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Background There are conflicting reports for the outcome of the patients with giant cell tumor of bone (GCTB) and pathological fracture at presentation treated with curettage or resection. This study compared local recurrence, complications, and function after curettage versus resection for these patients. Materials and methods We retrospectively studied the files of 46 patients with histologically confirmed GCTB of the extremities admitted and treated from 1982 to 2015. The median follow-up was 79.5 months (57.0-125.5 months). We evaluated local recurrence and type of surgery-related complications with imaging and function with the Musculoskeletal Tumor Society (MSTS) score. Results Overall local recurrence was 6.5%. There were one patient with curettage and two patients with resection; local recurrence rate was similar between the two procedures but the time to local recurrence was shorter after curettage. MSTS score was significantly better after curettage. Complications occurred in two patients after curettage and in five patients after resection; because of the low number of patients with complications, a statistical comparison was not possible; however, by direct comparison of the numbers, complications were more common after resection compared with curettage. Conclusion Curettage is recommended for GCTB and pathological fracture at presentation because of similar local recurrence but better function compared with resection. The treating physicians should be aware and inform their patients for a shorter time to local recurrence after curettage and for more complications after resection.

To present the pathophysiology, biology, clinical presentation, diagnosis, and current treatment options for lumbar disc herniation. A thorough literature search was undertaken in PubMed and Google Scholar to summarize the current knowledge and future perspectives on lumbar disc herniation. Several changes in the biology of the intervertebral disc are thought to contribute to disc herniation; nevertheless, the exact inciting event leading to disc herniation is yet to be discovered. Non-operative treatments have stood the test of time as the first-line treatment for most patients with lumbar disc herniation; however, operative treatment remains the current gold standard, with minimally invasive endoscopic microdiscectomy techniques showing best results with respect to postoperative pain and function. The exact event leading to disc herniation remains unclear. Non-operative treatments should be the first-line treatment for most patients with lumbar disc herniation. Operative treatment remains the current gold standard, with minimally invasive endoscopic microdiscectomy techniques showing best results with respect to postoperative pain and function. Regenerative medicine is promising.

Gunshot wounds and blast injuries constitute a major public health problem, as the increasing availability of firearms and explosives in conjunction with increasing violence in the city setting have brought this reality into civilian life. Extremities are most commonly involved; therefore, orthopedic surgeons should be trained to manage these types of injuries. Complete and accurate assessment of the injury itself is of great importance, as it will determine the severity and the risk of patients. High-risk injuries from missiles and injuries from explosions are associated with moderate or poor outcomes, major complications, and increased need for multiple surgical procedures. On the other hand, low-risk injuries frequently present optimal results and rather low morbidity. The role of microsurgery is essential, especially in the high- and very high-risk injuries, since complex and multiple reconstructions have to be performed, which include the utilization of free flaps, nerve grafts, and tendon transfers.

The lifetime risk for diabetic patients to develop a diabetic foot ulcer (DFU) is 25%. In these patients, the risk of amputation is increased and the outcome deteriorates. More than 50% of non-traumatic lower-extremity amputations are related to DFU infections and 85% of all lower-extremity amputations in patients with diabetes are preceded by an ulcer; up to 70% of diabetic patients with a DFU-related amputation die within five years of their amputation. Optimal management of patients with DFUs must include clinical awareness, adequate blood glucose control, periodic foot inspection, custom therapeutic footwear, off-loading in high-risk patients, local wound care, diagnosis and control of osteomyelitis and ischaemia. Cite this article: EFORT Open Rev 2018;3:513-525. DOI: 10.1302/2058-5241.3.180010

Last and second name of an author have been mixed up. It shows Piergiuseppe as the last name, but his second name is Tanzi and the first name is Piergiuseppe.

Background There are conflicting reports regarding the therapeutic effect of platelet-rich plasma (PRP) versus autologous whole-blood (platelet poor plasma, PPP) injections for plantar fasciitis. Therefore, this study was conducted to compare the effectiveness of a single ultrasound (US)-guided PRP versus PPP injection in patients with chronic plantar fasciitis. Materials and methods 36 patients were recruited with clinical and sonographic evidence of chronic (>6 months) plantar fasciitis, refractory to analgesics and physical therapy in a double-blinded, randomized, prospective study. The patients were randomly allocated into two groups with a sealed envelope method. Group A included 18 patients who underwent a single US-guided PRP injection and group B included another 18 patients who underwent PPP injection with the same technique. Follow-up was set at 3 and 6 months; no patient was lost to follow-up. Pain, function and satisfaction were assessed using visual analogue scales, and occurrence of complications. Results All scores statistically significantly improved for both groups from baseline at the 3- and 6-month follow-up evaluation, without, however, any statistically significant differences between the two groups with respect to pain, function and satisfaction scores. Complications were not observed. Conclusions A single US-guided PRP injection yields similar results with PPP injection in patients with chronic plantar fasciitis. Both treatments provide significant improvement at 3 and 6-month follow-up after the injection.

A series of clinical trials focused on the use of ultrasound-guided platelet-rich plasma (PRP) infusions for the treatment of patients with carpal tunnel syndrome (CTS) were published over the last few years. However, the role of PRP for CTS remains unclear. We performed a systematic review according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Two reviewers independently conducted the search using multiple databases: MEDLINE/PubMed, SCOPUS, Cochrane Database, and Web of Science. These databases were searched using terms "platelet" AND "rich" AND "plasma" AND "carpal" AND "tunnel". To maximize the search, backward chaining of references from retrieved papers was also undertaken. From the initial 19 studies, only five met our eligibility criteria. These articles included one randomized controlled double-blind study, one randomized controlled single-blind study, one randomized controlled non-blind study, one case-control study, and one case report. The vast majority of the included studies supported that PRP infusion improved the clinical condition of the patients and that PRP infusion was beneficial for patients with mild-to-moderate CTS. Therefore, PRP seems to be an interesting alternative for the treatment of mild-to-moderate CTS which, still, has not been thoroughly investigated. However, despite the promising results of the present studies, PRP has to be further tested before we reach to a definite conclusion regarding its therapeutic value.

