Treatment of Unicameral Bone Cysts Utilizing the Sclerograft™ Technique.

PURPOSE: To evaluate the Sclerograft™ procedure, which is an image-guided, minimally invasive approach of chemical sclerotherapy followed by bone grafting of unicameral bone cysts (UBC). MATERIALS AND METHODS: A retrospective evaluation from August 2018 through August 2023 was performed at a single institution on patients that underwent the Sclerograft™ procedure for UBCs. Radiographic healing was evaluated utilizing the Modified Neer Classification. Two different regenerative grafts, CaSO4-CaPO4 and HA-CaSO4 were utilized. A total of 50 patients were evaluated with 41 patients grafted with CaSO4-CaPO4 and 9 patients grafted with HA-CaSO4. RESULTS: The average age of the patient was 12.1 years with an average radiographic follow-up of 14.5 months. Average cyst size was 5.5 cm in the largest dimension and average cyst volume was 20.2 cc. 42 out of 50 (84%) showed healed cysts (Modified Neer Class 1) on the most recent radiograph or MRI. Recurrences occurred on average at 7.2 months. Activity restrictions were lifted at 3-4.5 months post-procedure. Cyst stratification by size did not show a difference in recurrence rates (p = 0.707). There was no significant difference in recurrence rate between lesions abutting the physis compared to those that were not abutting the physis (p = 0.643). There were no major complications. CONCLUSIONS: The Sclerograft™ procedure is an image-guided approach to treating unicameral bone cysts, utilizing chemical sclerosis and regenerative bone grafting. The radiographic healing of cysts compares favorably to open curettage and grafting as determined utilizing previously published trials.

Immediate Plastic Surgery Intervention after Soft Tissue Sarcoma Resection: Examining Wound Healing, Readmission, and Reoperation.

Many orthopedic and surgical oncologists use a multidisciplinary approach to soft tissue sarcoma (STS) resection. This study assesses the role of immediate plastic surgeon involvement during index soft tissue sarcoma resection. Methods: Adult patients who underwent index STS resection between 2005 and 2018 were queried from an institutional database. Main outcomes analyzed were 90-day same-site reoperation, any-cause readmission, and wound healing complications. Univariate and multivariate logistic regression were used to identify risk factors. Additional evaluation was then performed for the following two cohorts: patients with and without plastic surgeon involvement. Results: In total, 228 cases were analyzed. Multivariate regression demonstrated the following predictors for 90-day wound-healing complications: plastic surgery intervention [OR = 0.321 (0.141-0.728), P = 0.007], operative time [OR = 1.003 (1.000-1.006), P = 0.039], and hospital length of stay [OR = 1.195 (1.004-1.367), P = 0.010]. For 90-day readmission, operative time [OR = 1.004 (1.001-1.007), P = 0.023] and tumor stage [OR = 1.966 (1.140-3.389), P = 0.015] emerged as multivariate predictors. Patients whose resection included a plastic surgeon experienced similar primary outcomes despite these patients having expectedly longer operative times (220 ± 182 versus 108 ± 67 minutes, P < 0.001) and hospital length of stay (3.99 ± 3.69 versus 1.36 ± 1.97 days, P < 0.001). Conclusions: Plastic surgeon involvement emerged as a significant protector against 90-day wound healing complications. Cases that included plastic surgeons achieved similar complication rates in all categories relative to cases without plastic surgery intervention, despite greater operative time, hospital length of stay, and medical complications.

Vascularized Medial Femoral Condyle Periosteal Flaps With Allograft Bone for Distal Radius Giant Cell Tumors: A Case Report.

CASE: Distal radius reconstruction after giant cell tumor (GCT) resection is typically performed with free fibular flaps when a vascularized bone is needed. However, vascularized fibular flaps are contraindicated in patients with peroneal artery variants. We present 2 patients with GCTs of the radius and bilateral peronea arteria magna who underwent resection with wrist fusion using an allograft bone and vascularized free medial femoral condyle periosteal flaps. Both patients had excellent outcomes with minimal postoperative morbidity. CONCLUSION: Allograft bone with vascularized medial femoral condyle periosteal flaps is an effective option for reconstructing distal radius defects after GCT resection when conventional methods fail.

Minimally Invasive Treatment for Unicameral Bone Cysts with Chemical Sclerosis and Bone Graft Substitute: A Preliminary Report.

