A novel treatment for bone lesions of multifocal epithelioid sarcoma-like hemangioendothelioma.

Epithelioid sarcoma-like hemangioendothelioma (ES-H) is a rare, indolent vascular neoplasm with characteristics similar to epithelioid sarcoma. It typically affects young males who present with skin and subcutaneous lesions in the extremities. Bone lesions, occurring in approximately 20% of patients, are often multifocal, seen in conjunction with soft tissue lesions, and usually found in bones of the lower extremities. This report details the case of a 20-year-old male who presented with a 1-year history of painful skin lesions on his left lower extremity. Staging studies revealed bone lesions in the cuboid and calcaneus. Bone and soft tissue pathology was consistent with ES-H. The soft tissue lesions were treated with wide excision and the bony lesions with radiofrequency ablation (RFA). The patient had no evidence of recurrence at the 2-year follow-up. Treatment of ES-H typically consists of wide excision of all soft tissue lesions and possible adjuvant radiation therapy. Management of bony lesions has included marginal excision, wide excision, amputation, chemotherapy, observation, or a combination of these modalities. ES-H has the potential for distant metastases. There is no consensus regarding the appropriate treatment of multifocal epithelioid sarcoma-like hemangioendothelioma involving bone. A potential treatment strategy of wide excision of soft tissue lesions and RFA of bone lesions is proposed.

Assessing Pain and Functional Outcomes of Percutaneous Stabilization of Metastatic Pelvic Lesions via Photodynamic Nails: A Bi-Institutional Investigation of Orthopaedic Outcomes.

Background: Minimally invasive surgical interventions for metastatic invasion of the pelvis have become more prevalent and varied. Our group hypothesized that the use of percutaneous photodynamic nails (PDNs) would result in decreased pain, improved functional outcomes and level of ambulation, and decreased use of opioid pain medication. Methods: We performed a retrospective chart review of patients with metastatic pelvic bone disease undergoing stabilization with PDNs (IlluminOss Medical) at 2 institutions. Functional outcome measures assessed include the Combined Pain and Ambulatory Function (CPAF), Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function, and PROMIS Global Health-Physical. Pain was assessed using a visual analog scale (VAS). Outcomes were assessed preoperatively and at 6 weeks, 3 months, 6 months, and 1 year following surgery. Results: A total of 39 patients treated with PDNs were included. No cases of surgical site infection or implant failure were identified. The median pain VAS score decreased from 8 preoperatively to 0 at the 6-week time point (p < 0.0001). The median CPAF score improved from 5.5 points preoperatively to 7 points at the 3-month mark (p = 0.0132). A significant improvement in physical function was seen at 6 months in the PROMIS Physical Function (p = 0.02) and at both 6 months (p = 0.01) and 1 year (p < 0.01) for the PROMIS Global Health-Physical. The rate of patients prescribed opioid analgesia dropped from 100% preoperatively to 20% at 6 months following surgery (p < 0.001). By 6 weeks, all patients were fully weight-bearing and able to walk independently with or without assistive devices. Conclusions: Percutaneous stabilization of metastatic periacetabular defects using PDNs is a safe and effective palliative procedure that has been shown to improve patient mobility and provide early pain relief. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Bisphosphonate-loaded Bone Cement as a Local Adjuvant Therapy for Giant Cell Tumor of Bone: A 1 to 12-Year Follow-up Study.

