Bone Mass Changes Following Percutaneous Radiofrequency Ablation, Osteoplasty, Reinforcement, and Internal Fixation of Periacetabular Osteolytic Metastases.

BACKGROUND: The success of orthopedic interventions for periacetabular osteolytic metastases depends on the progression or regression of cancer-induced bone loss. PURPOSE: To characterize relative bone mass changes following percutaneous radiofrequency ablation, osteoplasty, cement reinforcement, and internal screw fixation (AORIF). METHODS: Of 70 patients who underwent AORIF at a single institution, 21 patients (22 periacetabular sites; average follow-up of 18.5 ± 12.3 months) had high-resolution pelvic bone CT scans, with at least one scan within 3 months following their operation (baseline) and a comparative scan at least 6 months post-operatively. In total, 73 CT scans were measured for bone mass changes using Hounsfield Units (HU). A region of interest was defined for the periacetabular area in the coronal, axial, and sagittal reformation planes for all CT scans. For 6-month and 1-year scans, the coronal and sagittal HU were combined to create a weight-bearing HU (wbHU). Three-dimensional volumetric analysis was performed on the baseline and longest available CT scans. Cohort survival was compared to predicted PathFx 3.0 survival. RESULTS: HU increased from baseline post-operative (1.2 ± 1.1 months) to most recent follow-up (20.2 ± 12.1 months) on coronal (124.0 ± 112.3), axial (140.3 ± 153.0), and sagittal (151.9 ± 162.4), p < 0.05. Grayscale volumetric measurements increased by 173.4 ± 166.4 (p < 0.05). AORIF median survival was 27.7 months (6.0 months PathFx3.0 predicted; p < 0.05). At 12 months, patients with >10% increase in wbHU demonstrated superior median survival of 36.5 months (vs. 26.4 months, p < 0.05). CONCLUSION: Percutaneous stabilization leads to improvements in bone mass and may allow for delays in extensive open reconstruction procedures.

Comparison of Percutaneous Interventional Ablation-Osteoplasty-Reinforcement-Internal Fixation (AORIF), Long Intramedullary Nailing, and Hemiarthroplasty for the Treatment of Focal Metastatic Osteolytic Lesions in the Femoral Head and Neck.

PURPOSE: Osteolytic metastatic lesions in the femoral head and neck are traditionally treated with intramedullary long nailing (IM) or hemiarthroplasty (HA). Recovery, surgical complications, and medical co-morbidities delay oncologic care. This study sought to elucidate the comparative efficacy of percutaneous ablation-osteoplasty-reinforcement-internal fixation (AORIF), IM, and HA in stabilizing osteolytic lesions in the femoral head and neck. METHODS: A retrospective study of 67 patients who underwent IM, AORIF, or HA for osteolytic femoral head and neck lesions was performed. Primary outcome was assessed using a combined pain and ambulatory score (Range 1-10: 1 = bedbound, 10 = normal ambulation) at first follow-up (~ 2 weeks). Surgical complications associated with each treatment were compared. RESULTS: Sixty-seven patients (mean age, 65 ± 13, 36 men and 31 women) underwent IM (40), AORIF (19), and HA (8) with a mean follow-up of 9 ± 11 months. Two patients in the IM group (5%), three in the AORIF group (16%), and none in the HA (0%) group required revision procedures. AORIF demonstrated superior early improvement in combined pain and ambulatory function scores by 3.0 points [IQR = 2.0] (IM p = 0.0008, HA p = 0.0190). Odds of post-operative complications was 10.3 times higher in HA than IM (95% confidence interval 1.8 to 60.3). Future revision procedures were not found to be statistically significant between AORIF and IM (p = 0.234). CONCLUSIONS: A minimally invasive interventional skeletal procedure for focal femoral head and neck osteolytic lesions may serve as an effective alternative treatment to traditional surgical approaches, conferring a shorter recovery time and fewer medical complications.

Percutaneous Ablation, Osteoplasty, Reinforcement, and Internal Fixation for Pain and Ambulatory Function in Periacetabular Osteolytic Malignancies.

