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.0000000000000913
D. Ring
Radial head replacement is more akin to silicone arthroplasty of the metacarpophalangeal joint than it is to total hip or knee replacement. A prosthetic radial head is a spacer that keeps the elbow aligned while the ligaments scar. A prosthetic radial head is helpful for stabilizing the elbow during the 3 or 4 weeks after dislocation, particularly when there is an associated fracture of the tip of the coronoid (the so-called “terrible triad fracture-dislocation”). It’s unclear whether a prosthetic radial head improves the health of the elbow more than 4 weeks after dislocation. A prosthetic radial head might limit the development of ulnotrochlear arthritis by helping to support the elbow, but it might cause arthritis by contributing to subluxation if not appropriately sized or an abnormal articular milieu to the degree that a metal articulation with cartilage is unhealthy. Intentionally loose radial heads are associated with radiographic lucencies in the radial neck [3, 7]. Prostheses intended to bond with the bone of the radial neck may create substantial lucencywhen they don’t [8] or loss of bone at the collar of the prosthesis when they do [4]. Bipolar arthroplasties canhave osteolysis and this inflammation can harm the ulnohumeral cartilage [9]. Prostheses that are too long may be associated with capitellar wear, capitellar lucency, and ulnohumeral subluxation [1]. But none of these factors seem to correlate well or consistently with symptom intensity, magnitude of limitations, or even elbow motion. Cristofaro and colleagues [2] describe a second operation to revise (three patients) or remove (27 patients) a radial head prosthesis among 119 total prostheses (25%). Seventy percent had re-operation within a year (median time from initial to second surgery, 7 months). If we consider synovitis, subluxation, and ulnar neuritis as types of pain (otherwise it’s unclear why the prosthesis would be removed), then 29 out of the 30 operationswere for pain (with one operation due to deep infection). It’s possible that the subluxations were technical issues with the prosthesis, but we don’t know how many people had similar issues and did not have subsequent surgery.More than half the silastic implants (nine out of 17) were removed [2].
{"title":"CORR Insights®: High Risk of Further Surgery After Radial Head Replacement for Unstable Fractures: Longer-term Outcomes at a Minimum Follow-up of 8 Years.","authors":"D. Ring","doi":"10.1097/CORR.0000000000000913","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000913","url":null,"abstract":"Radial head replacement is more akin to silicone arthroplasty of the metacarpophalangeal joint than it is to total hip or knee replacement. A prosthetic radial head is a spacer that keeps the elbow aligned while the ligaments scar. A prosthetic radial head is helpful for stabilizing the elbow during the 3 or 4 weeks after dislocation, particularly when there is an associated fracture of the tip of the coronoid (the so-called “terrible triad fracture-dislocation”). It’s unclear whether a prosthetic radial head improves the health of the elbow more than 4 weeks after dislocation. A prosthetic radial head might limit the development of ulnotrochlear arthritis by helping to support the elbow, but it might cause arthritis by contributing to subluxation if not appropriately sized or an abnormal articular milieu to the degree that a metal articulation with cartilage is unhealthy. Intentionally loose radial heads are associated with radiographic lucencies in the radial neck [3, 7]. Prostheses intended to bond with the bone of the radial neck may create substantial lucencywhen they don’t [8] or loss of bone at the collar of the prosthesis when they do [4]. Bipolar arthroplasties canhave osteolysis and this inflammation can harm the ulnohumeral cartilage [9]. Prostheses that are too long may be associated with capitellar wear, capitellar lucency, and ulnohumeral subluxation [1]. But none of these factors seem to correlate well or consistently with symptom intensity, magnitude of limitations, or even elbow motion. Cristofaro and colleagues [2] describe a second operation to revise (three patients) or remove (27 patients) a radial head prosthesis among 119 total prostheses (25%). Seventy percent had re-operation within a year (median time from initial to second surgery, 7 months). If we consider synovitis, subluxation, and ulnar neuritis as types of pain (otherwise it’s unclear why the prosthesis would be removed), then 29 out of the 30 operationswere for pain (with one operation due to deep infection). It’s possible that the subluxations were technical issues with the prosthesis, but we don’t know how many people had similar issues and did not have subsequent surgery.More than half the silastic implants (nine out of 17) were removed [2].","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"12 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"81896566","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.0000000000000890
N. SooHoo
In the current study, Bernstein and colleagues [2] look beyond patientreported outcomemeasure (PROM) scores to determine how acceptable the functional limitations these scores reflect are to patients with foot and ankle injuries, and to what degree the level of acceptable symptoms may vary with patient demographics. Using the Patient-Acceptable Symptom State score, the authors found a strong association between income level and both the severity of functional limitations on presentation and the degree to which patients find these limitations acceptable [2]. Bernstein and colleagues created six brackets based on median income: # USD 24,999, USD 25,000USD34,999, USD 35,000-USD 49,999, USD 50,000-USD74,999, USD 75,000USD 99,000, and$USD 100,000 [2]. It is perhaps not surprising that patients in lower income brackets might seek care only when they have more severe limitations, given that they may have fewer resources and less access to health care. It is a novel finding, however, that patients in lower income brackets find more severe functional limitations to be acceptable while patients in higher income brackets have a much higher threshold for an acceptable level of function. Previous studies [1, 3, 4] have noted that patients with more functional limitations had higher expectations for improvement following foot and ankle surgery; lower functional status is also associated with a higher likelihood of clinical improvement following surgery of the foot and ankle.
