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Introduction The hypothesis of this study was that patient selection for midshaft clavicle fracture (open reduction internal fixation with plate versus conservative) would give better functional outcome than random treatment allocation. Methods We performed a systematic literature search for primary studies providing functional score and non-union rate after conservative or surgical management of midshaft clavicle fractures. Six randomized controlled trial and 19 non-randomized controlled trial studies encompassing a total of 1348 patients were included. Results Patients treated with surgical management were found to have statistically superior Constant scores in non-randomized controlled trials than in randomized controlled trials (94.76 ± 6.4 versus 92.49 ± 6.2; p < 0.0001). For conservative treatment, randomized controlled trials were found to have significantly better functional outcome. The prevalence of non-union (6.1%) did not show significant statistical difference between non-randomized controlled trial and randomized controlled trial studies. The functional outcome after surgical management was significantly higher than after conservative management in both randomized controlled trial and non-randomized controlled trial groups. The non-union rate after surgery (1.1% for both non-randomized controlled trial and randomized controlled trial) was significantly lower than following conservative treatment (9.9% non-randomized controlled trial versus 15.1% randomized controlled trial). Discussion This review shows that patient selection for surgery may influence functional outcome after midshaft clavicle fracture. Our results also confirm that plate fixation provides better functional outcome and lower non-union rate. [ABSTRACT FROM AUTHOR]

Background: Metastatic dedifferentiated liposarcoma (DDLPS) is primarily managed with chemotherapy, yet with poor response rate. Locoregional therapies, such as radiotherapy and percutaneous cryoablation, can provide palliation for inoperable metastatic sarcomas. In rare instances, those ablative therapies can elicit an immune-mediated regression of untreated metastases in a process named the abscopal effect. With the growing use of immunotherapy, reports on the abscopal effect have become more frequent during the last decade., Case Description: A 55-year-old patient with no prior medical history was diagnosed with a stage IV DDLPS. The patient was first treated with induction chemotherapy followed by en bloc resection and adjuvant radiotherapy. After two local relapses treated with chemotherapy, the patient developed a systemic disease progression. While progressing on immunochemotherapy, the patient underwent palliative percutaneous cryoablation. Three months after the procedure, the 18 fluorodeoxyglucose positron emission tomography/computed tomography ( 18 FDG PET/CT) showed regression of the distant metastasis alongside the regression of the cryoablated tumor, suggesting an abscopal effect., Conclusions: The occurrence of the abscopal effect after progressive disease suggests that cryoablation triggered a systemic immune response, highlighting the potential of this treatment combination. However, it remains a rare phenomenon, and further research and clinical trials are required to determine optimal treatment sequencing., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://atm.amegroups.com/article/view/10.21037/atm-23-1868/coif). R.D. reports payment or honoraria via institution by Society of Interventional Oncology, Boston Scientific, Guerbet and BTG. A.D. reports payment or honoraria via the institution by Genentech/Roche, Pharmamar, Traconpharma, AstraZeneca, Boston Scientific and Bristol-Myers Squibb. The other authors have no conflicts of interest to declare., (2024 AME Publishing Company. All rights reserved.)

Tenosynovial giant cell tumor is a benign condition that originates from synovial cells within joints, tendon sheaths, or bursae and may present either in localized (benign) or diffuse (locally aggressive) forms. Currently, the primary treatment approach is surgical, yielding satisfactory results with low recurrence rates in the localized forms, whereas the diffuse type displays high recurrence rates. In parallel, clinical trials are underway to explore pharmaceutical treatment options for the advanced diffuse type. This article aims at consolidating current knowledge about diagnosis and management of this rare tumor, additionally proposing a brief overview of novel therapeutic approaches., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Aging compromises hematopoietic and immune system functions, making older adults especially susceptible to hematopoietic failure, infections and tumor development, and thus representing an important medical target for a broad range of diseases. During aging, hematopoietic stem cells (HSCs) lose their blood reconstitution capability and commit preferentially toward the myeloid lineage (myeloid bias) 1,2 . These processes are accompanied by an aberrant accumulation of mitochondria in HSCs 3 . The administration of the mitochondrial modulator urolithin A corrects mitochondrial function in HSCs and completely restores the blood reconstitution capability of 'old' HSCs. Moreover, urolithin A-supplemented food restores lymphoid compartments, boosts HSC function and improves the immune response against viral infection in old mice. Altogether our results demonstrate that boosting mitochondrial recycling reverts the aging phenotype in the hematopoietic and immune systems., (© 2023. The Author(s), under exclusive licence to Springer Nature America, Inc.)

