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To evaluate the utility and complications of using carbon fiber implants (CFIs) compared with standard titanium alloy (TI) intramedullary implants for stabilization of impending or existing pathologic fractures.Retrospective comparison.Ninety-four patients undergoing intramedullary fixation of 100 impending or existing pathologic fractures between 2014-2019 were identified for inclusion.The primary outcome was postoperative complications. Other outcomes included implant type, pathology, indication, and adjuvant therapy.Fifty-three percent of cases used a CFI, whereas 47% of cases used a TI. There were no differences between groups with regard to anatomic location (P = 0.218), indication for surgery (P = 0.066), histology (P = 0.306), or postoperative adjuvant therapy (P = 0.308). Nineteen percent of cases incurred a postoperative complication in each group (P = 0.530), and no differences were noted with regard to complication type including implant failure (P = 0.442) and wound complications (P = 0.322). There was a cost saving of $400 with TI implants compared with CFI.This is a high-risk population for postoperative complications after stabilization of pathologic fractures. Although there were no statistical differences in complications between CFI and TI, implant choice depends on patient characteristics and surgeon preference.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Introduction The purpose of this study was to evaluate nationwide trends and regional variability in opioid prescriptions after common orthopaedic procedures. Methods A retrospective analysis of privately insured subjects from the MarketScan database between 2015 and 2016 was conducted. Median oral morphine equivalents and interquartile ranges were analyzed by region for the initial post-op prescriptions and 90-day total prescriptions for opioid-naive patients undergoing the following: carpal tunnel release; anterior cruciate ligament reconstruction; arthroscopic meniscectomy; bimalleolar ankle fracture open reduction and internal fixation; distal radius fracture open reduction and internal fixation; arthroscopic rotator cuff repair; single-level anterior cervical discectomy and fusion; and total shoulder, hip, and knee arthroplasties. We hypothesized that notable regional variability exists with postoperative narcotic prescribing habits. Results Seventy three thousand nine hundred twenty-one opioid-naive patients were identified. A notable regional variability was observed across the United States in the prescriptions given for all procedures, except total joint arthroplasty. Furthermore, although patients undergoing soft-tissue-only procedures required the fewest refills, patients undergoing total joint arthroplasty required the most. Discussion Notable regional variability exisits in opioid prescribing patterns for many common orthopaedic procedures. Furthermore, prescriptions were smallest in the region most affected by the opioid epidemic. This information can be used to re-evaluate recommendations, serve as a benchmark for surgeons, and develop institutional and quality improvement guidelines to reduce excess postoperative opioid prescriptions. Level of evidence Level III observational cohort study.

Surgical specialties are at an increased risk for occupational hazards, including sharps-related injuries. The objective of this study was to report the frequency of sharps injuries and evaluate which characteristics influence the number of injuries and reporting behaviors.A web-based, anonymous survey was available for 10 weeks to 46 US orthopaedic surgery residency programs (1,207 potential residents) participating in an education research collaborative. The survey was divided into the following areas: demographics, training and attitudes concerning occupational hazards, and sharps injuries and reporting. Logistic regression was used to evaluate the association between the above variables on experiencing sharps injuries with significance threshold set at P0.05.In this study, 518 surveys were included yielding a response rate of 42.9% (518/1,207). Nearly 80% of the residents recalled some form of safety training during intern orientation and 62% of the respondents felt that they received adequate occupation safety training specifically related to orthopaedic surgery. Four hundred seventeen residents (80.5%) experienced a sharps injury (mean 2.8). Nearly 20% of the respondents experienced ≥5 sharps injuries. Needle sticks (38.8%) were responsible for the greatest percentage of injuries, followed by Kirschner wires (33.6%), scalpel (22.5%), and bone (17.3%). Only 42% of the residents consistently reported all injuries. Reasons included feelings of no risk (63.1%), too much hassle (58.9%), embarrassment (14.5%), other (8.7%), forgot (5.8%), and unclear what to do (3.3%). Inadequate safety training specific to orthopaedic surgery (odds ratio, 2.32 [95% confidence interval, 1.20 to 4.46]; P = 0.012) and greater training seniority (odds ratio, 2.04 [95% confidence interval, 1.64 to 2.52]; P0.0001) were associated with acquiring five or more sharps injuries.Sharps injuries are a prevalent and concerning reality for orthopaedic surgical trainees. Despite this common occurrence, only 42% of the residents always reported their injuries. Inadequate training specific to orthopaedic surgery and each subsequent year of postgraduate training are associated with increased sharps injuries.Level III, retrospective observational survey.

