Spine Injuries Sustained After Falls While Crossing the U.S.-Mexico Border.

This study is to report the demographics, incidence, and patterns of spinal injuries associated with border crossings resulting from a fall from a significant height. A retrospective cohort study was performed at a Level I trauma center from January 2016 to December 2021 to identify all patients who fell from a significant height while traversing the U.S.-Mexico border and were subsequently admitted. A total of 448 patients were identified. Of the 448 patients, 117 (26.2%) had spine injuries and 39 (33.3%) underwent operative fixation. Females had a significantly higher incidence of spine injuries (60% vs. 40%; p < 0.00330). Patients with a spine fracture fell from a higher median fall height (6.1 vs. 4.6 m; p < 0.001), which resulted in longer median length of stay (LOS; 12 vs. 7 days; p < 0.001), greater median Injury Severity Score (ISS; 20 vs. 9; p < 0.001), and greater relative risk (RR) of ISS >15 (RR = 3.2; p < 0.001). Patients with operative spine injuries had significantly longer median intensive care unit (ICU) LOS than patients with non-operative spine injuries (4 vs. 2 days; p < 0.001). Patients with spinal cord injuries and ISS >15 sustained falls from a higher distance (median 6.1 vs. 5.5 m) and had a longer length of ICU stay (median 3 vs. 0 days). All patients with operative spine injuries had an ISS >15 relative to 50% of patients with non-operative spine injuries (median ISS 20 vs. 15; p < 0.001). Patients with spine trauma requiring surgery had a higher incidence of head (RR = 3.5; p 0.0353) and chest injuries (RR = 6.0; p = 0.0238), but a lower incidence of lower extremity injuries (RR = 0.5; p < 0.001). Thoracolumbar injuries occurred in 68.4% of all patients with spine injuries. Patients with operative spine injuries had a higher incidence of burst fracture (RR = 15.5; p < 0.001) and flexion-distraction injury (RR = 25.7; p = 0.0257). All patients with non-operative spine injuries had American Spinal Injury Association (ASIA) D or E presentations, and patients with operative spine injuries had a higher incidence of spinal cord injury: ASIA D or lower at time of presentation (RR = 6.3; p < 0.001). Falls from walls in border crossings result in significant injuries to the head, spine, long bones, and body, resulting in polytrauma casualties. Falls from higher height were associated with a higher frequency and severity of spinal injuries, greater ISS, and longer ICU length of stay. Operative spine injuries, compared with non-operative spine injuries, had longer ICU length of stay, greater ISS, and different fracture morphology. Spine surgeons and neurocritical care teams should be prepared to care for injuries associated with falls from height in this unique population.

A Masquerading Hematoma Resulting in the Delayed Diagnosis of a Soft Tissue Sarcoma: A Case Report.

A 27-year-old male with insidious right arm swelling was diagnosed with a hematoma secondary to a partial biceps tear, later identified as a rhabdomyosarcoma. Soft tissue sarcomas (STS) may present with misleading patient histories and nonspecific symptoms, resulting in misdiagnosis and delayed treatment. One of the classic masqueraders of soft tissue sarcomas is hematomas secondary to trauma. Obtaining a prudent history with careful scrutiny of appropriate imaging often helps establish the correct diagnosis. Ultimately, tissue biopsy can resolve any ambiguous cases and prevent delays in diagnosis and treatment.

What's Important: Care of the Migrant Trauma Patient.

UPDATE: This article was updated on December 20, 2023, because of a previous error, which was discovered after the preliminary version of the article was posted online. On page 1993, the text that had read "Once apprehended by U.S. CBP, migrant trauma patients are often taken to local hospitals in the U.S. health-care systems along the U.S.-Mexico border that are tasked with providing care to this particularly vulnerable patient population" now reads "Once apprehended by U.S. CBP, migrant trauma patients are often brought to local hospitals in the U.S. These hospitals, located along the U.S.-Mexico border, are tasked with providing care to this particularly vulnerable population."

