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We report the case of a 14 year-old teenager who has SC hemoglobinosis and presented with a tumor syndrome with a retro-peritoneal mass, a supraclavicular lymph node and a mid-renal lesion. The microscopic examination revealed an undifferentiated tumor proliferation infiltrating the lymph node parenchyma. This tumor proliferation was INI1/SMARCB1-deficient, and expressed cytokeratins. Given the fact that the histopathological data showed an undifferentiated INI1-deficient carcinoma and that the patient has a kidney lesion and a sickle cell trait, the final diagnosis was lymph node metastasis of SMARCB1-deficient renal medullary carcinoma (OMS 2022)., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

The bony shoulder girdle consists of the clavicle, humerus, and scapula, which work synergistically to form a complex articulation that is essential for use of the upper extremity. The shoulder girdle is the most common location for primary and secondary bone tumors in the upper extremity, and following resection of these tumors, reconstruction of the upper extremity is challenging. Compared with those in the lower extremity, reconstructive techniques in the upper extremity have historically been unreliable and fraught with complications and poor functional outcomes. Newer reconstructive techniques using reverse total shoulder arthroplasty and functional muscle flaps have shown promise to improve outcomes while reducing complications for proximal humerus reconstructions. Despite these advancements, reconstruction following scapulectomy remains challenging and is still associated with more frequent complications and compromised function.

Rationale: Florid reactive periostitis (FRP), a rare reactive bone lesion, typically presents in the short tubular bones of the extremities, with infrequent occurrences in the long tubular bones. This report discusses a unique case of FRP in the clavicle, managed through comprehensive lesion debridement and bone grafting, yielding positive results over a 3-year duration., Patient Concern: A 25-year-old male presented with a discernible mass at the left sternal end of the clavicle, discovered incidentally 2 weeks prior. The patient exhibited no clinical signs of inflammation, pain, sinus tract, or suppuration., Diagnosis: Initial pathological examination of the local excision suggested benign lesions, although malignancy could not be ruled out. A definitive diagnosis of clavicular FRP was reached post complete lesion resection, with supporting evidence from postoperative pathology, imaging, and clinical symptoms., Intervention: The left clavicle was reconstructed through an open surgical procedure involving total mass removal and ipsilateral extraction of an iliac bone of suitable dimensions. This was implanted into the clavicular bone defect and internally fixed with a plate., Outcomes: Three years of consecutive follow-up revealed no recurrence of hyperplasia, absence of mass or tenderness at the left sternal end of the clavicle, and unimpaired function of adjacent joints., Lessons: The primary clinical challenge with FRP is its diagnosis. While pathological diagnosis remains crucial, it is also important to incorporate imaging and clinical symptoms for a comprehensive assessment. Complete mass excision may offer specific benefits in distinguishing FRP from its malignant counterparts., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Atypical progeroid syndromes (APS) are premature aging syndromes caused by pathogenic LMNA missense variants, associated with unaltered expression levels of lamins A and C, without accumulation of wild-type or deleted prelamin A isoforms, as observed in Hutchinson-Gilford progeria syndrome (HGPS) or HGPS-like syndromes. A specific LMNA missense variant, (p.Thr528Met), was previously identified in a compound heterozygous state in patients affected by APS and severe familial partial lipodystrophy, whereas heterozygosity was recently identified in patients affected by Type 2 familial partial lipodystrophy. Here, we report four unrelated boys harboring homozygosity for the p.Thr528Met, variant who presented with strikingly homogeneous APS clinical features, including osteolysis of mandibles, distal clavicles and phalanges, congenital muscular dystrophy with elevated creatine kinase levels, and major skeletal deformities. Immunofluorescence analyses of patient-derived primary fibroblasts showed a high percentage of dysmorphic nuclei with nuclear blebs and typical honeycomb patterns devoid of lamin B1. Interestingly, in some protrusions emerin or LAP2α formed aberrant aggregates, suggesting pathophysiology-associated clues. These four cases further confirm that a specific LMNA variant can lead to the development of strikingly homogeneous clinical phenotypes, in these particular cases a premature aging phenotype with major musculoskeletal involvement linked to the homozygous p.Thr528Met variant., (© 2023 Wiley Periodicals LLC.)

Background: To achieve clear margins in rare malignant clavicular neoplasms, claviculectomy may become necessary. This study aimed to review clinical, functional, and oncologic outcomes following partial or total claviculectomy without reconstruction., Methods: This study retrospectively included 15 patients from 2 tertiary sarcoma centers (mean age, 42.6 ± 20.3 years; 66.7% male patients). The median length of clinical and oncologic follow-up was 48.0 months (interquartile range [IQR], 24.0-83.5 months). Functional follow-up (Musculoskeletal Tumor Society score and QuickDASH score [short version of the Disabilities of the Arm, Shoulder and Hand questionnaire]) was available in 9 patients at a median of 36.0 months (IQR, 20.0-100.0 months)., Results: Of the 15 patients, 7 underwent total claviculectomy; 5, partial lateral claviculectomy; and 3, partial medial claviculectomy. No postoperative complications emerged. The median Musculoskeletal Tumor Society and QuickDASH scores at latest follow-up amounted to 26.0 points (IQR, 24.0-29.0 points) and 18.0 points (IQR, 11.0-22.0 points), respectively. Notably, scores tended to be lower in patients who underwent total claviculectomy (n = 2) in comparison to partial claviculectomy (n = 7)., Conclusion: Satisfactory clinical and functional results can be achieved following partial or total claviculectomy without reconstruction, with a low complication rate and acceptable mid- to long-term function., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Echinococcosis, also known as hydatid disease, is a zoonotic parasitic disease prevalent in pastoral areas, mainly involving the liver and lungs, and less frequently the bones and surrounding soft tissues. Diagnosis and treatment of bone hydatid disease is a challenge, and because of the insidious course of the disease, the lesions are often widely disseminated by the time patients seek medical attention., Case Presentation: A 29-year-old woman presented with a painless mass that was gradually increasing in size in the cervical thorax. Imaging revealed an enlarged clavicle with multiple bone cortical defects and the existence of cysts in the soft tissues surrounding the clavicle, for which complete excision of the clavicle and the attached cysts was performed. There was no recurrence of the cyst within one year after the operation, and the patient felt well and had normal shoulder joint movement., Conclusions: Bone hydatid may appear in bones throughout the body, and cysts that leak from the bone into the surrounding soft tissues may spread at a relatively rapid rate. Prompt surgical removal of the affected bone and surrounding cysts is necessary for treatment., (© 2023. The Author(s).)