Objective The purpose of this study is to evaluate the effect of resident participation on operative time and surgical complications in isolated lower extremity fracture care. Setting Patients who were treated at teaching hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program database. Participants A total of 2,488 patients who underwent surgical fixation of isolated hip fractures, femoral or tibial shaft fractures, and ankle fractures. Design Patients were stratified by surgical procedure and post-graduate year (PGY) of the resident involved. Total operative time and surgical complications were analyzed with respect to resident participation and seniority. Multivariable logistic regression analyses were used to adjust for potential confounders including case complexity, wound class, and patient comorbidity burden. Results As PGY level increased, operative time increased for each procedure. The odds for a deep surgical site infection decreased as resident seniority increased, but the odds for wound dehiscence increased as resident seniority increased. We found no difference in the incidences of superficial infections or return to the OR with respect to PGY level. Academic quarter within the academic year did not correlate with any of the surgical complications. Furthermore, when cases performed with residents were compared to those performed without residents, there was no increased risk of superficial infections, deep infections, or return to the OR. Conclusions This nationally representative dataset demonstrates that operative times for lower extremity orthopedic trauma increased as resident seniority increased. Additionally, senior resident participation was associated with increased wound dehiscence, whereas junior resident participation was associated with an increased risk of deep surgical site infections. However, there was no associated “July effect” for residents at any level of training and there was no increased risk for surgical site infections or return to the OR in cases involving resident participation.

Extensor mechanism injuries are disabling injuries that require prompt evaluation and treatment and complications are often devastating. While smoking has been shown to increase complications following total joint arthroplasty, this relationship has not yet been established in those undergoing extensor mechanism repair. The purpose of this study was to evaluate the risk of smoking on postoperative complications following extensor mechanism repair. The National Surgical Quality Improvement Program (NSQIP) database was used to identify patients who underwent an extensor mechanism repair from 2005 to 2016. Patients were stratified by tobacco use, as either “current” or “nonsmokers.” A multivariate logistic regression was used to control for demographic and comorbid factors while assessing perioperative complications. 5208 patients were identified, and of these, 843 (16.2%) were current smokers. Smokers were younger, male, and with lower BMIs compared to nonsmokers (p = 0.001, p = 0.003, p = 0.002, respectively). They had a higher rate of surgical complications (OR 1.61, CI 1.02–2.52), including deep surgical site infections (OR 3.27, CI 1.03–10.43) and unplanned return to the operating room (OR 2.001, 1.24–3.23). Smokers were more likely to be readmitted within 30 days of surgery (OR 1.78, OR 1.09–2.90). Tobacco use is associated with a 1–2% increase in surgical, but not medical, complications following repair of extensor mechanism injuries. Smokers are at higher risk for deep infections, unplanned return to the OR, and hospital readmission. Identifying these patients preoperatively will allow surgeons to accurately counsel patients on perioperative risks. Counseling in preoperative smoking cessation is valuable for optimizing patient outcomes following extensor mechanism repair. Retrospective comparative study, Level III.

