Osteosarcoma Arising as a Secondary Malignancy following Treatment for Hematologic Cancer: A Report of 33 Affected Patients from the Cooperative Osteosarcoma Study Group (COSS).

PURPOSE: Osteosarcoma may arise as a secondary cancer following leukemias or lymphomas. We intended to increase the knowledge about such rare events. PATIENTS AND METHODS: We searched the Cooperative Osteosarcoma Study Group's database for individuals who developed their osteosarcoma following a previous hematological malignancy. The presentation and treatment of both malignancies was investigated, and additional neoplasms were noted. Outcomes after osteosarcoma were analyzed and potential prognostic factors were searched for. RESULTS: A total of 33 eligible patients were identified (male: 23, female: 10; median age: 12.9 years at diagnosis of hematological cancer; 20 lymphomas, 13 leukemias). A cancer predisposition syndrome was evident in one patient only. The hematological cancers had been treated by radiotherapy in 28 (1 unknown) and chemotherapy in 26 cases, including bone-marrow transplantation in 9. The secondary bone sarcomas (high-grade central 27, periosteal 2, extra-osseous 2, undifferentiated pleomorphic sarcoma of bone 2) arose after a median lag-time of 9.4 years, when patients were a median of 19.1 years old. Tumors were considered radiation-related in 26 cases (1 unknown). Osteosarcoma-sites were in the extremities (19), trunk (12), or head and neck (2). Metastases at diagnosis affected eight patients. Information on osteosarcoma therapy was available for 31 cases. All of these received chemotherapy. Local therapy involved surgery in 27 patients, with a good response reported for 9/18 eligible patients. Local radiotherapy was given to three patients. The median follow-up was 3.9 (0.3-12.0) years after bone tumor diagnosis. During this period, 21 patients had developed events as defined, and 15 had died, resulting in 5-year event-free and overall survival rates of 40% (standard error: 9%) and 56% (10%), respectively. There were multiple instances of additional neoplasms. Several factors were found to be of prognostic value (p < 0.05) for event-free (osteosarcoma site in the extremities) or overall (achievement of a surgical osteosarcoma-remission, receiving chemotherapy for the hematologic malignancy) survival. CONCLUSIONS: We were able to prove radiation therapy for hematological malignancies to be the predominant risk factor for later osteosarcomas. A resulting overrepresentation of axial and a tendency towards additional neoplasms affects prognosis. Still, selected patients may become long-term survivors with appropriate therapies, which is an argument against therapeutic negligence.

Accuracy Analysis of 3D Bone Fracture Models: Effects of Computed Tomography (CT) Imaging and Image Segmentation.

The introduction of three-dimensional (3D) printed anatomical models has garnered interest in pre-operative planning, especially in orthopedic and trauma surgery. Identifying potential error sources and quantifying their effect on the model dimensional accuracy are crucial for the applicability and reliability of such models. In this study, twenty radii were extracted from anatomic forearm specimens and subjected to osteotomy to simulate a defined fracture of the distal radius (Colles' fracture). Various factors, including two different computed tomography (CT) technologies (energy-integrating detector (EID) and photon-counting detector (PCD)), four different CT scanners, two scan protocols (i.e., routine and high dosage), two different scan orientations, as well as two segmentation algorithms were considered to determine their effect on 3D model accuracy. Ground truth was established using 3D reconstructions of surface scans of the physical specimens. Results indicated that all investigated variables significantly impacted the 3D model accuracy (p < 0.001). However, the mean absolute deviation fell within the range of 0.03 ± 0.20 to 0.32 ± 0.23 mm, well below the 0.5 mm threshold necessary for pre-operative planning. Intra- and inter-operator variability demonstrated fair to excellent agreement for 3D model accuracy, with an intra-class correlation (ICC) of 0.43 to 0.92. This systematic investigation displayed dimensional deviations in the magnitude of sub-voxel imaging resolution for all variables. Major pitfalls included missed or overestimated bone regions during the segmentation process, necessitating additional manual editing of 3D models. In conclusion, this study demonstrates that 3D bone fracture models can be obtained with clinical routine scanners and scan protocols, utilizing a simple global segmentation threshold, thereby providing an accurate and reliable tool for pre-operative planning.

Two-stage revision for periprosthetic joint infection after hip and knee arthroplasty.