Critical Review of Oncologic Medical Malpractice Claims Against Orthopaedic Surgeons.

INTRODUCTION: The purpose of this study was to determine the most common allegations for malpractice litigation brought against orthopaedic surgeons for oncologic matters and the resulting verdicts. METHODS: The Westlaw Legal research database was queried for malpractice cases filed against orthopaedic surgeons for oncologic matters in the United States after 1980. Plaintiff demographics, state of filing, allegations, and outcomes of lawsuits were recorded and reported accordingly. RESULTS: A total of 36 cases met the inclusion and exclusion criteria and were subsequently included in the final analysis. The overall rate of cases filed remained consistent through the past four decades and was primarily related to a primary sarcoma diagnosis in adult women. The primary reason for litigation was failure to diagnose a primary malignant sarcoma (42%) followed by failure to diagnose unrelated carcinoma (19%). The most common states of filing were primarily located in the Northeast (47%), where a plaintiff verdict was also more commonly encountered as compared with other regions. Damages awarded averaged $1,672,500 with a range of $134, 231 to $6,250,000 and a median of $918,750. CONCLUSION: Failure to diagnose primary malignant sarcoma and unrelated carcinoma was the most common reason for oncologic litigation brought against orthopaedic surgeons. Although most of the cases ruled in favor of the defendant surgeon, it is important for orthopaedic surgeons to be aware of the potential errors that not only prevent litigation but also improve patient care.

Premalignant Conditions of Bone.

Development of malignancy is a multifactorial process, and there are multitude of conditions of bone that may predispose patients to malignancy. Etiologies of malignancy include benign osseous conditions, genetic predisposition, and extrinsic conditions. New-onset pain or growth in a previously stable lesion is that should concern for malignant change and should prompt a diagnostic workup for malignancy.

Atypical Cartilaginous Tumors: Trends in Management.

INTRODUCTION: Chondrosarcomas are the most common primary bone malignancy in adults within the United States. Low-grade chondrosarcomas of the long bones, now referred to as atypical cartilaginous tumors (ACTs), have undergone considerable changes in recommended management over the past 20 years, although controversy remains. Diagnostic needle biopsy is recommended only in ambiguous lesions that cannot be clinically diagnosed with a multidisciplinary team. Local excision is preferred due to better functional and equivalent oncologic outcomes. We sought to determine whether these changes are reflected in reported management of ACTs. METHODS: The National Cancer Database (NCDB) 2004 to 2016 was queried for ACTs of the long bones. Reported patient demographics and tumor clinicopathologic findings were extracted and compared between patients who underwent local excision versus wide resection. RESULTS: We identified 1174 ACT patients in the NCDB. Of these, 586 underwent local excision and 588 underwent wide resection. No significant differences were found in patient demographics. No significant change was found in the reported percentage of diagnostic biopsies or wide resections performed over time. After multivariate regression, the single greatest predictor of performing wide resection on an ACTs was presenting tumor size. DISCUSSION: Evaluation of the NCDB demonstrated that despite changes in the recommended management of ACTs, there has not been a significant change in surgical treatment over time. Surgeons have been performing diagnostic biopsies and wide resections at similar to historical rates. Persistency of these practices may be due to presenting tumor size, complex anatomic location, uncertainty of underlying tumor grade, or patient choice as part of clinical shared decision making. The authors anticipate that the rate of biopsies and wide resections performed will decrease over time as a result of improvements in advanced imaging and the implementation of recently updated clinical practice guidelines.

Periosteal Chondroma of the Pelvis: An Uncommon Tumor in an Unusual Location.

