Medial cortical bone thickness of the tibial diaphysis in osteoarthritis is related to lower extremity alignment and tibial morphology.

BACKGROUND: The purpose of this study was to clarify (1) the differences in cortical bone thickness (CBT) of the tibial diaphysis between healthy and osteoarthritic knees and (2) the influences of the femorotibial angle (FTA) and inclination of the medial compartment of the proximal tibia (MCT) on tibial CBT. METHODS: The study assessed 60 subjects with varus knee osteoarthritis (OA) (22 males and 38 females; mean age, 74 ± 7 years) and 53 healthy elderly subjects (28 males and 25 females; mean age, 70 ± 6 years). Three-dimensional estimated CBT of the tibial diaphysis was automatically calculated for 2752-11,296 points using high-resolution measurements from CT. The standardized CBT was assessed in 24 regions by combining six heights and four areas. Additionally, the association between the CBT, each FTA, and MCT inclination was investigated. RESULTS: The OA group showed a thicker CBT in the medial areas than in the lateral areas of the proximal tibia, while the healthy group had a thicker lateral CBT. The medial-to-lateral ratio of the proximal tibia was significantly higher in the OA group than in the healthy group. The proximal-medial CBT correlated with FTA and MCT inclinations in the OA group. CONCLUSIONS: This study demonstrated that varus osteoarthritic knees showed a different trend of proximal-medial CBT with associations in FTA and MCT inclination from healthy knees, possibly due to medial load concentration.

Enriched mesoporous bioactive glass scaffolds as bone substitutes in critical diaphyseal bone defects in rabbits.

In the field of orthopedic surgery, there is an increasing need for the development of bone replacement materials for the treatment of bone defects. One of the main focuses of biomaterials engineering are advanced bioceramics like mesoporous bioactive glasses (MBG´s). The present study compared the new bone formation after 12 weeks of implantation of MBG scaffolds with composition 82,5SiO2-10CaO-5P2O5-x 2.5SrO alone (MBGA), enriched with osteostatin, an osteoinductive peptide, (MBGO) or enriched with bone marrow aspirate (MBGB) in a long bone critical defect in radius bone of adult New Zealand rabbits. New bone formation from the MBG scaffold groups was compared to the gold standard defect filled with iliac crest autograft and to the unfilled defect. Radiographic follow-up was performed at 2, 6, and 12 weeks, and microCT and histologic examination were performed at 12 weeks. X-Ray study showed the highest bone formation scores in the group with the defect filled with autograft, followed by the MBGB group, in addition, the microCT study showed that bone within defect scores (BV/TV) were higher in the MBGO group. This difference could be explained by the higher density of newly formed bone in the osteostatin enriched MBG scaffold group. Therefore, MBG scaffold alone and enriched with osteostatin or bone marrow aspirate increase bone formation compared to defect unfilled, being higher in the osteostatin group. The present results showed the potential to treat critical bone defects by combining MBGs with osteogenic peptides such as osteostatin, with good prospects for translation into clinical practice. STATEMENT OF SIGNIFICANCE: Treatment of bone defects without the capacity for self-repair is a global problem in the field of Orthopedic Surgery, as evidenced by the fact that in the U.S alone it affects approximately 100,000 patients per year. The gold standard of treatment in these cases is the autograft, but its use has limitations both in the amount of graft to be obtained and in the morbidity produced in the donor site. In the field of materials engineering, there is a growing interest in the development of a bone substitute equivalent. Mesoporous bioactive glass (MBG´s) scaffolds with three-dimensional architecture have shown great potential for use as a bone substitutes. The osteostatin-enriched Sr-MBG used in this long bone defect in rabbit radius bone in vivo study showed an increase in bone formation close to autograft, which makes us think that it may be an option to consider as bone substitute.

Tandem Reconstruction of the Femoral Diaphysis Using an Intercalary Prosthesis and a Fibular Free Flap.

