Anterior Malreduction is Associated With Lag Screw Cutout After Internal Fixation of Intertrochanteric Fractures.

BACKGROUND: Lag screw cutout is a devastating complication after internal fixation of an intertrochanteric fracture. Although the tip-apex distance (TAD) is known to be associated with this complication, another factor we thought was potentially important-fracture reduction on an oblique lateral view-has not, to our knowledge, been explored. QUESTIONS/PURPOSES: (1) Is a well-reduced fracture position on an oblique lateral view after internal fixation of intertrochanteric fracture associated with a lower odds of postoperative cutout, independently of the TAD? (2) Is postoperative sliding of the lag screw after fixation associated with postoperative cutout? METHODS: Patients with intertrochanteric fractures who were at least 65 years old and who had been treated with internal fixation in one of six facilities between July 2011 and December 2017 were included. All patients in the study group had lag screw cutout, and controls were selected by risk-set sampling of age-matched and sex-matched patients using a ratio of 4:1 for patients from each hospital. Of the 2327 intertrochanteric fractures, there were 36 patients (0.02 per person-year), with a mean age of 85 years; 89% (32) were women. In the control group, there were 135 controls. There was no difference in age or sex between the two groups. Sagittal reduction was evaluated using an immediate postoperative oblique lateral radiograph (anterior malreduction versus anatomic reduction or posterior malreduction). The association between anterior malreduction and the odds of cutout was estimated by conditional logistic regression analysis with the TAD and interaction between the TAD and the reduced position as covariates. As a sensitivity analysis, we estimated whether sliding within 2 weeks postoperatively was associated with cutout. RESULTS: After controlling for the potentially confounding variables of age and sex, we found that anterior malreduction was independently associated with a higher odds of cutout compared with anatomic reduction or posterior malreduction (adjusted OR 4.2 [95% CI 1.5 to 12]; p = 0.006). There was also an independent association between cutout and larger TAD (≥ 20 mm) (adjusted OR 4.4 [95% CI 1.4 to 14]; p = 0.01). However, the association between cutout and reduction was not modified by the TAD (adjusted OR of interaction term 0.6 [95% CI 0.08 to 4]; p = 0.54). Postoperative sliding ≥ 6 mm within 2 weeks was associated with higher odds of cutout after adjusting for age and sex (adjusted OR 11 [95% CI 3 to 40]; p < 0.001). CONCLUSION: In patients older than 65 years with intertrochanteric fractures, anterior malreduction on a lateral oblique view was associated with much greater odds of postoperative cutout than anatomic reduction or posterior malreduction. Because anterior malreduction is within the surgeon's control, our findings may help surgeons focus on intraoperative reduction on an oblique lateral view to prevent cutouts. Although this factor is a reliable indicator, the results should be applied to cephalomedullary nails, because there was only one patient with cutout among those with sliding hip screws. Because this study was conducted in a homogenous Japanese population, future studies should focus on the association between anterior malreduction and cutout in people of different ethnicities, adjusting for confounding factors such as implant type and surgeon level. LEVEL OF EVIDENCE: Level III, therapeutic study.

What Are the Complication Rates and Factors Associated With Total Femur Replacement After Tumor Resection? Findings From the Japanese Musculoskeletal Oncology Group.

BACKGROUND: Patients undergoing massive tumor resection and total femur replacement (TFR) face a substantial risk of hip dislocation and infection, often resulting in multiple implant revisions or hip disarticulation. These complications can impact their independence and prognosis. Additionally, their shorter life expectancy is influenced by challenges in achieving local radical resection and controlling metastases. Identifying suitable candidates for TFR is vital, necessitating investigations into dislocation, infection, implant failure rates, local recurrence, overall survival, and associated factors. QUESTIONS/PURPOSES: (1) What is the postsurgical complication (hip dislocation and infection) rate and factors associated with postsurgical complications in patients who underwent TFR after tumor resection? (2) What is the local recurrence rate, implant failure rate, overall survival rate, and factors associated with local recurrence and implant failure? METHODS: We retrospectively evaluated 42 patients (median [range] age 47 years [10 to 79 years]) who underwent TFR and tumor resection at the time of the same surgical procedure between 1990 and 2020 at 12 registered institutions that specialized in tumor treatment in Japan. A total of 55% (23) of the patients were men, and 79% (33) had bone sarcoma. The median (range) follow-up period was 36.5 months (2 to 327 months). Of the 42 patients, 12% (5) were lost to follow-up before 2 years without meeting a study endpoint (postsurgical complications, revision, or amputation), and another 19% (8) died before 2 years with implants intact, leaving 69% (29) of the original group who had either follow-up of at least 2 years or met a study endpoint before the minimum surveillance duration. Another 10% (4) had a minimum of 2 years of follow-up but had not been seen in the past 5 years. Infection was defined as deep-seated infection involving soft tissues, bones, joints, and the area around the implant. We did not consider superficial infections. Implant failure was defined when a patient underwent reimplantation or amputation. The complication and implant failure rates were assessed by the cumulative incidence function method, considering competing events. The Kaplan-Meier method was used to estimate the overall survival rate. RESULTS: The 1-month, 6-month, 1-year, and 2-year dislocation rates were 5%, 12%, 14%, and 14%, respectively. The 1-month, 6-month, 1-year, and 2-year infection rates were 5%, 7%, 10%, and 15%, respectively. Multivariable analyses for hip dislocation and infection revealed that resection of the abductor muscles and large tumor size were positively associated with hip dislocation. The 6-month, 1-year, and 2-year local recurrence rates were 5%, 15%, and 15%, respectively. The 6-month, 1-year, 2-year, and 5-year implant failure rates were 5% (95% confidence interval 1% to 15%), 7% (95% CI 2% to 18%), 16% (95% CI 6% to 29%), and 16% (95% CI 6% to 29%), respectively. Multivariable analyses of local recurrence and implant failure that led to reimplantation or amputation revealed that a positive surgical margin was positively associated with local recurrence. The 1-year, 2-year, and 5-year overall patient survival rates were 95% (95% CI 87% to 102%), 77% (95% CI 64% to 91%), and 64% (95% CI 48% to 81%), respectively. CONCLUSION: Hip dislocation, infection, and local recurrence were frequently observed in patients who received massive tumor resection and TFR in our study, eventually leading to reimplantation or amputation. Preserving the abductor muscles and resecting the tumor with a wide margin can prevent postoperative dislocation and local recurrence. Future research should focus on patient selection criteria, prevention of hip dislocation, and innovative treatments. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Effect of postoperative fracture gap on bone union: A retrospective cohort analysis of simple femoral shaft fractures.

