SHIP1 deficiency causes inflammation-dependent retardation in skeletal growth.

Inflammation and skeletal homeostasis are closely intertwined. Inflammatory diseases are associated with local and systemic bone loss, and post-menopausal osteoporosis is linked to low-level chronic inflammation. Phosphoinositide-3-kinase signalling is a pivotal pathway modulating immune responses and controlling skeletal health. Mice deficient in Src homology 2-containing inositol phosphatase 1 (SHIP1), a negative regulator of the phosphoinositide-3-kinase pathway, develop systemic inflammation associated with low body weight, reduced bone mass, and changes in bone microarchitecture. To elucidate the specific role of the immune system in skeletal development, a genetic approach was used to characterise the contribution of SHIP1-controlled systemic inflammation to SHIP1-dependent osteoclastogenesis. Lymphocyte deletion entirely rescued the skeletal phenotype in Rag2 -/- /Il2rg -/- /SHIP1 -/- mice. Rag2 -/- /Il2rg -/- /SHIP1 -/- osteoclasts, however, displayed an intermediate transcriptomic signature between control and Rag2 +/+ /Il2rg +/+ /SHIP1 -/- osteoclasts while exhibiting aberrant in vitro development and functions similar to Rag2 +/+ /Il2rg +/+ /SHIP1 -/- osteoclasts. These data establish a cell-intrinsic role for SHIP1 in osteoclasts, with inflammation as the key driver of the skeletal phenotype in SHIP1-deficient mice. Our findings demonstrate the central role of the immune system in steering physiological skeletal development.

Exploring the Potential of Electronic Patient-Reported Outcome Measures to Inform and Assess Care in Sarcoma Centers: A Longitudinal Multicenter Pilot Study.

BACKGROUND: Electronic patient-reported outcome measures (ePROMs) are useful tools to assess care needs of patients diagnosed with cancer and to monitor their symptoms along the illness trajectory. Studies regarding the application of ePROMs by advanced practice nurses (APNs) specialized in sarcoma care and the use of such electronic measures for care planning and assessing quality of care are lacking. OBJECTIVE: To explore the potential of ePROMs in clinical practice for assessing the patient's quality of life, physical functionality, needs, and fear of progression, as well as distress and the quality of care in sarcoma centers. METHODS: A multicenter longitudinal pilot study design was chosen. Three sarcoma centers with and without APN service located in Switzerland were included. The instruments EQ-5D-5L, Pearman Mayo Survey of Needs, the National Comprehensive Cancer Network Distress Thermometer, PA-F12, and Toronto Extremity Salvage Score were used as ePROMs. Data were analyzed descriptively. RESULTS: Overall, 55 patients participated in the pilot study; 33 (60%) received an intervention by an APN, and 22 (40%) did not. Patients in sarcoma centers with APN service reported overall higher scores in quality of life and functional outcome. The number of needs and distress level were lower in sarcoma centers with APN service. No differences were found with respect to patients' fear of progression. CONCLUSIONS: Most of the ePROMs proved to be reasonable in clinical practice. PA-F12 has shown low clinical relevance. IMPLICATIONS FOR PRACTICE: Using ePROMs appears to be reasonable to obtain clinically relevant patient information and to evaluate the quality of care in sarcoma centers.

Flap Reconstruction Outcome Following Surgical Resection of Soft Tissue and Bone Sarcoma in the Setting of (Neo)adjuvant Therapy: A Sarcoma Center Experience.

BACKGROUND: Soft tissue and bone sarcomas are heterogeneous groups of malignant tumors. The shift in their management, with an emphasis on limb salvage, has deemed the involvement of reconstructive surgeons an integral part of their multidisciplinary treatment. We present our experience with free and pedicled flaps in the reconstruction of sarcomas at a tertiary referral university hospital and major sarcoma center. MATERIALS AND METHODS: All patients undergoing flap reconstruction after sarcoma resection over a 5-year period have been included in the study. Patient-related data and postoperative complications were collected retrospectively, ensuring a minimum follow-up of 3 years. RESULTS: A total of 90 patients underwent treatment with 26 free flaps and 64 pedicled flaps. Postoperative complications occurred in 37.7% of patients, and the flap failure rate was 4.4%. Diabetes, alcohol consumption and male gender were associated with increased early necrosis of the flap. Preoperative chemotherapy significantly increased the occurrence of early infection and late dehiscence, while preoperative radiotherapy was associated with a higher incidence of lymphedema. Intraoperative radiotherapy was associated with late seromas and lymphedema. CONCLUSIONS: Reconstructive surgery with either pedicled or free flaps is reliable, but it can be demanding in the setting of sarcoma surgery. A higher complication rate is to be expected with neoadjuvant therapy and with certain comorbidities.

