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Background: Radiation-associated soft tissue sarcomas (RA-STS) are rare complications of patients receiving radiation therapy (RT) and are generally associated with a poor prognosis. Most of the literature surrounding RA-STS of the chest is centered on angiosarcoma. Therefore, we aim to document the management and outcome of patients with non-angiosarcoma RA-STS of the chest., Methods: We reviewed 17 patients (all female, median age 65 years) diagnosed with RA-STS. The most common primary malignancy was breast carcinoma (n = 15), with a median RT dose of 57.9 Gy. All patients underwent surgical resection; five patients (29%) received radiotherapy; and five patients (29%) received peri-operative chemotherapy., Results: The 5-year local recurrence and metastatic-free survival were 61% and 60%, while the 5-year disease-specific survival was 53%. Local recurrence was associated with death due to disease (HR 9.06, p = 0.01). Complications occurred in nine of patients, most commonly due to a wound complication (n = 7). At the most recent follow-up, the median Musculoskeletal Tumor Society Score was 63%., Conclusion: RA-STS involving the chest wall are aggressive tumors with a high risk of local relapse and death due to disease. Local recurrence was associated with death due to disease; as such, we recommend aggressive surgical management with evaluation for adjuvant therapies., (© 2024 Wiley Periodicals LLC.)

Background: Management of periprosthetic fractures has been guided by the Vancouver classification, which recommends revision for fractures around a loose femoral implant (B2). New studies have challenged this approach, demonstrating acceptable outcomes with internal fixation. This study evaluates our experience with Vancouver B2 fractures, comparing internal fixation to femoral revision. We hypothesized that in select cases with cementless stems, internal fixation would provide acceptable results with reduced morbidity., Methods: A retrospective review was performed of periprosthetic hip fractures treated at our institution between 1 January 2012 and 4 November 2022. We excluded patients who did not have prior radiographs and evidence of stem subsidence, suggestive of a Vancouver B2 fracture. Thirteen patients were included in the analysis., Results: Four patients (31%) underwent revision of the femoral component, 4 patients (31%) underwent plating, and 5 patients (38%) underwent internal fixation with cerclage cabling. The average operative duration was 158 minutes, 203 minutes, and 62 minutes for the revision, plating, and cabling cohorts, respectively ( P  = .009). Blood loss was 463 cc, 510 cc, and 90 cc for the revision, plating, and cabling cohorts, respectively ( P  = .036). Three patients in both the revision and plating cohorts each received a transfusion (75%), whereas no patients in the cabling cohort required a transfusion ( P  = .033). All patients demonstrated fracture healing on the postoperative radiographs. No patients required additional surgery during the follow-up period., Conclusions: We have demonstrated that Vancouver B2 periprosthetic fractures with intact lateral cortices may be treated with internal fixation with cerclage cabling with excellent results., (© 2024 The Authors.)

Background: While there has been much interest in the increased dislocation rate in total hip arthroplasty (THA) patients with a lumbar spine fusion (LSF), there is minimal literature comparing the risk based on surgical approach. The purpose of this study was to determine if a direct anterior (DA) approach was protective against dislocation when compared to the anterolateral and posterior approaches in this high-risk patient population., Methods: A retrospective review was performed of 6554 THAs performed at our institution from January 2011 to May 2021. 294 (4.5%) patients had a prior LSF and were included in the analysis. The surgical approach, timing of LSF in relation to THA, vertebral levels fused, timing of THA dislocation, and the need for revision surgery were recorded for statistical analysis., Results: In total, 39.7.3% of patients underwent a DA approach (n = 117), 25.9% underwent an anterolateral approach ( n  = 76), and 34.3% underwent a posterior approach ( n  = 101). There was no difference in number of vertebral levels fused between groups (mean 2.5, all p  > 0.05). There was a total of 13 (4.4%) THA dislocation events, with an average time from surgery to dislocation of 5.6 months (0.3-30.5 months). There were fewer dislocations in the DA cohort (0.9%) in comparison to both the anterolateral (6.6%, p  = 0.036) and posterior groups (6.9%, p  = 0.026)., Conclusions: The DA approach demonstrated a significantly lower THA dislocation rate compared to both the anterolateral and posterior approaches in patients with a concomitant LSF., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: BW: receives research support from Summit Medical, Desmoid Tumor Research Foundation.All other authors declare that there is no conflict of interest.

Introduction: The personality traits of those who become orthopaedic surgeons may also lead to overwork, work-life balance issues, and burnout. Health and wellness practices of orthopaedic surgeons have not been widely explored. This study evaluated the personal health habits, wellness, and burnout of practicing orthopaedic surgeons in the United States., Methods: An anonymous self-assessment survey was completed by 234 practicing orthopaedic surgeon alumni from two large residency programs. The survey assessed exercise habits according to Centers for Disease Control and Prevention recommendations, compliance with preventive medical care practices according to the United States Preventive Services Task Force, prioritization of occupational wellness strategies, and the presence of burnout via an adapted Maslach Burnout Inventory. Survey responders' mean age was 52 years, 88% were male, and 93% had a body mass index <30 kg/m2. Surgeons were stratified according to practice type, years in practice, and subspecialty., Results: Among orthopaedic surgeons, compliance with aerobic and strength exercise recommendations was 31%. Surgeons in academic practice were significantly (P = 0.007) less compliant with exercise recommendations (18%) compared with private (34%) or employed (43%) practicing surgeons. Most (71%) had seen their primary care provider within 2 years and were up to date on age-appropriate health care screening including a cholesterol check within 5 years (79%), colonoscopy (89%), and mammogram (92%). Protecting time away from work for family/friends and finding meaning in work were the most important wellness strategies. The overall burnout rate was 15% and remained not significantly different (P > 0.3) regardless of years in practice, practice type, or subspecialty., Conclusion: This survey study identifies practicing orthopaedic surgeons' health habits and wellness strategies, including limited compliance with aerobic and strength exercise recommendations. Orthopaedic surgeons should be aware of areas of diminished personal wellness to improve quality of life and avoid burnout., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Background: Although risk factors for heterotopic ossification (HO) have been defined, the effect from surgical approach is not fully understood. The primary objective of our study was to evaluate the effect that surgical approach has on the risk for developing severe HO after total hip arthroplasty (THA) and compare this with other known risk factors. We hypothesized that there would be no difference in HO formation based on the surgical approach., Methods: We retrospectively reviewed all patients who underwent primary THA at our hospital between March 2011 and March 2021. Patients with HO documented in the radiology reports were cross-referenced with our THA data set and manually reviewed to determine Brooker classification. Patient demographics, medical comorbidities, surgical details, and medication information were collected from the electronic medical record and compared., Results: Of 3,427 patients who underwent THA, 677 (19.8%) developed HO postoperatively. A multivariable analysis confirmed that surgical approach was independently associated with increased odds for HO development. The anterolateral (odds ratio [OR], 3.43; P < 0.001) and posterior (OR, 2.24; P < 0.001) approaches had increased odds for developing HO compared with the direct anterior approach. However, only the anterolateral approach (OR, 1.85; P = 0.033) demonstrated an increased association with the development of severe HO (Brooker 3, 4) postoperatively., Conclusion: Although the use of the direct anterior approach had the lowest overall OR for developing HO after THA, this is likely only clinically notable when compared with the anterolateral approach., Level of Evidence: III., (Copyright © 2023 by the American Academy of Orthopaedic Surgeons.)

