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Soccer participation is increasing among female adolescents with a concomitant rise of injuries in this group. Age- and sex-related factors, such as the transition from skeletal immaturity to skeletal maturity as well as anatomic, physiologic, neuromuscular, and behavioral differences between females and males, all play a role in injury patterns for these athletes. Anterior cruciate ligament (ACL) tears in this group have received a great deal of attention in the medical literature and the media in recent years with increasing knowledge about causative factors, surgical management, and injury prevention. There have been fewer studies specifically focused on female adolescent soccer players in relation to other types of injuries, such as patellar dislocation/instability; other knee and ankle ligament tears; hip labral tears; muscle strains and tears; and overuse injuries such as apophysitis, patellofemoral pain syndrome, and bone stress injuries. Because imaging plays a critical role in diagnosis of soccer-related injuries in female adolescents, knowledge of the mechanisms of injury, imaging findings, and clinical considerations are essential for radiologists involved in the care of these patients.
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BACKGROUND: Patella alta is an anatomic risk factor for patellar instability in adolescents that is also linked to the risk factor of trochlear dysplasia. This study aims to determine the age of onset and age-related incidence of patella alta in a pediatric population of patients with patellar instability. We hypothesized that patellar height ratios would not increase with age, suggesting a congenital rather than the developmental origin of patella alta. METHODS: A retrospective cross-sectional cohort of patients was collected with the following inclusion criteria: patients aged 5 to 18 who had a knee magnetic resonance imaging performed from 2000 to 2022 and the International Classification of Diseases code for patellar dislocation. Demographic information and details of the patellar instability episode(s) were collected with a chart review. Sagittal magnetic resonance imaging was used to measure Caton-Deschamps Index (CDI) and the Insall-Salvati Ratio (ISR) by 2 observers. Data were analyzed to assess for associations between patellar height ratios and age of the first dislocation and to assess if the proportion of patients categorized as having patella alta changed with age. RESULTS: The 140 knees included in the cohort had an average age of 13.9 years (SD=2.40; range: 8-18) and were 55% female. Patella alta was present in 78 knees (55.7%) using CDI>=1.2 and in 59 knees (42.1%) using ISR>=1.3. The earliest age patella alta was observed was at age 8 using CDI>=1.2 and age 10 using ISR>=1.3. There were no statistically significant associations between CDI and age without adjustment ( P =0.14) nor after adjustment for sex and body mass index ( P =0.17). The proportion of knees above the CDI threshold for patella alta to the knees below the cutoff did not show a significant change with age ( P =0.09). CONCLUSIONS: Patella alta, as defined by CDI, is seen in patients as young as 8 years old. Patellar height ratios do not change with age in patients with patellar dislocation, suggesting that patella alta is established at a young age rather than developing during the adolescent years. LEVEL OF EVIDENCE: Level III-diagnostic, cross-sectional.
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Instabilidade Articular , Luxação Patelar , Articulação Patelofemoral , Adolescente , Humanos , Criança , Feminino , Masculino , Luxação Patelar/diagnóstico por imagem , Luxação Patelar/complicações , Instabilidade Articular/diagnóstico por imagem , Instabilidade Articular/epidemiologia , Instabilidade Articular/etiologia , Patela/diagnóstico por imagem , Estudos Retrospectivos , Estudos Transversais , TíbiaRESUMO
BACKGROUND: Juvenile osteochondritis dissecans (OCD) of the knee is a defect of subchondral bone seen primarily in active children and adolescents. Studies have evaluated the incidence of surgery in knee OCD, but the incidence of subsequent surgery in patients with stable, healing lesions cleared to return to activities is unknown. This study sought to determine the incidence of surgery in participants with knee OCD lesions cleared to return to activities and evaluate predictors of subsequent surgery. METHODS: A single center, retrospective review was performed of participants aged 7 to 18 with knee OCD. Inclusion criteria were stable lesion, skeletal immaturity, no history of previous knee surgery, release to activity without surgery, and at least 12 months of follow-up. Documentation of subsequent surgery was queried in the electronic health record. Participants with no recorded surgery were contacted through phone. Analysis included bivariate and logistic regression. RESULTS: Twenty-five individuals were included in this study, with 7 undergoing surgery after returning to activity. Medial femoral condyle lesions were less likely to undergo surgery (B=-2.6, P=0.038). Average lesion size for the Surgery and No Surgery groups was 1.76±0.65 and 1.32±0.81 cm2, respectively, though not significantly different (P=0.21). The Surgery group returned to activity sooner (3.7 mo, range 1.1 to 6.4) than the No Surgery group (8.1 mo, range 1.8 to 35.4), though not significantly different (P=0.18). Mean follow-up time for the study was 42.7 (range 12.6 to 77.6) months. No participants contacted by phone progressed to surgery or reported symptoms that limited their activities. CONCLUSIONS: While the majority of participants with stable, healing, and asymptomatic knee OCD lesions have favorable outcomes with nonoperative management, some lesions may progress to surgery. Lesions on the medial femoral condyle may be predictive of lower likelihood of progression to surgery. Our study provides insight on the outcomes of nonoperative management of OCD lesions. LEVEL OF EVIDENCE: Level IV-prognostic study.
