (6/9) required internal fixation at a mean of 20.3 months after index treatment, and 11% (1/9) did not require revision treatment. Eighty-eight percent (8/9) of patients treated with casting required revision treatment compared with 40% (2/5) of those treated with internal fixation (P=0.05). Nonunion occurred after 1 refracture, malunion with coxa vara occurred in 2 fractures, and the remaining 11/14 (84%) fractures had a union at a mean of 4.9±3.0 months All cases of malunion occurred in patients initially treated nonoperatively. There were 19 distinct complications in 10/14 (71%) patients. The incidence of any revision surgery was 64% (9/14). CONCLUSIONS: In this series, pediatric pathologic proximal femur fractures demonstrated prolonged time to union, high incidence of revision surgery (64%), and substantial complication rate (71%). In children with pathologic proximal femur fractures, treatment with internal fixation is recommended as this series showed a 78% failure rate of initial conservative management. LEVEL OF EVIDENCE: Level IV.

Effect of Static Alignment on Dynamic Knee Abduction Moments in Adolescent Athletes with Recent ACL Reconstruction.

PURPOSE: Dynamic limb valgus, particularly high knee abduction moments, is a known risk factor for anterior cruciate ligament (ACL) injury and may result from poor static anatomic limb alignment, faulty biomechanics, or a combination of both. The purpose of this study was to assess the influence of static lower extremity anatomic alignment and dynamic kinematic/kinetic measures on knee abduction moments during sidestep cutting in adolescent athletes with recent ACL reconstruction. METHODS: This retrospective study included 50 adolescents with recent unilateral ACL reconstruction (18/50 female, mean age = 15.8 yr, 7.6 months postsurgery). Frontal plane hip-to-ankle imaging was used to measure mechanical axis deviation and tibial-femoral angle. Three-dimensional motion capture provided lower extremity kinematics and kinetics during quiet standing and during the loading phase (initial contact to peak knee flexion) of an anticipated 45° sidestep cut. Imaging, static motion capture, and dynamic motion capture measures were investigated as potential predictors of average dynamic knee abduction moment using correlation and backward stepwise linear regression. RESULTS: Dynamic knee abduction moment was best predicted by a combination of younger age and dynamic measures: trunk lean toward the planting limb, knee abduction and external rotation, and ankle inversion. Although static measures were correlated with dynamic knee abduction moment in univariate analysis, no static/anatomic variables entered the model once the dynamic measures were included. CONCLUSION: Knee abduction moments during sidestep cutting were related to dynamic factors reflecting frontal and transverse plane motion. Static (anatomic) lower limb alignment did not influence knee abduction moments once these dynamic factors were considered. Knee abduction moments and ACL injury risk are therefore not dictated by anatomic alignment and can be altered through neuromuscular/biomechanical training.

Iliotibial Band Autograft Provides the Fastest Recovery of Knee Extensor Mechanism Function in Pediatric Anterior Cruciate Ligament Reconstruction.

Iliotibial band autograft is an increasingly popular option for pediatric anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to compare recovery of knee extensor mechanism function among pediatric patients who underwent ACLR using iliotibial band (IT), hamstring tendon (HT), quadriceps tendon (QT), and patellar tendon (PT) autografts. One hundred forty-five pediatric athletes (76 female; age 15.0, range 7-21 years) with recent (3-18 months) unilateral ACLR performed drop-jump landing and 45° cutting with 3D motion capture. Knee extensor mechanism function (maximum knee flexion angle, maximum internal knee extensor moment, energy absorption at knee) during the loading phase (foot contact to peak knee flexion) was compared among graft types (20 IT, 29 HT, 39 QT, 57 PT) and sides (ACLR or contralateral) using linear mixed models with sex, age, and time since surgery as covariates. Overall, knee flexion was significantly lower on the operated vs. contralateral side for HT, QT, and PT during both tasks (p < 0.03). All graft types exhibited lower knee extensor moments and energy absorption on the operated side during both movements (p ≤ 0.001). Kinetic asymmetry was significantly lower for IT compared with QT and PT during both movements (p ≤ 0.005), and similar patterns were observed for HT vs. QT and PT (p ≤ 0.07). Asymmetry was similar between IT and HT and between QT and PT. This study found that knee extensor mechanism function recovers fastest in pediatric ACLR patients with IT autografts, followed by HT, in comparison to QT and PT, suggesting that IT is a viable option for returning young athletes to play after ACLR.