Surgical treatment of pelvic sarcoma involving the bone is the standard of care but is associated with several sequelae and reduced functional quality of life (QOL). Treatment with photon and proton radiotherapy is associated with relapse. Carbon ion radiotherapy (CIRT) may reduce both relapse rates and treatment sequelae. The PROSPER study is a tricontinental, nonrandomized, prospective, three-arm, pragmatic trial evaluating treatments of pelvic sarcoma involving the bone. Patients aged at least 15 years are eligible for inclusion. Participants must have an Eastern Cooperative Oncology Group Performance Status score of two or less, newly diagnosed disease, and histopathologic confirmation of pelvic chordoma, chondrosarcoma, osteosarcoma, Ewing sarcoma with bone involvement, rhabdomyosarcoma (RMS) with bone involvement, or non-RMS soft tissue sarcoma with bone involvement. Treatment arms include (1) CIRT ( n = 30) delivered in Europe and Asia, (2) surgical treatment with or without adjuvant radiotherapy ( n = 30), and (3) proton therapy ( n = 30). Arms two and three will be conducted at Mayo Clinic campuses in Arizona, Florida, and Minnesota. The primary end point is to compare the 1-year change in functional QOL between CIRT and surgical treatment. Additional comparisons among the three arms will be made between treatment sequelae, local control, and other QOL measures.

Background: The deep peroneal nerve (DPN) plays a role in afferent nociceptive dorsal midfoot joint pain perception. DPN neurectomy for treatment of symptomatic dorsal midfoot osteoarthritis allows early mobilization and weightbearing. The purpose of our study was to evaluate the patient satisfaction and pain relief after DPN neurectomy for treatment of chronic dorsal midfoot pain due to osteoarthritis., Methods: In this retrospective, IRB-approved, questionnaire-based study, we evaluated 48 patients (55 feet) with an average follow-up of 35.1 (range, 16-51) months who underwent DPN neurectomy at our institution between September 2017 and February 2021. There were 38 women and 10 men, 41 unilateral (22 right, 19 left) and 7 bilateral procedures, with an average age of 67.8 (range, 35-88) years at the time of surgery. A questionnaire that included questions regarding postsurgical dorsal midfoot pain relief, surgical result satisfaction, and current functional limitations was administered via telephone. Demographic information, patient responses, and complications were recorded., Results: Of the 48 patients, 80.8% were satisfied with the result of the surgery in relieving their dorsal midfoot pain, 84.6% would repeat the surgery under the same circumstances, 83.8% would recommend the surgery to a friend, 10.4% reported they wish they had undergone arthrodesis, 91.7% reported pain relief in the first 6 months, and 55.6% reported current activity limitations. Six feet (10.9%) underwent a second procedure with an average postoperative time of 20.5 (range, 1-36) months. Complications included 1 hematoma and deep wound infection, 1 DPN neuroma and superficial peroneal nerve entrapment, and 4 patients with inadequate pain relief., Conclusion: In this cohort, DPN neurectomy appeared to be a reasonable surgical alternative to arthrodesis for the management of chronic dorsal midfoot pain due to midfoot osteoarthritis after failed nonoperative management., Level of Evidence: Level IV, retrospective case series.

Multidisciplinary communication and planning between the musculoskeletal radiologist and orthopedic oncologist are essential for proper biopsy planning when a primary musculoskeletal malignancy is suspected. Image-guided percutaneous biopsy allows for real-time visualization of the biopsy needle and surrounding structures, combining high diagnostic accuracy with safety and cost-effectiveness. However, determining a surgically optimal biopsy trajectory for a mass can be technically challenging due to critical surrounding anatomy or challenging needle approach angles. Inappropriately placed biopsies can have serious repercussions on patient function and oncological survival. The potential for needle tract seeding and local recurrence after biopsy of sarcoma has been central to the debate regarding the need for excision of the biopsy tract. This multidisciplinary review highlights current controversies in the field, including the issue of core needle biopsy tracts and their excision, technical considerations and advances in image-guidance in the setting of challenging biopsies, advances in histopathological diagnostics with implications for targeted therapy in sarcoma, as well as surgical and oncological outcomes after needle tract biopsy., (© 2022. The Author(s), under exclusive licence to International Skeletal Society (ISS).)

Purpose: The purpose of this pilot study was to examine the clinical efficacy and safety of serial triamcinolone injections for the treatment of desmoid tumors., Patients and Methods: Nine patients were enrolled into this prospective study and underwent three serial ultrasound-guided triamcinolone injections (120 mg) at 6-week intervals. MRI was compared at baseline and every 6 months, out to 24 months. Safety and tolerability were assessed by clinical evaluation and questionnaires, including the 12-item short form survey (SF-12), visual analog scale (VAS), and desmoid patient-reported outcome (PRO) tool., Results: At 24 months, 8 (88.9%) patients demonstrated a reduction in the volume of their tumor while 1 (11.1%) enlarged. Median tumor volume change was -26.9% (-81.1% to 34.6%; P = 0.055) All 9 tumors remained stable based on World Health Organization criteria, whereas 2 (22.2%) demonstrated partial response based on RECIST. There was a significant decrease in the tumor:muscle postcontrast mean signal intensity ratio at 6 months (P = 0.008) and 24 months (P = 0.004). There was a similar decrease in the tumor:muscle T2 mean signal intensity ratio at 24 months (P = 0.02). We found no difference in the SF-12 and VAS scores, but there were significant improvements in the desmoid PRO., Conclusions: Treatment of desmoid tumors with serial triamcinolone injections appears safe and well tolerated by patients, with a 22% partial response based on RECIST. Further research is needed to confirm our results and determine factors predictive of response., (©2022 American Association for Cancer Research.)

Scapular resections are large oncologic undertakings. Due to the soft tissue coverage of the scapula, tumors are often able to be resected with a negative margin. Involvement of the brachial plexus and axillary vessels is rare, allowing for a limb-salvage surgery in most cases. Functional outcomes are based on the magnitude of resection; patients undergoing a partial scapulectomy and those with glenoid preservation demonstrate improved outcomes compared to patients undergoing a total scapulectomy or glenoid resection. Although scapular endoprosthetics are available, there is limited data to support their routine use., Competing Interests: Disclosure The authors have no disclosures., (Copyright © 2022 Elsevier Inc. All rights reserved.)

High-volume total joint arthroplasty centers are becoming designated as destination centers of excellence to ensure quality of care while containing costs. This study aimed to evaluate the surgical patient journey through a new destination center of excellence program, review acute perioperative course trajectories, and report clinical outcomes. Our institution developed and implemented a destination center of excellence program to integrate into the existing total joint arthroplasty practice. A retrospective record review and analysis were performed for the first 100 destination center of excellence total knee arthroplasties and total hip arthroplasties enrolled in the program to evaluate program efficacy at a minimum 1-year follow-up. The study initially screened 213 patients, of whom 100 (47%) met program criteria and completed surgery (67 total knee arthroplasties and 33 total hip arthroplasties). The complication rate was 2%, and five patients (7.5%) required manipulation under anesthesia for stiffness after total knee arthroplasty. Two reoperations were needed: a neurectomy after total knee arthroplasty and a revision after total hip arthroplasty. The early experience of a destination center of excellence program has been favorable, with low complication rates and excellent outcomes., Competing Interests: All authors have no financial interests to disclose or conflicts of interest., (Copyright © 2023 by National Association of Orthopaedic Nurses.)