Although bone repair is typically an efficient process, an inadequate healing response can occur, with approximately 5-20% of fractures developing nonunion. Even with improved healing strategies and external fixation devices, overall rate of nonunion has not been significantly reduced, particularly for atrophic nonunion. Atrophic nonunion is characterized by sparse or no callus formation and is difficult to treat clinically, resulting in long-term pain and functional limitation. Reliable preclinical models are needed to study the pathophysiology of atrophic nonunion to create better treatment options. The MouseNail kit (RISystem, Landquart, Switzerland) provides a highly standardized approach in which stabilized segmental bone defects are achieved through interlocked intramedullary nailing. However, reliably performing this surgery is technically challenging, particularly while maintaining strict asepsis. Skilled and aseptic surgical execution is important and necessary because it ensures optimal animal welfare and reproducibility. Therefore, the aim of this paper is to describe:•Novel modifications to the MouseNail kit that allow for: 1) a completely aseptic surgical environment, including description of a hanging limb orthopedic aseptic preparation and 2) a reduction in fracture gap size necessary for induction of atrophic nonunion.•Pre- to post-operative recommendations to facilitate successful performance of murine orthopedic survival surgery., Graphical Abstract Image, graphical abstract

INTRODUCTION The purpose of this study is to investigate the current disparities for major lower extremity amputation in patients with critical limb ischemia (CLI) and infection. METHODS A retrospective analysis of the National Surgical Quality Improvement Program's database for the years 2011 to 2017 was conducted. Multivariate models were used to isolate the effect of race and ethnicity on the likelihood of a below-knee or above-knee amputation (BKA and AKA, respectively) for CLI secondary to type 2 diabetes mellitus, atherosclerosis, peripheral vascular disease, chronic osteomyelitis, and deep soft-tissue infections. RESULTS For all diagnoses, blacks were 93.3%, and Hispanics were 61.9% more likely to undergo a BKA than white patients (P < 0.001). In addition, black patients had a 133.0% higher risk of an AKA than white patients (P < 0.001). Disparities were greatest with blacks undergoing surgery for CLI secondary to atherosclerosis (BKA odds ratio 2.093; AKA: odds ratio 2.625). Black patients also had an elevated risk of amputation secondary to diabetes, peripheral vascular disease, and deep soft-tissue infections (P < 0.001). DISCUSSION This nationally representative, cohort-based study demonstrates that notable racial and ethnic disparities for lower extremity amputations persist, with a higher proportion of black and Hispanic patients undergoing amputation compared with limb salvage procedures for atraumatic CLI and infection. LEVEL OF EVIDENCE Level III prognostic.

BACKGROUND AND OBJECTIVES With recent advances in chemotherapy and surgical techniques, the trend in the treatment of osteosarcoma continues to progress towards limb salvage. However, studies comparing limb salvage with amputation continue to be limited by selection bias and small sample sizes. This study utilized propensity-score matching to minimize potential confounders and selection bias to compare the survival rates in patients with osteosarcoma that were treated with amputation vs limb salvage surgery. METHODS The Surveillance, Epidemiology, and End Results Program was utilized to identify all patients with a diagnosis of extremity osteosarcoma. Patients were matched with demographics, tumor characteristics, and treatment information. These variables were then fitted in a multivariate model and hazard ratios (HR) for overall- and disease-specific mortality was calculated. RESULTS A total of 4107 patients were identified, of which, 1538 were left after propensity-score matching. Older age, Black race, upper extremity location, and higher American joint committee on cancer (AJCC) class were associated with worse overall- and disease-specific mortality rates (P ≤ .0389). Compared with their matched counterparts, patients treated with amputation had higher overall mortality (HR 1.677; P

