Survivorship, complications, and outcomes following distal femoral replacement for neoplastic indications.

Background: Distal femoral replacements (DFRs) are excellent treatment options for limb salvage procedures in patients who have bone loss secondary to neoplasm. Multiple studies report adequate survivorship and complication rates following DFR implantation, primarily for non-neoplastic indications. However, current literature regarding neoplasm-specific reports is often limited by sample size, survivorship, and patient reported outcome measurements. Therefore, we sought to examine patients who received a DFR for a neoplastic indication at multiple tertiary academic centers. Specific outcomes analyzed included: (1) revision-free survival, (2) medical/surgical complications, and (3) Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR). Methods: All patients who underwent a DFR for a neoplastic indication were retrospectively reviewed. A total of 29 knees were included for various neoplastic indications. Outcomes of interest included: post-operative thromboses, pneumonia, dislocations, periprosthetic joint infections (PJIs), aseptic loosening, osteolysis, emergency department visits, inpatient readmissions, and revision surgeries. Patient-reported outcome measure (PROM) collected included: Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR). Results: Revision-free survivorship was 72.4 % at 23 months with radiographic follow-up. PJI was the most common post-operative complication, affecting 3 knees (10.3 %). The mean number of emergency department visits and inpatient readmissions averaged less than one per patient (0.63 and 0.41, respectively). KOOS JR scores improved markedly among from baseline to final follow-up (44.1-57.8). Conclusion: The use of DFR led to satisfactory medium-term clinical outcomes with an acceptable complication rate for this challenging group of patients. The marked improvement in patient satisfaction for this patient population gives a promising outlook for patients who will undergo this procedure in the future and can guide patient-provider regarding surgical expectations.

Nonagenarian hip fractures: Morbidity and mortality at a single institution.

OBJECTIVES: The incidence of hip fractures continues to rise dramatically, but few studies have examined these injuries in the population of individuals over 90 years of age, which is one of the fastest growing populations. We present the largest such study specifically examining hip fractures in the super-elderly. METHODS: A review of 216 hip fracture patients over 90 years of age were examined for immediate postoperative complications and in-house, 30-day, and 1-year mortality. RESULTS: Overall 1-year mortality was 38.1%. Statistically-significant risk factors for 1-year mortality included oncologic fracture, dementia, and CHF. Fracture classification and hospital length of stay were associated with perioperative complications including anemia and pneumonia. CONCLUSION: The nonagenarian hip fracture is associated with a higher 1-year mortality than prior reported rates of mortality for elderly hip fractures. Factors previously reported to influence the risk of 1-year mortality in hip fractures are not observed in the super-elderly.

Current Biopsy Methods for Primary Musculoskeletal Lymphoma: A Retrospective Multicenter Review.

Primary musculoskeletal lymphoma often requires multiple biopsies for tissue confirmation. This challenge is understood by specialists but has not been specifically quantified. One-hundred-eighteen biopsies performed in 100 cases of primary musculoskeletal lymphoma was performed. Demographics, tumor location and the method and performer of biopsy were recorded. Pearson chi-square and analysis of variance (ANOVA) statistics were used to compare rates of diagnostic yield, time to diagnosis and the presence of crush artifact based on method of biopsy, imaging, performer and tumor location. Diagnostic yield of initial biopsy is 82%. Open biopsy is associated with a higher yield compared to percutaneous techniques (p = 0.005). Biopsies performed by the treating surgeon had a higher yield compared to other practitioners (p = 0.035). Musculoskeletal lymphomas are a greater diagnostic challenge compared to other lesions. A higher index of suspicion and more aggressive sampling procedure may be necessary to establish this diagnosis. (Journal of Surgical Orthopaedic Advances 29(3):149-153, 2020).

Marjolin's Tumor Complicating Chronic Periprosthetic Infection of a Total Knee Arthroplasty.

Marjolin's tumor is a term used to describe a malignancy developing in the setting of a chronic wound, infection, or other tissue subject to chronic inflammatory changes. These malignancies usually present after many years of chronicity, and can range from lower grade basal cell carcinomas to high-grade sarcomas. We present the case of a squamous cell carcinoma that developed within a chronic periprosthetic infection of a total knee arthroplasty of 7 years duration. The intra-articular location, association with an orthopaedic implant, and brief latency period are all unique features of this case.

The Accuracy and Clinical Utility of Intraoperative Frozen Section Analysis in Open Biopsy of Bone.