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Osteocondrite Dissecante , Adolescente , Criança , Seguimentos , Humanos , Incidência , Articulação do Joelho/cirurgia , Osteocondrite Dissecante/diagnóstico por imagem , Osteocondrite Dissecante/epidemiologia , Osteocondrite Dissecante/cirurgia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Although studies have shown increased rates of chondral injury with delayed surgical treatment of pediatric anterior cruciate ligament (ACL) injuries, it is unknown if this is related to a delay in diagnosis and appropriate activity restrictions. The purpose of this study was to determine if the time from injury to diagnosis, time from diagnosis to reconstruction, and preoperative activity level correlate with the degree of cartilage injury seen intraoperatively. METHODS: A retrospective review of skeletally immature patients who underwent ACL reconstruction was performed. Patients were stratified based on the time from injury to diagnosis (≤6 vs. >6 wk), diagnosis to surgery (≤6 vs. >6 wk), and injury to surgery (≤12 vs. >12 wk). Weight-bearing status, brace usage, athletic participation, and meniscus tears were characterized as binary variables. Articular cartilage injury was graded on a scale of 0 to 3. Differences between groups were analyzed using the χ test. RESULTS: In total, 91 subjects with mean age of 13 years (range, 9 to 16 y) were included. In total, 71% were diagnosed within 6 weeks of injury and 40% underwent surgery within 6 weeks of diagnosis. No differences were found in the presence of medial or lateral meniscus tears or the grade of articular cartilage damage when groups were analyzed by time from injury to diagnosis, diagnosis to surgery, and injury to surgery (P>0.05 in all cases). When stratified by weight-bearing status, brace status, and athletic activity, there were no significant differences between groups for meniscal tears or cartilage injury in any compartment (P>0.05). CONCLUSIONS: Diagnosis of ACL rupture within 6 weeks of injury and surgical reconstruction within 6 weeks of diagnosis or 12 weeks of injury do not appear to affect the rate of cartilage injury in skeletally immature patients. Weight-bearing status, brace use, and participation in athletic activities between the time of injury and diagnosis also did not impact the rate of intra-articular injury following ACL tear. LEVEL OF EVIDENCE: Level IV.
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Lesões do Ligamento Cruzado Anterior/diagnóstico , Reconstrução do Ligamento Cruzado Anterior/métodos , Ligamento Cruzado Anterior/diagnóstico por imagem , Diagnóstico Tardio , Meniscos Tibiais/diagnóstico por imagem , Lesões do Menisco Tibial/diagnóstico , Tempo para o Tratamento , Adolescente , Ligamento Cruzado Anterior/cirurgia , Lesões do Ligamento Cruzado Anterior/cirurgia , Braquetes , Cartilagem Articular/diagnóstico por imagem , Cartilagem Articular/lesões , Cartilagem Articular/cirurgia , Criança , Feminino , Humanos , Masculino , Meniscos Tibiais/cirurgia , Estudos Retrospectivos , Lesões do Menisco Tibial/cirurgia , Fatores de TempoRESUMO
PURPOSE: The primary purpose was to compare ipsilateral hip internal rotation (IR) in male and female athletes with or without an anterior cruciate ligament (ACL) tear. A secondary purpose was to compare radiographic markers of femoroacetabular impingement (FAI) in patients with or without an ACL tear. METHODS: In this prospective case-control study, based on a power analysis, a convenience sample of 25 ACL-injured and 25 control patients matched by age and gender were examined over 14 months. The ACL injury group included preoperative patients 12-40 years old with an ACL rupture within the previous 3 months with no prior lower extremity injuries, ligamentous laxity, or arthralgias. Controls included patients presenting with an upper extremity complaint with no history of knee injury. In the outpatient clinic, hip axial rotation range of motion was measured with a goniometer on physical examination and hip radiographs were evaluated for morphologic variations consistent with FAI. Univariate analysis of variance was used to examine differences between groups. RESULTS: Each group had 13 males and 12 females, average ages of 22.8 ± 7.2 years (ACL group) versus 24.5 ± 7.9 years (controls; P = .439). The average sum of hip rotation (internal plus external) in patients with an ACL tear was 60.3 ± 12.4° compared with 72.6 ± 17.2° in controls (P = .006). ACL-injured patients had decreased hip IR compared with controls, with respective mean measurements of 23.4 ± 7.6° versus 30.4 ± 10.4° (P = .009). For every 10° increase in hip IR, the odds of having an ACL tear decreased by a factor of 0.419 (P = .015). CONCLUSIONS: Risk of ACL injury is associated with restricted hip IR, and as hip IR increases, the odds of having an ACL tear decreases. In addition, ACL injury is associated with FAI in a generalized population of male and female athletes, although causality cannot be determined and most ACL-injured patients do not exhibit hip complaints. LEVEL OF EVIDENCE: Level II, prognostic, prospective cohort study.
