Opioid-Sparing Nonsteroid Anti-inflammatory Drugs Protocol in Patients Undergoing Intramedullary Nailing of Tibial Shaft Fractures: A Randomized Control Trial.

INTRODUCTION: Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective analgesics commonly used in fracture management. Although previously associated with delayed fracture healing, multiple studies have demonstrated their safety, with minimal risks of fracture healing. Given the current opioid crisis in the United States, alternate pain control modalities are essential to reduce opioid consumption. This study aims to determine whether the combination of oral acetaminophen and intravenous ketorolac is a viable alternative to opioid-based pain management in closed tibial shaft fractures treated with intramedullary nailing. METHODS: We conducted a randomized controlled trial evaluating postoperative pain control and opioid consumption in patients with closed tibial shaft fractures who underwent intramedullary nailing. Patients were randomized into an NSAID-based pain control group (52 patients) and an opioid-based pain control group (44 patients). Visual analog scale (VAS) scores and morphine milligram equivalents (MMEs) were evaluated at 12-hour postoperative intervals during the first 48 hours after surgery. Nonunion and delayed healing rates were recorded for both groups. RESULTS: A statistically significant decrease in MMEs was noted at every measured interval (12, 24, 36, and 48 hours) in the NSAID group compared with the opioid group ( P -value 0.001, 0.001, 0.040, 0.024, respectively). No significant change in visual analog scale scores was observed at 12, 36, and 48 hours between both groups ( P -value 0.215, 0.12, and 0.083, respectively). A significant decrease in VAS scores was observed at the 24-hour interval in the NSAID group compared with the opioid group ( P -value 0.041). No significant differences in union rates were observed between groups ( P -value 0.820). DISCUSSION: Using an NSAID-based postoperative pain protocol led to a decrease in opioid consumption without affecting pain scores or union rates. Owing to the minimal risk of short-term NSAID use, their role in the perioperative management of tibia shaft fractures is justified, especially when they reduce opioid consumption markedly. LEVEL OF EVIDENCE: Therapeutic Level I.

Patient Perception of Robotic-Assisted Total Joint Arthroplasty in a Hispanic Population.

Background: Robotic-assisted orthopaedic surgery has become popular and widely available, mainly for total joint arthroplasty. However, there has been a persistent concern regarding access to robotic-assisted surgery and the utilization rate of total joint arthroplasty among minority groups. As an imperative effort to close the gap regarding health inequalities, we assessed the knowledge and perspective of Hispanics regarding robotic-assisted orthopaedic surgery. Methods: A 28-item questionnaire was established to evaluate Hispanics' perceptions of robotic-assisted orthopaedic surgery. Participants answered questions about demographic features, knowledge about robotic-assisted orthopaedic surgery, and preferences regarding manual vs robotic-assisted procedures. Results: A total of 580 questionnaires were analyzed in our study, with an average age of participants of 49.1 years. Only 44.2% of the participants were familiar with robotic-assisted orthopaedic surgery. Fifty-three percent of the respondents preferred robotic-assisted surgery over conventional procedures, with many participants believing that robotic-assisted surgery leads to better outcomes (54.7%) and faster recovery (53.1%). Conclusions: Knowledge about specific factors such as clinical outcomes and costs may influence the perception and preference of Hispanics toward robotic-assisted orthopaedic surgery. Therefore, patient education may play a crucial role in the informed decision-making process in Hispanics when opting between robotic-assisted or traditional orthopaedic surgery.

Clinical Relevance of Painful Congenital Early-onset Scoliosis: A Magnetic Resonance Image-based Study.