Standardized multi-planar reformation improves the reliability of the assessment of the anterolateral ligament in ACL-deficient knees.

PURPOSE: The anterolateral ligament (ALL) is an important structure for controlling anterolateral rotatory stability of the knee. Its assessment, however, is difficult using standardized MRI images. The goal of this study was to assess the reliability of judging the integrity of the ALL on multi-planar reformatted (MPR) MRI images and on standard coronal reformatted (SCR) MRI images in knees with an anterior cruciate ligament (ACL) rupture. METHODS: Forty-eight patients (14 females, 34 males, 30 ± 6 years (mean age ± standard deviation)) with acute ACL ruptures (< 2 weeks) and no additional knee injuries (except segond fractures) were included. Images were assessed by two independent raters twice with at least a 2-week interval in between. The assessment was first performed on SCR images and thereafter on MPR images. Images were judged for assessability of the ALL and then the integrity of the ALL was rated. RESULTS: Depending on rater and read, the ALL was judged as "torn" in between 5 (10.4%) and 11 (22.9%) patients out of 48 patients on SCR images. On MRP images, the ALL was judged as "torn" in between 5 (10.4%) and 6 (12.5%) patients out of 48 patients, depending on rater and read. Inter- and intra-rater reliability for the assessment of the ALL using MPR images was "substantial" to "almost perfect". Inter- and intra-rater reliability for the assessment using SCR was "fair" to "substantial". CONCLUSION: MPR images should be used when assessing the integrity of the ALL. Assessment quality is independent of patient positioning during MRI acquisition and the ALL can be displayed in full length on one image. LEVEL OF EVIDENCE: Level III.

Survival, functional outcome and satisfaction of first revision total knee arthroplasty at a mean eleven-year follow-up.

PURPOSE: Providing long-term outcome data after rTKA and compare one- versus two-stage and septic versus aseptic revisions. METHODS: This study represents a single-center retrospective study of first rTKAs performed for any reason with a final follow-up of a minimum of five years. Outcome parameters included stability assessment ROM, radiologic assessment, HSS score, KSS score, OKS score, EQ-5D-3L and VAS. 44 patients were included in the study. Subgroups analysis of one- versus two-stage revision and septic versus aseptic revision was performed. RESULTS: The leading causes of rTKA in this mean 11 year follow-up study were aseptic loosening (36%) and periprosthetic joint infection (27%). At the final follow-up, there was a 89% survivorship of the implants. Patients showed a ROM of 114 ± 13°, HSS score of 78 ± 12, KKS objective score of 77 ± 16, KSS expectation and satisfaction score of 32 ± 11, KSS functional activity score of 50 ± 20, OKS of 30 ± 9, VAS of 53 ± 25 and EQ-5D index of 0.649. Functional outcome scores were not significantly altered in the analyzed subgroups. CONCLUSIONS: In our 11 years follow-up, we obtained 89% implant survivorship. Measurements regarding functional outcome and pain showed results in the medium range of the respective scores, while patient satisfaction lay in the upper third. No significant differences in outcome scores between one- and two-stage revisions and septic versus aseptic revisions were observed. Level of Evidence Level III, retrospective cohort study.

Indications, clinical outcome and survival of rotating hinge total knee arthroplasty in a retrospective study of 63 primary and revision cases.