{"title":"CORR Insights®: Do Patient Sociodemographic Factors Impact the PROMIS Scores Meeting the Patient-Acceptable Symptom State at the Initial Point of Care in Orthopaedic Foot and Ankle Patients?","authors":"N. SooHoo","doi":"10.1097/CORR.0000000000000890","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000890","url":null,"abstract":"In the current study, Bernstein and colleagues [2] look beyond patientreported outcomemeasure (PROM) scores to determine how acceptable the functional limitations these scores reflect are to patients with foot and ankle injuries, and to what degree the level of acceptable symptoms may vary with patient demographics. Using the Patient-Acceptable Symptom State score, the authors found a strong association between income level and both the severity of functional limitations on presentation and the degree to which patients find these limitations acceptable [2]. Bernstein and colleagues created six brackets based on median income: # USD 24,999, USD 25,000USD34,999, USD 35,000-USD 49,999, USD 50,000-USD74,999, USD 75,000USD 99,000, and$USD 100,000 [2]. It is perhaps not surprising that patients in lower income brackets might seek care only when they have more severe limitations, given that they may have fewer resources and less access to health care. It is a novel finding, however, that patients in lower income brackets find more severe functional limitations to be acceptable while patients in higher income brackets have a much higher threshold for an acceptable level of function. Previous studies [1, 3, 4] have noted that patients with more functional limitations had higher expectations for improvement following foot and ankle surgery; lower functional status is also associated with a higher likelihood of clinical improvement following surgery of the foot and ankle.","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"11 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"86471001","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.0000000000000966
J. Wylie
Our understanding of hip dysplasia has greatly evolved since 1939, when Wiberg’s monograph described the lateral center-edge angle (LCEA) [12]. While his writings concentrated on lateral acetabular coverage, numerous papers have since examined the comprehensive evaluation of acetabular coverage [5, 13]. A comprehensive radiographic evaluation of acetabular coverage now includes LCEA, Tönnis angle, anterior and posterior wall index on the AP pelvis radiograph, and anterior centeredge angle (ACEA) on the false-profile radiograph [5]. Three-dimensional (3D) imaging is also more commonly ordered in the young adult with hip pain, where measurements like acetabular version at 1, 2, and 3 o’clock, coronal and sagittal center-edge angles, and femoral version can be obtained to further understand the 3-D anatomy. Some researchers have even quantified the cartilage surface area of the acetabulum, which is important in order to understand the true weightbearing surface that makes up the lunate cartilage, and ultimately, whether the socket is deficient or not [6]. This allows us to compare the degree of dysplasia in patients with anterior versus posterior acetabular deficiency or a large acetabular fossa. Improved radiographic evaluation and advanced imaging has led us to better understand anterior, posterior, and lateral undercoverage of the acetabulum. In the current study, Tachibana and colleagues [7] add sector angles to quantify geometric coverage. The sector angles used in this study and the correlation to radiographic measures give us a powerful new tool to evaluate 3-D acetabular coverage on CT, and validates our radiographic measures of anterior and posterior coverage, the anterior and posterior wall indicies. Regarding the differing morphologies of hip dysplasia [5, 13], one study found that women more commonly presented with anterolateral undercoverage while men presented more commonly with posterior undercoverage [5]. Tachibana and colleagues build off of this by measuring sector angles on CT scans to examine femoral head coverage of the acetabulum in multiple planes. In addition, they found differences in both CT and radiographic measures from the supine to standing position and found an increased posterior pelvic tilt in the standing position, which increases the functional acetabular anteversion compared to the supine position. This is illustrated by their decreased anterior and anterior-superior sector angles on CT imaging and decreased anterior wall index on radiographs. While there are small differences in LCEA and Tönnis angle, these are likely not noteworthy changes. This is similar to prior reports of minimal differences in LCEA and Tönnis angle in different degrees of pelvic tilt [8].
