Fracture of the Supracondylar Process in a Child: A Case Report and Review of the Literature.

CASE: A 5-year-9-month-old boy sustained a fracture of the supracondylar process of the distal humerus. The fracture healed with cast immobilization and with no neurovascular complications. Magnetic resonance imaging showed the medial nerve and the brachial artery to be located under the ligament of Struthers that extended from the supracondylar process to the medial epicondyle. CONCLUSIONS: Fracture of the supracondylar process of the humerus in children is rare and easy to misdiagnose, but once discovered, the fracture can be treated successfully with cast immobilization and without compromise to the neurovascular structures passing under the ligament of Struthers.

Rates of Perioperative Complications Among Patients Undergoing Orthopedic Trauma Surgery Despite Having Positive Results for Methamphetamine.

The burden of psychosocial problems, including substance abuse, is high among trauma patients. Use of illicit substances is often noted during urine toxicology screening on admission and can delay surgery because of concerns for an interaction with anesthesia. Methamphetamine theoretically has potential to increase perioperative anesthetic risks. However, the authors are unaware of any studies documenting increased rates of cardiovascular complications in the perioperative period among orthopedic trauma patients. This study sought to determine the rate of cardiovascular complications in these patients. The authors reviewed the medical records of all patients between 2013 and 2018 who underwent orthopedic trauma surgery at two level I trauma centers in the setting of a methamphetamine-positive urine toxicology screening prior to surgery. Information on demographics, injury, type of surgical intervention, and incidence of perioperative cardiovascular and overall medical complications prior to discharge was recorded. Ninety-four patients were included in the study (mean age, 44 years; range, 16-78 years). Twenty-six (28%) patients had multiple injuries. Thirteen (14%) patients had debridement and/or provisional stabilization of an open or unstable fracture, 18 (19%) had treatment for an infection, and 63 (67%) had definitive fracture surgery. The overall rates of perioperative cardiovascular complications and perioperative medical complications were 2.1% and 3.2%, respectively. This study provides both a baseline understanding of the complication rate for methamphetamine-positive orthopedic trauma patients during general anesthesia and justification for larger multicenter studies to further investigate this topic. [Orthopedics. 2019; 42(4):192-196.].

Operative management of metastatic melanoma in bone may require en bloc resection of disease.

BACKGROUND: Bone metastasis is a poor prognostic indicator in melanoma. Some authors have advocated only palliative treatment for patients with osseous disease. QUESTIONS/PURPOSES: We determined (1) overall survival after surgery for bone metastasis in patients with malignant melanoma, (2) the rate of local relapse after surgery for bone metastasis, (3) whether certain patients might benefit from more extensive surgery to reduce the risk of local recurrence, and (4) whether there is an effect of prior radiation on survival and local progression. METHODS: We identified 37 patients who underwent 41 orthopaedic procedures for metastatic melanoma to bone in the pelvis or appendicular skeleton, including 20 for pathologic fracture, from our institutional orthopaedic database and performed a retrospective review of their charts and radiographs. The femur (n = 19) and humerus (n = 11) were the most common operative sites. Kaplan-Meier survivorship was used to determine overall survival and local progression-free survival. RESULTS: The median survival from surgery was 9 months (range, 1-135 months). Kaplan-Meier analysis showed overall survival of 30% at 12 months and 17% at 24 months. Local recurrence developed in seven of 41 lesions (17%). The local progression-free survival was 87% at 12 months and 67% at 24 months. Patients for whom prior radiation failed and patients who did not have excision of osseous metastases had higher rates of local recurrence. Two patients underwent amputation for uncontrolled local progression of disease. CONCLUSIONS: Osseous metastasis from melanoma behaves aggressively. The rate of local progression is substantial, and two of 37 patients in this series required amputation for progressive disease. Despite the poor overall prognosis, local control of bone disease is an important issue, and patients may benefit from resection of osseous metastases, particularly if prior radiation has failed.

High VEGF with rapid growth and early metastasis in a mouse osteosarcoma model.

A murine model of osteosarcoma was developed to investigate the association between the expression of VEGF and the progression of osteosarcoma. Two human osteosarcoma cell lines with distinct VEGF expressions were introduced into proximal tibiae of immuno-deficient SCID mice, either by direct injection through the cortical bone or surgical exposing and drilling on the tibial metaphysis to seed tumor cells. Bone tumors were obvious on microCT within 4 weeks following osteosarcoma cell inoculation through surgical delivery. In contrast, direct injection without drilling often resulted in periosteal tumors. Although neoplasms were developed regardless of VEGF levels, orthotopic tumors derived from high VEGF-expressing cells were detected 2 weeks earlier on CT images than the ones from VEGF negative cells. At sacrifice, high VEGF tumors were distinctively larger in size and more frequently invaded the adjacent bone tissue. Multiple metastatic lesions were found in all the lung tissues at 8 weeks from high VEGF group, whereas only 1 of 7 VEGF negative tumors exhibited pulmonary metastasis. Overall, this model developed with the surgical tumor cell delivery results in histological and radiographic features more consistent with primary osteosarcoma. Interestingly, VEGF expression correlates with the early establishment, rapid tumor growth, and the development of pulmonary metastasis.