Geriatric chronic recurrent multifocal osteomyelitis (CRMO) mimicking multifocal multiple myeloma: a first in an octogenarian.

Chronic recurrent multifocal osteomyelitis (CRMO), an autoinflammatory bone disorder characterized by non-bacterial osteomyelitis causing recurrent multifocal bone lesions, is a well-known, yet uncommon pediatric condition that rarely affects adults; to date, it has never been diagnosed over the age of 75. The following report will discuss the first octogenarian diagnosed with CRMO and therefore represents an exceptionally rare presentation of a rare disease. An 83-year-old woman presented with progressive right shoulder, forearm, and hip pain, with associated weight loss and global weakness, requiring a wheelchair for mobility. Imaging revealed a pathologic right ulna fracture in addition to lytic lesions of the right proximal humerus and proximal femur. The clinical picture was thus that of a patient with probable multiple myeloma versus metastatic disease. After an extensive workup, however, the lesions were not malignant; histologic findings were instead suggestive of chronic osteomyelitis with negative cultures. Given the multifocal nature of this condition, combined with a lack of clinical symptoms of infection, a diagnosis of CRMO was rendered. The patient underwent intramedullary nailing of the right femur and splinting of the ulna, with a subsequent remarkable recovery to painless ambulation, complete union of the right ulna fracture, and resolution of the lytic lesions without receiving any targeted medical treatment. This case highlights the importance of maintaining CRMO on the differential for multifocal skeletal lesions, regardless of age. Performing a thorough workup with necessary imaging, biopsy, and culture are critical to establishing this diagnosis, which can only made as a diagnosis of exclusion.

To Bundle or Not to Bundle? The Financial Impact of Pathologic Hip Disease on Hip Arthroplasty Episodes of Care.

BACKGROUND: The Comprehensive Care for Joint Replacement model aims to support more efficient care for patients. We examined the impact of patient and surgical characteristics, post-acute care, and clinical outcomes on episode of care (EOC) costs in patients undergoing hip arthroplasty for all diagnoses. METHODS: We retrospectively collected data from a large database of patients undergoing hip arthroplasty for oncologic and nononcologic diagnoses between 2014 and 2017. We compared EOC costs and outcomes between the 2 groups using Student's t-tests. We estimated the association between an oncologic-associated procedure and EOC costs from a multiple regression analysis. RESULTS: There were 2122 total patients included: 1993 in the nononcologic group and 129 in the oncologic group. The length of stay was significantly greater in the oncologic group (7.2 vs 4.2 days, P = .00). In the post-acute period, a greater proportion of oncologic patients was readmitted (29% vs 14%, P = .05) and discharged to skilled nursing (93% vs 51%, P = .00). Index hospitalization costs (mean difference [MD] $1561, P = .05), skilled nursing costs (MD $5932, P = .001), and total EOC costs (MD $20,012, P = .00) were all greater in the oncologic group. Along with increasing age and fracture diagnosis, an oncologic diagnosis is independently associated with greater EOC costs from a multivariate analysis (ß = 16,163 ± 2258, P = .00, r2 = 29%). CONCLUSION: Comprehensive Care for Joint Replacement should incorporate risk adjustment for oncologic disease because hip arthroplasty for an oncologic diagnosis is associated with worse outcomes and greater costs than in the general population.

Treatment trends of benign bone lesions in a suburban New York healthcare system.

Introduction: The management of benign bone lesions is controversial as it is dependent on a multitude of factors such as age, anatomic location, comorbidities, lesion metabolic activity, surgeon preferences, and goals of care, among others. Thus far, many studies have attempted to report on these lesions; however, most are heterogeneous compilations of benign and malignant lesions with nearly all failing to report patient treatment and none of which have originated from a suburban area of the United States. The goal of this study was to establish a modern database dedicated solely to benign bone tumors to reflect current diagnosis and treatment trends in suburban New York. Materials and Methods: This was a multicenter retrospective observational study with inclusion criteria limited to benign bone lesions of all ages. Malignant lesions were excluded. Patients were drawn from both primary care provider and surgeon records, with documentation of their associated management. Results: A total of 689 patients met inclusion criteria. The overall operative rate for this cohort was 71.6%. In agreement with current literature, aneurysmal bone cysts, giant cell tumors, and osteochondromas underwent surgery more frequently than enchondromas; older patients underwent surgery less frequently; benign bone lesions were more commonly found in younger males, and the distal femur and proximal tibia were the most common locations for lesions (P < .05 for all findings). Conclusion: This study demonstrates the management of a globally representative variety of benign bone lesions in a diverse suburban population of New York and should facilitate future research on how lesion type, location, management, and other factors relate to patient outcomes.

An Unusual Pathologic Ulna Fracture Induced by Intraosseous Tumoral Calcium Pyrophosphate Dihydrate Crystal Deposition Disease.