Aims: Tobacco, in addition to being one of the greatest public health threats facing our world, is believed to have deleterious effects on bone metabolism and especially on bone healing. It has been described in the literature that patients who smoke are approximately twice as likely to develop a nonunion following a non-specific bone fracture. For clavicle fractures, this risk is unclear, as is the impact that such a complication might have on the initial management of these fractures., Methods: A systematic review and meta-analysis were performed for conservatively treated displaced midshaft clavicle fractures. Embase, PubMed, and Cochrane Central Register of Controlled Trials (via Cochrane Library) were searched from inception to 12 May 2022, with supplementary searches in Open Grey, ClinicalTrials.gov, ProQuest Dissertations & Theses, and Google Scholar. The searches were performed without limits for publication date or languages., Results: The meta-analysis included eight studies, 2,285 observations, and 304 events (nonunion). The random effects model predicted a pooled risk ratio (RR) of 3.68 (95% confidence interval 1.87 to 7.23), which can be considered significant (p = 0.003). It indicates that smoking more than triples the risk of nonunion when a fracture is treated conservatively., Conclusion: Smoking confers a RR of 3.68 for developing a nonunion in patients with a displaced middle third clavicle fracture treated conservatively. We know that most patients with pseudarthrosis will have pain and a poor functional outcome. Therefore, patients should be informed of the significantly higher risks of nonunion and offered smoking cessation efforts and counselling. Moreover, surgery should be considered for any patient who smokes with this type of fracture., Competing Interests: None declared., (© 2023 The British Editorial Society of Bone & Joint Surgery.)

Background: Individuals requiring non-traumatic Gritti-Stokes amputation or mid-thigh amputation usually have multiple comorbidities that place them at high risk of mortality., Objective: To determine survival rate 5 years after Gritti-Stokes and mid-thigh amputation in individuals with vascular insufficiency and to identify the predictors of survival., Methods: We conducted a retrospective observational study including all individuals with vascular insufficiency who underwent amputation from September 2007 to December 2015 in our University Hospital. The indication for amputation was limb necrosis in 86% of cases, infection in 10%, and complications with the stump (discomfort, neuroma or scar dehiscence) in 4%. Medical records were analysed to determine factors and comorbidities. The date of death was retrieved from the national death registry at a minimum of 5 years after amputation. Cox proportional-hazard regression was used to estimate associations between factors and post-amputation survival with hazard ratios (HR) and 95% confidence intervals (CIs)., Results: We included 126 people with vascular insufficiency (83 men), mean age was 70 years [20; 97]; eighty-nine participants (71%) died during the study period. Survival rate was 68% at 1 year, 48% at 3 years and 37% at 5 years. Survival was associated with prosthetic fitting (HR 0.306 [95% CI 0.180; 0.521], p<0.001) and length of stay (HR 0.992 [95% CI 0.987; 0.997], p = 0.003). Conversely, limb necrosis was associated with a lower survival rate (HR 3.801 [95% CI 1.615; 8.949], p = 0.002). In a secondary multivariable analysis, Gritti-Stokes amputation was the only factor positively associated with prosthetic fitting (odds ratio 7.407 [95% CI 2.439; 22.489], p<0.001)., Conclusions: The survival rate at 5 years after Gritti-Stokes and mid-thigh amputation in people with vascular insufficiency was 37%. Prosthetic fitting was independently associated with better survival, and Gritti-Stokes amputation was the only factor positively related to prosthetic fitting., Competing Interests: Declarations of competing interest None., (Copyright © 2022 The Author(s). Published by Elsevier Masson SAS.. All rights reserved.)

Bone marrow (BM) cellularity assessment is a crucial step in the evaluation of BM trephine biopsies for hematologic and nonhematologic disorders. Clinical assessment is based on a semiquantitative visual estimation of the hematopoietic and adipocytic components by hematopathologists, which does not provide quantitative information on other stromal compartments. In this study, we developed and validated MarrowQuant 2.0, an efficient, user-friendly digital hematopathology workflow integrated within QuPath software, which serves as BM quantifier for 5 mutually exclusive compartments (bone, hematopoietic, adipocytic, and interstitial/microvasculature areas and other) and derives the cellularity of human BM trephine biopsies. Instance segmentation of individual adipocytes is realized through the adaptation of the machine-learning-based algorithm StarDist. We calculated BM compartments and adipocyte size distributions of hematoxylin and eosin images obtained from 250 bone specimens, from control subjects and patients with acute myeloid leukemia or myelodysplastic syndrome, at diagnosis and follow-up, and measured the agreement of cellularity estimates by MarrowQuant 2.0 against visual scores from 4 hematopathologists. The algorithm was capable of robust BM compartment segmentation with an average mask accuracy of 86%, maximal for bone (99%), hematopoietic (92%), and adipocyte (98%) areas. MarrowQuant 2.0 cellularity score and hematopathologist estimations were highly correlated (R 2  = 0.92-0.98, intraclass correlation coefficient [ICC] = 0.98; interobserver ICC = 0.96). BM compartment segmentation quantitatively confirmed the reciprocity of the hematopoietic and adipocytic compartments. MarrowQuant 2.0 performance was additionally tested for cellularity assessment of specimens prospectively collected from clinical routine diagnosis. After special consideration for the choice of the cellularity equation in specimens with expanded stroma, performance was similar in this setting (R 2  = 0.86, n = 42). Thus, we conclude that these validation experiments establish MarrowQuant 2.0 as a reliable tool for BM cellularity assessment. We expect this workflow will serve as a clinical research tool to explore novel biomarkers related to BM stromal components and may contribute to further validation of future digitalized diagnostic hematopathology workstreams., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction: The lympho-venous shunt using the distal vein of ALT flap pedicle allowed at the same time the coverage of the inguinal defects and to perform lymphovenous shunt into a run-in vein of the descending branch of the lateral circumflex femoral pedicle, draining the lymph through the flap pedicle. Surgical technique, complications and final outcomes (both clinical and lymphoscintigraphic) are reported., Methods: Five patients (45.8 y.o.[22-70]) with groin soft tissue loss with lymphatic leakage or lower limb lymphedema, benefited of the described technique. The ALT flap was used to cover the defect and, at the same time, we could perform a lymphovenous shunt between afferent lymphatics to the thigh and the descending branch of the lateral circumflex femoral pedicle, distal to the perforator nourishing the flap. Clinical and lymphoscintigraphic assessment of the limbs, cease of lymphorrhea or cellulitis/lymphangitis episodes, eventual downstaging of physiologic/physical therapy were recorded. LYMphatic Quality Of Life in leg (LYMQoLLeg) and patient satisfaction were evaluated., Results: Average flap size was 88.8cm 2 (range 84-126). The mean number of multi-lymphovenous anastomosis (MLVA) performed was 1.8 (range 1-3) per patient with 1-3 lymphatics shunted into each vein. Only one hemato-seroma requiring surgical revision. Mean improvement of perometer values was 48.2% (range 27.7-67.7) with an average follow-up of 13.6 months (range 12-17). Lymphoscintigraphy showed disappearing of the lymphatic leak and lymphedema with a high satisfaction of LYMQoL score., Discussion: The combination of pedicle flap with lympho-venous bypass as lymphatic derivation concept, improving the chronic morbidity scenarios of lymphatic complications.