BACKGROUND: Back pain, as a clinical marker in scoliosis, has been associated with underlying pathology for many years, warranting further magnetic resonance imaging (MRI). Failures of segmentation, mixed defects, female gender, rib anomalies, congenital thoracic anomalies, and neurocutaneous markers are known risk factors for abnormal MRI pathology findings in patients with congenital early-onset scoliosis (Congenital-EOS). Yet, back pain has not been evaluated as a risk factor for underlying MRI pathology in patients with Congenital-EOS. This study aimed to assess back pain as a risk factor for underlying pathology in Congenital-EOS using MRI as a diagnostic tool. METHODS: A retrospective database review from the Pediatric Spine Study Group (PSSG) of all patients with Congenital-EOS who reported a back pain complaint, and underwent a spinal MRI study before surgical intervention was performed. Patients were divided into those with an underlying MRI pathology and those without. Demographics were compared between groups. RESULTS: From a total of 2355 patients with Congenital-EOS registered in PSSG, 107 patients reported a back pain complaint, with only 42 patients fulfilling the inclusion criteria (being evaluated with an MRI study). Overall group mean age was 8.1±4.5 years, with 25 of the 42 patients (60%) being females. Twenty-four of 42 patients (57%) had a comorbidity reported such as cardiac problems, musculoskeletal complaints, neurological deficits/myelopathy, gastrointestinal symptoms, developmental delay, respiratory problems, craniofacial abnormalities, and chromosomal conditions. An underlying MRI pathology was found in 21 of 42 patients with Congenital-EOS (50%) with back pain. The underlying MRI pathologies found were tethered spinal cord, spinal canal stenosis, syringomyelia, Arnold-Chiari malformation, and arachnoid cyst. CONCLUSIONS: Abnormal MRI findings are common in patients with Congenital-EOS who report back pain. Gender, age, major coronal curve angle, thoracic or lumbar predominance deformity, and comorbidities type or amount were not associated with abnormal MRI findings. LEVEL OF EVIDENCE: Level II-Prognostic study.

Effect of Proximal Row Carpectomy and Wrist Arthrodesis on the Resting Length of Extrinsic Digit Flexor Tendons: A Cadaveric Study.

Background Spastic joint contractures remain a complex and challenging condition. For patients with upper extremity spastic dysfunction, improving the muscle balance is essential to maximize their hand function. Multiple procedures, including proximal row carpectomy (PRC) and wrist arthrodesis (WA), are considered among the different surgical alternatives. However, the biomechanical consequences of these two procedures have not been well described in current literature. Hence, the objective of our study is to assess the change in the extrinsic digit flexor tendon resting length after proximal row carpectomy and wrist arthrodesis. Methods Six fresh-frozen cadaver upper extremities (four females and two males) with no obvious deformity underwent dissection, PRC, and WA. All the flexor digitorum profundus (FDP), flexor digitorum superficialis (FDS), and flexor pollicis longus (FPL) tendons were marked proximally 1-cm distal to their respective myotendinous junction and cut distally at the marked point. The overlapping segment of each distal flexor tendon from its proximal mark was considered the amount of flexor tendon resting length change after PRC and WA. A descriptive evaluation was performed to assess the increment in tendon resting length. Additionally, a regression analysis was performed to evaluate the relation between the tendon resting length and the proximal carpal row height. Results Following PRC and WA, the mean digit flexor tendon resting length increment achieved across all tendons was 1.88 cm (standard deviation [SD] = 0.45; range: 1.00-3.00 cm). A weak direct relationship ( R = 0.0334) between the increment in tendon resting length and proximal carpal row height was initially suggested, although no statistical significance was demonstrated ( p = 0.811). Conclusion This study provides an anatomic description of the increased extrinsic digit flexor tendon resting length after PRC and WA in cadaveric specimens. Findings provide a useful framework to estimate the amount of extrinsic digit flexor resting length increment achieved after wrist fusion and the proximal carpal row removal.

Efficacy of an Opioid-Sparing Perioperative Multimodal Analgesia Protocol on Posterior Lumbar Fusion in a Hispanic Population: A Randomized Controlled Trial.