BACKGROUND: Intramedullary nailing (IMN) is considered the gold-standard treatment for femoral shaft fractures. The post operative fracture gap is commonly recognized as a risk factor for nonunion. However, no evaluation standard for measuring the fracture gap size has yet been established. In addition, the clinical implications of the fracture gap size have also not been determined so far. This study aims to clarify how we should evaluate fracture gaps when assessing simple femoral shaft fractures with radiographs and to determine the acceptable cut-off value of the fracture gap size in simple femoral shaft fractures. METHOD: A retrospective observational study with a consecutive cohort was conducted at the trauma center of a university hospital. We investigated the fracture gap using postoperative radiography and the postoperative bone union of transverse and short oblique femoral shaft fractures fixed by IMN. The receiver operating characteristic curve analysis was conducted to obtain the fracture gap's mean, minimum, and maximum cut-off values. Fisher's exact test was used at the cut-off value of the most accurate parameter. RESULTS: In the four nonunions among the 30 cases, the analysis using ROC curves revealed that the maximum value had the highest accuracy among the maximum, minimum, and mean values of fracture-gap size. The cut-off value was determined to be 4.14 mm with high accuracy. Fisher's exact test showed that the incidence of nonunion was higher in the group with a maximum fracture gap of 4.14 mm or greater (risk ratio = not applicable, risk difference = 0.57, P = 0.001). CONCLUSION: In simple transverse and short oblique femoral shaft fractures fixed with IMN, the fracture gap on radiographs should be evaluated by the maximum gap in the AP and lateral views. The remaining maximum fracture gap of ≥4.14 mm would be a risk factor for nonunion.

Comparison of visibility in needle arthroscopy of the ankle according to surgical experience: A cadaveric study.

BACKGROUND: Literature regarding the feasibility of inexperienced surgeons using needle arthroscopy is limited. The present study aimed to clarify the feasibility of performing ankle needle arthroscopy for inexperienced surgeons. METHODS: Diagnostic needle arthroscopy was performed for 10 cadaveric ankles by two surgeons with different levels of experience in ankle arthroscopy (inexperienced and expert surgeons). The visibility of arthroscopy was assessed based on a 15-point checklist and compared between surgeons. In addition, iatrogenic articular cartilage injury created by the inexperienced surgeon was investigated. RESULTS: The number of visible points was significantly larger for the expert surgeon than for the inexperienced surgeon (14.1 ± 1.0 vs. 13.7 ± 1.0, P = 0.035). The location of cartilage injury was greatest on the medial talar dome when viewing from the anteromedial portal at a rate of 30%. CONCLUSION: Ankle needle arthroscopy may be an option for surgeons in the future, however, differences in surgeon experience may impact effective visualization.

Cancer may accelerate locomotive syndrome and deteriorate quality of life: a single-centre cross-sectional study of locomotive syndrome in cancer patients.

BACKGROUND: Thanks to recent advancement in cancer treatment, an increasing number of cancer patients are expected to live longer with cancer. The ambulatory ability is essential for cancer patients to spend their own independent lives, but locomotive syndrome (LS), a condition of reduced mobility due to impairment of locomotive organs, in cancer patients has been seldom examined. METHODS: This was a single-institutional cross-sectional study. Cancer patients receiving cancer therapy between April 2020 and March 2021 were asked to participate. LS was classified as stage 0-3, and compared with their performance status (PS). Physical component summary (PCS) and mental component summary (MCS) were calculated from the results of Short Form-8. Logistic regression analysis was performed to identify risk factors for LS stage 3. RESULTS: One hundred and seventy-six cancer patients were included. The rate of LS was 96.0%. That of LS stage 3 was 40.9% and as high as 29.7% even if limited to those with PS 0. The mean PCS and MCS were both inferior to the national averages. PCS decreased as the LS stage advanced. Old age and underweight were revealed as independent risk factors for LS stage 3. CONCLUSIONS: The ratio of LS in cancer patients was extremely high, and the LS stage correlated with physical QOL. Even those with PS 0 can have severe LS; thus, LS can be a sensitive detector of physical disability of cancer patients than PS. The improvement of LS can be a key to the preservation of their ADL and QOL.