Aims: Histology is widely used for diagnosis of persistent infection during reimplantation in two-stage revision hip and knee arthroplasty, although data on its utility remain scarce. Therefore, this study aims to assess the predictive value of permanent sections at reimplantation in relation to reinfection risk, and to compare results of permanent and frozen sections. Methods: We retrospectively collected data from 226 patients (90 hips, 136 knees) with periprosthetic joint infection who underwent two-stage revision between August 2011 and September 2021, with a minimum follow-up of one year. Histology was assessed via the SLIM classification. First, we analyzed whether patients with positive permanent sections at reimplantation had higher reinfection rates than patients with negative histology. Further, we compared permanent and frozen section results, and assessed the influence of anatomical regions (knee versus hip), low- versus high-grade infections, as well as first revision versus multiple prior revisions on the histological result at reimplantation. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), chi-squared tests, and Kaplan-Meier estimates were calculated. Results: Overall, the reinfection rate was 18%. A total of 14 out of 82 patients (17%) with positive permanent sections at reimplantation experienced reinfection, compared to 26 of 144 patients (18%) with negative results (p = 0.996). Neither permanent sections nor fresh frozen sections were significantly associated with reinfection, with a sensitivity of 0.35, specificity of 0.63, PPV of 0.17, NPV of 0.81, and accuracy of 58%. Histology was not significantly associated with reinfection or survival time for any of the analyzed sub-groups. Permanent and frozen section results were in agreement for 91% of cases. Conclusion: Permanent and fresh frozen sections at reimplantation in two-stage revision do not serve as a reliable predictor for reinfection.

Dimensional accuracy and precision and surgeon perception of additively manufactured bone models: effect of manufacturing technology and part orientation.

BACKGROUND: Additively manufactured (AM) anatomical bone models are primarily utilized for training and preoperative planning purposes. As such, they must meet stringent requirements, with dimensional accuracy being of utmost importance. This study aimed to evaluate the precision and accuracy of anatomical bone models manufactured using three different AM technologies: digital light processing (DLP), fused deposition modeling (FDM), and PolyJetting (PJ), built in three different part orientations. Additionally, the study sought to assess surgeons' perceptions of how well these models mimic real bones in simulated osteosynthesis. METHODS: Computer-aided design (CAD) models of six human radii were generated from computed tomography (CT) imaging data. Anatomical models were then manufactured using the three aforementioned technologies and in three different part orientations. The surfaces of all models were 3D-scanned and compared with the original CAD models. Furthermore, an anatomical model of a proximal femur including a metastatic lesion was manufactured using the three technologies, followed by (mock) osteosynthesis performed by six surgeons on each type of model. The surgeons' perceptions of the quality and haptic properties of each model were assessed using a questionnaire. RESULTS: The mean dimensional deviations from the original CAD model ranged between 0.00 and 0.13 mm with maximal inaccuracies < 1 mm for all models. In surgical simulation, PJ models achieved the highest total score on a 5-point Likert scale ranging from 1 to 5 (with 1 and 5 representing the lowest and highest level of agreement, respectively), (3.74 ± 0.99) in the surgeons' perception assessment, followed by DLP (3.41 ± 0.99) and FDM (2.43 ± 1.02). Notably, FDM was perceived as unsuitable for surgical simulation, as the material melted during drilling and sawing. CONCLUSIONS: In conclusion, the choice of technology and part orientation significantly influenced the accuracy and precision of additively manufactured bone models. However, all anatomical models showed satisfying accuracies and precisions, independent of the AM technology or part orientation. The anatomical and functional performance of FDM models was rated by surgeons as poor.

The influence of biological DMARDs on aseptic arthroplasty loosening: a retrospective cohort study.

