Herrick J. Siegel

Phosphate-32 colloid radiosynovectomy in hemophilia: outcome of 125 procedures.

Radiosynovectomy offers a potentially effective, minimally invasive option for patients with chronic hemarthrosis and synovitis. The long-term outcome of patients with hemophilia who were treated with phosphate-32 chromic phosphate radiosynovectomy was evaluated. One hundred twenty-five procedures in 81 patients were done. Two-to 10-year followup by age and joint included joint bleeding and quality-of-life assessment. In addition, a relative cost comparison, scintigraphic imaging, and evaluation of biodistribution of the radionuclide were done. Of 125 procedures, 54% resulted in complete cessation of bleeding into the treated joint after the procedure, and 73% of patients reported improved mobility of the treated joint. Of patients 18 years old and younger, 79% had a greater than 75% reduction in bleeding incidence, and of patients older than 40 years, only 56% had a similar reduction. Seventy-nine percent of patients surveyed had a significant improvement in quality of life attributable to the treated joint. No evidence of significant leakage was observed. Billing records analysis indicated that radiosynovectomy costs less than 5% of surgical synovectomy. Phosphate-32 chromic phosphate radiosynovectomy is a clinically useful, safe, and cost-effective outpatient procedure in the treatment of patients with chronic hemarthrosis and synovitis.

Current concepts on the surgical and medical management of osteosarcoma

Although advances have been made in both surgical and medical management of patients with osteosarcoma, the overall survival of patients with osteosarcoma has remained constant, with no substantial improvement in the past 15 years. Advances in imaging have had a substantial impact on surgical planning and staging. These advances have, in turn, had a major impact on the surgeon’s ability to perform limb-sparing surgery. Surgical techniques have improved in terms of instrumentation, modularity of implants and availability. Limb salvage has proven to be an acceptable method of treatment both with respect to oncologic and functional outcome in those patients where a wide resection may be achieved. The use of massive allografts has been largely replaced with the use of modern oncologic endoprostheses. Biologic targets that will enable new therapies to have maximum effect on tumor cells while minimizing toxicity to the host tissues need to be identified.

Synovial Sarcoma: Clinicopathologic Features, Treatment, and Prognosis

Synovial sarcoma is a characteristic subtype of soft tissue sarcomas with a predilection for young people. There may be a long delay in diagnosis or misdiagnosis, because of its insidious growth, varied presentation on imaging studies and associated joint pain, which can be confused with trauma. Diagnosis requires a tissue sample in the form of a needle or open biopsy. The needle biopsy may not be representative of the tumor, particular if it is biphasic, and it may be necessary to proceed to open biopsy. Ideally, the biopsy should be performed by the surgeon who will be performing the definitive surgical resection. Although treatment is predicated on surgery, adjuvant radiation and/or chemotherapy may be beneficial, particularly in high risk patients. Significant prognostic factors include: size > 5 cm, deep-seated location, adequacy of surgical margins, and history of recurrence. In the future, multi-institutional prospectively randomized, controlled studies will be needed to better define the role of adjuvant chemotherapy. Currently, outcome may be optimized by early suspicion and detection with referral to an orthopedic oncology specialist prior to the biopsy.

Advances in radionuclide therapeutics in orthopaedics.

Abstract Radiopharmaceuticals not only are used for diagnostic purposes but also increasingly in the treatment of many orthopaedic‐related disorders. With the development of specific bone‐seeking radiopharmaceuticals, the side effects of treatment are minimized, therapeutic effects are sustained, and concomitant use with other modalities may have synergistic effects. These new radiopharmaceuticals, such as strontium 89 and samarium 153‐ethylene diamine tetramethylene phosphate, have been used as palliative treatment for patients with bone pain from osseous metastases. Excellent clinical responses with acceptable hematologic toxicity have been observed, and clinical results rival those of external beam radiation therapy. Radiosynovectomy has become a procedure of choice at many institutions to treat recurrent hemarthrosis and chronic synovitis in patients whose hemophilia is poorly controlled with medical management. Radiosynovectomy also remains a viable option to treat chronic synovitis secondary to inflammatory arthropathies, particularly rheumatoid arthritis.

The outcome of composite bone graft substitute used to treat cavitary bone defects.

