Wound healing outcomes following treatment with synthetic hybrid-scale fiber matrix after resection of soft tissue tumors or infections.

BACKGROUND: Wide excision of soft tissue tumors or infections often results in large defects that can be challenging to manage. Advanced treatment modalities-including NPWT, skin grafts, and xenografts-can all be considered for post-resection wound management, but each has its limitations. An SHSFM, engineered to resemble human extracellular matrix, has demonstrated positive wound healing outcomes in prior studies. MATERIALS AND METHODS: Adult patients at a single institution who underwent resection of soft tissue tumor or infected tissue followed by treatment with SHSFM from 2020-2023 were retrospectively reviewed. RESULTS: Ten patients were included in the review after meeting the inclusion criteria. Overall, 7 of 10 wounds had documented complete closure, with 3 lost to follow-up. Average time to wound closure was 119 days. Patients either healed via secondary intention or were bridged to a split-thickness skin graft. The average VSS score was 3.3 when assessed. CONCLUSION: The current case series demonstrated that the SHSFM can support granulation tissue formation over exposed structures as a bridge to skin graft or can completely reepithelialize large wounds without skin grafting. The SHSFM offers a novel treatment option for post-resection surgical wounds.

Biopsia en ortopedia y riesgo de contaminación bacteriana durante el muestreo de tejidos: hechos y estrategias / Biopsy in orthopaedics and risk of bacterial contamination during tissue sampling: facts and strategies

Las biopsias en el campo de la ortopedia se utilizan para guiar las opciones de diagnóstico y tratamiento para el proceso de la enfermedad que puede estar ocurriendo. La preparación de la piel de estas biopsias sigue la preparación estándar para un procedimiento quirúrgico, con el objetivo de disminuir la cantidad de microbiota que podría conducir a la contaminación del tejido de la biopsia e incluso a una posible infección. El tejido obtenido de la biopsia a menudo se somete a un studio histopatológico y cultivo. La tasa de contaminación bacteriana informada es aproximadamente inferior al 4%. Esta revisión cuestiona si las muestras de las biopsias se contaminan con la microbiota que permanece en la piel y cómo puede afectar el manejo. Además, qué técnicas o pasos pueden disminuir la tasa de contaminación al realizar una biopsia. Nuestra revisión bibliográfica identificó pocos estudios sobre la contaminación bacteriana de las biopsias. Identificamos diferentes factores implicados en el conocimiento de la microbiota de la piel: técnicas y soluciones de preparación de la piel, variación de la microbiota típica que coloniza la piel según la región anatómica, retención preoperatoria versus administración profiláctica de antibióticos y uso de diferentes hojas de bisturí para la piel superficial y para tejidos profundos, entre otros. Aunque no pudimos identificar ningún dato que proporcionara respuestas a nuestra pregunta original y cuantificar cada factor individualmente, la mayoría de los estudios en diferentes campos ortopédicos proporcionaron hallazgos significativos hasta cierto punto. Describimos algunas recomendaciones prácticas basadas en el consenso y la efectividad teórica para disminuir la tasa de contaminación. Se necesitan más investigaciones en el campo de la ortopedia que impliquen la contaminación por microbiota de la piel de una biopsia

Biopsies in the field of orthopaedics are used to guide diagnostics and treatment options for the disease process that may be occurring such as a tumor or infection. Skin preparation of these biopsies follows the standard skin preparation for a surgical procedure, with the aim to decrease the amount of microbiota that could lead to contamination of the tissue biopsy and even possible infection. The tissue obtained from the biopsy often undergoes pathology and culture. The reported bacterial contamination rate is roughly below 4%. This review questions how samples from the biopsies are getting contaminated by microbiota that remains on the skin and how it affects infection management. In addition, which techniques or steps can decrease the rate of contamination when performing a biopsy. Our review identified little to no data on investigating bacterial contamination of biopsies. In doing this, the review identified different factors implicated in skin microbiota awareness: skin preparation techniques and solutions, variation of typical microbiota that colonize the skin based on the anatomical region, preoperative withholding versus administrating antibiotics prophylactically and using different scalpel blades for superficial and deep incisions, among others. Although we failed to identify any data that provided answers to our original question and quantify each factor individually, most studies in different orthopaedic fields provided significant findings to some extent. We outline some practical recommendations based on consensus and theoretical effectiveness in decreasing the contamination rate. Further research entailing skin microbiota contamination of a biopsy is needed in the field of orthopaedics.