INTRODUCTION: Posterior lumbar fusion surgery has become more common amid an aging population, with degenerative disease as its most common indication. Historically, postoperative pain control for spine surgery has relied on opioids. However, opioid use is associated with adverse effects such as dependence, respiratory depression, and altered cognition. Our study aimed to determine whether an opioid-sparing multimodal analgesia regimen (ketorolac, orphenadrine, and gabapentin) could be a viable alternative to diminish opioid use compared with a standard opioid-based regimen in Hispanic patients undergoing posterior lumbar spinal fusion. METHODS: This was a randomized controlled trial of Hispanic patients scheduled to undergo elective posterior spinal fusion. Inclusion criteria included age 30 to 85 years, Hispanic ethnicity, lumbar stenosis between L1 and S1, elective posterior spinal fusion with instrumentation, American Society of Anesthesiologists Score <2, and consent to participate in the study. Patients were randomized into two groups, an experimental multimodal analgesia and control (opioid-based) treatment groups, and outcomes such as morphine milligram equivalents used, visual analog scale score, and length of hospital stay were compared between the groups. RESULTS: The MMA experimental group used significantly lower amounts of opioid (measured with morphine milligram equivalent) than the opioid-based group during the 12-hour and 24-hour postoperative periods ( P -value = 0.023 and P -value = 0.033, respectively). No statistically significant difference was observed in opioid use in the 48-hour postoperative period between both groups ( P -value = 0.066). The MMA group had significantly lower VAS scores reported at the 12-hour, 24-hour, and 48-hour postoperative periods compared with the opioid-based group ( P -values = 0.016, 0.020, and 0.020, respectively). No difference was observed in the length of hospital stay between groups ( P -value = 0.169). DISCUSSION: Implementing an MMA protocol in Hispanic patients undergoing posterior lumbar fusion resulted in decreased overall opioid use and decreased pain intensity compared with the opioid-based group. MMA is an effective alternative for pain control in patients who want to avoid opioid use. CLINICAL TRIAL REGISTRATION: Identifier: NCT05413902.

Complete Endoscopic Resection of an Osteoid Osteoma in the Body of a Thoracic Vertebra: A Case Report.

CASE: A 29-year-old man presented nontraumatic diffuse thoracic pain. Magnetic resonance imaging of the spine showed a cortical lesion with peripheral hyperintensity, a central sclerotic hypointense nidus, and surrounding paraspinal inflammatory changes at the T3 vertebral body. Clinical and radiologic findings were consistent with an osteoid osteoma. The patient successfully underwent an endoscopic partial corpectomy and mass resection. At the 6-month follow-up, radiographs showed complete tumor resolution. CONCLUSION: Endoscopic resection is an adequate and minimally invasive technique for the complete resection of osteoid osteomas.

Is the whole-day use of surgical masks during the coronavirus pandemic increasing the contamination of surgeons' masks?

Evaluating the impact of surgical masks' conservation practices during the Coronavirus Disease pandemic in the bioburden of the operating room seems imperative, as they play a critical role against this pandemic. We demonstrate that surgeons' masks tend to be contaminated due to the conservation techniques to maximize protection equipment during the pandemic. Health institutions should highlight the importance of surgical mask exchange to avoid increments in surgical mask contamination.

Opioid-Sparing Multimodal Analgesia Efficacy in Hispanic Patients Undergoing Total Knee Arthroplasty.