BACKGROUND Excessive radiation to health-care providers has been linked to risks of cancer and cataracts, but its negative effects can be substantially reduced by lead aprons, thyroid shields, and leaded glasses. Hospitals are required to provide education and proper personal protective equipment, yet discrepancies exist between recommendations and compliance. This article presents the results of a survey of U.S. orthopaedic surgery residents concerning attitudes toward radiation exposure and personal protective equipment behavior. METHODS An invitation to participate in a web-based, anonymous survey was distributed to 46 U.S. allopathic orthopaedic surgery residency programs (1,207 potential resident respondents). The survey was conceptually divided into the following areas: demographic characteristics, training and attitudes concerning occupational hazards, personal protective equipment provision and use, and general safety knowledge. Prevalence ratios (PRs) and 95% confidence intervals (CIs) were calculated for the association between these characteristics and compliance with thyroid shield or lead gown wear. RESULTS In this study, 518 surveys were received, with 1 survey excluded because of insufficient response, leaving 517 surveys for analysis (42.8% response rate). Ninety-eight percent of residents believed that personal protective equipment should be provided by the hospital or residency program. However, provision of personal protective equipment was not universal, with 33.8% reporting none and 54.2% reporting provision of a gown and thyroid shield. The prevalence of leaded glasses usage was 21%. Poor lead gown compliance and thyroid shield wear were associated with difficulty finding the corresponding equipment: PR, 2.51 (95% CI, 1.75 to 3.62; p < 0.001) for poor lead gown compliance and PR, 2.14 (95% CI, 1.46 to 3.16; p < 0.0001) for poor thyroid shield wear. Not being provided with personal protective equipment was also significantly associated with low compliance with both lead gowns (PR, 1.47 [95% CI, 1.04 to 2.08]; p = 0.03) and thyroid shields (PR, 1.69 [95% CI, 1.18 to 2.41]; p = 0.004). Respondents from the Southeast, West, or Midwest had lower compliance with lead gown usage. Forgetting was the number 1 reason to not wear a lead apron (42%). CONCLUSIONS Radiation exposure is associated with increased risk of serious health problems. Our findings identified that the availability of lead personal protective equipment leads to increased compliance among residents surveyed. In addition to yearly occupational hazard training specific to orthopaedic surgery, greater efforts by residency programs and hospitals are needed to improve access to lead personal protective equipment and compliance for orthopaedic residents.

Background There are few data on the types of procedures orthopaedic oncologists perform in their first years of practice. Because fellowships are graduating fellows each year and the number of tumor patients is limited, defining the practice patterns of early-career orthopaedic oncologists may help diminish early employment discontent and enhance workforce discussions.

Aneurysmal bone cysts (ABCs) were first described by Jaffe and Lichtenstein in 19421. Eighty percent of these lesions occur during the first two decades of life2; the most common location is the metaphysis of long bones. To the best of our knowledge, only four cases of individuals with multiple ABCs occurring over a period of time (metachronous ABCs) have been described to date3-6 (Table I). The cases all have been similar in presentation, imaging, and pathology to solitary ABCs; the only difference has been regarding the sex of the patient. While solitary ABCs have been shown to be predominant in females (62%)7, the reported cases of metachronous ABCs have all occurred in males. We report the case of an adolescent girl with multiple ABCs presenting separately in the proximal part of the femur and the distal part of the humerus over a five-month period. The patient and her parents were informed that data concerning the case would be submitted for publication, and they provided consent. View this table: TABLE I Reported Cases of Metachronous Aneurysmal Bone Cysts A healthy and active fourteen-year-old girl presented to the sports medicine clinic with unilateral hip pain. She had no history of trauma or an activity-related injury. Radiographs demonstrated a well-defined (5.4 × 2.8 cm) oval lucent geographic lesion in the proximal part of the femur, which initially was thought to be consistent with a unicameral bone cyst. At the short interval follow-up, the pain had worsened, and a new palpable mass was noted. Additional radiographs revealed substantial interval progression of the lesion with extension into the adjacent soft tissues with expansion of the bone (Fig. 1). Fig. 1 Anteroposterior radiograph demonstrates a lucent geographic lesion with a well-defined border (black arrow) in the right hip. However, there is focal extension …

Left ventricular assist devices (LVADs) augment the cardiac function of patients with severe left-sided cardiac disease. These devices are typically used as a bridge to transplantation and have proven effective at improving longevity and overall quality of life1. Improved longevity results in increased numbers of noncardiac surgical procedures for other medical conditions2. Although these procedures carry obvious risk, they have been performed with favorable outcomes1-6. Infection is of utmost concern with noncardiac surgery in a patient with an LVAD. While infection rates have improved with the use of second-generation LVADs, the infection rate remains at 30% to 50%, with 20% to 27% classified as bloodstream infections7. The concerns regarding infection are especially important with arthroplasty procedures because implants are susceptible to biofilms, and complications from infection can be devastating. Also of concern is the nonpulsatile flow that the LVADs deliver, which can have serious implications when a patient is under general anesthesia and placed in the lateral position because preload and systemic vascular resistance are affected. Despite these risks, a literature search revealed two total knee arthroplasties that were performed in patients with LVADs4. Both patients developed postoperative infections related to the LVAD, but neither total knee arthroplasty became infected. In terms of cardiac function, total hip arthroplasty has been shown to be extremely effective at playing a role in improving cardiac function, with postarthroplasty patients showing substantial improvements in exercise duration, maximum workload, peak oxygen consumption, and percentage of predicted maximum oxygen uptake achieved by six months postsurgery8. We present a case of a total hip arthroplasty in a patient with a HeartMate II LVAD (Thoratec Corporation, Pleasanton, California). To the best of our knowledge, there are no previous reports in the literature of a …