Background: Megaprostheses are one of the preferred choices of reconstruction after tumor resection. Periprosthetic joint infections are one of the most serious complications of joint prostheses surgeries. In this study, our aim was to analyze the efficacy of silver-coated megaprostheses in reducing the risk of prosthesis-related infection., Methods: One hundred forty-two patients who had undergone implantation of a mega-endoprosthesis for non-neoplastic or post-neoplastic conditions were included in this retrospective study. The end-point of the survival analysis was the prosthesis failure due to infection., Results: Thirty-eight patients had undergone implantation of a silver-coated megaprosthesis and 104 patients a megaprosthesis without silver coating. The survival analysis showed an overall infection-free survival rate of 82.3% at five years and 61.9% at 10 years. Silver-coated prostheses had an HR of 0.72 (95% CI: 0.26-2.05; P=0.54 )., Conclusion: Implantation of a silver-coated mega-prosthesis in non-oncological patients did not significantly reduce the risk of prosthesis-related infection., Competing Interests: All authors declare that they have no conflict of interest related to the publication of this paper.

Objectives: The COVID-19 pandemic is unprecedented as a global crisis over the last century. How do specialist surgeons make decisions about patient care in these unprecedent times?, Design: Between April and May 2020, we conducted an international qualitative study. Sarcoma surgeons from diverse global settings participated in 60 min interviews exploring surgical decision making during COVID-19. Interview data were analysed using an inductive thematic analysis approach., Setting: Participants represented public and private hospitals in 14 countries, in different phases of the first wave of the pandemic: Australia, Argentina, Canada, India, Italy, Japan, Nigeria, Singapore, Spain, South Africa, Switzerland, Turkey, UK and USA., Participants: From 22 invited sarcoma surgeons, 18 surgeons participated. Participants had an average of 19 years experience as a sarcoma surgeon., Results: 17/18 participants described a decision they had made about patient care since the start of the pandemic that was unique to them, that is, without precedence. Common to 'unique' decisions about patient care was uncertainty about what was going on and what would happen in the future ( theme 1: the context of uncertainty ), the impact of the pandemic on resources or threat of the pandemic to overwhelm resources ( theme 2: limited resources ), perceived increased risk to self ( theme 3: duty of care ) and least-worst decision making, in which none of the options were perceived as ideal and participants settled on the least-worst option at that point in time ( theme 4: least-worst decision making )., Conclusions: In the context of rapidly changing standards of justice and beneficence in patient care, traditional decision-making frameworks may no longer apply. Based on the experiences of surgeons in this study, we describe a framework of least-worst decision making. This framework gives rise to actionable strategies that can support decision making in sarcoma and other specialised fields of surgery, both during the current crisis and beyond., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Targeting of the most aggressive tumor cell subpopulations is key for effective management of most solid malignancies. However, the metastable nature of tumor heterogeneity, which allows cells to transition between strong and weak tumorigenic phenotypes, and the lack of reliable markers of tumor-promoting properties hamper identification of the most relevant cells. To overcome these obstacles, we designed a functional microRNA (miR)-based live-cell reporter assay to identify highly tumorigenic cells in xenotransplants of primary Ewing sarcoma (EwS) 3D cultures. Leveraging the inverse relationship between cell pluripotency and miR-145 expression, we successfully separated highly tumorigenic, metastasis-prone (miR-145 low ) cells from poorly tumorigenic, nonmetastatic (miR-145 high ) counterparts. Gene expression and functional studies of the two cell populations identified the EPHB2 receptor as a prognostic biomarker in patients with EwS and a major promoter of metastasis. Our study provides a simple and powerful means to identify and isolate tumor cells that display aggressive behavior., (Copyright © 2021 The Authors, some rights reserved; exclusive licensee American Association for the Advancement of Science. No claim to original U.S. Government Works. Distributed under a Creative Commons Attribution NonCommercial License 4.0 (CC BY-NC).)

