Femoral neck shortening as a sequela of internal fixation for femoral neck fractures and its effect on the coronal alignment of the limb: a pilot study.

INTRODUCTION: Femoral neck shortening is a common phenomenon following osteosynthesis for femoral neck fractures, which was shown to have a negative effect on hip function. There is paucity of literature on the effect of shortening on the ipsilateral limb mechanical axis and knee coronal alignment. We hypothesized that postoperative femoral neck shortening can alter the limb's mechanical axis into valgus. METHODS: Of 583 patients screened, 13 patients with severe neck shortening (< 10 mm) following femoral neck fracture fixation, were found eligible and agreed to participate. A full-length lower limb radiographs were obtained and radiographic parameters (offset, neck-shaft angle, HKA, mLPFA, mDLFA, mMPTFA, MAD, MAD-r) as well as functional scores were obtained. RESULTS: Statistically significant differences in mechanical axis deviation ratio (MAD-r) were found between the ipsilateral and the contralateral extremities (0.41 ± 0.16 versus 0.55 ± 0.11, p = 0.03). A correlation between femoral neck length differences and MAD was not statistically significant although a tendency towards lateral deviation of the mechanical axis was noted (r = - 0.5, p = 0.077). A negative correlation was found between a greater difference in the femoral neck length and the SF12 score, both in the physical and the mental parts (r = - 0.69, p = 0.008; r = - 0.58, p = 0.035, respectively). CONCLUSION: We found a more lateralized mechanical axis in limbs that demonstrated post-operative ipsilateral femoral neck severe shortening. These findings may provide a possible explanation and rationale for knee pain and perhaps for the development of knee osteoarthritis as a sequalae of femoral neck shortening. Further investigation and larger cohort, long-term studies are needed to further explore this hypothesis.

Do cancer patients undergoing surgery for a non-neoplastic related fragility hip fracture have worse outcomes? A retrospective study.

INTRODUCTION: An increasing number of patients sustaining a fragility hip fracture (FHF) have either an active diagnosis or a history of cancer. However, little is known about the outcomes of non-malignant related FHF in this group of patients. We aimed to evaluate the mortality and complications rates during hospitalization, as well as at 1-year follow-up within this population. METHODS: A retrospective cohort study of patients 65 years of age and above, who underwent surgery for the treatment of proximal femoral fractures between January 2012 and June 2016 was conducted. Patients diagnosed with malignancies, both solid (Carcinomas) and a hematological neoplasias (Lymphomas, Multiple Myeloma) were included, along with consecutive controls without a diagnosis of cancer in the 5 years prior to the study period. Demographic, clinical and radiographic parameters were recorded and analyzed. RESULTS: Seven hundred and fifty-two patients with FHF were included, of whom 51 had a malignancy diagnosis within the 5-year period preceding the fracture (18% metastatic disease). The mean time from malignancy diagnosis to FHF was 4.3 ± 4.8 years. Time to surgery did not differ between groups, and the vast majority of patients from both groups (over 87%) were operated within the desirable 48 h from admission. Patients with malignancy had a higher probability of being admitted to an internal medicine department both pre and post-surgically (p < 0.001), and were more susceptible to pre-operative anemia (p = 0.034). In-hospital mortality did not differ between groups, yet 1-year mortality was higher for the malignancy group (41.2% vs 19.5%, p < 0.001). At 1-year post-operatively, orthopedic complications were similar between groups. CONCLUSION: Patients with a history of malignancy in the 5-years prior to a non-neoplastic FHF, showed similar mortality and complications rates during admission but increased 1 year mortality rate when compared to patients without cancer undergoing surgical treatment of a non-neoplastic proximal femoral fracture.

The quality of immediate postoperative radiographs, performed after total hip replacement in the operating room versus in the post-anesthesia care unit: is there a difference?