BACKGROUND: Femoral diaphyseal reconstructions with metal prostheses have mediocre results because of high mechanical forces that result in eventual implant failure. Biological alternatives require prolonged restrictions on weight-bearing and have high rates of infection, nonunion, and fracture. A novel method of utilizing a vascularized fibula in combination with an intercalary prosthesis was developed to complement the immediate stability of the prosthesis with the long-term biological fixation of a vascularized fibular graft. METHODS: A prospectively maintained database was retrospectively reviewed to identify patients who underwent reconstruction of an oncological intercalary femoral defect using an intercalary prosthesis and an inline fibular free flap (FFF). They were compared with patients who underwent femoral reconstruction using an intercalary allograft and an FFF. RESULTS: Femoral reconstruction with an intercalary metal prosthesis and an FFF was performed in 8 patients, and reconstruction with an allograft and an FFF was performed in 16 patients. The mean follow-up was 5.3 years and 8.5 years, respectively (p = 0.02). In the bioprosthetic group, radiographic union of the fibula occurred in 7 (88%) of 8 patients, whereas in the allograft group, 13 (81%) of 16 patients had allograft union (p = 1.00) and all 16 patients had fibular union (p = 0.33). The mean time to fibular union in the bioprosthetic group was 9.0 months, whereas in the allograft group, the mean time to allograft union was 15.3 months (p = 0.03) and the mean time to fibular union was 12.5 months (p = 0.42). Unrestricted weight-bearing occurred at a mean of 3.7 months in the prosthesis group and 16.5 months in the allograft group (p < 0.01). Complications were observed in 2 (25%) of 8 patients in the prosthesis group and in 13 (81%) of 16 patients in the allograft group (p = 0.02). Neither chemotherapy nor radiation affected fibular or allograft union rates. Musculoskeletal Tumor Society scores did not differ significantly between the groups (mean, 26 versus 28; p = 0.10). CONCLUSIONS: Bioprosthetic intercalary femoral reconstruction with a metal prosthesis and an FFF resulted in earlier weight-bearing, a shorter time to union, fewer operations needed for union, and lower complication rates than reconstruction with an allograft and an FFF. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

What Is the Prosthetic Survival After Resection and Intercalary Endoprosthetic Reconstruction for Diaphyseal Bone Metastases of the Humerus and Femur?

BACKGROUND: Large metastatic lesions of the diaphysis can cause considerable pain and result in difficult surgical challenges. Resection and cemented intercalary endoprosthetic reconstruction offer one solution to the problem, but it is an extensive operation that might not be tolerated well by a debilitated patient. The risk of aseptic loosening and revision after intercalary endoprosthetic replacement has varied in previous reports, which have not examined the risk of revision in the context of patient survival. QUESTIONS/PURPOSES: (1) In a small case series from one institution, what is the survivorship of patients after cemented intercalary endoprosthetic replacement for diaphyseal metastasis, and what is the cumulative incidence of revision for any reason? (2) What are the complications associated with cemented intercalary reconstruction? (3) What is the functional outcome after the procedure as assessed by the MSTS93 score? METHODS: We retrospectively studied 19 patients with diaphyseal long bone metastases who were treated with resection and cemented intercalary endoprosthetic reconstruction by five participating surgeons at one referral center from 2006 to 2017. There were 11 men and eight women with a median age of 59 years (range 46 to 80 years). The minimum follow-up required for this series was 12 months; however, patients who reached an endpoint (death, radiographic loosening, or implant revision) before that time were included. One of these 19 patients was lost to follow-up but was not known to have died. The median follow-up was 24 months (range 0 to 116 months). Eight of the 19 patients presented with pathologic fractures. Ten of 19 lesions involved the femur, and nine of 19 were in the humerus. The most common pathologic finding was renal cell carcinoma (in 10 of 19). Survival estimates of the patients were calculated using the Kaplan-Meier method. A competing risks estimator was used to evaluate implant survival, using death of the patient as the competing risk. We also estimated the cumulative incidence of aseptic loosening in a competing risk analysis. Radiographs were analyzed for radiolucency at the bone-cement-implant interfaces, fracture, integrity of the cement mantle, and component position stability. Complications were assessed using record review that was performed by an individual who was not involved in the initial care of the patients. Functional outcomes were assessed using the MSTS93 scoring system. RESULTS: Patient survivorship was 68% (95% CI 50% to 93%) at 1 year, 53% (95% CI 34% to 81%) at 2 years, and 14% (95% CI 4% to 49%) at 5 years; the median patient survival time after reconstruction was 25 months (range 0 to 116 months). In the competing risk analysis, using death as the competing risk, the cumulative incidence of implant revision was 11% (95% CI 2% to 29%) at 1 year and 16% (95% CI 4% to 36%) at 5 years after surgery; however, the cumulative incidence of aseptic loosening (with death as a competing risk) was 22% (95% CI 6% to 43%) at 1 year and 33% (95% CI 13% to 55%) at 5 years after surgery. Other complications included one patient who died postoperatively of cardiac arrest, one patient with delayed wound healing, two patients with bone recurrence, and one patient who experienced local soft tissue recurrence that was excised without implant revision. Total MSTS93 scores improved from a mean of 12.6 ± 8.1 (42% ± 27%) preoperatively to 21.5 ± 5.0 (72% ± 17%) at 3 months postoperatively (p < 0.001) and 21.6 ± 8.5 (72% ± 28%) at 2 years postoperatively (p = 0.98; 3 months versus 2 years). CONCLUSION: Resection of diaphyseal metastases with intercalary reconstruction can provide stability and short-term improvement in function for patients with advanced metastatic disease and extensive cortical destruction. Aseptic loosening is a concern, particularly in the humerus; however, the competing risk analysis suggests the procedure is adequate for most patients, because many in this series died of disease without undergoing revision. LEVEL OF EVIDENCE: Level IV, therapeutic study .