{"title":"CORR Insights®: Does Acetabular Coverage Vary Between the Supine and Standing Positions in Patients with Hip Dysplasia?","authors":"J. Wylie","doi":"10.1097/CORR.0000000000000966","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000966","url":null,"abstract":"Our understanding of hip dysplasia has greatly evolved since 1939, when Wiberg’s monograph described the lateral center-edge angle (LCEA) [12]. While his writings concentrated on lateral acetabular coverage, numerous papers have since examined the comprehensive evaluation of acetabular coverage [5, 13]. A comprehensive radiographic evaluation of acetabular coverage now includes LCEA, Tönnis angle, anterior and posterior wall index on the AP pelvis radiograph, and anterior centeredge angle (ACEA) on the false-profile radiograph [5]. Three-dimensional (3D) imaging is also more commonly ordered in the young adult with hip pain, where measurements like acetabular version at 1, 2, and 3 o’clock, coronal and sagittal center-edge angles, and femoral version can be obtained to further understand the 3-D anatomy. Some researchers have even quantified the cartilage surface area of the acetabulum, which is important in order to understand the true weightbearing surface that makes up the lunate cartilage, and ultimately, whether the socket is deficient or not [6]. This allows us to compare the degree of dysplasia in patients with anterior versus posterior acetabular deficiency or a large acetabular fossa. Improved radiographic evaluation and advanced imaging has led us to better understand anterior, posterior, and lateral undercoverage of the acetabulum. In the current study, Tachibana and colleagues [7] add sector angles to quantify geometric coverage. The sector angles used in this study and the correlation to radiographic measures give us a powerful new tool to evaluate 3-D acetabular coverage on CT, and validates our radiographic measures of anterior and posterior coverage, the anterior and posterior wall indicies. Regarding the differing morphologies of hip dysplasia [5, 13], one study found that women more commonly presented with anterolateral undercoverage while men presented more commonly with posterior undercoverage [5]. Tachibana and colleagues build off of this by measuring sector angles on CT scans to examine femoral head coverage of the acetabulum in multiple planes. In addition, they found differences in both CT and radiographic measures from the supine to standing position and found an increased posterior pelvic tilt in the standing position, which increases the functional acetabular anteversion compared to the supine position. This is illustrated by their decreased anterior and anterior-superior sector angles on CT imaging and decreased anterior wall index on radiographs. While there are small differences in LCEA and Tönnis angle, these are likely not noteworthy changes. This is similar to prior reports of minimal differences in LCEA and Tönnis angle in different degrees of pelvic tilt [8].","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"73 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"73936524","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.0000000000000911
Lukas M. Nystrom
Generally speaking, lymph node involvement is only considered to occur in certain histologic sarcoma subtypes, such as rhabdomyosarcoma, angiosarcoma, clear cell sarcoma, epithelioid sarcoma, and synovial sarcoma [1, 6, 7, 10, 11]. However, according to some investigations, synovial sarcoma nodal metastases are quite rare, and myxoid liposarcoma may be more deserving of being on that list [5]. In the current study, Wan and colleagues [13] use a large database to evaluate a rare disease, and they learned that the prevalence of lymph node involvement across all chondrosarcoma subtypes (excluding the misnomer extraskeletal myxoid chondrosarcoma) was 1.3%. While an admittedly small prevalence, this number is perhaps larger than one would expect as reports of nodal metastases from bone sarcoma are extremely rare [3, 4, 12]. The current study discusses nodal involvement at the time of initial staging. The authors designed the study this way because the SEER database does not support longitudinal evaluation of these parameters. Therefore, the prevalence of node involvement discussed is really the prevalence at the time of the initial diagnosis and not the likelihood of developing nodal metastatic disease over the course of treating chondrosarcoma. That being so, in a study like this, there is no way to confirm the accuracy of true nodal disease (metastatic spread to the lymph nodes) as compared to direct extension into the lymphatic system (tumor invasion into the lymph nodes). Similarly, there is no way to confirm whether the physician who entered the data for each patient carefully considered the nodal evaluation in their reporting of the stage. This may be important, because surgeons may not have paid careful attention to the lymphnode status of tumors that aren’t supposed to spread by way of the lymphatic system. Unfortunately, most of what we know about this topic comes from case reports [3, 8, 9]. Nevertheless, the authors nicely demonstrate here that lymph node involvement is an independent risk factor for having a poor oncologic outcome. Given that the overall survival was nearly 50% less for patients with lymph node involvement, it should be considered another surrogate marker of biologic activity of the tumor (similar grade and metastatic status). Perhaps not surprisingly, lymph node involvement was demonstrated to be more likely in patients with larger, higher-grade tumors. However, we learn in the current study that there is a threefold increase of lymph node metastases if the primary tumor originates in an extraskeletal location [13], a finding we’ve also seen in patients with osteosarcoma [12].