Nearly 1% of all bone cancers are primary clavicular tumors and because of their rarity, treating clinicians are unfamiliar with their diagnosis, classification, treatment options, and prognosis. In terms of preserving function and avoiding complications, clavicle reconstruction seems logical; however, further studies are needed to support this measure. Reconstruction techniques are difficult taking into account the anatomical structures surrounding the clavicle. When chest wall defects are present, a multidisciplinary team, including an orthopedist and thoracic and plastic surgeons, is of paramount importance for optimal surgical management. Malignant clavicle tumors may include primary and secondary malignancies and neighboring tumors with clavicular invasion. Surgical resection of complex thoracic tumors invading the clavicles can result in larger defects, requiring chest wall reconstruction, which is a substantial challenge for surgeons. Correct diagnosis with proper preoperative planning is essential for limiting complications. Post-resection reconstruction of the partial or total claviculectomy is important for several reasons, including maintaining the biomechanics of the scapular girdle, protecting the vessels and nerves, reducing pain, and maintaining the anatomical appearance of the shoulder. The chest wall resection and reconstruction techniques can involve either partial or full chest wall thickness, influencing the choice of reconstructive technique and materials. In the present paper, we aimed to synthesize the anatomical and physiopathological aspects and the small number of therapeutic surgical options that are currently available for these patients.

Background/aim: The effectiveness of clavicula pro humero (CPH) reconstruction for pediatric proximal humerus sarcoma has been reported in a small number of cases. We aimed to investigate the effectiveness of biological CPH reconstruction for malignant bone tumors of the proximal humerus in children and adults., Patients and Methods: This was a retrospective cohort study that included eight patients who underwent CPH reconstruction due to a malignant bone tumor around the proximal humerus. Postoperative parameters, including complications, postoperative upper limb function, and the period until bone fusion, were investigated., Results: Three patients had non-union and fracture of the clavicular segment. Among them, one patient underwent revision surgery for internal fixation and bone grafting. Five patients achieved bone fusion, and the overall mean Musculoskeletal Tumor Society score was 70%, which is comparable to previous reports., Conclusion: CPH reconstruction is an effective technique for malignant bone tumors of the proximal humerus in all ages., (Copyright © 2022 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: Congenital pseudarthrosis of the clavicle (CPC) is a rare congenital entity with unresolved aetiology and pathogenesis. Nearly 250 cases have been reported to date. CPC is characterized by a definite defect in the mid-clavicle at birth and is usually diagnosed when the deformity becomes evident in late childhood or adolescence. Surgical management is controversial, especially in asymptomatic children, with various techniques reported in the literature., Case Report: We report a case of a 6-year-old boy who was diagnosed with CPC during a medical examination for primary school enrollment. Operative treatment included debridement of pseudoarthrosis, internal fixation with third tube plate, and barrel-shaped mono-cortical iliac crest autograft., Results: A complete bone union was obtained 9 months after the operation, and satisfactory function and cosmetic appearance were observed 4 years and 3 months postoperatively., Conclusion: In our opinion, reconstruction with barrel-shaped mono-cortical iliac crest autograft was an effective and reproducible surgical technique to treat CPC.

Objectives: The aim of this study was to examine the characterization of tumors and tumor-like lesions located in the clavicle and to present their clinical results., Patients and Methods: Between January 2006 and December 2018, a total of 44 patients (25 males, 19 females; mean age: 36.2±21.8 years; range, 2 to 87 years) who were operated in our clinic for a clavicular lesion were included. Among 4,856 extremity tumors operated in our clinic between these years, 44 cases (0.9%) located in the clavicle were eligible. Demographic data, tumor types, location, surgical method, metastasis, survival analyzes and clinical results of these patients were reviewed retrospectively. According to the clavicle location, the patients were divided into groups according to their involvement in proximal, middle, lateral and more than one region., Results: The most frequently involved site was the lateral edge of the clavicle, and the most common tumor was aneurysmal bone cyst. The most common malignant tumor was Ewing sarcoma and plasmacytoma (13.6%) and the most common surgical method in the clavicle was wide resection with 34.1%. Of the 38 primary clavicle tumors remaining after the metastatic lesions were removed, 21 (55%) were benign, while 17 (45%) were malignant. Aneurysmal bone cyst was most common in the group under 30 years of age, osteochondroma was most common in the 30-50 age group, and plasmacytoma was most common in those over 50 years of age. The mean musculoskeletal tumor society (MSTS) score of 15 patients (34.1%) who underwent clavicle resection was 79.4±6., Conclusion: We believe that a wide spectrum should be considered in the differential diagnosis of tumors located in the clavicle. Age is an important predictive factor for malignancy. We believe that resection should be applied without fear considering its effects on function and recurrence.