INTRODUCTION: Currently, there are no clear guidelines regarding the optimal settings for immediate postoperative imaging following total hip arthroplasty (THA). Authors' primary aim was to determine the preferred setting for postoperative radiographs by comparing a technical quality of imaging performed in postanesthesia care unit (PACU) versus operating room (OR). MATERIALS AND METHODS: Our study is a retrospective comparison of quality of postoperative radiographs following THAs, performed in PACU versus OR. The evaluated factors included a technical quality (penetration, collimation and presence of foreign bodies), proper patient positioning, and clinical significance of the imaging expressed in number of decisions to perform immediate revision surgery that were based on postoperative imaging. RESULTS: 267 radiographs of patients who underwent primary unilateral THA were evaluated (139 performed in PACU and 128 in OR). In terms of technical quality, PACU radiographs were characterized by better penetration (69.1% vs 27.3%, p < 0.001) and less foreign bodies in the field (95.7% vs 83.6%, p < 0.001), but less adequate collimation (41.7% vs 79.7%, p < 0.001). There was a significant difference in the number of radiographs obtained without any noteworthy technical errors - 24 (17.3%) in PACU group vs 10 (7.8%) in OR group. CONCLUSION: Postoperative X-rays performed in the PACU were characterized by better technical quality compared to postoperative radiographs performed in OR. We, therefore, suggest to perform immediate postoperative evaluation in PACU to provide baseline radiographs of higher quality for future follow-up.

Overutilization of Radiographs for Pulled Elbow Among Orthopedic Surgeons Compared With Pediatricians.

METHODS: Electronic medical records of the largest health provider in Israel, which provides health services to more than 50% of the population, were reviewed for pulled elbow cases between 2005 and 2020. Patients aged 4.5 months to 7 years were included. Demographic information, the discipline of the treating physician, and acquisition of elbow radiographs were gathered. RESULTS: A total of 4357 patients, 62.8% girls, were included. The average body mass index was 16.1 (SD, 1.2). Most patients were from communities in the upper half of the socioeconomic status clusters 6 to 10 (64.63%). Most patients were attended by a pediatrician (51.5%), followed by an orthopedic surgeon (19.9%). Radiographs were acquired for 570 children (13.1%). Most radiographs (36.5%) were requested by orthopedic surgeons and for children in the boundary age groups. The patient's socioeconomic status was associated with access to physicians of different subspecialties, and lower income families had a higher tendency to be treated by nonspecialized physician ( P < 0.001). CONCLUSIONS: Orthopedic surgeons use elbow radiographs much more than pediatricians; effort should aim at reducing the imaging rate for this population.

The Impact of the COVID-19 2020 Pandemic on Hospital Length of Stay Following Fragility Hip Fracture Surgery.

BACKGROUND: Hip fractures in elderly patients are a major cause of morbidity and mortality. Variability in length of hospital stay (LOS) was evident in this population. The coronavirus disease-2019 (COVID-19) pandemic led to prompt discharge of effected patients in order to reduce contagion risk. LOS and discharge destination in COVID-19 negative patients has not been studied. OBJECTIVES: To evaluate the LOS and discharge destination during the COVID-19 outbreak and compare it with a similar cohort in preceding years. METHODS: A retrospective study was conducted comparing a total of 182 consecutive fragility hip fracture patients operated on during the first COVID-19 outbreak to patients operated on in 2 preceding years. Data regarding demographic, co-morbidities, surgical management, hospitalization, as well as surgical and medical complications were retrieved from electronic charts. RESULTS: During the pandemic 67 fragility hip fracture patients were admitted (COVID group); 55 and 60 patients were admitted during the same time periods in 2017 and 2018, respectively (control groups). All groups were of similar age and gender. Patients in the COVID group had significantly shorter LOS (7.2 ± 3.3 vs. 8.9 ± 4.9 days, P = 0.008) and waiting time for a rehabilitation facility (7.2 ± 3.1 vs. 9.3 ± 4.9 days, P = 0.003), but greater prevalence of delirium (17.9% vs. 7% of patients, P = 0.028). In hospital mortality did not differ among groups. CONCLUSIONS: LOS and time to rehabilitation were significantly shorter in the COVID group. Delirium was more common in this group, possibly due to negative effects of social distancing.

C5 Palsy Following Cervical Spine Decompression.