Current practice trends in the surgical management of patellofemoral instability: a survey of the Paediatric Research in Sports Medicine (PRiSM) Society.

PURPOSE: Patellofemoral instability (PFI) in young athletes presents both diagnostic and management dilemmas for which consensus often does not exist. The purpose of this study was to identify trends in management of PFI in children and adolescents in the United States and nationwide. METHODS: A 27-question multiple choice survey was distributed in 2018 to the members of the Pediatric Research in Sports Medicine (PRiSM) Society regarding treatment of PFI in paediatric and adolescent patients. RESULTS: In all, 56 of the respondents who were orthopaedic surgeons that manage patellar instability in children and adolescents and had performed PFI surgery more than five times in the past year completed the entire survey. A total of 41% of respondents reported that surgery for fragment refixation or loose body removal was indicated when a loose body or osteochondral fragment was evident, regardless of fragment size. Overall, 74% reported that if surgery was performed for an osteochondral loose body, primary repair (36%) or reconstruction (38%) of medial patellofemoral ligament (MPFL) was also completed. A total of 89% of members reported MPFL reconstruction in the absence of alignment or rotational abnormalities, tibial tubercle lateralization or trochlear dysplasia in skeletally immature patients; 59% reported performing the MPFL reconstruction with hamstring allograft, while 30% prefer autograft (hamstring, quadriceps). For patients with significant trochlear dysplasia, 87% reported no surgical management of trochlea in first-time or in revision surgery. CONCLUSION: There is a lack of consensus regarding optimal diagnostic and treatment algorithms in the management of PFI, however, consistent trends have emerged among paediatric sports medicine surgeons. LEVEL OF EVIDENCE: Level V - survey of expert opinion and experience.

Movement variability in pre-teen and teenage athletes performing sports related tasks.

BACKGROUND: Understanding movement variability is important to guide biomechanical assessment. Variability may change with age, and more repetitions of a movement need to be assessed when variability is high. RESEARCH QUESTION: This study quantified the trial-to-trial (within subject) variability of three tasks commonly assessed during sports biomechanical testing: vertical drop jump, heel touch (single leg squat from step), and single leg hop. We hypothesized that pre-teen athletes would exhibit greater variability than more mature teenage athletes when performing all of these movements. METHODS: Fifty-five uninjured pediatric athletes ages 7-15 years performed 3 repetitions of vertical drop jump, heel touch, and single leg hop for distance tasks during 3D motion analysis testing. Trial-to-trial variability was assessed using the standard deviation (SD) and range (maximum-minimum) of clinically relevant kinematic and kinetic metrics among the multiple repetitions of each task performed by each participant. Variability was compared between age groups using 2-sided t-tests. Standard error of measurement (SEM) and minimum detectable difference (MDD) were also calculated for each variable of interest. RESULTS: For drop jump and heel touch, kinetic variability was similar between groups, but the younger group had greater kinematic variability. However, the older group was much more variable than the younger group during single leg hop landing, particularly in terms of kinetics and sagittal plane kinematics. Overall, kinematic variability had a median within-subject SD of 1-9°, median range of 2-17°, and 95th percentile for range of >15-20° for many of the variables examined. MDD was >10° for many kinematic variables, >0.2 Nm/kg for all frontal plane moments, >0.4 Nm/kg for most sagittal plane moments, and >0.5 W/kg for most energy absorption variables. SIGNIFICANCE: The high within-subject trial-to-trial variability in performing sports tasks suggests that multiple trials should be analyzed for a more complete and representative evaluation.

Failure Rates of Autograft and Allograft ACL Reconstruction in Patients 19 Years of Age and Younger: A Systematic Review and Meta-Analysis.