Rationale: Three-dimensional (3D) printing has attracted wide attention for its potential and abilities in the assistance of surgical planning and the development of personalized prostheses. We herewith report a unique case of chronic clavicle osteomyelitis treated with a two-stage subtotal clavicle reconstruction using a 3D printed polyether-ether-ketone (PEEK) prosthesis., Patient Concerns: A 23-year-old Chinese female presented to our clinic complaining about a progressive pain of her right clavicle for about 1 year., Diagnoses: Chronic clavicle osteomyelitis confirmed by percutaneous biopsy and lesion biopsy., Interventions: This patient accepted a long-term conservative treatment, which did not gain satisfactory outcomes. Thus, a subtotal removal and two-stage reconstruction of the right clavicle with a 3D-printed polyether-ether-ketone prosthesis stabilized by screw fixation system was performed., Outcomes: At 2-year follow-up, complete pain relief and satisfactory functional recovery of her right shoulder were observed., Lessons: Personalized 3D printed prosthesis is an effective and feasible method for reconstruction of complex bone defects., Competing Interests: The authors declared that they have no conflicts of interest to this work. We declare that we do not have any commercial or associative interest that represents a conflict of interest in connection with the work submitted., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

A null mutation in a patient can facilitate phenotype assignment and uncovers the function of that specific gene. We present five sibs of a consanguineous Pakistani family afflicted with a new syndrome with an unusual combination of skeletal anomalies including cranial asymmetry, fused sagittal sutures deviating from the medial axis, mandibular prognathia, maxillary hypoplasia, misaligned and crowded teeth, delayed bone age, multiple dislocations, hypoplastic and malpositioned patellae, humeral intracondylar fissures, scapular dyskinesis, long limbs, lumbar lordosis, protruding chest, prominent clavicles, short 5th digital rays, and ventral transverse digital creases plus features of cutis laxa. We mapped the disease gene locus to a 3.62-Mb region at 17q25.3 and identified a homozygous deletion of maximal 7.3 kb deduced to totally inactivate MYADML2 and downstream gene PYCR1, biallelic variants in which cause autosomal recessive cutis laxa (ARCL). All five affected sibs had the most common features of ARCL but not many of the less common ones. We attributed the anomalies not typical for ARCL to MYADML2 deficit, because no other genetic defect possibly a candidate to underlie the skeletal phenotype was found. MYADML2 is a gene of unknown function, has not been studied, and has not been associated with disease. Our findings present a possible phenotype for MYADML2 deficit that includes impaired bone patterning and maturation, definitely show that the gene is not essential for survival, and provide a start point for future studies on the function of MYADML2 protein. Detection of new patients is needed to confirm and delineate MYADML2-deficiency phenotype.

Background: Plate fixation and intramedullary nail/Knowles pin fixation methods are commonly used to treat displaced midshaft clavicle fractures. However, the differences between these 2 methods are unclear., Objective: This meta-analysis aimed to compare plate fixation and intramedullary nail/Knowles pin fixation for displaced midshaft clavicle fractures., Methods: We searched PubMed, EBM reviews, and Ovid Medline online for studies related to comparison of plate fixation versus intramedullary nail/Knowles pin fixation for displaced midshaft clavicle fracture from inception to June 30, 2019. Relevant literature search, data extraction, and quality assessment will be performed by 2 researchers independently. The methodological quality of all included studies was appraised using the Cochrane system for randomized trials. The RevMan 5.2 software was used for heterogeneity assessment, generating funnel-plots, data synthesis, sensitivity analysis, and determining publication bias. The fixed-effects or random-effects model was used to calculate mean difference (MD)/relative risks (RRs) and 95% confidence intervals (CIs)., Results: This meta-analysis included 839 patients from 12 randomized controlled trials. We found that compared to plate fixation, intramedullary nail/Knowles pin fixation yielded a higher shoulder constant score [MD = -2.43, 95% CI (-3.46 to -1.41), P < .00001] and lower disabilities of the arm, shoulder and hand (DASH) score [MD = 2.98, 95% CI (0.16-5.81), P = .04], and lower infection rates [RR = 2.05, 95% CI (1.36-3.09), P = .003], operation time [MD = 20.20, 95% CI (10.80-29.60), P < .0001], incision size [MD = 6.09, 95% CI (4.54-7.65), P < .00001], and hospital stay [MD = 1.10, 95% CI (0.56-1.64), P < .00001] but with a higher removal rate [RR = 0.52, 95% CI (0.41-0.65), P < .00001] compared to plate fixation. There were no significant differences in nonunion, reintervention, or revision and refracture between these two methods. The limitation is that many studies did not demonstrate the random generated details, and only English articles were enrolled in this meta-analysis., Conclusions: Intramedullary nail/Knowles pin fixation might be an optimum choice for treating displaced midshaft clavicle fractures, with similar performance in terms of the nonunion, reintervention, or revision and refracture, and better shoulder constant and DASH scores, infection rates, and operative parameters.