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Lesões do Ligamento Cruzado Anterior/cirurgia , Impacto Femoroacetabular/cirurgia , Articulação do Quadril/fisiologia , Adolescente , Adulto , Lesões do Ligamento Cruzado Anterior/diagnóstico por imagem , Lesões do Ligamento Cruzado Anterior/etiologia , Reconstrução do Ligamento Cruzado Anterior , Atletas , Estudos de Casos e Controles , Criança , Feminino , Impacto Femoroacetabular/complicações , Impacto Femoroacetabular/diagnóstico por imagem , Humanos , Masculino , Estudos Prospectivos , Amplitude de Movimento Articular , Fatores de Risco , Rotação , Adulto JovemRESUMO
PURPOSE: To compare passive and real-time active hip range of motion (ROM) in asymptomatic collegiate pitchers, to investigate whether differences in hip morphology and ROM exist between lead and trail hips, and to relate active hip ROM during the pitch to hip morphology and femoroacetabular impingement. METHODS: Eleven collegiate baseball pitchers participated in kinematic testing that involved throwing 4 fastball pitches while wearing a full-body inertial-based motion-capture system. Passive flexion and rotation of each hip were measured using a goniometer. Nine pitchers also underwent a computed tomography (CT) pelvic scan, from which subject-specific computer models for each hip were created. Morphologic measurements were calculated from the models, and the models were tested for impingement during simulated pitching. RESULTS: Hip flexion was the only passive ROM measurement showing a significant difference between the lead and trail hips (mean difference [MD], 4°; P = .027). During the pitching motion, within-individual differences were discovered between the lead and trail hips for flexion (MD, 34°; P < .0001), extension (MD, 26°; P < .0001), abduction (MD, 8°; P = .026), adduction (MD, 6°; P = .008), external rotation (MD, 20°; P = .001), and total arc of rotation (MD, 13°; P = .001). There were no significant differences in morphologic measures between the lead and trail hips. Dynamic CT modeling did not lead to bony impingement in any subject. CONCLUSIONS: Asymptomatic collegiate pitchers approach their extremes of passive hip rotation when executing a fastball pitch. No differences were found in passive hip ROM or morphology other than a small difference in passive hip flexion. Dynamic CT modeling did not show femoroacetabular impingement during the pitching motion. CLINICAL RELEVANCE: Hip dysmorphology or poor pitching mechanics may lead to a high risk of bony impingement because pitchers have little reserve hip motion during the fastball pitch.
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Beisebol/fisiologia , Articulação do Quadril/fisiologia , Artrometria Articular , Fenômenos Biomecânicos , Simulação por Computador , Articulação do Quadril/diagnóstico por imagem , Humanos , Masculino , Amplitude de Movimento Articular/fisiologia , Rotação , Tomografia Computadorizada por Raios X , Adulto JovemRESUMO
BACKGROUND: Patellofemoral instability commonly occurs during sports activities. The return to sports (RTS) rate for pediatric patients after bilateral medial patellofemoral ligament reconstruction (MPFLR) is unknown. PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate RTS outcomes for pediatric patients undergoing bilateral MPFLR. It was hypothesized that (1) fewer pediatric patients would RTS after bilateral MPFLR compared with unilateral MPFLR and that (2) for those in the bilateral cohort who were able to RTS, fewer patients would attain the same level of play as or higher level than the preinjury level. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: We prospectively collected RTS data on retrospectively identified matched cohorts of patients aged ≤18 years who underwent unilateral and bilateral MPFLR. We matched each participant with bilateral MPFLR at a 1 to 2 ratio with a participant with unilateral MPFLR by concomitant procedure, age, and sex. Postoperative complications and preoperative imaging measurements were collected from medical records. Patient-reported outcomes were obtained using a current Single Assessment Numeric Evaluation score collected at the time of primary outcome data. RESULTS: We matched 16 participants (mean age, 14 years) who underwent bilateral MPFLR to 32 participants (mean age, 14.3 years) in a corresponding unilateral MPFLR cohort. We found a significant decrease in RTS rates for pediatric patients after bilateral MPFLR when compared with unilateral MPFLR (69% vs 94%; P = .03). Among those who returned to sports, there was no difference in the level of play achieved. For participants who did not RTS or returned at a lower level of play after bilateral MPFLR, 57% cited fear of reinjury as the primary reason. There were no differences in postoperative complications or current Single Assessment Numeric Evaluation scores between cohorts. The bilateral cohort had a significantly higher Caton-Deschamps index compared with the unilateral cohort, although the absolute difference was small (1.3 vs 1.2; P = .005). CONCLUSION: We found that pediatric patients have a lower RTS rate after bilateral MPFLR when compared with a matched unilateral MPFLR cohort. No differences in the level of play were achieved among those who returned to sports. Fear of reinjury was a commonly cited reason for not returning to sports.