BACKGROUND: Graft choice for pediatric anterior cruciate ligament reconstruction (ACLR) is determined by several factors. There is limited information on the use and outcomes of allograft ACLR in pediatric patients. The purpose of this systematic review and meta-analysis was to quantify reported failure rates of allograft versus autograft ACLR in patients ≤19 years of age with ≥2 years of follow-up. We hypothesized that there would be higher rates of failure for allograft compared with autograft ACLR in this population. METHODS: PubMed/MEDLINE and Embase databases were systematically searched for literature regarding allograft and autograft ACLR in pediatric/adolescent patients. Articles were included if they described a cohort of patients with average age of ≤19 years, had a minimum of 2 years of follow-up, described graft failure as an outcome, and had a Level of Evidence grade of I to III. Qualitative review and quantitative meta-analysis were performed to compare graft failure rates. A random-effects model was created to compare failure events in patients receiving allograft versus autograft in a pairwise fashion. Data analysis was completed using RevMan 5.3 software (The Cochrane Collaboration). RESULTS: The database search identified 1,604 studies; 203 full-text articles were assessed for eligibility. Fourteen studies met the inclusion criteria for qualitative review; 5 studies were included for quantitative meta-analysis. Bone-patellar tendon-bone (BTB) represented 58.2% (n = 1,012) of the autografts, and hamstring grafts represented 41.8% (n = 727). Hybrid allografts (autograft + supplemental allograft) represented 12.8% (n = 18) of all allograft ACLRs (n = 141). The unweighted, pooled failure rate for each graft type was 8.5% for BTB, 16.6% for hamstring, and 25.5% for allograft. Allografts were significantly more likely than autografts to result in graft failure (odds ratio, 3.87; 95% confidence interval, 2.24 to 6.69). CONCLUSIONS: Allograft ACLR in pediatric and adolescent patients should be used judiciously, as existing studies revealed a significantly higher failure rate for allograft compared with autograft ACLR in this patient population. Additional studies are needed to improve the understanding of variables associated with the high ACLR failure rate among pediatric and adolescent patients. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Improvements in landing biomechanics following anterior cruciate ligament reconstruction in adolescent athletes.

Motion analysis offers objective insight into biomechanics, rehabilitation progress and return to sport readiness. This study examined changes in three-dimensional movement patterns during drop jump landing between early and late stages of rehabilitation in adolescent athletes following anterior cruciate ligament reconstruction (ACLR). Twenty-four athletes (58% female; mean age 15.4 years, SD 1.2) with unilateral ACLR underwent motion analysis testing 3-6 months and again 6-10 months post-operatively. Kinematics and kinetics were compared between visits and between limbs using repeated measures ANOVA. The operative side exhibited lower vertical ground reaction force, less energy absorption and lower sagittal external moments at the knee and ankle, and lower peak dorsiflexion angles compared with the non-operative side regardless of visit. Between visits, hip and knee flexion increased bilaterally, as well as hip flexion moments and energy absorption. During early rehabilitation following ACLR, adolescent athletes reduced flexion and loading of the knee and ankle on their operative limb. Motion and loading increased over time, particularly at the hip, but remained reduced at the knee and ankle 6-10 months post-operatively.

Prospective Evaluation of a Treatment Protocol Based on Fracture Displacement for Pediatric Lateral Condyle Humerus Fractures: A Preliminary Study.

BACKGROUND: To prospectively evaluate a displacement-based classification system and an outcome-derived algorithm in the treatment of children with lateral condyle fractures. METHODS: All children with a lateral condyle fracture were prospectively enrolled at our institution between 2013 and 2016. Fractures were classified and treated on the basis of the following classification system: type 1: <2 mm; treated with long arm casting, type II: 2 to 4 mm; treated with closed reduction and percutaneous pinning (CRPP), and type III: >4 mm; open reduction and percutaneous pinning (ORPP). Functional outcomes were assessed at 6 to 12 weeks and at 1-year follow-ups using the Pediatric Outcomes Data Collection Instrument (PODCI). RESULTS: A total of 55 patients (mean age, 6 y; range 2 to 12 y) were prospectively enrolled. There were 17 (31%) type I fractures treated with a long arm cast, 8 (15%) type II treated with CRPP, and 30 (54%) type III treated with ORPP. Postoperative complications included delayed union (N=5) and pin site infection (N=3). Delayed unions on the basis of fracture type was type I (1/17, 6%), type II (1/8, 13%), and type III (3/30, 10%) (P=0.85). The rate of delayed unions in type II and III fractures fixed with k-wires was 11% (4/38). Four patients required a second operation with screw fixation. No significant differences were found across PODCI domains at 1-year follow-up when comparing our study population with normative data. CONCLUSIONS: This is the first prospective study of a treatment protocol for pediatric lateral condyle fractures and validates the use of displacement as a guide for best evidence-based treatment. Children with a lateral condyle fracture can achieve excellent functional outcomes in all classification types with comparable complication rates when radiographic fracture displacement is used to guide surgical and clinical decision making. LEVEL OF EVIDENCE: Level II.