In this case report, we describe a novel occurrence of tumoral calcium pyrophosphate dihydrate crystal deposition disease (TCPPDCD) in a 76-year-old man that presented as an unusual, intraosseous, metadiaphyseal lesion of a long bone causing a pathologic fracture. A routine intralesional biopsy was performed, demonstrating granular deposits composed of polarizing, overlapping rhomboid crystals consistent with TCPPDCD. With limited numbers of reported cases of TCPPDCD, and the atypical intraosseous origin seen in this case, it is paramount to thoroughly evaluate all cases of TCPPDCD to clearly differentiate key findings that are essential in diagnosing and managing TCPPDCD.

Did COVID-19 related delays in surgical management lead to patient morbidity in the orthopaedic oncological population?

AIMS: The aim of this study was to assess orthopaedic oncologic patient morbidity resulting from COVID-19 related institutional delays and surgical shutdowns during the first wave of the pandemic in New York, USA. METHODS: A single-centre retrospective observational study was conducted of all orthopaedic oncologic patients undergoing surgical evaluation from March to June 2020. Patients were prioritized as level 0-IV, 0 being elective and IV being emergent. Only priority levels 0 to III were included. Delay duration was measured in days and resulting morbidities were categorized into seven groups: prolonged pain/disability; unplanned preoperative radiation and/or chemotherapy; local tumour progression; increased systemic disease; missed opportunity for surgery due to progression of disease/lost to follow up; delay in diagnosis; and no morbidity. RESULTS: Overall, 25 patients met inclusion criteria. There were eight benign tumours, seven metastatic, seven primary sarcomas, one multiple myeloma, and two patients without a biopsy proven diagnosis. There was no priority level 0, two priority level I, six priority level II, and 17 priority level III cases. The mean duration of delay for priority level I was 114 days (84 to 143), priority level II was 88 days (63 to 133), and priority level III was 77 days (35 to 269). Prolonged pain/disability and delay in diagnosis, affecting 52% and 40%,respectively, represented the two most frequent morbidities. Local tumour progression and increased systemic disease affected 32% and 24% respectively. No patients tested positive for COVID-19. CONCLUSION: COVID-19 related delays in surgical management led to major morbidity in this studied orthopaedic oncologic patient population. By understanding these morbidities through clearer hindsight, a thoughtful approach can be developed to balance the risk of COVID-19 exposure versus delay in treatment, ensuring optimal care for orthopedic oncologic patients as the pandemic continues with intermittent calls for halting surgery. Cite this article: Bone Jt Open 2021;2(4):236-242.

Outcomes of press-fit uncemented versus cemented hip arthroplasty in the oncologic patient.

BACKGROUND AND OBJECTIVES: Cemented hip arthroplasty is considered the standard of care for treating both osteoporotic femoral neck fractures and pathologic disease of the proximal femur due to the ability to achieve strong fixation in poor quality bone. There is minimal literature evaluating uncemented arthroplasty for pathologic disease of the proximal femur. This objective of this study is to compare outcomes of patients undergoing cemented and uncemented arthroplasty of the proximal femur for an oncologic indication. METHODS: Patients who underwent hip arthroplasty procedures in one health system for an oncologic indication were identified. Demographics, cancer history, operative history, and complications were collected retrospectively. Harris Hip Scores (HHS) and Musculoskeletal Tumor Society Scores (MSTS) were prospectively collected via telephone. RESULTS: 41 patients met criteria for review. 18 underwent cemented and 23 underwent uncemented arthroplasty. There were no significant differences in age, demographics, complications, 30-day mortality, intraoperative blood loss, transfusion requirements, average HHS, or average MSTS. CONCLUSION: No significant differences were found for patients undergoing hip arthroplasty for an oncologic indication regardless of whether or not the femoral component was cemented. Our results suggest that cemented and uncemented techniques are both safe and effective methods to be used at the oncologic surgeon's discretion.

5-Aminolevulinic acid tumor paint and photodynamic therapy for myxofibrosarcoma: an in vitro study.

BACKGROUND: 5-Aminolevulinic acid (5-ALA), a fluorescent contrast agent, has been used for tumor paint and photodynamic therapy (PDT) for various tumors, but its use with soft tissue sarcomas is not well documented. Myxofibrosarcoma, a subtype of soft tissue sarcoma with a high local recurrence rate, may benefit from similar types of treatment. The purpose of this study was to analyze the effects of 5-ALA tumor paint and PDT on a myxofibrosarcoma cell line. METHODS: Tumor paint was assessed by exposing micromass pellets of human adipose-derived stromal (ADS) cells or myxofibrosarcoma (MUG-Myx1) cells to 5-ALA. Cell pellets were then visualized using a microscope at established excitation and emission wavelengths. Corrected total cell fluorescence was calculated per accepted protocols. Photodynamic therapy was similarly assessed by exposing ADS and MUG-Myx1 cells to 5-ALA, with subsequent analysis via flow cytometry and real-time confocal microscopy. RESULTS: The use of 5-ALA tumor paint led to a selective fluorescence in MUG-Myx1 cells. Findings were confirmed by flow cytometry. Interestingly, flow cytometry results showed progressive selective cell death with increasing 5-ALA exposure as a result of the PDT effect. PDT was further confirmed using confocal microscopy, which revealed progressive cellular bubble formation consistent with advancing stages of cell death-a finding that was not seen in control ADS cells. CONCLUSIONS: 5-ALA tumor paint and PDT were successfully used on a human myxofibrosarcoma cell line (MUG-Myx1). Results from this study showed both selective fluorescent tagging and selective cytotoxicity of 5-ALA toward malignant myxofibrosarcoma cells, while sparing benign adipose control cells. This finding was further confirmed in a dramatic time-lapse video, visually confirming active, targeted cell death. 5-ALA's two-pronged application of selective tumor identification and cytotoxicity may transform surgical and medical approaches for treating soft tissue sarcomas.