{"title":"CORR Insights®: Regional Lymph Node Involvement Is Associated with Poorer Survivorship in Patients with Chondrosarcoma: a SEER Analysis.","authors":"Lukas M. Nystrom","doi":"10.1097/CORR.0000000000000911","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000911","url":null,"abstract":"Generally speaking, lymph node involvement is only considered to occur in certain histologic sarcoma subtypes, such as rhabdomyosarcoma, angiosarcoma, clear cell sarcoma, epithelioid sarcoma, and synovial sarcoma [1, 6, 7, 10, 11]. However, according to some investigations, synovial sarcoma nodal metastases are quite rare, and myxoid liposarcoma may be more deserving of being on that list [5]. In the current study, Wan and colleagues [13] use a large database to evaluate a rare disease, and they learned that the prevalence of lymph node involvement across all chondrosarcoma subtypes (excluding the misnomer extraskeletal myxoid chondrosarcoma) was 1.3%. While an admittedly small prevalence, this number is perhaps larger than one would expect as reports of nodal metastases from bone sarcoma are extremely rare [3, 4, 12]. The current study discusses nodal involvement at the time of initial staging. The authors designed the study this way because the SEER database does not support longitudinal evaluation of these parameters. Therefore, the prevalence of node involvement discussed is really the prevalence at the time of the initial diagnosis and not the likelihood of developing nodal metastatic disease over the course of treating chondrosarcoma. That being so, in a study like this, there is no way to confirm the accuracy of true nodal disease (metastatic spread to the lymph nodes) as compared to direct extension into the lymphatic system (tumor invasion into the lymph nodes). Similarly, there is no way to confirm whether the physician who entered the data for each patient carefully considered the nodal evaluation in their reporting of the stage. This may be important, because surgeons may not have paid careful attention to the lymphnode status of tumors that aren’t supposed to spread by way of the lymphatic system. Unfortunately, most of what we know about this topic comes from case reports [3, 8, 9]. Nevertheless, the authors nicely demonstrate here that lymph node involvement is an independent risk factor for having a poor oncologic outcome. Given that the overall survival was nearly 50% less for patients with lymph node involvement, it should be considered another surrogate marker of biologic activity of the tumor (similar grade and metastatic status). Perhaps not surprisingly, lymph node involvement was demonstrated to be more likely in patients with larger, higher-grade tumors. However, we learn in the current study that there is a threefold increase of lymph node metastases if the primary tumor originates in an extraskeletal location [13], a finding we’ve also seen in patients with osteosarcoma [12].","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"44 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74327438","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.0000000000000983
Megan E Anderson, Jim S. Wu, S. Vargas
What are the surgical and research implications of this study? Megan E. Anderson MD Orthopaedic Oncology Surgeon Beth Israel Deaconess Medical Center and Boston Children’s Hospital In our last CORR Tumor Board column [2], we detailed the ways that advanced surgical and imaging technology integrate in the presurgical planning of pelvic and sacral sarcoma resections, how computer navigation systems can help surgeons achieve negative margins as they perform those resections, and how those margins ultimately are assessed by pathologists. The article by Tsuda and colleagues [10], makes the next logical step: Tying the quality of the margin to local and distant relapse and thus overall survival. That study reports on a specific type of chondrosarcoma, peripheral pelvic chondrosarcomas, or what some also refer to as pelvic surface chondrosarcomas. These are uncommon tumors, about which there is limited evidence [5, 7], necessitating multicenter collaboration like that in the study by Tsuda’s team [10]. They found that achieving a completely negative margin improves local control for these tumors, and pelvic chondrosarcomas can behave more aggressively clinically than their grade would suggest. Local relapse for a pelvic sarcoma can portend death in some cases, not frommetastasis to vital organs, but from the pressure of large recurrences on neighboring vital organs, which diminishes overall survival. These tumors are easy to underestimate because they appear as a somewhat dysplastic osteochondroma, but with a large cartilage cap. And while it seems straightforward simply to remove the surface of the involved bone and achieve a negative margin, these tumors often extend under the