PURPOSE: The purpose of this study is to report and compare outcome data of both primary and revision cases using a rotating hinge knee (RHK) implant. METHODS: This study retrospectively analyzed 63 cases (19 primary, 44 revisions) at a mean follow-up of 34 ± 8 months after RHK implantation. Outcome parameters were stability, range of motion (ROM), loosening, Hospital of Special Surgery Score (HSS), Knee Society Score (KSS), Oxford Knee Score (OKS), EQ-5D-3L, and Visual Analog Scale (VAS) for overall function. Revision rates and implant survival are reported. RESULTS: Eleven percent showed medio-lateral instability < 5 mm, a mean ROM of 115° ± 17° and radiologic loosening occurred in 8% (2% symptomatic). PROMS showed the following results: HSS 79 ± 18, KSS 78 ± 27, OKS 26 ± 10, EQ-5D index 0.741 ± 0.233 and VAS 70 ± 20. Primary cases revealed better outcomes in HHS (p = .035) and OKS (p = 0.047). KSS, EQ-5D index and VAS did not differ between primary and revision cases (p = 0.070; p = 0.377; p = 0.117). Revision rate was 6.3% with an implant survival of 96.8%. CONCLUSIONS: RHK arthroplasty can be performed with good clinical outcome and low revision rate in revision and complex primary cases. RHK is an option in cases where standard arthroplasty and even implants with a higher degree of constraint have reached their limits. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Treatment of Knee Dislocation With Primary Repair and Suture Augmentation: A Viable Solution.

Background: Different surgical techniques have been described for the treatment of knee dislocation (KD). Nonoperative approaches are frequently combined with surgical reconstruction using auto- or allograft. Purpose: To evaluate the midterm results of primary surgical repair and suture augmentation to treat KD. Study Design: Case series; Level of evidence, 4. Methods: A total of 22 patients (5 women, 17 men; mean age, 45 ± 15 years) with KD were evaluated at a mean of 49 ± 16 months after surgical treatment that included primary repair and suture augmentation. Magnetic resonance imaging, stress radiographs, and outcome scores were obtained at the follow-up. Clinical examination including hop tests and force measurements for flexion and extension was performed. Results: The mean difference in pre- to postinjury Tegner scores was -2 ± 1. The outcome scores showed mean values of 84 ± 15 (Lysholm), 73 ± 15 (International Knee Documentation Committee) and 65 ± 25 (Anterior Cruciate Ligament-Return to Sport after Injury scale). Compared with the uninjured knee, the range of motion of the injured knee was reduced by 21° ± 12°. Twelve patients felt fit enough to perform hop tests and showed a mean deficit of 7% ± 17%° compared with the uninjured leg. The mean force deficit was 19% ± 18% for extension and 8% ± 16% for flexion. Stress radiographs revealed an 11 ± 7-mm higher anteroposterior translation on the injured side. Four patients had secondary ligament reconstructions due to persistent instability and 7 underwent arthroscopic arthrolysis due to stiffness. A significant increase of osteoarthritis was found for the medial, lateral, and patellofemoral compartments (P = .007, .004, and .006, respectively). Conclusion: Primary repair and suture augmentation of KD led to satisfactory clinical midterm results despite persistent radiological instability and a significant increase in osteoarthritis. This technique allows the return to activities of daily living without subjective instability in most nonathletic patients. Secondary ligament reconstructions should be performed if relevant instability persists to decrease the risk of secondary meniscal and cartilage damage.

Quantitative determination of the femoral offset templating error in total hip arthroplasty using a new geometric model.

AIMS: Traditionally, total hip arthroplasty (THA) templating has been performed on anteroposterior (AP) pelvis radiographs. Recently, additional AP hip radiographs have been recommended for accurate measurement of the femoral offset (FO). To verify this claim, this study aimed to establish quantitative data of the measurement error of the FO in relation to leg position and X-ray source position using a newly developed geometric model and clinical data. METHODS: We analyzed the FOs measured on AP hip and pelvis radiographs in a prospective consecutive series of 55 patients undergoing unilateral primary THA for hip osteoarthritis. To determine sample size, a power analysis was performed. Patients' position and X-ray beam setting followed a standardized protocol to achieve reproducible projections. All images were calibrated with the KingMark calibration system. In addition, a geometric model was created to evaluate both the effects of leg position (rotation and abduction/adduction) and the effects of X-ray source position on FO measurement. RESULTS: The mean FOs measured on AP hip and pelvis radiographs were 38.0 mm (SD 6.4) and 36.6 mm (SD 6.3) (p < 0.001), respectively. Radiological view had a smaller effect on FO measurement than inaccurate leg positioning. The model showed a non-linear relationship between projected FO and femoral neck orientation; at 30° external neck rotation (with reference to the detector plane), a true FO of 40 mm was underestimated by up to 20% (7.8 mm). With a neutral to mild external neck rotation (≤ 15°), the underestimation was less than 7% (2.7 mm). The effect of abduction and adduction was negligible. CONCLUSION: For routine THA templating, an AP pelvis radiograph remains the gold standard. Only patients with femoral neck malrotation > 15° on the AP pelvis view, e.g. due to external rotation contracture, should receive further imaging. Options include an additional AP hip view with elevation of the entire affected hip to align the femoral neck more parallel to the detector, or a CT scan in more severe cases.Cite this article: Bone Jt Open 2022;3(10):795-803.

