Pub Date : 2019-11-07DOI: 10.1097/CORR.0000000000001044
Heath B. Henninger, Garrett V. Christensen, Carolyn E. Taylor, J. Kawakami, Bradley Hillyard, R. Tashjian, P. Chalmers
BACKGROUND Muscle volume is important in shoulder function. It can be used to estimate shoulder muscle balance in health, pathology, and repair and is indicative of strength based on muscle size. Although prior studies have shown that muscle area on two-dimensional (2-D) images correlates with three-dimensional (3-D) muscle volume, they have not provided equations to predict muscle volume from imaging nor validation of the measurements. QUESTIONS/PURPOSES We wished to create an algorithm that quickly, accurately, and reliably estimates the volume of the shoulder muscles using cross-sectional area on MR images with low error. Specifically, we wished to (1) determine which MR imaging planes provide the highest correlation between shoulder muscle cross-sectional area and volume; (2) derive equations to predict muscle volume from cross-sectional area and validate their predictive capability; and (3) quantify the reliability of muscle cross-sectional area measurement. METHODS Three-dimensional MRI was performed on 10 cadaver shoulders, with sample size chosen for comparison to prior studies of shoulder muscle volume and in consideration of the cost of comprehensive analysis, followed by dissection for muscle volume measurement via water displacement. From each MR series, 3-D models of the rotator cuff and deltoid muscles were generated, and 2-D slices of these muscle models were selected at defined anatomic landmarks. Linear regression equations were generated to predict muscle volume at the plane(s) with the highest correlation between volume and area and for planes identified in prior studies of muscle volume and area. Volume predictions from MR scans of six different cadaver shoulders were also made, after which they were dissected to quantify muscle volume. This validation population allowed the calculation of the predictive error compared with actual muscle volume. Finally, reliability of measuring muscle areas on MR images was calculated using intraclass correlation coefficients for inter-rater reliability, as measured between two observers at a single time point. RESULTS The rotator cuff planes with the highest correlation between volume and area were the sum of the glenoid face and the midpoint of the scapula, and for the deltoid, it was the transverse plane at the top of the greater tuberosity. Water and digital muscle volumes were highly correlated (r ≥ 0.993, error < 4%), and muscle areas correlated highly with volumes (r ≥ 0.992, error < 2%). All correlations had p < 0.001. Muscle volume was predicted with low mean error (< 10%). All intraclass correlation coefficients were > 0.925, suggesting high inter-rater reliability in determining muscle areas from MR images. CONCLUSION Deltoid and rotator cuff muscle cross-sectional areas can be reliably measured on MRI and predict muscle volumes with low error. CLINICAL RELEVANCE Using simple linear equations, 2-D muscle area measurements from common clinical image analysis software can b
{"title":"The Muscle Cross-sectional Area on MRI of the Shoulder Can Predict Muscle Volume: An MRI Study in Cadavers.","authors":"Heath B. Henninger, Garrett V. Christensen, Carolyn E. Taylor, J. Kawakami, Bradley Hillyard, R. Tashjian, P. Chalmers","doi":"10.1097/CORR.0000000000001044","DOIUrl":"https://doi.org/10.1097/CORR.0000000000001044","url":null,"abstract":"BACKGROUND\u0000Muscle volume is important in shoulder function. It can be used to estimate shoulder muscle balance in health, pathology, and repair and is indicative of strength based on muscle size. Although prior studies have shown that muscle area on two-dimensional (2-D) images correlates with three-dimensional (3-D) muscle volume, they have not provided equations to predict muscle volume from imaging nor validation of the measurements.\u0000\u0000\u0000QUESTIONS/PURPOSES\u0000We wished to create an algorithm that quickly, accurately, and reliably estimates the volume of the shoulder muscles using cross-sectional area on MR images with low error. Specifically, we wished to (1) determine which MR imaging planes provide the highest correlation between shoulder muscle cross-sectional area and volume; (2) derive equations to predict muscle volume from cross-sectional area and validate their predictive capability; and (3) quantify the reliability of muscle cross-sectional area measurement.\u0000\u0000\u0000METHODS\u0000Three-dimensional MRI was performed on 10 cadaver shoulders, with sample size chosen for comparison to prior studies of shoulder muscle volume and in consideration of the cost of comprehensive analysis, followed by dissection for muscle volume measurement via water displacement. From each MR series, 3-D models of the rotator cuff and deltoid muscles were generated, and 2-D slices of these muscle models were selected at defined anatomic landmarks. Linear regression equations were generated to predict muscle volume at the plane(s) with the highest correlation between volume and area and for planes identified in prior studies of muscle volume and area. Volume predictions from MR scans of six different cadaver shoulders were also made, after which they were dissected to quantify muscle volume. This validation population allowed the calculation of the predictive error compared with actual muscle volume. Finally, reliability of measuring muscle areas on MR images was calculated using intraclass correlation coefficients for inter-rater reliability, as measured between two observers at a single time point.\u0000\u0000\u0000RESULTS\u0000The rotator cuff planes with the highest correlation between volume and area were the sum of the glenoid face and the midpoint of the scapula, and for the deltoid, it was the transverse plane at the top of the greater tuberosity. Water and digital muscle volumes were highly correlated (r ≥ 0.993, error < 4%), and muscle areas correlated highly with volumes (r ≥ 0.992, error < 2%). All correlations had p < 0.001. Muscle volume was predicted with low mean error (< 10%). All intraclass correlation coefficients were > 0.925, suggesting high inter-rater reliability in determining muscle areas from MR images.\u0000\u0000\u0000CONCLUSION\u0000Deltoid and rotator cuff muscle cross-sectional areas can be reliably measured on MRI and predict muscle volumes with low error.\u0000\u0000\u0000CLINICAL RELEVANCE\u0000Using simple linear equations, 2-D muscle area measurements from common clinical image analysis software can b","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"65 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"75199345","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-06DOI: 10.1097/CORR.0000000000001046
J. Healey
During the last several decades, treatment for desmoid tumors has evolved away from surgery and toward fewer and lessinvasive operations. I believe this movement started when a study on Gardner’s syndrome (familial adenomatous polyposis) found that sulindac and indomethacin plus high-dose vitamin C caused regression of intestinal polyps, resulting in fewer colorectal cancers, as well as a decrease in desmoid tumors [10]. While selective estrogen-receptor inhibitors or of lowdose chemotherapy (methotrexate and vinblastine) are seeing wider use [11], the pendulum swung further away from surgery when a study found that negative margins did not predict remaining recurrence free, nor were positive margins routinely associated with local recurrence [2]. More-sophisticated, targeted therapies have achieved high response rates [4]. One study found an 87% lower risk of progression or death in a group treated with sorafenib than in the placebo group, although 12% still progressed while on the active drug [4]. Responses can be monitored by assessing the relative cellularity of the tumor, since it is the cellular component that can grow and shrink far more dramatically than the relatively stable fibrous component [4]. This approach has become the first-line treatment for desmoid tumors. However, the responses to targeted agents are timedependent, and can take many months; as a result, patients often are treated for 1 to 2 years. Despite prolonged therapy, patients had partial response rates of 33% by RESIST 1.1 criteria. The favorable news is that disease rarely progressed while on these targeted therapies. However, the toxicity of treatment can be severe. Palmar-plantar erythrodysesthesia (painful redness, swelling and sometimes blistering, often referred to as hand-foot syndrome) occurs in about 20% of patients and hypertension in 9.4% to 18.9% of patients [8]. In the current study, Newman and colleagues [7] use the Patient-Reported Outcomes Measurement Information System (PROMIS) to assess the quality of life (QOL) of patients treated for desmoid tumors. Because desmoid tumors are a local disease, where the treatment can be worse than the disease, QOL and patient satisfaction are very important outcomes to consider.