BACKGROUND: Cervical spinal surgery is considered safe and effective. One of the few specific complications of this procedure is C5 nerve root palsy. Expressed primarily by deltoid muscle and biceps brachii weakness, it is rare and has been related to nerve root traction or to ischemic spinal cord damage. OBJECTIVES: To determine the clinical and epidemiological traits of C5 palsy. To determine whether C5 palsy occurs predominantly in one specific surgical approach compared to others. METHODS: A retrospective study of patients who underwent cervical spine surgery at our medical center during a consecutive 8-year period was conducted. The patient data were analyzed for demographics, diagnosis, and surgery type and approach, as well as for complications, with emphasis on the C5 nerve root palsy. RESULTS: The study group was comprised of 124 patients. Seven (5.6%) developed a C5 palsy following surgery. Interventions were either by anterior, by posterior or by a combined approach. Seven patients developed this complication. All of whom had myelopathy and were older males. A combined anteroposterior (5 patients) and posterior access (2 patients) were the only approaches that were associated with the C5 palsy. None of the patients who were operated via an anterior approach did develop this sequel. CONCLUSIONS: The incidence of the C5 root palsy in our cohort reached 5.6%. Interventions performed through a combined anterior-posterior access in older myelopathic males, may carry the highest risk for this complication.

Morphological and Histological Changes in the Human Anterior Cruciate Ligament after Rupture.

BACKGROUND: Injuries to the anterior cruciate ligament (ACL) are common and complete tears often fail to heal. ACL reconstruction is considered the surgical gold standard of care for ACL injuries in young active patients. OBJECTIVES: To determine the corresponding morphological and histological features of the torn ACL in different time periods after injury. METHODS: The study included 28 remnant specimens of torn ACLs from patients who had ACL reconstruction surgery of the knee. The remnant pathology was evaluated by its morphology during arthroscopy and by histopathologic measurements. RESULTS: At surgery there were three progressive and distinct morphological tear patterns. The first pattern was noticed within the first 3 months from injury and showed no scar tissue. The second pattern appeared later and was characterized by the appearance of scar tissue with adhesion to the femoral wall. The third pattern was characterized by adhesion of the ACL remnant to the posterior cruciate ligament. The histological changes of the first morphological pattern showed abundance of blood vessels and lymphocytes at the torn femoral end with few irregular collagen fibers. The second and third tear patterns showed decrement in the number of blood vessels and lymphocytes with longitudinally oriented collagen fibers. CONCLUSIONS: The morphological features of the ACL remnant in the first 3 months after injury showed no scar tissue and its histological features had the characteristics of a reparative phase. This phase was followed by a prolonged remodeling phase that ended with attachment of the remnant to the posterior cruciate ligament.

Lateral Column Lengthening for Flexible Flat Foot: Was It Short to Begin With?

BACKGROUND: Flexible flatfoot (FF) is a common foot deformity that can often consist of foot pain. Surgical treatment is designed to lengthen the lateral column. OBJECTIVES: To resolve whether radiographic standing feet measurements of normo-plantigrade feet and FF, symptomatic or not, differ and to determine whether the lateral column is shorter. METHODS: The study comprised 72 patients (127 feet) consecutive patients, 18 years of age and older, who were divided into three groups: normal feet (56), asymptomatic FF (29), and symptomatic FF (42). All patients had a standing anterior posterior (AP) and lateral radiographs. AP images were used for the measurement of the talocalcaneal angle, talar-1st metatarsal angle, and talonavicular coverage. Lateral X-rays were used to estimate the talocalcaneal angle, talar-1st metatarsal angle, calcaneal pitch, naviculocuboid overlap, and column ratio. RESULTS: All three of the AP radiograph measurements differed among groups, and higher values were measured in the symptomatic FF group. Post hoc analysis found that the talonavicular coverage and the talocalcaneal angles also differed between symptomatic and asymptomatic FF patients. While some lateral measurements differed within groups, only the lateral talar-1st metatarsal angle distinguished between asymptomatic and symptomatic patients. The lateral column length was not found to be shorter among FF patients, weather symptomatic or not. CONCLUSIONS: Only the talonavicular coverage, the AP talocalcaneal, and the lateral talar-1st metatarsal angles were found to differ between asymptomatic and symptomatic FF patients. The lateral column was not found to be shorter.

Unplanned excision of soft tissue sarcoma: does it impact the accuracy of intra-operative pathologic assessment at time of re-excision?