Forensic assessment of skeletal material includes age estimation of unknown individuals. When dealing with extremely fragmented human remains that lack macro-features used in age estimation, histological assessment of the skeletal elements can be employed. Historically, microscopic methods for age assessment used by forensic anthropologists have been available since 1965. Several skeletal elements have been used for this purpose. Among them, the clavicle has garnered very little attention. The purpose of this study is to explore the validity of clavicular histomorphometry as an age marker in a modern Balkan sample. This study examined a modern clavicular autopsy sample from Albania. The sample consisted of 33 individuals of known age and cause of death. Data were collected for micro-anatomical features including osteon population density (OPD) and cortical area. Intra- and inter-observer errors were assessed through technical error of measurement (TEM) and R coefficient. A validation study was performed in order to test the accuracy of existing histological formulae. Regression analysis was run to developed age prediction models with the best models tested through cross-validation and the comparison between OPD for the Albanian sample and a European-American sample examined. Intra- and inter-observer error TEM results demonstrated values falling within the limits of acceptance. The existing histological methods did not perform accurately on the sample under study. Regression equations for Albanians produced age estimations deviating 8 and 11 years from known age. Cross-validation on the most accurate regression formula which includes OPD as a single variable demonstrated similar mean errors. Statistically significant differences were observed between the Albanian and the European-American population when the two samples were compared. The research presented is the fifth article published and the fifth population explored on clavicular microstructure. The potential of histology to estimate age on the Albanian population is shown here; however, population effect, diet and health status might be considered. Further inclusion of individuals will corroborate our preliminary findings., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflicts of interest., (Copyright © 2020 Elsevier B.V. All rights reserved.)

We report the case of a myopericytoma of the neck. A 23-year-old female noticed a small, nontender mass in her left supraclavicular fossa. The mass grew over a period of 5 months, prompting the patient to seek evaluation. There were no motor or sensory deficits. Imaging suggested a mass originating from the middle scalene muscle. Computed tomography-guided core needle biopsy demonstrated a spindle cell neoplasm with smooth muscle differentiation. Complete surgical excision was performed. Histopathological and immunohistochemical evaluation of the tissue sample suggested myopericytoma. Myopericytoma is an extremely rare tumor of the head and neck. To our knowledge, this is the first reported case of a myopericytoma originating from a scalene muscle.

Introduction: Displaced and shortened clavicle fractures are frequently treated surgically. Although extramedullary fixation using a plate and screws is most commonly used, intramedullary nailing has become increasingly popular over the last decade. Traditional intramedullary nailing is usually associated with a high risk of hardware migration as well as hardware irritation at its entry point. Newer devices, however, seem to mitigate these problems. The aim of this narrative review is to provide an overview of clavicle shaft fractures and treatment with intramedullary nails, in particular the newer, locked devices., Areas Covered: In general, this review covers current literature related to clavicle shaft fractures with a specific focus on the treatment of displaced and shortened fractures with intramedullary nails., Expert Opinion: Clavicle shaft fractures can be effectively treated with an intramedullary nail. The risk of hardware migration when employing the newer, improved designs appears to be minimal. The advantages of using intramedullary fixation include smaller incision sizes as well as the avoidance of routine procedures generally associated with the removal of prominent subcutaneous hardware as per extramedullary fixation.

Clavicle fractures account for approximately 2-5% of all fractures in adults and 10-15% in children. There is a bimodal distribution, with two peaks occurring in patients <25 years of age as a result of direct trauma and in those >55 years of age secondary to a fall onto an outstretched arm. Approximately two-thirds of all clavicle fractures occur in men. This article provides an overview of the presentation, assessment and management of clavicle fractures for both core surgical trainees and acute care common stem/emergency medicine trainees.

Background: Osteogenesis imperfecta (OI) type V is a rare heritable bone disorder caused by pathogenic variants of IFITM5. Only two mutated alleles in IFITM5 have been identified worldwide, the role of which in OI pathology is not fully understood., Methods: A neonatal case of suspected OI, clinically manifested as a rare clavicle transection fracture with delayed early fracture healing, was studied. Subtle variants of OI-associated genes were analyzed by whole exome sequencing and confirmed by Sanger sequencing., Results: A de novo heterozygous pathogenic variant of IFITM5 within the 5'-UTR (c.-9C > A) was discovered in the proband. Bioinformatics analysis using a combination of various algorithms predicted that the variant would generate a new in-frame start codon 9 bp upstream of the original and express a mutant IFITM5 protein with three additional amino acids (Met-Glu-Pro). After transfection into a eukaryocyte in vitro, the mutant IFITM5 construct produced a longer transcription product than that of wild-type IFITM5., Conclusion: This study identified a novel pathogenic variant of IFITM5, which not only manifested the molecular characteristics of IFITM5, but also provided new evidence for the study of the molecular mechanisms of IFITM5 association with OI., (© 2020 The Authors. Molecular Genetics & Genomic Medicine published by Wiley Periodicals LLC.)

Background: Chronic sclerosing osteomyelitis (CSO) of the clavicle, especially its unifocal subset, is scarcely reported, and little is known about its characteristic features and treatment. We aim to describe the characteristic features and outcome of treatment in a series of patients with unifocal CSO of the clavicle., Materials and Methods: In a retrospective study, we identified 6 patients with a diagnosis of unifocal CSO of the clavicle. All patients underwent a core needle biopsy, and histologic examination confirmed the diagnosis. Laboratory investigations included the white blood cell count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, and bacteriologic culture. We used plain radiographs, computed tomography scanning, and magnetic resonance imaging for the radiologic evaluation., Results: The median age of the patients was 16.5 years (range, 10-29 years). The ESR and CRP level were elevated in 5 cases. The bacterial culture results were negative in all cases. Sclerosis was the main radiologic symptom. Other radiologic features such as bone expansion, cystic change, periosteal reaction, cortex destruction, and soft-tissue edema could accompany sclerosis. Anti-inflammatory medications temporarily and slightly reduced the symptoms. Four patients underwent extended curettage, in whom the clinical, radiologic, and laboratory symptoms considerably subsided. In the 2 patients who did not agree to undergo surgical intervention, the clinical and radiologic symptoms fluctuated at the follow-up visits., Conclusion: Unifocal CSO of the clavicle is associated with negative bacterial culture results, but the ESR and CRP level are frequently elevated. The symptoms fluctuate if not adequately treated. Extended curettage could be regarded as the treatment of choice., (Copyright © 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