Periosteal reaction-like lesions at the cranial aspect of the humeral diaphysis have a high prevalence in older, large breed dogs and may represent entheses of the superficial pectoral muscles.

Authors have commonly observed lamellar periosteal new bone formation at the cranial aspect of the humeral diaphysis in mediolateral radiographs of the humerus for large breed dogs with no evidence of pain or lameness. The aim of this retrospective, analytical study was to investigate the appearance and prevalence of "humeral periosteal reaction-like lesions" (HPRLL) in dogs and identify any predispositions. Mediolateral radiographs of humeri were evaluated and the presence and extent of "humeral periosteal reaction-like lesions" at the cranial aspect of the humerus were recorded. Macroscopic and histological examination of the humeri were performed for one dog with HPRLL. A total of 2877 mediolateral radiographs of 1727 dogs were included and focal or extended periosteal reaction-like lesions were found in 643 humeri of 387 dogs. Body weight ≥ 30 kg and age ≥ 7 years had a statistically significant, positive effect (P < 0.001) on the presence of HPRLL. German Shepherd dogs and Rottweilers were overrepresented in the group with HPRLL (P < 0.01). At the level of the HPRLL, the enthesis of the superficial pectoral muscles (M. pectoralis descendens and M. pectoralis transversus) to the Crista tuberculi majoris and Crista humeri were macroscopically and histologically identified. The authors propose that higher mechanical loads to the enthesis in large breed dogs may lead to physiological, age-related remodeling processes of the muscular attachment. The finding should not be confused with a pathological condition such as bone neoplasia.

Diaphyseal giant cell tumor with multiple relapses in a skeletally immature patient: a case report.

Giant cell tumor (GCT) is an aggressive osteolytic lesion mostly affecting the meta-epiphyses of long bones at skeletal maturity. Occurrence of the GCT in diaphysis is a rare entity in adult and exceptionally rare in pediatric population. This is the only third diaphyseal case reported in pediatric population. We report a case of recurrent diaphyseal GCT in a skeletally immature patient of 15-year-old male at the right radius after previous resection with plate and screw fixation. Upon optimal investigations, en-bloc resection of the tumor with radial resection and ulna centralization with wrist arthrodesis was done for a campanacci stage III GCT. The patient had an uneventful recovery without recurrence for 2 years and 2 months following surgery. The main challenge relies on accurate diagnosis due to uncommon location that hinders adequate treatment plan, therefore diagnosis should be solely based on histopathology findings.

Can fracture healing be accelerated by serum transfer in head trauma cases? An experimental head trauma model in rats.

OBJECTIVES: In this study, we aimed to investigate whether the positive union effect caused by head trauma could be transferred between individuals. MATERIALS AND METHODS: Seventy-two male rats with an average weight of 375 g were used in this study and divided into four groups including 18 in each group. Group 1 consisted of serum donor rats that were exposed to head trauma, while Group 2 consisted of study rats with long bone fractures that were given the serum obtained from the rats in Group 1, Group 3 included control rats with isolated long bone fractures, and Group 4 included control rats with both head trauma and long bone fractures. For radiological evaluation, the ratio of the width of the callus to the width of the neighboring diaphysis was considered as the callus-to-diaphyseal ratio in the study and control groups. Histopathological and radiological evaluations was made on Days 10, 20, and 30. RESULTS: In evaluation of the radiological data regarding the callus-to-diaphyseal ratio, Group 3 was found to have significantly lower radiological values than Group 4 on Day 10 (p=0.006). Group 2 had significantly higher values than Group 3 (p=0.02). On Day 20, Group 2 exhibited significantly higher radiological values than Group 3 (p=0.004), but lower than Group 4 (p=0.032). As for Day 30, Group 2 exhibited significantly higher radiological values than Group 3, but lower than Group 4 (p=0.001). In the evaluation of the Huo scores obtained for histopathological evaluation, there was no significant difference among the groups on Days 10, 20, and 30 (p=0.295, p=0.569, and p=0.729, respectively). CONCLUSION: Our study results suggest that the osteoinductive effect after head trauma can be transmitted between individuals by means of serum transfer.

Differences in subtrochanteric and diaphyseal atypical femoral fractures in a super-aging prefectural area: YamaCAFe Study.