Giant cell tumor (GCT) of the soft tissue (GCT-ST) is a rare, unusual primary soft tissue tumor that is completely distinct from, and should not be confused with, any giant cell–rich tumor of bone or soft tissue. Currently, GCT-ST is included in the group of so-called fibrohistiocytic tumors of intermediate (borderline) malignancy. The most common symptom is a painless, slow-growing mass in a superficial location. Computed tomography and magnetic resonance imaging show a solid, nonhomogeneous, frequently hemorrhagic mass. Differential diagnosis is broad and should include benign and malignant entities. The treatment and excision margins of GCT-ST are controversial. Incomplete surgical excision is usually followed by local recurrence. Biological behavior is unpredictable. Giant cell tumor of the soft tissue has shown a lower mean local recurrence rate compared to GCT of bone but has a higher metastatic and death rate. Therefore, close clinical follow-up is recommended. [ Orthopedics . 2019; 42(4):e364–e369.]

Ultrasonography has gained a unique role in assisting emergency medicine physicians in the trauma setting. Its major advantages include safety, bedside availability, repeatability, and portability. In addition, it does not have to interrupt resuscitation, it does not require sedation, it takes image

Pycnodysostosis or Maroteaux-Lamy syndrome is a genotypic bone disorder, with autosomal recessive inheritance, individualized by Lamy and Maroteaux in 1962. It is characterized by diffuse condensation of the skeleton with thickening of the cortex and narrowing of the medullary cavity. This condensation is reminiscent of the one observed in Albers-Schonberg disease, which differs essentially in dysmorphism of the skull (no closure of fontanelles, gaping sutures, hypoplasia of the lower jaw with open mandibular angle) and extremities (hypoplasia or osteolysis of the phalanges). The patients have a short stature, short hands and feet, and malformed nails. The first scientifically correct diagnosis was made by Dr. G. Sejournet who, under the guidance of his teacher Professor J.-A. Lievre, performed extensive research and diagnosed Henri de Toulouse-Lautrec with achondroplasia-related dwarfism. This article describes pycnodysostosis and reports the life of the painter Henri de Toulouse-Lautrec who died from the disease.

Clinical studies and experimental research have described therapeutic hypothermia for patients suffering from traumatic brain injury (TBI), cardiac arrest, and neonatal hypoxic ischemic encephalopathy. This procedure is implemented by intensive care unit (ICU)-trained nurses. The aim of the present study was to compare cold compresses/ ice packs, cooling blankets, and heat-exchange systems via intravascular catheters used in the ICU for therapeutic hypothermia from a nursing perspective with respect to ease of application, additional workload, ease of temperature monitoring, and effectiveness. A questionnaire was completed by ICU nurses to evaluate these techniques for therapeutic hypothermia. The results were calculated and a score of 1 to 5 was obtained, where 1 = very bad, 2 = bad, 3 = moderate, 4 = good, and 5 = very good. Overall, heat exchange via intravascular catheters had the best score for implementation of therapeutic hypothermia. Regarding ease of the application, cold compresses/ice packs had the best score. Regarding additional workload, cold compresses/ice packs had the worst score, whereas the heat-exchange system via intravascular catheters scored the best. Regarding ease of temperature monitoring, the heat-exchange system via intravascular catheters had the best score and, regarding effectiveness, cold compresses/ice packs scored the best.

Congenital anomalies of the limbs have been observed since ancient human civilizations, capturing the imagination of ancient physicians and people. The knowledge of the era could not possibly theorize on the biologic aspects of these anomalies; however, from the very beginning of civilization the spiritual status of people attempted to find a logical explanation for the existence of such cases. The next logical step of the spiritual and religious system of the ancients was to correlate these anomalies with the Gods and to attribute them to a different level of existence in order to rationalize their existence. In these settings, the mythology and religious beliefs of ancient civilizations comprised several creatures that were related to the observed congenital anomalies in humans. The purpose of this historic review is to summarize the depiction of congenital anomalies of the limbs in mythology and antiquity, to present several mythological creatures with resemblance to humans with congenital anomalies of the limbs, to present the atmosphere of the era concerning the congenital anomalies, and to theorize on the anomaly and medical explanation upon which such creatures were depicted. Our aim is to put historic information in one place, creating a comprehensive review that the curious reader would find interesting and enjoyable.

Purpose: To compare short with long intramedullary hip nailing for elderly patients with unstable pertrochanteric fractures. Methods: We prospectively studied 50 patients (33 women, 17 men; mean age, 80 years; range, 74–93 years) with unstable pertrochanteric fractures admitted and treated with a short (group A) or a long (group B) intramedullary hip nail from January 2013 to 2017. The patients were randomly allocated into each group according to their order of admission. The mean follow-up was 2 years (range, 1–5 years). We evaluated operative time, function, fracture healing, varus/valgus loss of reduction, and distance between the distal line of the fracture and the distal locking screw of the nail. Results: Operative time was significantly shorter in group A. Function, fracture healing and varus/valgus loss of reduction was similar between the two groups. The mean distance between the distal fracture line and distal locking screw was 7.2 cm (range, 3–10 cm) in patients of group A; in all patients of group B, an appropriate nail length was chosen so that the distal locking screw was inserted at least 3 times the diameter of the bone at the distal fracture line. Complications included periprosthetic fracture (one patient of group A), and z-effect phenomenon (one patient of group B); complications rate was similar between the two groups. Conclusion: Short intramedullary hip nailing is associated with similar function and complications, but shorter operative time compared to long intramedullary hip nails for patients with unstable pertrochanteric fractures.

