Joseph J. King

Serial arterial embolization for large sacral giant-cell tumors: mid- to long-term results.

Study Design. Level III retrospective case series with historical controls. Objective. To evaluate the mid- to long-term outcomes of serial arterial embolization as a primary treatment modality for large sacral giant-cell tumors (SGCT). Summary of Background Data. Giant-cell tumors are potentially aggressive benign tumors that can cause significant morbidity and may occasionally prove lethal. Large GCTs in the sacrum present a significant challenge, and treatment methods, including surgical resection and radiation, are associated with morbid complications and high recurrence rates. This report presents the mid- to long-term follow-up results of our cases of SGCT treated with serial arterial embolization. Methods. Nine consecutive patients with biopsy-proven SGCTs received initial primary treatment with serial arterial embolization between 1984 and 2006. All patients underwent angiography and selective arterial embolization at the time of diagnosis, followed by repeat embolization every 6 weeks until no new vessels were noted, and then at 6 and 18 months following stabilization of the lesion. Patients were closely monitored with MRI and/or CT every 6 months for 5 years and annually thereafter. Functional outcomes were measured using the 1993 Musculoskeletal Tumor Society Rating Scale (MSTS93). Results. The mean duration of follow-up in this series was 8.96 years (median, 7.8 years; range, 3.8–21.2 years). No progression was noted in 7 of the 9 cases. Two cases experienced tumor progression of less than 1 cm early in the treatment course and continued to remain asymptomatic. Adjuvant radiation therapy provided local control in 1 of these cases, while radiation and chemotherapy failed in the other case with ultimate mortality. All patients demonstrated substantial pain relief. Cross-sectional MSTS93 scores were obtained in the 8 surviving patients at their most recent follow-up visit with a mean score of 29/30. Conclusions. Serial arterial embolization is a useful primary treatment modality for large SGCTs given the favorable long-term results and potential morbidity of alternative treatments.

Treatment of adult rhabdomyosarcoma.

Objectives:Rhabdomyosarcoma is an exceedingly rare tumor in adults, and standard chemotherapy used for children is much less effective in adults. This study examines short-term outcomes using doxorubicin, ifosfamide, and vincristine for adult rhabdomyosarcoma. Methods:Pathology records were searched for adults (age, >18) with rhabdomyosarcoma treated at our musculoskeletal tumor center. Treatment involved surgical resection, radiation therapy, and chemotherapy with doxorubicin, ifosfamide, and vincristine. Eleven met inclusion criteria. Mean age was 49 (range: 19–72). Tumors sites included upper extremity (4 patients), lower extremity (6), and cervix (1). Subtypes were pleomorphic (7), alveolar (1), embryonal (1), and mixed alveolar/embryonal (2). Results:Of the 7 patients with nonmetastatic disease, 6 had no evidence of disease posttreatment, but 1 died of myelodysplastic syndrome after 51 months. Three patients who received neoadjuvant chemotherapy had 100% tumor necrosis. One patient with positive margins scheduled for adjuvant chemotherapy had local recurrence and metastasis within 2 weeks and died 5 months later. Of the 4 patients with metastatic disease on presentation, 1 had complete response, 2 had partial response with later progression and death at 8 and 24 months, and 1 had immediate progression and died at 12 months. Mean overall survival was 24 months with 6 of 11 (55%) alive at last follow-up. Mean disease-free survival was 17 months for all patients and 23 months for the 7 patients who had remission of all disease. Conclusions:When combined with surgery and radiation therapy, chemotherapy using doxorubicin, ifosfamide, and vincristine yielded 55% overall and 64% disease-free survival at 2 years.

Outcomes of reverse total shoulder arthroplasty as primary versus revision procedure for proximal humerus fractures.