Background: Chordoma is a rare malignant tumor of the axial skeleton. Percutaneous cryoablation (PCA) is a minimally invasive technique that allows freezing of tumors under imaging control. The purpose of our retrospective study was to investigate the outcome of PCA in a selected cohort of patients with sacrococcygeal chordoma, with a minimum of 5 years follow-up., Materials and Methods: Four patients were treated in 10 sessions. The mean follow-up was 57.3 months. We evaluated the feasibility, the procedure-related complications, the impact on pain control and oncological outcomes., Results: Freezing of 100% of the tumor volume was possible in 60%. Pain control was not reliably evaluable. Local recurrence occurred in 90% of the treated lesions; the mean time to progression was 8.1 months (range 1.5-16). At last follow-up, one patient had died of the disease, one of another cause and one was receiving the best supportive care. The only patient alive without the disease had received additional carbon-ion radiotherapy. The 5-year survival rate after index PCA was 50%., Conclusion: Complete freezing of the tumor was technically challenging, mainly due to the complex local anatomy. Recurrence occurred in 90% of the lesions treated. PCA should be considered with caution in the curative management of sacrococcygeal chordoma., (© 2020 Wiley Periodicals LLC.)

Synovial sarcoma (SyS) is an aggressive neoplasm driven by the SS18-SSX fusion, and is characterized by low T cell infiltration. Here, we studied the cancer-immune interplay in SyS using an integrative approach that combines single-cell RNA sequencing (scRNA-seq), spatial profiling and genetic and pharmacological perturbations. scRNA-seq of 16,872 cells from 12 human SyS tumors uncovered a malignant subpopulation that marks immune-deprived niches in situ and is predictive of poor clinical outcomes in two independent cohorts. Functional analyses revealed that this malignant cell state is controlled by the SS18-SSX fusion, is repressed by cytokines secreted by macrophages and T cells, and can be synergistically targeted with a combination of HDAC and CDK4/CDK6 inhibitors. This drug combination enhanced malignant-cell immunogenicity in SyS models, leading to induced T cell reactivity and T cell-mediated killing. Our study provides a blueprint for investigating heterogeneity in fusion-driven malignancies and demonstrates an interplay between immune evasion and oncogenic processes that can be co-targeted in SyS and potentially in other malignancies.

Background: Total hip arthroplasty (THA) is one of the most successful procedures in orthopedic surgery. The most frequent THA indications are osteoarthritis and avascular necrosis, whereas symptomatic aseptic loosening is the most common indication to revision surgery. Chondrosarcoma (CS) is the most frequent bone sarcoma in adults, and proximal femur is the most prevalent location. Wide resection is the treatment of choice.We report 3 cases of unrecognized high-grade CS in the setting of primary or revision THA and reviewed the literature on this rare clinical presentation., Methods: A systematic literature review on CS in the setting of THA, published between 1980 and 2020, was performed on PubMed, Embase, Medline, Ovid SP, and Web of Science, using the guidelines set in the Preferred Reporting Items for Systematic Reviews and Mata-analyses (PRISMA)., Results: Case series: Three patients were referred to our sarcoma center after failure of THA due to unrecognized high-grade CS. All 3 had rapid fatal outcome. Literature review: Fifty-nine articles were identified, of which 8 were included in the study. They confirmed that primary or revision THA failure due to unrecognized CS is extremely rare, with only few cases reported in the literature., Conclusions: Before proceeding to primary or revision arthroplasty, diagnosis must be ascertained. Atypical presentation of a common pathology, such as osteoarthritis, avascular necrosis, or aseptic loosening of an endoprosthesis, should raise suspicion for another cause to symptoms, and additional workup be performed. As our cases demonstrated, unrecognized or inadequately managed bone sarcoma may lead to poor or even fatal outcome., (© 2020 The Authors.)