BACKGROUND: Historically, nontargeted adjuvant therapies such as liquid nitrogen, phenol, argon beam, and alcohol have been applied locally after curettage of giant cell tumors (GCT) in the extremities. Systemic bisphosphonates (BP) and denosumab have emerged as osteoclast-targeting therapies because osteoclast-like giant cells, responsible for aggressive bone resorption, are susceptible to BP or denosumab. However, such drugs may cause systemic side effects. We examined the effects of an alternative intraoperative local delivery of BP on GCTs. MATERIALS AND METHODS: In total, 17 patients with GCTs underwent extended surgical curettage procedures consisting of high-speed burring, traditional adjuvant therapy, and application of BP-loaded polymethylmethacrylate bone cement. Clinical data and follow-up radiographs were reviewed to investigate local recurrence (LR) rate and complications in a retrospective manner. RESULTS: There were 6 males and 11 females (mean age, 33.7 y). There were no cases of pulmonary metastases. Patient follow-up ranged from 1 to 12 years. There was 1 LR during the follow-up period for an LR rate of 5.9%. The mean final Musculoskeletal Tumor Society (MSTS) score was 29. There were no systemic or localized avascular necrosis or atypical fractures related to BPs noted. CONCLUSIONS: BP-loaded polymethylmethacrylate is a targeted local adjuvant therapy that is feasible, safe, and may reduce LRs while alleviating the risk of systemic side effects of BPs such as avascular necrosis of jaw and atypical femur fractures. Future prospective randomized clinical trials will strengthen the level of evidence of this proposed targeted therapy. LEVEL OF EVIDENCE: Therapeutic level IV-see instructions for authors for a complete description of evidence.

Evaluating the Duration of Prophylactic Post-Operative Antibiotic Agents after Open Reduction Internal Fixation for Closed Fractures.

BACKGROUND: The importance of timely pre-operative antibiotic agents for effective surgical prophylaxis has been established but the optimal duration of antimicrobial coverage post-operatively has not yet been defined clearly. The purpose of this study was to determine if prophylactic post- operative cefazolin for 23 hours decreases the risk of surgical site infection (SSI) after open reduction internal fixation (ORIF) of closed extremity fractures. PATIENTS AND METHODS: After Institutional Reviews Board approval, patients undergoing ORIF of closed extremity fractures who had a planned post-operative stay of at least 23 hours were randomly assigned to either receive 23 hours of cefazolin or a placebo. Both groups received weight-based pre-operative cefazolin and intra-operative re-dosing at three-hour intervals until surgery completion. The primary end point was infection. Patients were followed clinically until bony union. Published risk factors were accumulated as a risk score to help determine risk of SSI. RESULTS: A total of 227 patients were randomized to either receive post-operative cefazolin or placebo and 160 patients completed clinical follow-up to bony union. There were 83 patients in the cefazolin group and 77 in the placebo group. Surgical site infections occurred in a total of 15 patients (9.4%) in this trial without any differences between the cefazolin and placebo groups. Patients with diabetes mellitus were 4.33 times more likely to develop an SSI (95% confidence interval [CI], 1.30-14.38; p = 0.02). Patients with a risk score of two or more were 3.14 times more likely to develop an infection (95% CI, 1.02-9.68; p < 0.05). CONCLUSIONS: Although not statistically significant, in a randomized double-blinded placebo-controlled trial, patients who were treated with a 23-hour post-operative regimen of antibiotics after ORIF were less likely to develop SSIs. Patients with diabetes mellitus and those with a risk score of two or greater were more likely to develop an SSI.

Primary TKA with a zirconia ceramic femoral component.

This article presents the 2-year clinical results of primary total knee arthroplasty (TKA) performed with a zirconia ceramic femoral component. A posterior-stabilized TKA was performed for degenerative arthritis in 36 patients (39 knees). The components included a zirconia femoral component, a cobalt-chrome alloy tibial baseplate, and a polyethylene patella; all were implanted with bone cement. The ultra-high molecular-weight polyethylene-bearing insert had a deep-dish, ultra-congruent design. At the 2-year interval, mean Western Ontario and McMaster Universities (WOMAC) osteoarthritis indices improved from 41 to 86, and mean Knee Society Scores improved from 40 to 92. Revision to constrained implants was necessary in one patient for persistent knee instability after trauma. These early results are encouraging, but more data are needed to determine whether ceramics are a suitable alternative to metal countersurfaces in TKAs.

Surveillance Strategies for Sarcoma: Results of a Survey of Members of the Musculoskeletal Tumor Society.