Background Osteolytic neoplasms to periacetabular bone frequently cause pain and fractures. Immediate recovery is integral to lifesaving ambulatory oncologic care and maintaining quality of life. Yet, open acetabular reconstructive surgeries are associated with numerous complications that delay cancer treatments. Purpose To determine the effectiveness for short- and long-term pain and ambulatory function following percutaneous ablation, osteoplasty, reinforcement, and internal fixation (AORIF) for periacetabular osteolytic neoplasm. Materials and Methods This retrospective observational study evaluated clinical data from 50 patients (mean age, 65 years ± 14 [SD]; 25 men, 25 women) with osteolytic periacetabular metastases or myeloma. The primary outcome of combined pain and ambulatory function index score (range, 1 [bedbound] through 10 [normal ambulation]) was assessed before and after AORIF at 2 weeks and then every 3 months up to 40 months (overall median follow-up, 11 months [IQR, 4-14 months]). Secondary outcomes included Eastern Cooperative Oncology Group (ECOG) score, infection, transfusion, 30-day readmission, mortality, and conversion hip arthroplasty. Serial radiographs and CT images were obtained to assess the hip joint integrity. The paired t test or Wilcoxon signed-rank test and Kaplan-Meier analysis were used to analyze data. Results Mean combined pain and ambulatory function index scores improved from 4.5 ± 2.4 to 7.8 ± 2.1 (P < .001) and median ECOG scores from 3 (IQR, 2-4) to 1 (IQR, 1-2) (P < .001) at the first 2 weeks after AORIF. Of 22 nonambulatory patients, 19 became ambulatory on their first post-AORIF visit. Pain and functional improvement were retained beyond 1 year, up to 40 months after AORIF in surviving patients. No hardware failures, surgical site infections, readmissions, or delays in care were identified following AORIF. Of 12 patients with protrusio acetabuli, one patient required a conversion hemiarthroplasty at 24 months. Conclusion The ablation, osteoplasty, reinforcement, and internal fixation, or AORIF, technique was effective for short- and long-term improvement of pain and ambulatory function in patients with periacetabular osteolytic neoplasm. © RSNA, 2023.

Bone Scans Have Little Utility in the Evaluation of Well-Differentiated Cartilaginous Lesions of the Humerus.

In the humerus, pain is a poor guide for differentiating between benign enchondromas and malignant well-differentiated chondrosarcomas. Radionuclide bone scans often are used, and chondrosarcomas reliably show increased uptake. However, it remains to be seen whether enchondromas consistently have negative findings on bone scans, which would provide reliable differentiation from malignant lesions. Imaging and medical records were reviewed for patients who underwent radionuclide bone scans for enchondroma of the humerus at one academic medical center over a period of 7 years. Bivariate logistic regression was used to determine the association of bone scan results with the finding of endosteal scalloping on radiographs and magnetic resonance imaging (MRI) scans. During initial evaluation, 25 patients who had enchondroma of the humerus underwent radionuclide bone scans. No patients showed progression of lesions during an average follow-up of 69 weeks. On bone scan, 18 (72%) had significantly positive findings, 5 (20%) had mildly positive findings, and 2 (8%) had negative findings. Of the 22 patients who underwent MRI scans, 4 showed endosteal scalloping and none showed aggressive features. No statistically significant association was seen between significantly positive (P=.299) or mildly positive findings on bone scans (P=.810) and the finding of endosteal scalloping on radiographs or MRI scans. Enchondromas rarely showed negative findings on bone scans, and bone scan findings did not correlate with the findings on radiographs or MRI scans. The diagnosis of enchondroma can be made based on clinical and radiographic findings, and the added utility of bone scans does not justify their regular use. [Orthopedics. 2020;43(6):e498-e502.].

Minimally Invasive Image-Guided Ablation, Osteoplasty, Reinforcement, and Internal Fixation (AORIF) for Osteolytic Lesions in the Pelvis and Periarticular Regions of Weight-Bearing Bones.