{"title":"CORR Insights®: PROMIS Function Scores Are Lower in Patients Who Underwent More Aggressive Local Treatment for Desmoid Tumors.","authors":"J. Healey","doi":"10.1097/CORR.0000000000001046","DOIUrl":"https://doi.org/10.1097/CORR.0000000000001046","url":null,"abstract":"During the last several decades, treatment for desmoid tumors has evolved away from surgery and toward fewer and lessinvasive operations. I believe this movement started when a study on Gardner’s syndrome (familial adenomatous polyposis) found that sulindac and indomethacin plus high-dose vitamin C caused regression of intestinal polyps, resulting in fewer colorectal cancers, as well as a decrease in desmoid tumors [10]. While selective estrogen-receptor inhibitors or of lowdose chemotherapy (methotrexate and vinblastine) are seeing wider use [11], the pendulum swung further away from surgery when a study found that negative margins did not predict remaining recurrence free, nor were positive margins routinely associated with local recurrence [2]. More-sophisticated, targeted therapies have achieved high response rates [4]. One study found an 87% lower risk of progression or death in a group treated with sorafenib than in the placebo group, although 12% still progressed while on the active drug [4]. Responses can be monitored by assessing the relative cellularity of the tumor, since it is the cellular component that can grow and shrink far more dramatically than the relatively stable fibrous component [4]. This approach has become the first-line treatment for desmoid tumors. However, the responses to targeted agents are timedependent, and can take many months; as a result, patients often are treated for 1 to 2 years. Despite prolonged therapy, patients had partial response rates of 33% by RESIST 1.1 criteria. The favorable news is that disease rarely progressed while on these targeted therapies. However, the toxicity of treatment can be severe. Palmar-plantar erythrodysesthesia (painful redness, swelling and sometimes blistering, often referred to as hand-foot syndrome) occurs in about 20% of patients and hypertension in 9.4% to 18.9% of patients [8]. In the current study, Newman and colleagues [7] use the Patient-Reported Outcomes Measurement Information System (PROMIS) to assess the quality of life (QOL) of patients treated for desmoid tumors. Because desmoid tumors are a local disease, where the treatment can be worse than the disease, QOL and patient satisfaction are very important outcomes to consider.","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"32 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89454662","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-04DOI: 10.1097/CORR.0000000000001038
Nathan H. Varady, Bishoy T Ameen, Antonia F. Chen
BACKGROUND Delayed time to surgery of at least 2 days after hospital arrival is well known to be associated with increased complications after standard hip fracture surgery; whether this association is present for pathologic hip fractures, however, is unknown. QUESTIONS/PURPOSES (1) After controlling for differences in patient characteristics, is delayed time to surgery (at least 2 days) for patients with pathologic hip fractures independently associated with increased complications compared with early surgery (fewer than 2 days)? (2) What preoperative factors are independently associated with major complications and mortality after surgery for pathologic hip fractures? METHODS A retrospective study was conducted using the American College of Surgeons National Surgical Quality Improvement Program database of pathologic hip fractures (including femoral neck, trochanteric, and subtrochanteric fractures) from 2007 to 2017. This database was chosen over other databases given the high-quality preoperative medical history and postoperative complication (including readmissions, reoperations, and mortality) data collected from patient medical records through the thirtieth postoperative day. Patients were identified using Common Procedural Terminology codes for hip fracture treatment (THA, hemiarthroplasty, proximal femur replacement, intramedullary nail, and plate and screw fixation) with associated operative diagnoses for pathologic fractures as identified with International Classification of Diseases codes. A total of 2627 patients with pathologic hip fractures were included in this study; 65% (1714) had surgery within 2 days and 35% (913) had surgery after that time. Patient demographics, hospitalization information, and 30-day postoperative complications were recorded. Differences in characteristics between patients who underwent surgery in the early and delayed time periods were assessed with chi-square tests for categorical variables and t-tests for continuous variables. Delayed-surgery patients were more medically complex at the time of admission than early-surgery patients, including having higher American Society of Anesthesiologists classification (mean ± SD 3.18 ± 0.61 versus 2.94 ± 0.60; p < 0.001) and prevalence of advanced, "disseminated" cancer (53% versus 39%; p < 0.001). Propensity-adjusted multivariable logistic regression analyses were performed to assess the effect of delayed time to surgery alone on the various outcome measures. Additional independent risk factors for major complications and mortality were identified using backwards stepwise regressions. RESULTS After controlling for baseline factors, the only outcome associated with delayed surgery was extended postoperative length of stay (odds ratio 1.94 [95% CI 1.62 to 2.33]; p < 0.001). Delayed surgery was not associated with any postoperative complications, including major complications (OR 1.23 [95% CI 0.94 to 1.6]; p = 0.13), pulmonary complications (OR 1.24 [95% CI 0.8
背景:众所周知，到达医院后延迟至少2天的手术时间与标准髋部骨折手术后并发症的增加有关;问题/目的(1)在控制了患者特征的差异后，与早期手术(少于2天)相比，延迟手术时间(至少2天)是否与并发症的增加独立相关?(2)哪些术前因素与病理性髋部骨折术后主要并发症和死亡率独立相关?方法采用美国外科医师学会国家外科质量改进计划数据库对2007 - 2017年病理性髋部骨折(包括股骨颈、粗隆和粗隆下骨折)进行回顾性研究。考虑到从患者病历中收集的高质量的术前病史和术后并发症(包括再入院、再手术和死亡率)数据，我们选择了该数据库，而不是其他数据库。使用髋部骨折治疗的通用程序术语代码(THA、半关节置换术、股骨近端置换术、髓内钉、钢板螺钉固定)对患者进行识别，并根据国际疾病分类代码对病理性骨折进行相关手术诊断。本研究共纳入2627例病理性髋部骨折患者;65%(1714例)在2天内手术，35%(913例)在2天后手术。记录患者人口统计、住院信息和术后30天并发症。分类变量采用卡方检验，连续变量采用t检验，对早期和延迟手术患者的特征差异进行评估。延迟手术患者入院时的医学复杂性高于早期手术患者，包括具有更高的美国麻醉医师学会分类(平均±SD为3.18±0.61比2.94±0.60;P < 0.001)和晚期“播散性”癌症患病率(53% vs 39%;P < 0.001)。采用倾向校正多变量logistic回归分析来评估延迟手术时间对各种结果测量的影响。主要并发症和死亡率的其他独立危险因素使用反向逐步回归确定。在控制基线因素后，与延迟手术相关的唯一结果是术后住院时间延长(优势比1.94 [95% CI 1.62至2.33];P < 0.001)。延迟手术与任何术后并发症无关，包括主要并发症(OR 1.23 [95% CI 0.94至1.6];p = 0.13)，肺部并发症(OR 1.24 [95% CI 0.83 ~ 1.86];p = 0.29)和死亡率(OR 1.26 [95% CI 0.91至1.76];P = 0.16)。慢性阻塞性肺疾病(OR 2.48)、充血性心力衰竭(OR 2.64)和播散性癌症(OR 1.68)病史与主要并发症的风险增加相关，而依赖功能状态(OR 2.27)、美国麻醉师学会高级分类(IV+ vs I-II, OR 4.81)和播散性癌症与死亡风险增加相关(OR 2.2;P≤0.002)。在控制了基线患者因素后，延迟手术时间与病理性髋部骨折手术治疗后30天并发症的增加没有独立关联。这些结果与标准髋部骨折的传统教条相反，传统教条认为在入院后2天内进行手术可减少并发症。虽然手术不应该不必要地延迟，如果外科医生认为额外的时间对患者有益，本研究的结果建议外科医生不应该加速手术，因为观察到标准髋部骨折手术延迟的风险。证据等级:III级，治疗性研究。