Technical Strategies for Harvest of the Subtotal Pedicled Fillet of Thigh Flap for Reconstruction of External Hemipelvectomy and Hemicorporectomy Defects.

External hemipelvectomy and hemicorporectomy have been described in the literature for a variety of indications. A commonly used reconstructive technique is the pedicled anterior subtotal fillet of thigh flap. However, there are few descriptions regarding the technical pearls of harvest and inset of this flap. Here, we describe our step-by-step technique, as performed in three patients. The flap is pedicled on the common femoral artery and extends longitudinally to the knee to achieve the length required to extend past the midline and resurface sacral pressure ulcers, which are commonly found in patients who undergo this procedure for refractory pelvic osteomyelitis. Additionally, we describe a potential salvage option with late division of the popliteal artery to preserve the option for free tissue transfer of a subtotal fillet of lower leg flap.

Giant Cell Tumor of the Wrist After Fracture Osteosynthesis: A Case Report.

A 60-year-old female sustained a distal radius fracture and underwent open reduction internal fixation with a volar locking plate. The patient had an uneventful recovery until four months postoperatively when the patient clinically regressed, and an expansile, radiolucent metaepiphyseal lesion was found. Further workup revealed this was a giant cell tumor of bone (GCTB). Definitive management consisted of extensive curettage, cryoablation, and cementation of the lesion, and the hardware was left intact. The current case presents an uncommon presentation of GCTB. The case illuminates the importance of thorough scrutiny of postoperative radiographs when clinical improvement plateaus or regresses and the need to pursue additional workup when the clinical course is atypical. The authors query the possibility of a sub-radiological presentation of GCTB.

Intraoperative Cryotherapy in the Treatment of Metastatic Renal Cell Carcinoma of the Bone.

Osseous metastases in renal cell carcinoma (RCC) are a heterogeneous mix of cells with hypervascular and rapidly destructive properties that frequently exhibit resistance to both radiation and chemotherapy. Despite this, some patients with isolated and oligometastatic disease have the potential to be cured. Regardless, aggressive metastatic control is critical to minimizing morbidity and mortality for all patients with metastatic RCC. Percutaneous cryoprobes were developed as a minimally invasive technique for both pain relief and tumor control. However, there is little evidence describing an alternative use of this technology in the operating room to assist with open tumor resections, and no formal role for its use in orthopedics exists. Therefore, the authors added this modality to their intraoperative treatment of osseous RCC to investigate whether it would influence their ability to obtain local metastatic control. The authors performed a retrospective chart review of prospectively obtained data to evaluate the role of intraoperative cryotherapy in the treatment of osseous RCC. From 2004 to 2017, cryotherapy was used in 43 procedures, alleviating the need for additional radiation 84% (36 of 43) of the time. Local tumor control was achieved in 100% (43 of 43) of cases. There were 2 wound-related complications and 1 pathologic fracture. Despite the study's limitations, the authors believe that cryotherapy contributed to the reliability and reproducibility of their intralesional resections. Given the palliative, and potentially curative, opportunities afforded by complete locoregional tumor control, the authors support further investigation into the use of intraoperative cryotherapy to treat osseous metastases secondary to RCC. [Orthopedics. 2021;44(5):e645-e652.].

Disseminated Nocardiosis Masquerading as Soft-Tissue Malignancy: A Case Report.

CASE: A 59-year-old man, immunosuppressed after renal transplant, presented with a painful posterior thigh mass concerning for malignancy, as well as pulmonary and posterior chest wall nodules. Cultures and mass spectrometry identified Nocardia paucivorans. The patient underwent operative irrigation and debridement of the posterior thigh and chest wall, with 12 months of antibiotic therapy. CONCLUSION: A 2-week delay in appropriate treatment was due to low suspicion for infectious etiology. Since cultures generally take weeks for positive diagnosis, advanced molecular or biochemical methods should be used. This case demonstrates importance in maintaining a high index of suspicion for nocardiosis in immunocompromised patients with soft-tissue masses.