Staged treatment of a comminuted femoral fracture with Masquelet technique and 3D printed reposition guides.

Background: Comminuted femoral fractures pose a challenge to the trauma surgeon due to the absence of bony references during surgery. Therefore, malalignment of length and axis can occur and necessitate revision surgery. During the last decade, 3D-planning has evolved as a surgical aid in difficult cases. Case report: An 18-year-old male patient suffered a polytrauma following a motorcycle accident. This report is about the treatment of a 3rd degree open and comminuted fracture of the left distal femur. The fracture was treated with Masquelet's two-staged technique. With the intent of avoiding malalignment, the second stage surgery was performed with the aid of 3D-planned reduction guides. Despite complex fracture pattern, complete fracture union was achieved with acceptable final alignment (side-to-side comparison of length, axis and femoral torsion). Conclusion: In this case, performing Masquelet's two-staged surgery with the aid of 3D-printed reposition guides yielded favorable results in regards to rotational malalignment. The malrotation of the femur was reduced after the second operation to a clinically acceptable side-to-side difference (10°). This technique remains technically challenging due to soft tissue tension and limited possibility of soft tissue release.

3D printed fracture reduction guides planned and printed at the point of care show high accuracy - a porcine feasibility study.

PURPOSE: After surgical treatment of comminuted diaphyseal femoral and tibial fractures, relevant malalignment, especially rotational errors occur in up to 40-50%. This either results in a poor clinical outcome or requires revision surgery. This study aims to evaluate the accuracy of reduction if surgery is supported by 3D guides planned and printed at the point of care. METHODS: Ten porcine legs underwent computed tomography (CT) and 3D models of femur and tibia were built. Reduction guides were virtually constructed and fitted to the proximal and distal metaphysis. The guides were 3D printed using medically approved resin. Femoral and tibial comminuted diaphyseal fractures were simulated and subsequently reduced using the 3D guides. Postoperative 3D bone models were reconstructed to compare the accuracy to the preoperative planning. RESULTS: Femoral reduction showed a mean deviation ± SD from the plan of 1.0 mm ± 0.9 mm for length, 0.9° ± 0.7° for varus/valgus, 1.2° ± 0.9° for procurvatum/recurvatum and 2.0° ± 1.7° for rotation. Analysis of the tibial reduction revealed a mean deviation ± SD of 2.4 mm ± 1.6 mm for length, 1.0° ± 0.6° for varus/valgus, 1.3° ± 1.4° for procurvatum/recurvatum and 2.9° ± 2.2° for rotation. CONCLUSIONS: This study shows high accuracy of reduction with 3D guides planned and printed at the point of care. Applied to a clinical setting, this technique has the potential to avoid malreduction and consecutive revision surgery in comminuted diaphyseal fractures. LEVEL OF EVIDENCE: Basic Science.

Collagen wrapping and local platelet-rich fibrin do not improve the survival rates of ACL repair with dynamic intraligamentary stabilization: a retrospective case series after ≥5 years postoperatively.