{"title":"CORR® Tumor Board: 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":"Megan E Anderson, Jim S. Wu, S. Vargas","doi":"10.1097/CORR.0000000000000983","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000983","url":null,"abstract":"What are the surgical and research implications of this study? Megan E. Anderson MD Orthopaedic Oncology Surgeon Beth Israel Deaconess Medical Center and Boston Children’s Hospital In our last CORR Tumor Board column [2], we detailed the ways that advanced surgical and imaging technology integrate in the presurgical planning of pelvic and sacral sarcoma resections, how computer navigation systems can help surgeons achieve negative margins as they perform those resections, and how those margins ultimately are assessed by pathologists. The article by Tsuda and colleagues [10], makes the next logical step: Tying the quality of the margin to local and distant relapse and thus overall survival. That study reports on a specific type of chondrosarcoma, peripheral pelvic chondrosarcomas, or what some also refer to as pelvic surface chondrosarcomas. These are uncommon tumors, about which there is limited evidence [5, 7], necessitating multicenter collaboration like that in the study by Tsuda’s team [10]. They found that achieving a completely negative margin improves local control for these tumors, and pelvic chondrosarcomas can behave more aggressively clinically than their grade would suggest. Local relapse for a pelvic sarcoma can portend death in some cases, not frommetastasis to vital organs, but from the pressure of large recurrences on neighboring vital organs, which diminishes overall survival. These tumors are easy to underestimate because they appear as a somewhat dysplastic osteochondroma, but with a large cartilage cap. And while it seems straightforward simply to remove the surface of the involved bone and achieve a negative margin, these tumors often extend under the","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"89 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83865680","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.0000000000000900
G. Grammatopoulos, Paul Jamieson, J. Dobransky, K. Rakhra, S. Carsen, P. Beaulé
BACKGROUND Acetabular version influences joint mechanics and the risk of impingement. Cross-sectional studies have reported an increase in acetabular version during adolescence; however, to our knowledge no longitudinal study has assessed version or how the change in version occurs. Knowing this would be important because characterizing the normal developmental process of the acetabulum would allow for easier recognition of a morphologic abnormality. QUESTIONS/PURPOSES To determine (1) how acetabular version changes during adolescence, (2) calculate how acetabular coverage of the femoral head changed during this period, and (3) to identify whether demographic factors or hip ROM are associated with acetabular development. METHODS This retrospective analysis of data from a longitudinal study included 17 volunteers (34 hips) with a mean (± SD) age of 11 ± 2 years; seven were male and 10 were female. The participants underwent a clinical examination of BMI and ROM and MRIs of both hips at recruitment and at follow-up (6 ± 2 years). MR images were assessed to determine maturation of the triradiate cartilage complex, acetabular version, and degree of the anterior, posterior, and superior acetabular sector angles (reflecting degree of femoral head coverage provided by the acetabulum anteriorly, posteriorly and superiorly respectively). An orthopaedic fellow (GG) and a senior orthopaedic resident (PJ) performed all readings in consensus; 20 scans were re-analyzed for intraobserver reliability. Thereafter, a musculoskeletal radiologist (KR) repeated measurements in 10 scans to test interobserver reliability. The intra- and interobserver interclass correlation coefficients for absolute agreement were 0.85 (95% CI 0.76 to 0.91; p < 0.001) and 0.77 (95% CI 0.70 to 0.84), respectively. All volunteers underwent a clinical examination by a senior orthopaedic resident (PJ) to assess their range of internal rotation (in 90° of flexion) in the supine and prone positions using a goniometer. We tested investigated whether the change in anteversion and sector angles differed between genders and whether the changes were correlated with BMI or ROM using Pearson's coefficient. The triradiate cartilage complex was open (Grade I) at baseline and closed (Grade III) at follow-up in all hips. RESULTS The acetabular anteversion increased, moving caudally further away from the roof at both timepoints. The mean (range) anteversion angle increased from 7° ± 4° (0 to 18) at baseline to 12° ± 4° (5 to 22) at the follow-up examination (p < 0.001). The mean (range) anterior sector angle decreased from 72° ± 8° (57 to 87) at baseline to 65° ± 8° (50 to 81) at the final follow-up (p = 0.002). The mean (range) posterior (98° ± 5° [86 to 111] versus 97° ± 5° [89 to 109]; p = 0.8) and superior (121° ± 4° [114 to 129] to 124° ± 5° [111 to 134]; p = 0.07) sector angles remained unchanged. The change in the anterior sector angle correlated with the change in version (rho = 0.5; p = 0.