Background: Immersive virtual reality (IVR) is utilized as an adjunct to anesthesia to distract patients from their intraoperative environment, thereby potentially reducing sedative and narcotic medication usage. This study evaluated intraoperative and acute postoperative results of patients undergoing primary total hip (THA) and total knee arthroplasty (TKA) with and without IVR., Methods: Utilizing IVR as an adjunct to spinal anesthesia, 18 primary THAs (n = 8) and TKAs (n = 10) were performed. These cases were 1:2 matched based on procedure type, age, sex, and body mass index to those performed without IVR. Intraoperative and postanesthesia care unit sedative/narcotic usage, vital signs, and pain scores were compared. Acute perioperative outcomes, including 24-hour oral morphine equivalent (OME), first ambulation distance, length of stay, and 30-day complications, were also analyzed. Pearson Chi-square and Wilcoxon-Mann-Whitney tests evaluated categorical and continuous variables, respectively., Results: When compared to non-IVR primary THAs and TKAs, those performed with IVR utilized significantly less intraoperative sedation (48 mg vs 708 mg of propofol; P < .001) and trended toward less narcotic usage (13 mcg vs 39 mcg of fentanyl; P  = .07). In the postanesthesia care unit, IVR and non-IVR patients showed no significant differences ( P > .3) in vital signs, pain scores, or OME received. Additionally, similar ( P > .3) postoperative outcomes were noted in both cohorts' 24-hour OME use, distance at first ambulation, length of stay, and 30-day complications., Conclusions: The use of spinal anesthesia with the IVR adjunct to perform primary THAs and TKAs appears to be well-tolerated and associated with less intraoperative sedative medication usage than spinal anesthesia alone., (© 2022 The Authors.)

Background: Solid organ transplantation (SOT) recipients have complex medical and surgical risk factors; however, the outcomes of these patients undergoing surgical fixation of hip fractures are unknown. This study sought to evaluate SOT patients' outcomes and survivorship after intertrochanteric (IT) fracture fixation., Methods: A retrospective review identified 12 SOT patients who underwent cephalomedullary (CMN) nail fixation for IT fractures and were matched (1:2) to a cohort of 24 non-SOT IT fracture patients. Perioperative results and complications, mortality/patient survivorship, and clinical outcomes were compared between the cohorts., Results: The time from presentation to surgical fixation was within 48 h of presentation for the non-SOT patients, while only 75% of SOT patients underwent surgery within 48 h of presentation (p = 0.034). The 90-day readmission rate for SOT patients was 25% versus 13% in the non-SOT group (p = 0.38). Similarly, the SOT cohort experienced a higher rate of major medical complication (25% vs. 13%, p = 0.38). There were two (16%) reoperations in the SOT group and three (13%) in the non-SOT matched group (p = 0.99). Respectively, the 90-day and 1-year estimated patient survivorship was similar between the two cohorts: SOT patients with 92% (95% CI 54-99%) and 73% (95% CI 24-93%) versus 86% (95% CI 62-95%) and 72% (95% CI 47-86%, HR 0.92, 95% CI 0.18-4.62, p = 0.92) in non-SOT patients., Conclusion: SOT patients who underwent CMN fixation for IT fractures required more time from hospital presentation to surgical management than non-SOT patients. Although not statistically significant, SOT patients demonstrated more acute complications and readmissions, but similar mortality compared to those without transplant., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Total knee arthroplasty is a common operation performed to relieve pain and restore functional activity. While overall widely successful, a subset of patients has continued pain postoperatively with no identifiable cause. Neuroma formation has been identified as a possible contributor to this unexplained pain, often necessitating an additional procedure for neuroma removal. The purpose of our study was to evaluate if prophylactic neurectomy could reduce the occurrence of postoperative pain., Methods: A total of 112 patients were compared, 44 control patients and 68 neurectomy patients. Demographic information, Numerical rating pain scale (NRS) and Knee Society Scores (KSS) were collected pre- and post-operatively. Patients were additional asked if they were overall satisfied with the operation., Results: There were no differences between groups with respect to age (Median: 71 vs 69 years, p = 0.28), male sex (41% vs 44%, p = 0.85), or body mass index (Median: 32.2 vs 31.3, p = 0.80). When comparing the degree of change following surgery there were no statistically significant differences observed in NRS pain scores (Median change: -7 vs -6, p = 0.89) or KSS scores (Median change: +44 vs +40, p = 0.14). Similarly, there was no statistically significant difference in overall patient-reported satisfaction with the knee replacement (82.5% vs 86.6%, p = 0.59)., Conclusion: We did not find a statistically significant difference in NRS, KSS, or overall patient satisfaction between the prophylactic neurectomy and control patient groups. Larger studies with evaluation of the nerve diameter will be needed to determine which patients are at risk for symptomatic neuroma development following total knee arthroplasty.

Neurotrophic tyrosine receptor kinase (NTRK)-rearranged spindle cell neoplasm is a recently characterized soft tissue tumor and has been classified as provisional by the World Health Organization. Detection of the genetic rearrangement is important because these tumors are amenable to targeted tyrosine kinase inhibitor therapy, which can play a key role in patients with unresectable or advanced disease. Although the spectrum of histopathology associated with this entity is broad, one notable feature is the infiltrative growth pattern, which is most reminiscent of lipofibromatosis-like neural tumor. Description of their diverse histologic attributes has aided recognition, but so far little attention has been paid to correlating the gross appearance and imaging features of these lesions. In this report, we describe the clinical, imaging, histopathological, and genetic features of a soft tissue NTRK-rearranged spindle cell neoplasm. Inclusion of this more recently identified entity into the imaging differential of tumors with intratumoral relatively hypovascular nodules and infiltrative margins is important because testing for NTRK rearrangement is not routinely performed., (© 2022. ISS.)

Background: For elective total joint arthroplasty, tranexamic acid (TXA) is considered safe and efficacious. However, evidence of TXA's safety in high-risk patients undergoing nonelective surgery for hip fracture is sparse. This study aimed to assess whether TXA administration to high-risk patients with an intertrochanteric (IT) hip fracture increased the risk of thromboembolic complications or mortality., Methods: All patients treated surgically for IT hip fracture between 2015 and 2019 across 4 hospitals of a single hospital system were considered. High- versus low-risk patients and those receiving TXA versus no TXA treatment were identified. Propensity scores adjusted for risk differences between patient groups with TXA and no TXA administration were calculated for (1) high-risk patients (n = 141) and (2) the entire population (n = 316). Postoperative mortality, deep venous thrombosis (DVT), pulmonary embolism (PE), myocardial infarction (MI), and stroke within 90 days of surgery were evaluated., Results: No association between TXA administration and increased risk of mortality or complications in either group was identified. Specifically, out of 282 matched high-risk patients, no differences in mortality (odds ratio [OR], 0.97 [95% confidence interval (CI), 0.90, 1.05]), DVT (OR, 0.97 [95% CI, 0.93, 1.00]), PE (OR 1.00 [95% CI, 0.95, 1.05]), MI (OR, 1.04 [95% CI, 0.98, 1.10]), or stroke (OR, 1.00 [95% CI, 0.95, 1.05]) were identified., Conclusions: In our review of propensity-matched high-risk patients undergoing surgical repair for IT fracture, we found that TXA administration compared with no TXA administration was not associated with an increased risk of mortality, DVT, PE, MI, or stroke within 90 days of surgery., Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H28 )., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Metabolic syndrome (MetS) represents a constellation of interrelated conditions including insulin resistance, abdominal obesity, hypertension, and dyslipidemia. The goals of this study are to determine the impact of MetS on implant survivorship, complications, and clinical outcomes after primary total hip arthroplasty (THA)., Methods: Utilizing our institutional total joint registry, 1,268 patients undergoing primary THA were identified with MetS based on the World Health Organization definition and matched 1:1 to those without MetS based on age, gender, and surgical year. MetS patients were further stratified according to the World Health Organization body mass index (BMI) classification to contextualize obesity. Kaplan-Meier analyses were utilized to compare survivorship free of any reoperation, revision, and complications. Clinical outcomes were assessed with Harris hip scores. Mean follow-up after THA was 5 years., Results: MetS patients had significantly worse 5-year survivorship free from any reoperation compared to those without MetS (93.5% vs 96.1%, respectively; hazard ratio [HR] 1.4, P = .04). When stratifying MetS and BMI classification, the BMI >40 kg/m 2 had significantly decreased 5-year implant survivorship free from any reoperation (85.9% vs 96.1%, HR 3.4, P < .001), any revision (91.7% vs 97.3%, HR 2.7, P < .001), and reoperation for periprosthetic joint infection (95% vs 99%, HR 5.1, P < .001). Both groups experienced significant and similar improvement in final Harris hip scores (P < .001)., Conclusion: Patients with MetS had a 1.4-fold increased risk of reoperation after primary THA compared to a matched cohort without the condition. MetS patients with a BMI >40 kg/m 2 had the highest risk of reoperation, and had a significantly higher revision and periprosthetic joint infection rates, suggesting that morbid obesity remains a critical, independent risk factor beyond MetS., Level of Evidence: Level 3, Case-control study., (Copyright © 2022 Elsevier Inc. All rights reserved.)