Gastrocnemius flaps have been used for decades to reconstruct defects of the proximal tibia and knee. They have proven to be useful in the soft-tissue reconstruction of defects caused by trauma, tumors, and infections about the knee, and the reconstruction of extensor mechanism discontinuity with and without total joint arthroplasty. The flaps have low failure rates and a distinct proximally based blood supply that allows them to be elevated and rotated up to 15 cm above the level of the knee joint. The vascular anatomy is reproducible because rotational flaps do not require microvascular anastomosis. An understanding of the applied surgical anatomy, approaches, and utility of the gastrocnemius flap makes the technique a useful tool for the orthopaedic surgeon when plastic surgery assistance is not readily available.

Background: Osteosarcoma with metastatic disease at the time of presentation necessitates a very different clinical discussion with patients than those who present with isolated disease. Therefore, the purpose of this study was to evaluate the role of local control surgery in patients with metastatic osteosarcoma as well as to further investigate confounding variables such as demographic, socioeconomic, and tumor characteristics on the overall and cancer-specific mortality rates. Methods: The National Cancer Institute’s Surveillance, Epidemiology, and End Results Program was queried for all patients with a diagnosis of metastatic osteosarcoma between the years 2004–2014. Patients who did not undergo any treatment (excisional surgery or chemotherapy) for their disease, were diagnosed at autopsy, or whose histologic subtypes were surface (parosteal and periosteal) or secondary osteosarcomas (Paget’s and radiation-induced) were excluded from further analyses. Multivariate models were used to isolate and evaluate the impact of excisional surgery of the primary tumor on the likelihood of survivorship. Results: A total of 3,277 patients were identified, of which 42.5% underwent excisional surgery of the primary tumor. The 5-year survival rate for all patients with metastatic osteosarcoma was 24.4% whereas it was 34.5% in patients who underwent surgery and 5.8% in those who did not undergo surgery. Patients in the lowest quartile for income and education were more likely to be treated nonoperatively. Older age, axial location, and lower education level portended a much worse overall- and cancer-specific mortality. However, surgical excision of the primary tumor was most strongly associated with prolonged survivorship. Conclusions: Patients with metastatic osteosarcoma whose primary tumor characteristics are amenable to surgery have a better prognosis than patients whose tumor characteristics preclude surgical resection. Level of evidence: III prognostic.

This study investigated complication rates for 68 solid-organ transplant patients who had undergone 94 primary hip or knee joint replacements at a single institution from 1995 to 2008. There was a deep infection rate of 6.8% in the transplant patients compared to a 1.9% deep infection rate for all primary joint replacement patients at the Medical University of South Carolina over the same time period (odds ratio 4.48). All four infections in the transplant group occurred in diabetic patients. The joint revision rate for transplant patients was 13% (deep infection 6.8%, aseptic loosening 5.1%, instability 1.7%). Other complications included superficial infections (5.1%), deep venous thromboses (3.4%), and a nonfatal pulmonary embolus (1.7%). The deep infection rate for joint replacement in solid-organ transplant patients was higher than rates reported by most similar studies, and diabetic patients may be at particular risk.

