Prospective study for establishing minimal clinically important differences in patients with surgery for lower extremity metastases.

BACKGROUND: The clinical relevance of patient-reported outcomes score changes is often unclear. Especially in patients undergoing surgery due to lower extremity metastases - where surgery is performed in the palliative setting and the goal is to optimize functional mobility, relieve pain and improve overall quality of life. This study assessed the minimal clinically important difference (MCID) of Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference, Cancer-specific Physical Function, and Global (Physical and Mental Health) in patients treated surgically for impending or completed pathologic fractures. METHODS: Patients undergoing surgery for osseous metastasis of the lower extremity because of an impending or completed pathologic fracture were consecutively enrolled in this tertiary center study. Patients completed the three PROMIS questionnaires preoperatively (n = 56) and at postoperative follow-up (n = 33) assessment one to three months later. Of the 23 patients that did not complete the postoperative survey, 5 patients died within 1-3 months and 18 patients were alive at 3-months but did not respond or show up at their postoperative consult. Thirty-one patients (94%) of the 33 included patients reported at least minimal improvement and two patients (6.1%) no change 1-3 months after the surgery based on an anchor-based approach. RESULTS: The PROMIS MCIDs (95% confidence interval) for Pain Interference was 7.5 (3.4-12), Physical Function 4.1 (0.6-7.6), Global Physical Health 4.2 (2.0-6.6), and Global Mental Health 0.8 (-4.5-2.9). CONCLUSION: This prospective study successfully defined a MCID for PROMIS Pain Interference of 7.5 (3.4-12), PROMIS Physical Function of 4.1 (0.6-7.6), and Global Physical Health of 4.2 (2.0-6.6) in patients with (impending) pathological fractures due to osseous metastases in the lower extremity; no MCID could be established for PROMIS Global Mental Health. Defining a narrower MCID value for each subpopulation requires a large, prospective, multicenter study. Nevertheless, the provided MCID values allow guidance to clinicians to evaluate the impact of surgical treatment on a patient's QoL. LEVEL OF EVIDENCE: Level II Diagnostic study.

Functional and oncological outcome after surgical resection of the scapula and clavicle for primary chondrosarcoma.

PURPOSE: The scapula is a relatively common site for chondrosarcoma to develop in contrary to the clavicle, which is rarely affected by these tumors. The aim of this study is to determine the functional and oncological outcome for patients treated operatively for scapular or clavicular chondrosarcoma. METHODS: In this single-center retrospective study, we included a sample of 20 patients that received the diagnosis of a primary chondrosarcoma of the scapula or clavicle. Of the surviving patients, the functional function was assessed using the DASH and the PROMIS Physical Function-Upper Extremity. Patients were longitudinally tracked for their oncological outcome. RESULTS: All patients were followed for at least 2 years or until death. The mean age of the cohort was 47 years. Eighteen patients suffered from a chondrosarcoma of the scapula, and in 2 patients, the tumor was located in the clavicle. Metastasis, local recurrence and a higher tumor grade were all associated with a decreased overall survival. For the patients with a chondrosarcoma of the scapula, the average DASH score was 16 ± 16 and the mean PROMIS Physical Function-Upper Extremity score was 48 ± 10. Patients with both an intact rotator cuff and glenoid had a better physical function. CONCLUSIONS: Upper extremity function after (partial) scapulectomy varied depending on whether the glenoid was spared and whether a functioning shoulder abductor remained. When the resection spared these structures, then excellent functional outcomes were reported. Oncologic outcomes depended upon the grade of the tumor and whether local recurrence and metastases occurred.

Management of a parturient with high-grade osteosarcoma of the proximal femur: a multidisciplinary approach.

Osteosarcoma is the most common primary malignant bone tumor, yet it is exceedingly rare in pregnancy. We present a case of a 33-year-old multiparous woman diagnosed with high-grade osteosarcoma during the third trimester of pregnancy. A plan was formulated to perform cesarean delivery at 33 weeks of gestation under spinal anesthesia, and, in subsequent surgery, radical femoral neck resection with limb salvage and adjuvant chemotherapy. The outcome was a healthy newborn baby boy and a disease-free mother. This case highlights the benefits of multidisciplinary planning: balancing the needs of the developing fetus with those of the mother, mitigating the risk of pathologic fracture and ensuring timely oncologic therapy.

CT guided percutaneous calcaneoplasty: a case of metastatic intra-articular calcaneus fracture.

Symptomatic bone metastases to the calcaneus are rare.1 Minimally invasive percutaneous augmentation is an option in the palliative management of patients with metastatic bone disease, and has been commonly used in the setting of vertebral compression fractures.2 Calcaneal augmentation can potentially allow for earlier weight bearing and a shorter period of disability. A case report is presented of percutaneous intra-articular calcaneal fracture augmentation using polymethyl methacrylate.

Recurrent intravascular papillary endothelial hyperplasia of the right middle finger treated with radiation therapy.