Synovial sarcoma (SyS) is an aggressive mesenchymal malignancy invariably associated with the chromosomal translocation t(X:18; p11:q11), which results in the in-frame fusion of the BAF complex gene SS18 to one of three SSX genes. Fusion of SS18 to SSX generates an aberrant transcriptional regulator, which, in permissive cells, drives tumor development by initiating major chromatin remodeling events that disrupt the balance between BAF-mediated gene activation and polycomb-dependent repression. Here, we developed SyS organoids and performed genome-wide epigenomic profiling of these models and mesenchymal precursors to define SyS-specific chromatin remodeling mechanisms and dependencies. We show that SS18-SSX induces broad BAF domains at its binding sites, which oppose polycomb repressor complex (PRC) 2 activity, while facilitating recruitment of a non-canonical (nc)PRC1 variant. Along with the uncoupling of polycomb complexes, we observed H3K27me3 eviction, H2AK119ub deposition and the establishment of de novo active regulatory elements that drive SyS identity. These alterations are completely reversible upon SS18-SSX depletion and are associated with vulnerability to USP7 loss, a core member of ncPRC1.1. Using the power of primary tumor organoids, our work helps define the mechanisms of epigenetic dysregulation on which SyS cells are dependent., (© 2020 Boulay et al.)

Imaging-guided percutaneous core needle biopsy (CNB) is the preferred diagnostic method for bone and soft tissue tumors. In less than 1% of cases, complications are clinically significant and include mainly haema-toma and bleeding. We present a case of acute compartment syndrome (ACS) following CNB of the proximal fibula. A 26-year-old female patient was referred to our sarcoma center with a suspicion of giant cell tumor (GCT) of the proximal fibula. The CT-guided CNB under local anesthesia had caused transient severe pain irradiating to the foot, rapidly subsiding after correction of the needle trajectory. The patient was discharged on the same day without residual symptoms. She presented at the emergency department 48 hours later with severe leg pain and swelling. Compartment pressure was elevated. Urgent fasciotomies were performed, revealing muscle edema, without significant haematoma. Postoperatively, paresthesia improved progressively and the patient regained a normal neurologic status within 4 months. Pathologic analysis confirmed the diagnosis of GCT, which was resected after neoadjuvant denosumab therapy. At the 2-year follow up visit, the patient still presented pain at exertion, but had no objective neurological sequela. ACS is not a well-known complication of CNB in the diagnosis of bone tumors. This rare complication might be diagnosed too late, or even missed, due to pre-existing pain, which can sometimes be severe in GCT, and to the usually short post-procedure surveillance in an outpatient procedure.

Background: Surgical procedures interfering with the draining nodes in the inguinal region carry the intrinsic risk of lymphatic complications. Lesions of the inguinal lymphatic network can lead to lymphocele or lymphocutaneous fistulas and can eventually be associated to limb lymphedema with consequent high morbidity., Objectives: This article describes a new surgical algorithm based on wound properties to properly address lymphatic complications of the inguinal area. Based on our experience, surgical solutions ranged from selective lymphatic vessel ligation to microsurgical lymphatic fistula treatment and free tissue transfer., Methods: Fourteen consecutive patients underwent surgery in our department following failed attempts to address persistent lymphatic leaks. Patient characteristics such as smoking, previous surgeries, comorbidities, and wound properties were considered. Identification of the leak was performed using blue patent dye and indocyanine green fluorescence. Surgical reconstruction occurred, according to our algorithm., Results: Lymphatic leaks were visualized in 11 of 14 patients. Direct closure of the wound after leak ligation could be performed in 4 of 14 patients. Multilymphatic into vein anastomosis was performed in 3 of 14 patients, and the remaining patients benefited from flap surgery based on the wound defects. All 14 patients had successful outcomes (100%) with early drain removal (average, 6 [SD, 6] days) and definitive wound healing 2 weeks postoperatively. After a mean follow-up of 12 (SD, 2.9) months, no clinical infection, lymphatic complication, or wound breakdown occurred. One patient had a partial recurrence that did not require surgical intervention., Conclusions: A stepwise approach, combining lymphatic surgery principles and plastic surgery flap techniques, can lead to an effective treatment algorithm where surgical options are wound tailored to guarantee the best functional outcomes.

Cryoablation (CA) has gained popularity in the treatment of benign and malignant musculoskeletal tumors. While extra-abdominal desmoid (EAD) tumors are not malignant, they remain challenging to treat because of their high local recurrence rate. We reviewed all EAD tumors treated with CA at our institution between November 2012 and March 2020. Fourteen procedures were performed on nine females and one male (mean age, 33 ± 18 years) as either first-line ( n = 4) or salvage therapy ( n = 6) with curative intent ( n = 8) or tumor debulking ( n = 2). Mean tumor size was 63.6 cm 3 (range, 3.4-169 cm 3 ). Contrast-enhanced MRI was performed before treatment and at 3-, 6-, and 12-month follow-up. Treatment outcome was based on the change in enhanced tumor volume (ET-V). For curatively treated patients, the mean ET-V change was -97 ± 7%, -44 ± 143%, and +103 ± 312% at 3, 6, and 12 months, respectively. For debulking patients, the mean ET-V change was -98 ± 4%, +149 ± 364%, and +192 ± 353% at 3, 6, and 12 months, respectively. During a mean follow-up of 53.7 months (range, 12-83 months), one grade III and one grade IV complication were noted. We found CA to be safe and well tolerated in patients with EAD.