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Articulação Patelofemoral , Volta ao Esporte , Humanos , Adolescente , Masculino , Feminino , Criança , Estudos Retrospectivos , Articulação Patelofemoral/cirurgia , Instabilidade Articular/cirurgia , Traumatismos em Atletas/cirurgia , Procedimentos de Cirurgia Plástica , Medidas de Resultados Relatados pelo Paciente , Ligamentos Articulares/cirurgiaRESUMO
Effective tendon regeneration following injury is contingent on appropriate differentiation of recruited cells and deposition of mature, aligned, collagenous extracellular matrix that can withstand the extreme mechanical demands placed on the tissue. As such, myriad biomaterial approaches have been explored to provide biochemical and physical cues that encourage tenogenesis and template aligned matrix deposition in lieu of dysfunctional scar tissue formation. Fiber-reinforced hydrogels present an ideal biomaterial system toward this end given their transdermal injectability, tunable stiffness over a range amenable to tenogenic differentiation of progenitors, and capacity for modular inclusion of biochemical cues. Here, tunable and modular, fiber-reinforced, synthetic hydrogels are employed to elucidate salient microenvironmental determinants of tenogenesis and aligned collagen deposition by tendon progenitor cells. Transforming growth factor ß3 drives a cell fate switch toward pro-regenerative or pro-fibrotic phenotypes, which can be biased toward the former by culture in softer microenvironments or inhibition of the RhoA/ROCK activity. Furthermore, studies demonstrate that topographical anisotropy in fiber-reinforced hydrogels critically mediates the alignment of de novo collagen fibrils, reflecting native tendon architecture. These findings inform the design of cell-free, injectable, synthetic hydrogels for tendon tissue regeneration and, likely, that of a range of load-bearing connective tissues.
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Colágeno , Hidrogéis , Tendões , Engenharia Tecidual , Hidrogéis/química , Hidrogéis/farmacologia , Colágeno/química , Tendões/metabolismo , Tendões/efeitos dos fármacos , Animais , Engenharia Tecidual/métodos , Matriz Extracelular/metabolismo , Alicerces Teciduais/química , Diferenciação Celular/efeitos dos fármacos , Fator de Crescimento Transformador beta3/metabolismo , Células-Tronco/metabolismo , Células-Tronco/citologia , Células-Tronco/efeitos dos fármacos , Materiais Biocompatíveis/química , Materiais Biocompatíveis/farmacologia , Regeneração/efeitos dos fármacosRESUMO
Purpose: To characterize functional outcomes of patients with complete proximal hamstring tendon ruptures who were treated nonoperatively and determine whether there are patient characteristics associated with unfavorable outcomes. Methods: We retrospectively identified patients aged 18-80 (treated 1/2000-12/2019) who received nonoperative management of complete rupture of the hamstring tendon origin. Participants completed the Lower Extremity Functional Scale (LEFS), as well as Tegner Activity Scale (TAS), and a chart review was conducted to obtain demographic and medical information. Preinjury and postinjury TAS scores were compared, and additional models quantified associations between LEFS scores or changes in TAS scores (ΔTAS) and patient characteristics. Results: Twenty-eight subjects (mean age: 61.5 ± 1.5 years; 10 male) were included. The mean follow-up time was 5.8 ± 0.8 years (range: 2-22 years). Mean preinjury and postinjury TAS scores were 5.3 ± 0.4 and 3.7 ± 0.4, respectively, with a change of 1.5 ± 0.3 (P = .0002). Degree of tendon retraction showed a negative correlation with LEFS score (P = .003) and ΔTAS (P = .005). Increased follow-up time (P = .015) and body mass index (P = .018) were associated with lower LEFS scores. Moreover, increased follow-up time (P = .002) and younger age at injury (P = .035) were associated with more negative ΔTAS. Patients classified with an American Society of Anesthesiologists (ASA) score of 2 had a median LEFS score that was 20 points (95% CI: 6.9-33.6) lower than those classified as ASA 1 (P = .015). Conclusions: In this study, we found that increased degree of tendon retraction, increased follow-up time, and younger age at initial injury were associated with significantly worse self-reported functional outcomes. Level of Evidence: Level IV, prognostic case series.