What Are the Complications, Function, and Survival of Tumor-devitalized Autografts Used in Patients With Limb-sparing Surgery for Bone and Soft Tissue Tumors? A Japanese Musculoskeletal Oncology Group Multi-institutional Study.

BACKGROUND: Tumor-devitalized autografts treated with deep freezing, pasteurization, and irradiation are biological reconstruction methods after tumor excision for aggressive or malignant bone or soft tissue tumors that involve a major long bone. Tumor-devitalized autografts do not require a bone bank, they carry no risk of viral or bacterial disease transmission, they are associated with a smaller immunologic response, and they have a better shape and size match to the site in which they are implanted. However, they are associated with disadvantages as well; it is not possible to assess margins and tumor necrosis, the devitalized bone is not normal and has limited healing potential, and the biomechanical strength is decreased owing to processing and tumor-related bone loss. Because this technique is not used in many countries, there are few reports on the results of this procedure such as complications, graft survival, and limb function. QUESTIONS/PURPOSES: (1) What was the rate of complications such as fracture, nonunion, infection, or recurrence in a tumor-devitalized autograft treated with deep freezing, pasteurization, and irradiation, and what factors were associated with the complication? (2) What were the 5-year and 10-year grafted bone survival (free from graft bone removal) of the three methods used to devitalize a tumor-containing autograft, and what factors were associated with grafted bone survival? (3) What was the proportion of patients with union of the tumor-devitalized autograft and what factors were associated with union of the graft-host bone junction? (4) What was the limb function after the tumor-devitalized autograft, and what factors were related to favorable limb function? METHODS: This was a retrospective, multicenter, observational study that included data from 26 tertiary sarcoma centers affiliated with the Japanese Musculoskeletal Oncology Group. From January 1993 to December 2018, 494 patients with benign or malignant tumors of the long bones were treated with tumor-devitalized autografts (using deep freezing, pasteurization, or irradiation techniques). Patients who were treated with intercalary or composite (an osteoarticular autograft with a total joint arthroplasty) tumor-devitalized autografts and followed for at least 2 years were considered eligible for inclusion. Accordingly, 7% (37 of 494) of the patients were excluded because they died within 2 years; in 19% (96), an osteoarticular graft was used, and another 10% (51) were lost to follow-up or had incomplete datasets. We did not collect information on those who died or were lost to follow-up. Considering this, 63% of the patients (310 of 494) were included in the analysis. The median follow-up was 92 months (range 24 to 348 months), the median age was 27 years (range 4 to 84), and 48% (148 of 310) were female; freezing was performed for 47% (147) of patients, pasteurization for 29% (89), and irradiation for 24% (74). The primary endpoints of this study were the cumulative incidence rate of complications and the cumulative survival of grafted bone, assessed by the Kaplan-Meier method. We used the classification of complications and graft failures proposed by the International Society of Limb Salvage. Factors relating to complications and grafted autograft removal were analyzed. The secondary endpoints were the proportion of bony union and better limb function, evaluated by the Musculoskeletal Tumor Society score. Factors relating to bony union and limb function were also analyzed. Data were investigated in each center by a record review and transferred to Kanazawa University. RESULTS: The cumulative incidence rate of any complication was 42% at 5 years and 51% at 10 years. The most frequent complications were nonunion in 36 patients and infection in 34 patients. Long resection (≥ 15 cm) was associated with an increased risk of any complication based on the multivariate analyses (RR 1.8 [95% CI 1.3 to 2.5]; p < 0.01). There was no difference in the rate of complications among the three devitalizing methods. The cumulative graft survival rates were 87% at 5 years and 81% at 10 years. After controlling for potential confounding variables including sex, resection length, reconstruction type, procedure type, and chemotherapy, we found that long resection (≥ 15 cm) and composite reconstruction were associated with an increased risk of grafted autograft removal (RR 2.5 [95% CI 1.4 to 4.5]; p < 0.01 and RR 2.3 [95% CI 1.3 to 4.1]; p < 0.01). The pedicle freezing procedure showed better graft survival than the extracorporeal devitalizing procedures (94% versus 85% in 5 years; RR 3.1 [95% CI 1.1 to 9.0]; p = 0.03). No difference was observed in graft survival among the three devitalizing methods. Further, 78% (156 of 200 patients) of patients in the intercalary group and 87% (39 of 45 patients) of those in the composite group achieved primary union within 2 years. Male sex and the use of nonvascularized grafts were associated with an increased risk of nonunion (RR 2.8 [95% CI 1.3 to 6.1]; p < 0.01 and 0.28 [95% CI 0.1 to 1.0]; p = 0.04, respectively) in the intercalary group after controlling for confounding variables, including sex, site, chemotherapy, resection length, graft type, operation time, and fixation type. The median Musculoskeletal Tumor Society score was 83% (range 12% to 100%). After controlling for confounding variables including age, site, resection length, event occurrence, and graft removal, age younger than 40 years (RR 2.0 [95% CI 1.1 to 3.7]; p = 0.03), tibia (RR 6.9 [95% CI 2.7 to 17.5]; p < 0.01), femur (RR 4.8 [95% CI 1.9 to 11.7]; p < 0.01), no event (RR 2.2 [95% CI 1.1 to 4.5]; p = 0.03), and no graft removal (RR 2.9 [95% CI 1.2 to 7.3]; p = 0.03) were associated with an increased limb function. The composite graft was associated with decreased limb function (RR 0.4 [95% CI 0.2 to 0.7]; p < 0.01). CONCLUSION: This multicenter study revealed that frozen, irradiated, and pasteurized tumor-bearing autografts had similar rates of complications and graft survival and all resulted in similar limb function. The recurrence rate was 10%; however, no tumor recurred with the devitalized autograft. The pedicle freezing procedure reduces the osteotomy site, which may contribute to better graft survival. Furthermore, tumor-devitalized autografts had reasonable survival and favorable limb function, which are comparable to findings reported for bone allografts. Overall, tumor-devitalized autografts are a useful option for biological reconstruction and are suitable for osteoblastic tumors or osteolytic tumors without severe loss of mechanical bone strength. Tumor-devitalized autografts could be considered when obtaining allografts is difficult and when a patient is unwilling to have a tumor prosthesis and allograft for various reasons such as cost or socioreligious reasons. LEVEL OF EVIDENCE: Level III, therapeutic study.