Periosteal chondromas (PCs) are rare tumors composed of hyaline cartilage that are typically present in long bones and tubular bones of the hand. These lesions are easily mistaken for other, more common tumors. This study reports a case of PC located in the posterior pelvis of a 24-year-old female. The patient initially presented with a four-month history of pelvic pain with a presumptive diagnosis of endometriosis. However, when an MRI was performed, a 6.0 cm x 5.6 cm x 4.5 cm mass was found along the right posterior ilium extending to the ipsilateral sacroiliac joint. The patient underwent intralesional excision and curettage of the mass. Histologic analysis of the excised lesion revealed a proliferation of chondrocytes and abundant hyaline cartilage without chondroblasts, further suggesting the diagnosis of PC. The current study highlights the unusual location of this rare tumor and alerts the physician of the clinical presentation and differential diagnosis.

A Life- and Limb-Threatening Case of Clostridium septicum in a Total Hip Arthroplasty.

A 46-year-old male with bilateral metal-on-metal hip prostheses presented with a left periprosthetic hip infection, as well as chronic, progressive osteolysis of the proximal femur and acetabulum with pelvic erosion. Three years before, the bearing surface was changed to metal-on-polyethylene prosthesis during an attempted revision but was complicated by extensive blood loss. At our institution, gross inspection demonstrated a soft-tissue hip mass of unknown etiology. Open biopsy and culture were performed, but extensive hemorrhaging required interventional radiology. Cultures revealed Clostridium septicum infection-known for its associations with gastrointestinal malignancy. Workup in the hospital was negative for malignancy, and definitive management was left hip disarticulation and intravenous antibiotics. The patient developed a chronic wound on the left hip incision but was ultimately lost to follow-up.

Geographic Differences in Sex and Racial Distributions Among Orthopaedic Surgery Residencies: Programs in the South Less Likely to Train Women and Minorities.

INTRODUCTION: Women and minorities have been reported to be underrepresented in orthopaedic residency programs. The main goal of this study was to describe the representation of women and minorities in orthopaedic surgery residency programs and to identify any geographic differences across the United States. METHODS: Data for active residents within the United States during the academic year 2013 to 2014 were obtained from the American Medical Association. According to the US census method, the program regions were divided into Northeast, Midwest, South, and West. RESULTS: The representation of female residents markedly varied by the geographic region with the lowest female representation in the South and the highest female representation in the West and the Northeast (P = 0.034). Orthopaedic residency programs in the South were less likely to include racial minorities, whereas racial minorities were more commonly represented in residency programs in the West and the Northeast (P < 0.001). DISCUSSION: Our study demonstrates geographic differences in sex and minority representations in orthopaedic residency programs. Training programs in the South are less likely to train women and minorities compared with training programs in the West and the Northeast region. Both applicant-related factors and program-related factors may contribute to this finding.

Assessment of Orthopedic Educational Research in 2015 Publications.

BACKGROUND: Due to orthopedic surgery's unique educational model, recent changes within graduate medical education have the potential to impact the methods and outcomes of specialty training significantly. Using Mind the Gap: Representation of Medical Education in Cardiology-Related Articles and Journals (Allred et al., 2016) as a framework, this study investigates educational research within the field of orthopedics. OBJECTIVE: Two main objectives were evaluated: (1) quantitative analysis of the amount and type of orthopedic education-related research in orthopedic, general surgery, and medical education journals and (2) estimate the priority of orthopedic journals to publish education-focused articles. METHODS: Using a composite citation-based 5-metric scoring system, a complete list of journals pertaining to orthopedics, nonorthopedic specific surgery journals, and general medical education journals was ranked. All publications during 2015 for the selected cohort of journals were then analyzed for orthopedic education-related publications. Aim and scope of the top 15 selected orthopedic journals (along with the mission statements of their associated societies) were evaluated with a word cloud generator to determine priority on education. RESULTS: Review of 7112 articles from the top 15 selected orthopedic journals yielded 37 publications with an educational focus. Evaluation of 15 general surgery or medical education journals, containing 4661 publications, generated an additional 28 positive articles. In total, 51 unique orthopedic education-related publications (0.43% of total evaluated articles) were identified from the 11,773 articles published in the selected 30 journals for 2015. CONCLUSION: The lack of emphasis on orthopedic educational research output is multifactorial, needing further evaluation to determine specific causes and methods of improvement. This article adequately sheds light on the need to increase support of educational research programs within the field of orthopedics.