The clavicle is an infrequent location for primary tumors in general, and aneurysmal bone cyst (ABC) of the clavicle is particularly rare. The challenge of the functional and esthetic result in the treatment of these lesions in the pediatric population is high when considering the reconstruction of critical bone defects. In this article, we present the case of a seven-year-old boy with an ABC in the middle third of the clavicle, treated by resection and reconstruction with free autograft of the fibula stabilized by using an intramedullary titanium nail. We offer a description of the used technique, considerations about treatment options in children, and a follow-up of more than two-and-a-half years.

BACKGROUND This retrospective analysis was designed to compare the outcomes of mid-shaft clavicle fracture operative treatment using bridge combined fixation system (BCFS) versus clavicular locking plate (CLP). MATERIAL AND METHODS Operative surgeries performed between January 2016 and July 2018 were included in the analysis. The surgical internal fixation implants were chosen according to surgeon preference and the choice of patients between the BCFS and CLP. Functional outcomes, fracture union, complications, pain, and patient satisfaction post-operation were assessed at a follow-up of 12 to 24 months. RESULTS Two hundred and seventeen (217) patients, aged 21-79 years, were operated, 87 using BCFS and 130 using CLP. The operation time of the BCFS group was significantly less than the CLP group (P<0.01). We also found that BCFS group had higher degree of satisfaction (100% vs. 97%, P<0.03) and less VAS scale (0.25±0.18 vs. 0.35±0.21, P<0.001) compared with the CLP group, but the significance could only be obtained during the follow-up at 3 months after surgery. No significant differences were observed between the 2 groups when compared for fracture unions, functional scores, or complications. CONCLUSIONS BCFS significantly reduced the operation time when compared with CLP. No significant differences were observed for functional outcomes, including fracture union and complications, and there was less pain and higher patient satisfaction. Both methods appeared to be safe in terms of complications. However, the effectiveness and safety of BCFS in treating comminuted multi-fragmentary mid-shaft clavicle fractures (AO/OTA 15-2C classification) need further confirmation.

Competing Interests: Competing interests: None declared.

BACKGROUND This research aimed to determine high-risk factors of supraclavicular recurrence for limited-stage small cell lung cancer (LS-SCLC) patients to discover a potential subpopulation that can benefit from prophylactic supraclavicular irradiation (PSCI). MATERIAL AND METHODS Between July 2006 and July 2011, LS-SCLC patients without supraclavicular lymph node (SCLN) involvement consecutively treated with concurrent chemo-radiation but without PSCI in the Radiotherapy Department of the Cancer Institute and Hospital of Tianjin Medical University, were retrospectively analyzed. SCLN recurrence rate, overall survival (OS), and distant metastasis-free survival (DMFS) were assessed. Binary logistic regression analysis was conducted to discover the high-risk factors related to the SCLN recurrence. The receiver operating characteristic (ROC) curves were drawn to evaluate logistic regression model prediction performance. RESULTS Eighty-eight LS-SCLC patients were analyzed in this study. During 99 months (ranging from 72 months to 124 months) for survivors, 28 (31.8%) had SCLN recurrence. There were significant differences for median DMFS and OS between LS-SCLC patients with and without SCLN recurrence. The logistic regression model revealed that lymphadenopathy at mediastinal level 2 and level 3 prior to chemotherapy were significantly associated with SCLN recurrence, which was validated by ROC. CONCLUSIONS Lymphadenopathy at mediastinal level 2 and level 3 prior to chemotherapy were the high-risk factors associated with SCLN recurrence for patients with LS-SCLC. Further work is needed to determine whether patients with these factors can benefit from PSCI.

Background: To retrospectively analyze the tumor resection method used in 20 patients with clavicular tumors and evaluate its clinical efficacy., Methods: A total of 9 patients with clavicular benign tumors underwent intracapsular resection, and 11 patients with clavicular malignant tumors underwent tumor resection from May 2012 to May 2017. Of the 11 patients, 5 underwent clavicular reconstruction using the plate-cement complex. Surgical efficacy was assessed using the Musculoskeletal Tumor Society, Constant-Murley, and American Shoulder and Elbow Surgeons shoulder outcome scores preoperatively until 12 months postoperatively., Results: The average duration of follow-up care was 33.7 (12-71) months. Of the 20 patients, 3 patients died, 3 survived with tumor recurrence or metastasis, and 14 survived with no tumor recurrence. Among the 5 patients who underwent resection of malignant clavicular tumors and reconstruction, 2 underwent a re-operation because of a loose screw and plate displacement. In the functional assessment of the shoulder joint, patients with benign and malignant clavicular tumors showed significantly higher scores postoperatively compared with preoperative scores. For malignant clavicular tumors, no significant improvement was observed when comparing the non-reconstruction and reconstruction groups., Conclusions: Surgery is an optimal treatment for clavicular tumors. In patients with benign clavicular tumors, simple intracapsular resection can achieve a satisfactory prognosis. Reconstruction of a clavicular defect after resection of a clavicular malignant tumor is not recommended.