{"title":"Is Delayed Time to Surgery Associated with Increased Short-term Complications in Patients with Pathologic Hip Fractures?","authors":"Nathan H. Varady, Bishoy T Ameen, Antonia F. Chen","doi":"10.1097/CORR.0000000000001038","DOIUrl":"https://doi.org/10.1097/CORR.0000000000001038","url":null,"abstract":"BACKGROUND\u0000Delayed time to surgery of at least 2 days after hospital arrival is well known to be associated with increased complications after standard hip fracture surgery; whether this association is present for pathologic hip fractures, however, is unknown.\u0000\u0000\u0000QUESTIONS/PURPOSES\u0000(1) After controlling for differences in patient characteristics, is delayed time to surgery (at least 2 days) for patients with pathologic hip fractures independently associated with increased complications compared with early surgery (fewer than 2 days)? (2) What preoperative factors are independently associated with major complications and mortality after surgery for pathologic hip fractures?\u0000\u0000\u0000METHODS\u0000A retrospective study was conducted using the American College of Surgeons National Surgical Quality Improvement Program database of pathologic hip fractures (including femoral neck, trochanteric, and subtrochanteric fractures) from 2007 to 2017. This database was chosen over other databases given the high-quality preoperative medical history and postoperative complication (including readmissions, reoperations, and mortality) data collected from patient medical records through the thirtieth postoperative day. Patients were identified using Common Procedural Terminology codes for hip fracture treatment (THA, hemiarthroplasty, proximal femur replacement, intramedullary nail, and plate and screw fixation) with associated operative diagnoses for pathologic fractures as identified with International Classification of Diseases codes. A total of 2627 patients with pathologic hip fractures were included in this study; 65% (1714) had surgery within 2 days and 35% (913) had surgery after that time. Patient demographics, hospitalization information, and 30-day postoperative complications were recorded. Differences in characteristics between patients who underwent surgery in the early and delayed time periods were assessed with chi-square tests for categorical variables and t-tests for continuous variables. Delayed-surgery patients were more medically complex at the time of admission than early-surgery patients, including having higher American Society of Anesthesiologists classification (mean ± SD 3.18 ± 0.61 versus 2.94 ± 0.60; p < 0.001) and prevalence of advanced, \"disseminated\" cancer (53% versus 39%; p < 0.001). Propensity-adjusted multivariable logistic regression analyses were performed to assess the effect of delayed time to surgery alone on the various outcome measures. Additional independent risk factors for major complications and mortality were identified using backwards stepwise regressions.\u0000\u0000\u0000RESULTS\u0000After controlling for baseline factors, the only outcome associated with delayed surgery was extended postoperative length of stay (odds ratio 1.94 [95% CI 1.62 to 2.33]; p < 0.001). Delayed surgery was not associated with any postoperative complications, including major complications (OR 1.23 [95% CI 0.94 to 1.6]; p = 0.13), pulmonary complications (OR 1.24 [95% CI 0.8","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"32 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"84592027","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-01DOI: 10.1097/CORR.0000000000000899
G. Trovarelli, Alessandro Cappellari, A. Angelini, E. Pala, P. Ruggieri
BACKGROUND After proximal humerus resection for bone tumors, restoring anatomy and shoulder function remains demanding because muscles and bone are removed to obtain tumor-free surgical margins. Current modes of reconstruction such as anatomic modular prostheses, osteoarticular allografts, or allograft-prosthetic composites and arthrodeses are associated with relatively poor shoulder function related to loss of the deltoid and rotator cuff muscles. Newer prosthetic designs like the reverse total shoulder arthroplasty (RTSA) are felt to be useful in other reconstructions where rotator cuff function is compromised, so it seemed logical that it might help in tumor reconstructions as well in patients where the deltoid muscle and its innervation can be preserved. QUESTIONS/PURPOSES In patients with a tumor of the proximal humerus that can be resected with preservation of the deltoid muscle, (1) What complications are associated with tumor resection and reconstruction with a modular RTSA? (2) What are the functional results of modular RTSA in these patients? METHODS From January 2011 to January 2018, we treated 52 patients for bone tumors of the proximal humerus. Of these, three patients were treated with forequarter amputation, 14 were treated with standard modular proximal humerus implants, seven were treated with allograft-prosthetic composites (RTSA-APC), and 28 were treated with a modular RTSA. Generally, we used anatomic modular prosthetic reconstruction if during the tumor resection none of the abductor mechanism could be spared. Conversely, we preferred reconstruction with RTSA if an innervated deltoid muscle could be spared, but the rotator cuff and capsule could not, using RTSA-APC or modular RTSA if humeral osteotomy was distal or proximal to deltoid insertion, respectively. In this study, we retrospectively analyzed only patients treated with modular RTSA after proximal humerus resection. We excluded three patients treated with modular RTSA as revision procedures after mechanical failure of previous biological reconstructions and three patients treated after December 2016 to obtain an expected minimum follow-up of 2 years. There were nine men and 13 women, with a mean (range) age of 55 years (18 to 71). Reconstruction was performed in all patients using silver-coated modular RTSA protheses. Patients were clinically checked according to oncologic protocol. Complications and function were evaluated at final follow-up by the treating surgeon (PR) and shoulder surgeon (AC). Complications were evaluated according to Henderson classification. Functional results were assessed with the Musculoskeletal Tumor Society score (range 0 points to 30 points), Constant-Murley score (range 0 to 100), and American Shoulder and Elbow Surgeons score (range 0 to 100). The statistical analysis was performed using Kaplan-Meier curves. RESULTS Complications occurred in five of 22 patients; there was a shoulder dislocation (Type I) in four patients and aseptic
{"title":"What Is the Survival and Function of Modular Reverse Total Shoulder Prostheses in Patients Undergoing Tumor Resections in Whom an Innervated Deltoid Muscle Can Be Preserved?","authors":"G. Trovarelli, Alessandro Cappellari, A. Angelini, E. Pala, P. Ruggieri","doi":"10.1097/CORR.0000000000000899","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000899","url":null,"abstract":"BACKGROUND\u0000After proximal humerus resection for bone tumors, restoring anatomy and shoulder function remains demanding because muscles and bone are removed to obtain tumor-free surgical margins. Current modes of reconstruction such as anatomic modular prostheses, osteoarticular allografts, or allograft-prosthetic composites and arthrodeses are associated with relatively poor shoulder function related to loss of the deltoid and rotator cuff muscles. Newer prosthetic designs like the reverse total shoulder arthroplasty (RTSA) are felt to be useful in other reconstructions where rotator cuff function is compromised, so it seemed logical that it might help in tumor reconstructions as well in patients where the deltoid muscle and its innervation can be preserved.\u0000\u0000\u0000QUESTIONS/PURPOSES\u0000In patients with a tumor of the proximal humerus that can be resected with preservation of the deltoid muscle, (1) What complications are associated with tumor resection and reconstruction with a modular RTSA? (2) What are the functional results of modular RTSA in these patients?\u0000\u0000\u0000METHODS\u0000From January 2011 to January 2018, we treated 52 patients for bone tumors of the proximal humerus. Of these, three patients were treated with forequarter amputation, 14 were treated with standard modular proximal humerus implants, seven were treated with allograft-prosthetic composites (RTSA-APC), and 28 were treated with a modular RTSA. Generally, we used anatomic modular prosthetic reconstruction if during the tumor resection none of the abductor mechanism could be spared. Conversely, we preferred reconstruction with RTSA if an innervated deltoid muscle could be spared, but the rotator cuff and capsule could not, using RTSA-APC or modular RTSA if humeral osteotomy was distal or proximal to deltoid insertion, respectively. In this study, we retrospectively analyzed only patients treated with modular RTSA after proximal humerus resection. We excluded three patients treated with modular RTSA as revision procedures after mechanical failure of previous biological reconstructions and three patients treated after December 2016 to obtain an expected minimum follow-up of 2 years. There were nine men and 13 women, with a mean (range) age of 55 years (18 to 71). Reconstruction was performed in all patients using silver-coated modular RTSA protheses. Patients were clinically checked according to oncologic protocol. Complications and function were evaluated at final follow-up by the treating surgeon (PR) and shoulder surgeon (AC). Complications were evaluated according to Henderson classification. Functional results were assessed with the Musculoskeletal Tumor Society score (range 0 points to 30 points), Constant-Murley score (range 0 to 100), and American Shoulder and Elbow Surgeons score (range 0 to 100). The statistical analysis was performed using Kaplan-Meier curves.\u0000\u0000\u0000RESULTS\u0000Complications occurred in five of 22 patients; there was a shoulder dislocation (Type I) in four patients and aseptic","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"41 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88028631","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-01DOI: 10.1097/CORR.0000000000000967