Bone Tumors and Reconstructive Options in Pediatric and Young Adult Patients.

Sarcomas represent less than 1% of adult cancers but account for approximately 21% of pediatric malignancies and pose great risks for mortality and morbidity in children and young adults. Both benign bone and soft-tissue tumors may not be life-threatening but can be limb-threatening. Missed diagnosis, misdiagnosis, and mismanagement of either benign or malignant tumors may lead to increased mortality and morbidity. A good understanding of the clinical presentation, radiographic findings, and treatment options is needed to make the proper diagnosis and successfully treat these patients. Children and young adults present unique challenges in the management these tumors. Often, there is no right or wrong answer. Surgeons must work with patients and their families to make the right reconstructive decision.

Diffuse Pigmented Villonodular Synovitis as a Rare Cause of Graft Failure Following Anterior Cruciate Ligament Reconstruction.

This case report describes a 42-year-old woman who was diagnosed with pigmented villonodular synovitis (PVNS) in the knee. The patient had received a bone-patella tendon-bone autograft reconstruction of her anterior cruciate ligament (ACL) 22 years prior to her diagnosis of PVNS. After a traumatic event that tore her ACL graft, she underwent a second surgery to repair the initial reconstruction. However, her pain and joint instability remained unresolved. When radiolucent lesions in her tibia and femur were identified through a radiographic image, the patient was referred to the authors' orthopedic oncology clinic. Additional imaging, including magnetic resonance imaging, revealed PVNS, and she was scheduled for debridement and a complete synovectomy of the knee. After surgery, the patient's pain decreased dramatically. She continues to maintain an active lifestyle despite a relatively minor decrease in range of motion. In this case, PVNS proved to be an unlikely complication after ACL reconstruction. The patient remains at risk for the development of degenerative arthritis. [Orthopedics. 2018; 41(1):e142-e144.].

Denosumab Therapy for Giant Cell Tumor of Bone Pulmonary Metastasis.

CASE: A 68-year-old female was diagnosed with giant cell tumor of bone (GCTB) metastatic to her lungs. The patient was treated with IV denosumab for the course of 4.5 years for these metastases. The metastatic tumor burden decreased significantly after only 3 months of therapy. The size of the metastases has been stable for over 4 years. CONCLUSION: Denosumab therapy has promise in the treatment of GCTB, including pulmonary metastasis. However, the long-term role of denosumab for pulmonary metastases is yet to be determined.

Oncogenic Osteomalacia From a Primary Phosphaturic Mesenchymal Tumor of the Toe: A Case Report.

Oncogenic osteomalacia is an acquired, rare paraneoplastic syndrome characterized by renal phosphate wasting and subsequent hypophosphatemic osteomalacia. The condition is usually associated with a phosphaturic mesenchymal tumor, which produces fibroblast growth factor 23, the primary circulating factor responsible for reduced tubular phosphate reabsorption. Clinically, adult patients typically present with bone pain, myalgia, recurrent and/or multiple stress fractures, and fatigue, with serum levels typified by low 1,25-(OH)2 vitamin D3, increased alkaline phosphatase, and normal calcium, parathyroid hormone, calcitonin, 25-OH-vitamin D3, and 25,25-(OH)2 vitamin D3 levels. The tumor in question is typically benign and can be of little clinical significance apart from its role in causing hypophosphatemic osteomalacia. Detection of the tumor, therefore, can often be delayed and requires an astute index of suspicion.

How much tumor surgery do early-career orthopaedic oncologists perform?