Background Sentinel lymph node (SLN) biopsy is a staging technique for occult lymph node disease. SLN biopsy has been applied to select patients with sarcoma, although the clinical utility remains uncertain. Methods A PubMed/MEDLINE literature search was performed, and SLN biopsy outcomes were analyzed using a Bayesian meta-analytic approach to obtain point and interval estimates of rates of interest. Results Sixteen studies involving SLN biopsy in patients with sarcoma were identified. Of 114 patients reported, 14 patients had positive SLNs (crude estimate, 12%; meta-analysis estimate, 17%). The meta-analysis false-negative rate was 29% (95% credible interval, 5%–59%). Recurrence and death rates in the SLN-positive group were higher than in the SLN-negative group. Conclusions This investigation highlights the current role of SLN biopsy in select patients with sarcoma for tumor staging. Questions regarding the high false-negative rate and management of micrometastatic lymphatic disease in patients with sarcoma still exist.

Objectives To determine the association between race on severe heterotopic ossification (HO) following acetabular fracture surgery. Design Retrospective case control study. Setting Level I university trauma centre. Methods Two hundred and fifty-three patients who were surgically treated for acetabular fractures were retrospectively evaluated. Postoperative radiographs were evaluated for HO by a blinded musculoskeletal radiologist, and classified based on a modified Brooker classification. Results Of the 253 patients that met inclusion and exclusion criteria, 175 (69%) were male and 78 (31%) were female. One hundred and fifty-four (61%) patients were Caucasian, and 99 (39%) were African American (AA). Fifty-five (21%) patients developed severe HO. Of those who developed severe HO, 25 were Caucasian (45%), 30 were African American (55%). Forty-one patients (75%) with severe HO were male, and 14 (25%) were female. No statistical differences (p > 0.05) were found between groups in terms of age, days to surgery, GCS at presentation, surgical approach, perioperative HO prophylaxis, or AO/OTA fracture classification. The patient population was then stratified by race, gender, and race/gender. AA were more likely than Caucasians to develop severe HO (odds ratio [OR], 2.24; confidence interval [CI], 1.22–4.11). When gender was considered independent of race, no statistical differences (p > 0.05) were observed (OR, 1.40; CI, 0.71–2.75). AA males were much more likely to develop severe HO when compared to Caucasian females (OR, 4.4; CI, 1.38–14.06). Conclusion Race is associated with different rates of severe HO formation following acetabular fracture surgery. AA patients are significantly more likely to develop severe HO following acetabular fracture surgery when compared to Caucasian patients.

Patients often receive advanced imaging before referral to an orthopaedic oncologist. The few studies that have evaluated the value of these tests have been single-center studies, and there were large discrepancies in the estimated frequencies of unnecessary use of diagnostic tests.(1) Is there regional variation in the use of advanced imaging before referral to an orthopaedic oncologist? (2) Are these prereferral studies helpful to the treating orthopaedic oncologist in making a diagnosis or treatment plan? (3) Are orthopaedic surgeons less likely to order unhelpful studies than other specialties? (4) Are there any tumor or patient characteristics that are associated with the ordering of an unhelpful study?We performed an eight-center prospective analysis of patients referred for evaluation by a fellowship-trained orthopaedic oncologist. We recorded patient factors, referral details, advanced imaging performed, and presumptive diagnosis. The treating orthopaedic oncologist determined whether each study was helpful in the diagnosis or treatment of the patient based on objective and subjective criteria used in prior investigations. We analyzed the data using bivariate methods and logistic regression to determine regional variation and risk factors predictive of unhelpful advanced imaging. Of the 371 participants available for analysis, 301 (81%) were referred with an MRI, CT scan, bone scan, ultrasound, or positron emission tomography scan.There were no regional differences in the use of advanced imaging (range of patients presenting with advanced imaging 66%-88% across centers, p = 0.164). One hundred thirteen patients (30%) had at least one unhelpful study; non-MRI advanced imaging was more likely to be unhelpful than MRIs (88 of 129 [68%] non-MRI imaging versus 46 of 263 [17%] MRIs [p0.001]). Orthopaedic surgeons were no less likely than nonorthopaedic surgeons to order unhelpful studies before referral to an orthopaedic oncologist (56 of 179 [31%] of patients referred by orthopaedic surgeons versus 35 of 119 [29%] referred by primary care providers and 22 of 73 [30%] referred by nonorthopaedic specialists, p = 0.940). After controlling for potential confounding variables, benign bone lesions had an increased odds of referral with an unhelpful study (59 of 145 [41%] of benign bone tumors versus 54 of 226 [24%] of soft tissue tumors and malignant bone tumors; odds ratio, 2.80; 95% confidence interval, 1.68-4.69, p0.001).We found no evidence that the proportion of patients referred with advanced imaging varied dramatically by region. Studies other than MRI were likely to be considered unhelpful and should not be routinely ordered by referring physicians. Diligent education of orthopaedic surgeons and primary care physicians in the judicious use of advanced imaging in benign bone tumors may help mitigate unnecessary imaging.Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

