Systematic review on the incidence, operative treatments, and outcomes of deltoid ruptures.

Background: A deltoid rupture can result in significant losses of shoulder function, and in the setting of a rotator cuff tear, the deltoid serves as the sole abductor of the shoulder. Deltoid ruptures can be secondary to trauma, a consequence of massive rotator cuff tears, or a result of postoperative complications. There is a paucity of literature on the management of deltoid ruptures. In this systematic review, we aim to report on the incidence of deltoid ruptures, the surgical treatment options, and the outcomes following operative treatment. Methods: A literature search was conducted on February 1, 2023 on MEDLINE and Google Scholar. Titles and abstracts were screened and the full text versions of articles that met criteria were reviewed. Criteria for inclusion included peer-reviewed studies evaluating the outcomes following surgical treatment of deltoid ruptures (direct repair, mobilization, reconstruction, and pedicled pectoralis transfer, with or without a reverse total shoulder arthroplasty). Secondary outcomes included incidence and causes of deltoid ruptures. Results: A total of 101 studies were retrieved. After review and additional studies identified from reference lists, a total of 14 studies were included in the review. The incidence of deltoid ruptures ranged from 0.3% to 7%, and large, full-thickness rotator cuff tears were found to be a significant risk factor. Surgical treatment options for deltoid ruptures include direct repair, rotationplasty, and pedicelled muscle-tendon transfers; and when indicated, these procedures can be paired with a reverse total shoulder replacement. Postoperatively, the operative extremity should be immobilized in the position of least tension (forward flexion and abduction, 30°-70°) for 4-8 weeks. Most patients in this systematic review who underwent surgical treatment of their deltoid rupture had significant improvements in pain and mean postoperative forward elevation and abduction above 90°. Discussion: The current available literature demonstrates that direct deltoid repair, rotationplasty, or reconstruction (muscle tendon transfer) with or without a concomitant reverse total shoulder arthroplasty can be an acceptable treatment option in patients with deltoid defects and massive rotator cuff tear. The average shoulder flexion and abduction increased postoperatively with improvements in pain.

Management of limb length discrepancy after bone sarcoma resection about the knee in the skeletally immature.

Patients with bone sarcomas increasingly choose limb salvage. This can lead to issues with limb length discrepancy (LLD) for the skeletally immature. We synthesize management options into an algorithm and report our results. Patients with bone sarcomas involving any location from the femoral diaphysis to the tibial diaphysis 12 years or younger were reviewed. Our clinical pathway prescribed patients with metadiaphyseal lesions to intercalary allograft reconstruction, epiphyseal lesions and less than 5 cm expected LLD to osteoarticular allograft and patients with more than 5 cm expected LLD to extendable prosthesis. Twenty patients met inclusion criteria: 11 with osteoarticular allografts, 5 with extendable prostheses and 4 with intercalary allografts; median age 11.5 years; median follow-up 8.2 years; and final median LLD 1.6 cm. Five patients had contralateral epiphysiodesis, two patients underwent contralateral femoral shortening and a median of 6 (range 4-8) lengthenings were performed for extendable prostheses. Four patients had residual LLD over 3 cm. There were 13 revisions in 8 patients and 2 amputations. Limb-salvage in paediatric bone sarcoma of the knee can be managed with multiple techniques producing satisfactory results in regards to LLD. Careful pre-operative planning and shared decision making is a requisite given the high rate of secondary procedures for both LLD and reconstructive failures. Level of evidence: Level III Retrospective Comparative Study.

Critical Review of Oncologic Medical Malpractice Claims Against Orthopaedic Surgeons.

INTRODUCTION: The purpose of this study was to determine the most common allegations for malpractice litigation brought against orthopaedic surgeons for oncologic matters and the resulting verdicts. METHODS: The Westlaw Legal research database was queried for malpractice cases filed against orthopaedic surgeons for oncologic matters in the United States after 1980. Plaintiff demographics, state of filing, allegations, and outcomes of lawsuits were recorded and reported accordingly. RESULTS: A total of 36 cases met the inclusion and exclusion criteria and were subsequently included in the final analysis. The overall rate of cases filed remained consistent through the past four decades and was primarily related to a primary sarcoma diagnosis in adult women. The primary reason for litigation was failure to diagnose a primary malignant sarcoma (42%) followed by failure to diagnose unrelated carcinoma (19%). The most common states of filing were primarily located in the Northeast (47%), where a plaintiff verdict was also more commonly encountered as compared with other regions. Damages awarded averaged $1,672,500 with a range of $134, 231 to $6,250,000 and a median of $918,750. CONCLUSION: Failure to diagnose primary malignant sarcoma and unrelated carcinoma was the most common reason for oncologic litigation brought against orthopaedic surgeons. Although most of the cases ruled in favor of the defendant surgeon, it is important for orthopaedic surgeons to be aware of the potential errors that not only prevent litigation but also improve patient care.

The impact of radiotherapy on survival after surgical resection of chordoma with minimum five-year follow-up.