This article focuses on soft tissue sarcomas, including the workup, management, and potential complications in dealing with these rare mesenchymal tumors. We present the information that is critical in the decision-making process for orthopedic oncologists to help facilitate a multidisciplinary approach to these complex cases., Competing Interests: Disclosure The authors have received research support from Summit Medical and the Desmoid Tumor Research Foundation., (Copyright © 2021 Elsevier Inc. All rights reserved.)

This article focuses on skeletal sarcomas, a group of rare, heterogenous malignant tumors. We present information on the multi-disciplinary approach to the diagnosis, staging, treatment, and surveillance of these complex tumors that are critical to enhancing function and improving survival., Competing Interests: Disclosure The authors have received research support from Summit Medical and the Desmoid Tumor Research Foundation., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: The Centers for Disease Control (CDC) created a classification to help stratify surgical wounds based on contamination and risk of developing a surgical site infection. The classification includes four options (I to IV) depending on the level of contamination present. Although universally applied to a variety of surgical specialties, it is unknown whether the current system is reliable when considering orthopaedic surgeries. The purpose of this study was to compare the degree of interobserver reliability between orthopaedic surgeons using the current CDC wound class definitions., Methods: A questionnaire containing 30 clinical vignettes was completed by 39 orthopaedic surgeons at our institution. After each vignette, respondents were asked to determine the appropriate wound class based on information provided in the vignette. The overall interobserver agreement among all participants was analyzed. In addition, respondents were queried about the adequacy of the current classification system in describing orthopaedic surgical wound class., Results: Interobserver agreement was poor at 66%, with a coefficient of concordance of 0.48. Only six physicians (15.4%) thought that the current wound classification system adequately covered orthopaedic surgery., Conclusions: There is poor interobserver reliability using the CDC surgical wound class definitions for orthopaedic surgeries. Alternate definitions are needed to improve the validity of the system for subspecialty procedures., (Copyright © 2021 by the American Academy of Orthopaedic Surgeons.)

Background: Tranexamic acid (TXA) is considered safe and efficacious for elective total joint arthroplasty. However, evidence of TXA's safety in high-risk patients with hip fracture requiring nonelective arthroplasty has been lacking. This study aimed to assess whether TXA administration to high-risk patients with a hip fracture requiring arthroplasty increased the risk of thrombotic complications or mortality., Methods: All patients who underwent hip hemiarthroplasty (HHA) or total hip arthroplasty (THA) for displaced femoral neck fractures between 2011 and 2019 at 4 sites within 1 hospital system were retrospectively identified. Patients were grouped by risk (high-risk or low-risk) and TXA treatment (with or without TXA). Propensity scores were used for risk adjustment in comparisons between surgery with and without TXA for only the high-risk group (n = 1,066) and the entire population (n = 2,166). Differences in the occurrence of postoperative mortality, deep venous thrombosis, pulmonary embolism, myocardial infarction, and stroke within 90 days of hip arthroplasty were evaluated., Results: TXA administration was not associated with an increased risk of thrombotic complications or mortality within 90 days in either high-risk or all-patient groups. Specifically, among 1,066 matched high-risk patients who did not or did receive TXA, there were no significant differences in mortality (14.82% and 10.00%; p = 0.295), deep venous thrombosis (3.56% and 3.04%; p = 0.440), pulmonary embolism (2.44% and 1.96%; p = 0.374), myocardial infarction (3.38% and 2.14%; p = 0.704), or stroke (4.32% and 5.71%; p = 0.225)., Conclusions: In our review of 1,066 propensity-matched high-risk patients undergoing hip arthroplasty for displaced femoral neck fractures, we found that TXA administration (compared with no TXA administration) was not associated with an increased risk of mortality, deep venous thrombosis, pulmonary embolism, myocardial infarction, or stroke., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G669)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Solid organ transplant (SOT) patients have increased risk of complications, infection, and mortality after elective total hip arthroplasty (THA). The study aims to compare SOT recipients' clinical outcomes to a matched group of nontransplant patients after nonelective THA and hemiarthroplasty for acute femoral neck fracture (FNF)., Methods: A retrospective review identified 31 SOT patients undergoing hip arthroplasty (24 hemiarthroplasty and 7 THA) for FNF and were matched 1:1 to non-SOT patients based on age, sex, body mass index, surgical procedure, and year of surgery. Patient survivorship, perioperative outcomes, complications, and reoperations were compared. The mean follow-up was 3 years., Results: The estimated survivorship free from mortality for SOT and non-SOT patients at 1- year was not different (77% and 84%, respectively, P  = .52). The 90-day readmission rate was significantly higher with 8 (26%) in the SOT cohort and none in the non-SOT group ( P < .01). Major medical complications occurred in 16% of SOT patients compared to 5% in controls ( P  = .21). Three (10%) reoperations/revisions were required for SOT patients and none in non-SOT group ( P  = .24)., Conclusion: SOT recipients undergoing nonelective hip arthroplasty for FNF demonstrated increased readmission rates compared to matched controls. For this rare clinical scenario, diligent perioperative care by surgeons and multidisciplinary transplant specialists is necessary to mitigate increased risk of SOT patients., (© 2021 The Authors.)