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A decrease in non-emergent procedure volume was observed during the COVID-19 pandemic to conserve protective equipment, increase hospital capacity, and limit nosocomial infection. Decreasing COVID-19 infection rates, paired with increasing hospital financial pressure and concerns for patient welfare, have prompted the development of guidelines for re-introduction of medically-necessary time-sensitive (MeNTS) procedures. Such protocols have received criticism for potentially perpetuating inequities disfavoring vulnerable populations. Limited access to testing supplies and protective equipment, coupled with higher incidence of medical comorbidities attributable to social determinants of health, disadvantages vulnerable populations in seemingly objective prioritization schema. Here, we detail both an analysis of current guidelines as well as strategies aimed at mitigating these disparities (including prioritizing essential infrastructure workers, implementing questionnaires, improving scheduling communication, tracking patients via ZIP codes and insurance status, facilitating post-operative rehabilitation, acknowledging physician bias, and favoring lottery selection over first-come, first-served). These guidelines and strategies can apply to future pandemics and even routine prioritization schema.
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COVID-19 , Disparidades em Assistência à Saúde , Procedimentos Ortopédicos , Humanos , COVID-19/epidemiologia , COVID-19/prevenção & controle , Prioridades em Saúde , Guias de Prática Clínica como AssuntoRESUMO
BACKGROUND: Solitary bone cysts (SBC), nonossifying fibromas (NOF), and fibrous dysplasia (FD) create benign intramedullary lytic bone lesions. They are typically asymptomatic and treated conservatively. We present a series of lesions that caused performance-limiting pain in young athletes, a symptom phenomenon and possible treatment indication that has been poorly described in the literature. QUESTIONS/PURPOSES: We asked whether intralesional curettage and defect grafting of these lesions would alleviate pain in young athletes and permit their return to unrestricted athletic activities. PATIENTS AND METHODS: We retrospectively identified 29 patients (30 lesions) who underwent curettage and grafting for SBC (12 patients), NOF (nine), or FD (eight). All patients had pain predominantly with athletic involvement. The mean age of the patients was 18 years (range, 12-31 years). Tumor locations were the femur (eight lesions), humerus (seven), tibia (six), fibula (five), pubic ramus (two), ulna (one), and calcaneus (one). Signs/symptoms were pain alone (24 patients) and pain plus fracture (five). Surgery involved curettage and packing with allograft cancellous chips, bone substitute, or demineralized bone matrix. Two patients required internal fixation. The mean followup was 21 months (range, 2-114 months). RESULTS: Twenty-four patients had no pain and five had occasional mild pain at last followup. All patients resumed full activity at a mean of 3.3 months (range, 1.5-8.3 months), excluding two who required repeat surgery. CONCLUSIONS: Our observations suggest curettage and packing with bone graft/substitute can provide pain relief and allow full athletic recovery for young athletes with benign lytic bone lesions. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Desempenho Atlético , Cistos Ósseos/cirurgia , Neoplasias Ósseas/cirurgia , Transplante Ósseo , Curetagem , Fibroma/cirurgia , Displasia Fibrosa Óssea/cirurgia , Dor/prevenção & controle , Adolescente , Adulto , Cistos Ósseos/complicações , Cistos Ósseos/diagnóstico por imagem , Neoplasias Ósseas/complicações , Neoplasias Ósseas/diagnóstico por imagem , Criança , Fibroma/complicações , Fibroma/diagnóstico por imagem , Displasia Fibrosa Óssea/complicações , Displasia Fibrosa Óssea/diagnóstico por imagem , Fixação Interna de Fraturas , Fraturas Ósseas/etiologia , Fraturas Ósseas/cirurgia , Humanos , Dor/etiologia , Medição da Dor , Philadelphia , Radiografia , Recuperação de Função Fisiológica , Reoperação , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Rehabilitation is an important component of care in postsurgical knee patients, especially as it pertains to return to preinjury activity level. Despite the established significance of rehabilitation in improving outcomes after certain surgical procedures, there is a lack of investigation into compliance rates and factors that affect compliance in pediatric patients. PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate sociodemographic factors associated with noncompliance in pediatric patients after knee surgery to characterize health disparities in this population. Our hypothesis was that certain sociodemographic factors would be associated with decreased compliance. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A retrospective review of medical records was used to gather data on compliance rate, demographics, and socioeconomic factors for pediatric patients undergoing rehabilitation after knee surgery. Compliance rate was determined by counting the total scheduled appointments, cancellations, and no-shows (defined as visits for which patients did not show up and did not provide notification of cancellation). Various types of knee injuries were included in this study. Data were evaluated using bivariate analyses in addition to hierarchical linear and binary logistic regression to assess for associations between sociodemographic factors and compliance rate. RESULTS: Our total sample size was 186 patients. When compared with patients from non-single-parent households, patients from single-parent households were found to have a lower rate of physical therapy compliance (72.2% vs 80.1%; P < .001), were less likely to reach the 85% compliance threshold (9.1% vs 42.4%; P < .001), and had an increased amount of cancellations and no-shows (16.7 vs 11.7 visits; P = .02). Although a small sample size, Hispanic/Latino patients were shown to have a lower achievement of the 85% compliance threshold compared with non-Hispanic/Latino patients (0% vs 38.2%; P = .04). Increased distance from the rehabilitation clinic was associated with lower achievement of the 85% compliance threshold (P = .033). CONCLUSION: Overall, there were several significant demographic and socioeconomic variables associated with rehabilitation compliance, specifically single-parent status, distance to rehabilitation clinic, and ethnicity. These results suggest potential predictors of decreased compliance that warrant prospective investigation.
