Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Published in
Clinical Orthopaedics and Related Research®
Volume 471 | Issue 3 | Mar, 2013

Prophylactic Stabilization for Bone Metastases, Myeloma, or Lymphoma: Do We Need to Protect the Entire Bone?

Hasham M. Alvi MD, Timothy A. Damron MD

The current operative standard of care for disseminated malignant bone disease suggests stabilizing the entire bone to avoid the need for subsequent operative intervention but risks of doing so include complications related to embolic phenomena.

Emerging Ideas: Engineering the Periosteum: Revitalizing Allografts by Mimicking Autograft Healing

Michael D. Hoffman MS, Danielle S. W. Benoit PhD

To fulfill the need for large volumes, devitalized allografts are used to treat massive bone defects despite a 60%, 10-year postimplantation fracture rate. Allograft healing is inferior to autografts where the periosteum orchestrates remodeling.

Orthopaedic Case of the Month: A 51-year-old Man with a Painless Wrist Mass

Razvan Nicolescu MD, Paul D. Clifford MD, Philip G. Robinson MD, Sheila A. Conway MD

Which Implant Is Best After Failed Treatment for Pathologic Femur Fractures?

Jonathan Agner Forsberg MD, Rikard Wedin MD, PhD, Henrik Bauer MD, PhD

Successful treatment of pathologic femur fractures can preserve a patient’s independence and quality of life. The choice of implant depends on several disease- and patient-specific variables; however, its durability must generally match the patient’s estimated life expectancy. Failures do occur, however, it is unclear which implants are associated with greater risk of failure.

Constrained Total Hip Megaprosthesis for Primary Periacetabular Tumors

Takafumi Ueda MD, PhD, Shigeki Kakunaga MD, PhD, Satoshi Takenaka MD, PhD, Nobuhito Araki MD, PhD, Hideki Yoshikawa MD, PhD

Limb-salvage reconstruction for periacetabular malignant tumors is one of the most challenging problems in orthopaedic oncology. Reconstructive options include resection arthroplasty, endoprosthesis, allograft, recycled autobone graft, arthrodesis, and pseudarthrosis. However, no standard procedure exists because of rarity and clinical variability of the disease. We previously developed a megaprosthetic system with a constrained total hip mechanism (C-THA).

Computer-assisted Tumor Surgery in Malignant Bone Tumors

Kwok Chuen Wong MD, Shekhar Madhukar Kumta MD

Small recent case series using CT-based navigation suggest such approaches may aid in surgical planning and improve accuracy of intended resections, but the accuracy and clinical use have not been confirmed.

Joint-preserving Tumor Resection and Reconstruction Using Image-guided Computer Navigation

Kwok Chuen Wong MD, Shekhar Madhukar Kumta MD

Joint-preserving surgery is performed in select patients with bone sarcomas of extremities and allows patients to retain the native joint with better joint function. However, recurrences may relate to achieving adequate margins and there is frequently little room for error in tumors close to the joint surface. Further, the tumor margin on preoperative CT and/or MR images is difficult to transpose to the actual extent of tumor in the bone in the operating room.

Compress® Knee Arthroplasty Has 80% 10-year Survivorship and Novel Forms of Bone Failure

John H. Healey MD, Carol D. Morris MD, Edward A. Athanasian MD, Patrick J. Boland MD

Compliant, self-adjusting compression technology is a novel approach for durable prosthetic fixation of the knee. However, the long-term survival of these constructs is unknown.

Making a Case for the Socioeconomic Determinacy of Survival in Osteosarcoma

Saminathan S. Nathan FRCS, John H. Healey FACS

The literature on osteosarcoma survival generally focuses on tumor and treatment variables, although it is unclear whether and how ethnic and socioeconomic factors might influence survival.

Can a Less Radical Surgery Using Photodynamic Therapy With Acridine Orange Be Equal to a Wide-margin Resection?