Surgical treatment for impending or actual pathologic femoral fractures due to metastatic carcinoma has been shown to improve pain and quality of life. Surgery usually involves manipulation of the intramedullary (IM) portion of the femur to provide adequate stability and to restore function. IM nailing is generally considered the preferred treatment over plate osteosynthesis for most areas of the femur due to load sharing capabilities. Several reports have shown a high incidence of oxygen desaturation, hypotension, fat or air embolism, and mortality in the surgical treatment of femoral metastatic disease. The patient with a metastatic lesion in the femur is at risk for cardiopulmonary complications associated with entering the IM canal. Complications and mortality reported in the literature are varied. Benefits of IM nailing of femoral lesions and associated complications in the literature are discussed. The theoretical benefit of aspiration and irrigation while reaming is also reviewed. Reaming while irrigating under negative pressure provided through suction may potentially minimize cardiopulmonary and oncologic complications.

Chondrosarcoma is a cartilage forming neoplasm, which is the second most common primary malignancy of bone. Clinicians who treat chondrosarcoma patients must determine the grade of the tumor, and must ascertain the likelihood of metastasis. Acral lesions are unlikely to metastasize, regardless of grade, whereas axial, or more proximal lesions are much more likely to metastasize than tumors found in the distal extremities with equivalent histology. Chondrosarcoma is resistant to both chemotherapy and radiation, making wide local excision the only treatment. Local recurrence is frequently seen after intralesional excision, thus wide local excision is sometimes employed despite significant morbidity, even in low-grade lesions. Chondrosarcoma is difficult to treat. The surgeon must balance the risk of significant morbidity with the ability to minimize the chance of local recurrence and maximize the likelihood of long-term survival.

Oncogenic osteomalacia is a rare paraneoplastic syndrome of systemic bone demineralization secondary to a tumor-induced dysregulation of phosphorus metabolism. The tumor's low prevalence, small size, and variable location often result in years of muscular weakness and bone pain before diagnosis. With complete treatment, patient's symptoms swiftly dissipate. We report the case of a 63-year-old previously healthy man with a 20-month course of musculoskeletal symptoms before diagnosis and resection of a posterior tibial tumor. Postoperatively, the patient had returned to his previous lifestyle when an insufficiency fracture required prophylactic stabilization.

Background/hypothesis Surgical management of displaced unstable proximal humerus fracture remains a challenge due to poor proximal bone quality and significant deforming forces. We hypothesized that the technique of application and mechanical properties of the proximal humeral locking plate would allow successful treatment of unstable and displaced proximal humeral fractures even in the face of osteoporotic bone. Method We evaluated prospectively the results of open reduction internal fixation of 22 displaced unstable proximal humerus fractures in 22 patients utilizing a proximal humeral locking plate. Results Results according to the ASES scoring system at a minimum of 2 years were excellent in 13, good in 4, fair in 1, and poor in 3. One patient was lost to follow-up. All fractures healed. Anatomic alignment was obtained in 72%. Two patients developed avascular necrosis of the humeral head. There were no cases of hardware failure, infection, or loss of reduction. Three separate reduction maneuvers were employed in this series depending on fracture type. Conclusion The locking plate is an excellent device in the management of displaced unstable proximal humeral fractures and is expanding the indications for ORIF in these fractures.