INTRODUCTION: Atypical femoral fractures (AFFs) have been correlated with long-term use of bisphosphonates (BPs), glucocorticoids (GCs), and femoral geometry. We investigated the incidence and characteristics of subtrochanteric (ST) and diaphyseal (DP) AFFs in all institutes in a super-aging prefectural area. MATERIALS AND METHODS: We performed a blinded analysis of radiographic data in 87 patients with 98 AFFs in all institutes in Yamagata prefectural area from 2009 to 2014. Among the 98 AFFs, 57 AFFs comprising 11 ST fractures in 9 patients and 46 DP fractures in 41 patients with adequate medical records and X-rays were surveyed for time to bone healing and geometry. RESULTS: Of the 87 patients, 67 received BPs/denosumab (77%) and 10 received GCs (11%). Surgery was performed in 94 AFFs. Among 4 AFFs with conservative therapy, 3 required additional surgery. In univariate regression analyses for ST group versus DP group, male-to-female ratio was 2/7 versus 1/40, mean age at fracture was 58.2 (37-75) versus 78 (60-89) years, rheumatic diseases affected 55.5% (5/9) versus 4.9% (2/41), femoral lateral bowing angle was 1.7 (0-6) versus 11.8 (0.8-24)°, GC usage was 67% (6/9) versus 4.9% (2/41), and bone healing time was 12.1 (6-20) versus 8.1 (3-38) months (p < 0.05). In multivariate analyses, higher male-to-female ratio, younger age, greater proportion affected by rheumatic diseases, and higher GC usage remained significant (p < 0.05). CONCLUSIONS: The incidence of AFFs in our prefectural area was 1.43 cases/100,000 persons/year. This study suggests that the onset of ST AFFs have greater correlation with the worse bone quality, vice versa, the onset of DP AFFs correlated with the bone geometry. The developmental mechanisms of AFFs may differ significantly between ST and DP fractures.

Intramedullary injury combined with osteoporosis therapeutics regulates targeted local osteogenesis.

Bone marrow ablation prompts transient bone formation in nearly the entire medullary cavity before marrow regeneration occurs. Here, we establish a procedure to direct bone formation in a desired particular site within the medullary cavity for support of biomedical devices. Local intramedullary injury was performed in the tibiae of rats and parathyroid hormone (PTH), alendronate, or saline was administered. Newly generated bone in the medulla was assessed by micro-CT and histology. To evaluate the function of newly generated bone, animals received intramedullary injury in tibiae followed by daily PTH. At day-14, implants were placed in the endocortical bone and the bone response to the implants was assessed. The fate of newly generated bone was compared with and without implants. We found that neither intramedullary injury nor medication alone resulted in bone formation. However, when combined, substantial bone was generated locally inside the diaphyseal medulla. Newly formed bone disappeared without implant placement but was retained with implants. Bone was especially retained around and between the implants. This study found that local bone marrow disruption followed by PTH or alendronate generated substantial cancellous bone locally in the diaphyseal medulla. This approach offers promise as a tissue engineering tool in medicine and dentistry.

Effects of FK506 on the healing of diaphyseal, critical size defects in the rat femur.

There is much interest in understanding the influence of the immune system on bone healing, including a number of reports suggesting a beneficial effect of FK506 (tacrolimus) in this regard. The influence of FK506 in a rat, femoral, critical size defect was examined using locally implanted, recombinant, human (rh) BMP-2 and adenovirally-transduced, autologous, adipose-derived mesenchymal stromal cells (AD-MSCs) expressing BMP-2. FK506 was delivered systemically using an implanted osmotic pump. Empty defects and those implanted with unmodified AD-MSCs did not heal in the presence or absence of FK506. Defects treated with rhBMP-2 healed with a large callus containing thin cortices and wispy trabeculae; this, too, was unaffected by FK506. A third of defects implanted with adenovirally-transduced AD-MSCs healed, but this improved to 100 % in the presence of FK506. New bone formed in response to BMP-2 synthesised endogenously by the genetically modified cells had a slimmer callus than those healed by rhBMP-2, with improved cortication and advanced reconstitution of marrow. These results suggest that FK506 may have had little effect on the intrinsic biology of bone healing, but improved healing in response to adenovirally-transduced cells by inhibiting immune responses to the first-generation adenovirus used here. Because the genetically modified cells produced bone of higher quality at far lower doses of BMP-2, this approach should be explored in subsequent research.

Locking plate femur fracture repair in a juvenile Western chimpanzee (Pan troglodytes verus) in Sierra Leone.

This case reports the successful management of a traumatic diaphyseal femoral fracture in an infant Western chimpanzee (Pan troglodytes verus) from a rescue centre in Sierra Leone using a 2.4-mm intramedullary pin and two 2.7-mm String of Pearls™ locking plates. Locking plate use has not been previously described in chimpanzees.

Distal third femoral shaft fractures in school-aged children: A comparative study of elastic stable intramedullary nail and external fixator.