OBJECTIVE: To investigate whether biological DMARDs affect the risk of aseptic loosening after total hip/knee arthroplasty (THA/TKA) in patients with RA. METHODS: We retrospectively identified all patients suffering from RA who underwent THA/TKA at our academic centre between 2002 and 2015 and linked them with an existing prospective observational RA database at our institution. The risk of aseptic loosening was estimated using radiological signs of component loosening (RCL). A time-dependent Cox regression analysis was used to compare the risk of implant loosening between patients treated with traditional DMARDS and biological DMARDs, or alternately both over time. RESULTS: A total of 155 consecutive total joint arthroplasties (TJAs) (103 TKA vs 52 THA) was retrospectively included in the study. Mean age at implantation was 59 ± 13 years. Mean follow-up time was 69 ± 43 months. Overall, 48 (31%) TJAs showed signs of RCL, with 28 (27.2%) RCLs occurring after TKA compared with 20 after THA (38.5%). A significant difference regarding the incidence of RCL between the traditional DMARDs group (39 cases of RCL, 35%) and the biological DMARDs group (nine cases of RCL, 21%) (P = 0.026) was observed using the log-rank test. This was also true when using a time-dependent Cox regression with therapy as well as arthroplasty location (hip vs knee) as variables (P = 0.0447). CONCLUSION: Biological DMARDs may reduce the incidence of aseptic loosening after TJA in patients with RA compared with traditional DMARDs. This effect seems to be more pronounced after TKA than THA.

Ultra-long-term results of the Chiari pelvic osteotomy in hip dysplasia patients: a minimum of thirty-five years follow-up.

PURPOSE: The Chiari pelvic osteotomy was the first surgical procedure to address hip dysplasia by changing the position of the acetabulum by medialization, thus creating a bony roof and improving biomechanical conditions. The aim of this retrospective cohort study was to report on the very long-term results of this technique. METHODS: Out of a consecutive series of 1536 hips, 504 in 405 patients were available for follow-up. The patients were assessed by physical and radiological examination. A Kaplan-Meier survival analysis with total hip arthroplasty as an endpoint was performed and stratified for age groups, pre-operative diagnosis, sex and osteoarthritis stage. RESULTS: The average follow-up was 36 ± 8.1 years (range, 35.2 to 54). The average pain level on the Visual Analogue Scale was 2.9 ± 2.6 (range 0 to 8.7). The average Harris Hip Score was 80.2 ± 17.4 (range 17.4 to 100). Correction of dysplasia was effective and remained stable over time. Osteoarthritis significantly increased over time with 53% Tönnis grade 3 at follow-up. The cumulative survivorship was 79.8% (95% confidence interval (CI), 76.1-83.2%) at 20 years, 57.1% (95% CI, 52.8-61.8%) at 30 years and 35% (95% CI, 30.3-40.3%) at 40 years. Young age, male sex and low osteoarthritis grade were positive prognostic factors. CONCLUSIONS: Although the Chiari pelvic osteotomy is considered a salvage procedure nowadays, it achieved excellent long-term results even in indications, which would be treated differently today. Young patients without osteoarthritis had the best outcome.

Soft tissue tumor imaging in adults: European Society of Musculoskeletal Radiology-Guidelines 2023-overview, and primary local imaging: how and where?

OBJECTIVES: Early, accurate diagnosis is crucial for the prognosis of patients with soft tissue sarcomas. To this end, standardization of imaging algorithms, technical requirements, and reporting is therefore a prerequisite. Since the first European Society of Musculoskeletal Radiology (ESSR) consensus in 2015, technical achievements, further insights into specific entities, and the revised WHO-classification (2020) and AJCC staging system (2017) made an update necessary. The guidelines are intended to support radiologists in their decision-making and contribute to interdisciplinary tumor board discussions. MATERIALS AND METHODS: A validated Delphi method based on peer-reviewed literature was used to derive consensus among a panel of 46 specialized musculoskeletal radiologists from 12 European countries. Statements were scored online by level of agreement (0 to 10) during two iterative rounds. Either "group consensus," "group agreement," or "lack of agreement" was achieved. RESULTS: Eight sections were defined that finally contained 145 statements with comments. Overall, group consensus was reached in 95.9%, and group agreement in 4.1%. This communication contains the first part consisting of the imaging algorithm for suspected soft tissue tumors, methods for local imaging, and the role of tumor centers. CONCLUSION: Ultrasound represents the initial triage imaging modality for accessible and small tumors. MRI is the modality of choice for the characterization and local staging of most soft tissue tumors. CT is indicated in special situations. In suspicious or likely malignant tumors, a specialist tumor center should be contacted for referral or teleradiologic second opinion. This should be done before performing a biopsy, without exception. CLINICAL RELEVANCE: The updated ESSR soft tissue tumor imaging guidelines aim to provide best practice expert consensus for standardized imaging, to support radiologists in their decision-making, and to improve examination comparability both in individual patients and in future studies on individualized strategies. KEY POINTS: • Ultrasound remains the best initial triage imaging modality for accessible and small suspected soft tissue tumors. • MRI is the modality of choice for the characterization and local staging of soft tissue tumors in most cases; CT is indicated in special situations. Suspicious or likely malignant tumors should undergo biopsy. • In patients with large, indeterminate or suspicious tumors, a tumor reference center should be contacted for referral or teleradiologic second opinion; this must be done before a biopsy.

