Complex Reconstruction for Acetabular Pathologic Fracture in Unusual Chondroblastoma With Aneurysmal Bone Cyst.

Treating bone loss with complex arthroplasty poses a significant challenge for the arthroplasty surgeon. When considering a reconstructive case after pathologic fracture and oncologic excision, a multidisciplinary approach with reliance on arthroplasty principles is critical. An 18-year-old patient presented with a complex acetabular pathologic fracture through a chondroblastoma with a secondary aneurysmal bone cyst. An outside institution performed a biopsy and placed a hip-spanning external fixator. Multidisciplinary planning led to tumor excision, complex acetabular arthroplasty reconstruction including structural bone grafting, and internal fixation. At the third year of follow-up, there was no evidence of mechanical loosening of the hip arthroplasty, reoperation, or tumor recurrence. The structural graft was completely osseointegrated, confirmed by a computed tomography scan obtained at 2 years postoperatively. This report demonstrates an unusual location of chondroblastoma, presenting with acetabular fracture definitively treated with complex multidisciplinary reconstruction leading to an excellent outcome in a young patient.

Humeral stem lucencies correlate with clinical outcomes in anatomic total shoulder arthroplasty.

BACKGROUND: Humeral stem lucencies are uncommon after uncemented anatomic total shoulder arthroplasty (aTSA), and their clinical significance is unknown. This study compares clinical outcomes of aTSA with and without humeral stem lucencies. METHODS: Two-hundred eighty aTSAs using an uncemented grit-blasted metaphyseal-fit humeral stem between 2005 and 2013 were retrospectively evaluated for radiographic humeral stem lucencies. All shoulders were evaluated at a minimum 5-year follow-up from a multicenter database. Clinical outcomes included range of motion (ROM) and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, Constant score, University of California-Los Angeles Shoulder Score (UCLA), Simple Shoulder Test (SST), and Shoulder Pain and Disability Index (SPADI) scores. Postoperative radiographs were evaluated and complications were recorded. RESULTS: Two-hundred forty-three humeral stems showed no radiolucent lines. Among the 37 humeral stems with lucent lines, lines were most common in zones 8, 4, 7, and 3. Preoperative ROM and functional outcomes were similar between groups. Postoperative change in outcomes exceeded the minimal clinically important difference (MCID) for all ROM and outcomes in both groups. Postoperative change between groups showed no significant difference in ROM or outcome scores, but improved mean abduction exceeded the MCID in the patients without humeral lines. The complication rate after omitting patients with humeral loosening was higher in patients with humeral lucencies, as was the revision rate. There was also a higher glenoid-loosening rate in patients with humeral lucencies. CONCLUSION: Humeral lucent lines after uncemented stemmed aTSA have a small negative effect on ROM and functional outcomes compared with patients without lucent humeral lines, which may not be clinically significant. The complication and revision rates were significantly higher in patients with humeral lucencies.

Outcome Measure Utilization Demonstrates No Relation to Journal Rank or Level of Evidence for Superior Labral Tears of the Shoulder.

Introduction Superior labrum anterior to posterior (SLAP) tears are injuries of the shoulder's glenoid labrum involving biceps tendon insertion. We describe the scope of outcome measures used in the SLAP tear literature over the last decade and evaluate whether objective study metrics relate to level of evidence (LOE) and journal rank. Methods A comprehensive review of the literature was performed to identify all articles on the outcomes of the treatment of patients with SLAP tears published over the period of a decade (2007-2016). Studies were reviewed for LOE, SCImago Scientific Journal Ranking (SJR), study characteristics, and patient demographics. The utilization frequencies of outcome measures were recorded. Outcome measures were categorized as clinician-measured outcomes (CMOs), outcome scores/patient-reported outcomes (PROs), or other reported outcomes (OROs). Univariate analyses compared demographics and outcome-measure utilization among studies grouped by LOE (high: I/II vs. low: III/IV) and SJR (high: >2 vs. low: <2). Results The literature review identified 86 studies meeting inclusion criteria from an initial search of 582 articles. The mean study SJR was 2.02 and 0.85 +/- 0.79 CMOs were included. Twenty different outcome scores were utilized in the reviewed literature with a mean of 2.66 +/- 1.61 PROs/study. The most common outcome scores were ASES score, pain Visual Analog Scale (VAS), and constant score. High SJR studies had longer follow-up (p=0.036). High LOE studies utilized more CMOs (p=0.008) and more commonly included physical exam findings (p=0.0015). Revision surgery rate was less commonly reported in high LOE studies (p=0.036). None of the other outcome measures studied were associated with high study LOE or SJR. Conclusions Considerable variability exists in outcome-measure utilization within the recent SLAP tear literature. ASES score, pain VAS, and constant score are the most commonly reported PROs. CMOs and OROs are infrequently reported. There is little objectivity distinguishing higher and lower quality studies based on the proxy metrics used. Future SLAP tear research should focus on improving the consistency of outcome-measure reporting to enable more meaningful cross-study comparisons.