Internal fixation such as elastic stable intramedullary(ESIN) nail and submuscular plate (SMP) is gaining popularity for femoral shaft fractures in school-aged children. However, external fixation (ExFix) might be a valuable option for the distal third femoral shaft fractures, where the fracture heals rapidly, but it is crucial to avoid angular malunion. This study aims to compare the clinical outcomes, postoperative complications of distal third femoral shaft fractures in school-aged children treated by ESIN versus ExFix.Patients aged 5 to 11 years with distal third femoral shaft fractures treated at our institute from January 2014 to January 2016 were included and categorized into ESIN (n = 33) and ExFix (n = 38) group. The preoperative data, including baseline information of the patients, radiographic parameters, and type of surgical procedure, were collected from the hospital database, and postoperative data, including complications, were collected during the follow-up visit.In all, 33 patients (average, 8.0 ±â€Š2.1 years, male 20, female 13) in the ESIN group and 38 patients (average, 8.3 ±â€Š2.3 years, male 23, female 15) in the ExFix group were included in this study. There was significantly less operative time for the ExFix group (45.4 ±â€Š7.8 min) as compared to the ESIN group (57.8 ±â€Š11.3 min) (P < .01), reduced estimated blood loss (EBL) in the ExFix group (9.9 ±â€Š3.5) as compared to the ESIN group (16.4 ±â€Š6.5) (P < .01). As for the frequency of fluoroscopy, there was a significant difference between the ExFix group (13.9 ±â€Š2.4) and the ESIN group (15.5 ±â€Š3.2) (P = .02). The rate of major complications was not significantly different between the 2 groups (P = .19). The rate of implant irritation was significantly higher in the ExFix group (28/38, 73.7%) than the ESIN group (12/33, 36.4%) (P < .01). The rate of surgical site infection (SSI) is significantly higher in the ExFix group (18/38, 47.4%)) than the ESIN group (1/33, 3%) (P < .01). The rate of scar concern was significantly higher in the ExFix (9/38, 23.7%) than the ESIN (2/33, 6.1%), (P = .04). According to the Flynn scoring system, 30(90.9%) patients in the ESIN group and 24(89.5%) patients in the ExFix group were rated as excellent. None of the patients had poor outcomes.Both ESIN and ExFix produced satisfactory outcomes in distal third femoral shaft fractures. ExFix remains a viable choice for selected cases, especially in resource-challenged and austere settings.

Marrow adipose tissue in adolescent girls with obesity.

BACKGROUND: Marrow adipose tissue (MAT) is increasingly recognized as an active and dynamic endocrine organ that responds to changes in nutrition and environmental milieu. Compared to normal weight controls, adolescent girls with anorexia nervosa have higher MAT content, which is associated with impaired skeletal integrity, but data are limited regarding MAT content in adolescents with obesity and how this interacts with bone endpoints. OBJECTIVE: To evaluate (i) MAT content in adolescents with obesity compared to normal-weight controls, (ii) the association of MAT with bone endpoints, and (iii) whether these associations of MAT are affected by body weight. METHODS: We assessed MAT, bone endpoints, and body composition in 60 adolescent girls 14-21 years old: 45 with obesity (OB) and 15 normal-weight controls (NW-C). We used (i) DXA to assess areal bone mineral density (aBMD) at the lumbar spine and total hip, and total body fat and lean mass, (ii) proton magnetic resonance spectroscopy (1H-MRS) to assess MAT at the 4th lumbar vertebra and femur, and MRI to assess visceral (VAT) and subcutaneous adipose tissue (SAT), (iii) high resolution peripheral quantitative CT (HR-pQCT) to assess volumetric BMD (vBMD), (iv) individual trabeculae segmentation to evaluate trabecular bone (plate-rod morphology), and (v) finite element analysis to assess stiffness (a strength estimate) at the distal radius and tibia. RESULTS: Groups did not differ for age or height. Weight, BMI, and areal BMD Z-scores at all sites were higher in the OB group (p<0.0001). MAT was lower in OB at the femoral diaphysis (p= <0.0001) and the lumbar spine (p=0.0039). For the whole group, MAT at the lumbar spine and femoral diaphysis was inversely associated with BMI, total fat mass, lean mass, and VAT. Even after controlling for body weight, independent inverse associations were observed of femoral diaphyseal and lumbar MAT with total tibial vBMD, and of lumbar MAT with radial trabecular vBMD. CONCLUSION: Adolescent girls with obesity have lower MAT than normal-weight controls despite having an excess of total body fat. These findings confirm that MAT is regulated uniquely from other adipose depots in obesity. MAT was inversely associated with vBMD, emphasizing an inverse relationship between MAT and bone even in adolescent girls with obesity.

Efficacy of a Modified Scoring System to Facilitate Surgical Decision-making for Diaphyseal Malignancies: When is Devitalized Tumor-bearing Autograft of Value?