Background: Interest around carbon/PEEK plates and nails has been raising. The elastic modulus close to the bone, the high load-carrying capacity and radiolucency make CFR/PEEK materials a potential breakthrough. In the literature, there are abundant data about CFR/PEEK plates in the treatment of proximal humerus, distal radius and distal fibula fractures. In patients affected by bone metastasis, CFR/PEEK nails were proved effective and safe with 12 months of follow-up. Very little is known about performances of CFR/PEEK nails in patients affected by other pathologies., Purposes: The aim of the study was to evaluate safety and efficacy of CFR/PEEK nails in the treatment of various pathological conditions. It was also investigated whatever radiolucency of this nails could lead to a more objective evaluation of bone callus or disease site., Patients and Methods: In the study group were included 20 patients (22 bone segments) who underwent CFR/PEEK nail implantation (eight humerus, one tibia, nine femur and four knee arthrodesis). They were affected by pathological fractures, and in four cases, they required an arthrodesis of the knee. They were retrospectively evaluated considering nail failures and bone callus or disease progression (RUSH scores). Mean follow-up time was 11 months (min 6.8-max 20.3). In the control group were included patients treated with titanium nails in the same institution for the same pathologies. An interclass correlation coefficient (ICC) analysis was performed in both groups considering RUSH scores by two expert surgeon from two institution to assess whether radiolucency could lead to a more objective evaluation of disease or bone callus site., Results: The ICC of mean values between RUSH scores was 0.882 (IC 95%: 0.702-0.953) in the CFR/PEEK group, while it was 0.778 (IC 95%: 0.41-0.91) in the titanium group. Observers' evaluation showed a significantly higher obscuration by titanium nails than by CFR/PEEK nails. No osteosynthesis failures were reported in both groups., Conclusions: Our results confirm the safety of CFR/PEEK nails in the short-medium term. The radiolucency of these materials led our observers to perform more objective evaluations of bone callus formation or disease progression compared to the titanium group given the higher ICC., Level of Evidence: III Case-control therapeutic study.

Background: Treatment of soft tissue sarcomas (STS) should only be initiated once the diagnosis is fully established. Resection of tumors of unknown nature should be avoided. Nevertheless, specialized centers continue to face numbers of unplanned excisions (UPE) in STS., Aim: To compare oncologic and functional outcomes, number of surgeries, length of hospital stay and treatment costs of UPE versus planned excision (PE) in STS., Method: A retrospective single tertiary center study was performed on 201 patients. Survival, local and distant recurrence rates were compared between PE (n = 137) and UPE (n = 64). In a subgroup analysis of 60 patients, functional outcome (MSTS and TESS scores), and socio-economic impact (number of surgeries, length of hospital stay and treatment costs) in "functional planned excision" (fPE) group (n = 30) and "functional unplanned excision" (fUPE) group (n = 29) were compared., Results: There was no significant difference in oncological outcome between PE and UPE. In the subgroup analysis, we found a non-significant difference in functional outcome. Patients in the fUPE had significantly more surgeries (3.5 vs. 1.4; p < 0.00001) and costs of their management was 64% higher than fPE (p = 0.048). Hospital stay was longer after fUPE but not statistically significant (18.3 days vs. 11.8 days; p = 0.13)., Conclusion: Even though oncological and functional outcomes are comparable after PE and UPE of STS, the number of surgeries, length of hospital stay and treatment costs were higher in patients with UPE. Our data underscore the importance of specialized STS treatment centers including multidisciplinary management., (Copyright © 2020 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Aging of the population results in an increase of the incidence of cancer and bone metastases. The proximal femur is one of the most frequent locations of bone metastases. A pathological fracture has a major impact on the quality of life and potentially on survival. In case of impending fracture, prophylactic fixation is therefore strongly recommended. The management of metastases of the proximal femur depends on multiple parameters, life expectancy and fracture risk being the most important ones. If survival is estimated to be less than 6 weeks, surgery is generally not indicated. Beyond 6 weeks, surgical indication essentially depends on location of the metastases on the proximal femur and the presence of a fracture., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Purpose: Extra-abdominal desmoid tumours are benign and rare, and lead to a persistent treatment dilemma because of their high recurrence rate and their heterogeneous behaviour. The goal of this retrospective study was to evaluate the results of different treatment modalities for extra-abdominal desmoid tumours at four sarcoma treatment centres., Methods: The mean follow-up time for the 96 patients included in the study (63.5% female; mean age 38.9 years) was 8.4 years (2.0&ndash;40.5 years). The initial treatments were surgery (n = 44), surgery with radiation (n = 16), watchful waiting (n = 15), radiation only (n = 9), or systemic treatment (n = 12). Patient demographics, tumour sites, and the follow-up status of all patients were reviewed and evaluated for each of the treatment modalities., Results: The local recurrence rate was 45.5% in patients with primary surgical treatment and 37.5% following surgery combined with irradiation. Patients who were treated with radiation alone showed regressive (33.3%) or stable disease (66.6%). Systemic treatment alone resulted in disease progression in 41.7% of our patients. In the watchful waiting group, 73.3% showed stable disease, 20.0% showed spontaneous regression, and 6.7% showed progression after a mean follow-up of 4.1 years (2.0&ndash;11.5 years)., Conclusions: Our results suggest that a watchful waiting approach should be the first line treatment in asymptomatic desmoid tumours. However, radiation can help improve local control rates in patients who have undergone surgery. Progression and local recurrence rates following systemic treatment were comparable to those observed in surgery combined with radiation.