A. Cosgrove
The development of hip dysplasia and dislocation is an unwelcome complication for a child with cerebral palsy. It can result in problems with positioning, loss of function, and pain [9]. In individuals with an established dislocation, the options are limited and, for many children, are a matter of palliation rather than correction. Generally, surgical intervention for hip dysplasia is more effective—and may be less invasive—when the condition is detected early. The Swedish national surveillance program has shown that systematic surveillance and timely surgery reduces the incidence of hip dislocation in patients with cerebral palsy [2, 3]. Based on recently published studies [2, 11], more centers are adopting a surveillance program with encouraging results for young patients with cerebral palsy and hip dysplasia. It has been widely believed that the imbalance of forces disturbs the loading on the proximal femoral physis, and according to the Heuter-Volkmann law, results in the horizontal physis and coxa valga as well as the persistence of femoral anteversion [7, 8, 10]. This contributes to eccentric loading at the edge of the acetabulum and the acquired acetabular dysplasia [6]. However, the relationship between femoral deformity and hip subluxation has been challenged [1]. In the past, surgical approaches have focused on addressing the overactive muscles. The more proactive use of tone-reducing interventions such as rhizotomy may affect the natural history of the hip, but currently, there is no clear evidence of a change in incidence of hip pathology. In the current study, Hsieh and colleagues [4] report on their use of guided growth for coxa valga in patients with cerebral palsy. They found that the physis became less horizontal and there was a modest reduction in the head shaft angle of the proximal femur as well as a reduction in the migration percentage. Empirically, one would expect that this technique would work best for hips that have not developed acetabular dysplasia or hip subluxation, and this appears to be borne out by their findings. Those hips that continued to migrate and require further surgery had a straighter head shaft angle, more acetabular dysplasia, and a higher migration percentage. The authors suggest that guided growth may not be suitable for hips that have a migration percentage above 50% [4].
{"title":"CORR Insights®: Guided Growth Improves Coxa Valga and Hip Subluxation in Children with Cerebral Palsy.","authors":"A. Cosgrove","doi":"10.1097/CORR.0000000000000967","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000967","url":null,"abstract":"The development of hip dysplasia and dislocation is an unwelcome complication for a child with cerebral palsy. It can result in problems with positioning, loss of function, and pain [9]. In individuals with an established dislocation, the options are limited and, for many children, are a matter of palliation rather than correction. Generally, surgical intervention for hip dysplasia is more effective—and may be less invasive—when the condition is detected early. The Swedish national surveillance program has shown that systematic surveillance and timely surgery reduces the incidence of hip dislocation in patients with cerebral palsy [2, 3]. Based on recently published studies [2, 11], more centers are adopting a surveillance program with encouraging results for young patients with cerebral palsy and hip dysplasia. It has been widely believed that the imbalance of forces disturbs the loading on the proximal femoral physis, and according to the Heuter-Volkmann law, results in the horizontal physis and coxa valga as well as the persistence of femoral anteversion [7, 8, 10]. This contributes to eccentric loading at the edge of the acetabulum and the acquired acetabular dysplasia [6]. However, the relationship between femoral deformity and hip subluxation has been challenged [1]. In the past, surgical approaches have focused on addressing the overactive muscles. The more proactive use of tone-reducing interventions such as rhizotomy may affect the natural history of the hip, but currently, there is no clear evidence of a change in incidence of hip pathology. In the current study, Hsieh and colleagues [4] report on their use of guided growth for coxa valga in patients with cerebral palsy. They found that the physis became less horizontal and there was a modest reduction in the head shaft angle of the proximal femur as well as a reduction in the migration percentage. Empirically, one would expect that this technique would work best for hips that have not developed acetabular dysplasia or hip subluxation, and this appears to be borne out by their findings. Those hips that continued to migrate and require further surgery had a straighter head shaft angle, more acetabular dysplasia, and a higher migration percentage. The authors suggest that guided growth may not be suitable for hips that have a migration percentage above 50% [4].","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"158 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79999765","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-01DOI: 10.1097/CORR.0000000000000982
Y. Lam
Chondrosarcoma generally is resistant to radiotherapy and chemotherapy. Because of this, surgeons usually treat highergrade chondrosarcoma malignancies with wide surgical excision [2]. Achieving this in the pelvis calls for a good understanding of local anatomy, the tumor margin, and the tumor’s aggressiveness. A more-aggressive tumor with longer pseudopodia, more distant tumor satellites, and/or wider reactive zone warrants a wider resection margin. The chondrosarcoma tumor grading system divides the chondrosarcoma into three grades (I, II, III) based on the degree of cellularity, nuclear pleomorphism, necrosis and chondroid, or myxoid matrix. The higher the grade, the more aggressive the lesion. Unfortunately, tumor grading of cartilaginous lesions, even among experienced musculoskeletal pathologists and radiologists, is not reliable [5]. In addition, although the histology report categorizes these tumors into three distinct grades, the reality is that chondrosarcoma probably is better considered as a continuum of disease; even within tumors of the same grade, aggressiveness may vary widely. Making matters more complex, the grade on a pre-operative biopsy may also be misleading [10] as it and may not reflect the true histological grade of the tumor. In the current study, Tsuda and his colleagues [8] confirmed that there was a high percentage of underreporting of the histologic tumor grade. This can cause serious harm, since a surgeon may tolerate a narrower margin in a lower-grade tumor, while doing so in a high-grade malignancy could result in an unacceptable risk of local recurrence or worse. But in better news, this study also found that patients treated with a 1 mm surgical margin of the final resection specimen experienced no local recurrence, metastasis, or disease-related death regardless of chondrosarcoma tumor grade [8]. Based on this, a 1 mm surgical margin of the final resection specimen may be a reasonable goal in planning the resection plane preoperatively.