OBJECTIVES: To evaluate the validity of a modified scoring system (MSS) for inferring the bony quality of tumor-bearing diaphyses and predicting the risk of reconstructive failure after devitalized bone replantation (DBR). METHODS: In this retrospective cohort study, we reviewed the records of 30 patients surgically treated for diaphyseal malignancies between 1996 and 2015. There were 18 male and 12 female subjects; the average age was 34.0 ± 24.5 years (8-82 years). Tumor locations comprised the femur (21), the humerus (4), the tibia (3), the radius (1), and the fibula (1). Histological diagnoses included osteosarcoma (13), metastases (4), Ewing sarcoma (3), chondrosarcoma (3), malignant fibrohistiocytoma (2), periosteal osteosarcoma (1), Langerhans cell sarcoma (1), lymphoma (1), rhabdomyosarcoma (1), and malignant giant cell tumor (1). All primary tumors were rated as stage IIB. Twenty patients underwent DBR. Prosthetic procedures and segmental autografting/allografting were performed in 7 and 3 cases, respectively. MSS (comprising 5 elements: pain, tumor location, bone destruction, localized dimension, and longitudinal dimension) for each patient was calculated in accordance with their preoperative presentations. Outcome measurements included oncological results, outcomes of reconstructions, complications, and functional preservation, presented using the musculoskeletal tumor society (MSTS) scale. RESULTS: Follow up was available in 29 cases for an average duration of 61.0 ± 49.9 months (12-152 months). Infection occurred in 2 patients (6.9%), primary nonunion in 6 (27.3%), metastases in 9 (31.9%), recurrences in 4 (13.8%), and deaths in 7 (24.1%); 1 subject underwent amputation due to recurrence following endoprosthetic replacement (3.4%). In the DBR group, fractures occurred in 4 cases (21.1%) and nonunion in 5 (25%); internal fixation was related to nonunion (nails, 44.4% vs plates, 9.1%, P = 0.02). MSS was associated with fractures of devitalized autografts (11.0 ± 1.2 vs 8.3 ± 1.8, P = 0.01); the system was efficacious in predicting chances of fractures of these grafts (P = 0.02). MSS ≥ 10 (with false positive rate ≤ 6.7%) suggested increased fracture probability (≥22.7%) after DBR; therefore, 10 was considered a cutoff value. CONCLUSIONS: Diaphyseal malignancies with MSS ≥10 may contraindicate DBR for increased chances of reconstructive failure. In this situation, alternative procedures are advisable. Further investigations are warranted to assess the efficacy of MSS in implying the validity of DBR for diaphyseal malignancies.

Impact of Diaphyseal Cortical Thickness on Functional Outcomes After Arthroscopic Rotator Cuff Repair.

PURPOSE: To study the influence of combined cortical thickness (CCT) of the proximal humerus on arthroscopic rotator cuff tear repair outcomes. METHODS: The study included 210 patients who underwent arthroscopic repair of full-thickness supraspinatus tears. An independent reviewer measured CCT on preoperative radiographs, and patients were evaluated postoperatively at 3, 6, 12, and 24 months. Functional outcome was assessed with the Constant shoulder score (CSS), Oxford shoulder score (OSS), and University of California at Los Angeles Shoulder rating scale (UCLASS). The patients were divided based on CCT: ≥4 mm (higher CCT) and <4 mm (lower CCT). Univariate analysis and multivariate linear regressions were applied to study the effect of higher CCT on functional scores. RESULTS: At 6 months' follow-up, CSS and UCLASS were higher in the patients with higher CCT (mean ± standard deviation, 59 ± 17 vs 54 ± 14, P = .020; and 30 ± 5 vs 28 ± 5, P = .020, respectively). At 12 months' follow-up, CSS, UCLASS, and OSS were higher in the patients with higher CCT (71 ± 13 vs 65 ± 14, P = .002; 30 ± 5 vs 28 ± 5, P = .009; and 15 ± 6 vs 18 ± 7, P = .001, respectively). At 24 months' follow-up, CSS and OSS were higher in the patients with higher CCT (74 ± 11 vs 69 ± 13, P = .006; and 14 ± 4 vs 16 ± 8, P = .041, respectively). CONCLUSION: We conclude that although a higher CCT is not associated with clinically significant differences in functional outcomes, further studies examining postoperative imaging as well as perioperative optimization of bone mineral density may yield valuable results regarding the impact of CCT on cuff healing and functional outcomes. LEVEL OF EVIDENCE: III (retrospective comparative therapeutic trial).

Outcome of segmental prosthesis reconstruction for diaphyseal bone tumors: a multi-center retrospective study.