Although autogenous bone graft remains the gold standard graft material, it is associated with an unacceptably high incidence of morbidity. Furthermore, operative time, blood loss, and length of hospitalization are often increased. In order for a graft substitute to replicate the optimal bone healing properties of autogenous graft, 3 essential elements must be present: scaffolding for osteoconduction, growth factors for osteoinduction, and progenitor cells for osteogenesis. A composite graft that combines a synthetic scaffold with osteoprogenitor cells from bone marrow aspirate (BMA) may potentially deliver the advantages of autogenous bone grafts without the procurement morbidity. Sixty consecutive patients with cavitary bone defects were treated with a composite of b-tricalcium phosphate (beta-TCP), Vitoss (Orthovita, Malvern, Pennsylvania), and BMA. The cavitary defects were measured on orthogonal views by experienced musculoskeletal radiologists. Radiographically, resorption and trabeculation increased steadily with time. This differential was slightly more noticeable in large defects with a central trabeculation occurring in advance of the peripheral region. The majority of patients progressed to unrestricted activities by 6 weeks and had returned to their usual activities by 12 weeks. No significant difference in graft incorporation rate was noted based on age, size of defect, or use of adjuvant local treatment. The use of a composite graft (ultraporous beta-TCP+BMA) in the treatment of cavitary lesions appears to be safe and effective.

Bone cancer, version 2.2017 featured updates to the NCCN guidelines

The NCCN Guidelines for Bone Cancer provide interdisciplinary recommendations for treating chordoma, chondrosarcoma, giant cell tumor of bone, Ewing sarcoma, and osteosarcoma. These NCCN Guidelines Insights summarize the NCCN Bone Cancer Panels guideline recommendations for treating Ewing sarcoma. The data underlying these treatment recommendations are also discussed.

Silver Negative Pressure Dressing With Vacuum-assisted Closure of Massive Pelvic and Extremity Wounds

BackgroundMassive soft tissue loss involving the pelvis and extremities from trauma, infections, and tumors remains a challenging and debilitating problem. Although vacuum-assisted closure (VAC) technology is effective in the management of soft tissue loss, the adjunct of a silver dressing in the setting of massive wounds has not been as well tested.Questions/purposesDoes a silver negative pressure dressing used in conjunction with a wound VAC decrease (1) the length of acute hospital stay and overall length of treatment; (2) the number of surgical débridements the patients underwent as part of their care; and (3) the likelihood of wound closure without soft tissue transposition?MethodsWe evaluated 42 patients with massive (> 200 cm2) pelvic and extremity wounds from trauma, infection, or tumor who were treated with the wound VAC with or without a silver negative pressure dressing between January 2003 and January 2010; the first 26 patients were treated with the wound VAC alone, and in the final 16 consecutively treated patients, the silver dressing was added to the regimen. We reviewed medical records to determine length of treatment as well as the number and type of surgical interventions these patients underwent. We compared the group treated with the wound VAC alone with those patients treated with the wound VAC and silver negative pressure dressing.ResultsHospital stay averaged 19 days in the VAC only group and 7.5 days in the VAC with silver dressing group (p < 0.041), length of overall treatment averaged 33 days in the VAC only group and 14.3 days in the VAC with silver dressing group (p < 0.022), number of operative débridements averaged 7.9 in the VAC alone group and 4.1 in the VAC with silver dressing group (p < 0.001), and success of wound closure without soft tissue transposition was 16 of 26 patients in the VAC alone group and three of 16 patients in the VAC with silver dressing group (p < 0.033).ConclusionsBased on the reduced length of care and the number of surgical procedures these patients with massive wounds of the pelvis and extremities underwent, we now use the silver negative pressure dressing in combination with the wound VAC as part of routine care of such patients. These results may be used as hypothesis-generating data for future randomized studies.Level of EvidenceLevel III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

The use of bipolar hemosealing technology in orthopedic oncology: safety and clinical impact.

Bipolar hemosealing technology appears to be a safe and efficient tool for obtaining intraoperative hemostasis in the orthopedic oncology patient, especially in wide resections around the shoulder and hip.

Stabilization of Pathologic Long Bone Fractures With the Fixion Expandable Nail

The Fixion intramedullary nail technology is safe and effective in the treatment of pathologic bone fractures.

Crossed fused renal ectopia with metastatic renal cell carcinoma

The patient is an 83-year-old man with a 4-month history of right arm pain. He had no previous history of cancer. Radiographs showed a minimal pathologic fracture of the proximal right humerus with new callus formation atthe fracture site. A bone scan was done but did not demonstrate other areas of involvement. However, it was noted that the patient did not appear to have a left kidney, and there were 2 areas of increased uptake in the region of the right kidney. A CT scan of the abdomen and pelvis was done and showed a crossed fused ectopic kidney with a 3 X 4 cm mass on its inferior pole. A biopsy of the right humerus lesion confirmed that it was metastatic renal cell carcinoma, and the patient underwent a nephrectomy of the involved kidney.