Background: Chronic nonbacterial osteomyelitis (CNO) is a rare chronic autoinflammatory syndrome affecting mainly children and young adults. The natural history of the disease is marked by recurrent pain as the mainstay of inflammatory outbreaks. Typical radiographic findings are osteosclerosis and hyperostosis of the medial clavicle, sternum and first rib. Compression of the brachial plexus is exceedingly rare and one of the few surgical indications. Literature on total clavicle reconstruction is scarce. While claviclectomy alone has been associated with fair functional and cosmetic outcomes, several reconstruction techniques with autograft, allograft or even cement ("Oklahoma prosthesis") have been reported with the aim of achieving better pain control, cosmetic outcome and protecting the brachial plexus and subclavian vessels. We herewith report a unique case of complicated CNO of the clavicle treated with total clavicle reconstruction using a free peroneal graft., Case Presentation: A 21-year-old female patient presented with CNO of her left clavicle, associated with recurrent, progressive and debilitating pain as well as limited range of motion. In recent years, she started complaining of paresthesia, weakness and pain radiating to her left arm during arm abduction. The clavicle diameter reached 6 cm on computed tomography, with direct compression of the brachial plexus and subclavian vessels. Following surgical biopsy for diagnosis confirmation, she further developed a chronic cutaneous fistula. Therefore, a two-stage total clavicle reconstruction using a vascularized peroneal graft stabilized by ligamentous reconstruction was performed. At two-year follow-up, complete pain relief and improvement of her left shoulder Constant-Murley score were observed, along with satisfactory cosmetic outcome., Conclusions: This case illustrates a rarely described complication of CNO with direct compression of the brachial plexus and subclavian vessels, and chronic cutaneous fistula. To our knowledge, there is no consensus regarding the optimal management of this rare condition in this context. Advantages and complications of clavicle reconstruction should be carefully discussed with patients due to limited evidence of superior clinical outcome and potential local and donor-site complications. While in our case the outcomes met the patient's satisfaction, it remains an isolated case and further reports are awaited to help surgeons and patients in their decision process.

Background: Bone metastases are frequently painful and may lead to various complications that can affect quality of life. While external beam radiation therapy is the standard first-line treatment, 20-30% of patients do not experience sufficient pain relief. Cryoablation is increasingly being used for the treatment of musculoskeletal metastases. The purpose of our retrospective study was to analyze pain relief and local disease control after percutaneous image-guided cryoablation (PCA) therapy of painful bone metastases., Materials and Methods: Sixteen patients treated with PCA for painful bone metastases (n=18) over a 5-year period (from June 2011 to June 2016) were retrospectively reviewed. Five patients also benefited from long bone fixation because of an impending fracture. We analyzed the impact of treatment on pain relief, using a numerical rating scale (NRS), and local disease control., Results: The mean follow-up period was 12 months (range, 1.5-39 months). At last oncological outpatient consultation, 75% (12/16) of patients had good pain relief, while 63% (10/16) had locally stable disease or no local recurrence of the treated bone metastases. The mean NRS score decreased significantly from 3.3 to 1.2 after PCA (p=0.0024). The five patients with concomitant long bone fixation all had satisfactory pain relief at the last follow-up visit., Conclusion: PCA is a safe and valid treatment option for pain and local disease control in cases of painful bone metastases after failed standard first-line therapy. This technique can also be effectively associated to prophylactic long bone fixation and may allow for easier rehabilitation protocols when treating weight-bearing bones., Level of Evidence: IV, Retrospective case series., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

It has been recently shown that increased oxidative phosphorylation, as reflected by increased mitochondrial activity, together with impairment of the mitochondrial stress response, can severely compromise hematopoietic stem cell (HSC) regeneration. Here we show that the NAD + -boosting agent nicotinamide riboside (NR) reduces mitochondrial activity within HSCs through increased mitochondrial clearance, leading to increased asymmetric HSC divisions. NR dietary supplementation results in a significantly enlarged pool of progenitors, without concurrent HSC exhaustion, improves survival by 80%, and accelerates blood recovery after murine lethal irradiation and limiting-HSC transplantation. In immune-deficient mice, NR increased the production of human leucocytes from hCD34+ progenitors. Our work demonstrates for the first time a positive effect of NAD + -boosting strategies on the most primitive blood stem cells, establishing a link between HSC mitochondrial stress, mitophagy, and stem-cell fate decision, and unveiling the potential of NR to improve recovery of patients suffering from hematological failure including post chemo- and radiotherapy., (Copyright © 2019. Published by Elsevier Inc.)

So-called metal allergy is a new interesting subject in orthopedics. Two different ways of thinking prevail in the literature. In the German orthopaedic literature, the diagnosis of metal allergy is often described and considered a real pathology, while we can find a more skeptical approach to this entity in Anglo-Saxons literature. Being an exclusion diagnostic, without any universal consensus on how to diagnose or on the treatment, the aim of this article is to clarify what we know about metal allergy today.