Takao Matsubara MD, Katsuyuki Kusuzaki MD, Akihiko Matsumine MD, Tomoki Nakamura MD, Akihiro Sudo MD

Wide-margin resections are an accepted method for treating soft tissue sarcoma. However, a wide-margin resection sometimes impairs function because of the lack of normal tissue. To preserve the normal tissue surrounding a tumor, we developed a less radical (ie, without a wide margin) surgical procedure using adjunctive photodynamic therapy and acridine orange for treating soft tissue sarcoma. However, whether this less radical surgical approach increases or decreases survival or whether it increases the risk of local recurrence remains uncertain.

Surgical Technique: Tibia Cortical Strut Autograft Interposition Arthrodesis After Distal Radius Resection

Michiel A. J. Sande MD, PhD, Niels H. W. Geldorp MSc, P. D. Sander Dijkstra MD, PhD, Antonie H. M. Taminiau MD, PhD

Distal radius reconstruction after en bloc tumor resection remains a surgical challenge. Although several surgical techniques, either reconstructing the wrist or achieving a stable arthrodesis, have been described, it is unclear to what degree these restore function.

Surgical Resection of Relapse May Improve Postrelapse Survival of Patients With Localized Osteosarcoma

Kwok Chuen Wong FHKAM (Orth), Vincent Lee FHKAM (Paed), MRCP, Matthew M. K. Shing FHKAM (Paed), MRCPCH, Shekhar Kumta PhD

Despite neoadjuvant chemotherapy and wide surgical ablation, 15% to 25% of patients with primary osteosarcoma will relapse (local recurrence or metastases). Neither chemotherapy nor radiation therapy alone will render a patient disease-free without concomitant surgical ablation of relapse. We prefer excision of relapse when possible. However, it is unclear whether excision enhances survival.

Giant Cell Tumor With Pathologic Fracture: Should We Curette or Resect?

Lizz Heijden MSc, P. D. Sander Dijkstra MD, PhD, Domenico A. Campanacci MD, PhD, C. L. Max H. Gibbons MD, PhD, Michiel A. J. Sande MD, PhD

Approximately one in five patients with giant cell tumor of bone presents with a pathologic fracture. However, recurrence rates after resection or curettage differ substantially in the literature and it is unclear when curettage is reasonable after fracture.

A Novel Imaging System Permits Real-time in Vivo Tumor Bed Assessment After Resection of Naturally Occurring Sarcomas in Dogs

William C. Eward DVM, MD, Jeffrey K. Mito MD, PhD, Cindy A. Eward DVM, Jessica E. Carter, Jorge M. Ferrer PhD, David G. Kirsch MD, PhD, Brian E. Brigman MD, PhD

Treatment of soft tissue sarcoma (STS) includes complete tumor excision. However, in some patients, residual sarcoma cells remain in the tumor bed. We previously described a novel hand-held imaging device prototype that uses molecular imaging to detect microscopic residual cancer in mice during surgery.

Treating Metastatic Disease: Which Survival Model Is Best Suited for the Clinic?

Jonathan Agner Forsberg MD, Daniel Sjoberg MA, Qing-Rong Chen PhD, Andrew Vickers PhD, John H. Healey MD

To avoid complications associated with under- or overtreatment of patients with skeletal metastases, doctors need accurate survival estimates. Unfortunately, prognostic models for patients with skeletal metastases of the extremities are lacking, and physician-based estimates are generally inaccurate.

Haptic Robot-assisted Surgery Improves Accuracy of Wide Resection of Bone Tumors: A Pilot Study

Fazel Khan MD, Andrew Pearle MD, Christopher Lightcap PhD, Patrick J. Boland MD, John H. Healey MD

Accurate reproduction of the preoperative plan at the time of surgery is critical for wide resection of primary bone tumors. Robotic technology can potentially help the surgeon reproduce a given preoperative plan, but yielding control of cutting instruments to a robot introduces potentially serious complications. We developed a novel passive (“haptics”) robot-assisted resection technique for primary bone sarcomas that takes advantage of robotic accuracy while still leaving control of the cutting instrument in the hands of the surgeon.