BACKGROUND: There are few data on the types of procedures orthopaedic oncologists perform in their first years of practice. Because fellowships are graduating fellows each year and the number of tumor patients is limited, defining the practice patterns of early-career orthopaedic oncologists may help diminish early employment discontent and enhance workforce discussions. QUESTIONS/PURPOSES: The aim of the study was to use the objective case log volumes of a cross-section of early career orthopaedic oncologists to describe (1) the number of operations performed annually; (2) the proportion of tumor, trauma, adult reconstruction, and other operations for individual participants, (3) individual practice characteristics that were associated with the number of tumor procedures; and (4) the sources of satisfaction and challenges in each individual's career and surgical practice. METHODS: Fifteen fellowship-trained orthopaedic oncologists out of a potential pool of 33 (45%) in their first 4 years of practice responded to a survey by submitting complete operative case lists for a 2-year period. We recorded the type of procedure and determined associations between the annual number of tumor operations and total operative caseload, years in practice, and some details of individual practice patterns. Each participant completed a survey regarding practice-related sources of stress and satisfaction. A total of 5611 surgical cases were available for review. For the entire cohort, there were 3303 (59%) tumor procedures, 973 (17%) trauma, 890 (16%) adult reconstruction, and 445 (8%) other. RESULTS: The median annual number of total operations was 214 (range, 63-356) and median annual number of tumor operations was 135 (range, 47-216). The median proportion of tumor operations in an individual practice was 56% (range, 43%-94%). The annual number of tumor operations correlated with the total annual number of operations (r = 0.73, p < 0.001). Sources of stress and satisfaction were similar to the general membership of the Musculoskeletal Tumor Society (MSTS), apart from more early-career surgeons regarding case volume as important (29 of 104 [28%] of MSTS versus 11 of 15 [73%] of early-career, p < 0.001). CONCLUSIONS: The typical early-career orthopaedic tumor surgeon had fewer than 60% of his or her operative procedures directly related to the subject of his or her fellowship training in orthopaedic oncology. Overall, the challenges and rewards of clinical practice are similar to oncologic surgeons later in their career. This study is a first step in assessing early practice characteristics and may be of value to the prospective orthopaedic oncologist, fellowship educators, and the society in workforce discussions. Early-career practice patterns have not been previously presented, to our knowledge, for any subspecialty of orthopaedic surgery, and we hope that this study will stimulate similar efforts throughout the field. LEVEL OF EVIDENCE: Level IV, economic and decision analyses. See Guidelines for Authors for a complete description of levels of evidence.

Giant Cell Tumors of the Foot and Ankle Bones: High Recurrence Rates After Surgical Treatment.

Giant cell tumor (GCT) of the bone is a benign primary bone tumor most often treated with intralesional surgery. Most cases occur around the knee; however, rarely, GCT of bone can occur in the foot and ankle. Limited data exist about the outcomes after treatment of GCT in this location. We retrospectively reviewed an orthopedic oncology database from 1970 to 2010 for cases of GCT of the bone, specifically within the foot and ankle bones. After exclusionary criteria were applied, a total of 19 disease sites in 18 patients were included for analysis. Of the 19 disease sites, 10 recurred. Patients, on average, required 1.7 operations per disease site. Of the 18 patients, 10 required ≥2 operations, 3 required ≥3 operations, and 1 required 4 operations. A total of 4 amputations were performed, including 2 below the knee amputations. Of the 10 patients with recurrence, 2 also had evidence of metastatic disease. The recurrence rates of GCT in the foot and ankle bones appear to be greatest after intralesional curettage without the use of cement. Although the recurrence rates are high, intralesional operations with multiple adjuvant therapy can eventually result in cure.

Epiphysiolysis of the femoral neck due to closed reduction of an adolescent hip dislocation with a 4-year follow-up: a case report and review of the literature.

This case study discusses a 13-year-old girl diagnosed with a displaced Salter Harris II fracture of the proximal femoral epiphysis post reduction of a dislocated hip. Radiographs before reduction revealed a small fracture of the inferomedial femoral head. This, however, did not induce concern before reduction. The patient underwent reparative surgery of the epiphysis only to develop a collapsed femoral head, which was remedied through total hip arthroplasty. A decrease in blood flow, the delicacy in reduction, and unknown predispositions might have been contributing factors toward the unique development in this case.