George Georgoudis,1,2 Bledjana Felah,2 Pantelis T Nikolaidis,3 Maria Papandreou,1 Evanthia Mitsiokappa,4 Andreas F Mavrogenis,4 Thomas Rosemann,5 Beat Knechtle5,6 1Musculoskeletal and Respiratory Research Lab, Department of Physiotherapy, University of West Attica, Athens, Greece; 2PhysioPain Group, Pain Specialist & Rehabilitation Centers, Athens, Greece; 3Exercise Physiology Laboratory, Nikaia, Greece; 4First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece; 5Institute of Primary Care, University of Zurich, Zurich, Switzerland; 6Medbase St. Gallen Am Vadianplatz, St. Gallen, Switzerland Introduction: Nonpharmacological therapies have been widely used to treat tension-type headache (TTH); however, limited evidence exists with regards to their effectiveness. Therefore, the aim of the present study was to examine the combined effect of acupuncture, stretching, and physiotherapy (myofascial release techniques and microwave diathermy) on psychocognitive, somatic, quality of life, and disability characteristics in such patients. Subjects and methods: Patients with TTH (n=44) performed either acupuncture or stretching (control group, n=20) or acupuncture, stretching, and physiotherapy (experimental group, n=24) during a 4-week intervention period including 10 treatment sessions. They were tested for the Greek version of the Short-Form McGill Pain Questionnaire, the Greek version of the Migraine Disability Assessment Questionnaire, the Greek version of the Hospital Anxiety and Depression Scale, Short Form Health Survey 12 9 (SF-12), and Pain Catastrophizing Scale at baseline after the fifth and tenth sessions. Results: All measures were improved throughout the first to tenth session (P0.05). Conclusion: In summary, a significant beneficial role of acupuncture, stretching, and physiotherapy on cognitive, psychosomatic pain measures, disability index, quality of life, and catastrophizing in patients with TTH was observed. Keywords: tension-type headache, acupuncture, physiotherapy, stretching, psychocognitive characteristics, myofascial release

To present palliative selective and superselective arterial embolization with N-butyl-cyanoacrylate for cancer patients with spinal metastases. We studied the files of 164 cancer patients (94 men and 70 women; mean age 57.6 years; range 35–81 years) treated from March 2003 to March 2013 with 178 selective arterial embolization procedures for metastases of the spine from variable primary cancers. We evaluated the technical success of the embolization procedure with post-procedural angiography, the clinical effect in pain relief, need for analgesics and tumor size reduction, and the embolization-related complications. Post-embolization angiography showed complete occlusion of the pathological feeding vessels in all procedures. Pain score and need for analgesics reduced by 50 % in 159 patients (97 %); no response was achieved in five patients with metastases of the sacrum. The mean duration of pain relief was 9.2 months (range 1–12 months). Metastatic tumor size reduced from a mean of 5.5 cm (range 3.5–7.5 cm) pre-embolization to a mean of 4.5 cm (range 3–5 cm) at the 6-month follow-up; the difference was not statistically significant. Ninety-three patients (56.7 %) experienced embolization-related complications the most common being post-embolization syndrome (80 patients, 48.8 %) followed by leg paresthesias (ten patients, 6 %), and rupture of a lumbar artery (one patient, 0.6 %). Selective arterial embolization with N-butyl-cyanoacrylate should be considered for pain palliation of patients with metastases of the spine. However, pain relief is temporary, and complications, although minor may occur.

Rapid destructive arthritis of the hip is a rare entity with unknown pathogenesis and outcome. First described by Forestier in 1957, it is characterized by a rapidly progressive hip disease resulting in rapid destruction of both the femoral and acetabular aspects of the hip joint, with almost complete disappearance of the femoral head within a few months. Since the original description, case reports and small series have been reported, and many names have been proposed to describe the rapid destruction of the femoral head and occasionally the acetabulum. Initial presentation includes acute hip pain with the lack of radiographic evidence of joint destruction, rapidly progressing to complete vanishing of the proximal femur within a few months. This article summarizes the related literature aiming to present the current concepts for the diagnosis and treatment of rapid destructive arthritis of the hip.

Second malignant neoplasms (SMN) or second cancers may occur in 2–5 % of childhood cancer survivors within 5–25 years after diagnosis and treatment of a bone sarcoma. The most common are leukemia and breast cancer; salivary gland SMN are exceptional. To enhance the literature, we reviewed our patients with bone sarcomas and evaluated the incidence and outcome of salivary gland SMN. We retrospectively studied all patients with osteosarcoma and Ewing’s sarcoma treated at the Istituto Ortopedico Rizzoli with chemotherapy from January 1983 to December 2012. There were 883 osteosarcoma and 543 Ewing’s sarcoma patients. We evaluated the date of diagnosis and histology of bone sarcoma, chemotherapy administered, date of diagnosis and histology of SMN, and survival of patients. The 10-year incidence of SMN was 3.6 %; the most common were breast cancer, leukemia, sarcomas, and salivary gland neoplasms. The incidence of salivary gland SMN was 0.5 %; there were five male and two female patients with a mean age of 19 years (range 13–28 years) who experienced a salivary gland SMN within a mean interval of 79 months (range 51–97 months). The most common salivary gland involved was the parotid followed by the submandibular gland. One of the seven patients with salivary gland SMN died from his SMN. Treating physicians should be aware of the risk of salivary gland SMN after chemotherapy for bone sarcomas in children and adolescents. Close follow-up of childhood bone sarcoma survivors for SMN is important.