Secondary upper limb lymphoedema is usually caused by lymphatic system dysfunction. Diagnosis is primarily based on clinical features. However, there are no distinct diagnostic criteria for lymphoedema. Although conventional lymphoscintigraphy is a useful technique to diagnose the severity of lymphoedema, the resultant data are two-dimensional. In this study, we examined the pathology of lymphoedema using single photon emission computed tomography-computed tomography lymphoscintigraphy (SPECT-CT LSG), a new technique that provides 3-dimensional information on lymph flow. We observed lymph flow pathways in the subcutaneous and muscle layers of the upper limbs. A significant positive correlation was found between the dermal back flow (DBF) type and the visualization of lymph nodes around the clavicle (p = 0.000266), the type of lymph flow pathways and the visualization of lymph nodes around the clavicle (p = 0.00963), and the DBF type and the lymph flow pathway (p = 0.00766). As the severity of lymphoedema increased, the DBF appeared more distally in the upper limb and the flow into the lymph nodes around the clavicle decreased, whereas the lymph flow pathways in the muscle layer became dominant. These findings demonstrate the features of lymphoedema pathology and the functional anatomy and physiology of the lymphatic system without the need for cadaver dissection.

Purpose: Postoperative standing radiographs are usually performed before hospital discharge after AIS fusion. However, patients are often still painful and have not recovered yet their physiological balance. The aim of this study was therefore to evaluate the relevance of such early radiographs and more specifically investigate whether postoperative alignment could be analyzed., Methods: All consecutive AIS patients operated between January 2015 and December 2015 were included. All patients underwent biplanar stereoradiographs before hospital discharge, at 4 months postoperative and at last follow-up. Fifteen parameters (eight coronal and seven sagittal), reflecting correction and spinal alignment were measured and compared. The incidence of implant misplacement, requiring or not surgical revision, was recorded., Results: In total, 100 patients were included. A significant difference was found for 12 out of the 15 (80%) parameters between the first erect radiograph and the 4-month follow-up visit, including the CVA and the SVA, which are commonly used to assess postoperative alignment. Clavicle, UIV and LIV tilts also decreased significantly at 4 months postoperative. In opposition, no significant change occurred for the same parameters between the 4-month visit and latest follow-up. In nine patients, a pedicle screw was considered misplaced on the first radiograph, but all patients remained asymptomatic and no revision was performed., Conclusion: There is no need for additional immediate postoperative radiographs in AIS, if an intraoperative radiograph has already been taken. This finding could help reducing radiation exposure in immature patients and should be further studied in other etiologies. These slides can be retrieved under Electronic Supplementary Material.

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.

Identifying tool mark and involved weapon in sharp force trauma is essential to understanding the circumstances of death. But accuracy and reliability of such expert testimony remains unknown, and validation studies are rare in forensic literature. That is why, we conducted an experiment in order to determine error rates and predictive values on identifying the right implement through different types of knife-inflicted trauma. Human bone cut marks were analysed through epifluorescence microscopy. The samples were examined through a randomised, blinded, controlled study by three researchers with varying degrees of experience with direct and indirect observation of cut marks (photography). Our results showed that identifying the weapon involved is possible thanks to numerous criteria analysis. Correct classification rates were high and misclassifications rare. Asymmetric blades obtained better results than symmetric blades. Predictive values were also calculated, and the negative one reached very high levels, near 100% with regard to all the implements. Positive predictive values were more variable. But even if individual diagnoses remain in doubt, triage can be done and tools not implicated in injury can be eliminated with certainty. Moreover, our work clearly highlighted the importance of experience in such activities. A high level of experience is fundamental to obtain the best values, especially in such a context where evidence reliability is extremely important for forensic admissibility testimony in the court.