We describe a case of recurrent intravascular papillary endothelial hyperplasia involving the middle finger which was successfully-treated with photon and proton radiotherapy following two previous surgical excisions.

Congenital vascular malformations in the hand and forearm.

PURPOSE: To review a single-center experience in the management of symptomatic congenital vascular malformations of the hand and forearm with special attention to embolotherapy. METHODS: A retrospective chart review was performed to identify patients with vascular malformations referred for arteriography and possible intervention between 1983 and 1998. Arteriography and venography were performed in all patients to differentiate between true high-flow arteriovenous malformations (AVM) and low-flow primary venous malformations (PVM). The clinical and radiological data, procedural results, and follow-up data were retrieved and reviewed. RESULTS: In a 15-year period, 39 patients (22 men; mean age 22.5 years, range 1-51) had symptomatic vascular lesions diagnosed in the forearm and hand: 21 AVMs, 17 PVMs, and one complex lesion with both AVM and PVM. Thirty-four (87%) lesions were treated with immediate technical success achieved in 31 (91%) cases; 5 (13%) lesions were not amenable to percutaneous treatment. There were no major complications, but 3 embolized AVMs had significant residual flow (81.6% technical success on intention to treat basis). Long-term follow-up ranging to 5 years was available in 26 of the 34 treated patients; the mean symptom-free period was 30 months for the AVM patients and 30.5 months for the PVM group, with an average of 1.5 and 1.2 embolization procedures, respectively. CONCLUSIONS: Vascular malformations of the hand and forearm are extremely rare lesions that demand a multidisciplinary approach for optimal diagnosis and management. Microembolotherapy with or without surgery has offered the highest level of safety and success to date.

Volar plate arthroplasty of the distal interphalangeal joint.

Ten patients with chronic dorsal fracture subluxation of the distal interphalangeal joint were managed over 5 years with volar plate advancement arthroplasty. The mean time from injury to definitive surgical treatment was 8 weeks (range, 2 weeks to 4 months). All injuries were characterized by volar comminution and impaction of the distal phalanx, with associated dorsal subluxation. Surgical treatment included volar plate advancement arthroplasty and K-wire fixation of the reduced joint for 4 weeks. All patients were evaluated at an average postoperative duration of 25 months (range, 10-60 months). The average arc of motion of the distal interphalangeal joint of the 4 fingers (6) was 42 degrees and of the interphalangeal joint of the thumb (4) was 51 degrees. All patients had a residual flexion contracture averaging 12 degrees (range, 6 degrees to 25 degrees ). Volar plate advancement arthroplasty is an effective treatment for chronic distal interphalangeal joint dorsal fracture subluxation.

Galeazzi fracture-dislocation: a new treatment-oriented classification.

Forty patients with Galeazzi fracture-dislocations were treated with open reduction and internal fixation of the radial shaft fracture. Intraoperative distal radioulnar joint (DRUJ) instability after anatomic reduction was managed with supplemental wire transfixion of the DRUJ (10 patients) or open reduction and triangular fibrocartilage complex repair (3 patients). Two patterns of fracture-dislocation were identified based on the location of the radial shaft fracture. Twenty-two type I fractures were in the distal third of the radius within 7.5 cm of the midarticular surface of the distal radius; 12 of these cases were associated with intraoperative DRUJ instability. Eighteen type II fractures were in the middle third of the radial shaft more than 7.5 cm from the midarticular surface of the distal radius. Only one of these fractures had intraoperative DRUJ instability after open reduction and internal fixation of the radial shaft fracture. A high index of suspicion, early recognition, and acute treatment of DRUJ instability will avoid chronic problems in this complex injury.

Dorsal open repair of proximal pole scaphoid fractures.

Proximal pole fractures of the scaphoid are well suited for comprehension screw fixation. A dorsal approach allows for direct visualization of the fracture site, accurate reduction, and internal fixation. Bone grafting can also be achieved through the same incision without additional significant dissection. Successful uncomplicated union in the majority of cases with a considerably shortened period of immobilization has lead to a growing interest in this surgical procedure.

Indications and surgical techniques for digit replantation.

Finger amputations are devastating, life-changing injuries. They can occur from many different types of injury, but most often are caused by power tools or machinery in the workplace. Modern microvascular surgical techniques have enabled surgeons to successfully reattach fingers that have been amputated at almost level of injury. Patient outcome and digit viability have improved as surgeons have gained more experience with microvascular techniques, and have narrowed the operative indications for replantation. Currently, replantation is recommended for amputated thumbs, multiple digit amputations, and single digit amputations distal to the FDS insertion, as well as all amputations in children. Replantation surgery is technically demanding. Success relies on patient selection, meticulous operative technique, and postoperative monitoring. Most patients have successful outcomes with at least protective sensation and useful range of motion in the replanted digit. Though complications, including joint stiffness, tendon adhesions, malunion, and cold intolerance are not infrequent, patient satisfaction following replantation is high.

Acute fractures of the distal radius.