Adequate pain control after total knee arthroplasty (TKA) has been associated with improved patient mobility and satisfaction, and is a task that has historically relied on opioids. Multimodal analgesic regimens can be considered a therapeutic alternative for postoperative pain control to avoid opioid consumption and its adverse side effects. This study aimed to evaluate the use of a multimodal analgesia protocol based on nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen as an alternative to reduce opioid consumption in Hispanic patients undergoing primary TKA. Methods: An institutional review board-approved, randomized controlled trial evaluated postoperative pain control after TKA in a Hispanic population. The experimental opioid-sparing group received 30-mg ketorolac intravenously every 6 hours and 1-g acetaminophen orally every 6 hours as the patient requested. The experimental group had the option to use morphine and oxycodone combined with acetaminophen as a rescue therapy. The control group received opioids in the form of 0.1-mg/kg morphine intravenously every 6 hours and/or oxycodone combined with acetaminophen (2.5 and 325 mg), 2 tablets orally every 6 hours, as the patient requested. Sociodemographic, operative, and immediate postoperative data and pain intensity measurements according to the numerical rating scale (NRS) were compared between groups. Analgesic efficacy was assessed according to the NRS scores at 12, 24, and 48 hours postoperatively. Results: Eighty-one Hispanic patients met inclusion criteria: 42 patients in the experimental group and 39 patients in the control group. None of the patients in the experimental group requested oxycodone combined with acetaminophen as a rescue therapy. Only 2 patients in the experimental group used a mean of 3.0 ± 1.4 mg of rescue morphine; in comparison, the control group consumed a mean of 28.0 ± 7.9 mg of morphine and 64.8 ± 26.0 mg of oxycodone per patient. A pain intensity decrease was observed in the experimental and control groups, with no postoperative evaluation differences at 12 hours (6.7 ± 2.9 compared with 5.9 ± 2.8; p = 0.209), 24 hours (6.2 ± 2.0 compared with 6.1 ± 2.2; p = 0.813), and 48 hours (4.7 ± 2.1 compared with 4.6 ± 1.7; p = 0.835). Conclusions: The use of a multimodal analgesic regimen based on intravenous ketorolac and oral acetaminophen was adequate in reducing postoperative pain and opioid consumption in Hispanic patients undergoing TKA. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Simultaneous Total Hip Arthroplasty for Delayed Management of Bilateral Acetabular Fractures due to Alcohol-Withdrawal Seizures.

Bilateral acetabular fractures after seizure activity are rare, as most of these injuries are associated with high-energy trauma. It is hypothesized that rapid forceful contracture of hip musculature during a seizure can lead to the femoral head fracturing the medial wall and driving in proximal and medial directions. Absence of standardized surgical treatment algorithms and literature-reported outcomes makes this fracture pattern challenging to orthopedic surgeons. To the best of our knowledge, no published data describe delayed simultaneous total hip arthroplasty for treating seizure-induced bilateral acetabular fractures with protrusio. We present a patient that sustained bilateral acetabular fractures after an alcohol-withdrawal seizure. The patient underwent delayed simultaneous total hip arthroplasty 3 months later with excellent functional outcomes at the 6-month follow-up.

Factors Influencing Graduating Medical Students in Puerto Rico to Pursue a Primary Care Residency in the Continental United States.

BACKGROUND AND OBJECTIVES: Primary care physician shortage represents a challenge for many countries and territories, including Puerto Rico (PR), where a significant proportion of the graduating medical students preferred the continental United States (C-US) to complete their training and even as the definitive setting for their practice. We surveyed medical students who graduated from medical schools in PR and have been accepted in a residency program to evaluate the influence of a set of demographics, academic, and personal factors in their decision to pursue a primary care residency program in the C-US. METHODS: A 19-item questionnaire was distributed by institutional email to those medical students who graduated from one of the four Liaison Committee on Medical Education fully accredited medical schools in PR in 2019. We summarized our data by frequency and percentages. We performed data analysis with statistical significance considered for P values <.05. RESULTS: The questionnaire had a response rate of 51% (138/273), where 49% (67/138) were accepted in a primary care residency. Sixty percent (40/67) matched in a primary care program in the C-US. Among the evaluated factors, a prior degree in C-US (65%) and first-degree relatives living in the C-US (70%) were associated with students who matched in the mainland. First-degree relatives living in PR (96%) were associated with students who remained on the island for training. CONCLUSIONS: The results provide insight into the influence that personal factors have on the decision of medical students in PR to pursue primary care training in the C-US.

Early-onset scoliosis: a narrative review.