PURPOSE: To assess early outcome, safety, and complications of an alternative to open surgical treatments of osteolytic lesions in periarticular load-bearing bones. MATERIALS AND METHODS: A single-center, prospective clinical cohort study of 26 lesions in 23 consecutive patients with painful osteolytic skeletal lesions was performed. Patients were followed for an average of 7 mo (1-18 mo). Lesions were targeted from the most intact bone via minimally invasive percutaneous approach for stable anchorage of internal fixation screws using fluoroscopic guidance. Cannulated screws served as universal portals for ablation, balloon osteoplasty, and delivery of bone cement in addition to internal fixation for cement anchoring and prophylactic stabilization of uninvolved bone. RESULTS: There were 19 osteolytic lesions in the pelvis, 4 in the proximal femur, 2 in the proximal tibia, and 1 in the calcaneus. All defects were associated with severe pain or fractures. There were no conversions to open surgery and no infection or bleeding requiring transfusion, embolization, or additional procedures. There was significant improvement in visual analogue scale (VAS) pain score from 8.32 ± 1.70 to 2.36 ± 2.23, combined pain and functional ambulation score from 4.48 ± 2.84 to 7.28 ± 2.76, and Musculoskeletal Tumor Society score from 45% to 68% (P < .05). CONCLUSIONS: Ablation, osteoplasty, reinforcement, and internal fixation is a safe and effective minimally invasive percutaneous image-guided treatment option for functional improvement or palliation of painful osteolytic lesions in the pelvis and periarticular loadbearing bones.

Predictors of Lymph Node Involvement by Soft Tissue Sarcoma of the Trunk and Extremity: An Analysis of the National Cancer Database.

Background and Objectives Lymph node metastases (LNM) in soft tissue sarcoma (STS) of the trunk and extremity are rare but are associated with worse survival. Established risk factors for LNM in this group are based on small institutional retrospective reviews. This study identifies the risk factors associated with LNM in otherwise non-metastatic trunk/extremity STS patients using the National Cancer Database (NCDB) and sought out to delineate a high-risk group that may be considered for pathologic nodal evaluation. Methods The files of 10,731 patients with STS of the trunk/extremity without distant metastasis from 2004 - 2015 were evaluated. Exclusion criteria included neoadjuvant therapy and a lack of pathologic nodal evaluation. Univariate and multivariable logistic regression models were performed to evaluate variables associated with LNM. Results Of the total of 10,731 patients, 223 (2.1%) had LNM. On multivariable analysis, LNM was associated with Grade 3 tumors (odds ratio (OR) 15.6, 95% confidence interval (CI) 6.36 - 38.04, p < 0.001) and clear cell/angiosarcoma/rhabdomyosarcoma/epithelioid (CARE) histology (OR 4.72, 95% CI 3.35 - 6.66, p < 0.001), lymphovascular invasion (LVI) (OR 5.86, 95% CI 3.33 - 10.31, p < 0.001, and bone invasion (BI) (OR 2.73, 95% CI 1.32 - 5.61, p = 0.006). Patients with Grade 3 CARE tumors (n = 402) had an 11.9% risk of LNM vs. 1.7% of adults without all these characteristics (p < 0.001). Patients with Grade 3 CARE tumors and either LVI or BI (n = 36) had a 33.3% risk of LNM. Conclusions High-grade and CARE histology are associated with LNM in STS. Adult patients with both features have an overall 11.9% risk of LNM and may be considered for pathologic LN assessment, particularly with the presence of LVI or BI.

Polypharmacy, Hazardous Alcohol and Illicit Substance Use, and Serious Falls Among PLWH and Uninfected Comparators.