Objectives: To determine the location and stage of the tibial nailing procedure where infrapatellar saphenous nerve (IPSN) injury may occur., Methods: Fourteen fresh-frozen right cadaveric knees underwent tibial nailing. Six knees underwent a suprapatellar approach and 8 a medial parapatellar approach. Two proximal medial-to-lateral screws were placed using the aiming guide. The incisions were then closed. After the procedure, medial retinacular and saphenous nerves were dissected under surgical 2.5× loupe magnification from a proximal to distal direction. The branch of the IPSN closest to the locking screws was measured, as was the distance between the IPSN branch and the inferior pole of the patella., Results: Twelve of 14 cadavers had prominent IPSN (main branch from the saphenous proper) with an average of 2.5 sub-branches. The mean (SD) distance from the main branch of the IPSN to the inferior pole of the patella was 40.9 (24.4) mm. Four medial retinacular nerve branches, branching from the femoral nerve and not IPSN, were identified proximal to the patella during the medial parapatellar approach. All were cut after the medial parapatellar arthrotomy. The mean (SD) distance from the IPSN to the nearest locking screw was 10.2 (14.1) mm. Seven of 14 had IPSN injuries, and one had hamstring injury. Two direct screw entrapments occurred, whereas two IPSNs were lacerated by the incision. Suture closure entrapped three nerve branches, and one specimen had injured fibers of the hamstring tendinous insertion., Conclusions: Injury to the IPSN can occur at different locations and stages of tibial nailing, including approach, proximal locking screw insertion, and closure., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Introduction: Postoperative wound complications after resection of soft-tissue sarcomas are challenging. Indocyanine green (ICG) angiography has previously been used to predict wound complications, but not for soft-tissue sarcomas. We aimed to evaluate whether this technology could help lower wound complications after soft-tissue sarcoma resections., Materials and Methods: We conducted a prospective study from 10/2017 to 9/2019 using ICG angiography during sarcoma resection surgery. Rates of wound complications were compared with a historical control consisting of surgeries before utilization of ICG angiography., Results: A total of 88 patients were included in the study. We found significantly lower rates of infection (11.8% versus 38%; P = 0.03) and wound dehiscence (11.8% versus 42.3%; P = 0.02) in the ICG angiography cohort compared with the historical controls., Conclusion: ICG angiography use during soft-tissue sarcoma resections is promising technology and warrants further investigation to help reduce postoperative complications., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Background: Previous studies have demonstrated success in using autogenous bone graft for arthrodesis in patients with failed surgeries of the hallux. These patients have several causes for pain and dysfunction preoperatively, including a shortened first ray, nonunion, and poor hallux alignment., Methods: In this study, a consecutive series of 36 patients (38 procedures) were treated with a patellar wedge interposition structural allograft to salvage bone loss from great toe arthrodesis malunion, painful joint replacement, failed osteotomy, or infection of the great toe metatarsophalangeal (MP) joint with shortening of the first ray. The goals of the surgery were to restore length to the first ray and provide a stable MP joint fusion to relieve pain. The 38 treated toes were evaluated for preoperative and postoperative American Orthopaedic Foot & Ankle Society (AOFAS) MP scores, subjective patient outcome scores, and clinically successful fusion of the hallux., Results: At a minimum 1-year follow-up (mean, 3.2 years), all but 2 feet healed with a solid fusion, and all healed patients reported good or excellent outcomes. AOFAS MP scores averaged 43.5 preoperatively and 77.2 postoperatively. Three patients with infection as cause for nonunion of the initial procedure were treated with staged procedures, including the use of a temporary antibiotic spacer and mini external fixator; all 3 healed without recurrent infection. One patient had a fracture of her allograft following her interposition arthrodesis, but it fused successfully after a second interposition arthrodesis surgery. Two patients developed a nonunion of the revision arthrodesis., Conclusion: The use of an interposition patellar wedge allograft can restore length to the first ray and provide successful salvage of arthrodesis nonunions and bone loss from failed hemiarthroplasty and total joint implants of the great toe MP joint., Level of Evidence: Level IV, retrospective case series.

Background: Wound complications after a soft-tissue sarcoma surgery are common, occurring in up to 30% to 40% of patients who undergo preoperative radiation therapy. Although risk factors for developing complications are well-known, there is a paucity of literature on the increased healthcare costs after a wound complication. The purpose of this study was to detail these additional costs after a soft-tissue sarcoma surgery., Methods: A retrospective review of 99 patients from January 2013 to October 2019 was performed. Hospital and professional charges for the primary surgical procedure and any subsequent hospitalization or procedure related to a wound complication were compiled. Costs were inflated to 2019 dollars., Results: Total costs were 21.3% higher for patients who developed a wound complication (P = 0.006). Most patients (32 of 42; 76.2%) who developed a complication required a return trip to the operating room. The average number of return trips was 1.2 (range 0 to 5). For each return trip to the operating room because of a wound complication, an associated increased overall cost of 13.2% was noted (P < 0.001)., Conclusion: Wound complications after a soft-tissue sarcoma resection are common and add considerable expense to the episode of care. A reduction in wound complications may markedly decrease the cost of treating soft-tissue sarcomas and continues to be an opportunity for improvement., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Introduction: Indocyanine green (ICG) angiography is a novel technology that has been predictive of postoperative wound complications. It is unknown whether this technology can successfully predict complications after sarcoma resection. In this study, we aimed to evaluate the sensitivity and specificity of ICG angiography in predicting postoperative wound complications after soft-tissue sarcoma resection., Methods: A prospective cohort study of 23 patients was performed beginning October 2017 at our institution. Patients who underwent soft-tissue sarcoma resection were included. After tumor resection and wound closure, evaluation of tissue perfusion in skin edges was performed with ICG angiography. Wound complications were recorded in the postoperative follow-up., Results: Eight patients developed postoperative wound complications. Six patients were predicted to have wound complications on the final ICG scans. The accuracy of ICG angiography was dependent on the anatomic location, with improved accuracy in the lower extremity. ICG angiography had a sensitivity of 50%, a specificity and a positive predictive value of 100%, and a negative predictive value of 70% for wound complications after soft-tissue sarcoma resections located in the lower extremity., Conclusion: ICG angiography has a high predictive value in the lower extremity for postoperative wound complications., Level of Evidence: Level III, Diagnostic., (Copyright © 2021 by the American Academy of Orthopaedic Surgeons.)

Background: Total hip arthroplasty (THA) performed for displaced femoral neck fractures (FNF) is becoming a more frequent treatment in the active elderly population. The complication profiles associated with THA surgical approaches in the fracture setting are unclear. The purpose of this study was to compare a series of THA for FNF performed via the direct anterior (DA) approach vs alternative approaches (anterolateral and posterolateral)., Methods: A retrospective review identified 52 patients who underwent primary THA for FNF between 2009 and 2018, including 20 via the DA approach and 32 by alternative approaches. All procedures were exclusively performed by high-volume arthroplasty surgeons. Perioperative results, complications, and clinical outcomes were compared with those of routine statistical methods. Mean follow-up duration was 3 years (range, 1-8)., Results: The average age was 74 years (range, 57-92) with similar baseline characteristics between the 2 groups ( P  = .09). The DA cohort demonstrated significantly shorter length of stay (3 days vs 5 days, P < .01) and discharge to home vs skilled nursing facility (40.0% vs 9.4% P  = .014). There was a trend toward decreased complications (0% vs 16%, P  = .08). There were no dislocations or fractures in either cohort. Final Harris Hip Scores (94 vs 81, P  = .07) and return to community ambulation (96%) were similar between DA and alternative approach groups., Conclusion: The DA approach to THA performed for FNF appears safe with improved outcomes compared with alternative approaches. Larger studies are needed to verify these results., (© 2021 The Authors.)

Case: We report a case of a 71-year-old man diagnosed with high-grade undifferentiated pleomorphic sarcoma in the left thigh. He underwent partial resection of the quadriceps and proximal femoral bone, followed by reconstruction with a latissimus dorsi free muscle flap through end-to-end vascular and nerve anastomosis with the femoral vessels and a branch of the femoral nerve, respectively. Recovery of 3/5 knee extension function was achieved 3 months postsurgery without complications., Conclusion: Free neurotized latissimus dorsi muscle transfer is a successful reconstructive option to restore knee extension after quadriceps resection., Level of Evidence: Level IV., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B309)., (Copyright © 2020 by The Journal of Bone and Joint Surgery, Incorporated.)