Early-onset scoliosis (EOS) is defined as any spinal deformity that is present before 10 years old, regardless of etiology. Deformity must be evaluated based on the intercorrelation between the lungs, spine, and thorax. Curvatures of early-onset have increased risk of progression, cardiorespiratory problems, and increased morbidity and mortality. Progression of the deformity may produce thoracic insufficiency syndrome, where a distorted thorax is unable to support normal respiratory function or lung growth. Management and treatment of EOS should pursue a holistic approach in which the psychological impact and quality of life of the patient are also taken into consideration. Growth-friendly surgical techniques have not met the initial expectations of correcting scoliotic deformity, promoting thoracic growth, and improving pulmonary function.

Patient Experience and Perspective on Medical Cannabis as an Alternative for Musculoskeletal Pain Management.

INTRODUCTION: The current rate of opioid prescription is disquieting because of their high abuse potential, adverse effects, and thousands of overdose deaths. This situation imposes urgency in seeking alternatives for adequate pain management. From this perspective, this study aimed to evaluate the experience and the perceived analgesic efficacy of medical cannabis in managing the pain associated with musculoskeletal conditions. METHODS: A 28-question survey was distributed to patients at a major medical cannabis center in Puerto Rico for 2 months. Demographics, medical history, cannabis usage, cannabis use perspective, and analgesic efficacy were assessed in the questionnaire. RESULTS: One hundred eighty-four patients completed our survey. The majority (67%) were males, and the participants' average age was 38 years. This study showed an average pain reduction score of 4.02 points on the Numeric Rating Scale among all the participants. Those with musculoskeletal conditions reported a notable average pain reduction score of 4.47 points. In addition, 89% of the participants considered medical cannabis to be more effective than narcotics for adequate pain management. CONCLUSIONS: This study demonstrated that the use of medical cannabis among patients with musculoskeletal conditions effectively reduced pain levels based on their Numeric Rating Scale reported scores.

Distal Femoral Replacement as a Salvage Treatment After Desmoplastic Fibroma Resection.

Desmoplastic fibroma is an extremely rare primary bone tumor that can mimic the presentation of other bone lesions. We describe the case of a middle-aged male with a mass on the left distal femur initially diagnosed as fibrous dysplasia that underwent a wide margin excision followed by a distal femoral replacement to restore anatomy and functionality. Histologic examination of the complete surgical specimen was consistent with a desmoplastic fibroma. This case is the first report of a successful application of endoprosthetic reconstruction after desmoplastic fibroma resection.

Evaluating the Efficacy of Rib-to-pelvis Growth-friendly Surgery for the Treatment of Non-ambulatory Early-Onset Scoliosis Myelomeningocele Patients.

INTRODUCTION: Early-onset scoliosis (EOS) is a well-known orthopaedic manifestation in patients with myelomeningocele. The rib-based growing system (RBGS) has been proposed as an alternative for these individuals because of the poor outcomes with traditional surgical techniques. We aimed to describe the effect of RBGS in patients with nonambulatory EOS myelomeningocele. METHODS: We retrospectively reviewed the Pediatric Spine Study Group Multicenter Database for all patients with nonambulatory EOS myelomeningocele treated with RBGS from 2004 to 2019. Demographics, surgical data, radiographic findings, and postoperative complications were obtained. The quality-of-life parameters were assessed postoperatively using the Early-onset Scoliosis Questionnaire-24. RESULTS: Thirty patients (18 women; 60%) were patients with nonambulatory EOS myelomeningocele treated with RBGS. The mean age at the initial surgery was 5.3 years. The thoracic (T1-T12) spine height showed a significant increase from initial surgery to the most recent follow-up (P < 0.001). Spine (T1-S1) height was also significantly increased (P < 0.001). The postoperative complication rate was 87%. The Early-onset Scoliosis Questionnaire-24 demonstrates significant improvements in the quality-of-life scores (P = 0.037). CONCLUSION: This study demonstrated that RBGS could improve the reported quality-of-life scores in patients with nonambulatory EOS myelomeningocele when assessed with an EOS-oriented tool. Moreover, we confirmed the ability of RBGS to hold or even correct spinal deformity.