To evaluate clinical efficacy/safety of augmented peripheral osteoplasty in oncologic patients with long-term follow-up. Percutaneous augmented peripheral osteoplasty was performed in 12 patients suffering from symptomatic lesions of long bones. Under extensive local sterility measures, anesthesiology care, and fluoroscopic guidance, direct access to lesion was obtained and coaxially a metallic mesh consisting of 25–50 medical grade stainless steel micro-needles (22 G, 2–6 cm length) was inserted. PMMA for vertebroplasty was finally injected under fluoroscopic control. CT assessed implant position 24-h post-treatment. Clinical evaluation included immediate and delayed follow-up studies of patient’s general condition, NVS pain score, and neurological status. Imaging assessed implant’s long-term stability. Mean follow-up was 16.17 ± 10.93 months (range 2–36 months). Comparing patients’ scores prior (8.33 ± 1.67 NVS units) and post (1.42 ± 1.62 NVS units) augmented peripheral osteoplasty, there was a mean decrease of 6.92 ± 1.51 NVS units. Overall mobility improved in 12/12 patients. No complication was observed. Percutaneous augmented peripheral osteoplasty (rebar concept) for symptomatic malignant lesions in long bones seems to be a possible new technique for bone stabilization. This combination seems to provide necessary stability against shearing forces applied in long bones during weight bearing.

Craniovertebral junction tuberculosis is rare, accounting for 0.3 to 1% of all tuberculous spondylitis cases. MR imaging is the modality of choice to detect bone involvement, abscess formation and subligamentous spreading of the pus, to differentiate from other lesions affecting the craniovertebral junction, and to determine the efficacy of treatment. Given the fact that surgical treatment of patients with craniovertebral junction tuberculosis has been associated with a high mortality rate ranging up to 10% and recurrence rate ranging up to 20%, conservative is the standard of treatment for most patients.This article presents a patient with craniovertebral junction Mycobacterium tuberculosis infection diagnosed with CT-guided biopsy. A halo vest was applied and antituberculous treatment with rifampicin, isoniazid and ethambutol was initiated. At 6-month follow-up, the patient was asymptomatic; CT of the cervical spine showed healing of the bony lesions. The halo vest was removed and physical therapy was recommended. Antituberculous treatment was continued for a total of 18 months, without any evidence of infection recurrence

Venous thromboembolism (deep vein thrombosis and pulmonary embolism) and bone cement implantation syndrome are major sources of embolic events in trauma patients. In these patients, embolic events due to venous thromboembolism and bone cement implantation syndrome have been detected with cardiac and vascular ultrasonography in the emergency setting, during the perioperative period, and in the intensive care unit. This article discusses the ultrasonography modalities and imaging findings of embolic events related to venous thromboembolism and bone cement implantation syndrome. The aim is to present a short review with exceptional illustrations that can enable physicians to identify sources of emboli in trauma patients with cardiovascular ultrasonography.

Institution of National Bodies on Ethics in Science, strict selection criteria, robust peer-reviewing, careful statistical validation, anti-plagiarism software, and image fraud detection contribute to production of high-quality manuscripts. However, scientific misconduct (fraud) still remains a considerable issue that can take many forms, at times difficult to recognize promptly. Even though clamorous examples occasionally appear in the media, detection of fraud in medical publishing is most of the time not as straightforward as one might think. This brief review attempts to present the types of misconduct that exist in publishing and the tools that journals implement to unmask them.

Introduction: There are limited information and inconclusive results for dual head screw intramedullary hip nails for trochanteric fractures. Therefore, we performed a prospective study to evaluate the healing of fractures, and survival, function, and complications of patients operated with this implant. Methods: We prospectively studied 79 patients (61 women and 18 men; mean age: 84.7 years; range: 65–96 years) with a low-energy trochanteric fracture, treated with a dual head screw intramedullary hip nail from 2013 to 2016. The mean follow-up was 2.1 years (range: 1–3 years); seven patients were lost to follow up. This left 72 patients for further analysis. We evaluated the healing of fractures, and survival, function, and complications of patients. Results: Fracture healing was evident in 70 patients (97.2%) at 2–3 months postoperatively. One patient experienced cut-out and z-effect phenomenon of the head screws. Another patient experienced a periprosthetic femoral diaphysis fracture at the distal tip of the nail. A third patient experienced an acute postoperative superficial skin infection that was treated successfully with wound dressing changes and a course of antibiotics. Sixteen patients (22.2%) deceased within 12 months postoperatively. In the remaining patients, the Harris Hip Score (HHS) at 12 months postoperatively was excellent in 16 (28.6%), good in 23 (41.1%), fair in 10 (17.8%), and poor in 7 patients (12.5%). The function declined after the patients’ fracture. Fair and poor results were related to age > 85 years, poor pre-fracture level of function, and AO/OTA-31-A3 fracture types. Conclusion: The dual head screw intramedullary hip nail is associated with high healing and low complication rates for intertrochanteric fractures. The function of the patients is good or excellent in most cases; however, it declines, especially for those patients with age > 85 years, poor pre-fracture level of function, and AO/OTA-31-A3 fracture types.

Trans-scaphoid transcapitate (TSTC) perilunate fracture-dislocation (PLFD) is a rare type of perilunate injury. Because of the rarity and complexity of this entity, initial diagnosis may be delayed and the extent of osseous and ligamentous lesions underestimated. Early surgical treatment by open reduction and fracture stabilization is recommended to avoid complications such as avascular necrosis, nonunion, posttraumatic arthritis, and functional impairment. In this article, we report the case of a 32-year-old man who sustained a TSTC-PLFD. We describe the radiographic and intraoperative findings, review the current surgical principles for reduction and stabilization of this injury, and assess the clinical and radiologic outcomes.