Long-Term Results after Chiari Pelvic Osteotomy in the Skeletally Immature and the Role of the Anti-Chiari Effect.

Several authors observed a loss of correction after performing Chiari pelvic osteotomy (CPO) in young patients. Hence, the aim of this study was to answer two questions: (1) Does the Chiari pelvic osteotomy affect the development of the acetabulum in skeletally immature patients in the long term? (2) Is there any evidence of the previously described "Anti-Chiari" effect after a mean follow-up of 36 years? Data from 21 patients (27 hips) undergoing CPO before the age of 16 years were clinically assessed, and the evolution of radiological parameters over time was analyzed. The mean age at CPO was 11.2 years (±3; 4.4-15.7). The 20- and 30-year survival rates of the CPO were 100% and 92.6%, respectively. Mean postoperative medialization was 54% (±18; 23-99). The average osteotomy angle was 11° (±7; 2-28). No significant changes were found for the center-edge angle (CEA) and acetabular index (AI) over time; the angle of Idelberger and Frank (ACM) almost reached normal values at follow-up (FU); for the acetabular-head index (AHI), a slight shift toward the initial situation could be detected. The morphology of the acetabulum remained unchanged over time. The "Anti-Chiari effect" seems to be primarily caused by insufficient coverage of the femoral head rather than damage to the apophysis due to surgery.

Open surgical treatment of unicameral bone cysts : A retrospective data analysis.

BACKGROUND: A variety of treatment options for unicameral bone cysts (UBC) exist. The controversy of open management of UBC is discussed. The aim of this study was to analyze a single institution's experience in the open surgical treatment of UBC. PATIENTS AND METHODS: By retrospective analysis of the Vienna Bone and Soft Tissue Tumor Registry, 119 patients with open surgery and histologically verified UBC with a mean follow up of 4.8 years (range 1-30 years) were included. Lesion treatment failure was defined as surgically addressed UBC undergoing revision surgery due to persistence or recurrence. RESULTS: Local revision-free survival for lesion treatment failure was 93% after 1 year, 80% after 2 years, 60% after 5 years and 57% after 10 years. Of the patients 34 (29%) had at least 1 revision surgery due to lesion treatment failure. We found that patients with lesion treatment failure were younger (p = 0.03), had UBC with less minimal distance to the growth plate (p = 0.02) and more septation chambers in radiologic imaging (p = 0.02). Patients with open revision surgery were less likely to require a second revision due to lesion treatment failure than patients with percutaneous revision surgery (p = 0.03). CONCLUSION: Open surgery for UBC can only be recommended as reserve treatment in younger children with actively growing lesions. Open UBC surgery carries a relatively high risk of almost 30% of lesion treatment failure and therefore the indications should be limited to extensive osteolysis with high risk of pathological fractures, lesions with displaced pathological fractures, and lesions with an ambiguous radiological presentation that require tissue collection.

Metabolic rewiring controlled by c-Fos governs cartilage integrity in osteoarthritis.