{"title":"Acetabular Version Increases During Adolescence Secondary to Reduced Anterior Femoral Head Coverage.","authors":"G. Grammatopoulos, Paul Jamieson, J. Dobransky, K. Rakhra, S. Carsen, P. Beaulé","doi":"10.1097/CORR.0000000000000900","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000900","url":null,"abstract":"BACKGROUND\u0000Acetabular version influences joint mechanics and the risk of impingement. Cross-sectional studies have reported an increase in acetabular version during adolescence; however, to our knowledge no longitudinal study has assessed version or how the change in version occurs. Knowing this would be important because characterizing the normal developmental process of the acetabulum would allow for easier recognition of a morphologic abnormality.\u0000\u0000\u0000QUESTIONS/PURPOSES\u0000To determine (1) how acetabular version changes during adolescence, (2) calculate how acetabular coverage of the femoral head changed during this period, and (3) to identify whether demographic factors or hip ROM are associated with acetabular development.\u0000\u0000\u0000METHODS\u0000This retrospective analysis of data from a longitudinal study included 17 volunteers (34 hips) with a mean (± SD) age of 11 ± 2 years; seven were male and 10 were female. The participants underwent a clinical examination of BMI and ROM and MRIs of both hips at recruitment and at follow-up (6 ± 2 years). MR images were assessed to determine maturation of the triradiate cartilage complex, acetabular version, and degree of the anterior, posterior, and superior acetabular sector angles (reflecting degree of femoral head coverage provided by the acetabulum anteriorly, posteriorly and superiorly respectively). An orthopaedic fellow (GG) and a senior orthopaedic resident (PJ) performed all readings in consensus; 20 scans were re-analyzed for intraobserver reliability. Thereafter, a musculoskeletal radiologist (KR) repeated measurements in 10 scans to test interobserver reliability. The intra- and interobserver interclass correlation coefficients for absolute agreement were 0.85 (95% CI 0.76 to 0.91; p < 0.001) and 0.77 (95% CI 0.70 to 0.84), respectively. All volunteers underwent a clinical examination by a senior orthopaedic resident (PJ) to assess their range of internal rotation (in 90° of flexion) in the supine and prone positions using a goniometer. We tested investigated whether the change in anteversion and sector angles differed between genders and whether the changes were correlated with BMI or ROM using Pearson's coefficient. The triradiate cartilage complex was open (Grade I) at baseline and closed (Grade III) at follow-up in all hips.\u0000\u0000\u0000RESULTS\u0000The acetabular anteversion increased, moving caudally further away from the roof at both timepoints. The mean (range) anteversion angle increased from 7° ± 4° (0 to 18) at baseline to 12° ± 4° (5 to 22) at the follow-up examination (p < 0.001). The mean (range) anterior sector angle decreased from 72° ± 8° (57 to 87) at baseline to 65° ± 8° (50 to 81) at the final follow-up (p = 0.002). The mean (range) posterior (98° ± 5° [86 to 111] versus 97° ± 5° [89 to 109]; p = 0.8) and superior (121° ± 4° [114 to 129] to 124° ± 5° [111 to 134]; p = 0.07) sector angles remained unchanged. The change in the anterior sector angle correlated with the change in version (rho = 0.5; p = 0.","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"3 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79528813","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.0000000000000960
C. DeFrancesco, B. Striano, K. Baldwin
An estimation of postoperative event rates and survivorship after surgical interventions can be an important part of the informed consent process. However, biased methodology can yield misleading measures of the event burden. Surgeons must critically evaluate reported rates and understand common pitfalls to provide better patient counseling. However, because the methods used in clinical research may be confusing and intimidating, many doctors have difficulty doing so. To try to demystify this important topic, we will discuss alternative approaches to evaluating survivorship and the burden of events by using a hypothetical patient sample to illustrate available methods (Fig. 1A). All figures here use the same patient sample; their visual dissimilarity highlights how different methods handle sample data differently. We also cite real-world studies on ACL reconstruction to show the relative strengths and weaknesses of each technique.