Introduction: Treatment for bone sarcomas are large undertakings. Emergency department (ED) visits and unplanned hospital readmissions are a potential target for cost containment. The purpose of this study was to evaluate the risk factors for ED visits and unplanned readmissions following extremity bone sarcoma surgery., Methods: Data from Optum Labs Data Warehouse, a national administrative claims database, was analyzed to identify patients with extremity bone sarcomas from 2006 to 2017. Multivariable logistic regression was used to identify factors associated with ED visits and readmissions., Results: Of 1390 (743 males, 647 female) adult patients, 137 (12%) visited the ED and 245 (18%) were readmitted within 30 days of discharge. The most common indication for ED visits (n = 63, 45.9%) and readmission (n = 119, 48.5%) were complications of surgery. Length of stay >10 days was associated with ED utilization (OR, 1.83; P = .01) and readmission (OR, 4.47; P < .001)., Conclusion: One in ten patients will use the ED, and one in five patients will be readmitted to the hospital within 30 days of discharge following extremity bone sarcoma surgery. Length of stay was associated with ED visits and readmission. These patients could be targeted with alternative management strategies in the outpatient setting with early clinical follow-up to minimize readmission., (© 2020 Wiley Periodicals LLC.)

Background: Robotic-assisted total knee arthroplasty represents an increasingly utilized surgical technology; however, there remains clinical question whether the technique produces improved clinical and patient-reported outcomes. The purpose of this study was to evaluate early clinical outcomes and patient preference of robotic-assisted total knee arthroplasty (rTKA) versus manual TKA (mTKA) in a direct crossover cohort of patients who underwent consecutive TKAs by each technique., Materials and Methods: A retrospective chart review and telephone interview was performed on 36 patients who underwent both rTKA and mTKA by a single surgeon between 2012-2018. Perioperative outcomes-complications/reoperations and patient-preferred technique-were collected with mean clinical follow up of 4.8 and 2.0 years for mTKA and rTKA, respectively., Results: mTKA were performed significantly (p<0.01) more quickly than rTKA, including shorter tourniquet time (56 versus 73 minutes) and total operating room time (93 versus 116 minutes). rTKA patients length of stay (LOS) was significantly (p<0.01) decreased (1.8 days) compared to mTKA (2.3 days). For rTKA and mTKA, respectively, there was no difference in final range of motion (119 versus 122 degrees), Visual Analog Scale (1.6 versus 0.9), or Knee Osteoarthritis Outcome Score, Jr (85 versus 87). Twenty (56%) reported rTKA as the preferred technique over mTKA., Conclusion: In same patient direct comparison, rTKA required longer operative time but improved LOS compared to mTKA. There was no difference in final outcomes with only slightly more patients preferring rTKA.

Background: The utilization of the direct anterior approach (DAA) for total hip arthroplasty (THA) continues to markedly increase. Despite proposed advantages, there are limited data regarding outcomes of staged bilateral THA via 2 different approaches in the same patient. The purpose of this study was to elucidate patient perspective on the THA approach in a crossover cohort of patients who underwent consecutive THAs via the posterolateral approach (PLA) followed by a contralateral DAA., Methods: A retrospective chart review and telephone interview were performed on 37 patients who underwent both THA approaches by a single surgeon from 2009 to 2019. Perioperative outcomes, complications/reoperations, and the patient-preferred approach were collected. The mean clinical follow-up was 105 and 44 months after PLA and DAA, respectively., Results: After DAA THA, patients demonstrated lower postoperative day 1 visual analog scale pain scores (1.8 vs 2.9, P  = .016) and ambulation (239 feet vs 31 feet, P < .001). The length of stay was significantly less ( P < .001) for the DAA (1.9 days) compared with the PLA (3.1 days). There were no major complications or reoperations in either cohort. Most patients (26/37, 70%) preferred the DAA and stated that it was easier to recover from (30/37, 81%)., Conclusion: In the same patient direct comparison, the DAA for THA may lead to less pain and improved ambulation in the early postoperative period. Furthermore, most patients prefer the DAA and believe it is easier to recover from than the PLA., (© 2020 The Authors.)

Background: Allograft-prosthetic composite (APC) reconstruction of the proximal humerus is a technique for reconstruction of large bone deficits, provides improvement in pain and function, and is thought to restore bone if revision surgery is needed. The purpose of this study was to evaluate the ability of proximal humeral APCs to restore usable bone at the time of revision surgery., Methods: Two institutional electronic medical records were reviewed to evaluate proximal humeral APC procedures performed between 1970 and 2018. We identified 115 cases, of which 14 underwent revision for aseptic causes. The indications for revision included nonunion (n = 7), glenohumeral instability (n = 5), and allograft fracture (n = 2). Three categories were used to classify the amount of usable allograft retained at revision surgery: type A, complete allograft retention; type B, partial retention; and type C, no retention., Results: A total of 14 patients (6 male and 8 female patients) underwent revision of the APC reconstruction at a mean of 22.8 months. At revision, allograft retention was classified as type A in 6 shoulders, type B in 3, and type C in 5. Type A cases were associated with nonunion with a well-fixed stem, type B cases were associated with instability and were converted from a hemiarthroplasty to a reverse total shoulder arthroplasty, and type C cases were associated with an allograft fracture or nonunion with a loose humeral component., Conclusion: A substantial number of revisions of proximal humeral APC reconstructions maintain a portion of the allograft bone (64.3%). This study supports the ongoing use of the APC reconstruction technique for large bone deficits., (Copyright © 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Previous studies have recommended synovial fluid cell count thresholds of 50,000 cells/mm -3 to diagnose septic arthritis; however, data to support this are limited. It is also unknown if this value is valid in immunosuppressed patients., Methods: We retrospectively reviewed 33 immunosuppressed patients treated at our institution from 2008 to 2018. We compared culture-positive patients with culture-negative patients., Results: We found no statistically significant differences in synovial fluid cell count, percent synovial fluid neutrophils, erythrocyte sedimentation rate, or C-reactive protein between the groups (all P = 0.081). The median synovial fluid cell count in the culture-positive cohort was 29,000 cells/mm -3 , with only 31.2% having >50,000 cells/mm -3 ., Conclusion: Traditional synovial fluid cell thresholds are not a reliable method of diagnosing septic arthritis in immunosuppressed patients., Competing Interests: Dr. Wilke or an immediate family member has received research or institutional support from Summit Medical. None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Bell, Dr. Rasmussen, Dr. Kumar, Dr. Heckman, Dr. Lesser, Dr. Whalen, and Dr. Shi., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