OBJECTIVES: The activator protein-1 (AP-1) transcription factor component c-Fos regulates chondrocyte proliferation and differentiation, but its involvement in osteoarthritis (OA) has not been functionally assessed. METHODS: c-Fos expression was evaluated by immunohistochemistry on articular cartilage sections from patients with OA and mice subjected to the destabilisation of the medial meniscus (DMM) model of OA. Cartilage-specific c-Fos knockout (c-FosΔCh) mice were generated by crossing c-fosfl/fl to Col2a1-CreERT mice. Articular cartilage was evaluated by histology, immunohistochemistry, RNA sequencing (RNA-seq), quantitative reverse transcription PCR (qRT-PCR) and in situ metabolic enzyme assays. The effect of dichloroacetic acid (DCA), an inhibitor of pyruvate dehydrogenase kinase (Pdk), was assessed in c-FosΔCh mice subjected to DMM. RESULTS: FOS-positive chondrocytes were increased in human and murine OA cartilage during disease progression. Compared with c-FosWT mice, c-FosΔCh mice exhibited exacerbated DMM-induced cartilage destruction. Chondrocytes lacking c-Fos proliferate less, have shorter collagen fibres and reduced cartilage matrix. Comparative RNA-seq revealed a prominent anaerobic glycolysis gene expression signature. Consistently decreased pyruvate dehydrogenase (Pdh) and elevated lactate dehydrogenase (Ldh) enzymatic activities were measured in situ, which are likely due to higher expression of hypoxia-inducible factor-1α, Ldha, and Pdk1 in chondrocytes. In vivo treatment of c-FosΔCh mice with DCA restored Pdh/Ldh activity, chondrocyte proliferation, collagen biosynthesis and decreased cartilage damage after DMM, thereby reverting the deleterious effects of c-Fos inactivation. CONCLUSIONS: c-Fos modulates cellular bioenergetics in chondrocytes by balancing pyruvate flux between anaerobic glycolysis and the tricarboxylic acid cycle in response to OA signals. We identify a novel metabolic adaptation of chondrocytes controlled by c-Fos-containing AP-1 dimers that could be therapeutically relevant.

Early postoperative laboratory parameters are predictive of initial treatment failure in acute septic arthritis of the knee and shoulder joint.

Septic arthritis is an orthopedic emergency potentially causing irreversible joint damage. However, the predictive value of potential risk factors such as early postoperative laboratory parameters remains uncertain. We investigated risk factors for initial surgical treatment failure using data from 249 patients (194 knees, 55 shoulders) treated for acute septic arthritis between 2003 and 2018. Necessity for further surgical intervention was defined as primary outcome. Demographic data, medical history, initial and postoperative laboratory parameters, Charlson Comorbidity Index (CCI), and Kellgren and Lawrence classification were collected. Two scoring systems were developed as tools for failure risk estimation after initial surgical irrigation and debridement. More than one intervention was necessary in 26.1% of cases. Treatment failure occurred significantly more often for those with longer symptom duration (p = 0.003), higher CCI grades (p = 0.027), Kellgren-Lawrence grade IV (p = 0.013), shoulder arthroscopy (p = 0.010), positive bacterial culture results (p < 0.001), slow postoperative CRP decline until day three (p = 0.032) and five (p = 0.015), reduced WBC-decline (p = 0.008), and lower hemoglobin (p < 0.001). Scores for third and fifth postoperative day achieved AUCs of 0.80 and 0.85, respectively. This study identified risk factors for treatment failure in patients with septic arthritis, suggesting that early postoperative laboratory parameters can guide further treatment.

Do Elevated Serum C-Reactive-Protein Levels Excuse Delayed Surgery for Femoral Neck Fractures?

In elderly patients with femoral neck fractures, preoperative serum C-reactive protein (CRP) values might be elevated due to active infections. Although there are limited data on CRP as a predictor of periprosthetic joint infection (PJI), out of concern, this could lead to delayed surgery. Therefore, we aim to investigate whether elevated serum-CRP levels justify delayed surgery for femoral neck fractures. A retrospective analysis was performed of the records of patients undergoing arthroplasty who were found to have an elevated CRP level of 5 mg/dL or more between January 2011 to December 2020. The patients were stratified to three groups, according to initial serum CRP levels at a cut off of 5 mg/dL and the time between admission and surgery (<48 vs. ≥48 h after admission). This study revealed that the patients with elevated serum CRP levels and delayed surgery showed a worse survival rate and significantly more postoperative complications than the patients on whom surgery was performed immediately. There were no significant differences in terms of PJI and prolonged wound healing in the inter-group comparison. Therefore, delays to surgery on the basis of elevated CRP values offer no benefits to patients with femoral neck fractures.

Early postoperative gain in activity levels of lower extremity sarcoma survivors positively affects long-term physical activity and performance.