Orthopaedic trauma epidemiology after Hurricane Maria in the Puerto Rico Trauma Centre.

PURPOSE: Hurricane Maria is the most devastating natural phenomenon in the recent history of Puerto Rico. Due to its destructive path through the island, the Puerto Rico Trauma Center (PRTC) remained the only hospital managing orthopaedic trauma in the immediate post-disaster period. We investigated the impact of this hurricane on the orthopaedic trauma epidemiology in the PRTC. METHODS: We evaluated the admissions by the orthopaedic surgery service in terms of demographics, mechanisms of injury, and orthopaedic diagnoses for two months after the impact of Hurricane Maria (HM) on September 20, 2017. We compared our study group with the same two month period for two years prior (2015 and 2016) and after (2018 and 2019) as control periods. A p value of < 0.05 was considered statistically significant. RESULTS: We included 384 admissions from September 20 to November 20, 2017. The majority were males (63%) and had an average age of 54 years. The most-reported mechanism of injury was fall from standing height (FFSH), showing a significant increment compared with the control periods. Contrarily, motor vehicle accidents (MVA) showed a significant reduction. Among the orthopaedic diagnoses, the hip + pelvis category showed a significant decline within the study group. CONCLUSIONS: This study highlighted the impact of HM on the orthopaedic trauma epidemiology at the PRTC. Our findings provide valuable evidence to healthcare institutions to better prepare to manage the potential changes in the orthopaedic trauma epidemiology after a major atmospheric event.

Orthopedic Provider Gender Preference Among Patients in an Orthopedic Surgery Residency Program of a Hispanic American Community.

Background: There are limited data regarding the gender preferences of Hispanic Americans when selecting their orthopedic surgeon. This study aimed to evaluate the gender preferences of Hispanic Americans when choosing a physician as their orthopedic provider. Materials and Methods: A cross-sectional survey was administered to all consecutive Hispanic American patients treated at the outpatient orthopedic clinics of a tertiary medical center in Puerto Rico between October 4, 2019 and March 4, 2020. Sociodemographic status and opinion of gender preference in orthopedic surgery were assessed and analyzed between female and male respondents. Results: A total of 628 surveys were completed. There were 343 (54.6%) females and 285 (45.4%) males with an average age of 51.0 ± 13.0 years. A significantly higher portion of female respondents was widowed (p = 0.01), had a higher educational level (p = 0.02), were unemployed (p = 0.01), and had a lower individual annual income salary (p = 0.04); when compared with males. Most of the respondents had no gender preference (91.1% = 572/628) for an orthopedic provider. Among those with a gender preference, 5.1% (32/628) preferred a male surgeon, and 3.8% (24/628) preferred a female surgeon. No significant difference was found between male and female respondents in the opinion of an orthopedic provider. Conclusions: This study illustrates that Hispanic Americans have no gender preference when choosing an orthopedic provider. Therefore, patient preference should not be considered a factor contributing to women's under-representation in our orthopedic surgery training program. Our findings may also assist future studies in search of other indications attributed to the under-representation of females in this field.

Myoepithelial tumor in the popliteal area: A diagnostic dilemma.

INTRODUCTION AND IMPORTANCE: Myoepithelial tumors are under-recognized neoplasms that could be difficult to identify due to their rarity and limited comprehension. Their diverse morphology, varied cytologic features and heterogenous immunohistochemical characteristics create a significant diagnostic challenge. CASE PRESENTATION: We report the case of a 72-year-old-male patient who received conservative treatment during one year for a popliteal mass on the right knee that showed synovial hyperplasia (benign findings) at initial open tissue biopsy. New symptoms of popliteal area enlargement and discomfort required a second incisional biopsy to reach the diagnosis of a soft tissue myoepithelial tumor through tissue analysis and immunohistochemical staining. CLINICAL DISCUSSION: The myoepithelial tumors represent a medical dilemma due to their heterogenic features requiring high level of suspicion and adequate immunohistochemical markers for their diagnosis. CONCLUSION: Orthopaedic surgeons should be aware of the atypical presentation of these rare neoplasms to provide an early diagnosis and adequate management.