BACKGROUND: Open biopsy of bone is the diagnostic benchmark for the diagnosis of skeletal lesions. Intraoperative pathology consultation with frozen section analysis is commonly performed to confirm adequacy of lesional tissue and guide intraoperative decision making. The purpose of this study was to determine the accuracy and clinical utility of intraoperative frozen section during open bone biopsy. METHODS: A retrospective review of 485 open biopsies of osseous lesions from 474 patients between 1997 and 2014 was performed. Pathology reports, operative notes, and prebiopsy imaging were assessed to determine the accuracy rates of frozen section analysis compared with final pathology. Pearson chi-squared and Fisher exact tests were performed to compare the accuracy and clinical utility rates based on soft-tissue extension, previous biopsy, lesional consistency, disease, and location. RESULTS: Overall diagnostic yield of open bone biopsy was 95.3%. Frozen section analysis was accurate in 54.2%, equivocal positive in 21.2%, equivocal negative in 21.0%, and incorrect in 3.5% of cases. Previous nondiagnostic biopsy and the type of disease were found to have statistically significant effects on the accuracy of frozen section analysis. CONCLUSION: Frozen section analysis was diagnostic in approximately one half of open biopsy cases. Additional information in equivocal positive results suggests that frozen section analysis is helpful for intraoperative decision making (clinical utility) in 75.4% of cases. LEVEL OF EVIDENCE: Retrospective review level IV.

Gouty involvement of the patella and extensor mechanism of the knee mimicking aggressive neoplasm. A case series.

Gout is a common inflammatory crystal deposition disease that occurs in many joints throughout the body. Active gout is most often associated with painful synovitis causing searing joint pains, but gout can also produce large masses of space-occupying deposits called tophi. Tophi are most frequently seen in juxta-articular locations with or without bony erosion and are often misdiagnosed as degenerative joint disease. Soft tissue deposits and tendon involvement are also known manifestations of gout, but can present with indeterminate and alarming findings on imaging. We present three cases of tophaceous gout mimicking aggressive neoplasms in the extensor mechanism of the knee. All cases presented as extensor tendon masses eroding into the patella, with imaging findings initially concerning for primary musculoskeletal malignancy.

Results of cement versus bone graft reconstruction after intralesional curettage of bone tumors in the skeletally immature patient.

BACKGROUND: Resection of periphyseal tumors in children presents several unique challenges and complications. Injury to the adjacent physis during resection and adjuvant application has been associated with adverse growth-related outcomes including angular deformities and physeal arrest. The appropriate method of reconstructing bone defects after resection is also controversial. To date there is scant literature on the use of polymethylmethacrylate (PMMA) bone cement as a method of reconstruction in children, and few long-term studies exist on the incidence of growth-related complications after reconstruction. The objective of this study is to evaluate the mechanical, oncological, and developmental outcomes of PMMA use in children. METHODS: The authors retrospectively reviewed the medical records and radiographs of 36 skeletally immature patients who underwent intralesional resections of locally aggressive bone tumors. These patients were divided into 17 patients who received reconstruction with PMMA cement, and 19 patients who were reconstructed with bone graft. Follow-up clinical and radiographic evaluations performed after skeletal maturity were reviewed to assess the structural durability, local tumor recurrence rates, reoperation rates, and the incidence of postoperative complications such as deformity, adjacent joint arthrosis, growth arrest, pain, and functional limitation. RESULTS: The average patient age at the time of surgery was 11.79 years (range, 6 to 15 y). The average length of patient follow-up was 5.3 years (range, 2 to 11.5 y). There were no statistically significant differences observed in the rates of reoperation, local tumor recurrence, growth-related complications, adjacent joint arthrosis, or postoperative pain between the 2 groups. There were no postoperative fractures in the cement group, compared to 3 fractures in the bone graft group, although this was not statistically significant. CONCLUSIONS: PMMA cement as a structural augment after resection may be used in the pediatric population for improving the mechanical stability of bone. Cement use is associated with complication rates of arthrosis, local recurrence, and growth complications comparable to those observed with bone grafting. LEVEL OF EVIDENCE: Level III: Retrospective comparison study.

Traumatic C4-C5 unilateral facet dislocation with posterior disc herniation above a prior anterior fusion.

We report the case of a unilateral cervical facet dislocation above the level of a prior non-instrumented cervical discectomy and fusion, resulting in incomplete neurologic injury. Pre-reduction imaging demonstrated a large posterior disk extrusion. This finding altered our management approach from closed reduction to urgent anterior cervical discectomy, open anterior reduction, and fusion. The patient had excellent neurologic recovery and outcome at 12 months postoperative follow-up.