Surgery Quality and Tumor Status Impact on Survival and Local Control of Resectable Liposarcomas of Extremities or the Trunk Wall

Piotr Rutkowski MD, PhD, Sławomir Trepka MD, PhD, Konrad Ptaszynski MD, PhD, Milena Kołodziejczyk MD, PhD

The 5-year survival rates for localized liposarcomas reportedly vary from 75% to 91% with histologic grade as the most important prognostic factor. However, it is unclear which other factors, including the initial surgery quality and recurrent tumors, influence survival in localized liposarcomas (LPS).

Primary Osseous Tumors of the Hindfoot: Why the Delay in Diagnosis and Should We Be Concerned?

Peter S. Young MRCS, Stuart W. Bell MRCS, MRCP, Elaine M. MacDuff BSc, MBChB, FRCPath, Ashish Mahendra FRCS Tr & Orth

Bony tumors of the foot account for approximately 3% of all osseous tumors. Diagnosis is frequently delayed as a result of lack of clinician familiarity and as a result of their rarity. The reasons for the delays, however, are unclear.

Compressive Osseointegration Into a Custom Acetabular Implant Masquerading as Tumor Recurrence: A Case Report

Adam J. Schwartz MD, Christopher P. Beauchamp MD

Compressive osseointegration is a durable method of method of achieving fixation in long-bone reconstruction, and radiographic findings are well described. The radiographic appearance of integration into the pelvis is poorly defined in the available literature.

Does Combined Open and Arthroscopic Synovectomy for Diffuse PVNS of the Knee Improve Recurrence Rates?

Matthew W. Colman MD, Jason Ye MD, Kurt R. Weiss, Mark A. Goodman MD, Richard L. McGough MD

Diffuse-type pigmented villonodular synovitis (PVNS) has a high local recurrence rate and as such can lead to erosive destruction of the involved joint. Multiple surgical modalities exist, but it is unknown which technique best minimizes local recurrence and surgical morbidity.

Adult Soft Tissue Sarcoma Local Recurrence After Adjuvant Treatment Without Resection of Core Needle Biopsy Tract

Odion Binitie MD, Shawn Tejiram MD, Sheila Conway MD, David Cheong MD, H. Thomas Temple MD, G. Douglas Letson MD

Core needle biopsies of sarcomas allow a diagnosis in a high percentage of patients with few complications. However, it is unclear whether the tract needs to be excised to prevent recurrences.

Staples Equal Sutures for Skin Closure After Soft Tissue Tumor Resection

David C. Moore BA, Meredith H. Sellers BA, Kristin R. Archer PhD, DPT, Herbert S. Schwartz MD, Ginger E. Holt MD

Wound closure accounts for a relatively constant portion of the time required to complete a surgical case. Both longer closure times and wound infections contribute to higher medical costs and patient morbidity.

Using the CUSUM Test to Control the Proportion of Inadequate Open Biopsies of Musculoskeletal Tumors

David J. Biau MD, PhD, Kurt R. Weiss MD, MSc, Rej S. Bhumbra PhD, FRCS (Tr & Orth), Darin Davidson MD, MSc, Chris Brown MD, PhD, Jay S. Wunder MD, MSc, Peter C. Ferguson MD, MSc

Biopsies of musculoskeletal tumors lead to alterations in treatment in almost 20% of cases. Control charts are useful to ensure that a process is operating at a predetermined level of performance, although their use has not been demonstrated in assessing the adequacy of musculoskeletal biopsies.

Lipid-functionalized Dextran Nanosystems to Overcome Multidrug Resistance in Cancer: A Pilot Study

Eisuke Kobayashi MD, PhD, Arun K. Iyer PhD, Francis J. Hornicek MD, PhD, Mansoor M. Amiji PhD, Zhenfeng Duan MD, PhD

The toxicity of anticancer agents and the difficulty in delivering drugs selectively to tumor cells pose a challenge in overcoming multidrug resistance (MDR). Recently, nanotechnology has emerged as a powerful tool in addressing some of the barriers to drug delivery, including MDR in cancer, by utilizing alternate routes of cellular entry and targeted delivery of drugs and genes. However, it is unclear whether doxorubicin (Dox) can be delivered by nanotechnologic approaches.