PURPOSE: An "unplanned excision" refers to soft tissue sarcomas excised without planning imaging studies and a diagnostic biopsy, resulting in the presence of residual disease and usually necessitating a re-excision procedure. We aimed to assess the impact of previous unplanned excisions on the intra-operative pathologic assessment at the time of re-excision, in terms of need to perform repeat assessments and the accuracy to predict margin status of the final pathologic specimen. METHODS: Data was collected for all patients with extremity soft tissue sarcoma who had undergone wide local excision limb salvage surgery or amputation between 2012 and 2017. Intra-operative pathologic assessment with frozen sections was performed in all cases and was classified as negative, negative but close (< 1 mm), and positive. RESULTS: A total of 173 patients with extremity soft tissue sarcoma were included, 54 in the unplanned excision group and 119 in the planned excision group. The accuracy of intra-operative pathologic assessment to predict the margin status on final pathology was similar between groups (87% unplanned vs. 90.7% planned excisions). However, the need for repeat intra-operative pathologic assessment and subsequent resection due to microscopically positive margins was found to be higher within the unplanned excision group ((p = 0.04), OR = 3.2 (95% CI: 1.1-9.1, p = 0.048)). CONCLUSIONS: Intra-operative pathologic assessment of resection margins had a similar accuracy in planned and unplanned excisions; however, unplanned excisions showed a higher risk of re-resection during the same surgical setting.

Impact of the Holocaust on the outcomes of elderly patients sustaining a fragility hip fracture.

INTRODUCTION: Holocaust survivors (HS) were under an immense continues physical and mental stressors in their younger years, putting them at increased risk for both fragility hip fractures and worse medical and functional outcomes. We aimed to evaluate whether being a HS could affect the functional outcomes of fragility hip fractures in patients 80 years of age and older following surgery. MATERIALS AND METHODS: A retrospective study comparing consecutive patients, 80 years and older, who were operated for fragility hip fractures between 2011 and 2016. HS survival status was self-defined by survivors who were born in European and northern African countries that were later occupied by the Nazi regime during World War II and experienced incarceration in concentration camps, forced labor camps and mass transport. Primary outcomes were mortality either within hospital or in the post-operative year. Secondary outcomes were in-hospital complications, recurrent hospitalizations and orthopedic complications within the post-operative year. RESULTS: Two hundred thirty-one HS and 339 controls, ages 86.4 ± 4.4 years who were operated for fragility hip fracture between January 2011 to June of 2016 were included in the study. Patients from both groups were of similar age, Carlson's co-morbidity index score, leaving arrangement and pre-fracture mobility. Among HS there were more women (p = 0.029). HS did not have lower survival rates either within hospital or in the post- operative year. Both length of stay and in-hospital complication rates were similar between groups. In the post-operative year, HS were less likely to be hospitalized than controls (p = 0.021). The rate of orthopedic complications was also similar. CONCLUSIONS: Holocaust survivors patients do not achieve worse outcome following fragility hip fracture surgery and present distinctive resilience.

Biocompatibility of a Marine Collagen-Based Scaffold In Vitro and In Vivo.

Scaffold material is essential in providing mechanical support to tissue, allowing stem cells to improve their function in the healing and repair of trauma sites and tissue regeneration. The scaffold aids cell organization in the damaged tissue. It serves and allows bio mimicking the mechanical and biological properties of the target tissue and facilitates cell proliferation and differentiation at the regeneration site. In this study, the developed and assayed bio-composite made of unique collagen fibers and alginate hydrogel supports the function of cells around the implanted material. We used an in vivo rat model to study the scaffold effects when transplanted subcutaneously and as an augment for tendon repair. Animals' well-being was measured by their weight and daily activity post scaffold transplantation during their recovery. At the end of the experiment, the bio-composite was histologically examined, and the surrounding tissues around the implant were evaluated for inflammation reaction and scarring tissue. In the histology, the formation of granulation tissue and fibroblasts that were part of the inclusion process of the implanted material were noted. At the transplanted sites, inflammatory cells, such as plasma cells, macrophages, and giant cells, were also observed as expected at this time point post transplantation. This study demonstrated not only the collagen-alginate device biocompatibility, with no cytotoxic effects on the analyzed rats, but also that the 3D structure enables cell migration and new blood vessel formation needed for tissue repair. Overall, the results of the current study proved for the first time that the implantable scaffold for long-term confirms the well-being of these rats and is correspondence to biocompatibility ISO standards and can be further developed for medical devices application.