{"title":"CORR Insights®: Is the Width of a Surgical Margin Associated with the Outcome of Disease in Patients with Peripheral Chondrosarcoma of the Pelvis? A Multicenter Study.","authors":"Y. Lam","doi":"10.1097/CORR.0000000000000982","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000982","url":null,"abstract":"Chondrosarcoma generally is resistant to radiotherapy and chemotherapy. Because of this, surgeons usually treat highergrade chondrosarcoma malignancies with wide surgical excision [2]. Achieving this in the pelvis calls for a good understanding of local anatomy, the tumor margin, and the tumor’s aggressiveness. A more-aggressive tumor with longer pseudopodia, more distant tumor satellites, and/or wider reactive zone warrants a wider resection margin. The chondrosarcoma tumor grading system divides the chondrosarcoma into three grades (I, II, III) based on the degree of cellularity, nuclear pleomorphism, necrosis and chondroid, or myxoid matrix. The higher the grade, the more aggressive the lesion. Unfortunately, tumor grading of cartilaginous lesions, even among experienced musculoskeletal pathologists and radiologists, is not reliable [5]. In addition, although the histology report categorizes these tumors into three distinct grades, the reality is that chondrosarcoma probably is better considered as a continuum of disease; even within tumors of the same grade, aggressiveness may vary widely. Making matters more complex, the grade on a pre-operative biopsy may also be misleading [10] as it and may not reflect the true histological grade of the tumor. In the current study, Tsuda and his colleagues [8] confirmed that there was a high percentage of underreporting of the histologic tumor grade. This can cause serious harm, since a surgeon may tolerate a narrower margin in a lower-grade tumor, while doing so in a high-grade malignancy could result in an unacceptable risk of local recurrence or worse. But in better news, this study also found that patients treated with a 1 mm surgical margin of the final resection specimen experienced no local recurrence, metastasis, or disease-related death regardless of chondrosarcoma tumor grade [8]. Based on this, a 1 mm surgical margin of the final resection specimen may be a reasonable goal in planning the resection plane preoperatively.","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"32 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"86281529","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-01DOI: 10.1097/CORR.0000000000001037
Matthaios Savvidis, K. Papavasiliou, I. Taitzoglou, A. Giannakopoulou, D. Kitridis, N. Galanis, I. Vrabas, E. Tsiridis
BACKGROUND Alpha-tocopherol, a well-known antioxidative agent, may have a positive effect on bone formation during the remodeling phase of secondary fracture healing. Fracture healing and osseointegration of implants share common biological pathways; hence, alpha-tocopherol may enhance implant osseointegration. QUESTIONS/PURPOSES This experimental study in rats assessed the ability of alpha-tocopherol to enhance osseointegration of orthopaedic implants as determined by (1) pull-out strength and removal torque and (2) a histomorphological assessment of bone formation. In addition, we asked, (3) is there a correlation between the administration of alpha-tocopherol and a reduction in postoperative oxidative stress (as determined by malondialdehyde, protein carbonyls, reduced and oxidized glutathione and their ratio, catalase activity and total antioxidant capacity) that develops after implantation of an orthopaedic implant? METHODS This blinded study was performed in study and control groups, each consisting of 15 young adult male Wistar rats. On Day 0, a custom-designed stainless-steel screw was implanted in the proximal metaphysis of both tibias of all rats. On Day 1, animals were randomized to receive either alpha-tocopherol (40 mg/kg once per day intraperitoneally) or saline (controls). Animals were treated according to identical perioperative and postoperative protocols and were euthanized on Day 29. All animals completed the study and all tibias were suitable for evaluation. Implant pullout strength was assessed in the right tibias, and removal torque and histomorphometric evaluations (that is, volume of newly formed bone surrounding the implant in mm, percentage of newly formed bone, percentage of bone marrow surrounding the implant per optical field, thickness of newly formed bone in μm, percentage of mineralized bone in newly formed bone, volume of mature newly formed bone surrounding the implant in mm and percentage of mineralized newly formed bone per tissue area) were performed in the left tibias. The plasma levels of alpha-tocopherol, malondialdehyde, protein carbonyls, glutathione, glutathione disulfide, catalase, and the total antioxidant capacity were evaluated, and the ratio of glutathione to oxidized glutathione was calculated. RESULTS All parameters were different between the alpha-tocopherol-treated and control rats, favoring those in the alpha-tocopherol group. The pullout strength for the alpha-tocopherol group (mean ± SD) was 124.9 ± 20.7 newtons (N) versus 88.1 ± 12.7 N in the control group (mean difference -36.7 [95% CI -49.6 to -23.9]; p < 0.001). The torque median value was 7 (range 5.4 to 8.3) versus 5.2 (range 3.6 to 6 ) N/cm (p < 0.001). The newly formed bone volume was 29.8 ± 5.7 X 10 versus 25.2 ± 7.8 X 10 mm (mean difference -4.6 [95% CI -8.3 to -0.8]; p = 0.018), the percentage of mineralized bone in newly formed bone was 74.6% ± 8.7% versus 62.1% ± 9.8% (mean difference -12.5 [95% CI -20.2 to -4.8]; p = 0.003
背景:生育酚是一种众所周知的抗氧化剂，在继发性骨折愈合的重塑阶段可能对骨形成有积极作用。骨折愈合和种植体骨整合具有共同的生物学途径;因此，α -生育酚可促进种植体骨整合。问题/目的本实验研究评估了α -生育酚增强骨科植入物骨整合的能力，通过(1)拔出强度和移除扭矩和(2)骨形成的组织形态学评估来确定。此外，我们提出(3)在植入矫形植入物后，α -生育酚的使用与术后氧化应激(由丙二醛、蛋白羰基、还原性和氧化性谷胱甘肽及其比例、过氧化氢酶活性和总抗氧化能力决定)的减少之间是否存在相关性?方法采用盲法研究，分为实验组和对照组，每组15只成年雄性Wistar大鼠。第0天，在所有大鼠的双胫骨近端干骺端植入一枚定制的不锈钢螺钉。在第1天，动物随机接受α -生育酚(40 mg/kg，每天1次，腹腔注射)或生理盐水(对照组)。动物按照相同的围手术期和术后方案处理，并于第29天安乐死。所有的动物都完成了研究，所有的胫骨都适合评估。评估右胫骨的种植体拔出强度、移除扭矩和组织形态学评估(即种植体周围新形成的骨体积(mm)、新形成的骨百分比、种植体周围每光场的骨髓百分比、新形成的骨厚度(μm)、新形成的骨中矿化的骨百分比、在左胫骨进行种植体周围成熟新形成骨的体积(mm)和矿化新形成骨的百分比(每组织面积)。测定血浆α -生育酚、丙二醛、蛋白羰基、谷胱甘肽、谷胱甘肽二硫、过氧化氢酶水平和总抗氧化能力，计算谷胱甘肽与氧化谷胱甘肽的比值。结果α -生育酚组大鼠与对照组大鼠各项指标均有差异，α -生育酚组大鼠优于对照组大鼠。α -生育酚组的拔牙强度(平均±SD)为124.9±20.7牛顿(N)，对照组为88.1±12.7牛顿(N)(平均差为-36.7 [95% CI -49.6 ~ -23.9];P < 0.001)。扭矩中位数为7 N/cm(范围为5.4 - 8.3)vs 5.2 N/cm(范围为3.6 - 6)(p < 0.001)。新生骨体积分别为29.8±5.7 X 10和25.2±7.8 X 10 mm(平均差为-4.6 [95% CI -8.3 ~ -0.8];p = 0.018)，矿化骨占新生骨的比例分别为74.6%±8.7%和62.1%±9.8%(平均差异为-12.5 [95% CI -20.2 ~ -4.8];p = 0.003)，每组织面积矿化新生骨的百分比分别为40.3±8.6%和34.8±9%(平均差为-5.5 [95% CI -10.4 ~ -0.6];p = 0.028)，谷胱甘肽水平为2±0.4 μmol/g vs 1.3±0.3 μmol/g血红蛋白(平均差为-0.6 [95% CI -0.9 ~ -0.4];P < 0.001)，谷胱甘肽/氧化谷胱甘肽比值中位数为438.8(范围298 - 553)vs 340.1(范围212 - 454;p = 0.002)，过氧化氢酶活性分别为155.6±44.6和87.3±25.2 U/mg Hb(平均差异为-68.3 [95% CI -95.4至-41.2];p < 0.001)，丙二醛水平为0.07±0.02比0.14±0.03 μmol/g蛋白(平均差异0.07 [95% CI 0.05 ~ 0.09];p < 0.001)，蛋白质羰基水平为0.16±0.04 vs 0.27±0.08 nmol/mg蛋白质(平均差值为-0.1 [95% CI 0.05 ~ 0.15];p = 0.002)， α -生育酚水平为3.9±4.1 vs 0.9±0.2 mg/dL(平均差值-3 [95% CI -5.2 ~ -0.7];p = 0.011)，总抗氧化能力分别为15.9±3.2和13.7±1.7 nmol 2,2-二苯基-1-苦味酰肼基自由基/g蛋白质(平均差为-2.1 [95% CI -4.1 ~ -0.18];P = 0.008)。结论:尽管α -生育酚与术后应激减轻之间的因果关系尚不能确定，但通过体内大鼠模型得出的结果支持术后给予α -生育酚可以增强骨科种植体的骨整合。这些研究结果表明，术后给予α -生育酚是一种很有前途的方法来增强患者骨科种植体的骨整合。在进行临床试验之前，需要对不同的动物模型和/或不同的植入物进行进一步的研究，并评估α -生育酚剂量的反应，以检验这些有希望的初步结果是否可以外推到临床环境中。