Persistent synovial actinomycosis in a native knee joint: A case report.

INTRODUCTION AND IMPORTANCE: Actinomycosis is a chronic granulomatous disease associated with the Actinomyces species. This unusual condition, especially in the musculoskeletal system, has been considered a diagnostic challenge due to its initial non-specific symptoms requiring high clinical suspicion and an adequate diagnostic approach for its identification. CASE PRESENTATION: We present the case of a 39-year-old Hispanic female with right knee pain and associated purulent secretions for the past four years, who demonstrated persistent synovial actinomycosis despite arthrotomy with cleansing and debridement plus a long-term antibiotic regime. CLINICAL DISCUSSION: Actinomyces species remain a rare cause of musculoskeletal disease. Its presentation could include localized swelling, tissue fibrosis, sinus tracts, or an abscess, yet these symptoms are not specific, requiring high clinical suspicion to avoid a potential misdiagnosis. Culture in an anaerobic media and pathologic specimens are vital diagnostic tools. Among the treatment alternatives, antimicrobial therapy and surgery are usually required to manage bone and joint infections. Adequate antibiotic selection is crucial, as suboptimal treatment could promote the development of a persistent infection. CONCLUSION: This case highlights the diagnostic challenge of synovial actinomycosis, a rarely reported condition in native knee joints. High clinical suspicion is critical as early diagnosis, and adequate management is essential to avoid a persistent infectious process.

Adverse Soft-Tissue Reaction After Ceramic-On-Ceramic Bearing Fracture Mimicking a Periprosthetic Joint Infection.

Prosthetic failure secondary to bearing fracture remains a potential complication in ceramic-on-ceramic total hip arthroplasty. We report the unusual presentation of a ceramic component fracture of a total hip arthroplasty performed 17 years ago that mimicked a periprosthetic joint infection. This case was managed based on the current guidelines and algorithms recommended for periprosthetic joint infection management. Histologic examination of periprosthetic tissue revealed an adverse inflammatory soft-tissue reaction to the ceramic fragments released from the fracture site. Our case highlights a misleading, inflammatory acute response usually associated with an infectious process corresponding to an adverse soft-tissue reaction. High clinical suspicion and a systematic approach are essential to address these deceiving clinical scenarios.

Primary leiomyosarcoma of the great saphenous vein: A case report.

INTRODUCTION AND IMPORTANCE: Vascular smooth muscle sarcomas are rare neoplasms that comprise less than 2% of all leiomyosarcomas. These malignancies usually originate in the inferior vena cava, with a limited number of cases affecting the great saphenous vein. Due to the limited reports on these sarcomas, epidemiologic data remains insufficient. CASE PRESENTATION: We report the case of a 67-year-old Hispanic female that presented with an asymptomatic growing mass in her right thigh. She was managed with an En bloc resection under the impression of a smooth muscle vascular sarcoma. The diagnosis was confirmed after histopathologic evaluation. CLINICAL DISCUSSION: Vascular leiomyosarcomas remain a rare and challenging diagnosis. They usually present as a slowly growing mass that is initially asymptomatic. High clinical suspicion and a comprehensive radiologic evaluation, including magnetic resonance imaging, are crucial. Histopathological evaluation is essential for diagnostic confirmation. Surgical excision remains the treatment of choice, with radiation therapy mostly considered for local disease control. Postsurgical surveillance is necessary every three months to monitor for signs of recurrence. CONCLUSION: Physicians should remain aware of the nonspecific presentation of leiomyosarcomas and the importance of a comprehensive diagnostic approach. Early diagnosis and adequate management are fundamental elements in the treatment of these aggressive tumors.