What is the use of imaging before referral to an orthopaedic oncologist? A prospective, multicenter investigation.

BACKGROUND: Patients often receive advanced imaging before referral to an orthopaedic oncologist. The few studies that have evaluated the value of these tests have been single-center studies, and there were large discrepancies in the estimated frequencies of unnecessary use of diagnostic tests. QUESTIONS/PURPOSES: (1) Is there regional variation in the use of advanced imaging before referral to an orthopaedic oncologist? (2) Are these prereferral studies helpful to the treating orthopaedic oncologist in making a diagnosis or treatment plan? (3) Are orthopaedic surgeons less likely to order unhelpful studies than other specialties? (4) Are there any tumor or patient characteristics that are associated with the ordering of an unhelpful study? METHODS: We performed an eight-center prospective analysis of patients referred for evaluation by a fellowship-trained orthopaedic oncologist. We recorded patient factors, referral details, advanced imaging performed, and presumptive diagnosis. The treating orthopaedic oncologist determined whether each study was helpful in the diagnosis or treatment of the patient based on objective and subjective criteria used in prior investigations. We analyzed the data using bivariate methods and logistic regression to determine regional variation and risk factors predictive of unhelpful advanced imaging. Of the 371 participants available for analysis, 301 (81%) were referred with an MRI, CT scan, bone scan, ultrasound, or positron emission tomography scan. RESULTS: There were no regional differences in the use of advanced imaging (range of patients presenting with advanced imaging 66%-88% across centers, p = 0.164). One hundred thirteen patients (30%) had at least one unhelpful study; non-MRI advanced imaging was more likely to be unhelpful than MRIs (88 of 129 [68%] non-MRI imaging versus 46 of 263 [17%] MRIs [p < 0.001]). Orthopaedic surgeons were no less likely than nonorthopaedic surgeons to order unhelpful studies before referral to an orthopaedic oncologist (56 of 179 [31%] of patients referred by orthopaedic surgeons versus 35 of 119 [29%] referred by primary care providers and 22 of 73 [30%] referred by nonorthopaedic specialists, p = 0.940). After controlling for potential confounding variables, benign bone lesions had an increased odds of referral with an unhelpful study (59 of 145 [41%] of benign bone tumors versus 54 of 226 [24%] of soft tissue tumors and malignant bone tumors; odds ratio, 2.80; 95% confidence interval, 1.68-4.69, p < 0.001). CONCLUSIONS: We found no evidence that the proportion of patients referred with advanced imaging varied dramatically by region. Studies other than MRI were likely to be considered unhelpful and should not be routinely ordered by referring physicians. Diligent education of orthopaedic surgeons and primary care physicians in the judicious use of advanced imaging in benign bone tumors may help mitigate unnecessary imaging. LEVEL OF EVIDENCE: Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

Response to sunitinib in combination with proton beam radiation in a patient with chondrosarcoma: a case report.

INTRODUCTION: Chondrosarcoma is well-known to be primarily resistant to conventional radiation and chemotherapy. CASE PRESENTATION: We present the case of a 32-year-old Caucasian man with clear cell chondrosarcoma who presented with symptomatic recurrence in his pelvis and metastases to his skull and lungs. Our patient underwent systemic therapy with sunitinib and then consolidation with proton beam radiation to his symptomatic site. He achieved complete symptomatic relief with a significantly improved performance status and had an almost complete and durable metabolic response on fluorine-18-fluorodeoxyglucose positron emission tomography. CONCLUSIONS: Our findings have important clinical implications and suggest novel clinical trials for this difficult to treat disease.

Treatment of Bone Tumors.

In this article, the authors summarize the state of the art and future potential in the management of Osteosarcoma, Ewing's sarcoma, and Chondrosarcoma. They cover systemic therapy, surgical therapy, and radiotherapy, along with targeted therapies to inhibit signal transduction pathways. They discuss staging and the role of imaging evaluation to provide an overview of bone tumor treatment. Images presenting pathologic-radiologic correlations are included.