Distal radius fractures commonly are sustained by athletes during competition. Typically, these are high energy injuries with severe displacement, metaphyseal comminution, and articular surface disruption. Each fracture is distinguished by its degree of articular displacement, stability, and reducibility. Management is contingent on recognition of the variable magnitude of articular disruption and skillful treatment based on specific fracture configuration.

Perilunate injuries. Repair by dual dorsal and volar approaches.

Controversy persists regarding optimal management of perilunate injuries. Traditionally, closed treatment, with or without percutaneous pin fixation, was advocated for these highly unstable carpal disruptions, but the inconsistent and often disappointing outcome of closed reduction, coupled with the recognition that functional recovery closely parallels the accuracy of restoring carpal alignment, have led to increasing enthusiasm for open treatment. The favorable outcome reported in this article supports both the contention that the acute perilunate injury affords the opportune time for operative preservation of carpal stability and the efficacy of the combined dorsal and volar approaches as the optimal means of surgical repair. This clinical experience also corroborates experimental evidence that perilunate injuries are apt to cause a predictable spectrum of osseous and soft tissue lesions--lesions usually suitable for early, precise repair. For the skilled athlete, prompt recognition and precision treatment of all components of injury are the critical factors to attain a functional outcome commensurate with a successful return to competition.

Congenital anomalies of the thumb. A brief review.

Congenital anomalies of the thumb are rare and challenging conditions. There are many possible ways of addressing these various disorders, with potential to improve the function and appearance of the hand.

Rotatory subluxation of the scaphoid.

Rotatory subluxation of the scaphoid remains a challenging problem; a thorough understanding of the basic anatomy, particularly the ligament complexes of the wrist, as well as wrist kinematics are required for the proper diagnosis and treatment. Our understanding of rotatory subluxation of the scaphoid has improved over the years and continues to expand.

Long-term follow-up of the one-bone forearm procedure.

The one-bone forearm procedure can be a successful salvage option for forearm stability in selected patients and is indicated if instability and bone loss are irreparable by other means. We report a case of a dysfunctional arm secondary to radical débridement of the ulna after osteomyelitis treated successfully with a one-bone forearm procedure and followed up for 8 years.

Retrograde compression screw fixation of acute proximal pole scaphoid fractures.

Seventeen consecutive patients with acute unstable proximal pole scaphoid fractures were managed over the past 5 years with open reduction and internal fixation. Four fractures were displaced, with greater than 1 mm of fragment offset and intercarpal malalignment. The operative technique consisted of a dorsal approach to the scaphoid, radius bone grafting, and freehand retrograde Herbert compression screw fixation. The patients were evaluated at an average of 37 months (range, 12-63 months) after surgery. All fractures healed within 13 weeks (average, 10 weeks). Functional wrist range of motion and grip strength were achieved in all patients. No patients developed osteonecrosis or radioscaphoid arthritis. Open reduction and internal fixation rather than primary casting is a better means of reducing the complications of delayed union, nonunion, and irreparable osteonecrosis that often occur after acute proximal pole scaphoid fracture treated with cast immobilization.

Long-term assessment of proximal row carpectomy for chronic perilunate dislocations.

Twelve patients with chronic stage III or stage IV perilunate dislocations were managed over the past 7 years by proximal row carpectomy. All dislocations were untreated or incompletely reduced for a minimum of 8 weeks after injury. The mean time from injury to definitive treatment was 15 weeks (range, 8 weeks to 6 months). Surgical management was inclusive of a dual dorsal and volar approach. Median nerve decompression, lunate excision, and capsuloligament repair was performed volarly and scaphoid and triquetrum carpectomy was accomplished dorsally. Temporary radio capitate K-wire fixation during early soft tissue healing was uniformly performed. All patients were evaluated at an average postoperative duration of 40 months (range, 28 months to 7 years). Marked relief of wrist pain and median nerve dysesthesias was routinely achieved. Effective wrist range of motion and grip strength were restored. Untreated stage III and IV chronic perilunate dislocation treated by proximal row carpectomy eliminates pain and restores function to a severely injured wrist.

Uterine rupture after use of a prostaglandin E2 vaginal insert during vaginal birth after cesarean. A report of two cases.

BACKGROUND: Prostaglandin E2, when used for cervical ripening, often initiates labor. Single dosing and ease of removal contribute to the common use of a commercially available prostaglandin E2 vaginal insert. We describe two cases of uterine rupture among 57 pregnancies undergoing attempted vaginal birth after cesarean section. CASES: Two cases of women attempting vaginal birth after a single low transverse cesarean section were treated with the insert either at 41 weeks, 4 days, or 39 weeks, 3 days, for postdatism or preeclampsia. Signs of uterine rupture included persistent suprapubic pain and repetitive fetal heart rate variable decelerations followed by bradycardia. Infant outcomes were favorable, and tears along the prior low transverse uterine scar were repaired without additional morbidity. CONCLUSION: This prostaglandin compound is not exempt from being associated directly or indirectly with uterine rupture and requires informed consent and continuous monitoring.