The infrapatellar nerve branch (IPNB) of the saphenous nerve supplies cutaneous sensation to the anterolateral knee. Given its location and variable course, the IPNB is suspected to be at risk of injury with commonly used incisions around the knee. Nerve injury may lead to painful neuroma formation. To our knowledge, no study has evaluated the incidence at which the IPNB is encountered during the anterior approach incision for a routine total knee arthroplasty (TKA). The purpose of this study was to see whether the general joint arthroplasty surgeon can identify and examine the location of the IPNB encountered during primary TKA and to determine whether these branches would be transected during a standard medial arthrotomy., Methods: Seventy-three patients (76 knees) underwent primary TKA using a standard midline approach with a medial parapatellar arthrotomy. The IPNB was identified, and the distance was measured from the inferior pole of the patella to the point where the nerve crossed the medial border of the patellar tendon. This distance was then compared with the length of the arthrotomy in the same knee to determine whether the nerve would be transected., Results: The IPNB was encountered in all knees with a mean distance of 2.82 cm (95% confidence interval, 2.58-3.06) distal to the inferior pole of the patella during the arthrotomy. Patient characteristics including sex, height, and body mass index were not markedly associated with nerve location., Conclusion: The IPNB of the saphenous nerve is at risk for injury and routinely encountered by the general orthopaedic surgeon during a standard TKA medial parapatellar approach without the aid of magnification or dye., (Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Background/aim: Controversy exists between performing limb salvage or amputation to treat osteosarcoma of the upper extremities. Our aim was to review the characteristics associated with limb amputation due to osteosarcoma of the upper extremities., Patients and Methods: A descriptive study was performed by querying the National Cancer Database from January 1, 2004 to December 31, 2015. Statistical analysis was performed using chi-squared test and a multivariate logistic regression model., Results: A total of 777 patients diagnosed with osteosarcoma of the upper extremities who underwent surgery met the inclusion criteria. Patients between 61 and 80 years were less likely to undergo limb amputation. Moreover, facilities located in the South Atlantic region, and stage IV of the disease were factors independently positively associated with amputation., Conclusion: Patients in facilities located in the South Atlantic region and those with stage IV disease were more likely to undergo amputation., (Copyright© 2019, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Case: The use of biologics is rapidly expanding. Over the past decade, there has been a significant increase in the number of cash-based "stem cell"/regenerative medicine clinics in the United States. These clinics provide cash-based services touting stem cell injections to cure a myriad of conditions. Largely, these clinics are unregulated and using injections in a non-Food and Drug Administration-approved manner. We report on 2 patients who presented with symptoms suggestive of septic arthritis following stem cell injections by cash-based local stem cell clinics. Case 1 involved a patient who developed septic arthritis following an injection of umbilical cord blood-derived cellular products (Genentech) and required an antibiotic spacer followed by a total hip arthroplasty. Case 2 involved a patient who developed a likely immune-mediated reaction following an injection of morselized human placental allograft tissue by a local chiropractic office at a cost of approximately $8,000., Conclusions: We present these cases to bring increased awareness to the issue and call for increased regulation of this practice.

Introduction: Referred to as the "fifth vital sign", pain is unique in that it cannot be obtained accurately by objective measurements. Instead, providers rely on patient-reported scales, such as the numerical rating scale (NRS), to determine a patient's pain level. Research has shown that patients report different pain scores to nurses and physicians in the clinic setting. It is unknown if this also occurs in the acute postoperative period. We hypothesized that patients report similar pain scores to the nursing staff and physician postoperatively. The primary aim of this study was to examine the degree of agreement between these patient-reported pain scores., Methods: A prospective study was conducted on 90 postoperative patients. During rounds, the surgeon collected a patient-reported pain score using the 11-point verbal NRS. Following rounds, the nursing staff obtained a pain score using the same scale. The patient was blinded to the study., Results: The median score reported to both the surgeon and nurses was 3 (range: 0-10), with a median difference of 0 (range: -2.5 to 7). Fifty-four percent of patients reported the same score to both the surgeon and the nurse and 88% of patients reported scores within a 1-point difference. This corresponded to an interclass correlation coefficient of 0.90, indicating very good agreement. The degree of agreement in pain scores reported to surgeons and nurses was consistent according to sex and age., Conclusion: The results of the study demonstrate a high degree of agreement between the pain scores reported by the patients to both the nursing staff and the surgeon postoperatively, with 88% of the scores at most being 1-point different., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2019, Foster et al.)

Epithelioid schwannoma is an uncommon benign peripheral nerve sheath tumor, with distinct morphological and pathological features. To our knowledge, the imaging features of epithelioid schwannoma have not been described. In this case report, we describe the imaging findings of a pathologically proven case of epithelioid schwannoma presenting as a slowly growing painless mass near the ankle. The MR imaging signs commonly associated with conventional schwannoma were absent. On correlative radiographs, there were intra-tumoral calcifications. Radiographs are an essential tool in the imaging evaluation of soft-tissue masses. Knowledge of soft-tissue tumor types that can be associated with intra-tumoral calcifications is helpful in honing the differential diagnosis.

Background: Dorsal pain from osteoarthritic midfoot joints is thought to be relayed by branches of the medial and lateral plantar, sural, saphenous, and deep peroneal nerves (DPN). However, there is no consensus on the actual number or pathways of the nervous branches for midfoot joint capsular innervation. This study examined the DPN's terminal branches at the midfoot joint capsules through anatomic dissection and confirmation of their significance in a clinical case series of patients with midfoot pain relief after DPN block., Methods: Eleven cadaveric lower leg specimens, 6 left and 5 right, were dissected using operative loupe magnification. We preserved the terminal branches and recorded their paths and branching patterns. Joint capsular innervations were individually noted. To confirm our hypothesis of significant dorsal midfoot joint capsular innervation by the DPN, we also performed an institutional review board-approved retrospective chart review of 37 patients with painful dorsal midfoot osteoarthritis who underwent diagnostic local anesthetic injection block of the DPN. The percentage of temporary pain relief after the injection was recorded., Results: Terminal innervation of the DPN branches showed distribution of the second and third tarsometatarsal joints in all specimens. Inconsistent innervation of the naviculocuneiform (9/11), fourth (7/11), first (6/11), and fifth (4/11) tarsometatarsal and calcaneocuboid joints (1/11) were observed. The retrospective review of pain relief in patients with dorsal midfoot pain due to arthritis after diagnostic injection demonstrated a mean of 92.1% improvement., Conclusion: Innervation of the dorsal midfoot joint capsule appears to follow a consistent distribution across 3 joints: second and third tarsometatarsal joints and the naviculocuneiform joint. Acute relief of dorsal midfoot arthritic pain after diagnostic injection suggests that dorsal midfoot nociceptive pain is at least partly transmitted by the DPN., Level of Evidence: Level IV, case series.

Purpose: Previous studies have grouped the treatment of axial and appendicular synovial sarcomas. The purpose of this study was to assess the prognostic variables of upper extremity synovial sarcomas (UESS) and compare the outcomes of those who underwent a nononcologic or inadvertent excision prior to definitive resection to those who underwent an initial oncologic resection., Methods: We reviewed the records of 23 UESS treated with definitive surgery at our institution between 1990 and 2014. There were 13 women and 10 men with a median age of 30 years (6-60) and median follow-up of 63 months (15-248). Prognostic variables, recurrence-free survival (RFS), and overall survival (OS) were then assessed., Results: Fifteen patients (65%) had a prior unplanned excision. Five patients required an amputation to obtain local control of disease. There were 3 observed local recurrences and 2 distant metastases at a median of 45 months from presentation. We found no difference in need for amputation, RFS, or OS between those who had undergone a planned excision and those who had an unplanned excision., Conclusion: While we were unable to find a significant difference in outcomes or amputation rates between those who underwent reexcision of a previously unplanned excision and those who underwent an initial planned resection, the high rate of unplanned excision is troubling and should remind practitioners to consider sarcoma in the differential of all upper extremity masses., Competing Interests: The authors declare that there are no conflicts of interest regarding the publication of this paper.