To describe the clinical and ultrasonography (US) findings of soft tissue hemangiomas, and to compare with the results of histologic diagnosis after US-guided biopsy. We retrospectively studied the files of 97 patients (48 female, 49 male; mean age, 34 years; range 4–84 years) with soft tissue hemangiomas diagnosed from 2004 to 2011. Mean follow-up was 9 years (range 7–13 years). Clinical presentation included intermittent mild pain associated with a soft tissue swelling/palpable mass in all patients, chronic pain and increased local heat in 29 patients, local swelling and decreased range of motion of the adjacent joint in 45 patients, and all the above symptoms in 23 patients. B-mode and color Doppler US evaluation included the site, location, size, shape, margins, presence of calcifications, echo structure and echogenicity. All patients had US-guided biopsy for histologic analysis. US-guided biopsy and histology confirmed the diagnosis of soft tissue hemangioma in 92 of the 97 lesions (94.8%). Histologic examination of the remaining five lesions showed nodular fasciitis (two lesions), endometriosis (one lesion), hemangioendothelioma (two lesions); US of these lesions showed variable size, irregular margins, and deep-seated location. Histologically documented soft tissue hemangiomas were most commonly superficial (74 lesions) and arteriovenous (45 lesions). Shape was most commonly oval (fusiform), margins were most commonly not well defined (irregular, hazing but circumscribed), phleboliths were more common in deep-seated lesions, echo structure was heterogeneous, and echogenicity was most commonly hyperechogen and involuting. Clinical presentation and typical B-mode and color Doppler US findings are adequate for the diagnosis of soft tissue hemangiomas without the need for biopsy and histologic analysis. If any clinical or US doubt, an US-guided biopsy should be performed.

Study Design Prospective controlled study. Introduction Previous studies evaluated the effectiveness of sensory reeducation (SR) after peripheral nerve injury and repair. However, evidence for long-term clinical usefulness of SR is inconclusive. Purpose of the Study The purpose of this study is to compare the sensory results of patients with low-median nerve complete transection and microsurgical repair, with and without SR at long term. Methods We prospectively studied 52 consecutive patients (mean age, 36 years; range, 20-47 years) with low-median nerve complete transection and microsurgical repair. When reinnervation was considered complete with perception of vibration with a 256-cycles per second tuning fork (mean, 3.5 months after nerve injury and repair), the patients were sequentially allocated (into 2 groups [group SR, 26 patients, SR; group R, 26 patients, reassured on recovery without SR). SR was conducted in a standardized fashion, in 2 stages, as an independent home-based program: the first stage was initiated when reinnervation was considered complete, and included instruction in home exercises to identify familiar objects and papers of different roughness, and localization of light touch (eyes open and closed); the second stage was initiated when the patients experienced normal static and moving 2-point discrimination (2PD) at the index fingertip of injured hand, and included instruction in home exercises for stereognosia, supplementary exercises for localization of light touch, and identification of small objects (eyes open and closed). Exercises were prescribed for 5-10 minutes, 4 times per day. At 1.5, 3, and 6 years after nerve injury and repair, we evaluated the static and moving 2PD, stereognosia with the Moberg's pick-up test, and locognosia with the modified Marsh test. Comparison between groups and time points was done with the nonparametric analysis of variance (Kruskal-Wallis analysis of variance). Results Static and moving 2PD and stereognosia were not significantly different between groups at any study period. Locognosia was significantly better at 1.5 and 3 years in group SR; locognosia was excellent in 17 patients of group SR vs 5 patients of group R at 1.5-year follow-up and in 14 patients of group SR vs 5 patients of group R at 3-year follow-up. Locognosia was not different between the study groups at 6-year follow-up. Conclusion A 2-stage home program of SR improved locognosia at 1.5 and 3 years after low-median nerve complete transection and repair without significant differences in other modalities or the 6-year follow-up of a small subsample.

An intercalary reconstruction is defined as replacement of the diaphyseal portion of a long bone after segmental skeletal resection (diaphysectomy). Intercalary reconstructions typically result in superior function compared to other limb-sparing procedures as the patient's native joints above and below the reconstruction are left undisturbed. The most popular reconstructive options after segmental resection of a bone sarcoma include allografts, vascularized fibula graft, combined allograft and vascularized fibula, segmental endoprostheses, extracorporeal devitalized autograft, and segmental transport using the principles of distraction osteogenesis. This article aims to review the indications, techniques, limitations, pros and cons, and complications of the aforementioned methods of intercalary bone tumor resections and reconstructions in the context of the ever-growing, brave new field of limb-salvage surgery.

With increases in both life expectancy and the number of patients with endoprosthetic replacements, more periprosthetic fractures are expected to occur. Periprosthetic fractures related to megaprostheses present a treatment challenge, with a high incidence (one-third of affected patients) of secondary revision as a result of prosthetic loosening, infection, nonunion, refracture, or even amputation. Efforts to improve endoprosthetic reconstruction should focus on preventing postoperative complications. Understanding the causes of complications and strategies to avoid them could lead to significant improvements in implant survival, limb function, and patient outcomes. This article presents a concise review of the current literature and an algorithmic approach to reconstruction of these complex injuries. [ Orthopedics. 2017; 40(3):e387–e394.]

Chondroblastoma (CB) is a rare benign tumor that occurs most commonly in the second decade of life. No studies on CB in adulthood have been reported. Our purposes were to report a single-institution experience on CB in adults and to discuss the clinical and imaging findings, type of treatment, oncologic and functional outcomes. All patients diagnosed and treated for CB from 1981 to 2014 were reviewed. The main inclusion criterion was patients above their 30 years of age at diagnosis. Clinical presentation, imaging, surgical treatment, complications and functional outcome were evaluated. Local recurrences were recorded. There were 15 males (65%) and 8 females (35%) with a mean age of 40 years (range 30–59 years). Tumor involved the small bones (talus, calcaneus, acromion, cuneiform, metatarsals) in 15 patients (65%) and the long bones in eight patients (35%). Treatment consisted of curettage only (6 cases), curettage plus phenol (13 cases), curettage plus radiotherapy (one patient with vertebral tumor), resection (two patients with CB of the acromion) and chopart amputation (one patient with a metatarsal tumor). At a mean follow-up of 8.4 years (range 3–30 years), twenty patients (87%) remained continuously disease-free, whereas three had local recurrences. None of the patients received chemotherapy. This study confirms that the occurrence and outcome of adult patients with CB are similar with those affecting younger patients. The main difference consists of the involved bones; flat bones and short tubular bones of the foot, especially the talus and calcaneus, are most commonly involved as opposed to long tubular bones. Therapeutic study, level IV-1 (case series).