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Level of Evidence: Level IV, case series.
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UNLABELLED: Management of large giant cell tumors of the proximal humerus is controversial because wide resection with reconstruction results in a poor functional outcome for most patients. We retrospectively reviewed the cases of six patients with Campanacci Grade III giant cell tumors of the proximal humerus to determine the feasibility of avoiding en bloc resections for large giant cell tumors in this location. We evacuated the tumor through curettage and then used burring (unless the remaining cavity was thinned and at risk for fracture) and phenolization, followed by packing of the defect with allograft cancellous bone. The mean age of the patients at surgery was 30 years, and the minimum followup was 2.5 years (mean, 5.6 years; range, 2.5-9.7 years). One of the six patients had local recurrence 1.2 years postoperatively and was treated with repeat intralesional surgery with no additional recurrence 5 years later. No other patient required additional treatment, had pulmonary metastases develop, or had progression to osteoarthritis. The mean Musculoskeletal Tumor Society and Toronto Extremity Salvage Score functional scores at last followup were 26 of 30 (range, 21-30) and 95% (range, 90%-100%), respectively. These functional scores are higher than reported scores for patients with segmental resection and reconstruction of the proximal humerus. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
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Neoplasias Ósseas/cirurgia , Transplante Ósseo , Tumor de Células Gigantes do Osso/cirurgia , Úmero/cirurgia , Adolescente , Adulto , Neoplasias Ósseas/complicações , Neoplasias Ósseas/patologia , Curetagem , Estudos de Viabilidade , Feminino , Tumor de Células Gigantes do Osso/complicações , Tumor de Células Gigantes do Osso/patologia , Humanos , Úmero/patologia , Úmero/fisiopatologia , Imageamento por Ressonância Magnética , Masculino , Recidiva Local de Neoplasia , Estadiamento de Neoplasias , Medição da Dor , Fenol/uso terapêutico , Recuperação de Função Fisiológica , Reoperação , Estudos Retrospectivos , Dor de Ombro/etiologia , Dor de Ombro/prevenção & controle , Fatores de Tempo , Transplante Homólogo , Resultado do Tratamento , Adulto JovemRESUMO
UNLABELLED: Osteoarticular allograft reconstruction after extremity tumor resection has been shown to have a high rate of complications. Although good functional results have been seen, long-term outcomes have not been well studied. We performed a retrospective review of 20 patients who underwent primary osteoarticular allograft reconstruction after extremity sarcoma resection. All postoperative complications related to the allograft reconstruction were recorded. Musculoskeletal Tumor Society 1993 and Toronto Extremity Salvage Score scores were used for functional evaluation at last followup. Minimum followup was 10 years (mean, 16 years; range, 10-21 years). Seventy percent of patients experienced an event during the followup period. Recorded events were fracture (nine patients), progressive arthritis (five), nonunion (four), and infection (two). Sixty percent of allografts were removed at a mean of 5.2 years. Progressive arthritis led to total joint arthroplasty in five patients (25%). Mean Musculoskeletal Tumor Society and Toronto Extremity Salvage Score functional scores were 25 of 30 and 95% for patients who retained their original allograft. Osteoarticular allograft reconstruction for extremity sarcomas had a high rate of adverse events (70%) and allograft removal (60%) at long-term followup. Functional outcomes of patients with intact grafts were comparable to outcomes with segmental replacement prostheses reported in the literature. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
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Neoplasias Ósseas/cirurgia , Transplante Ósseo , Sobrevivência de Enxerto , Salvamento de Membro , Sarcoma/cirurgia , Adolescente , Adulto , Artrite/etiologia , Artrite/cirurgia , Artroplastia de Substituição , Neoplasias Ósseas/mortalidade , Neoplasias Ósseas/fisiopatologia , Transplante Ósseo/efeitos adversos , Criança , Intervalo Livre de Doença , Feminino , Fraturas Ósseas/etiologia , Fraturas Ósseas/cirurgia , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Recuperação de Função Fisiológica , Reoperação , Estudos Retrospectivos , Sarcoma/mortalidade , Sarcoma/fisiopatologia , Infecção da Ferida Cirúrgica/etiologia , Infecção da Ferida Cirúrgica/cirurgia , Fatores de Tempo , Transplante Homólogo , Resultado do Tratamento , Adulto JovemRESUMO