BACKGROUND CONTEXT: Local control remains a vexing problem in the management of chordoma despite advances in operative techniques and radiotherapy (RT) protocols. Existing studies show satisfactory local control rates with different treatment modalities. However, those studies with minimum follow-up more than 4 years demonstrate increasing rates of local failure. Therefore, mid-term local survival rates may be inadvertently elevated by studies with less than 4 years follow-up. PURPOSE: The purpose of this study is to report the mid-term results of primary spinal chordoma treated with en bloc resection and proton-based RT with minimum 5 years of follow-up. STUDY DESIGN/SETTING: Retrospective, single-center, cohort study. PATIENT SAMPLE: Patients undergoing primary surgical excision of a spine or sacral chordoma tumor between 1990 and 2016 at a single-institution were included. Patients were included if they had a local failure at any time, or they had a minimum of 5 years of follow up with no local failure. Patients were excluded if a prior surgical excision was performed or metastases were present at the time of referral. OUTCOME MEASURES: The outcome measures were local recurrence-free interval (LRFI) and overall survival (OS). METHODS: Demographic, clinical, oncologic and surgical variables, including margin status, as well as radiation doses and schedule (neoadjuvant, adjuvant, or both) were compared using Wilcoxon rank-sum or chi-squared testing. The goal RT dose was 70 Gray (total) and patients were stratified based on completing (C70) or receiving incomplete (I70) dosing. Overall survival (OS) and local-recurrence free interval (LRFI) were calculated using the Kaplan-Meier method. FUNDING STATEMENT: No funding was obtained for this work. RESULTS: Seventy-six patients were included in the final analysis. All patients had a minimum of 5-year follow-up (median 9.3 years, range 5.1-24.7 years). There were no significant clinical differences between the C70 and I70 RT groups. OS was greater for the C70 RT group (5-year OS 82% vs. 63%, p=.001). There was similar OS for the positive margin group (5-year OS 70% vs. 61%, p=.266). LRFI was greater for the C70 RT group (5-year OS 93% vs. 78%, p=.017). There was similar LRFI for the positive margin group (5-year OS 90% versus 87%, p=.810). CONCLUSION: Chordoma outcomes trend towards diminishing LRFI rates in the literature. Here we report the results of the operative management of primary spinal chordoma with minimum five year follow-up, the addition of C70 RT to surgical excision conferred a benefit to OS and local recurrence.

COVID-19 surge readiness: use cases demonstrating how hospitals leveraged digital identity access management for infection control and pandemic response.

BACKGROUND: Surging volumes of patients with COVID-19 and the high infectiousness of SARS-CoV-2 challenged hospital infection control/safety, staffing, care delivery and operations as few crises have. Imperatives to ensure security of patient information, defend against cybersecurity threats and accurately identify/authenticate patients and staff were undiminished, which fostered creative use cases where hospitals leveraged identity access and management (IAM) technologies to improve infection control and minimise disruption of clinical and administrative workflows. METHODS: Working with a leading IAM solution provider, implementation personnel in the USA and UK identified all hospitals/health systems where an innovative use of IAM technology improved facility infection control and pandemic response management. Interviews/communications with hospital clinical informatics leaders collected information describing the use case deployed. RESULTS: Eight innovative/valuable hospital use cases are described: symptom-free attestation by clinicians at shift start; detection of clinician exposure/contact tracing; reporting of clinician temperature checks; inpatient telehealth consults in isolation units; virtual visits between isolated patients and families; touchless single sign-on authentication; secure access enabled for rapid expansion of personnel working remotely; and monitoring of temporary worker attendance. DISCUSSION: No systematic, comprehensive survey of all implemented IAM client sites was conducted, and other use cases may be undetected. A standardised reporting/information sharing vehicle is needed whereby IAM use cases aiding facility pandemic response and infection control can be disseminated. CONCLUSIONS: Clinical care, infection control and facility operations were improved using IAM solutions during COVID-19. Facility end-user innovation in how IAM solutions are deployed can improve infection control/patient safety, care delivery and clinical workflows during surges of epidemic infectious diseases.

Sclerostin immunohistochemical staining in surgically treated giant cell tumor of bone.

BACKGROUND: Giant cell tumor of bone (GCTB) is a destructive lesion with a high potential for recurrence. RANK-ligand targeted therapy has provided promising, yet mixed results. Sclerostin (SOST) inhibition results in a net anabolic response and is currently used in the treatment of osteoporosis. The application to GCTB is unknown. OBJECTIVES: We sought to determine if GCTB stained for SOST on immunohistochemistry and correlate its expression with predictor variables. METHODS: All patients at a single institution undergoing surgery for GCTB between 1993 and 2008 with a minimum of 6 months follow-up were included. Primary outcomes included the presence of SOST staining, secondary outcomes included the correlation of patient and tumor-specific predictor variables. RESULTS: SOST antibody staining of any cell type was present in 47 of 48 cases (97.9%). Positivity of the stromal cells was present in 39 of 48 cases (81.3%) and was associated with radiographic aggressiveness (p = 0.023), symptomatic presentation (p = 0.032), prior surgery (p = 0.005), and patient age (p = 0.034). Positivity of giant cells was present in 41 of 48 cases (85.4%) and was not significant with predictive factors. CONCLUSIONS: Sclerostin staining in GCTB is a novel finding and warrants further research to define the role of sclerostin as a prognostic factor and therapeutic target.