Scientific misconduct (fraud) in medical writing is an important and not infrequent problem for the scientific community. Although noteworthy examples of fraud surface occasionally in the media, detection of fraud in medical publishing is generally not as straightforward as one might think. National bodies on ethics in science, strict selection criteria, a robust peer-review process, careful statistical validation, and anti-plagiarism and image-fraud detection software contribute to the production of high-quality manuscripts. This article reviews the various types of fraud in medical writing, discusses the related literature, and describes tools journals implement to unmask fraud. [ Orthopedics. 2018; 41(2):e176–e183].

Malignant peripheral nerve sheath tumors are rare soft tissue tumors accounting for 3% to 10% of all soft tissue tumors. They are strongly related to neurofibromatosis type 1, an autosomal dominant disease, and are characterized by aggressive biologic behavior, high local recurrence rates, and frequent metastases. Although the major nerves of the lower extremities are a common location of these tumors, scarce cases have been reported of malignant peripheral nerve sheath tumors involving the interdigital nerves of the foot. We report the case of a patient with non-neurofibromatosis type 1 and a recurrent malignant peripheral nerve sheath tumor of the first interdigital nerve of the foot treated successfully with limb salvage surgery with wide resection margins and reconstruction with an autogenous fibula graft.

Interest in the direct anterior approach for total hip arthroplasty has increased over recent years; however, the potential for substantial complications exists, especially during the surgeon's learning curve. We evaluated the change in various metrics to help identify a single surgeon's learning curve. Additionally, we examined whether the learning curve was different for primarily arthroplasty versus trauma-trained surgeons.We reported outcomes from the first 50 total hip arthroplasties performed through a direct anterior approach by a trauma fellowship-trained orthopaedic surgeon. Intraoperative and post-operative clinical outcomes were evaluated, including length of procedure, estimated blood loss, length of hospitalization, disposition to home versus care facility, need for blood transfusion, and complications. Previous reported learning curve outcomes were analysed with a comparison between those who are primarily arthroplasty specialists versus those who include hip arthroplasty as only a portion of their practice.A significant difference in surgical time from 135 to 113 min was observed between the first 25 cases and the last 25. Estimated blood loss (EBL) and lateral femoral cutaneous nerve injury rates decreased but not to a significant degree. Among reported learning curves, surgical time was significantly lower among fellowship-trained arthroplasty specialists when compared with other surgeons.Our data support that surgeons who perform primarily joint arthroplasty will likely have a decreased surgical time, but similar EBL compared to those who include arthroplasty as only a portion of their practice, however, a number of confounding variables do exist, and additional investigation is warranted.

Arterial embolization for tumors was first described in 1975 [1, 2]. Since then, embolization for sacral tumors either primary or metastatic has been used extensively as a useful primary, palliative, or adjuvant therapy [3–6]. Preoperative embolization of hypervascular metastatic lesions reduces intraoperative blood loss and improves the surgeon’s ability for resection. Additionally, embolization may cause tumor growth arrest, pain alleviation, and shorter hospital stay [4–6]. The timing of preoperative embolization is important. Typically, best results are achieved when surgery is performed within 24–48 h after embolization [7, 8]. Serial embolization is safe and feasible; it can be performed in patients with persistent pain and/or imaging evidence of progressive disease. Serial embolization has been related with high rates of successful pain relief, tumor devascularization, tumor size reduction, and calcification of margins [9–11]. Serial embolization is typically performed in 4–6-week intervals until symptomatic improvement occurs, or the tumor’s pathological vascularity disappears. Unless there is a clear indication for general anesthesia, most procedures are performed under light conscious sedation. The optimal arterial approach is determined based on lesion location; most often is the common femoral artery using a Seldinger technique. Commonly, an arterial catheter is placed and standard 4 French or 5 French angiographic catheters are used for main arterial selection, and a 3 French microcatheter for subselectivity. A diagnostic angiography is performed from a major vessel, more commonly the aorta to delineate vascular supply to the tumor and to identify vessels of potential concern that may result in nontarget embolization. In general, microspheres of 100–700 μm are used because of their ease of delivery, range of available sizes, and lower potential for recanalization. Sponge gel, once the embolic agent of choice, has now fallen in disuse, because of its temporary nature and propensity for recanalization. Coils are avoided as an embolic agent for tumor vessels, because re-treatment may be necessary and blocking access sites should be avoided. Completion of the procedure is determined by complete occlusion of the tumor blush compared with the initial diagnostic angiography [12]. Complication rate is generally low [13]; reported complications include post-embolization syndrome (fever, pain, malaise), nerve palsy, subcutaneous or muscle necrosis, ischemic pain (usually transitory), infection, and tumor bleeding [14].

Giant cell tumors (GCTs) are relatively common, locally aggressive benign neoplasms of bone that demonstrate a high risk for local recurrence and an occasional propensity for metastatic dissemination [1, 2]. The sacrum is the third most common location of GCTs after the knee and distal radius and the most common location in the axial skeleton [1–4]. Most affected patients are between 20 and 40 years old, with approximately 70% of cases occurring in this age group [1].