BACKGROUND: Medication classes, polypharmacy, and hazardous alcohol and illicit substance abuse may exhibit stronger associations with serious falls among persons living with HIV (PLWH) than with uninfected comparators. We investigated whether these associations differed by HIV status. SETTING: Veterans Aging Cohort Study. METHODS: We used a nested case-control design. Cases (N = 13,530) were those who fell. Falls were identified by external cause of injury codes and a machine-learning algorithm applied to radiology reports. Cases were matched to controls (N = 67,060) by age, race, sex, HIV status, duration of observation, and baseline date. Risk factors included medication classes, count of unique non-antiretroviral therapy (non-ART) medications, and hazardous alcohol and illicit substance use. We used unconditional logistic regression to evaluate associations. RESULTS: Among PLWH, benzodiazepines [odds ratio (OR) 1.24; 95% confidence interval (CI) 1.08 to 1.40] and muscle relaxants (OR 1.29; 95% CI: 1.08 to 1.46) were associated with serious falls but not among uninfected (P > 0.05). In both groups, key risk factors included non-ART medications (per 5 medications) (OR 1.20, 95% CI: 1.17 to 1.23), illicit substance use/abuse (OR 1.44; 95% CI: 1.34 to 1.55), hazardous alcohol use (OR 1.30; 95% CI: 1.23 to 1.37), and an opioid prescription (OR 1.35; 95% CI: 1.29 to 1.41). CONCLUSION: Benzodiazepines and muscle relaxants were associated with serious falls among PLWH. Non-ART medication count, hazardous alcohol and illicit substance use, and opioid prescriptions were associated with serious falls in both groups. Prevention of serious falls should focus on reducing specific classes and absolute number of medications and both alcohol and illicit substance use.

Molecular Targeted Therapy Approach to Musculoskeletal Tumors.

The future of cancer treatment is promising. Although marred by years of plateau in outcomes, new avenues have been identified that are poised to change how we treat cancer. Molecular targeted therapy or targeted therapy is one of these methods. Molecular targeted therapy involves identifying specific pathways or markers that allow cancer cells to flourish. Once identified, specific molecules can be used to block proliferative pathways, thereby negatively impacting tumor growth. Targeting specific pathways that prolong the survival of the cancer cell can lead to a decreased cancer burden, and improved patient outcomes. This article reviews the tenets of molecular targeted therapy, common pathways, target acquisition for drug development, and the pathways that have been elucidated in musculoskeletal tumors.

Own the Bone, a System-Based Intervention, Improves Osteoporosis Care After Fragility Fractures.

BACKGROUND: The goal of this study was to evaluate the effectiveness of the American Orthopaedic Association's Own the Bone secondary fracture prevention program in the United States. METHODS: The objective of this quality improvement cohort study was dissemination of Own the Bone and implementation of secondary prevention (osteoporosis pharmacologic and bone mineral density [BMD] test recommendations). The main outcome measures were the number of sites implementing Own the Bone and implementation of secondary prevention, i.e., orders for BMD testing and/or pharmacologic treatment. The 177 sites participating in the program were academic and community hospitals, orthopaedic surgery groups, and a health system; data were obtained from the first 125 sites utilizing its registry, between January 1, 2010, and March 31, 2015. It included all patients, aged 50 years or older, presenting with fragility fractures (n = 23,132) who were enrolled in the Own the Bone web-based registry. The interventions were education, development of program elements, dissemination, implementation, and evaluation of the Own the Bone program at participating sites. RESULTS: A growing number of institutions implemented Own the Bone (14 sites in 2005-2006 to 177 sites in 2015). After consultation, 53% of patients had a BMD test ordered and/or pharmacologic therapy for osteoporosis. CONCLUSIONS: The Own the Bone intervention has succeeded in improving the behaviors of medical professionals in the areas of osteoporosis treatment and counseling, BMD testing, initiation of pharmacotherapy, and coordination of care for patients who have experienced a fragility fracture.

Case of a Missed Giant Cell Tumor of Bone: An Opportunity to Observe its Natural History Disease.

Giant cell tumor of bone (GCT) is a benign neoplasm that most commonly presents with pain and is rarely diagnosed as an incidental finding. We present the report of a young woman whose pre-operative MRI was only noted to have a tear of the anterior cruciate ligament (ACL). Subsequently, the patient underwent anACL reconstruction. A second MRI, performed four years later, demonstrated an enlarged mass in the same location. A retrospective evaluation of the initial MRI revealed an eccentric metaphyseal lesion. Histology obtained from the lesion demonstrated a giant cell tumor of bone. We present the case of an asymptomatic GCT discovered retrospectively as an incidental finding and reevaluated four years later. 'Ihis case serves as a reminder of the importance for the critical review of routine preoperative imaging and also offers a unique perspective on the natural history of giant cell tumor of bone.