BACKGROUND: The optimal reconstructive method after diaphyseal malignant bone tumor resection remains controversial. This multicenter clinical study was designed to investigate the clinical value and complications of segmental prosthesis in the repair of diaphyseal defects. METHODS: We present 49 patients from three clinical centers treated with wide resection for primary or metastatic bone tumors involving the diaphysis of the femur, tibia, humerus, or ulna, followed by reconstruction using a modular intramedullary segmental prosthesis. RESULTS: Enrolled patients included 23 men and 26 women with a mean age of 63.3 years. Of these, seven patients had primary bone tumors and 42 patients had metastatic lesions. At the mean follow-up of 13.7 months, 17 patients were alive, 31 patients were deceased due to tumor progression, and one patient was dead of another reason. There were eight nononcologic complications (two with radial nerve injury, three with delayed incision healing, two with aseptic loosening in the proximal humerus prosthetic stem and one with structural failure) and three oncologic complications (three with primary tumor recurrence) among all patients. The incidence of complications in primary tumor patients (4/7, 57.1%) was higher than that in patients with metastatic tumors (7/42, 16.7%) (p = 0.036). Aseptic loosening and mechanical complications were not common for patients with primary tumors, although the reconstruction length difference was statistically significant (p = 0.023). No statistically significant differences were observed in limb function, while the mean musculoskeletal tumor society score was 21.2 in femora, 19.6 in humeri, and 17.8 in tibiae (p = 0.134). CONCLUSIONS: Segmental prostheses represent an optional method for the reconstruction of diaphyseal defects in patients with limited life expectancy. Segmental prostheses in the humerus experienced more complications than those used to treat lesions in the femur.

Intra-medullary osteosclerosis of the tibia in children.

BACKGROUND: Intra-medullary osteosclerosis of the tibia is a rare condition characterised by chronic pain due to diaphyseal hyperostosis with no detectable triggering factor. The main differential diagnoses are stress fracture and osteoid osteoma. Of the few cases reported to date, most were in adults. The objective of this study was to assess paediatric patients with intra-medullary osteosclerosis to determine whether the first visit provides sufficient information to establish the diagnosis and rule out both osteoid osteoma and stress fracture, whether a biopsy is required, and which treatment is optimal. HYPOTHESIS: The diagnosis of intra-medullary osteosclerosis of the tibia can be made at the first visit. PATIENTS AND METHODS: Seven paediatric patients, 4 males and 3 females, with a mean age of 11 years, were included in this retrospective study. We evaluated the clinical features, findings from imaging studies (standard radiographs, computed tomography, magnetic resonance imaging, and bone scintigraphy), and treatment outcomes. RESULTS: At the first visit, all patients had a painful swelling at the middle of the shin and imaging study evidence of antero-lateral tibial cortical thickening extending into the medullary cavity; in 5 patients, a linear lucency was visible. No other bone abnormalities were seen. Treatments included non-operative measures, pinning, and nailing. None of these treatments provided permanent bone healing or pain relief, although transitory freedom from pain with or without radiological bone healing was achieved. DISCUSSION: Intra-medullary osteosclerosis of the tibia is rarely reported and therefore probably underdiagnosed. Distinctive characteristics of the cortical and endosteal thickening include location at the antero-lateral mid-diaphysis and, in some cases, the concomitant presence of a linear lucency that can provide the early diagnosis. The distinctive radiological features allow differentiation from a stress fracture. The management is challenging. LEVEL OF EVIDENCE: IV, retrospective observational study.

Effect of the humeral neck-shaft angle and glenosphere lateralization on stability of reverse shoulder arthroplasty: a cadaveric study.

BACKGROUND: Lateralizing the glenosphere and decreasing the humeral neck-shaft angles are implant design parameters that reduce the risk of scapular impingement. The effects of these parameters on joint stability remain unclear. This study evaluated the effect of glenosphere lateralization and humeral neck-shaft angle on joint stability by quantifying the anterior dislocation force in different arm positions. METHODS: Reverse shoulder arthroplasty was performed on 19 human shoulder specimens. Anterior dislocation force and maximum external rotation were evaluated using a robot-based shoulder simulator. By varying the neck-shaft angle and magnitudes of glenosphere lateralization, 12 configurations were analyzed with the glenohumeral joint in 30° and 60° of abduction, in neutral, and in 30° of external rotation. RESULTS: At 30° of abduction, measurements showed significantly higher dislocation forces for the 9-mm and 6-mm lateralized glenosphere than for the 0-mm (P < .0001, P = .007) nonlateralized glenosphere. At 60° of abduction, measurements showed significantly higher dislocation forces for the 9-mm and 6-mm lateralized glenosphere than for the 0-mm (P < .0001, P = .0007) and 3-mm (P = .0003, P = .04) glenosphere. Configurations with a neck-shaft angle of 135° showed significantly higher dislocation forces than configurations with a neck-shaft angle of 145° (P = .02) or 155° (P = .02) at 30° of abduction in 30° of external rotation. Neck-shaft angle and glenosphere lateralization had no influence on maximum external rotation capability. CONCLUSION: Glenosphere lateralization significantly increased anterior stability of the glenohumeral joint without influencing the range of passive external rotation. The humeral neck-shaft angle only had a minor effect on anterior stability.