Introduction Total knee arthroplasty (TKA) is a common procedure with significant advances over the past several years, many pertaining to improved perioperative pain control. Cryotherapy is one method thought to decrease swelling and pain postoperatively. To our knowledge no study has directly visualized the effect cryotherapy has on skin blood flow following TKA. The primary aim was to determine if cryotherapy (icing) affects peri-incisional skin blood flow and if this is lessened with an alternate placement of the ice. We hypothesized that blood flow would decrease following cryotherapy, and this decrease would be greater with ice placed directly over the incision as compared to placement along the posterior knee. Methods This study included 10 patients who underwent TKA. During the postoperative hospitalization, they were given an injection of indocyanine green dye. A baseline image was recorded of the skin blood flow. Images were then collected following a five-minute interval placement of ice over the incision. The experiment was then repeated with the ice placed along the posterior knee.  Results There was an approximate 40% decrease in skin blood flow following placement of the ice compared to baseline. We observed a greater decrease in blood flow when ice was placed over the incision as compared to when ice was placed posterior to the knee ( p ≤ 0.020). Conclusion We found a significant decrease in peri-incisional blood flow with icing of the knee. Physicians should be cognizant of this when recommending cryotherapy to patients after surgery, especially in at-risk wounds., Competing Interests: The authors have declared that no competing interests exist.

Background: The United States is combating an opioid epidemic. Orthopedic surgeons are the third highest opioid prescribers and therefore have an opportunity and obligation to assist in the efforts to reduce opioid use and abuse. In this article, we evaluate risk factors for patients requiring an opioid refill after primary total knee arthroplasty, with the goal to reduce opioid prescriptions for those patients at low risk of requiring a refill in order to reduce the amount of unused medication., Methods: We retrospectively reviewed narcotic-naïve patients who underwent total knee arthroplasty from December 2017 to May 2018. We performed multivariable analysis on demographics and preoperative, operative, and postoperative characteristics to determine risk factors for requiring a prescription refill following hospital discharge., Results: One-hundred fifty-seven patients were included in the analysis. Sixty percent of patients required a prescription refill. Risk factors included younger age (P = .003) and increased pain on postoperative day one (P < .001). The amount of narcotic medication given at discharge did not independently affect the refill rate (P = .21)., Conclusion: There is strong evidence that elderly patients and those with good pain control on postoperative day 1 are at a lower risk of requiring a narcotic refill postoperatively. With this information, physicians may begin to tailor narcotic prescriptions based on patient risk factors for requiring a prescription refill rather than provide patients with the same number of pills for a given surgery in an effort to reduce unused narcotic medication., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: Opioid pain medications are commonly prescribed following orthopedic procedures, with overprescribing of these pain medications implicated as a driver of the current opioid epidemic. In an effort to reduce reliance on opioid pain medications, surgeons are relying on periarticular injections or peripheral nerve blocks. The purpose of this study was to compare numerical rating scale (NRS) pain scores and oral morphine equivalents (OMEs) in patients who underwent primary total knee arthroplasty (TKA) with a periarticular injection alone to those who underwent a collaborative approach with a periarticular injection in the posterior tissue and an adductor canal catheter for anterior knee analgesia., Methods: In this study, 236 patients underwent a primary TKA between December 2017 and April 2018. Forty patients received an adductor canal catheter and 196 underwent a periarticular injection alone., Results: We found no difference in patient demographics between the cohorts (p>0.05). The patients that underwent the collaborative approach with a periarticular injection and adductor canal catheter had lower NRS pain scores on post-operative day 0, 1, and 2 (all P≤0.033). These patients demonstrated a reduction of 43% in opioid consumption during the hospitalization (P<0.001). These patients also demonstrated improved range of motion (ROM) (96 vs. 92 degrees) on the day of discharge (P=0.013)., Conclusion: This study provides strong evidence that in patients undergoing TKA, the collaborative approach with the adductor canal catheter and periarticular injection is associated with lower post-operative pain scores, fewer total OMEs per hospital day, and a greater ROM arc prior to discharge compared to patients receiving a periarticular injection alone., Competing Interests: The authors have declared that no competing interests exist.

Background: The Patient Reported Outcomes Measurement Information System (PROMIS) is a tool developed by the National Institutes of Health that allows comparisons across conditions or even the United States (U.S.) general population., Objectives: Our purpose was to compare PROMIS outcomes between patients who underwent a planned resection to those who underwent an initial unplanned excision of their sarcoma followed by a definitive oncologic resection. We then compared these groups to the U.S. general population., Methods: Eighty-five patients were included and were divided into those who underwent an initial planned resection (67) and unplanned excision (18). These patients were then further categorized based on the length of follow-up since their last surgery, either early (<12 months) or late (>12 months)., Results: We evaluated seven PROMIS domains and found no differences between patients who underwent planned resection versus those who underwent an initial unplanned excision followed by a wide resection of the previous wound bed. When compared to the U.S. population, both cohorts demonstrated significantly improved scores in several emotional health domains., Conclusions: Patients who undergo an unplanned excision followed by a definitive oncologic procedure have similar PROMIS scores compared to patients who undergo an initial planned resection.

Background: Ehlers-Danlos syndromes (EDS) are connective tissue disorders that cause defects in collagen synthesis or processing, resulting in joint hypermobility. Following total knee arthroplasty (TKA), concern exists that hypermobility will affect the outcome as prosthesis relies on soft tissues for stability. The purpose of this study is to investigate the outcome of TKA in the setting of EDS compared to patients undergoing TKA for osteoarthritis (OA)., Methods: We identified 16 patients (20 knees) with EDS who underwent a TKA between 2001 and 2016. Patients were matched 1:2 (n = 40) on age, gender, body mass index, and surgical date to patients undergoing TKA for OA., Results: We found no difference in age, body mass index, or follow-up between the cohorts (P > .05). EDS patients had significantly more surgical interventions prior to TKA (P = .03) and were more likely to require constrained components (x 2  = 0.002). Following TKA, 4 patients in the EDS group and 9 patients in the matched cohort underwent a reoperation for any reason including 1 revision in the EDS cohort and 3 in the OA cohort. We found no significant difference in reoperation or revision rates between the cohorts (P > .05). There was no difference in Knee Society Scores between groups at last follow-up (P = .63) or radiographic evidence of loosening., Conclusion: Although patients with EDS were more likely to require a constrained component, they are not at increased risk of revision or reoperation following TKA in the intermediate term., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Large bone deficiencies are a challenging problem, historically treated with an allograft-prosthetic composite (APC) or megaprosthesis. There were several advantages of the APC compared with early megaprostheses, including the theoretical benefit of restoring bone stock. To our knowledge, there are no studies that have evaluated this claim. Our purpose was to review our institution's experience with APCs of the proximal femur that underwent revision for an aseptic cause and determine if the allograft bone was retained or removed during the revision procedure., Methods: We identified 203 proximal femoral allograft prosthetic composites placed from 1988 through 2014. Twenty-seven of these patients underwent a revision because of an aseptic cause. Three categories were devised to classify the amount of allograft retention: type A, complete allograft retention; type B, partial retention; and type C, no allograft retention., Results: The mean time from the initial APC to revision surgery was 5 years. The most common indication for revision included failure of the allograft (loosening or fracture). At the time of revision, there were 3 type A cases (11%), 4 type B cases (15%), and 20 type C cases (74%). Three of the 4 type B cases used the retained allograft as a strut graft around a newly inserted megaprosthesis., Conclusion: The results of this study are contradictory to previous literature that suggests APCs restore bone stock. In this series, the allograft was retained in only a small percentage of cases when the APC was revised for an aseptic cause., Level of Evidence: IV., (Copyright © 2018 Elsevier Inc. All rights reserved.)