{"title":"Postoperative Administration of Alpha-tocopherol Enhances Osseointegration of Stainless Steel Implants: An In Vivo Rat Model.","authors":"Matthaios Savvidis, K. Papavasiliou, I. Taitzoglou, A. Giannakopoulou, D. Kitridis, N. Galanis, I. Vrabas, E. Tsiridis","doi":"10.1097/CORR.0000000000001037","DOIUrl":"https://doi.org/10.1097/CORR.0000000000001037","url":null,"abstract":"BACKGROUND\u0000Alpha-tocopherol, a well-known antioxidative agent, may have a positive effect on bone formation during the remodeling phase of secondary fracture healing. Fracture healing and osseointegration of implants share common biological pathways; hence, alpha-tocopherol may enhance implant osseointegration.\u0000\u0000\u0000QUESTIONS/PURPOSES\u0000This experimental study in rats assessed the ability of alpha-tocopherol to enhance osseointegration of orthopaedic implants as determined by (1) pull-out strength and removal torque and (2) a histomorphological assessment of bone formation. In addition, we asked, (3) is there a correlation between the administration of alpha-tocopherol and a reduction in postoperative oxidative stress (as determined by malondialdehyde, protein carbonyls, reduced and oxidized glutathione and their ratio, catalase activity and total antioxidant capacity) that develops after implantation of an orthopaedic implant?\u0000\u0000\u0000METHODS\u0000This blinded study was performed in study and control groups, each consisting of 15 young adult male Wistar rats. On Day 0, a custom-designed stainless-steel screw was implanted in the proximal metaphysis of both tibias of all rats. On Day 1, animals were randomized to receive either alpha-tocopherol (40 mg/kg once per day intraperitoneally) or saline (controls). Animals were treated according to identical perioperative and postoperative protocols and were euthanized on Day 29. All animals completed the study and all tibias were suitable for evaluation. Implant pullout strength was assessed in the right tibias, and removal torque and histomorphometric evaluations (that is, volume of newly formed bone surrounding the implant in mm, percentage of newly formed bone, percentage of bone marrow surrounding the implant per optical field, thickness of newly formed bone in μm, percentage of mineralized bone in newly formed bone, volume of mature newly formed bone surrounding the implant in mm and percentage of mineralized newly formed bone per tissue area) were performed in the left tibias. The plasma levels of alpha-tocopherol, malondialdehyde, protein carbonyls, glutathione, glutathione disulfide, catalase, and the total antioxidant capacity were evaluated, and the ratio of glutathione to oxidized glutathione was calculated.\u0000\u0000\u0000RESULTS\u0000All parameters were different between the alpha-tocopherol-treated and control rats, favoring those in the alpha-tocopherol group. The pullout strength for the alpha-tocopherol group (mean ± SD) was 124.9 ± 20.7 newtons (N) versus 88.1 ± 12.7 N in the control group (mean difference -36.7 [95% CI -49.6 to -23.9]; p < 0.001). The torque median value was 7 (range 5.4 to 8.3) versus 5.2 (range 3.6 to 6 ) N/cm (p < 0.001). The newly formed bone volume was 29.8 ± 5.7 X 10 versus 25.2 ± 7.8 X 10 mm (mean difference -4.6 [95% CI -8.3 to -0.8]; p = 0.018), the percentage of mineralized bone in newly formed bone was 74.6% ± 8.7% versus 62.1% ± 9.8% (mean difference -12.5 [95% CI -20.2 to -4.8]; p = 0.003","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"2006 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"86960594","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-01DOI: 10.1097/CORR.0000000000000926
Y. Tsuda, S. Evans, J. Stevenson, M. Parry, T. Fujiwara, M. Laitinen, Hidetatsu Outani, L. Jeys
BACKGROUND We attempted to resect peripheral chondrosarcoma of the pelvis with clear margins. Because of the proximity of vessels or organs, there is still concern that narrow surgical margins may have an adverse effect on disease outcomes. Although current guidelines recommend resection of histologic Grade II or Grade III chondrosarcomas with a "wide" margin, there are no specific recommendations for the adequate width of a surgical margin. QUESTIONS/PURPOSES (1) What is the disease-specific and local recurrence-free survival of patients with peripheral chondrosarcoma of the pelvis treated with resection or amputation? (2) Is the width of a surgical margin associated with the outcome of disease in patients with peripheral chondrosarcoma of the pelvis? (3) Does the histologic grade as determined with a preoperative biopsy correlate with the final grade after resection? (4) What are surgical complications in these patients? METHODS We retrospectively reviewed records from three international collaborating hospitals. Between 1983 and 2017, we resected 262 pelvic chondrosarcomas of all types. After reviewing the pathologic reports of these patients, we included 52 patients with peripheral chondrosarcomas of the pelvis who had an osteochondroma-like lesion at the base of the tumor and a cartilage cap with malignant cells in resected specimens. To be eligible for this study, a patient had to have a minimum of 1 year of follow-up. Two patients were excluded because they had less than 1 year of follow-up, leaving 50 patients for inclusion in this study. The median follow-up duration was 7.0 years (interquartile range 2.1-10 years). The median age was 37 years (IQR 29-54 years). The ilium was the most frequently affected bone (in 36 of 50 patients; 72%). The histologic status of the surgical margin was defined as microscopically positive (0 mm), negative < 1 mm, or negative ≥ 1 mm. Thirteen of the 50 patients (26%) had local recurrence. Seven of 34 patients had Grade I tumors, five of 13 had Grade II tumors, and one of three had a Grade III tumor. Nine of 16 patients had multiple local recurrences. Two patients with Grade I tumors and two with Grade II tumors died because of pressure effects caused by local recurrence. RESULTS The 10-year disease-specific and local recurrence-free survival rates were 90% (95% confidence interval, 70-97) and 69% (95% CI, 52-81), respectively. A surgical margin ≥ 1 mm (n = 16) was associated with a better local recurrence-free survival rate than a surgical margin < 1 mm (n = 17) or 0 mm (n = 11) (10-year local recurrence-free survival: resection margin ≥ 1 mm = 100% versus < 1 mm = 52% [95% CI, 31 to 70]; p = 0.008). No patients with a surgical margin ≥ 1 mm had local recurrence, metastasis, or disease-related death, irrespective of tumor grade. Patients with local recurrence (n = 13) showed worse disease-specific survival than those without local recurrence (n = 37) (10-year disease-specific survival: local recurren