Background. Surveillance is crucial to oncology, yet there is scant evidence to guide strategies. Purpose. This survey identified sarcoma surveillance strategies for Musculoskeletal Tumor Society (MSTS) members and rationales behind them. Understanding current practice should facilitate studies to generate evidence-based surveillance protocols. Methods. Permission was granted by the Research and Executive Committee of the MSTS to survey members on surveillance strategies. First, the questionnaire requested demographic and clinical practice information. Second, the survey focused on clinicians' specific surveillance soft tissue and bone sarcoma protocols. Results. 20 percent of MSTS members completed the survey. The primary rationale for protocols was training continuation, followed by published guidelines, and finally personal interpretation of the literature. 95% of the respondents believe that additional studies regarding appropriate surveillance protocols are needed. 87% reported patient concerns regarding radiation exposure from surveillance imaging. For soft tissue and bone sarcoma local recurrence, responders identified surgical margin, histologic grade, and tumor size as the most important factors. For metastases, important risk factors identified included histologic grade, tumor size, and histologic type. Protocols demonstrated wide variation. Conclusion. This survey demonstrates that surveillance strategies utilized by MSTS members are not evidence-based, providing rationale for multi-institutional studies. It also confirms the public health issue of excessive radiation exposure.

Rare case of dual lesion: nonossifying fibroma and osteochondroma.

In this paper, we offer radiographic and pathologic evidence of a unique coexisting dual lesion. A 14-year-old boy presented for evaluation of a painful right knee after sustaining a twisting injury. The patient was found to have a torn anterior cruciate ligament, in addition to incidental finding of distal femoral dual lesion composed of tissue consistent with a nonossifying fibroma and an osteochondroma. To our knowledge, this is the first report in the medical literature of a dual lesion containing both an osteochondroma and nonossifying fibroma.

Deceptively benign low-grade fibromyxoid sarcoma: array-comparative genomic hybridization decodes the diagnosis.

Low-grade fibromyxoid sarcoma (previously known as Evans tumor) is a rare soft tissue neoplasm characterized by a deceptively bland appearance despite the potential for late metastasis or recurrence. We describe a 13-year-old patient with a popliteal fossa mass initially thought to be benign that, because of array-comparative genomic hybridization findings and subsequent immunohistochemistry, was diagnosed as low-grade fibromyxoid sarcoma. The array-comparative genomic hybridization demonstrated a loss of 11p11.2p15.5 and a gain of 16p11.2p13.3 with breakpoints involving the CREB3L1 (cAMP responsive element-binding protein 3-like 1) and FUS (fused in sarcoma) genes, respectively. Subsequent fluorescence in situ hybridization analysis of a dual-labeled break-apart FUS probe on interphase cells was positive. Our case highlights the importance of using genetic information obtained via array-comparative genomic hybridization to classify accurately pediatric soft tissue tumors.

Allograft compared with autograft infection rates in primary anterior cruciate ligament reconstruction.

BACKGROUND: Injuries to the anterior cruciate ligament are the most common surgically treated knee ligament injury. There is no consensus regarding the optimal graft choice between allograft and autograft tissue. Postoperative septic arthritis is an uncommon complication after anterior cruciate ligament reconstruction. The purpose of this study was to compare infection rates between procedures with use of allograft and autograft tissue in primary anterior cruciate ligament reconstruction. METHODS: A combined prospective and retrospective multicenter cohort study was performed over a three-year period. Graft selection was determined by the individual surgeon. Inclusion and exclusion criteria were equivalent for the two groups (allograft and autograft tissue). Data collected included demographic characteristics, clinical information, and graft details. Patients were followed for a minimum of 5.5 months postoperatively. Our primary outcome was intra-articular infection following anterior cruciate ligament reconstruction. RESULTS: Of the 1298 patients who had anterior cruciate ligament reconstruction during the study period, 861 met the criteria for inclusion and formed the final study group. Two hundred and twenty-one patients (25.6%) received an autograft, and 640 (74.3%) received an allograft. There were no cases of septic arthritis in either group. The 95% confidence interval was 0% to 0.57% for the allograft group and 0% to 1.66% for the autograft group. The rate of superficial infections in the entire study group was 2.32%. We did not identify a significant difference in the rate of superficial infections between autograft and allograft reconstruction in our study group. CONCLUSIONS: While the theoretical risk of disease transmission inherent with allograft tissue cannot be eliminated, we found no increased clinical risk of infection with the use of allograft tissue compared with autologous tissue for primary anterior cruciate ligament reconstruction.