Multiplexed Evaluation of Microdosed Antineoplastic Agents In Situ in the Tumor Microenvironment of Patients with Soft Tissue Sarcoma.

PURPOSE: A persistent issue in cancer drug development is the discordance between robust antitumor drug activity observed in laboratory models and the limited benefit frequently observed when patients are treated with the same agents in clinical trials. Difficulties in accurately modeling the complexities of human tumors may underlie this problem. To address this issue, we developed Comparative In Vivo Oncology (CIVO), which enables in situ investigation of multiple microdosed drugs simultaneously in a patient's tumor. This study was designed to test CIVO's safety and feasibility in patients with soft tissue sarcoma (STS). PATIENTS AND METHODS: We conducted a single arm, prospective, 13-patient pilot study. Patients scheduled for incisional biopsy or tumor resection were CIVO-injected 1 to 3 days prior to surgery. Saline or microdoses of anticancer agents were percutaneously injected into the tumor in a columnar fashion through each of eight needles. Following excision, drug responses were evaluated in the injected tissue. RESULTS: The primary objective was met, establishing CIVO's feasibility and safety. Device-related adverse events were limited to transient grade 1 nonserious events. In addition, biomarker evaluation of localized tumor response to CIVO microinjected drugs by IHC or with NanoString GeoMx Digital Spatial Profiler demonstrated consistency with known mechanisms of action of each drug, impact on the tumor microenvironment, and historic clinical activity. CONCLUSIONS: These results are an advance toward use of CIVO as a translational research tool for early evaluation of investigational agents and drug combinations in a novel approach to phase 0 trials.See related commentary by Sleijfer and Lolkema, p. 3897.

Biomechanics of the flexor tendons.

This article examines basic tendon biomechanics, the anatomy and mechanics of digital flexor tendons, and the digital flexor pulley system. It also explores the various models that have tried to simulate the motion of the flexor tendons and several testing modalities that have been used. Finally, clinical applications are considered, including the biomechanics of flexor tendon repairs and tendon transfers. As we reach limits in the care of flexor tendon injuries, research into molecular, biochemical, and micromechanical methods of tendon repair will become the forefront of future investigation.

Complex coronal shear fractures of the distal humerus.

This is a retrospective review of nine coronal shear fractures of the distal humerus. Two were isolated fractures and seven were associated with other peri-articular elbow injuries, termed "complex" coronal shear fractures. All cases underwent immediate open reduction and internal fixation (ORIF) and were then followed for an average of 14 months (range: 6.5 to 23 months) with outcomes evaluated using the Mayo Elbow Performance Scoring system. There was a significant difference found between injuries limited to the radiocapitellar (RC) joint (isolated coronal shear fractures, or those associated only with radial head fractures) and the complex injuries extending beyond the RC joint. Scores for the RC injuries were 100 and other complex injuries had an average score of 69 (range: 35 to 95; p = .025). All complications were limited to the group with the complex injuries, including stiffness, nonunion, pain, and gross instability. Much of the current thinking in treatment of this fracture was upheld in this study; computed tomography aids in diagnosis, ORIF is a necessity, and there is a need for anatomic reduction. When a coronal shear fracture is complicated by a concomitant injury outside the RC joint, both the surgeon's and patient's expectation need to be adjusted accordingly.

Treatment of pediatric both-bone forearm fractures: a comparison of operative techniques.

Both-bone forearm fractures of the radius and ulna are a common injury in children. Closed reduction and casting has historically been the primary means of treatment in over 90% of these fractures. Unstable and irreducible fractures, however, often pose a therapeutic challenge, with little data available to compare outcomes. The authors performed a retrospective review of 50 children with both-bones fractures treated with closed reduction and cast immobilization, open reduction and internal fixation (ORIF), or intramedullary (IM) nailing. Complications were tabulated and separated by treatment modality and subdivided into minor/major complications. Statistical regression was performed. There were 54 operations in 50 patients with both-bones fractures. All fractures healed within 8 to 10 weeks, except for two delayed unions and one nonunion. The complication rate was 5% for closed treatment, 33% for ORIF, and 42% for IM nailing. Complication rates were significantly different between the closed and operative groups. When comparing treatments in pediatric both-bones fractures, there are significantly more complications with operative techniques. Patients with ORIF had more major complications, often requiring a return to the operating room. IM nailing, when done correctly, is as acceptable and safe a form of treatment.