Molecular profile of ultrastructure changes of the ligamentum flavum related to lumbar spinal canal stenosis.

Lumbar spinal canal stenosis (LSCS) is a degenerative disease observed by hypertrophy of the ligamentum flavum (LF) that cause compression of the lumbar neural content. Diabetes mellitus (DM) is a risk factor for the disease and we have shown previously that DM increases the fibrosis and elastic fiber loss in patients with LSCS. The purpose of this study was to find the proteins that play a role in the development of this clinical pathogenesis and the effect of DM on protein expression. LF tissue retrieved from patients diagnosed with LSCS, some were also diagnosed with DM, were compared with LF from patients diagnosed with herniated nucleus pulposus (HNP). The tissues were analyzed by mass spectrometry for proteins profile alteration. We found that LF of LSCS/DM patients exhibited significantly higher levels of proteoglycan proteins and latent transforming growth factor ß-binding protein (LTBP2 and LTBP4). Additionally, an increase of HTRA serine protease 1 and insulin-like growth factor binding protein-5 were noted. The higher fibrosis was also associated with proteins related to inflammation and slower tissue repair. Collagen 6 and transforming growth factor inhibitor are related to activation of the anti-inflammatory M2 pathway that is associated with tissue repair. The decrease of these proteins expression in LSCS/DM is associated with increased levels and activation of M1 pro-inflammatory pathways. Interestingly, C3 and C4b members of the complement complex and mannose receptor-like protein (CLEC18) paralogous proteins were detectable solely at the LSCS/DM patients' samples. Histology analysis shows that inflammatory was induced by the hyperglycemic conditions in diabetic patients involve in altering the matrix compositions. Thus, the protein profiles associated with inflammatory pathways affecting the LF suggested increasing susceptibility of developing the degeneration under hyperglycemic conditions.

The detached stump of the torn anterior cruciate ligament adheres to the femoral notch wall and then to the posterior cruciate ligament within 6 months from injury.

PURPOSE: To evaluate the progressive changes in the morphology of traumatic ruptures of the anterior cruciate ligament (ACL) over time. A secondary objective was evaluating their correlation with meniscal tears or chondral lesions. METHODS: The study included one hundred and one patients who underwent ACL reconstruction surgery of the knee after a definite date of injury. The torn ACL remnant morphological pattern was assessed and classified during arthroscopy. A correlation analysis was performed between the pathological features of the remnant and the time length from injury. In addition, correlation between ACL remnant subtypes and meniscal tears or chondral lesions was evaluated. RESULTS: At surgery there were four distinct ACL tear morphological patterns that were correlated to the time span from injury (r = 0.61, p < 0.001) and ended with scarring of the femoral remnant to the posterior cruciate ligament. The early pattern was noticed within median time of 2.6 months from injury and appeared as a separate stump with no scar tissue. The following two patterns appeared within 6 months from injury and were characterized by adhesion of scar tissue to different locations in the femoral notch. The last morphological pattern appeared as adherence of the ACL stump to the posterior cruciate ligament. This pattern was seen in some patients within 6 months from injury but was the dominant pattern later on and was also correlated with meniscal tears. CONCLUSIONS: During the first 3 months from injury the gross morphological features of the torn ACL remnant showed no scar. This phase was followed by scarring of the femoral remnant at first to the femoral notch, and eventually to the posterior cruciate ligament within 6 months from injury and later on. Therefore, further research on the healing potential of the human ACL stump and its biological environment should be focused on the first 3 months from injury. STUDY DESIGN: Case series; Level of evidence, 4.

The Role of 18F-Fluorodeoxyglucose Positron-Emission Tomography/Computed Tomography in the Diagnosis of Postoperative Hardware-Related Spinal Infections.