Lymphadenectomy and Histologic Subtype Affect Overall Survival of Soft Tissue Sarcoma Patients With Nodal Metastases

Chigusa Sawamura MD, MPH, Seiichi Matsumoto MD, PhD, Takashi Shimoji MD, PhD, Keisuke Ae MD, PhD, Atsushi Okawa MD, PhD

Lymph node metastases in patients with soft tissue sarcomas are rare and these metastases are frequently associated with certain histologic subtypes. The survival is believed to be poor if lymph node metastases occur and the potential benefit of lymphadenectomy is unclear.

Ultrasound as a First-line Test in the Diagnosis of Carpal Tunnel Syndrome: A Cost-effectiveness Analysis

John R. Fowler MD, Mitchell G. Maltenfort PhD, Asif M. Ilyas MD

The American Academy of Orthopaedic Surgeons (AAOS) recommends that surgeons obtain a confirmatory test in patients for whom carpal tunnel surgery is being considered. The AAOS, however, does not specify a preferred test. Ultrasound reportedly causes less patient discomfort and takes less time to perform, while maintaining comparable sensitivity and specificity to electrodiagnostic testing (EDX).

Lateralized Reverse Shoulder Arthroplasty Maintains Rotational Function of the Remaining Rotator Cuff

Stefan Greiner MD, Christan Schmidt, Christian König Dr Ing, Carsten Perka MD, Sebastian Herrmann MD

Humeral rotation often remains compromised after nonlateralized reverse shoulder arthroplasty (RSA). Reduced rotational moment arms and muscle slackening have been identified as possible reasons for this impairment. Although several clinical studies suggest lateralized RSA may increase rotation, it is unclear whether this is attributable to preservation of rotational moment arms and muscle pretension of the remaining rotator cuff.

Surgical Technique: Iliosacral Reconstruction With Minimal Spinal Instrumentation

Nader A. Nassif MD, Jacob M. Buchowski MD, Kelly Osterman RN, Douglas J. McDonald MD

Posterior pelvic ring reconstruction can be challenging and controversial. The choice regarding whether to reconstruct and how to reconstitute the pelvic ring is unclear. Many methods provide stability but often are technically difficult and require excessive dissection.

High Diagnostic Value of Synovial Biopsy in Periprosthetic Joint Infection of the Hip

Bernd Fink MD, Alexander Gebhard MD, Martin Fuerst MD, Irina Berger MD, Peter Schäfer MD

The role of the synovial biopsy in the preoperative diagnosis of a periprosthetic joint infection (PJI) of the hip has not been clearly defined.

Intraprosthetic Dislocation: A Specific Complication of the Dual-mobility System

Remi Philippot MD, PhD, Bertrand Boyer MD, Frederic Farizon MD

The dual-mobility concept was proposed as an alternative to prevent postoperative dislocation events. However, intraprosthetic dislocation (IPD) is a troublesome and specific complication induced by the loss of the polyethylene retentive rim and escape of the femoral head from the polyethylene liner. The factors associated with IPD are unknown as only isolated cases have been reported and do not provide a clear understanding of the mechanisms of failure.

Morbid Obesity May Increase Dislocation in Total Hip Patients: A Biomechanical Analysis

Jacob M. Elkins MS, Matej Daniel PhD, Douglas R. Pedersen PhD, Bhupinder Singh BS, H. John Yack PhD, John J. Callaghan MD, Thomas D. Brown PhD

Obesity has reached epidemic proportions in the United States. Recently, obesity, especially morbid obesity, has been linked to increased rates of dislocation after THA. The reasons are unclear. Soft tissue engagement caused by increased thigh girth has been proposed as a possible mechanism for decreased joint stability.

Physical Activity Level Improves After Periacetabular Osteotomy for the Treatment of Symptomatic Hip Dysplasia

Eduardo N. Novais MD, Benton Heyworth MD, Kerri Murray MPH, Victor M. Johnson MA, Young-Jo Kim MD, PhD, Michael B. Millis MD

Hip pain secondary to acetabular dysplasia can prevent participation in recreational activities.