PURPOSE: Little is known about the effect of sports activity levels on health-related quality of life (HRQOL) in long-term survivors of lower-extremity sarcoma. METHODS: Eighty-three long-term survivors of bone and soft tissue sarcoma of the lower extremities with a median follow-up of 14 (range: 5-35) years completed the University of California and Los Angeles (UCLA) activity scores before tumor resection, 1 year after surgery and at the latest follow-up, as well as a Short Form 36 (SF-36) health survey at the latest follow-up. Simple linear regression models as well as stepwise variable selection with Akaike information criterion (AIC) were undertaken. RESULTS: The preoperative UCLA activity level (median: 9, range: 2-10) dropped to a median of 4 (range: 1-10) 1 year after surgery before increasing to a score of 6 (range: 2-10) 5 years after surgery. The long-term SF-36 physical health component summary score (PCS) was 49 (SD: 9), and the mental health component summary score (MCS) was 54 (SD: 7). A linear model with stepwise variable selection identified a negative correlation of PCS with age at surgery (estimate: -0.2; p = 0.02), UCLA score at the last follow-up (estimate: 1.4; p = 0.02) and UCLA score 1 year after surgery (estimate: 1.0; p = 0.02). CONCLUSION: As not only the final activity levels but also the status immediately after surgery affect the PCS, higher early activity levels should be a goal of modern rehabilitation after sarcoma treatment. Further studies are needed to weigh the potential postoperative risks of higher sport activity levels against the benefits described in this study. LEVEL OF EVIDENCE: Level 4.

Three to six tissue specimens for histopathological analysis are most accurate for diagnosing periprosthetic joint infection.

AIMS: The aim of this study was to evaluate the optimal deep tissue specimen sample number for histopathological analysis in the diagnosis of periprosthetic joint infection (PJI). METHODS: In this retrospective diagnostic study, patients undergoing revision surgery after total hip or knee arthroplasty (n = 119) between January 2015 and July 2018 were included. Multiple specimens of the periprosthetic membrane and pseudocapsule were obtained for histopathological analysis at revision arthroplasty. Based on the Infectious Diseases Society of America (IDSA) 2013 criteria, the International Consensus Meeting (ICM) 2018 criteria, and the European Bone and Joint Infection Society (EBJIS) 2021 criteria, PJI was defined. Using a mixed effects logistic regression model, the sensitivity and specificity of the histological diagnosis were calculated. The optimal number of periprosthetic tissue specimens for histopathological analysis was determined by applying the Youden index. RESULTS: Based on the EBJIS criteria (excluding histology), 46 (39%) patients were classified as infected. Four to six specimens showed the highest Youden index (four specimens: 0.631; five: 0.634; six: 0.632). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of five tissue specimens were 76.5% (95% confidence interval (CI) 67.6 to 81.4), 86.8% (95% CI 81.3 to 93.5), 66.0% (95% CI 53.2 to 78.7), and 84.3% (95% CI 79.4 to 89.3), respectively. The area under the curve (AUC) was calculated with 0.81 (as a function of the number of tissue specimens). Applying the ICM and IDSA criteria (excluding histology), 40 (34%) and 32 (27%) patients were categorized as septic. Three to five specimens had the highest Youden index (ICM 3: 0.648; 4: 0.651; 5: 0.649) (IDSA 3: 0.627; 4: 0.629; 5: 0.625). CONCLUSION: Three to six tissue specimens of the periprosthetic membrane and pseudocapsule should be collected at revision arthroplasty and analyzed by a pathologist experienced and skilled in interpreting periprosthetic tissue.Cite this article: Bone Joint J 2023;105-B(2):158-165.

Patients' perception of changes and consequences after tumor resection : A qualitative study in Austrian patients with musculoskeletal malignancies.

OBJECTIVE: The aim of this study was to investigate the effects and consequences of surgical treatment of patients with musculoskeletal malignancies on everyday life. METHODS: A modified form of grounded theory was used for data collection and analysis. Data collection was systematic and analyzed simultaneously and 16 interviews were conducted: 2 narrative, 11 guided and 3 expert interviews (surgeon, physical therapist, support group). Data collection and analysis alternated until no new codes could be found. Once theoretical saturation was achieved, the main category was formed and described using the literature. RESULTS: The main category results from the combination of all categories and leads to the core category. In the center is the affected person and in the immediate environment are the patient's relatives/partners. In the next instance the primary care physician is necessary to establish a sense of normalcy. This depends on the individuality of the person and the restored possibilities of movement. CONCLUSION: Based on the results, the necessity of implementing psychosocial care involving the social environment is shown. The importance of relatives/partners for recovery is emphasized. Furthermore, the communication between the specialists and family physicians should be simplified.