The role of recombinant human platelet-derived growth factor-BB (rhPDGF-BB) in orthopaedic bone repair and regeneration.

Recombinant human PDGF BB homodimer (rhPDGF-BB) is a potent recruiter of, and strong mitogenic factor for, cells crucial to musculoskeletal tissue repair, including mesenchymal stem cells (MSCs), osteogenic cells and tenocytes. rhPDGF-BB also upregulates angiogenesis. These properties allow rhPDGF-BB to trigger the cascade of bone and adjoining soft tissue repair and regeneration. This mechanism of action has been established in numerous preclinical and clinical studies. Demonstration of the safety and efficacy of rhPDGF-BB in the healing of chronic foot ulcers in diabetic patients and regeneration of alveolar (jaw) bone lost due to chronic infection from periodontal disease has resulted in two FDA-approved products based on this molecule. A third product is in late stages of clinical development, with pilot and pivotal clinical studies of rhPDGF-BB mixed with an osteoconductive bone matrix (Augment(®) Bone Graft) in foot and ankle fusions demonstrating that this product is at least as effective as bone autograft, and has an improved safety profile. Additional combinations of rhPDGF-BB with tissue-specific matrices are also being studied clinically in additional musculoskeletal indications.

Recombinant human platelet-derived growth factor: biology and clinical applications.

The abilities of bone to remodel, fractures to repair, and bone grafts to incorporate are all fundamental reflections of the bone remodeling cycle. This process is characterized by the recruitment and differentiation of osteoblastic and osteoclastic cell populations, whose cellular activities are coordinated and regulated by an elaborate system of growth factors and cytokines. One of the crucial biological factors responsible for reparative osseous activity is platelet-derived growth factor (PDGF). The potent stimulatory effects of PDGF as a chemoattractant and mitogen for mesenchymal cells (including osteogenic cells), along with its ability to promote angiogenesis, have been demonstrated in a variety of preclinical models predicting maxillofacial, spine and appendicular skeletal, and soft-tissue applications. The biological profile of PDGF, including its ability to recruit osteoprogenitor cells, makes it particularly suited to address the skeletal defects that are seen with comorbid conditions such as osteoporosis, diabetes, and the effects of smoking. The clinical success and safety that have been demonstrated with use of recombinant human PDGF (rhPDGF) in the repair of periodontal defects have led to U.S. Food and Drug Administration (FDA) approval of rhPDGF for this indication. Ongoing pilot and pivotal trials in the United States and internationally will continue to clarify the promising role of PDGF in the treatment of challenging skeletal disorders.

Core needle biopsies of musculoskeletal tumors: potential pitfalls.

Core needle biopsy is a powerful tool used to diagnose and develop a treatment strategy for musculoskeletal tumors. With accuracy rates reported between 69% and 99%, it is evident that errors in diagnosis occur, and they can lead to devastating consequences. We reviewed pathology reports of preoperative core needle biopsies in an attempt to determine factors associated with false negative diagnoses for the purpose of improving surgical planning. We retrospectively reviewed all office-based core needle biopsies accomplished in our practice over a 6-year period. One hundred nineteen biopsies were identified, of which 82 fulfilled criteria to be included in the study population. The pathologist's report of each biopsy was reviewed and categorized based on the findings into 1 of 2 diagnostic groups: neoplastic or nonneoplastic. The results of the biopsies were then compared to the pathology results of the final surgical resection, and the rates and nature of false negative biopsy results (unrecognized malignant pathology) were compared for each group. Seventy-one biopsies were categorized as neoplastic based on the pathology report. No false negative results were found in this group when compared to the final surgical resection pathology. Eleven biopsies were categorized as nonneoplastic, of which 6 were found to be false negatives when compared to the final surgical pathologic diagnosis. The rate of false negative results significantly increased in biopsies whose reports were categorized as nonneoplastic compared to biopsies categorized as neoplastic (P<.0001). We found core needle biopsies of musculoskeletal lesions to be safe and effective in diagnosing pathologic processes. In cases in which analysis of the biopsy specimen did not identify a specific neoplastic process, we found a high incidence of undiagnosed malignancy upon definitive surgical resection. Pathology reports of core needle biopsies that specify only normal, inflammatory, or other nonspecific tissue descriptions should alert the clinician to the increased possibility of a false negative result, and require further tissue analysis.