PURPOSE: Anterior cruciate ligament (ACL) repair has been recommended as a treatment principle for ACL tears. Several authors have advocated a potential role for primary repair techniques in the ACL decision tree. However, long-term results have been controversial. This study aims to determine the survival of the primarily repaired ACL after dynamic intraligamentary stabilization (DIS) with and without augmentation. METHODS: Between 2014 and 2019, 102 patients with isolated proximal ACL ruptures underwent DIS repair within 21 days from injury and were available for follow-up either clinically or telephonically after ≥5 years postoperatively. In 45 cases, DIS repair was augmented with collagen fleece wrapping, platelet-rich fibrin (PRF) or both. Failure was defined as traumatic re-rupture or conversion to ACL reconstruction. The patients being available for physical examination underwent a.-p. stability measurement with a KT-1000 device. Functional outcome was measured with the IKDC, Tegner and Lysholm scores. Kaplan-Meier survival analysis, Log-Rank Test and Binominal logistic regression were performed. RESULTS: After a minimum 5-year follow-up, 71/102 (69.6%) DIS repairs were not re-reptured and clinically and/or subjectively stable. Augmentation did not improve survival rates (p = 0.812). The identified factors influencing failure were a younger age and a pre-injury Tegner activity level of ≥7. 95.7% of those patients with an intact ACL repair had normal or near normal knee function based on the IKDC scoring system. CONCLUSIONS: The 5-year overall survival rate of DIS was 69.6%. Collagen fleece wrapping and local PRF application did not improve survival. Patients not suffering failure of repair demonstrated high satisfaction. Nevertheless, the results are inferior to those of established ACL reconstruction procedures. LEVEL OF EVIDENCE: Case series, Level IV.

Multiplanar reformation improves identification of the anterolateral ligament with MRI of the knee.

The anterolateral ligament (ALL) is subject of the current debate concerning rotational stability in case of anterior cruciate ligament (ACL) injuries. Today, reliable anatomical and biomechanical evidence for its existence and course is available. Some radiologic studies claim to be able to identify the ALL on standard coronal plane MRI sections. In the experience of the authors, however, ALL identification on standard MRI sequences frequently fails and is prone to errors. The reason for this mainly lies in the fact, that the entire ALL often cannot be identified on a single MRI image. This study aimed to establish an MRI evaluation protocol improving the visualization of the ALL, using multiplanar reformation (MPR) with the goal to be able to evaluate the ALL on one MRI image. A total of 47 knee MRIs performed due to atraumatic knee pain between 2018 and 2019 without any pathology were analyzed. Identification of the ALL was performed twice by an orthopedic surgeon and a radiologist on standard coronal plane and after MPR. For the latter axial and coronal alignment was obtained with the femoral condyles as a reference. Then the coronal plane was adjusted to the course of the ALL with the lateral epicondyle as proximal reference. Visualization of the ALL was rated as "complete" (continuous ligamentous structure with a tibial and femoral insertion visible on one coronal image), "partial" (only parts of the ALL like the tibial insertion were visible) and "not visible". The distances of its tibial insertion to the bony joint line, Gerdy's tubercle and the tip of the fibular head were measured. On standard coronal images the ALL was fully visible in 17/47, partially visible in 27/47, and not visible in 3/47 cases. With MPR the ALL was fully visible in 44/47 and not visible in 3/47 cases. The median distance of its tibial insertion to the bony joint line, Gerdy's tubercle and the tip of the fibular head were 9, 21 and 25 mm, respectively. The inter- (ICC: 0.612; 0.645; 0.757) and intraobserver (ICC: 0.632; 0.823; 0.857) reliability was good to excellent. Complete visualization of the ALL on a single MRI image is critical for its identification and evaluation. Applying multiplanar reformation achieved reliable full-length visualization of the ALL in 94% of cases. The described MPR technique can be applied easily and fast in clinical routine. It is a reliable tool to improve the assessment of the ALL.

The EOS 3D imaging system reliably measures posterior tibial slope.