PURPOSE: Unicameral bone cysts (UBCs) are benign lesions that primarily occur in childhood and can present with pain, pathologic fracture and growth disturbances. Existing treatment approaches for the management of UBCs are highly variable and recurrence is not uncommon. This study seeks to evaluate near-term outcomes of an image-guided, minimally invasive combination of chemical sclerotherapy and synthetic grafting as a novel outpatient management treatment option for UBCs. MATERIALS AND METHODS: Retrospective evaluation from August 2018 to July 2020 of fourteen pediatric patients, ages 5-14 years, undergoing treatment for a UBC, at a single institution. All UBCs were treated in a single, minimally invasive, image-guided procedure using percutaneous needle access into the UBC followed by chemical sclerotherapy and injection of regenerative synthetic graft. Patients were followed clinically and with serial radiographs to evaluate for healing and complications, with an average follow-up of 13.7 months. Descriptive statistics were performed. RESULTS: Twelve of 14 (85.7%) patients showed Modified Neer classification class 1 or 2 healed cysts at their most recent follow-up. There were two recurrences. All patients were pain-free and returned to normal physical activity on average within 2.0 months, and all patients with healed cysts remained asymptomatic at the most recent follow-up. There were no complications related to the procedures. CONCLUSIONS: Image-guided chemical sclerosis and bone grafting is a minimally invasive treatment option for unicameral bone cysts and compares favorably to other existing treatment options. The preliminary findings of this technique are promising as an alternative management option for UBCs.

Pregnancy-Associated Perivascular Epithelioid Cell Tumor of the Tarsal Navicular: A Case Report.

CASE: A 30-year-old pregnant woman with perivascular epithelioid cell tumor (PEComa) of the tarsal navicular underwent intralesional curettage with allograft at 30 weeks' gestation. She had an uncomplicated delivery at term and is ambulating without tumor recurrence at 1-year follow-up. CONCLUSION: PEComas are rare tumors most commonly found in soft tissues but have been reported in bone and are occasionally associated with pregnancy. To the best of our knowledge, this is the first reported case of pregnancy-associated PEComa of bone.

Thromboembolic Disease in Patients with Metastatic Femoral Lesions: A Comparison Between Prophylactic Fixation and Fracture Fixation.

BACKGROUND: We are not aware of any previous studies that have compared the rate of venous thromboembolic events in patients who underwent prophylactic intramedullary nailing because of an impending fracture with the rate in patients who underwent intramedullary nailing after a pathological fracture. The objective of the present study was to determine if the rate of venous thromboembolic events varies between patients who are managed with prophylactic fixation and those who are managed with fixation after a pathological fracture. METHODS: We performed a retrospective comparative study in which the Nationwide Inpatient Sample database was used to identify all patients who had undergone femoral stabilization, either for a pathological femoral fracture or for prophylactic fixation of femoral metastatic lesion, over a period of 10 consecutive years (between 2002 and 2011) in the United States. Demographic data, comorbidities, venous thromboembolic event rates, and other common postoperative complications were compared between the 2 groups. RESULTS: Patients who were managed with prophylactic fixation had significantly higher rates of pulmonary embolism (p < 0.001; adjusted odds ratio, 2.1) and deep-vein thrombosis (p = 0.03; adjusted odds ratio, 1.5). Patients who were managed with fixation after a pathological fracture had a significantly greater need for blood transfusion, higher rates of postoperative urinary tract infection, and a decreased likelihood of being discharged to home (p < 0.001 for all). CONCLUSIONS: Patients with metastatic disease who undergo prophylactic intramedullary nailing have higher observed rates of venous thromboembolic events than those who undergo nailing for the treatment of a pathological fracture and should be actively and vigilantly managed in the postoperative period. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Conversion of cephalomedullary nail fixation to hip arthroplasty: technical points and pitfalls.

Cephalomedullary nail fixation is used to treat proximal femur fractures. Some of these internal fixation constructs fail secondary to hardware failure, fracture malunion or nonunion, or the interval development of degenerative arthritis. Converting one of these constructs to a hip arthroplasty is technically more demanding and has a higher complication rate compared with routine primary total hip replacement. In this article, we review tips, techniques, and potential pitfalls for converting cephalomedullary nail fixation to hip arthroplasty-knowledge that orthopedic surgeons can use to minimize intraoperative and postoperative complications.

Examination of national lymph node evaluation practices for adult extremity soft tissue sarcoma.