Chromosomal rearrangements in lipofibromatosis.

Lipofibromatosis is a relatively rare pediatric neoplasm, which usually manifests as an ill-defined soft tissue mass involving the upper and lower distal extremities, the trunk, and, less frequently, the head. To date, no cytogenetic abnormalities have been reported in this uncommon neoplasm. We present a case of lipofibromatosis featuring a three-way t(4;9;6) translocation in a 5-year-old boy.

Measuring the attitudes and impact of the eighty-hour workweek rules on orthopaedic surgery residents.

BACKGROUND: The literature on graduate medical education contains anecdotal reports of some effects of the new eighty-hour workweek on the attitudes and performance of residents. However, there are relatively few studies detailing the attitudes of large numbers of residents in a particular surgical specialty toward the new requirements. METHODS: Between July and November 2004, a survey created by the Academic Advocacy Committee of the American Academy of Orthopaedic Surgeons was distributed by mail, fax, and e-mail to a total of 4207 orthopaedic residents at the postgraduate year-1 through year-6 levels of training. The survey responses were tabulated electronically, and the results were recorded. RESULTS: The survey response rate was 13.2% (554 residents). Sixty-eight percent (337) of the 495 respondents whose postgraduate-year level was known were at the postgraduate year-4 level or higher. Attitudes concerning the duty rules were mixed. Twenty-three percent of the 554 respondents thought that eighty hours constituted an appropriate number of duty hours per week; 41% believed that eighty hours were too many, and 34% thought that eighty hours were not sufficient. Thirty-three percent of the respondents had worked greater than eighty hours during at least a single one-week period since the new rules were implemented; this occurred more commonly among the postgraduate year-3 and more junior residents. Orthopaedic trauma residents had the most difficulty adhering to the new duty-hour restrictions. Eighty-two percent of the respondents indicated that their residency programs have been forced to make changes to their call schedules or to hire ancillary staff to address the rules. The use of physician assistants, night-float systems, and so-called home-call assignments were the most common strategies used to achieve compliance. CONCLUSION: Resident attitudes toward the work rules are mixed. The rules have forced residency programs to restructure. Junior residents have more favorable attitudes toward the new standards than do senior residents. Self-reporting of duty hours is the most common method of monitoring in orthopaedic training programs. Such systems allow ample opportunity for inaccuracies in the measurement of hours worked. Although residents report an improved quality of life as a result of these new rules, the attitude that the quality of training is diminished persists.

Metastatic disease of the spine.

Metastatic spine disease accounts for 10% to 30% of new cancer diagnoses annually. The most frequent presentation is axial pain. A thorough spinal examination includes assessment of local tenderness, deformity, limitation of motion, and signs of nerve root or cord compression. Plain radiographs are obtained routinely; for a suspected or known malignancy, radionuclide studies are essential. Magnetic resonance imaging is more specific than bone scans. Computed tomography-guided biopsy is considered to be safe and accurate for evaluating spinal lesions. Treatment is multidisciplinary, and virtually all treatment is palliative. Management is guided by three key issues: neurologic compromise, spinal instability, and individual patient factors. Site-directed radiation, with or without chemotherapy, is the mainstay of treating painful lesions that are not impinging on neural elements. New data documenting the benefit of surgical decompression using improved techniques such as anterior approaches have amplified the role of the spine surgeon in the care of these patients.