Extraskeletal Osteosarcoma of the Hand.

Extraskeletal osteosarcoma is a rare disease that uncommonly affects the upper extremity. A 46-year-old African American man presented for evaluation of a right middle finger mass. Excisional biopsy demonstrated extraskeletal osteosarcoma of the soft tissues. We performed a transmetacarpal ray resection.

Financial Analysis of Treating Periprosthetic Joint Infections at a Tertiary Referral Center.

BACKGROUND: Periprosthetic joint infection (PJI) is a significant challenge to the orthopedic surgeon, patient, hospital, and insurance provider. Our study compares the financial information of self-originating and referral 2-stage revision hip and knee surgeries at our tertiary referral center for hip or knee PJI over the last 4 years. METHODS: We performed an in-house retrospective financial review of all patients who underwent 2-stage revision hip or knee arthroplasty for infection between January 2008 and August 2013, comparing self-originating and referral cases. RESULTS: We found an increasing number of referrals over the study period. There was an increased cost of treating hips over knees. All scenarios generated a positive net income; however, referral hip PJIs offered lower reimbursement and net income per case (although not statistically significant), whereas knee PJIs offered higher reimbursement and net income per case (although not statistically significant). CONCLUSION: With referral centers treating increased numbers of infected joints performed elsewhere, we show continued financial incentive in accepting referrals, although with less financial gain than when treating one's own hip PJI and an increased financial gain when treating referral knee PJIs.

The Effects of a Hospitalist Comanagement Model for Joint Arthroplasty Patients in a Teaching Facility.

BACKGROUND: The goal of this study was to compare postoperative medical comanagement of total hip arthroplasty and total knee arthroplasty patients using a hospitalist (H) and nonhospitalist (NH) model at a single teaching institution to determine the clinical and economic impact of the hospitalist comanagement. METHODS: We retrospectively reviewed the records of 1656 patients who received hospitalist comanagement with 1319 patients who did not. The NH and H cohorts were compared at baseline via chi-square test for the American Society of Anesthesiologists classification, the t test for age, and the Wilcoxon test for the unadjusted Charlson Comorbidity Index score and the age-adjusted Charlson Comorbidity Index score. Chi-square test was used to compare the postoperative length of stay, readmission rate at 30 days after surgery, diagnoses present on admission, new diagnoses during admission, tests ordered postoperatively, total direct cost, and discharge location. RESULTS: The H cohort gained more new diagnoses (P < .001), had more studies ordered (P < .001), had a higher cost of hospitalization (P = .002), and were more likely to be discharged to a skilled nursing facility (P < .001). The H cohort also had a lower length of stay (P < .001), but we believe evolving techniques in both pain control and blood management likely influenced this. There was no significant difference in readmissions. CONCLUSION: Any potential benefit of a hospitalist comanagement model for this patient population may be outweighed by increased cost.

High CD49f expression is associated with osteosarcoma tumor progression: a study using patient-derived primary cell cultures.

Overall prognosis for osteosarcoma (OS) is poor despite aggressive treatment options. Limited access to primary tumors, technical challenges in processing OS tissues, and the lack of well-characterized primary cell cultures has hindered our ability to fully understand the properties of OS tumor initiation and progression. In this study, we have isolated and characterized cell cultures derived from four central high-grade human OS samples. Furthermore, we used the cell cultures to study the role of CD49f in OS progression. Recent studies have implicated CD49f in stemness and multipotency of both cancer stem cells and mesenchymal stem cells. Therefore, we investigated the role of CD49f in osteosarcomagenesis. First, single cell suspensions of tumor biopsies were subcultured and characterized for cell surface marker expression. Next, we characterized the growth and differentiation properties, sensitivity to chemotherapy drugs, and anchorage-independent growth. Xenograft assays showed that cell populations expressing CD49f(hi) /CD90(lo) cell phenotype produced an aggressive tumor. Multiple lines of evidence demonstrated that inhibiting CD49f decreased the tumor-forming ability. Furthermore, the CD49f(hi) /CD90(lo) cell population is generating more aggressive OS tumor growth and indicating this cell surface marker could be a potential candidate for the isolation of an aggressive cell type in OSs.

Interscapulothoracic (forequarter) amputation for malignant tumors involving the upper extremity: surgical technique and case series.