BACKGROUND AND OBJECTIVES: Lymph node evaluation recommendations for extremity soft tissue sarcoma (ESTS) are absent from national guidelines. Our objectives were (1) to assess rates and predictors of nodal evaluation, and (2) to assess rates and predictors of nodal metastases. METHODS: ESTS patients from the National Cancer Data Base (2000-2009) were assessed, and regression models were used to identify factors associated with nodal evaluation and metastases. RESULTS: Of 27,536 ESTS patients, 1,924 (7%) underwent nodal evaluation, and of these, 290 (15%) had nodal metastases. Nodal evaluation was most frequently performed for rhabdomyosarcoma (15.6%), angiosarcoma (10.0%), clear cell sarcoma (39.3%), epithelioid sarcoma (28.1%), and synovial sarcoma (9.3%). On multivariable analysis, factors associated with nodal evaluation included histologic subtype, tumor size, and grade. Nodal metastasis rates were highest among patients with rhabdomyosarcoma (32.1%), angiosarcoma (24.1%), clear cell sarcoma (27.7%), and epithelioid sarcoma (31.8%). On multivariable analysis, factors associated with nodal metastases included histologic subtype, tumor size, and grade. CONCLUSIONS: Nodal evaluation rates are highest among certain expected subtypes but are generally low. However, nodal metastasis rates for many histologic subtypes in patients selected for lymph node evaluation may be higher than previously reported. Multi-institutional studies should address nodal evaluation for ESTS.

Assessment of multimodality therapy use for extremity sarcoma in the United States.

BACKGROUND: Extremity sarcoma national guidelines offer several stage-specific treatment options; therefore, treatment approaches are not standardized. Our objectives were to examine multimodality treatment trends, practice patterns, and factors associated with neoadjuvant or postoperative adjuvant therapy utilization. METHODS: Using the National Cancer Data Base (2000-2009), treatment of non-metastatic extremity sarcoma was examined. Regression models were developed to identify factors associated with neoadjuvant or postoperative adjuvant therapy receipt and treatment sequence. RESULTS: Twenty-two thousand fifty-one patients underwent resection (stage I: 45.2%, stage II: 27.7%, stage III: 27.1%). Over 10 years, neoadjuvant radiation (6.4-11.6%, P < 0.001) and chemotherapy utilization (1.4-1.8%, P = 0.037) increased, while postoperative radiation (34.3-29.2%, P = 0.023) and trimodality therapy decreased (10.5-9.6%, P = 0.002). After adjusting for age, comorbidities, and histology, patients with large high-grade tumors treated at high-volume academic centers were more likely to receive neoadjuvant therapy (all P < 0.001). Postoperative chemotherapy utilization was associated with younger age, synovial histology, high grade, and surgical margins (all P < 0.001). CONCLUSIONS: Utilization of neoadjuvant therapy for extremity sarcoma has increased over time. Practice patterns are not only related to tumor size, grade, histology, and margins but also hospital type. Opportunities remain to better define the most effective multimodality treatment for extremity sarcoma.

CASE REPORT Rotational Vascularized Tibiaplasty After Oncologic Resection and Major Wound Healing Problems: A Novel Technique.

OBJECTIVE: To describe a novel method to reconstruct, with a vascularized rotational tibiaplasty, a complex femoral defect in an adolescent. METHODS: After a femoral osteosarcoma resection, allograft reconstruction, and chemotherapy, an 11-year-old girl developed recurrent thigh wound infections and femoral allograft osteomyelitis despite multiple operative interventions. At the age of 13, she presented to our center with a complex right thigh wound and an unstable lower extremity secondary to a segmental femoral loss. To reestablish thigh stability and function and to avoid amputation at the hip, the authors performed a rotational vascularized tibiaplasty. The tibia was rotated 180° with the pivot at the knee. The distal tibia was internally stabilized to the residual proximal femur. RESULTS: Ten years later, the patient had a stable thigh, a functional hip, no evidence of infection or sarcoma, and a Toronto Extremity Salvage Score of 92.5 (minimal disability). CONCLUSIONS: In this patient, the tibial rotationplasty provided a vascularized bone strut mimicking the resected femur; saved the hip; obviated an allograft bone; and created a functional, biologic, stable, and durable thigh that allowed full weight bearing on a prosthesis, with a low physical disability level. We conclude that, for patients with complex femoral defects, a vascularized rotational tibiaplasty should be considered a feasible option before amputation.

Imaging differentiation of pathologic fractures caused by primary and secondary bone tumors.

OBJECTIVE: To describe pre-treatment imaging features of pathologic fractures caused by primary bone tumors (PBTs) and metastatic bone tumors (MBTs) and determine if radiographic or cross-sectional features can differentiate the underlying pathologies associated with the fractures. METHODS: Sixty-nine patients with a diagnosis of a pathologic fracture were enrolled. Biopsy established PBT as the cause of the pathologic fracture in 16 (23%) cases and MBT in 53 (77%) cases. The radiographs, computed tomography (CT) scans, and magnetic resonance imaging (MRI) scans of the subjects were retrospectively reviewed for the presence of multiple imaging features. RESULTS: Compared to pathologic fractures caused by MBTs, the fractures caused by PBTs demonstrated a higher incidence of lytic bone cortex, mineralization and a soft-tissue mass on radiographs, mineralization and a soft-tissue mass on CT scans, and periosteal abnormality on MRI scans (P<0.01). These features also exhibited a high negative predictive value in supporting the diagnosis of an underlying PBT over MBT. CONCLUSION: Pathologic fractures caused by PBT and MBT may be differentiated by a few specific radiographic and CT imaging features, though MRI was poor for characterization of the underlying lesion. Such knowledge may assist radiologists in raising the possibility of a PBT as the cause of a pathologic fracture.