Overweight increases perioperative spinal surgery complications: a single-center retrospective study.

BACKGROUND: The World Health Organization (WHO) defines a person with a body mass index (BMI) greater than or equal to 25 kg/m2 as overweight. Being overweight is a lifestyle-related disease; however, little is known about the impact of overweight on the perioperative complications of orthopedic surgery. This study aimed to define the effect of overweight on the perioperative complications of spinal surgery. METHODS: This retrospective case series study reviewed 269 consecutive patients who underwent spinal surgery. These patients were divided into the overweight (OW) and non-overweight (NOW) groups. Age, BMI, surgical time, blood loss, and perioperative complications were evaluated and compared between the groups. RESULTS: There were 117 patients (43%) in the OW group and 152 (57%) in the NOW group. Cervical surgery was performed in 72 cases, thoracic surgery in 34, and lumbosacral surgery in 159. The surgical time was significantly longer in the OW group than in the NOW group (204.6 ± 98 min vs. 175 ± 75 min; p = 0.01). Blood loss was greater in the OW group than in the NOW group (446.8 ± 447.9 mL vs. 279 ± 296.5 mL; p = 0.00). Durotomy was more frequent in the OW group than in the NOW group (10 vs. 3 cases; p = 0.02). There was no difference in complications other than durotomy. CONCLUSIONS: OW patients had longer surgical time, more blood loss, and more frequent durotomy than NOW patients. These findings indicate that overweight increases perioperative complications of spinal surgery.

Association of high kinesiophobia and pain catastrophizing with quality of life in severe hip osteoarthritis: a cross-sectional study.

BACKGROUND: While fear of movement is an important predictor of pain and disability in osteoarthritis (OA), its impact on patients with hip OA remains uncertain. This study aimed to determine whether fear of movement, evaluated by the Tampa Scale for Kinesiophobia (TSK)-11, and pain catastrophizing, evaluated by the Pain Catastrophizing Scale (PCS), were associated with quality of life (QOL) in patients with hip OA. METHODS: This cross-sectional study was conducted between November 2017 and December 2018. Ninety-one consecutively enrolled patients with severe hip OA were scheduled for primary unilateral total hip arthroplasty. The EuroQOL-5 Dimensions questionnaire was used to measure general QOL. The Japanese Orthopedic Association Hip Disease Evaluation Questionnaire was used to assess disease-specific QOL. The covariates included age, sex, body mass index (BMI), pain intensity, high pain catastrophizing (PCS ≥ 30), and high kinesiophobia (TSK-11 ≥ 25). Variables were subjected to multivariate analysis using each QOL scale. RESULTS: In multiple regression analysis, pain intensity, high pain catastrophizing, and BMI were independently correlated with the disease-specific QOL scale. High pain catastrophizing, pain intensity, and high kinesiophobia were independently correlated with the general QOL scale. CONCLUSIONS: High pain catastrophizing (PCS ≥ 30) was independently associated with disease and general QOL scales. High kinesiophobia (TSK-11 ≥ 25) was independently associated with the general QOL scale in preoperative patients with severe hip OA.

Inconsistent radiographic diagnostic criteria for lisfranc injuries: a systematic review.