UNLABELLED: Hemangiomas, benign vascular lesions, require intervention if causing pain or functional limitations. Functional deficits are common after excision, favoring minimally invasive treatments. To determine whether ethanol sclerotherapy reduces pain and lesion size and to assess complications in symptomatic musculoskeletal hemangiomas, we retrospectively reviewed 19 patients (six males, 13 females; mean age, 34 years) meeting criteria of confirmed hemangioma, treatment with ethanol sclerotherapy, and minimum of 6 weeks of followup. Fourteen were primary lesions and five were recurrent; all were painful. Thirty-eight sclerotherapy procedures were performed, with each patient undergoing a maximum of three procedures. Mean followup was 24 months (range, 2-95 months). Four patients reported full pain relief, 11 had partial relief, and four had no relief. With recurrent lesions, one patient had full pain relief, one had partial relief, and three had no relief. For patients with lesions larger than 5 cm, two had full relief, six had partial relief, and three had no relief. Lesion shrinkage occurred in 12 patients. Temporary complications included paresthesiae (three), tendon contracture (one), skin breakdown (one), and deep vein thrombosis (one). Ethanol sclerotherapy afforded prompt pain relief in 15 of 19 patients with hemangioma, making it a reasonable option for initially avoiding surgical excision. However, the short followup of our patients requires additional long-term studies to assess the duration of the results. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Neoplasias Ósseas/terapia , Etanol/uso terapêutico , Hemangioma/terapia , Escleroterapia/métodos , Neoplasias de Tecidos Moles/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Angiografia , Biópsia por Agulha , Neoplasias Ósseas/diagnóstico , Estudos de Coortes , Feminino , Seguimentos , Hemangioma/diagnóstico , Humanos , Injeções Intralesionais , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Medição da Dor , Estudos Retrospectivos , Medição de Risco , Escleroterapia/efeitos adversos , Neoplasias de Tecidos Moles/diagnóstico , Resultado do Tratamento , Ultrassonografia Doppler , Adulto JovemRESUMO
UNLABELLED: Internal hemipelvectomy is performed for pelvic sarcomas when the tumor can be safely resected without sacrificing the entire extremity. Wide exposure and awareness of major neurovascular structures are crucial to the success of this surgery. Various modifications on the standard utilitarian approach have been used to best achieve these goals. We reviewed our experience using the T-incision technique for 30 pelvic sarcoma resections. The minimum followup was 3.6 months (mean, 55 months; range, 3.6-185.4 months). Postoperative complications included minor complications (requiring no surgery or a simple incision and drainage with primary closure) in 27% of patients and major complications (involving a deep infection or more extensive surgical treatment) in 17%. Ninety-two percent of wound complications healed uneventfully with antibiotics and incision and drainage. The 2-, 5-, and 10-year patient survival rates were 67%, 59%, and 53%. The 2-, 5-, and 10-year disease-free survival rates were 68%, 42%, and 42%. The mean Musculoskeletal Tumor Society and Toronto Extremity Salvage Scores were 69% and 86%, respectively. We believe the T-incision technique for internal hemipelvectomy is an effective surgical approach for pelvic sarcomas when limb salvage is possible. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
Assuntos
Neoplasias Ósseas/cirurgia , Salvamento de Membro , Osteotomia/métodos , Ossos Pélvicos/cirurgia , Sarcoma/cirurgia , Adolescente , Adulto , Idoso , Neoplasias Ósseas/diagnóstico por imagem , Neoplasias Ósseas/mortalidade , Neoplasias Ósseas/secundário , Intervalo Livre de Doença , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia , Osteotomia/efeitos adversos , Ossos Pélvicos/diagnóstico por imagem , Radiografia , Estudos Retrospectivos , Sarcoma/diagnóstico por imagem , Sarcoma/mortalidade , Sarcoma/secundário , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Osteonecrosis of the femoral head has become increasingly common after steroid therapy and as a consequence of improved survival in children with sickle cell anemia and leukemia. Multiple operative and nonoperative treatments have been explored in the pediatric patient population, and core decompression is a relatively safe and possibly effective option. To optimize core decompression further, we have tested a new technique involving thorough decompression of the osteonecrotic zone under endoscopic visualization (TDEV) combined with cancellous bone grafting and stabilization with a nail plate device. METHODS: We retrospectively reviewed 16 hips in 13 patients (< or =20 years old) with femoral head osteonecrosis related to steroid treatment, sickle cell anemia, or leukemia. The Steinberg classification system was used to classify all cases. Each patient underwent TDEV, bone grafting, and stabilization of the grafting site. Patients were followed up postoperatively for changes in pain level, functional ability, and Steinberg radiologic stage. RESULTS: The mean follow-up was 28 months (range, 18-49 months). All patients in whom the procedure was successful had improvement in pain symptoms at latest follow-up, except for 1. Radiologically, all Steinberg stage II cases (B and C), except for 1, demonstrated good incorporation of graft without further progression of disease. Seven of the 8 patients that showed radiologic progression and deterioration of function or progressive symptoms had grade IIIB disease or higher at the time of procedure. CONCLUSIONS: Our initial results demonstrate that TDEV combined with cancellous bone grafting and stabilization produces encouraging early results for pediatric patients with lesions graded lower than Steinberg stage IIIB. Our findings were less optimistic for patients with higher-grade lesions. Our recommendation, therefore, is to use TDEV by trained surgeons for treatment of early-stage lesions, preferably less than Steinberg stage IIIB. LEVEL OF EVIDENCE: Level IV, Therapeutic Study.