Can Radiographic Morphometric Parameters for the Hip Be Assessed on MRI?

David Stelzeneder MD, Andreas Hingsammer MD, Sarah D. Bixby MD, Young-Jo Kim MD, PhD

Although morphometric hip parameters measured on radiographs are valuable tools guiding diagnosis and therapy in patients with hip disorders, some clinicians use MRI for such measurements, although it is unclear whether the parameters assessed on MRI differ from those assessed on radiographs.

Does A Kinematically Aligned Total Knee Arthroplasty Restore Function Without Failure Regardless of Alignment Category?

Stephen M. Howell MD, Stacey J. Howell BS, Kyle T. Kuznik BS, Joe Cohen, Maury L. Hull PhD

Kinematically aligned TKA restores function by aligning the femoral and tibial components to the normal or prearthritic joint lines of the knee. However, aligning the components to the joint lines of the normal knee also aligns the tibial component in varus, creating concern that varus alignment might result in poor function and early catastrophic failure.

Short-keeled Cemented Tibial Components Show an Increased Risk for Aseptic Loosening

Christian Ries MD, Markus Heinichen MD, Florian Dietrich, Eike Jakubowitz PhD, Christian Sobau MD, Christian Heisel MD, PhD

The choice of implant design plays an important role for primary fixation of a TKA. Short-keeled tibial components allow implantation through a smaller approach with less femorotibial subluxation.

The Vector of Quadriceps Pull is Directed From the Patella to the Femoral Neck

Osamu Tanifuji MD, John David Blaha MD, Shin Kai PhD

The quadriceps is the primary extensor of the knee. Its vector, which is perpendicular to the flexion axis of the knee, is important in understanding knee function and properly aligning total knee components. Three-dimensional (3-D) imaging enables evaluation using a 3-D model of each quadriceps component.

Does Valgus Femoral Osteotomy Improve Femoral Head Roundness in Severe Legg-Calvé-Perthes Disease?

Hui Taek Kim MD, Ja Kyung Gu MD, Sung Ho Bae MD, Jae Hoon Jang MD, Jong Seo Lee MD

Many surgeons perform a varus femoral or Salter pelvic osteotomy in patients with Legg-Calvé-Perthes (LCP) disease. However, more severely deformed femoral heads show greater congruency in adduction rather than in abduction. Therefore, a valgus-(flexion) femoral osteotomy (VFO) seems preferable rather than a varus femoral or Salter pelvic osteotomy.

Are Results After Single-event Multilevel Surgery in Cerebral Palsy Durable?

Erich Rutz MD, Richard Baker PhD, Oren Tirosh PhD, Reinald Brunner MD

Gait and function may deteriorate with time in patients with spastic diplegia. Single-event multilevel surgery often is performed to either improve gait or prevent deterioration. However it is unclear whether the presumed gait improvements are durable.

Locking Buttons Increase Fatigue Life of Locking Plates in a Segmental Bone Defect Model

Marc Tompkins MD, David J. Paller MS, Douglas C. Moore MS, Joseph J. Crisco PhD, Richard M. Terek MD

Durability of plate fixation is important in delayed union. Although locking plates result in stronger constructs, it is not known if locking affects the fatigue life of a plate. Two locking screws on either side of the nonunion could decrease working length and increase strain in the plate. However, the reinforcing effect of the locking head on the plate may compensate, so that it is unclear whether locking reduces fatigue life.

Fee-based Care is Important for Access to Prompt Treatment of Hip Fractures Among Veterans

Kelly K. Richardson PhD, Peter Cram MD, Mary Vaughan-Sarrazin PhD, Peter J. Kaboli MD, MS

Hip fracture is a medical emergency for which delayed treatment increases risk of disability and death. In emergencies, veterans without access to a Veterans Administration (VA) hospital may be admitted to non-VA hospitals under fee-based (NVA-FB) care paid by the VA. The affect of NVA-FB care for treatment and outcomes of hip fractures is unknown.

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