{"title":"Is the Width of a Surgical Margin Associated with the Outcome of Disease in Patients with Peripheral Chondrosarcoma of the Pelvis? A Multicenter Study.","authors":"Y. Tsuda, S. Evans, J. Stevenson, M. Parry, T. Fujiwara, M. Laitinen, Hidetatsu Outani, L. Jeys","doi":"10.1097/CORR.0000000000000926","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000926","url":null,"abstract":"BACKGROUND\u0000We attempted to resect peripheral chondrosarcoma of the pelvis with clear margins. Because of the proximity of vessels or organs, there is still concern that narrow surgical margins may have an adverse effect on disease outcomes. Although current guidelines recommend resection of histologic Grade II or Grade III chondrosarcomas with a \"wide\" margin, there are no specific recommendations for the adequate width of a surgical margin.\u0000\u0000\u0000QUESTIONS/PURPOSES\u0000(1) What is the disease-specific and local recurrence-free survival of patients with peripheral chondrosarcoma of the pelvis treated with resection or amputation? (2) Is the width of a surgical margin associated with the outcome of disease in patients with peripheral chondrosarcoma of the pelvis? (3) Does the histologic grade as determined with a preoperative biopsy correlate with the final grade after resection? (4) What are surgical complications in these patients?\u0000\u0000\u0000METHODS\u0000We retrospectively reviewed records from three international collaborating hospitals. Between 1983 and 2017, we resected 262 pelvic chondrosarcomas of all types. After reviewing the pathologic reports of these patients, we included 52 patients with peripheral chondrosarcomas of the pelvis who had an osteochondroma-like lesion at the base of the tumor and a cartilage cap with malignant cells in resected specimens. To be eligible for this study, a patient had to have a minimum of 1 year of follow-up. Two patients were excluded because they had less than 1 year of follow-up, leaving 50 patients for inclusion in this study. The median follow-up duration was 7.0 years (interquartile range 2.1-10 years). The median age was 37 years (IQR 29-54 years). The ilium was the most frequently affected bone (in 36 of 50 patients; 72%). The histologic status of the surgical margin was defined as microscopically positive (0 mm), negative < 1 mm, or negative ≥ 1 mm. Thirteen of the 50 patients (26%) had local recurrence. Seven of 34 patients had Grade I tumors, five of 13 had Grade II tumors, and one of three had a Grade III tumor. Nine of 16 patients had multiple local recurrences. Two patients with Grade I tumors and two with Grade II tumors died because of pressure effects caused by local recurrence.\u0000\u0000\u0000RESULTS\u0000The 10-year disease-specific and local recurrence-free survival rates were 90% (95% confidence interval, 70-97) and 69% (95% CI, 52-81), respectively. A surgical margin ≥ 1 mm (n = 16) was associated with a better local recurrence-free survival rate than a surgical margin < 1 mm (n = 17) or 0 mm (n = 11) (10-year local recurrence-free survival: resection margin ≥ 1 mm = 100% versus < 1 mm = 52% [95% CI, 31 to 70]; p = 0.008). No patients with a surgical margin ≥ 1 mm had local recurrence, metastasis, or disease-related death, irrespective of tumor grade. Patients with local recurrence (n = 13) showed worse disease-specific survival than those without local recurrence (n = 37) (10-year disease-specific survival: local recurren","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"157 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"86728155","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-01DOI: 10.1097/CORR.0000000000000876
Caroline Cristofaro, T. Carter, N. Wickramasinghe, M. McQueen, T. White, A. Duckworth
BACKGROUND The evidence for treating acute, unreconstructable radial head fractures in unstable elbows with radial head replacement predominantly consists of short- to mid-term follow-up studies with a heterogenous mix of implants and operative techniques. Data on longer-term patient-reported outcomes after radial head replacement is lacking. QUESTIONS/PURPOSES (1) What proportion of patients undergo revision or implant removal after radial head replacement? (2) At a minimum of 8 years follow-up, what are the patient-reported outcomes (QuickDASH, Oxford Elbow Score, and EuroQol-5D)? (3) What factors are associated with a superior long-term patient-reported outcome, according to the QuickDASH? METHODS Between September 1994 and September 2010, we surgically treated 157 patients for acute radial head fractures. We excluded patients where the radial head was excised (n = 21), internally fixed (n = 15), or replaced as a secondary procedure after failed internal fixation (n = 2). A total of 119 patients who underwent radial head replacement surgery for an acute unreconstructable fracture were included, with a mean age of 50 years (range 15 to 93 ± 19 years), and 53% of patients (63) were women. All but two implants were uncemented, loose-fitting, monopolar prostheses, of which 86% (102) were metallic and 14% (17) were silastic. Implants were only cemented if they appeared unstable within the proximal radius. Silastic implants were used in the earlier series and replaced by metallic implants starting in 2000. We reviewed electronic records to document postoperative complications and prosthesis revision and removal. A member of the local research team (THC, CDC) who was not previously involved in patient care contacted patients to confirm complications, reoperations and to obtain long-term patient-reported outcomes scores. Nineteen patients had died at the point of outcome score collection. Of the remaining 100 patients, 80 were contacted (67% of total cohort), at a median of 11 years (range 8 to 24 years) after injury. The primary outcome measure was the QuickDASH score. RESULTS Of 119 patients, 25% (30) underwent reoperation, with three patients undergoing revision and 27 patients undergoing prosthesis removal at a median of 7 months (range 0 to 125 months). Twenty-one of 30 procedures (70%) occurred within 1 year after implantation. Kaplan-Meier survivorship analysis demonstrated a cumulative implant survival rate of 71%. In the 80 patients contacted, the mean QuickDASH score was 13 ± 14, the mean Oxford Elbow Score was 43 ± 6, and the median EuroQol-5D score was 0.8 (-0.3 to 1.0). After controlling for covariates, we found that prothesis revision or removal (p = 0.466) and prosthesis type (p = 0.553) were not associated with patient-reported outcome, according to the QuickDASH. CONCLUSIONS The management of acute unreconstructable fractures of the radial head in unstable elbow injuries with radial head replacement has a high risk of reoperat