Background: The optimal treatment of displaced middle-third clavicular fractures in pediatric and adolescent patients remains controversial. Furthermore, risk factors for the failure of nonoperative treatment have not been clearly defined. Therefore, we designed a systematic review and critical analysis to assess appropriate Grades of Recommendation for evidence-based treatment of middle-third clavicular fractures in the pediatric and adolescent populations., Methods: We performed a systematic review following a search of the PubMed, Embase, and Cochrane databases that was conducted in May 2017. The search terms were clavicle, clavic*, and fracture. Our specific PubMed search was ("clavicle"[MeSH] OR clavic*) AND ("fracture"[MeSH] OR fracture*). The results were filtered for English language and subjects ≤18 years of age. There was no chronological limit on the results. The results were then assessed for relevance via a stepwise approach by first screening titles, then abstracts, and, finally, full text. The levels of evidence were determined for studies that met the inclusion criteria. The findings were summarized, and Grades of Recommendation were assigned by consensus., Results: Our search returned 3,615 studies. Of these, 215 were potentially relevant. Studies that did not meet our inclusion criteria were removed by consensus. One hundred and nineteen full-text articles were then assessed. Of these, 19 met the inclusion criteria. Overall, patients with both operative and nonoperative treatment of displaced middle-third clavicular fractures have good functional outcomes, with Grade-B supporting evidence. There is Grade-B evidence that operative treatment results in a high complication rate. Both plating and nailing have a high likelihood of requiring implant removal, with Grade-B evidence. There is conflicting evidence regarding the effect of both nonoperative and operative treatment on patient cosmesis following displaced fractures. There is Grade-B evidence that nonunions of pediatric clavicular fractures are exceptionally rare, regardless of treatment strategy. Nonoperatively treated displaced fractures have conflicting evidence regarding any adverse effect displacement may have on functional status., Conclusions: Existing literature does not clearly delineate appropriate indications for nonoperative care or relative indications for operative intervention. Further studies are needed to guide treatment and promote better informed consent., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Implantable catheter systems are the most common procedure used for patients requiring chemotherapy or long-term drug administration. Several procedures are used for the installation of these systems. Patients with long-term subclavian venous catheters described a progressive rupture of the catheter which is a rare complication. This rupture is most often due to costoclavicular forceps or Pinch-off syndrome (POS). We report 07 cases of Pinch-off syndrome to evaluate our diagnostic and therapeutic approach., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Background: The prognostic value of supra-clavicular lymph node (SCLN) metastases in esophageal cancer (EC) is still not clear., Method: From January 2009 to December 2015, a survival analysis was performed to retrospectively identify the prognostic value of SCLN metastasis on survival on 751 patients with EC treated with definitive chemo-radiotherapy (dCRT)., Results: The median follow-up duration for living patients was 56.6 months. The median overall survival (OS) for all patients was 16.6 months. Patients with SCLN metastasis had a much poorer prognosis for OS (χ 2  = 17.342, P < 0.001), distant metastasis-free survival (DMFS) (χ 2  = 24.793, P < 0.001) and progression-free survival (PFS) (χ 2  = 25.802, P < 0.001) than those without SCLN metastasis. The same results were found after propensity score matching. Nonetheless, the prognosis of patients with cervical or upper thoracic EC metastasis in SCLN was better than those of patients with middle or lower thoracic EC metastasis in SCLN for OS (χ 2  = 4.516, P = 0.038), DMFS (χ 2  = 8.326, P = 0.004) and PFS (χ 2  = 6.255, P = 0.012). Univariate analysis showed that gender, middle or lower thoracic EC with SCLN metastasis, tumor length, tumor diameter, concurrent chemo-radiotherapy (CCR) and number of lymph nodes were prognostic factors for PFS. Gender, age, middle or lower thoracic EC with SCLN metastasis, tumor diameter, tumor length, and number of lymph nodes were prognostic factors for DMFS. According to the multivariate analysis, only middle or lower thoracic EC with SCLN metastasis and number of lymph nodes were independent prognostic factors for DMFS and PFS., Conclusion: For patients with cervical or upper thoracic EC, metastasis in SCLN should be considered to be regional lymph nodes and treated with curative intent if the total number of lymph nodes is limited. However, for patients with middle or lower thoracic EC, metastasis should be considered to be a higher level N stage or M1 stage, and it is thus necessary to provide consolidation chemotherapy after dCRT.

Background and Objectives: Retroclavicular block is designed to overcome the negative aspects of the commonly utilized ultrasound-guided parasagittal approach to the infraclavicular block. However, this approach necessitates the needle traversing an area posterior to the clavicle inaccessible to ultrasound wave conduction. This study sought to document the structures vulnerable to needle injury during a retroclavicular block., Methods: A Tuohy needle was inserted using a retroclavicular approach to the infraclavicular block in 3 lightly embalmed cadavers followed by a catheter insertion 4 cm beyond the needle tip. The process was repeated on the contralateral side. With the needle and catheter in position, the cadavers were dissected and photographed., Results: In 4 of the 6 dissections, the needle was directly touching the suprascapular nerve deep to the clavicle. In the remaining 2 dissections, the suprascapular nerve was within 2 cm of the needle. In 1 dissection, the suprascapular vein was indented, behind the clavicle. The trapezius was the only muscle layer traversed by the needle in all dissections. In 3 of the 6 dissections, the catheter penetrated the posterior cord. In the remaining 3, the catheter threaded along the neurovascular bundle., Conclusions: The suprascapular nerve is consistently in the path of the block needle posterior to the clavicle. This raises the possibility of risk of injury to the suprascapular nerve when using this approach to the brachial plexus. Vascular injury is also possible deep to the clavicle, and because of the noncompressible location, caution is advised in patients with disordered coagulation.

Background: Breast cancer is a heterogenous and complex disease. A rare site of metastatic breast cancer disease is the neck. Data about supraclavicular metastases in patients with metastatic breast cancer are still lacking. Hence, our study aimed to analyze histological subtypes of supraclavicular metastases compared to the primary site., Materials and Methods: This was a retrospective hospital-based cohort study of patients with breast cancer who developed supraclavicular metastases. Diagnosis of supraclavicular metastases was confirmed by biopsy or diagnostic lymph node extirpation. Histological subtypes were analyzed and Kaplan-Meier estimates were calculated for overall survival., Results: A total of 20 patients were included in the analysis. The majority of the patients (12/20) had hormone receptor (HR)-positive/human epidermal growth factor receptor 2 (HER2)-negative supraclavicular metastases, disease in 3/20 patients was HR-positive/HER2-positive, HR-negative/HER2-positive in 1/20 patients and basal-like in 4/20 patients. Total discordance rates for estrogen receptor, progesterone receptor and HER2 between primary and metastatic tumors were 20.0%, 36.8% and 29.4%, respectively. The 5-year overall survival was 80%, whereas the 5-year survival after the onset of neck metastasis was 45%., Conclusion: As a rare site of metastatic breast cancer, supraclavicular metastases are associated with a worse median overall survival from their onset. The high rate of discordance of histological subtype stresses the necessity for biopsies in patients with supraclavicular metastasis., (Copyright© 2018, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Objective: To identify factors that influence shoulder balance and to determine whether a model can be made to predict shoulder balance after corrective surgery., Methods: This is a retrospective study in which we examined the records of with adolescent idiopathic scoliosis (AIS) patients who underwent single posterior spinal correction and fusion using all pedicle screws with derotation in our institution between January 2008 and June 2010. For the radiographic outcome measurement, we measured the preoperative lumbar curve, the main thoracic curve, and their difference (L&#95;TH&#95;D), and the degree of correction of the lumbar curve, the main thoracic curve, and their difference (c&#95;L&#95;TH&#95;D) to evaluate their influence on postoperative shoulder balance. The preoperative flexibility of the proximal non-fusion curve on the immediate postoperative tilt of the upper endplate of the uppermost vertebra of fusion segments (Up&#95;FuS) was used to evaluate and predict the shoulder balance at follow-up., Results: For patients who had shoulder balance at follow-up, the average balance time was 7.1 months, and in most of them, balance was detected within 12 months. The main thoracic curve has the greatest influence on preoperative shoulder tilt and correction of the main thoracic curve has the greatest influence on the postoperative alteration in shoulder balance. To evaluate the influence on the preoperative shoulder tilt, the lumbar curve must be larger than the main thoracic curve both pre operatively and postoperatively. If the preoperative flexibility of the proximal non-fusion curve on the immediate postoperative Up&#95;FuS includes the horizontal line (With Horizontal group), shoulder balance can be ensured. The postoperative Up&#95;FuS can be evaluated based on the preoperative Up&#95;FuS and the degree of correction of the lumbar and main thoracic curves., Conclusion: Shoulder balance can be ensured in patients in the With Horizontal group after surgery. If the preoperative Up&#95;FuS and the degree of correction of the main thoracic curve and the lumbar curve are considered in the preoperative plan, the desired postoperative Up&#95;FuS can be achieved, ensuring shoulder balance at follow-up., (© 2018 Chinese Orthopaedic Association and John Wiley & Sons Australia, Ltd.)