PURPOSE: To evaluate the radiographic diagnostic criteria and propose standardised radiographic criteria for Lisfranc injuries. METHODS: A systematic review of the PubMed and Embase databases was performed according to the PRISMA guidelines. The various radiographic criteria for the diagnosis of Lisfranc injuries were extracted. Descriptive statistics were presented for all continuous (as mean ± standard deviation) and categorical variables (as frequencies by percentages). RESULTS: The literature search included 29 studies that totalled 1115 Lisfranc injuries. The risk of bias ranged from "Low" to "Moderate" risk according to the ROBINS-I tool. The overall recommendations according to the GRADE assessment ranged from "Very Low" to "High". 1st metatarsal to 2nd metatarsal diastasis was the most common of the 12 various radiographic diagnostic criteria observed, as was employed in 18 studies. This was followed by 2nd cuneiform to 2nd metatarsal subluxation, as was employed in 11 studies. CONCLUSION: The radiographic diagnostic criteria of Lisfranc injuries were heterogeneous. The proposition for homogenous radiographic diagnostic criteria is that the following features must be observed for the diagnosis of Lisfranc injuries: 1st metatarsal to 2nd metatarsal diastasis of ≥ 2 mm on anteroposterior view or 2nd cuneiform to 2nd metatarsal subluxation on anteroposterior or oblique views. Further advanced imaging by CT or MRI may be required in patients with normal radiographs but with continued suspicion for Lisfranc injuries. LEVEL OF EVIDENCE: 4, systematic review.

Clinical analysis of multimodal treatment for localized synovial sarcoma: A multicenter retrospective study.

INTRODUCTION: Several prognostic factors for survival in synovial sarcoma have been proposed, but the role of adjuvant chemotherapy and radiotherapy is a matter of debate. The study aim was to clarify the effect of high-dose ifosfamide-containing chemotherapy and adjuvant radiotherapy for patients with localized synovial sarcoma. MATERIALS AND METHODS: Five tertiary musculoskeletal oncology hospitals participated in this retrospective study. The records of the patient diagnosed with synovial sarcoma without metastasis at diagnosis from 1990 to 2011 have been collected and reviewed. Overall, distant failure-free, and local failure-free survivals were calculated, and prognostic factors for each survival were evaluated by performing univariate and multivariate analyses. RESULTS: A total of 162 patients were enrolled in this study with a median follow-up period of 67 months (range, 5-267 months) for all surviving patients. The 5-year overall, distant failure-free, and local failure-free survival rates were 79.7%, 66.3%, and 98.4%, respectively. Univariate analyses demonstrated that high-dose ifosfamide-containing chemotherapy was significantly associated with better overall (p = 0.014) and distant failure-free survival (p = 0.0043) than that of low-dose or no ifosfamide-containing chemotherapy if we analyzed only patients with tumors >5 cm in size. Addition of radiotherapy was not a significant prognostic factor for overall survival in the univariate and multivariate analyses, but it did improve the overall survival of the patients with R1 resection (p = 0.053). CONCLUSION: Patients with localized synovial sarcoma >5 cm in size had better overall and distant failure-free survival after receiving adjuvant chemotherapy containing high-dose ifosfamide comparing to low-dose or no ifosfamide-containing chemotherapy. The addition of adjuvant radiotherapy was beneficial for the patients who received R1 resection. Alternatively, adjuvant radiotherapy could be avoided for patients who achieved an R0 margin.

Involvement of orthopaedic surgeons for cancer patients in orthopaedic training facilities certified by the Japanese Orthopaedic Association - A nationwide survey.

BACKGROUND: In order to improve cancer care in Japan further, it is now required for orthopaedic surgeons to get actively involved in managing locomotive organs such as bones, muscles and nerves in cancer patients. In 2018, the Japanese Orthopaedic Association (JOA) conducted a questionnaire survey to investigate the current status of cancer treatment at the orthopaedic training facilities certified by the JOA. We analyzed the results of that questionnaire survey, focusing on the data from the core hospitals for cancer care (designated cancer hospitals), to clarify the involvement of orthopaedic surgeons in cancer treatment. MATERIALS AND METHODS: A nationwide survey was conducted in the orthopaedic training facilities certified by the JOA using an online questionnaire from March 15th to 31st, 2018. To clarify the involvement of orthopaedic surgeons in cancer treatment, we analyzed the results of that questionnaire survey, focusing on the data from the designated cancer hospitals in Japan. RESULTS: From the questionnaire survey, it became clear that 24% of the orthopaedic training facilities certified by the JOA are designated cancer hospitals. There were significant differences concerning cancer treatment and the prospect of orthopaedic surgeons' involvement in the treatment for bone metastases between institutions classified according to number of both certified orthopaedic surgeons by the JOA and specialists for bone and soft tissue tumors. In addition, in 45% of the designated cancer hospitals, orthopaedic surgeons treated bone metastases that occur in cancer patients, but in the rest of the institutions, orthopaedic surgeons did not yet adequately respond. CONCLUSION: In order to further improve the locomotive function and quality of life (QOL) in cancer patients, it was seemed to be necessary that all medical professionals engaged in cancer treatment, including orthopaedic surgeons, recognize the importance of locomotive management for cancer patients. In addition, the results of this study suggested that the presence of more than six certified orthopaedic surgeons by the JOA, including one or more specialists for bone and soft tissue tumors, may be able to create an environment conducive to the involvement of orthopaedic surgeons in cancer treatment at the facility.