{"title":"Statistics in Brief: Evaluating Measures of the Postoperative Event Burden.","authors":"C. DeFrancesco, B. Striano, K. Baldwin","doi":"10.1097/CORR.0000000000000960","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000960","url":null,"abstract":"An estimation of postoperative event rates and survivorship after surgical interventions can be an important part of the informed consent process. However, biased methodology can yield misleading measures of the event burden. Surgeons must critically evaluate reported rates and understand common pitfalls to provide better patient counseling. However, because the methods used in clinical research may be confusing and intimidating, many doctors have difficulty doing so. To try to demystify this important topic, we will discuss alternative approaches to evaluating survivorship and the burden of events by using a hypothetical patient sample to illustrate available methods (Fig. 1A). All figures here use the same patient sample; their visual dissimilarity highlights how different methods handle sample data differently. We also cite real-world studies on ACL reconstruction to show the relative strengths and weaknesses of each technique.","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"128 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"87961600","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.0000000000000971
David R. Maldonado
Orthopaedic surgeons have a working knowledge of the association between cam deformity and increased activity during adolescence [6, 16]. But we are less familiar with development of the acetabulum during the adolescent period and the potential relationship between changes in acetabular orientation and a pincer femoroacetabular impingement (FAI) morphology. And while more research has been done in the last 5 years [7, 10], there is limited evidence on the arthroscopic treatment of FAI in patients who are skeletally immature. For example, we know that the incidence of cam-type deformity may be related to early sports activities [6]; however, less is known about the acetabular side. To my knowledge, there have been no important new studies on pincer morphology and its association with symptomatic FAI. In the current study, Grammatopoulos and colleagues [3] use MRI to investigate changes to acetabular version during adolescence and identify demographic factors associated with acetabular development in a cohort of 17 asymptomatic adolescent patients (34 hips). They found that: (1) Acetabular version increased during adolescence, and (2) the acetabular femoral coverage decreased anteriorly, which correlated with acetabular version change. The authors could not conclude, however, whether demographic variables were associated with their findings. Still, the results of this study indicate that acetabular version increases, particularly rostrally, with skeletal maturity. Acetabular version has major implications regarding the decisionmaking process for potential hip preservation surgery [14]. When treating acetabular retroversion, there are several options: reverse (anteverting) periacetabular osteotomy (PAO), open surgical dislocation, and hip arthroscopy. The degree of retroversion, the amount of posterior wall insufficiency, and the presence of any degree of dysplasia all are important when selecting surgical treatment. Global acetabular retroversion is characterized by an anterolateral acetabular over-coverage that can coexist with dysplasia and lead to impingement [17]. Acetabular retroversion can lead to symptomatic and painful FAI [15]. Historically, reverse (also known as anteverting) PAO has been the gold standard for surgical treatment for the retroverted acetabulum, and has shown good results during shortand mid-term follow-up [12]. And although this procedure has shown good results in patients with and without dysplasia, an arthroscopic approach involving anterior rim trimming, cam deformity correction, labral anatomy, and function restoration and capsular plication has been proposed as an alternative to achieve favorable results in patients with acetabular retroversion and without severe dysplasia [4]. Arthroscopic management could potentially decrease morbidity as well as improve treatments of intra-articular pathology [11, 13]. However, posterior wall deficiency This CORR Insights is a commentary on the article “Acetabular Version Increases
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Pub Date : 2019-11-01DOI: 10.1097/CORR.0000000000000928
P. Jayakumar, T. Teunis, A. Vranceanu, S. Lamb, Mark A Williams, D. Ring, S. Gwilym
BACKGROUND Patient perceptions of their limitations after illness and injury can be quantified using patient-reported outcome measures (PROMs). Few studies have assessed construct validity (using correlations and factor analysis) and precision (floor and ceiling effects) of a range of frequently used PROMs longitudinally in a population of patients recovering from common upper extremity fractures according to area (general health, region-specific, or joint-specific measures) and mode of administration (fixed-scale or computer adaptive test). QUESTIONS/PURPOSES (1) What is the strength of the correlation between different PROMs within 1 week, 2 to 4 weeks and 6 to 9 months after shoulder, elbow, and wrist fractures? (2) Using a factor analysis, what underlying constructs are being measured by these PROMs? (3) Are there strong floor and ceiling effects with these instruments? METHODS Between January 2016 and August 2016, 734 patients recovering from an isolated shoulder, elbow, or wrist fracture completed