Optimal glenosphere size cannot be determined by patient height.

BACKGROUND: Glenosphere size remains 1 surgeon-controlled variable that can affect patient outcomes following reverse shoulder arthroplasty (RSA). There remains no objective criterion to guide surgeons in choosing glenosphere size. This study's purpose was to evaluate range of motion (ROM) as a function of patient height and glenosphere size to determine the optimal glenosphere size based on patient height. METHODS: We retrospectively reviewed 589 primary RSAs from a multicenter shoulder arthroplasty database of a single RSA system with multiple glenosphere sizes. Shoulders were separated into groups based on glenosphere size (38 or 42 mm). Predictive accuracy was calculated in relation to height and sex for predicting glenosphere size. Improvements in active ROM and patient-reported outcome measures (PROMs) were compared based on glenosphere size as a function of height. RESULTS: Logistic regression analysis demonstrated a strong association of height and sex with surgeon selection of glenosphere size, with shorter heights preferentially treated with 38-mm glenospheres and taller heights with 42-mm glenospheres. There were no statistically significant interaction effects of glenosphere size and height on improvements in ROM or PROMs. These results indicate that for a given glenosphere size, there is not an optimal height range to maximize improvements in postoperative outcome measures. DISCUSSION: Height and sex are highly correlated with a surgeon's choice of glenosphere size. However, on the basis of improvements in ROM and PROMs, no recommendation can be made for surgeons to select a particular glenosphere size based on a patient's height. Surgeons should consider other variables when selecting a glenosphere size.

Obesity and neurocognitive recovery after sports-related concussion in athletes: a matched cohort study.

OBJECTIVES: Sports-related concussions (SRCs) are a significant public health concern in athletes. Data exist suggesting a link between obesity and decreased neurocognitive function, yet the effect of body mass index (BMI) on neurocognitive function and recovery after a SRC is unknown. The goal of our study was to discern the effect of BMI on recovery after SRC. METHODS: This study was a retrospective observational cohort study. Between 2013 and 2014, 7,606 athletes between the ages of 13-20 years valid baseline neurocognitive testing performed at multiple regional concussion centers sustained a concussion. Out of these athletes, 711 normal weight athletes and 711 obese athletes were matched by age, gender, number of previous concussions, and sport. The proportions of athletes returning to baseline within two weeks between the groups were defined by using 80% confidence reliable change index (RCI) criteria and were compared using Fisher's Exact Test. Kaplan-Meier survival curve analysis with log-rank test was used to compare the median time to neurocognitive recovery between groups. RESULTS: Fewer obese athletes returned to baseline within 2 weeks on measures of verbal memory, visual motor speed, reaction time, postconcussion symptom scale (PCSS), and overall recovery compared to normal weight athletes. Obese athletes also had greater median time of return to baseline with respect to reaction time, PCSS, and overall recovery. CONCLUSION: Using RCI methodology, there exists an association between obesity and increased time to return to neurocognitive and symptom baseline after SRC in athletes, specifically reaction time, symptom scores, and overall recovery.

A Review of the Clinical Side Effects of Bone Morphogenetic Protein-2.

Bone morphogenetic protein-2 (BMP-2) is currently the only Food and Drug Administration (FDA)-approved osteoinductive growth factor used as a bone graft substitute. However, with increasing clinical use of BMP-2, a growing and well-documented side effect profile has emerged. This includes postoperative inflammation and associated adverse effects, ectopic bone formation, osteoclast-mediated bone resorption, and inappropriate adipogenesis. Several large-scale studies have confirmed the relative frequency of adverse events associated with the clinical use of BMP-2, including life-threatening cervical spine swelling. In fact, the FDA has issued a warning of the potential life-threatening complications of BMP-2. This review summarizes the known adverse effects of BMP-2, including controversial areas such as tumorigenesis. Next, select animal models that replicate BMP-2's adverse clinical effects are discussed. Finally, potential molecules to mitigate the adverse effects of BMP-2 are reviewed. In summary, BMP-2 is a potent osteoinductive cytokine that has indeed revolutionized the bone graft substitute market; however, it simultaneously has accrued a worrisome side effect profile. Better understanding of these adverse effects among both translational scientists and clinicians will help determine the most appropriate and safe use of BMP-2 in the clinical setting.