Background and Objectives: Extensive surgery is often required for advanced soft tissue sarcoma (STS) of the limb. In the 1980s, a new approach was developed: isolated limb perfusion (ILP). This study aimed to assess incidence and impact on patient survival based on lymph node metastasis with systematic radical lymphadenectomy during ILP. Methods: Retrospective study of 57 consecutive patients treated by ILP for limb STS with simultaneous radical lymph node dissection in our tertiary referral center between 1992 and 2015. Results: Median age was 62 years (19-87) and 30 patients were male (53%). Lymph node involvement was observed in 13 patients (N1, 23%), regarded as metastatic spreading in 4 angiosarcomas, 3 epithelioid sarcomas, 2 leiomyosarcomas, 2 undifferentiated sarcomas and 2 synovial sarcomas. For the N0 patient group, median survival was 73.9 months (CI 95% 41.9-105.9) compared to 15.1 months (CI 95% 7.4-22.6) in case of metastatic lymph node ( p =0.002). The median disease-free survival was 33,0 months (CI 95% 12,5-53.5) in N0 group and 8.0 months (CI 95% 4.0-11.9) in N1 ( p =0.006). Conclusions: Lymph node metastases of STS patients selected for ILP seemed to have a negative impact on both overall and disease-free survival. Radical lymph node dissection should be included in ILP procedure., Competing Interests: Competing Interests: The authors have declared that no competing interest exists.

Sarcomas are rare diseases, the treatment of which requires an appropriate technical plateform and a broad spectrum of multidisciplinary specialists. Many are initially treated by unplanned excision, and then referred to specialized centres. Secondary treatments may lead to higher complication rates and local recurrence, with lower functional outcome, life quality and possibly overall survival. In order to improve the accessibility for referral to a specialist centre, the coordination of clinical and research activities, and the quality of the management of sarcomas in general, Lausanne University Hospital (CHUV) has opened a Sarcoma centre on October 1st 2016. The objective of the present paper is to illustrate the concept and provide useful clinical recommendations., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Background: Surgical access to benign neoplastic lesions of the femoral head are associated with significant morbidity, including contamination of intra-osseous access tracks, articular cartilage lesions, avascular bone necrosis or tumour recurrence due to incomplete curettage., Case Presentation: We present a case of a 20-year-old female with a giant cell tumour in the femoral head, which was treated with curettage through a trans-foveal approach and bone grafting. This technique includes a surgical dislocation of the hip with trochanteric osteotomy., Results: At the latest follow-up at 2 years, there was no evidence of local recurrence or avascular necrosis on MRI, and the patient was pain free and back to sports.

Lumbo-sacral chordoma is a rare, slow-growing tumor, arising from embryonic nothocordal remnants. Wide en bloc excision with clear margins remains mandatory to achieve satisfactory recurrence rates and disease-free survival. No chemotherapy has been demonstrated to be effective and radiotherapy is only marginally effective. Tyrosine kinase receptor inhibitors have showed encouraging results in locally advanced and metastatic chordoma. Reconstructive surgery may become very complex. Multidisciplinary approach in tertiary hospitals is always necessary., (© 2015 Wiley Periodicals, Inc.)

Objective: The purpose of this article is to assess the effect of the adaptive statistical iterative reconstruction (ASIR) technique on image quality in hip MDCT arthrography and to evaluate its potential for reducing radiation dose., Subjects and Methods: Thirty-seven patients examined with hip MDCT arthrography were prospectively randomized into three different protocols: one with a regular dose (volume CT dose index [CTDIvol], 38.4 mGy) and two with a reduced dose (CTDIvol, 24.6 or 15.4 mGy). Images were reconstructed using filtered back projection (FBP) and four increasing percentages of ASIR (30%, 50%, 70%, and 90%). Image noise and contrast-to-noise ratio (CNR) were measured. Two musculoskeletal radiologists independently evaluated several anatomic structures and image quality parameters using a 4-point scale. They also jointly assessed acetabular labrum tears and articular cartilage lesions., Results: With decreasing radiation dose level, image noise statistically significantly increased (p=0.0009) and CNR statistically significantly decreased (p=0.001). We also found a statistically significant reduction in noise (p=0.0001) and increase in CNR (p≤0.003) with increasing percentage of ASIR; in addition, we noted statistically significant increases in image quality scores for the labrum and cartilage, subchondral bone, overall diagnostic quality (up to 50% ASIR), and subjective noise (p≤0.04), and statistically significant reductions for the trabecular bone and muscles (p≤0.03). Regardless of the radiation dose level, there were no statistically significant differences in the detection and characterization of labral tears (n=24; p=1) and cartilage lesions (n=40; p≥0.89) depending on the ASIR percentage., Conclusion: The use of up to 50% ASIR in hip MDCT arthrography helps to reduce radiation dose by approximately 35-60%, while maintaining diagnostic image quality comparable to that of a regular-dose protocol using FBP.