Assuntos
Transplante Ósseo/métodos , Desbridamento/métodos , Necrose da Cabeça do Fêmur/cirurgia , Adolescente , Anemia Falciforme/complicações , Pinos Ortopédicos , Placas Ósseas , Criança , Progressão da Doença , Endoscopia/métodos , Feminino , Necrose da Cabeça do Fêmur/etiologia , Seguimentos , Humanos , Leucemia/complicações , Masculino , Dor/etiologia , Dor/cirurgia , Estudos Retrospectivos , Esteroides/efeitos adversos , Adulto JovemRESUMO
OBJECTIVES: Malignant peripheral nerve sheath tumors (MPNST) are rare soft-tissue sarcomas with a tendency for recurrence and metastasis. Treatment using chemotherapy is controversial, but benefit with some agents has been described. This study aimed to analyze early survival outcomes using doxorubicin and ifosfamide chemotherapy for MPNST. METHODS: Pathology records at our musculoskeletal tumor center were searched for patients with a new diagnosis of MPNST between 2003 and 2008. Treatment involved surgical resection, radiation, and chemotherapy with doxorubicin and ifosfamide. Ten patients met inclusion criteria, with mean age 40 years (range, 20-70). Four patients had metastatic disease on presentation. Four patients had neurofibromatosis type I (NF1). RESULTS: Of 6 patients with nonmetastatic disease on presentation, 5 had no evidence of disease post-treatment. The sixth had positive margins after surgery and initially received no further treatment due to noncompliance. Three from this subgroup developed local recurrence, but none developed distant metastases and 1 died of disease at last follow-up. One- and 2-year disease-free survival (DFS) for this subgroup was 80% and 60%, respectively. One- and 2-year overall survival (OS) for the subgroup was 100%. Of 4 patients with metastatic disease on presentation, 2 had no evidence of disease post-treatment. One of these 2 developed local recurrence, but none from the subgroup developed new metastatic disease. Two of these 4 died of disease at last follow-up. One- and 2-year DFS for this subgroup was 100% and 50%, respectively. One- and 2-year OS was 75% and 50%, respectively. Two of the 4 patients presenting with metastatic disease had NF1. All 3 local recurrences and 2 of the 3 deaths in this study occurred in NF1 patients. CONCLUSIONS: For all patients, when combined with surgery and radiation, chemotherapy using doxorubicin and ifosfamide yielded 57% DFS and 80% OS at 2 years. NF1 patients appeared to have worse outcomes, with a statistically significantly lower DFS than non-NF1 patients. Limitations of this study include a small sample size, retrospective design, and use of different chemotherapy regimens.
Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Recidiva Local de Neoplasia/tratamento farmacológico , Neoplasias de Bainha Neural/tratamento farmacológico , Neurofibromatose 1/tratamento farmacológico , Adulto , Idoso , Terapia Combinada , Doxorrubicina/administração & dosagem , Feminino , Seguimentos , Humanos , Ifosfamida/administração & dosagem , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/terapia , Neoplasias de Bainha Neural/terapia , Neurofibromatose 1/terapia , Radioterapia , Taxa de Sobrevida , Resultado do Tratamento , Adulto JovemRESUMO
In this article, we describe the presenting features, radiographic appearance, and proposed pathogenesis of tumoral calcinosis; highlight the surgical complications we have encountered with the syndrome; and review the complications reported in the literature.