Surgical site infection in high-energy peri-articular tibia fractures with intra-wound vancomycin powder: a retrospective pilot study.

BACKGROUND: Surgical site infections (SSI) continue to be a significant source of morbidity despite the introduction of perioperative intravenous antibiotics. Our objective was to assess the efficacy of local vancomycin powder on lowering deep SSI rates in high-energy tibial plateau and pilon fractures. MATERIALS AND METHODS: A retrospective review of all tibial plateau and pilon fractures treated in 2012 at our level I trauma center identified 222 patients. Of these, 107 patients sustained high-energy injuries that required staged fixation, and 93 had minimum 6 month follow-up. Ten patients received 1 gram vancomycin powder directly into the surgical wound at the time of definitive fixation, and the remaining 83 patients served as controls. SSI was defined according to criteria from the Centers for Disease Control. Demographic data, patient comorbidities, injury and treatment details, and infection details were recorded. Descriptive and comparative statistics were performed. RESULTS: Amongst the vancomycin powder group, 1 patient (10 %) developed a deep SSI; in the control group, 14 (16.7 %) developed deep SSI. The rate of deep SSI between the groups was not statistically significantly different (P = 1.0). The groups were statistically similar with regard to injuries, treatment, comorbidities, and infectious outcomes (P values range = 0.06-1.0). CONCLUSIONS: The application of local vancomycin powder into surgical wounds of high-energy tibial plateau and pilon fractures did not reduce the rate of deep SSI in this retrospective review. There is a need to find effective, cheap, and widely available methods for prevention of SSI. Basic science and larger prospective clinical studies are needed to further delineate the role of local vancomycin powder as a modality to reduce deep SSI in extremity trauma.

Clinical and histopathological diagnosis of glomus tumor: an institutional experience of 138 cases.

BACKGROUND: Glomus tumors are relatively uncommon subcentimeteric benign perivascular neoplasms usually located on the fingers. With their blue-red color and common subungual location, they are commonly confused for vascular or melanocytic lesions. To date there is no comprehensive review of an institutional experience with glomus tumors. METHODS: A 14-year retrospective review of all cases within University of California, Los Angeles, with either a clinical or pathological diagnosis of glomus tumor was performed. Data obtained included demographic information, tumor description, pathological diagnoses, immunohistochemical studies, radiographic and treatment information, and clinical course. Rates of concordance between clinical and pathological diagnoses and an evaluation of overlap with other entities were assessed. RESULTS: Clinical diagnosis of glomus tumor showed concordance with a histopathological diagnosis (45.4% of cases). The most common alternate clinical diagnoses included lipoma, cyst, or angioma. A pathological diagnosis of glomus tumor was most common in the fourth to seventh decades of life. The most common presentation was a subcentimeter lesion on the digit. Deep-seated tumors had a strikingly increased risk for malignancy (33%). Radiological studies were not relied on frequently (18.2% of cases). Immunohistochemical analysis showed diffuse αSMA and MSA expression in nearly all cases (99% and 95%, respectively), with focal to diffuse CD34 immunostaining in 32% of cases. DISCUSSION: Our study illustrates trends in the clinical versus pathologic diagnoses of glomus tumor, common competing diagnoses, a difference in demographics than is commonly reported (older age groups most commonly affected), and important differences in the use adjunctive diagnostic tools including radiology and immunohistochemistry.

NELL-1 expression in tumors of cartilage.

BACKGROUND/AIMS: NELL-1 is a novel osteochondral differentiation factor protein with increasing usage in tissue engineering. Previously, we reported the expression patterns of NELL-1 in bone-forming skeletal tumors. With increasing interest in the use of NELL-1 protein, we sought to examine the expression of NELL-1 in cartilage-forming tumors. METHODS: Immunohistochemical expression was examined in human pathologic specimens. RESULTS: Consistent NELL-1 overexpression across all cartilage-forming tumors was observed. Similar degrees of expression were observed in enchondroma, chondrosarcoma, and chondroblastic osteosarcoma. NELL-1 expression did not significantly vary by tumor grade. CONCLUSION: In summary, NELL-1 demonstrates reliable and consistent expression across cartilage-forming skeletal tumors.