Sclerostin Immunohistochemical Staining in Aggressive Maxillofacial Giant Cell Lesions: Initial Results and Potential Therapeutic Target.

INTRODUCTION: Maxillofacial (MF) giant cell lesions (GCLs) are benign, often locally aggressive lesions with potential for recurrence. Systemic treatments have included interferon alpha, calcitonin, bisphosphonates, and denosumab. Sclerostin (SOST) is typically thought to be a negative regulator of bone metabolism and anti-SOST agents have been used to treat osteoporosis; however, its role in central giant cell granuloma is unknown. The purpose of this study was to evaluate the expression of SOST in MF GCLs. MATERIALS AND METHODS: This was a retrospective study of patients with MF GCLs treated at a single institution between 1993 and 2008 with a minimum follow-up of 6 months. Representative tissue was used to create a tissue microarray and SOST immunohistochemical (IHC) staining and grading was performed. The primary outcomes were IHC staining of the stromal cells and giant cells. The secondary outcomes included correlation of IHC staining and patient predictor variables including clinically benign and aggressive lesions. All analyses were completed using univariate statistical tests. RESULTS: A total of 37 subjects were included (29 clinically aggressive and 8 clinically benign). Sclerostin staining was present in 30 of 37 subjects (81%). Of these, 22 (60%) had stromal cell staining and 28 (76%) had giant cell staining. The presence or absence of staining, of either cell type, was not associated with aggressiveness, presence of clinical symptoms, tumor size, previous interferon therapy, previous surgery, or the race or age of the patient. DISCUSSION: Maxillofacial GCLs have an overall high level of SOST staining; however, the role of SOST in treatment and prognosis is unknown and warrants further study.

Distant migration of gluteal augmentation fat presenting as a soft tissue knee mass.

Gluteal augmentation with autologous fat grafting is an increasingly popular procedure. While complication rates are low, the clinical and imaging evaluation of the various complications can be challenging. We report a case of distal migration of a failed gluteal fat graft in a young female patient presenting as a soft tissue mass in the knee, mimicking a soft tissue sarcoma. Surgical resection of the migrated fat graft confirmed the diagnosis. The diagnosis was challenging as the patient was initially reluctant to disclose her surgical history due to perceived negative social stigmas related to cosmetic contouring procedures. This case highlights the imaging findings of a rare complication following autologous fat grafting for gluteal augmentation and the importance of obtaining a thorough medical history.

Biology and Cellular Tropism of a Unique Astrovirus Strain: Murine Astrovirus 2.

Murine astrovirus 2 (MuAstV2) is a novel murine astrovirus recently identified in laboratory and wild mice. MuAstV2 readily transmits between immunocompetent mice yet fails to transmit to highly immunocompromised mouse strains-a unique characteristic when contrasted with other murine viruses including other astroviruses. We characterized the viral shedding kinetics and tissue tropism of MuAstV2 in immunocompetent C57BL/6NCrl mice and evaluated the apparent resistance of highly immunocompromised NOD- Prkdcem26Cd52Il2rgem26Cd22 /NjuCrl mice to MuAstV2 after oral inoculation. Temporal patterns of viral shedding were determined by serially measuring fecal viral RNA. Tissue tropism and viral load were characterized and quantified by using in-situ hybridization (ISH) targeting viral RNA. Cellular tropism was characterized by evaluating fluorescent colocalization of viral ISH with various immunohistochemical markers. We found a rapid increase of fecal viral RNA in B6 mice, which peaked at 5 d after inoculation (dpi) followed by cessation of shedding by 168 dpi. The small intestine had the highest percentage of hybridization (3.09% of tissue area) of all tissues in which hybridization occurred at 5 dpi. The thymus displayed the next highest degree of hybridization (2.3%) at 7 dpi, indicating extraintestinal viral spread. MuAstV2 RNA hybridization was found to colocalize with only 3 of the markers evaluated: CD3 (T cells), Iba1 (macrophages), and cytokeratin (enterocytes). A higher percentage of CD3 cells and Iba1 cells hybridized with MuAstV2 as compared with cytokeratin at 2 dpi (CD3, 59%; Iba1, 46%; cytokeratin, 6%) and 35 dpi (CD3, 14%; Iba1, 55%; cytokeratin, 3%). Neither fecal viral RNA nor viral hybridization was noted in NCG mice at the time points examined. In addition, mice of mixed genetic background were inoculated, and only those with a functioning Il2rg gene shed MuAstV2. Results from this study suggest that infection of, or interaction with, the immune system is required for infection by or replication of MuAstV2.