Introduction. Metastases are the most common type of malignancy involving the bone, while bone is the third most frequent site for metastases, after the lung and liver. In some patients, medical history, physical and laboratory exami­nation are not conclusive to identify the primary tumor site. In such cases a bone biopsy and immunohistochemical analysis may contribute to the diagnosis, determination of appropriate treatment and evaluation of prognosis. In this study, we tried to evaluate the imunochistochemical expression in bone metastases. Material and methods. We reviewed 125 patients, with a mean age of 63 years, treated for bone metastases in our institution. All patients received palliative orthopaedic surgery for bone metastatic carcinoma. Fifty-eight patients had already an established diagnosis of the primary tumor, while 67 patients presented metastases with an unknown primary tumor origin. Immunohistochemical analysis was performed to intra-operative bone biopsy specimens. The expression of cytokeratine 7, cytokeratin 20 and the expression of a panel of other organ-specific markers were re­corded. In patients with a known primary tumor, we examined the relationship between the origin of metastases, as suggested by the cytokeratin phenotype, compared with the one indicated by the initial histological diagnosis. We also recorded the efficacy of organ-specific markers to identify the primary tumor origin in epithelial bone metastases and we evaluated the prognosis between patients with a immunohistologically determined primary tumor origin, with those with an undetermined one. Results. Associations of cytokeratine 7 and cytokeratine 20 expression confirmed diagnosis in 51 out of the 58 patients (88%) with a known primary tumor (Cohen’s K test 0.79 SE 0.80, P < 0.0005). Immunohistochemical analysis also contributed to establish the diagnosis of patients with an unknown primary tumor, yielding diagnosis in 35 out of the 67 cases (52%). Patients with an immunochistologically undetermined primary tumor site presented a statisti­cally significant poorer prognosis. Conclusions. Cytokeratine 7 and cytokeratine20 are useful immunochistochemical markers in determining a pre­liminary evaluation of bone metastases. Organ-specific immunohistochemical markers have a reliable role in either suggesting or confirming the possible origin of metastases. An indeterminate immunohistochemical phenotype seems to relate to a less differentiated lesion, with a worse prognosis.

The most common malignancy to occur in the sacrum is metastatic bone disease [1–3]. The most common primary cancers are breast, lung, prostate, renal, and thyroid cancer [4–7]. Other less common primary lesions include lymphoma, myeloma/plasmacytoma, melanoma, and tumors of unknown origin [8]. Spread is mainly by hematogenous dissemination, although direct extension in case of recurrent rectal tumors and drop metastases of intradural tumors has also been described [9, 10].

Spinal canal infections may include the epidural space (epidural abscesses), the meninges (meningitis), the subdural space (subdural abscesses), and the spinal cord (intramedullary abscesses). Arachnoiditis involves the arachnoid lining along the spinal cord and accounts for approximately 20% of spinal tuberculosis (TB) cases. Extradural tuberculomas are the most common spinal tuberculomas (approximately 65%), while intramedullary tuberculomas are very rare. Helpful but nondiagnostic laboratory studies include an elevated leukocyte count and estimated sedimentation rate. In most patients, cerebrospinal fluid analysis reveals an active inflammatory response with lymphocytosis, hypoglycorrhachia, and increased protein values. Magnetic resonance imaging is the imaging modality of choice for the diagnosis of the disease. Differentiating from tumors and inflammatory and demyelinating diseases, vascular and granulomatous lesions may be extremely difficult to establish if the patient does not have systemic TB. Based on the location of the spinal infection and the neurological symptoms of the patients, surgical treatment may be indicated, and long-term anti-TB chemotherapy is recommended.

Peripheral nerve injury can have a potentially devastating impact on a patient's quality of life, resulting in severe disability with substantial social and personal cost. Refined microsurgical techniques, advances in peripheral nerve topography, and a better understanding of the pathophysiology and molecular basis of nerve injury have all led to a decisive leap forward in the field of translational neurophysiology. Nerve repair, nerve grafting, and nerve transfers have improved significantly with consistently better functional outcomes. Direct nerve repair with epineural microsutures is still the surgical treatment of choice when a tension-free coaptation in a well-vascularized bed can be achieved. In the presence of a significant gap (>2–3 cm) between the proximal and distal nerve stumps, primary end-to-end nerve repair often is not possible; in these cases, nerve grafting is the treatment of choice. Indications for nerve transfer include brachial plexus injuries, especially avulsion type, with long distance from target motor end plates, delayed presentation, segmental loss of nerve function, and broad zone of injury with dense scarring. Current experimental research in peripheral nerve regeneration aims to accelerate the process of regeneration using pharmacologic agents, bioengineering of sophisticated nerve conduits, pluripotent stem cells, and gene therapy. Several small molecules, peptides, hormones, neurotoxins, and growth factors have been studied to improve and accelerate nerve repair and regeneration by reducing neuronal death and promoting axonal outgrowth. Targeting specific steps in molecular pathways also allows for purposeful pharmacologic intervention, potentially leading to a better functional recovery after nerve injury. This article summarizes the principles of nerve repair and the current concepts of peripheral nerve regeneration research, as well as future perspectives. [ Orthopedics. 2017; 40(1):e141–e156.]