physical-limitation PROMs at baseline (the initial office visit after diagnosis in the emergency department), 2 to 4 weeks after injury, and at the final assessment 6 to 9 months after injury. In all, 775 patients were originally approached; 31 patients (4%) declined to participate due to time constraints, four patients died of unrelated illness, and six patients were lost to follow-up. The PROMs included the PROMIS Physical Function (PF, a computer adaptive, general measure of physical function), the PROMIS Upper Extremity (UE, a computer adaptive measure of upper extremity physical function), the QuickDASH (a fixed-scale, region-specific measure), the Oxford Shoulder Score (OSS), the Oxford Elbow Score (OES) and the Patient-rated Wrist Evaluation (PRWE) (a fixed-scale, joint-specific measure), and the EQ-5D-3L (a fixed-scale measure of general health). PROMs were evaluated during recovery for construct validity (using correlations and factor analysis) and precision (using floor and ceiling effects). RESULTS Physical-limitation PROMs were intercorrelated at all time points, and the correlation strengthened over time (for example, PROMIS UE and QuickDASH at 1 week, r = -0.4665; at 2 to 4 weeks, r = -0.7763; at 6 to 9 months, r = -0.8326; p < 0.001). Factor analysis generated two factors or groupings of PROMs that could be described as capability (perceived ability to perform or engage in activities), and quality of life (an overall sense of health and wellbeing) that varied by time point and fracture type, Joint-specific and general-health PROMs demonstrated high ceiling effects 6 to 9 months after injury and PROMIS PF, PROMIS UE and QuickDASH had no floor or ceiling effects at any time points. CONCLUSIONS There is a substantial correlation between PROMs that assess physical limitations (based on anatomic region) and general health after upper extremity fractures, and these relationships strengthen during recovery. Regardless of the delive
{"title":"Construct Validity and Precision of Different Patient-reported Outcome Measures During Recovery After Upper Extremity Fractures.","authors":"P. Jayakumar, T. Teunis, A. Vranceanu, S. Lamb, Mark A Williams, D. Ring, S. Gwilym","doi":"10.1097/CORR.0000000000000928","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000928","url":null,"abstract":"BACKGROUND\u0000Patient perceptions of their limitations after illness and injury can be quantified using patient-reported outcome measures (PROMs). Few studies have assessed construct validity (using correlations and factor analysis) and precision (floor and ceiling effects) of a range of frequently used PROMs longitudinally in a population of patients recovering from common upper extremity fractures according to area (general health, region-specific, or joint-specific measures) and mode of administration (fixed-scale or computer adaptive test).\u0000\u0000\u0000QUESTIONS/PURPOSES\u0000(1) What is the strength of the correlation between different PROMs within 1 week, 2 to 4 weeks and 6 to 9 months after shoulder, elbow, and wrist fractures? (2) Using a factor analysis, what underlying constructs are being measured by these PROMs? (3) Are there strong floor and ceiling effects with these instruments?\u0000\u0000\u0000METHODS\u0000Between January 2016 and August 2016, 734 patients recovering from an isolated shoulder, elbow, or wrist fracture completed physical-limitation PROMs at baseline (the initial office visit after diagnosis in the emergency department), 2 to 4 weeks after injury, and at the final assessment 6 to 9 months after injury. In all, 775 patients were originally approached; 31 patients (4%) declined to participate due to time constraints, four patients died of unrelated illness, and six patients were lost to follow-up. The PROMs included the PROMIS Physical Function (PF, a computer adaptive, general measure of physical function), the PROMIS Upper Extremity (UE, a computer adaptive measure of upper extremity physical function), the QuickDASH (a fixed-scale, region-specific measure), the Oxford Shoulder Score (OSS), the Oxford Elbow Score (OES) and the Patient-rated Wrist Evaluation (PRWE) (a fixed-scale, joint-specific measure), and the EQ-5D-3L (a fixed-scale measure of general health). PROMs were evaluated during recovery for construct validity (using correlations and factor analysis) and precision (using floor and ceiling effects).\u0000\u0000\u0000RESULTS\u0000Physical-limitation PROMs were intercorrelated at all time points, and the correlation strengthened over time (for example, PROMIS UE and QuickDASH at 1 week, r = -0.4665; at 2 to 4 weeks, r = -0.7763; at 6 to 9 months, r = -0.8326; p < 0.001). Factor analysis generated two factors or groupings of PROMs that could be described as capability (perceived ability to perform or engage in activities), and quality of life (an overall sense of health and wellbeing) that varied by time point and fracture type, Joint-specific and general-health PROMs demonstrated high ceiling effects 6 to 9 months after injury and PROMIS PF, PROMIS UE and QuickDASH had no floor or ceiling effects at any time points.\u0000\u0000\u0000CONCLUSIONS\u0000There is a substantial correlation between PROMs that assess physical limitations (based on anatomic region) and general health after upper extremity fractures, and these relationships strengthen during recovery. Regardless of the delive","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"20 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83698426","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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