BACKGROUND: Implant-related spinal infections are a surgical complication associated with high morbidity. Due to infection, hardware removal may be necessary, which could lead to pseudarthrosis and the loss of stability and alignment. OBJECTIVES: To evaluate the accuracy and diagnostic value of 18F-fluorodeoxyglucose positron-emission tomography/computed tomography (18F-FDG PET/CT) in the workup of patients with suspected implant-related infections of the spine and to assess the clinical impact of PET/CT results on the management of these infections. METHODS: The study included nine consecutive patients with a history of spinal surgery who underwent PET/CT for evaluation of suspected spinal implant related infection. All imaging studies were performed between January 2011 and December 2013. All 18F-FDG PET/CT scans were performed on an 8 slice PET/CT following an 18F-FDG injection. Images were scored both visually and semi-quantitatively by a radiology expert. Results were compared to additional imaging studies when available, which were correlated to clinical and bacteriological findings allowing calculation of sensitivity, specificity and accuracy. RESULTS: Among the patients, five experienced hardware-related spinal infection. 18F-FDG PET/CT sensitivity was 80%, specificity 100%, and accuracy 88.9%. One scan produced a false negative; however, a second PET/CT scan revealed an infection. CONCLUSIONS: PET/CT was found to be valuable for the diagnosis of postoperative hardware-related spinal infection, especially when other imaging modalities were uninformative or inconclusive. As such, PET/CT could be useful for management of infection treatment.

Denosumab treatment for giant-cell tumor of bone: a systematic review of the literature.

BACKGROUND: Denosumab is a human monoclonal antibody (mAb) that specifically inhibits tumor-associated bone lysis through the RANKL pathway and has been used as neoadjuvant therapy for giant-cell tumor of bone (GCTB) in surgical as well as non-surgical cases. The purpose of this systematic review of the literature, therefore, is to investigate: (1) demographic characteristics of patients affected by GCTBs treated with denosumab and the clinical impact, as well as, possible complications associated with its use (2) oncological outcomes in terms of local recurrence rate (LRR) and development of lung metastasis, and (3) characteristics of its treatment effect in terms of clinical, radiological, and histological response. METHODS: A systematic review of the literature was conducted using PubMed, EMBASE, and COCHRANE search including the following terms and Boolean operators: "Denosumab" AND "primary bone tumor", "denosumab" AND "giant cell tumor", "denosumab" AND "treatment", and finally, "denosumab" AND "giant cell tumor" AND "treatment" since 2000. After applying inclusion and exclusion criteria, a total of 19 articles were included. The quality of the included studies was assessed using STROBE for the assessment of observational studies. RESULTS: A total of 1095 patients were included across all 19 studies. Across all the studies included, there were 615 females and 480 males. The mean patient age was 33.7 ± 8.3 years when starting the denosumab treatment. The pooled weighted local recurrence rate was 9% (95% CI 6-12%) and the pooled weighted metastases rate was 3% (95% CI 1-7%). The most common adverse event was fatigue and muscular pain. Radiologic response was estimated to occur in 66-100% of the patients. A significant reduction in pain under denosumab treatment was reported in seven studies and additional improvement in function and mobility was reported by several authors. Only two studies reported musculoskeletal tumor society (MSTS) scores which were better after denosumab treatment. CONCLUSIONS: The use of denosumab as an adjuvant treatment of GCTB has shown a positive but variable histological response with consistent radiological changes and several types of adverse effects. There is a positive clinical response in terms of pain relief with decrease on the morbidity of surgical procedures to be performed. Finally, oncological outcomes are disparate with neither effect on metastatic disease nor local recurrence rates. LEVEL OF EVIDENCE: IV.

Surgical treatment of low-grade chondrosarcoma involving the appendicular skeleton: long-term functional and oncological outcomes.