Factors associated with recurrence of primary aneurysmal bone cysts: is argon beam coagulation an effective adjuvant treatment?

BACKGROUND: Our goal was to assess the effectiveness and safety of argon beam coagulation as an adjuvant treatment for primary aneurysmal bone cysts, to reevaluate the adjuvant effectiveness of the use of a high-speed burr alone, and, secondarily, to identify predictors of aneurysmal bone cyst recurrence. METHODS: We retrospectively reviewed the records of ninety-six patients with primary aneurysmal bone cysts who were managed at our institution from January 1, 1983, to December 31, 2008. Forty patients were managed with curettage, a high-speed burr, and argon beam coagulation; thirty-four were managed with curettage and a high-speed burr without argon beam coagulation; and the remaining twenty-two were managed with curettage with argon beam coagulation alone, curettage with no adjuvant treatment, or resection of the entire lesion. Demographic, clinical, and radiographic data were viewed comparatively for possible predictors of recurrence. Kaplan-Meier survival analysis with a log-rank test was performed to measure association and effectiveness. RESULTS: The median age at the time of diagnosis was fifteen years (range, one to sixty-two years). The median duration of follow-up was 29.5 months (range, zero to 300 months). The overall rate of recurrence of aneurysmal bone cyst after surgical treatment was 11.5%. The rate of recurrence was 20.6% after curettage and high-speed-burr treatment alone and 7.5% after curettage and high-speed-burr treatment plus argon beam coagulation. The five-year Kaplan-Meier survival estimate was 92% for patients managed with curettage and adjuvant treatment with a high-speed burr and argon beam coagulation, compared with 73% for patients managed with curettage and a high-speed burr only (p = 0.060). CONCLUSIONS: Surgical treatment of aneurysmal bone cyst with curettage and adjuvant argon beam coagulation is effective. Postoperative fracture appears to be a common complication of this treatment and needs to be studied further. Treatment with curettage and high-speed burr alone may not reduce recurrence.

Imaging features of chondrosarcoma.

Chondrosarcomas are malignant neoplasms of mesenchymal origin and represent a heterogeneous group of tumors ranging from indolent, low-grade lesions to aggressive, high-grade neoplasms. The early diagnosis and treatment of chondrosarcomas is paramount to achieving a better prognosis. Multiple imaging modalities have been used for the purpose of initial detection, characterization, and staging, as well as for the performance of image-guided biopsies. As imaging techniques continue to evolve, radiologists are assuming an increasingly important role in the management of chondrosarcomas. This review describes the imaging characteristics of chondrosarcomas on multiple modalities and emphasizes the imaging features that may assist in differentiating these tumors from their benign counterparts, enchondromas and osteochondromas, which frequently still pose challenging diagnostic dilemmas.

Pyoderma gangrenosum complicating bilateral total knee arthroplasty.

Pyoderma gangrenosum is an ulcerative, necrotic dermatosis of unknown etiology. It is frequently associated with inflammatory, hematologic, or neoplastic disease. Clinical and physical evaluation can imitate postoperative wound infections. This article reports a case of pyoderma gangrenosum in a patient who underwent bilateral total knee arthroplasty. Her postoperative course was complicated by wound dehiscence and ulceration in both knees. Her condition deteriorated despite debridements and antibiotic therapy. Deep intraoperative cultures were all negative. Once the diagnosis of pyoderma gangrenosum was established and once appropriate treatment with steroids was initiated, her condition improved. The diagnosis of pyoderma gangrenosum should be considered in patients with wound deterioration who remain culture-negative and fail to respond to debridement and antibiotic treatment. This case report highlights the presentation of pyoderma gangrenosum and its ability to be misdiagnosed as infection. A delay in treatment may result in unnecessary surgery that will further exacerbate this inflammatory condition.

Soft-tissue masses and masslike conditions: what does CT add to diagnosis and management?

OBJECTIVE: Although MRI is the technique of choice for evaluating most soft-tissue masses, CT often provides valuable complementary information. Specifically, there are distinguishing CT characteristics that can suggest a specific diagnosis, including the lesion's mineralization pattern, density, pattern of adjacent bone involvement, and degree and pattern of vascularity. CONCLUSION: This article provides an overview of the CT evaluation of soft-tissue masses, emphasizing a differential diagnosis based on these CT features.