{"title":"High Risk of Further Surgery After Radial Head Replacement for Unstable Fractures: Longer-term Outcomes at a Minimum Follow-up of 8 Years.","authors":"Caroline Cristofaro, T. Carter, N. Wickramasinghe, M. McQueen, T. White, A. Duckworth","doi":"10.1097/CORR.0000000000000876","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000876","url":null,"abstract":"BACKGROUND\u0000The evidence for treating acute, unreconstructable radial head fractures in unstable elbows with radial head replacement predominantly consists of short- to mid-term follow-up studies with a heterogenous mix of implants and operative techniques. Data on longer-term patient-reported outcomes after radial head replacement is lacking.\u0000\u0000\u0000QUESTIONS/PURPOSES\u0000(1) What proportion of patients undergo revision or implant removal after radial head replacement? (2) At a minimum of 8 years follow-up, what are the patient-reported outcomes (QuickDASH, Oxford Elbow Score, and EuroQol-5D)? (3) What factors are associated with a superior long-term patient-reported outcome, according to the QuickDASH?\u0000\u0000\u0000METHODS\u0000Between September 1994 and September 2010, we surgically treated 157 patients for acute radial head fractures. We excluded patients where the radial head was excised (n = 21), internally fixed (n = 15), or replaced as a secondary procedure after failed internal fixation (n = 2). A total of 119 patients who underwent radial head replacement surgery for an acute unreconstructable fracture were included, with a mean age of 50 years (range 15 to 93 ± 19 years), and 53% of patients (63) were women. All but two implants were uncemented, loose-fitting, monopolar prostheses, of which 86% (102) were metallic and 14% (17) were silastic. Implants were only cemented if they appeared unstable within the proximal radius. Silastic implants were used in the earlier series and replaced by metallic implants starting in 2000. We reviewed electronic records to document postoperative complications and prosthesis revision and removal. A member of the local research team (THC, CDC) who was not previously involved in patient care contacted patients to confirm complications, reoperations and to obtain long-term patient-reported outcomes scores. Nineteen patients had died at the point of outcome score collection. Of the remaining 100 patients, 80 were contacted (67% of total cohort), at a median of 11 years (range 8 to 24 years) after injury. The primary outcome measure was the QuickDASH score.\u0000\u0000\u0000RESULTS\u0000Of 119 patients, 25% (30) underwent reoperation, with three patients undergoing revision and 27 patients undergoing prosthesis removal at a median of 7 months (range 0 to 125 months). Twenty-one of 30 procedures (70%) occurred within 1 year after implantation. Kaplan-Meier survivorship analysis demonstrated a cumulative implant survival rate of 71%. In the 80 patients contacted, the mean QuickDASH score was 13 ± 14, the mean Oxford Elbow Score was 43 ± 6, and the median EuroQol-5D score was 0.8 (-0.3 to 1.0). After controlling for covariates, we found that prothesis revision or removal (p = 0.466) and prosthesis type (p = 0.553) were not associated with patient-reported outcome, according to the QuickDASH.\u0000\u0000\u0000CONCLUSIONS\u0000The management of acute unreconstructable fractures of the radial head in unstable elbow injuries with radial head replacement has a high risk of reoperat","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"32 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"86980532","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-01DOI: 10.1097/CORR.0000000000000981
Seper Ekhtiari, M. Bhandari
The number of deaths in the United States from opioid overdose, and the number of opioid prescriptions, both have quadrupled since 2000 [3, 4]. After family doctors and internists, orthopaedic surgeons are the third-highest prescribers of opioids among physicians in the United States [9]. The vast majority of surgical patients receive opioids in the peri-operative period, including many for the first time in their lives [4], and it is during this time when patients are at risk for developing opioid dependence. Thus, the concept of multimodal and opioid-reduced or opioid-free perioperative pain management has gained prominence [8]. In fact, a recent editorial in Clinical Orthopaedics and Related Research offered modest approaches to opioid-reduced painmanagement that orthopaedic surgeons should consider including writing smaller prescriptions for shorter periods of time, reassessing whether to use long-acting opioid medications in narcotic-naı̈ve patients, and setting realistic expectations about pain after surgery [7]. Several potential alternatives to opioids have been proposed and investigated, such as ketamine. Ketamine is a medication that provides analgesic, amnestic, and dissociative effects in a dose-dependent manner [11]. There are, however, safety concerns with ketamine including central nervous system symptoms such as hallucinations [10]. In this Cochrane review, the authors investigate the efficacy and safety of ketamine as an adjunct for postoperative pain in adult patients. The authors included 130 blinded, randomized controlled trials (8341 participants) comparing ketamine to either placebo, an opioid medication, or a non-steroidal anti-inflammatory. Overall, the authors found that peri-operative ketamine reduces pain, nausea, vomiting, and the use of opioids after surgery.
{"title":"Cochrane in CORR®: Perioperative Intravenous Ketamine for Acute Postoperative Pain in Adults.","authors":"Seper Ekhtiari, M. Bhandari","doi":"10.1097/CORR.0000000000000981","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000981","url":null,"abstract":"The number of deaths in the United States from opioid overdose, and the number of opioid prescriptions, both have quadrupled since 2000 [3, 4]. After family doctors and internists, orthopaedic surgeons are the third-highest prescribers of opioids among physicians in the United States [9]. The vast majority of surgical patients receive opioids in the peri-operative period, including many for the first time in their lives [4], and it is during this time when patients are at risk for developing opioid dependence. Thus, the concept of multimodal and opioid-reduced or opioid-free perioperative pain management has gained prominence [8]. In fact, a recent editorial in Clinical Orthopaedics and Related Research offered modest approaches to opioid-reduced painmanagement that orthopaedic surgeons should consider including writing smaller prescriptions for shorter periods of time, reassessing whether to use long-acting opioid medications in narcotic-naı̈ve patients, and setting realistic expectations about pain after surgery [7]. Several potential alternatives to opioids have been proposed and investigated, such as ketamine. Ketamine is a medication that provides analgesic, amnestic, and dissociative effects in a dose-dependent manner [11]. There are, however, safety concerns with ketamine including central nervous system symptoms such as hallucinations [10]. In this Cochrane review, the authors investigate the efficacy and safety of ketamine as an adjunct for postoperative pain in adult patients. The authors included 130 blinded, randomized controlled trials (8341 participants) comparing ketamine to either placebo, an opioid medication, or a non-steroidal anti-inflammatory. Overall, the authors found that peri-operative ketamine reduces pain, nausea, vomiting, and the use of opioids after surgery.","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"154 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79718273","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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