Nontuberculous Mycobacterial Musculoskeletal Infection Cases from a Tertiary Referral Center, Colorado, USA.

Nontuberculous mycobacteria represent an uncommon but important cause of infection of the musculoskeletal system. Such infections require aggressive medical and surgical treatment, and cases are often complicated by delayed diagnosis. We retrospectively reviewed all 14 nonspinal cases of nontuberculous mycobacterial musculoskeletal infections treated over 6 years by orthopedic surgeons at a university-affiliated tertiary referral center. All patients required multiple antimicrobial agents along with aggressive surgical treatment; 13 of 14 patients ultimately achieved cure. Four patients required amputation to control the infection. Half these patients were immunosuppressed by medications or other medical illness when they sought care at the referral center. Six cases involved joint prostheses; all ultimately required hardware removal and placement of an antimicrobial spacer for eradication of infection. Our findings highlight the importance of vigilance for nontuberculous mycobacterial musculoskeletal infection, particularly in patients who are immunosuppressed or have a history of musculoskeletal surgery.

Thermal Conductivity of Human Bone in Cryoprobe Freezing as Related to Density.

Cryoprobes create localized cell destruction through freezing. Bone is resistant to temperature flow but is susceptible to freezing necrosis at warmer temperatures than tumor cells. Few studies have determined the thermal conductivity of human bone. No studies have examined conductivity as related to density. The study goal was to examine thermal conductivity in human bone while comparing differences between cancellous and cortical bone. An additional goal was to establish a relationship between bone density and thermal conductivity. Six knee joints from 5 cadavers were obtained. The epiphyseal region was sliced in half coronally prior to inserting an argon-circulating cryoprobe directed away from the joint line. Thermistor thermometers were placed perpendicularly at measured increments, and the freezing cycle was recorded until steady-state conditions were achieved. For 2 cortical samples, the probe was placed intramedullary in metaphyseal samples and measurements were performed radially from the central axis of each sample. Conductivity was calculated using Fournier's Law and then plotted against measured density of each sample. Across samples, density of cancellous bone ranged from 0.86 to 1.38 g/mL and average thermal conductivity ranged between 0.404 and 0.55 W/mK. Comparatively, cortical bone had a density of 1.70 to 1.86 g/mL and thermal conductivity of 0.0742 to 0.109 W/mK. A strong 2-degree polynomial correlation was seen (R2=0.8226, P<.001). Bone is highly resistant to temperature flow. This resistance varies and inversely correlates strongly with density. This information is clinically relevant to maximize tumor ablation while minimizing morbidity through unnecessary bone loss and damage to surrounding structures. [Orthopedics. 2017; 40(2):90-94.].

Myxoid Liposarcoma of the Thigh with Metastasis to the Left Ventricle of the Heart: A Case Report.

CASE: This report describes a sixty-one-year old man who was diagnosed with a myxoid liposarcoma of the left thigh that was resected and then treated with radiation therapy. He underwent yearly surveillance imaging but presented seventeen years after initial resection with symptoms of heart failure. He was found to have a cardiac abnormality that was first thought to be a pseudoaneurysm but was later shown to be a myxoid liposarcoma, presumably metastatic. CONCLUSION: Myxoid liposarcoma can present with late metastasis, including to the heart.

Use of carbon-fiber-reinforced composite implants in orthopedic surgery.

Carbon-fiber-reinforced polyetheretherketone implants offer several benefits over traditional metal implants. Their radiolucent property permits improved, artifact-free radiographic imaging. Their lower modulus of elasticity better matches that of bone. Their fatigue strength is greater than most metal implants. This article reviews the use of these implants in orthopedic surgery, including treatment of conditions involving the spine, trauma, tumor, and infection.

Large joint osteoarticular infection caused by Mycobacterium arupense.