BACKGROUND: One of the values determined during the assessment of knee issues is the posterior tibial slope (PTS). A new option for measuring the PTS is the EOS 3D imaging system, which provides anteroposterior (AP) and lateral long leg radiographs (LLRs) using less radiation than a conventional LLR. We investigated the reliability of the EOS 3D imaging system with respect to PTS measurements. METHODS: We retrospectively searched our radiological database for patients who underwent an EOS scan and a computed tomography (CT) scan of their lower extremities between January and December 2019. Fifty-six knees were included in the study. Medial and lateral PTSs were determined using both modalities. A radiologist and an orthopaedic surgeon each performed all measurements twice and the intraclass correlation (ICC) was calculated to assess inter- and intrarater reliability. The Student t test and Pearson correlation were used to compare the results of both imaging modalities. RESULTS: The mean medial PTS was 8.5° (95% confidence interval [CI], 8.1-8.9°) for the EOS system and 7.7° (95% CI, 7.3-8.1°) for CT, and the lateral PTS was 7.4° (95% CI, 6.9-7.9°) for the EOS system, and 7.0° (95% CI, 6.5-7.4°) for CT. Interrater reliability (ICC) with respect to medial and lateral PTSs measured on the EOS (0.880, 0.765) and CT (0.884, 0.887) images was excellent. The intrarater reliability of reader 1 (ICC range, 0.889-0.986) and reader 2 (ICC range, 0.868-0.980) with respect to the same measurements was excellent. CONCLUSION: The PTS measurements from the EOS 3D imaging system are as reliable and reproducible as those from CT, the current gold standard method. We recommend using this system if possible, because it acquires more information (sagittal plane) in a scan than a conventional LLR, while exposing the patient to less radiation. LEVEL OF EVIDENCE: Level III, Retrospective cohort study.

Return to Work and Quality of Life in Disease-Free Adult Patients with Soft-Tissue and Bone Sarcoma of the Extremity

Treatment of extremital sarcoma patients may be associated with significant functional disabilities and psychosocial distress affecting return to work (RtW) and quality of life (QoL). In this exploratory study we prospectively investigated the RtW rate, explored biomedical and psychosocial predictors of RtW, and compared generic QoL with Swiss population norms. Forty people (89 %) returned to work. Full-time employment before sarcoma diagnosis, high educational level, and low tumor grade showed an increased probability of RtW. The median age was lower in patients who returned to work, and they reported less fear of progression. Generic QoL (SF-36) was reduced in almost all dimensions when compared to a normative Swiss population. Physical functioning and fear of progression have to be addressed in the rehabilitation process.

Avoiding unconscious injection of vial-derived rubber particles during intra-articular drug administration.

Objective: Vial coring describes the occurrence of small rubber particles, which are formed by needles when perforating vial stoppers. These particles may be aspirated along with the drug. Unconscious injection of rubber particles may increase the risks associated with intra-articular injections. This study aimed to analyze the frequency of this phenomenon and possibilities to avoid its occurrence. Method: 800 vials of 2 â€‹mL, filled with sodium chloride, were divided into 4 groups (n â€‹= â€‹200 each). Aspiration through the rubber stopper was performed with a 18-Gauge needle and the fluid was ejected onto a 10 â€‹µm filter paper through a 18-Gauge needle (group one) and a 23-Gauge needle (group two). In group three a 23-Gauge needle was used for aspiration and ejection. In group four, aspiration was performed using 18-Gauge needles with implemented 5 â€‹µm filters. Subsequently, a microscopic analysis of the filter papers was performed. Results: In none of the 800 specimen, a rubber particle was detected by naked eye. Microscopically, 20 (10%) rubber particles were detected in group one, 21 (11%) in group two and 65 (33%) in group three. In group four, no particles were visualized. Conclusion: This study shows the occurrence of rubber particles in 10-33% of the cases, when standard needles are used for the aspiration of drugs. We therefore recommend using industrially prefilled syringes, filter needles or removing the rubber stopper before withdrawing drugs from vials for intra-articular injections.

Prevalence of combined abnormalities of tibial and femoral torsion in patients with symptomatic hip dysplasia and femoroacetabular impingement.