Socioeconomic status impacts outcomes following pediatric anterior cruciate ligament reconstruction.

Previous research has shown that delays in pediatric anterior cruciate ligament (ACL) reconstruction are associated with increased prevalence of concomitant knee injuries and worse outcomes following surgery. However, few studies have described factors that may contribute to these delays and adverse outcomes. This study seeks to determine the effect of socioeconomic status on clinical outcomes following ACL reconstruction.A retrospective review of patients who underwent primary ACL reconstruction at a tertiary pediatric hospital between 2009 and 2015 was conducted. Variables included chronologic, demographic, and socioeconomic data, and postoperative complications. Socioeconomic status was measured using health insurance type and median household income levels derived from 2009 to 2015 US Census Bureau.A total of 127 patients (69 male, 58 female) were included. The mean age at time of surgery was 15.0 years. Overall, 68 patients had commercial insurance and 59 patients had government-assisted insurance. The mean household median income for patients with commercial insurance was $87,767 compared to $51,366 for patients with government-assisted insurance. Patients with government-assisted insurance plans demonstrated greater delays in time from injury to initial orthopaedic evaluation (P = .0003), injury to magnetic resonance imaging (MRI) examination (P = .021), injury to surgery (P < .0001), initial orthopaedic evaluation to surgery (P = .0036), and injury to return to play clearance, P = .044. Median household income was significantly related to time from injury to MRI examination (P = .0018), injury to surgery (P = .0017), and initial orthopaedic evaluation to surgery (P = .039). Intraoperatively, 81% of patients with government-assisted insurance had concomitant meniscal injuries compared 65% of patients with commercial insurance, P = .036. Postoperatively, 22% of patients with government-assisted insurance were found to have decreased knee range of motion ("stiffness") compared to 9% of patients with commercial insurance, P = .034.Pediatric patients who have government-assisted plans may experience delays in receiving definitive injury management and be at risk for postoperative complications. Our findings suggest a significant discrepancy in time to treatment as well as rates of concomitant knee injuries and postoperative complications between government and commercial insurance types.Level of Evidence: III.

Confirming the Presence of Unrecognized Meniscal Injuries on Magnetic Resonance Imaging in Pediatric and Adolescent Patients With Anterior Cruciate Ligament Tears.

BACKGROUND: Prior research has shown decreased accuracy of meniscal injury detection using magnetic resonance imaging (MRI) for anterior cruciate ligament (ACL)-deficient adult patients as well as ACL-deficient pediatric and adolescent patients. The objectives of this study were the following: (1) assess the diagnostic ability of MRI in detecting meniscal injuries for pediatric and adolescent patients undergoing arthroscopic ACL reconstruction and (2) characterize the unrecognized meniscal injuries. METHODS: The sensitivity, specificity, positive predictive value, and negative predictive value of meniscal tears (medial, lateral, or both) on MRI were calculated for the 107 patients in this cohort. Fisher exact tests were used to compare event frequencies between medial meniscal (MM) and lateral meniscal (LM) tears. One-way analysis of variance tests were performed to compare event rates between the location and type of unrecognized meniscal tears. RESULTS: The median age of the cohort was 15 (range: 7 to 18). The sensitivity, specificity, positive predictive value, and negative predictive value of MRI in detecting meniscal tears (medial, lateral, or both) in ACL-deficient pediatric and adolescent patients was 62.3%, 68.4%, 78.2%, and 50.0%, respectively. There were 26 (24.3%) cases in which a meniscal injury was not detected on MRI, but was discovered arthroscopically (MM: 5 knees, LM: 20 knees, both: 1 knee). These unrecognized meniscal injuries were more commonly the LM than the MM (77.8%, P-value=0.100), a vertical/longitudinal tear type (77.8%, P-value <0.001), and located in the posterior horn (74.1%, P-value <0.001). CONCLUSIONS: In this ACL-deficient pediatric and adolescent cohort, there were 26 (24.3%) patients with unrecognized meniscal injuries. A vertical tear in the posterior horn was the most commonly unrecognized meniscal injury, supporting the findings of prior research postulating that the location and configuration of a tear influence the accuracy of MRI in detecting these injuries. More research is needed to investigate strategies to improve the detection of meniscal tears in pediatric and adolescent patients preoperatively. These findings have implications with regard to patient counseling, operative planning, anticipatory guidance with regard to postoperative rehabilitation, recovery expectations, and surgical outcomes. LEVEL OF EVIDENCE: Level IV.