Background: For patients with adolescent idiopathic scoliosis, shoulder balance influences their treatment satisfaction and psychological well-being. Several parameters are known to affect postoperative shoulder balance, but few prognostic models are as yet available., Purpose: This study aimed to identify independent predictive factors that can be used to assess preoperatively which patients are at risk of postoperative shoulder elevation, and to build a linear prediction model., Methods: N = 102 patients with all Lenke types were reviewed radiographically before surgery and 1 year afterward. The outcome measures were coracoid height difference (CHD), clavicular angle (CA), and clavicle-first rib intersection difference (CiRID). Predictive factors commonly used in the literature were investigated using correlation analysis and statistical testing. Significant contributing factors were included in three multiple linear regression models (for CHD, CA, and CiRID)., Results: The mean shoulder level (CHD) significantly changed from a lower left shoulder value of -8.5 mm before surgery to 3.3 mm at the follow-up examination. A high preoperative left shoulder level by CiRID, a large amount of Cobb angle correction of the distal thoracic curve, a low preoperative Cobb angle in the lumbar curve, and a structural proximal thoracic curve proved to be determinants and thus risk factors for left-sided shoulder elevation after surgery. The three models predicting CHD, CA, and CiRID at the follow-up examination included these four risk factors and were significant., Conclusions: Preoperative variables have the strongest influence on shoulder level after spinal instrumentation. Additionally, extensive correction of the distal thoracic curve can cause elevation of the left shoulder.

Purpose: Plate fixation is a commonly used surgical method in clavicular fracture treatment. The main purpose of this treatment is making the painless shoulder girdle and bring the functions to the optimum level. Plate fixation position still remains controversial. We aimed to investigate the effect of the plate position in clavicle midshaft fractures during shoulder movements., Methods: A normal anatomical shoulder joint was modeled using computed tomography images. A fracture line was created on the clavicle. Plate was placed superior to the clavicle in group 1 and anterior in group 2. The impacts of joints, plates, screws, ligaments and clavicle have been shown during 150° flexion and abduction movements of the shoulder by finite element analysis. Analyzes were made non-linear using ANSYS (version 18) and the same boundary conditions were applied in all models., Results: The load values in the plate, screws, ligaments, and clavicle were higher in group 1 than group 2 during abduction and flexion movements. Especially the load on the ac ligament was excessive. Load value in the glenohumeral joint was found similar both groups. The load values in the flexion movement were higher than the abduction movement in both groups., Conclusions: Anterior clavicle plating provides less stress on material and shoulder girdle, compared to superior plating, during shoulder abduction and flexion movements.

Congenital pseudarthrosis of the clavicle (CPC) is a very rare pathology of which over 200 cases have been reported. Usually discovered during the first months of life, CPC is characterised by a definitive bone defect in the middle third of the clavicle. Generally asymptomatic, the pseudarthrosis of the clavicle can cause aesthetic issues and functional symptoms indicating a surgical repair. Different reconstruction techniques have been reported with various complications. We present a 14-year-old boy diagnosed with CPC and concerned about the cosmetic aspect of a swelling of his right clavicle. We performed a two-stage surgical repair using the induced membrane technique described by Masquelet. A complete bone union has been obtained, and patient is satisfied with the cosmetic appearance. In our opinion, the Masquelet technique is a safe and reproducible procedure to treat CPC in high-risk older patients with long gap allowing a rapid and lasting bone union., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: The objective of this systematic review was to evaluate the reliability and reproducibility of measurements of shortening in midshaft clavicle fractures (MSCF) using any available imaging technique., Methods: Electronic databases (PubMed, EMBASE, and Cochrane) were searched. The 4-point-scale COSMIN checklist was used to evaluate the methodological quality of studies., Results: Four studies on reliability of measurement of MSCF were identified. These studies were of fair and poor quality. The reported intrarater reliability varied between none to fair, and intrarater reliability was minimal., Conclusion: No definite conclusions could be drawn. In order to optimize future studies and the realization of comparable results, more research is necessary to identify a standardized method of imaging and measuring. Level of Evidence III.