[Orthopaedic Management of Bone Metastasis].

Thanks to advancement in cancer therapy, an increasing number of cancer patients are expected to live longer with cancer in Japan. Activities of daily living(ADL)and quality of life(QOL)of cancer patients has become much more important than ever. Because a decline in mobility negatively affects ADL and QOL, the management of locomotive organs of cancer patients is crucial. In 2018, the Japanese Orthopaedic Association decided their annual activity theme as"locomotive syndrome in cancer patients", with the concept of preventing and improving locomotive syndrome for longer and healthier life of cancer patients. Bone metastasis, as a major cause of locomotive syndrome in cancer patients, needs to be evaluated and managed properly for better ADL and QOL of cancer patients. Pathological fractures, spinal instability, and spinal injury cause not only severe pain and massive functional impairment of patients but increased nursing care burden. To resolve these problems, surgery plays a major role. Possible surgical procedures include internal fixation, curettage, cementation, and arthroplasty for the long bones, whereas percutaneous vertebroplasty, decompression, posterior/anterior spinal fusion, and total en bloc spondylectomy for the spine. Less invasive surgical procedure tends to be chosen for a patient with poorer prognosis. The main purpose of bone metastasis surgery is to maintain ADL and QOL of cancer patients hopefully during the remaining survival time; therefore, estimated survival should be considered when determining the surgical strategy. In addition, case-by- case careful peri-operative management is required because cancer therapy can vary widely in patient age, cancer type, and tumor stage. To accommodate the variety of orthopaedic surgeries to the diversity of cancer therapy, the corporation between oncologists and orthopaedic surgeons is indispensable.

Clinical features and treatment outcomes of dedifferentiated and grade 3 chondrosarcoma: A multi-institutional study.

Chondrosarcoma is the second most common primary malignant bone tumor. In this multicenter study, we sought to evaluate the disease-specific survival (DSS) and disease-free survival (DFS), and prognostic factors in patients with dedifferentiated chondrosarcoma (DDCS) or grade 3 chondrosarcoma (G3CS) in Japan. We retrospectively investigated the treatment outcomes and prognostic factors in 62 patients with DDCS and 19 patients with G3CS at 15 institutions participating in the Japanese Musculoskeletal Oncology Group. We also clarified significant clinicopathological factors for oncological outcomes. In surgery for primary lesions aimed at cure, a histologically negative margin (R0) was obtained in 93% (14/15) of patients with G3CS and 100% (49/49) of patients with DDCS. The 5-year DSS was 18.5% in patients with DDCS and 41.7% in patients with G3CS (p = 0.13). Local control was obtained in 80% (12/15) and 79.6% (39/49) of patients with G3CS and DDCS in the primary lesion after surgery with a wide surgical margin, respectively. In multivariate analysis, stage and no treatment/palliative treatment for the primary lesion were independent prognostic factors for DSS of DDCS, and age and no treatment/palliative treatment for DSS of G3CS. The 5-year DFS rate was 22.8% in 26 patients with DDCS who did not receive adjuvant chemotherapy, and 21.4% in 14 patients who received adjuvant chemotherapy. The prognosis of DDCS remains poor, although R0 resection was carried out in most cases. Effective and/or intensive chemotherapeutic regimens or agents should be considered or developed for patients with high-grade chondrosarcoma, particularly for those with DDCS.

Incidence of genitourinary injuries in pelvic fractures: A 12-year single-center retrospective study.

OBJECTIVE: This study aimed to determine the epidemiology of genitourinary injuries in pelvic fractures and elucidate the clinical outcomes of patients with pelvic fractures with and without genitourinary injuries at a tertiary trauma center in Japan. METHODS: Patients with pelvic fractures in our tertiary trauma center between May 2009 and April 2021 were retrospectively assessed. The patients' demographics, mechanism of injury, and hospital course details were collected. The outcomes of patients with pelvic fractures with and without genitourinary injuries were compared. RESULTS: Of 402 patients with pelvic fractures, 18 (4.5%) had genitourinary injuries. Falls were the most common mechanisms of injury for all pelvic fractures The incidence of bladder, kidney, urethral, and testis injuries were 2.0%, 1.2%, 1.2%, and 0.5%, respectively. Patients with genitourinary injuries were significantly younger (median age, 26 vs. 51 years; p < 0.001), had a higher rate of intensive care unit admission (94% vs. 58%; p = 0.002), remained hospitalized longer (median duration, 82 vs. 45 days; p < 0.001), and had a longer intensive care unit stay (median duration, 6 vs. 2 days; p < 0.001) when compared to patients without genitourinary injuries. Genitourinary injuries were not associated with in-hospital mortality. CONCLUSIONS: The incidence of genitourinary injuries with pelvic fractures was 4.5%. The presence of genitourinary injuries was associated with a higher rate of intensive care unit admission, longer hospital stay, and longer intensive care unit stay, but it was not associated with in-hospital mortality.