Primary bone tumors and tumor like lesions of the ulna.

OBJECTIVE: The aim of this study was to discuss the diagnosis and surgical management and their results according to stage of primary bone tumors at ulna and to share our experience on this exceptional location for bone tumors. METHODS: We have retrospectively reviewed our clinics database and identified 23 cases (14 males and 9 females, mean age was 28.9 (range 4-77)) with primary bone tumors and tumor like lesion involvement of ulna. The patients were evaluated according to complaints, type and grade of tumor, treatment, recurrence and functional status. RESULTS: The most common first referral complaint was constrictive pain in 52.1% of the cases, benign tumors and tumor like lesions of the bone constituted 73.9% whereas malignant bone tumors were 26.1%, 39.1% of the lesions were located in distal end of ulna and the mean follow up was 33.8 months (range 8-172 months). Local recurrence has unexpectedly occurred in 3 benign lesions (13.1%). CONCLUSION: Benign bone lesions tend to involve distal and proximal ends, malign bone lesions involve diaphysis mostly. Both benign and malignant diaphyseal lesions of the ulna have better postoperative results regarding the lesions at both ends of ulna. One should also take care of recurrences even after a decade from the primary surgery. LEVEL OF EVIDENCE: Level IV, Therapeutic study.

What Is the Adverse Event Profile After Prophylactic Treatment of Femoral Shaft or Distal Femur Metastases?

BACKGROUND: Prophylactic surgical treatment of the femur is commonly offered to patients with metastatic disease who have a high risk of impending pathologic fracture. Prophylactic fixation is associated with improved functional outcomes in appropriate patients selected based on established criteria, but the perioperative complication profile has received little attention. Given the substantial comorbidity in this population, it is important to characterize surgical risks for surgeons and patients to improve treatment decisions. QUESTIONS/PURPOSES: (1) What is the incidence of postoperative adverse events after prophylactic surgical stabilization of metastatic lesions of the femoral shaft or distal femur? (2) How does this complication profile compare with stabilization of pathologic fractures adjusted for differences in patient demographics and comorbidity? METHODS: We performed a retrospective study using the National Surgical Quality Improvement Program (NSQIP) database. We identified patients undergoing prophylactic treatment of the femoral shaft or distal femur by Current Procedural Terminology (CPT) codes. Patients undergoing treatment of a pathologic fracture were identified by CPT code for femur fracture fixation as well as an International Classification of Diseases code indicating neoplasm or pathologic fracture. We tracked adverse events, operative time, blood transfusion, hospital length of stay, and discharge to a facility within 30 days postoperatively. There were 332 patients included in the prophylactic treatment group and 288 patients in the pathologic fracture group. Patients in the prophylactic treatment group presented with greater body mass index (BMI), whereas the pathologic fracture group presented with a greater incidence of disseminated cancer. The odds of experiencing adverse events were initially compared between the two groups using bivariate logistic regression and then using multivariate regression controlling for age, sex, BMI, and American Society of Anesthesiologists (ASA) class and disseminated cancer causing marked physiological compromise per NSQIP guidelines. RESULTS: With multivariate analysis controlling for age, sex, BMI, and ASA class, patients with pathologic fracture were more likely to experience any adverse event (odds ratio [OR], 1.53; 95% confidence interval [CI], 1.03-2.29; p = 0.036), major adverse events (OR, 1.61; 95% CI, 1.01-2.55; p = 0.043), death (OR, 1.90; 95% CI, 1.07-3.38; p = 0.030), blood transfusion (OR, 1.57; 95% CI, 1.08-2.27; p = 0.017), and hospital stay ≥ 9 days (OR, 1.51; 95% CI, 1.05-2.19; p = 0.028) compared with patients undergoing prophylactic treatment. However, when additionally controlling for disseminated cancer, the only difference was that patients with pathologic fractures were more likely to receive a blood transfusion than were patients undergoing prophylactic fixation (OR, 1.61; 95% CI, 1.12-2.36; p = 0.011). CONCLUSIONS: After controlling for differences in patient characteristics, prophylactic treatment of femoral metastases was associated with a decreased likelihood of blood transfusion and no differences in terms of the frequency of other adverse events. In the context of prior studies supporting the mechanical and functional outcomes of prophylactic treatment, the findings of this cohort suggest that the current guidelines have achieved a reasonable balance of morbidity in patients with femoral lesions and further support the current role of prophylactic treatment of impending femur fractures in appropriately selected patients. LEVEL OF EVIDENCE: Level III, therapeutic study.