Management of Long-Term Complications in the Setting of Lateral Meniscal Deficiency After Saucerization of a Discoid Lateral Meniscus in an Adolescent Patient: A Case Report and Review of the Literature.

CASE: A 14-year-old adolescent with bilateral discoid menisci who had previously undergone discoid meniscal saucerization presented with pain and mechanical knee symptoms bilaterally. She had a torn left discoid lateral meniscus, a right lateral meniscal deficiency with an associated osteochondral defect, and valgus collapse of the right femur. She underwent successful repair of the left discoid meniscus as well as a femoral osteotomy, a meniscal transplant, and an osteochondral allograft transplantation in the right knee. CONCLUSION: New treatment paradigms following initial interventions for discoid menisci are discussed. Patients may benefit from longer follow-up after discoid meniscal surgery, and providers should consider joint-preserving techniques early in the setting of meniscal deficiency.

Comparison of drop jump landing biomechanics and asymmetry among adolescents with hamstring, patellar and quadriceps tendon autografts for anterior cruciate ligament reconstruction.

BACKGROUND: Adolescent anterior cruciate ligament reconstruction (ACLR) commonly utilizes hamstring (HT), patellar (PT) or quadriceps (QT) tendon autografts, but consensus is lacking regarding optimal graft choice. This study compared landing biomechanics and asymmetries among ACLR patients with HT, PT and QT grafts and uninjured controls. METHODS: This retrospective study included 61 adolescents with unilateral ACLR (27 HT, 20 PT, 14 QT; four to 12 months post-surgery, mean 6.4; age 15.4, SD 1.4 years) and 27 controls (14.6, SD 0.9 years) who were evaluated during drop jump landings. Lower extremity 3D biomechanics and asymmetries were compared. RESULTS: Compared to controls, all operative limbs exhibited 1) greater hip flexion and lower dorsiflexion angles; 2) higher hip and lower knee and ankle flexion moments; 3) higher energy absorption at the hip (HT and QT only) and lower at the knee and ankle; and 4) higher knee abduction moments. Asymmetries observed in all ACLR groups included 1) lower knee and ankle flexion angles; 2) lower knee and ankle flexion moments; 3) lower energy absorption at the knee and ankle; and 4) higher hip and knee abduction moments on the operative side. The PT and QT groups demonstrated greater asymmetry in hip and knee flexion moments compared to HT. CONCLUSIONS: While adolescent ACLR limbs offloaded the knee and ankle, patients with PT or QT grafts demonstrated greater deficiencies during rehabilitation than those reconstructed with HT. Graft choice in ACLR should remain patient-specific and aim to optimize biomechanics with the ultimate goal of minimizing graft re-tear and donor site morbidity.

Hop Distance Symmetry Does Not Indicate Normal Landing Biomechanics in Adolescent Athletes With Recent Anterior Cruciate Ligament Reconstruction.