Dedifferentiation in low-grade osteosarcoma: a Japanese Musculoskeletal Oncology Group (JMOG) study.

BACKGROUND: Low-grade osteosarcomas, namely parosteal osteosarcoma (POS) and low-grade central osteosarcoma (LGCOS), occasionally dedifferentiate into high-grade malignancy, referred to as dedifferentiation in low-grade osteosarcoma (DLOS). This study aimed to elucidate the clinicopathologic features of DLOS, which are poorly described to date due to the extreme rarity of the disease. METHODS: A total of 33 patients with DLOS were included. Clinical characteristics, including the diagnostic accuracy of tumor biopsy, multimodal treatments, and clinical course, were retrospectively reviewed. Univariate analysis was performed to identify prognostic factors associated with overall survival (OS) and metastasis-free survival (MFS). RESULTS: The tumor subtypes comprised 10 cases (30.3%) of LGCOS and 23 cases (69.7%) of POS. The timing of dedifferentiation was synchronous in 25 (75.8%) and metachronous in 8 (24.2%) patients. The rates of preoperative diagnosis of DLOS were 40.0% and 65.4% for core needle biopsy and incisional biopsy, respectively. All patients underwent surgery and 25 patients received perioperative chemotherapy. Of the 13 patients who received neoadjuvant chemotherapy, 11 exhibited a poor histological response. The 5-year OS and MFS rates were 88.1% and 77.7%, respectively. Univariate analysis revealed that local recurrence was associated with poor OS (P < 0.01) and MFS (P < 0.01). Perioperative chemotherapy did not affect OS or MFS. CONCLUSIONS: The diagnostic accuracy of tumor biopsy for DLOS was lower than that for bone sarcomas, as reported previously. In contrast to conventional osteosarcomas with high chemosensitivity, both histological responses and survival analysis revealed low efficacy of chemotherapy for DLOS.

Vacuum phenomenon as a predictor of kyphosis after implant removal following posterior pedicle screw fixation without fusion for thoracolumbar burst fracture: a single-center retrospective study.

BACKGROUND: Posterior pedicle screw fixation without fusion has been commonly applied for thoracolumbar burst fracture. Implant removal is performed secondarily after bone union. However, the occurrence of secondary kyphosis has recently attracted attention. Secondary kyphosis results in poor clinical outcomes. The purpose of this was to determine predictors of kyphosis after implant removal following posterior pedicle screw fixation without fusion for thoracolumbar burst fracture. METHODS: This retrospective study reviewed 59 consecutive patients with thoracolumbar burst fracture who underwent implant removal following posterior pedicle screw fixation without fusion. Inclusion criteria were non-osteoporotic fracture and T11-L3 burst fracture. Old age, sex, initial severe wedge deformity, initial severe kyphosis, and vacuum phenomenon were examined as factors potentially associated with final kyphotic deformity (defined as kyphotic angle greater than 25°) or loss of correction. Logistic regression analysis was performed using propensity score matching. RESULTS: Among the 31 female and 28 male patients (mean age 38 years), final kyphotic deformity was found in 17 cases (29%). Multivariate analysis showed a significant association with the vacuum phenomenon. Loss of correction was found in 35 cases (59%) and showed a significant association with the vacuum phenomenon. There were no significant associations with other factors. CONCLUSIONS: The findings of this study suggest that the vacuum phenomenon before implant removal may be a predictor of secondary kyphosis of greater than 25° after implant removal following posterior pedicle screw fixation without fusion for thoracolumbar burst fracture, but that old age, sex, initial severe kyphosis, and initial severe wedge deformity may not be predictors.

A new classification system for evaluating fatty infiltration of the gluteus minimus in hip osteoarthritis using plain computed tomography.

BACKGROUND: Fatty infiltration of the gluteus muscles increases due to the presence of hip osteoarthritis (OA); it is often evident in the gluteus minimus. The gluteus minimus acts not only as an abductor and rotator but also helps stabilize the femur's head. Moreover, the atrophy or fatty infiltration of the gluteus minimus leads to an increased risk of fall and fracture. Until now, fatty infiltration of this muscle has often been evaluated using magnetic resonance imaging using the Goutallier classification system, originally developed for the rotator cuff. However, the accessibility of magnetic resonance imaging remains problematic, and the reliability of the classification has room for improvement. Thus, this study aimed to devise a new classification system for the fatty infiltration of the gluteus minimus using plain computed tomography (CT). METHODS: We retrospectively reviewed 71 patients (141 hips) who underwent unilateral total hip arthroplasty for hip OA. To assess the system's reliability, three doctors classified the fatty infiltration of the gluteus minimus based on the CT images of 20 hips randomly selected from the study participants using both the Goutallier and the new classification systems. Then, we selected 113 hips with Crowe type 1 and evaluated them using the new classification system to assess the association between the extent of fatty infiltration and the severity of hip OA. RESULTS: Both classifications had good intra- and inter-observer reliability. The kappa values of the new classification system (0.83-0.95) were higher than that of the Goutallier classification system (0.72-0.87). The Jonckheere-Terpstra test showed that the degree of fatty infiltration of the gluteus minimus according to the new system progressed incrementally with the progression of hip OA (p = 0.016). CONCLUSIONS: The new classification system can be recommended for clinical use.

Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of soft tissue tumors 2020 - Secondary publication.

BACKGROUND: These clinical practice guidelines are intended to provide recommendations based on the best evidence obtained to date on key issues in clinical practice to improve the prognosis, diagnostic and therapeutic processes for patients with soft tissue tumors. METHODS: The Guidelines Development Committee and Systematic Review Committee were composed of a multidisciplinary team of specialists who play an important role in soft tissue tumor care. Clinical questions (CQs) were determined by choosing key decision-making points based on Algorithms for the diagnosis and treatment of soft tissue tumors. The guidelines were developed according to the "Medical Information Network Distribution Service (Minds) Handbook for Clinical Practice Guideline Development 2014" and "Minds Manual for Clinical Practice Guideline Development 2017." Recommendation strength was rated on two levels and the strength of evidence was rated on four levels. The recommendations were decided based on agreement by 70% or more voters. RESULTS: Twenty-two CQs were chosen by the Guidelines Development Committee. The Systematic Review Committee reviewed the evidence concerning each CQ, a clinical value judgment was added by experts, and the text of each recommendation was determined. CONCLUSION: We established 22 CQs and recommendations for key decision-making points in the diagnosis and treatment of soft tissue tumors according to the Minds Clinical Practice Guideline development methods. We hope that these guidelines will assist the decision-making of all medical staff engaged in the treatment and diagnosis of soft tissue tumors, and eventually lead to improved soft tissue tumor care in the country.

Assessment of locomotive syndrome in patients with visceral cancer, the comparison with non-cancer patients using propensity score matching.

BACKGROUND: When treating cancer patients, the progression of symptoms is accompanied by the deterioration of systemic conditions and motor function. From a risk-benefit perspective, a certain level of physical function must be maintained to continue cancer treatment. Recently, outpatient cancer treatment has become more common. Motor function is important to determine the feasibility of continuing cancer treatment. The study aimed to evaluate the motor function of patients with visceral cancer using locomo tests established by Japanese Orthopaedic Association. METHODS: Locomo tests were performed, and the results were compared with data from non-cancer individuals. Background data were matched by propensity score matching. Data from 53 cancer patients (group C) were compared with that of 75 non-cancer patients (group N). RESULTS: The average score in the two-step test of group C was lower than that of group N (1.27: 1.37, p = 0.004). The average function in the stand-up test of group C was worse than that of group N (p = 0.001). The average score in the 25-question geriatric locomotive function scale (GLFS) of group C was significantly higher than that of group N (19.92: 5.29, SE 2.21, p < 0.001). Higher 25-question GLFS scores indicate reduced mobility. The proportion of the locomo stage 2 in group C was significantly higher than in group N (51%: 13%, p < 0.001). The results of the two field tests revealed a clinically minimal difference between the two groups, but a statistically significant difference. Locomo tests may be detect potential motor dysfunction in outpatient cancer patients with apparently maintained motor function. CONCLUSIONS: Even in cancer patients who attend outpatient clinics, their motor functions could be potentially impaired. Therapeutic interventions to maintain and enhance motor function for cancer patients could be useful for continuing cancer treatment, and furthermore, improving prognosis.

Relationship between the Accuracy of the Acetabular Cup Angle and BMI in Posterolateral Total Hip Arthroplasty with CT-Based Navigation.

Background and Objectives: Precise acetabular cup placement is essential for successful total hip arthroplasty (THA). In obese patients, its accuracy is often difficult to achieve because of the thickness of the soft tissues. This study aimed to determine the relationship between the accuracy of acetabular cup angle and body mass index (BMI) in posterolateral THA using the computed tomography-based navigation (CT-navi) system. Materials and Methods: We retrospectively reviewed 145 consecutive primary THAs using the CT-navi system between January 2015 and January 2018. All surgeries were performed using cementless cups employing the posterolateral approach with the patient in the decubitus position. We compared the radiographic inclination and anteversion obtained intraoperatively from the CT-navi with those measured by postoperative CT using three-dimensional templating software. We evaluated the relationship between the extent of errors and correlation with BMI. Results: In non-overweight patients (BMI < 25, 88 hips), the mean navigation errors for inclination were 2.8 ± 2.2° and for anteversion were 2.6 ± 2.3°. Meanwhile, in overweight patients (BMI ≥ 25, 57 hips), the mean navigation errors were 2.6 ± 2.4° for inclination and 2.4 ± 2.4° for anteversion. We found no significant difference between overweight and non-overweight patients in both inclination and anteversion. There was no correlation between the extent of errors and BMI. Conclusions: In posterolateral THA, CT-navi can aid the precise placement of the acetabular cup irrespective of a patient's BMI.