Nontuberculous mycobacteria tenosynovitis and osteoarticular infections have increased during the past 25 years. At least 15 different species of atypical mycobacteria have been mentioned in the literature as the cause of orthopedic infections. Mycobacterium arupense is a recently discovered species that is closely related to the Mycobacterium terrae complex. A review of the literature found M arupense cited as the cause of a single case of tenosynovitis of the hand. To the authors' knowledge, this organism has never been cited as the cause of a large joint infection. This article describes a case of knee osteoarticular infection caused by M arupense in a 69-year-old woman with no known immunocompromising comorbidities. The patient had more than a decade of knee pain and infection refractory to multiple surgical debridements and broad-spectrum antibiotics. Radical debridement with synovectomy and large-quantity bone resection cleared the infection with more than 2 years of follow-up. Clinically relevant findings in this case include the unusual and challenging nature of diagnosing and treating atypical mycobacterial musculoskeletal infection. The operative principles and techniques that apply to other bacterial osteoarticular infections are appropriate for musculoskeletal infection with M arupense. Furthermore, correct identification and speciation of atypical mycobacteria is crucial to guide antibiotic treatment.

The application of cryoprobe therapy in orthopedic oncology.

The cryoprobe is a relatively new surgical tool offering a more selective destruction of unwanted cells. Using expanded versions of basic thermodynamic formulas of conduction and convection, mathematical models are becoming more effective at mapping out the zone of destruction that can be expected when using cryoprobes. The development of this technology will allow for better surgical planning and postoperative care to decrease patient morbidity and mortality. It is thought that this invaluable tool will become increasingly prevalent in orthopedics.

Surgical strategies to achieve a custom-fit TKA with standard implant technique.

Recent trends in implant design have been geared toward taking individual differences in knee anatomy into consideration and modifying implants to accommodate these distinctions. The unique anatomy of the female knee gave birth to sex-specific knee implants and began a new era in implant design. This opened the door for the next progression of patient-specific cutting guides and implants. The current trend in implant design addresses individual variation with 3-D modeling that necessitates preoperative magnetic resonance imaging or computed tomography scans. While these innovations may turn out to be worthwhile, their use is currently limited by their expense and debatable clinical significance. Surgeons should not forget the basic surgical strategies to tailor their surgery to customize the fit of the standard implant. The surgical pearls reviewed here will allow surgeons to better understand sizing and customize every total knee arthroplasty with a patient-specific surgery. [corrected]

Prevalence of methicillin-resistant Staphylococcus aureus among orthopedic patients at a large academic hospital.

Community-based methicillin-resistant Staphylococcus aureus (MRSA) contributes to postoperative surgical site infections, and it is therefore important to eliminate nasal carriage of MRSA before surgery. A total of 678 nasal swabs were performed on elective orthopedic patients undergoing surgery with the usage of metal implants. Thirty-eight specimens (5.6%) were positive for MRSA and 146 (21.5%) were positive for methicillin-sensitive S aureus (MSSA). A slow increase in the number of MSSA was noted between 2006 and 2007. Positive cases of MRSA nasal carriage were treated with nasal mupirocin ointment and chlorhexidine baths or showers for 5 days prior to surgery.

Unusual metastases from extremity soft tissue sarcomas.

The most common metastatic route for extremity soft-tissue sarcomas is via the venous system to the lungs. Metastases to other sites such as the brain, liver, and soft tissue distant from the primary tumor are rare. A tumor registry, prospectively kept since 1986, was reviewed for unusual metastatic spread. Of 3671 tumors, 346 high-grade extremity soft-tissue sarcomas were evaluated. A total of 15 patients (4.3%) presented with initial recurrence of disease that was extrapulmonary and distant from the site of the primary tumor. Four of these patients (27%) were successfully treated for their recurrence. Based on these findings, a different strategy for follow-up of patients after treatment of a high-grade extremity soft-tissue sarcoma is suggested.

Low-grade cartilage tumors: diagnosis and treatment.

As a result of reading this article, physicians should be able to: 1. List the features that are useful in differentiating a low-grade chondrosarcoma from an enchondroma. 2. Describe the treatment principles of low-grade cartilage tumors based on the anatomic location and stage of the tumor. 3. Discuss the characteristics of a local recurrence after initial treatment and the general consequences.