BACKGROUND: The traditional treatment for chondrosarcoma is wide local excision (WLE), as these tumors are resistant to chemotherapy and radiation treatment. While achieving negative margins has traditionally been the goal of chondrosarcoma resection, multiple studies have demonstrated good short-term results after intralesional procedures for low-grade chondrosarcomas (LGCS) with curettage and adjuvant treatments (phenol application, cauterization or cryotherapy) followed by either cementation or bone grafting. Due to the rarity of this diagnosis and the recent application of this surgical treatment modality to chondrosarcoma, most of the information regarding treatment outcomes is retrospective, with short or intermediate-term follow-up. The aim of this study was to assess the long-term results of patients with LGCS of bone treated with intralesional curettage (IC) treatment versus WLE. This retrospective analysis aims to characterize the oncologic outcomes (local recurrence, metastases) and functional outcomes in these two treatment groups at a single institution. METHODS: Using an institutional musculoskeletal oncologic database, we retrospectively reviewed medical records of all patients with LGCS of the appendicular skeleton that underwent surgical treatment between 1985 and 2007. Thirty-two patients (33 tumors) were identified with LGCS; 17 treated with IC and 15 with WLE. RESULTS: Seventeen patients (18 tumors) with a minimum clinical and radiologic follow-up of 10 years were included. Nine patients were treated with IC (four with no adjuvant, three with additional phenol, one with liquid nitrogen and one with H2O2) with either bone graft or cement augmentation, and nine others were treated with WLE and reconstruction with intercalary/osteoarticular allograft or megaprosthesis. The mean age at surgery was 41 years (range 14-66 years) with no difference (p = 0.51) between treatment cohorts. There was a mean follow-up of 13.5 years in the intralesional cohort (range 10-19 years) and 15.9 years in the WLE cohort (range 10-28 years, p = 0.36). Tumor size varied significantly between groups and was larger in patients treated with WLE (8.2 ± 3.1 cm versus 5.4 ± 1.2 cm, at the greatest dimension, p = 0.021). There were two local recurrences (LR), one in the intralesional group and one in the wide local excision group, occurring at 3.5 months and 2.9 years, respectively, and both required revision. No further LR could be detected with long-term follow-up. The MSTS score at final follow-up was significantly higher for patients managed with intralesional procedures (28.7 ± 1.7 versus 25.7 ± 3.4, p = 0.033). There were less complications requiring reoperation in the intralesional group compared with the wide local excision group, although this difference was not found to be statistically significant (one versus four patients, respectively; p = 0.3). CONCLUSION: This series of low-grade chondrosarcoma, surgically treated with an intralesional procedures, with 10-year follow-up, demonstrates excellent local control (88.9%). Complications were infrequent and minor and MSTS functional scores were excellent. Wide resection of LGCS was associated with lower MSTS score and more complications. In our series, the LR in both groups were detected within the first 3.5 years following the index procedure, and none were detected in the late surveillance period.

Diabetes mellitus is associated with increased elastin fiber loss in ligamentum flavum of patients with lumbar spinal canal stenosis: results of a pilot histological study.

PURPOSE: Lumbar spinal canal stenosis (LSCS) is associated with fibrosis, decreased elastin-to-collagen ratio, and hypertrophy of the ligamentum flavum (LF). Diabetes mellitus (DM) is known to cause metabolic disturbances within the extracellular matrix in multiple tissues. These alterations may play a major role in the severity of clinical symptoms of LSCS affecting diabetic patients. We aimed to examine the hypothesis that DM may contribute to the LF changes seen in patients with LSCS. METHODS: The study cohort included 29 patients: 23 with LSCS (10 with DM vs. 13 without DM) as well as six patients with lumbar disc herniation (LDH). Surgical LF specimens were retrieved for histological assessment. Morphologic quantification of confocal microscopy images using fast Fourier transform analysis allowed us to compare anisotropy and elastin fiber orientation between groups. RESULTS: There was a significant positive correlation between fasting plasma glucose values and degree of elastin degradation (r = 0.36, p = 0.043). The diabetic patients with LSCS showed a significantly greater loss of elastic fibers (2.3 ± 0.9 vs. 1.5 ± 0.55, p = 0.009), although fibrosis was shown to be similar (1.44 ± 0.7 vs. 1.43 ± 0.88, p = 0.98). There was no significant difference in the degree of calcification in the LSCS group between patients with and without diabetes (1.71 vs. 2.05%, p = 0.653). Fiber orientation was found to be less homogenous in the LSCS compared with the LDH group, although not significantly affected by DM. CONCLUSIONS: The present study points to a significant contribution of DM to the loss of elastin fibers that occurs in the LF of patients with LSCS.

Trochanteric Bursitis Following Primary Total Hip Arthroplasty: Incidence, Predictors, and Treatment.