Distal locking technique affects the rate of iatrogenic radial nerve palsy in intramedullary nailing of humeral shaft fractures.

BACKGROUND: Intramedullary humeral nailing is a common and reliable procedure for the treatment of humeral shaft fractures. Radial nerve palsy is a common complication encountered in the treatment of this pathology. The radial nerve runs from posterior to anterior at the lateral aspect of the distal humerus. Hence, there is reason to believe that due to the anatomic vicinity of the radial nerve in this area, lateral-medial distal locking in intramedullary nailing of the humerus may be associated with a greater risk for iatrogenic radial nerve injury compared to anterior-posterior locking. QUESTIONS/PURPOSE: To assess whether the choice of distal locking (lateral-medial versus anterior-posterior distal locking) in intramedullary humeral nailing of humeral shaft fractures affects the risk for iatrogenic radial nerve injury. PATIENTS AND METHODS: Overall, 203 patients (116 females, mean age 64.3 ± 18.6 years), who underwent intramedullary nailing of the humerus between 2000 and 2020 at a single level-one trauma center, met the inclusion criteria and were analyzed in this retrospective case-control study. Patients were subdivided into two groups according to the distal locking technique. RESULTS: Anterior-posterior locking was performed in 176 patients versus lateral-medial locking in 27 patients. We observed four patients with iatrogenic radial nerve palsy in both groups. Risk for iatrogenic radial nerve palsy was almost 7.5 times higher for lateral-medial locking (OR 7.48, p = 0.006). There was no statistically significant difference regarding intraoperative complications, union rates or revision surgeries between both groups. CONCLUSIONS: Lateral-medial distal locking in intramedullary nailing of the humerus may be associated with a greater risk for iatrogenic radial nerve palsy than anterior-posterior locking. Hence, we advocate for anterior-posterior locking. LEVEL OF EVIDENCE: Level III retrospective comparative study.

Treatment of benign bone lesions with an injectable biphasic bone substitute.

BACKGROUND: Injectable biphasic ceramic bone substitutes (BCBSs) represent a modern alternative to conventional options for bone defect filling, as they further open the possibilities for percutaneous cavity reconstruction. Although recent studies have shown good surgical outcomes after treatment with BCBSs, mid-term follow-up data are still missing. PATIENTS AND METHODS: Between 2013 and 2017, 18 patients were [1] treated with BCBS [2] for benign bone lesions and [3] had a complete set of retrospective information, including surgical protocols, imaging, patient dismission letters and outpatient clinic protocols, [4] with a minimum follow-up time of one year. Eleven patients received percutaneous surgery, while 7 patients had open curettage and BCBS filling. The median follow-up time was 36.5 (range 12-80) months. RESULTS: Local recurrence was reported in four patients. A distinctive bone remodelling pattern was noted on follow-up X-ray and magnetic resonance imaging showing a double-line phenomenon and continuously increasing cortical thickness one year after treatment in nine of thirteen patients. Regarding surgical complications, one patient suffered from a septic complication that required BCBS removal and lavage. One patient experienced superficial surgical site inflammation with redness and swelling, while two other patients had prolonged wound secretion. CONCLUSION: In a limited case series, the studied BCBS demonstrated acceptable surgical outcomes. Initial wound leakage and recurrence seemed to be associated with percutaneous injection. Further studies are needed to compare recurrence and bone graft resorption after open and percutaneous bone cyst surgeries and to further evaluate postoperative surgical site inflammation, which appears self-limiting in most cases.

Osteosarcoma and causes of death: A report of 1520 deceased patients from the Cooperative Osteosarcoma Study Group (COSS).