Background Return-to-sport protocols after anterior cruciate ligament reconstruction (ACLR) often include assessment of hop distance symmetry. However, it is unclear whether movement deficits are present, regardless of hop symmetry. Objectives To assess biomechanics and symmetry of adolescent athletes following ACLR during a single-leg hop for distance. Methods Forty-six patients with ACLR (5-12 months post surgery; 27 female; mean ± SD age, 15.6 ± 1.7 years) were classified as asymmetric (operative-limb hop distance less than 90% that of nonoperative limb [n = 17]) or symmetric (n = 29) in this retrospective cohort. Lower extremity biomechanics were compared among operative and contralateral limbs and 24 symmetric controls (12 female; mean ± SD age, 14.7 ± 1.5 years) using analysis of variance. Results Compared to controls, asymmetric patients hopped a shorter distance on their operative limb (P<.001), while symmetric patients hopped an intermediate distance on both sides (P≥.12). During landing, the operative limb, regardless of hop distance, exhibited lower knee flexion moments compared to controls and the contralateral side (P≤.04), with lower knee energy absorption than the contralateral side (P≤.006). During takeoff, both symmetric and asymmetric patients had less hip extension and smaller ankle range of motion on the operative side compared with controls (P≤.05). Asymmetric patients also had lower hip range of motion on the operative, compared with the contralateral, side (P = .001). Conclusion Both symmetric and asymmetric patients offloaded the operative knee; symmetric patients achieved symmetry, in part, by hopping a shorter distance on the contralateral side. Therefore, hop distance symmetry may not be an adequate test of single-limb function and return-to-sport readiness. J Orthop Sports Phys Ther 2018;48(8):622-629. Epub 30 Mar 2018. doi:10.2519/jospt.2018.7817.

Cytokine preconditioning of engineered cartilage provides protection against interleukin-1 insult.

BACKGROUND: During osteoarthritis and following surgical procedures, the environment of the knee is rich in proinflammatory cytokines such as IL-1. Introduction of tissue-engineered cartilage constructs to a chemically harsh milieu may limit the functionality of the implanted tissue over long periods. A chemical preconditioning scheme (application of low doses of IL-1) was tested as a method to prepare developing engineered tissue to withstand exposure to a higher concentration of the cytokine, known to elicit proteolysis as well as rapid degeneration of cartilage. METHODS: Using an established juvenile bovine model system, engineered cartilage was preconditioned with low doses of IL-1α (0.1 ng/mL, 0.5 ng/mL, and 1.0 ng/mL) for 7 days before exposure to an insult dose (10 ng/mL). The time frame over which this protection is afforded was investigated by altering the amount of time between preconditioning and insult as well as the time following insult. To explore a potential mechanism for this protection, one set of constructs was preconditioned with CoCl2, a chemical inducer of hypoxia, before exposure to the IL-1α insult. Finally, we examined the translation of this preconditioning method to extend to clinically relevant adult, passaged chondrocytes from a preclinical canine model. RESULTS: Low doses of IL-1α (0.1 ng/mL and 0.5 ng/mL) protected against subsequent catabolic degradation by cytokine insult, preserving mechanical stiffness and biochemical composition. Regardless of amount of time between preconditioning scheme and insult, protection was afforded. In a similar manner, preconditioning with CoCl2 similarly allowed for mediation of catabolic damage by IL-1α. The effects of preconditioning on clinically relevant adult, passaged chondrocytes from a preclinical canine model followed the same trends with low-dose IL-1ß offering variable protection against insult. CONCLUSIONS: Chemical preconditioning schemes have the ability to protect engineered cartilage constructs from IL-1-induced catabolic degradation, offering potential modalities for therapeutic treatments.

Prevention of wound complications following salvage laryngectomy using free vascularized tissue.