AIMS: The prevalence of combined abnormalities of femoral torsion (FT) and tibial torsion (TT) is unknown in patients with femoroacetabular impingement (FAI) and hip dysplasia. This study aimed to determine the prevalence of combined abnormalities of FT and TT, and which subgroups are associated with combined abnormalities of FT and TT. METHODS: We retrospectively evaluated symptomatic patients with FAI or hip dysplasia with CT scans performed between September 2011 and September 2016. A total of 261 hips (174 patients) had a measurement of FT and TT. Their mean age was 31 years (SD 9), and 63% were female (165 hips). Patients were compared to an asymptomatic control group (48 hips, 27 patients) who had CT scans including femur and tibia available for analysis, which had been acquired for nonorthopaedic reasons. Comparisons were conducted using analysis of variance with Bonferroni correction. RESULTS: In the overall study group, abnormal FT was present in 62% (163 hips). Abnormal TT was present in 42% (109 hips). Normal FT combined with normal TT was present in 21% (55 hips). The most frequent abnormal combination was increased FT combined with normal TT of 32% (84 hips). In the hip dysplasia group, 21% (11 hips) had increased FT combined with increased TT. The prevalence of abnormal FT varied significantly among the subgroups (p < 0.001). We found a significantly higher mean FT for hip dysplasia (31°; SD 15)° and valgus hips (42° (SD 12°)) compared with the control group (22° (SD 8°)). We found a significantly higher mean TT for hips with cam-type-FAI (34° (SD 6°)) and hip dysplasia (35° (SD 9°)) compared with the control group (28° (SD 8°)) (p < 0.001). CONCLUSION: Patients with FAI had a high prevalence of combined abnormalities of FT and TT. For hip dysplasia, we found a significantly higher mean FT and TT, while 21% of patients (11 hips) had combined increased TT and increased FT (combined torsional malalignment). This is important when planning hip preserving surgery such as periacetabular osteomy and femoral derotation osteotomy. Cite this article: Bone Joint J 2020;102-B(12):1636-1645.

Seventy percent long-term survival of the repaired ACL after dynamic intraligamentary stabilization.

PURPOSE: Primary repair of the anterior cruciate ligament (ACL) is regaining popularity. Long-term results are lacking. The purpose of the current study was to determine the survival of the primarily repaired ACL after dynamic intraligamentary stabilization. METHODS: Between 2011 and 2013, 57 patients with acute proximal ACL ruptures underwent DIS repair within 3 weeks from injury and were available for final follow-up at least 5 years postoperatively. Failure as an end point was defined as conversion to ACL reconstruction, failure to restore stability with persisting laxity side-to-side laxity of > 5 mm or a late-traumatic re-rupture or loss of stability. Kaplan-Meier survival analysis was performed. RESULTS: Kaplan-Meier survival analysis demonstrated an overall survival of 70.0% (standard error SE 6.6%) at 74 months follow-up. Patients performing competitive sports prior to injury demonstrated an inferior long-term ACL survival of 56.4% (SE 11.6%). Patients performing recreational sport activities demonstrated a survival rate of 79.2% (SE 7.7%). The one factor demonstrating a direct influence on failure after adjustment was a high-pre-injury level of physical (odds ratio 4.0 confidence interval 1.0-15.8, p = 0.04). CONCLUSION: The minimum 5 years survival rate after primary ACL repair using this technique was 70%. This value dropped to 56% in highly active patients performing competitive sports. Patients not suffering failure of repair demonstrated adequate restoration of knee laxity and high satisfaction. This study not only underlines the potential of ACL repair, but also highlights the danger of the procedure if strict patient selection is not appreciated. LEVEL OF EVIDENCE: Level IV.

Incidence, mortality, and survival trends of soft tissue and bone sarcoma in Switzerland between 1996 and 2015.