PURPOSE: Most aspects of osteosarcoma have been addressed in detail, but there is no comprehensive analysis of deceased patients and causes of death. METHODS: The database of the Cooperative Osteosarcoma Study Group COSS (1980-03/31/2021; 4475 registered high-grade central osteosarcoma patients) was searched deaths from any cause. Affected patients were analyzed for demographic and baseline variables and disease-status at the time of demise. Deaths from causes other than osteosarcoma were analyzed in detail. RESULTS: A total of 1520 deceased patients were identified (median age (range) at osteosarcoma diagnosis 16 (2-78) years; 908 (59.7%) male, 612 (40.3%) female; primary tumor: extremities 1263 (83.1%), trunk 208 (13.7%), craniofacial 47 (3.1%) (site unknown 2); metastases at registration: absent 1.051 (69.1%), present 466 (30.7%) (3 no data). The median time from diagnosis to death was 2.22 (0.08-32.02) years. 1286 (84.6%) patients succumbed to osteosarcoma (370 without achieving complete remission, 488 first, 428 more than one recurrences), 146 (9.6%) to other, 88 (5.8%) to unknown causes. Chemotherapy-related infections (40), secondary malignancies (39), and perioperative complications (19) were among the most frequent potentially treatment-related causes, and high-dose methotrexate (19), doxorubicin (17), and ifosfamide (15) were the drugs most commonly held responsible. Patients with unknown causes of death had an unusually long median follow-up. CONCLUSION: The major cause of death of patients after osteosarcoma is this malignancy, mostly from one of its multiple relapses. However, almost 10% of fatalities are due to other documented causes. Some of these deaths may be preventable with the knowledge gained from comprehensive analyses such as this.

Diagnosing periprosthetic joint infections : a comparison of infection definitions: EBJIS 2021, ICM 2018, and IDSA 2013.

AIMS: This study evaluated the definitions developed by the European Bone and Joint Infection Society (EBJIS) 2021, the International Consensus Meeting (ICM) 2018, and the Infectious Diseases Society of America (IDSA) 2013, for the diagnosis of periprosthetic joint infection (PJI). METHODS: In this single-centre, retrospective analysis of prospectively collected data, patients with an indicated revision surgery after a total hip or knee arthroplasty were included between 2015 and 2020. A standardized diagnostic workup was performed, identifying the components of the EBJIS, ICM, and IDSA criteria in each patient. RESULTS: Of 206 included patients, 101 (49%) were diagnosed with PJI with the EBJIS definition. IDSA and ICM diagnosed 99 (48%) and 86 (42%) as infected, respectively. A total of 84 cases (41%) had an infection based on all three criteria. In 15 cases (n = 15/206; 7%), PJI was present when applying only the IDSA and EBJIS criteria. No infection was detected by one definition alone. Inconclusive diagnoses occurred more frequently with the ICM criteria (n = 30/206; 15%) compared to EBJIS (likely infections: n = 16/206; 8%) (p = 0.029). A better preoperative performance of the EBJIS definition was seen compared with the ICM and IDSA definitions (p < 0.001). CONCLUSION: The novel EBJIS definition identified all PJIs diagnosed by any other criteria. Use of the EBJIS definition significantly reduced the number of uncertain diagnoses, allowing easier clinical decision-making.Cite this article: Bone Joint Res 2022;11(9):608-618.

The top fifty most influential articles on hip fractures.

PURPOSE: Hip fractures are one of the most common disabling fractures in elderly people and peri-operative management has advanced considerably over the past decades. The purpose of this study was to evaluate the change of scientific focus by creating a top 50 list of the most influential papers on this topic. METHODS: The Clarivate Web of Science Search was used to identify the most cited articles. The used search phrase was [(hip OR pertrochanteric OR (femoral neck)) AND fracture AND (surgery OR treatment)]. The number of citations, citation density, study type, study design, published year, fracture type, country, evidence level and published journal were recorded. RESULTS: The top 50 articles were published between 1973 and 2014 and cited between 88 and 496 times. The mean citation density increased noticeably after the year 2000, representing the knowledge gain of the last 20 years. The topics surgical treatment (n = 19), risk factor assessment (n = 19), perioperative hemodynamic management (n = 7), additional treatment (n = 4) and general reviews (n = 1) were covered. Twenty-five articles were published from institutions in Europe, 24 from institutions in North America and one from an institution in Asia. CONCLUSION: While studies about surgical treatment options and risk factor assessment have been historically important, there was a rise of articles about additional treatment options for osteoporosis and the optimal postoperative care after the year 2005. The presented lists and map of citation classics give an overview of the most influential studies on hip fractures.