BACKGROUND: Forequarter amputation (FQA) is reserved for large, multifocal, or recurrent tumors affecting the shoulder and upper extremity. Although it is performed less frequently with the advancement of limb salvage surgery, FQA remains an important treatment in select patients. The purpose of this study is to illustrate the surgical technique in a case series of 4 patients. METHODS: Between 2010 and 2012, 4 patients (mean age, 61 years; range, 36-78 years) presented with malignant disease of the upper extremity that was not amenable to or had failed limb salvage. All patients had FQA by the illustrated anterior clavicular osteotomy technique. Patient data were retrospectively reviewed from preoperative workup until last follow-up or death. RESULTS: All patients had tumors that involved major neurovascular structures of the upper extremity and shoulder girdle. One presented with neuroendocrine carcinoma and has achieved local control after FQA. Three presented with high-grade sarcoma. One of these had recurrence after prior limb salvage and neoadjuvant radiation and unfortunately succumbed to metastatic disease 6 months after FQA. An additional sarcoma patient who presented after shoulder arthroscopy for a "labral cyst" with recurrent and fulminant synovial sarcoma succumbed to her disease. The remaining sarcoma patient has had no recurrence and minimal phantom pain at last follow-up. DISCUSSION: Obtaining vascular control early in the procedure is crucial to minimize blood loss. When it is indicated, FQA is a relatively safe and reliable procedure for dealing with otherwise challenging tumors of the shoulder girdle and upper extremity. LEVEL OF EVIDENCE: Level IV, case series, treatment study.

Derivation and characterization of an extra-axial chordoma cell line (EACH-1) from a scapular tumor.

BACKGROUND: Extra-axial chordomas are rare low-grade malignant tumors thought to arise from notochordal remnants in the extra-axial skeleton. Few studies have been done on this neoplasm because of its rarity. In addition, there is a lack of a good in vitro model on which to perform more characterization. METHODS: We describe a twenty-eight-year-old man with a mass in the right scapula. Cytomorphology and immunohistochemistry, including brachyury staining, were used to formulate the final diagnosis. A fragment of the tumor was placed in culture, and cells obtained were injected subcutaneously in an immunocompromised mouse. From the tumor developed in mice, a cell line has been derived and characterized by fluorescence-activated cell-sorting analysis, karyotyping, clonogenicity, and cell and tumor growth curves. RESULTS: Cytomorphology on the tumor showed nests of round cells with vacuoles and also physaliferous-like cells with uniform nuclei. Immunochemistry revealed a tumor positive for vimentin, moderately positive for S-100 and cytokeratin AE1/AE3, weakly positive for epithelial membrane antigen, and negative for p63 and cytokeratin (CK)-7. Further analysis revealed the tumor was diffusely and strongly positive for brachyury. The cell line derived from the tumor showed rapid doubling-time, a strong expression of mesenchymal cell surface markers, a karyotype of diploid or hypotetraploid clones with numerous chromosomal aberrations, and the ability to form colonies without attachment and to form tumors in immunocompromised mice. CONCLUSIONS: The diagnosis of the extra-axial chordoma is difficult but can be resolved by the detection of a strong brachyury expression. In addition, the derivation of a human extra-axial chordoma cell line could be a useful tool for the basic research of this rare neoplasm.

Chondromyxoid fibroma of the radial shaft treated with nonvascularized fibular autograft.

Chondromyxoid fibroma is a benign yet highly recurrent neoplasm of bone, usually found in the metaphyseal segments of long bones. We present the case of an unusual diaphyseal chondromyxoid fibroma of the radius and review the literature regarding these rare chondroid neoplasms.

Bizarre parosteal osteochondromatous proliferation of the proximal humerus: case report.

Bizarre parosteal osteochondromatous proliferation (BPOP), or Nora's lesion, is a rare lesion of bone occurring predominantly in the long bones of the hands and feet. It exists as a puzzling clinical entity of uncertain origins and high recurrence rates after surgical resection. To our knowledge, this clinical entity has not been reported in the proximal aspect of the humerus. An interesting report of a lesion occurring in the proximal humerus, which initially was misinterpreted as a parosteal osteosarcoma, is discussed outlining the clinical, radiographic and pathologic features of the BPOP lesion.