BACKGROUND: Research on soft-tissue sarcoma (STS) and bone sarcoma (BS) is increasingly in the focus of physicians and pharmaceutical companies. Expanding knowledge has improved the management of sarcoma and possibly survival. Here we provide the first population-based data on time trends of incidence, mortality, and survival of STS and BS diagnosed in Switzerland between 1996 and 2015. METHODS: We performed a retrospective registry study with data from the National Institute for Cancer Epidemiology and Registration (NICER) database in Switzerland between 1996 and 2015. RESULTS: We identified 5384 STS patients and 940 BS patients. The three most common STS subtypes were undifferentiated/unclassified sarcoma (22.3%), liposarcoma (20.6%) and leiomyosarcoma (20.6%). Chondrosarcoma, osteosarcoma and Ewing sarcoma represented 40.4%, 27.0% and 15.2% of the BS group, respectively. The age-standardized incidence and mortality rates in 2011-2015 were 4.43 and 1.42 per 100,000 person-years for STS, and 0.91 and 0.42 for BS. Age-standardized incidence of STS in males was significantly higher during 1996-2000 than during 2001-2015; however, mortality rates did not change significantly over time. Five-year relative survival (RS) for STS improved significantly from 56.4% (95%CI 52.9-59.7 for 1996-2001) to 61.6% (95%CI 58.6-64.4 for 2011-2015) (p = 0.025). No improvement in 5-year RS for BS could be observed (RS 1996-2000: 69.6%, 95%CI 61.2-76.6; RS 2011-2015: 73.1%, 95%CI 66.6-78.6; p = 0.479). CONCLUSION: Incidence rates of STS and BS have been stable since 2001. The longer RS in STS can be attributed to advances in sarcoma patient management.

Application of Cytokines of the Bone Morphogenetic Protein (BMP) Family in Spinal Fusion - Effects on the Bone, Intervertebral Disc and Mesenchymal Stromal Cells.

Low back pain is a prevalent socio-economic burden and is often associated with damaged or degenerated intervertebral discs (IVDs). When conservative therapy fails, removal of the IVD (discectomy), followed by intersomatic spinal fusion, is currently the standard practice in clinics. The remaining space is filled with an intersomatic device (cage) and with bone substitutes to achieve disc height compensation and bone fusion. As a complication, in up to 30% of cases, spinal non-fusions result in a painful pseudoarthrosis. Bone morphogenetic proteins (BMPs) have been clinically applied with varied outcomes. Several members of the BMP family, such as BMP2, BMP4, BMP6, BMP7, and BMP9, are known to induce osteogenesis. Questions remain on why hyper-physiological doses of BMPs do not show beneficial effects in certain patients. In this respect, BMP antagonists secreted by mesenchymal cells, which might interfere with or block the action of BMPs, have drawn research attention as possible targets for the enhancement of spinal fusion or the prevention of non-unions. Examples of these antagonists are noggin, gremlin1 and 2, chordin, follistatin, BMP3, and twisted gastrulation. In this review, we discuss current evidence of the osteogenic effects of several members of the BMP family on osteoblasts, IVD cells, and mesenchymal stromal cells. We consider in vitro and in vivo studies performed in human, mouse, rat, and rabbit related to BMP and BMP antagonists in the last two decades. We give insights into the effects that BMP have on the ossification of the spine. Furthermore, the benefits, pitfalls, and possible safety concerns using these cytokines for the improvement of spinal fusion are discussed.

Extra-abdominal desmoid tumours - further evidence for the watchful waiting policy.

PURPOSE: Extra-abdominal desmoid tumours are benign and rare, and lead to a persistent treatment dilemma because of their high recurrence rate and their heterogeneous behaviour. The goal of this retrospective study was to evaluate the results of different treatment modalities for extra-abdominal desmoid tumours at four sarcoma treatment centres. METHODS: The mean follow-up time for the 96 patients included in the study (63.5% female; mean age 38.9 years) was 8.4 years (2.0–40.5 years). The initial treatments were surgery (n = 44), surgery with radiation (n = 16), watchful waiting (n = 15), radiation only (n = 9), or systemic treatment (n = 12). Patient demographics, tumour sites, and the follow-up status of all patients were reviewed and evaluated for each of the treatment modalities. RESULTS: The local recurrence rate was 45.5% in patients with primary surgical treatment and 37.5% following surgery combined with irradiation. Patients who were treated with radiation alone showed regressive (33.3%) or stable disease (66.6%). Systemic treatment alone resulted in disease progression in 41.7% of our patients. In the watchful waiting group, 73.3% showed stable disease, 20.0% showed spontaneous regression, and 6.7% showed progression after a mean follow-up of 4.1 years (2.0–11.5 years). CONCLUSIONS: Our results suggest that a watchful waiting approach should be the first line treatment in asymptomatic desmoid tumours. However, radiation can help improve local control rates in patients who have undergone surgery. Progression and local recurrence rates following systemic treatment were comparable to those observed in surgery combined with radiation.