BACKGROUND: Total laryngectomy following radiation therapy or concurrent chemoradiation therapy is associated with unacceptably high complication rates because of wound healing difficulties. With an ever increasing reliance on organ preservation protocols as primary treatment for advanced laryngeal cancer, the surgeon must develop techniques to minimize postoperative complications in salvage laryngectomy surgery. We have developed an approach using free tissue transfer in an effort to improve tissue vascularity, reinforce the pharyngeal suture line, and minimize complications in this difficult patient population. The purpose of this study was to outline our technique and determine the effectiveness of this new approach. METHODS: We conducted a retrospective review of a prospective cohort and compared it with a historical group (surgical patients of Radiation Therapy Oncology Group (RTOG)-91-11 trial). Eligibility criteria for this study included patients undergoing salvage total laryngectomy following failed attempts at organ preservation with either high-dose radiotherapy or concurrent chemo/radiation therapy regimen. Patients were excluded if the surgical defect required a skin paddle for pharyngeal closure. The prospective cohort consisted of 14 consecutive patients (10 males, 4 females; mean age, 58 years) who underwent free tissue reinforcement of the pharyngeal suture line following total laryngectomy. The historical comparison group consisted of 27 patients in the concomitant chemoradiotherapy arm of the RTOG-91-11 trial who met the same eligibility criteria (26 males, 1 female; mean age, 57 years) but did not undergo free tissue transfer or other form of suture line reinforcement. Minimum follow-up in both groups was 12 months. RESULTS: The overall pharyngocutaneous fistula rate was similar between groups-4/14 (29%) in the flap group, compared with 8/27 (30%) in the RTOG-91-11 group. There were no major wound complications in the flap group, compared with 4 (4/27, 14.8%) in the RTOG-91-11 group. There were no major fistulas in the flap group, compared with 3/27 (11.1%) in the RTOG-91-11 group. The rate of pharyngeal stricture requiring dilation was 6/14 (42%) in the flap group, compared with 7/27 (25.9%) in the RTOG-91-11 group. In our patients, the rate of tracheoesophageal speech was 14/14 (100%), and complete oral intake was achieved in 13/14 (93%) patients. Voice-Related Quality of Life Measure (V-RQOL) and Performance Status Scale for Head and Neck Cancer Patients (PSS-HN) scores suggest that speech and swallowing functions are reasonable following free flap reinforcement. CONCLUSIONS: Free vascularized tissue reinforcement of primary pharyngeal closure in salvage laryngectomy following failed organ preservation is effective in preventing major wound complications but did not reduce the overall fistula rate. Fistulas that developed following this technique were relatively small, did not result in exposed major vessels, and were effectively treated with outpatient wound care rather than readmission to the hospital or return to operating room. Speech and swallowing results following this technique were comparable to those following total laryngectomy alone.

The effect of tetrathiomolybdate on cytokine expression, angiogenesis, and tumor growth in squamous cell carcinoma of the head and neck.

OBJECTIVE: To assess the effect of tetrathiomolybdate on cytokine expression, angiogenesis, and tumor growth rate in human squamous cell carcinoma (SCC). DESIGN: Three human SCC cell lines were used in this study for both in vitro and in vivo investigations. Conditioned media from untreated and tetrathiomolybdate-treated cell lines were compared with regard to cytokine levels, endothelial cell chemotaxis, endothelial cell tubule formation, and migration and the ability to induce angiogenesis in a rat aortic ring array. In vivo UM-SCC-38 was seeded onto tissue-engineered scaffolds and surgically implanted into the flanks of immunodeficient mice. Tumor growth rates and the level of angiogenesis were compared after 2 weeks of therapy. SETTING: A tertiary care facility. RESULTS: In this study, we demonstrate that tetrathiomolybdate significantly decreases the secretion of interleukin 6 and basic fibroblast growth factor by head and neck SCC (HNSCC) cell lines in vitro. Furthermore, we demonstrate that tetrathiomolybdate significantly decreases the secretion of interleukin 6 and basic fibroblast growth factor by HNSCC cell lines in vitro. Furthermore, tetrathiomolybdate treatment of HNSCC cell lines results in significantly decreased endothelial cell chemotaxis, tubule formation, and neovascularization in a rat aortic ring assay. This in vitro evidence of decreased angiogenesis by tetrathiomolybdate is confirmed in vivo by using a severe combined immunodeficiency disorder mouse model in which tetrathiomolybdate therapy is shown to prevent human blood vessel formation. Finally, human HNSCC implanted into immunodeficient mice grow to a much larger size in untreated mice compared with those treated with 0.7 mL/kg per day of oral tetrathiomolybdate. CONCLUSIONS: These findings illustrate the ability of tetrathiomolybdate to down-regulate proinflammatory and proangiogenic cytokines in HNSCC. These observations are potentially exciting from a clinical perspective because a global decrease in these cytokines may decrease tumor aggressiveness and reverse the resistance to chemotherapy and radiation therapy seen in this tumor type.