To evaluate the outcome of selective arterial embolization with N-2-butyl-cyanoacrylate for aneurysmal bone cysts. We retrospectively studied 102 patients (72 male, 30 female; mean age, 16 years; range, 3–60 years) with aneurysmal bone cysts treated with embolization with N-2-butyl-cyanoacrylate. Mean follow-up was seven years (range, 3–13 years); no patient was lost to follow-up. We evaluated healing and recurrences of the lesions, complications and cost of the procedures, and recurrences with respect to age and gender of the patients, and size and location of the lesions. Embolization was feasible in 88 patients (86.3%), and not feasible in 14 patients (13.6%) because feeding arteries were not identified or the spinal artery of Adamkiewicz was recognized at the embolization field. Seventy two patients (81.8%) experienced complete healing of their lesions after a single (50 patients, 56.8%), a second (17 patients, 19.3%) or a third embolization (5 patients, 5.7%). Sixteen patients (18.2%) experienced recurrence within four months (range, 3–9 months) after embolization; these patients underwent surgical treatment. Recurrences were more common in patients younger than 15 years of age and cysts larger than 6 cm, without any difference with respect to gender and location. Four patients (4.5%) experienced a complication including skin necrosis, sciatic nerve paresthesias, and femoral artery pseudoaneurysm. The cost estimate was 3000 euro per procedure. Embolization of aneurysmal bone cysts with N-2-butyl-cyanoacrylate is associated with good results and low complication rates, however, experience, technical skills, and knowledge of the vascular anatomy of the area is necessary.

Primary malignant tumors of the sacrum are rare [1–3]. The most frequent are chordomas followed by hematologic neoplasms, osteosarcomas, Ewing’s sarcomas, and in very rare cases, chondrosarcomas [3]. Chondrosarcomas (CS) can be classified as a primary malignant bone tumor (>90%) when they arise de novo or as a secondary malignant transformation of an underlying enchondroma or osteochondroma (

Polyostotic fibrous dysplasia in combination with cafeau-lait macules and hyperfunctioning endocrinopathies consists of a rare clinical condition termed as McCune-Albright syndrome. Aneurysmal bone cysts are tumor-like cystic lesions, composed of blood-filled compartments. They may occur as primary lesions or secondary to other pathologies; most commonly giant cell tumors of bone. However, secondary aneurysmal bone cysts in McCune-Albright syndrome are exceptional. We present a 28-year-old female with McCune-Albright syndrome. She experienced precocious puberty at age 3 months. In childhood, she experienced multiple long bone fractures, facial deformity and progressive visual and hearing impairment. One year ago, she experienced a painful, gradually enlarging bone lesion involving the right ilium, pubic and ischial bone with groundglass appearance, septa, marginal sclerosis, endosteal scalloping and blow-out expansion resulting in localized thinning of the cortex. CT-guided needle biopsy of the pelvic lesion showed aneurysmal bone cyst. Selective arterial embolization was recommended, however, the patient and her relatives did not consent to proceed to treatment, and she remained in close surveillance thereafter.

Nerve sheath tumors comprise only a small portion of the wide variety of lesions that occur in the sacrum [1–5]. Schwannomas (neurilemomas) are benign, slow-growing neurogenic tumors arising from Schwann cells of the peripheral nerve sheath. Sacral schwannomas are exceedingly rare, with merely around 50 cases reported in related literature [6]. Due to their largely indolent nature, the mobility of the sacral nerve roots, and the generous width of the sacral canal, sacral schwannomas frequently grow to a considerable size prior to detection; hence, giant sacral schwannomas are often described in related reports [7, 8]. Although benign, these tumors may occasionally pose a surgical challenge, as en bloc resection may be associated with disproportionally high surgical morbidity [9].

In patients with spinal cord injury and multiple sclerosis, deterioration of body composition (changes in bone, fat and muscle mass) is associated with increased risk for diseases such as coronary artery heart disease, non-insulin dependent diabetes mellitus, lipid metabolism abnormalities, and osteoporotic fractures in these patients. Immobility leads to a changing pattern of loading in the paralyzed areas, and secondary alteration in structure. However, bone and soft tissue changes in these patients are usually neglected. The purpose of this article is to update on the pathophysiological mechanisms leading to bone and soft tissue changes, and to increase the awareness of the treating physicians with respect to bone, muscle and fat loss and their consequences aiming to obtain measures to prevent bone and soft tissue loss in these patients.

The purpose of this study was to review clinical and radiographic outcomes of perilunate dislocations and fracture dislocations treated with external fixation and K-wire fixation. Twenty patients (18 males and two females) with a mean age of 38 years (range 18-59) who had an acute dorsal perilunate dislocation or fracture dislocation were treated with the use of wrist external fixator and K-wires. The injuries included 12 perilunate dislocations, seven trans-scaphoid perilunate fracture dislocations, and one trans-styloid perilunate fracture dislocation. The median time from trauma to operation was 8 h (2-12 h). Indirect reduction via ligamentotaxis was achieved in all perilunate dislocation, and provisional K-wire fixation was added. In five of seven trans-scaphoid perilunate fracture dislocations, indirect reduction was achieved; whereas in the other two as well as in the case of trans-styloid perilunate fracture dislocation, open reduction was required. External fixator was supplemented with K-wires for stabilization of the fractures and the intercarpal intervals. The interosseous and capsular ligaments were not repaired, even after open reduction of fracture dislocations. The mean follow-up was 39 months (range 18-68 months). Range of motion and grip strength were measured. Cooney's scoring system was used for the assessment of clinical function. Radiographic evaluation included time to scaphoid union, measurement of radiographic parameters (scapholunate gap, scapholunate angle, lunotriquetral gap, and carpal height ratio) and any development of arthritis. The flexion-extension motion arc and grip strength of the injured wrist averaged 80 and 88%, respectively, of the corresponding values for the contralateral wrists. According to Cooney's clinical scoring system, overall functional outcomes were rated as excellent in four patients, good in eight, fair in six, and poor in two. Eighteen patients returned to their former occupations. Two patients with a trans-scaphoid perilunate injury developed nonunion of the scaphoid; one of them required scaphoid excision and midcarpal fusion. Two patients had radiographic evidence of arthritis. The use of external fixation and provisional K-wire fixation for the treatment of acute perilunate dislocations is associated with satisfactory midterm functional and radiographic outcomes. This minimally invasive treatment option is simple, reliable, and minimally invasive method that provides proper restoration and stable fixation of carpal alignment.