BACKGROUND: Trochanteric bursitis (TB) remains a common complication after total hip arthroplasty (THA), with an incidence between 3% and 17%, depending on the surgical approach, with the posterior approach (PA) being relatively protective compared to the lateral approach. The purposes of this study were to determine the incidence of TB after primary THA, identify potential risk factors for TB, and examine the utility of different modes of treatment. METHODS: Retrospective cohort data of 990 primary THAs performed in a single institution, including 613 PAs and 377 direct anterior approaches (DAAs), were analyzed. Data abstracted included demographic data, operative diagnosis, comorbidities, radiographic assessment, and other specific predictors of interest that were compared between patients diagnosed with TB following THA and controls. RESULTS: The incidence of TB following primary THA was 5.4% (54/990) for the entire cohort. The incidence did not differ significantly between the PA and DAA (5% vs 6.1%, respectively; P = .47). Charlson comorbidity index and American Society of Anesthesiology did not differ significantly in the TB group. Lumbar spinal stenosis and history of past smoking were significantly more common in patients who developed TB (P = .03, P = .01, respectively), but did not continue to be significant risk factors on multivariate analysis. All patients were treated nonoperatively by the time of final follow-up. Seventy-four percent required a local steroid injection and 30% required treatment with more than one modality. CONCLUSION: The occurrence of TB is not influenced by the surgical approach (PA or DAA), and could not be predicted by specific comorbidities or radiographic measurements. However, it can be effectively treated conservatively in most cases.

F-18 FDG PET differentiation of benign from malignant chondroid neoplasms: a systematic review of the literature.

INTRODUCTION: Discriminating among benign chondroid tumors, low-grade chondrosarcomas, and grade 2/3 chondrosarcomas is frequently difficult with standard imaging modalities. We systematically reviewed the literature to determine the performance of PET-CT in making this distinction. METHODS: A systematic review was performed identifying 811 PubMed- and Embase-indexed articles containing combinations of "chondrosarcoma," "enchondroma," "chondroid," "cartilage" and "PET/CT," "PET," "positron." Eight articles including 166 lesions were included. Age, gender, tumor size, histologic grade, and SUVmax values were extracted for individual lesions when possible and otherwise recorded as aggregated data. Comparisons in SUVmax among benign, low-grade, and intermediate-/high-grade chondroid neoplasms were made. RESULTS: Individual SUVs were available for 101 lesions; 65 additional lesions were reported as aggregated data. There were 101 malignant and 65 benign tumors. Benign tumors were seen more frequently in females (p = 0.04, Fischer's exact test), but malignancy was not associated with age or lesion size. SUVmax was lower for benign (1.6 ± 0.7) than malignant tumors (4.4 ± 2.5) (p < 0.0001, t-test). SUVmax was lower for grade 0/1 (2.0 ± 0.7) than grade 2/3 (6.0 ± 3.2) (p < 0.0001, t-test). Increasing SUVmax correlated with higher grade chondroid tumors (Spearman's rank, ρ = 0.78). SUVmax ≥4.4 was 99% specific for grade 2/3 chondrosarcoma. CONCLUSIONS: SUVmax correlates with histologic grade in intraosseous chondroid neoplasms; very low SUVmax supports a diagnosis of benign tumor, while elevated SUVmax is suggestive of higher grade chondrosarcoma.

The Accuracy of Digital Templating for Primary Total Hip Arthroplasty: Is There a Difference Between Direct Anterior and Posterior Approaches?

BACKGROUND: The direct anterior approach (DAA) has gained recent popularity for total hip arthroplasty (THA), as it provides immediate feedback on cup position and limb length using fluoroscopy. The purpose of this study is to evaluate any differences in the accuracy of digital templating for preoperative planning of THA, performed with 2 different surgical approaches: DAA using a radiolucent table with intraoperative fluoroscopy and the posterior approach (PA). METHODS: One hundred thirty-one consecutive patients (148 hips) underwent a THA by a single surgeon, using the same cup and stem designs. Seventy-five hips were performed using the DAA using a fracture table and fluoroscopy. Seventy-three hips were performed using the PA with the patient positioned in lateral decubitus using standard positioners without fluoroscopy. Preoperative radiographs were digitally templated by the same surgeon. RESULTS: The PA patients had a higher mean body mass index and were more likely to have a preoperative diagnosis of avascular necrosis. The accuracy of templating for predicting the cup size to be within 2 mm was 91% for DAA vs 88% for PA (P = .61). For stem size, the accuracy was 85% (to within 1 size) for the DAA vs 77% for the PA (P = .71). Likewise, there was no significant difference in predicting the final stem's neck angle or femoral offset. CONCLUSION: Digital templating was found to be a reliable and highly accurate method for predicting component sizes and offset for THA, regardless of using either the PA or the DAA with fluoroscopy.