BACKGROUND Reverse total shoulder arthroplasty (RTSA) has been shown to be an effective treatment for proximal humerus fracture (PHF). This study evaluates outcomes of all patients with PHF treated with RTSA as a primary procedure for acute PHF, a delayed primary procedure for symptomatic PHF malunion or nonunion, a revision procedure for failed PHF hemiarthroplasty (HA), or a revision procedure for failed open reduction and internal fixation (ORIF). METHODS Patients who underwent RTSA for PHF were evaluated for active range of motion and Shoulder Pain and Disability Index (SPADI), Simple Shoulder Test-12, American Shoulder and Elbow Surgeons (ASES), University of California-Los Angeles (UCLA) shoulder rating scale, Constant, and 12-Item Short Form Health Survey scores. Scaption and external rotation (ER) strength were also assessed. RESULTS RTSA was performed in 49 patients with PHF; 13 patients underwent RTSA for acute PHF, 13 for malunion or nonunion, 12 for failed PHF HA, and 11 for failed PHF ORIF. ER range of motion, SPADI, ASES, UCLA, and Constant scores achieved significance. The acute fracture group significantly outperformed the failed HA group in SPADI, ASES, and UCLA scores. The malunion/nonunion group significantly outperformed the failed HA group in ASES and UCLA scores. The acute fracture and malunion/nonunion groups each had significantly greater ER than the failed HA group. CONCLUSION RTSA is an effective treatment option for PHF as both a primary and a revision procedure. Primary RTSA outperformed RTSA done as a revision procedure. RTSA for acute PHF is comparable to RTSA for malunions and nonunions. Our outcomes of revision RTSA for failed HA and ORIF are more promising than previously published.

Allograft-prosthetic composite reverse total shoulder arthroplasty for reconstruction of proximal humerus tumor resections.

BACKGROUND Proximal humerus reconstructions after resection of tumors are challenging. Early success of the reverse shoulder arthroplasty for reconstructions has recently been reported. The reverse allograft-prosthetic composite offers the advantage of improved glenohumeral stability compared with hemiarthroplasty for proximal humeral reconstructions as it uses the deltoid for stability. METHODS This article describes the technique for treating proximal humeral tumors, including preoperative planning, biopsy principles, resection pearls, soft tissue tensioning, and specifics about reconstruction using the reverse allograft-prosthetic composite. Two cases are presented along with the functional outcomes with use of this technique. Biomechanical considerations during reconstruction are reviewed, including techniques to improve the deltoid compression force. RESULTS Reported instability rates are less with reverse shoulder arthroplasty reconstruction as opposed to hemiarthroplasty or total shoulder arthroplasty reconstructions of tumor resections. Reported functional outcomes are promising for the reverse allograft-prosthetic composite reconstructions, although complications are reported. CONCLUSION Reverse allograft-prosthetic composites are a promising option for proximal humeral reconstructions, although nonunion of the allograft-host bone junction continues to be a challenge for this technique.

Early Outcomes of Soft Tissue Sarcomas Presenting With Metastases and Treated With Chemotherapy

Objectives:The purpose of this study is to describe outcomes for patients with metastatic soft tissue sarcoma treated with chemotherapy. Methods:We retrospectively reviewed the records of 383 soft tissue sarcoma patients treated at our institution from 1997 to 2006. Thirty-five patients met the inclusion criteria–metastatic disease on presentation; primary tumor outside the abdomen; treatment with chemotherapy; and minimum follow-up of 3 months. Treatments were individualized and determined by a multidisciplinary oncology team. Patient survival was calculated from the diagnostic biopsy to the date of death or last follow-up using the Kaplan-Meier method. Results:Mean age was 47 years (range 17–74 years). Most common tumors involved were MFH and leiomyosarcoma. Sixteen of 35 (46%) patients had died at last follow-up. Mean patient survival was 24 months (range 4–102). The 2-year and 5-year survival rates were 64% and 24%, respectively. Twenty-nine patients (83%) presented with pulmonary metastasis, 6 with bone metastases (17%), 4 with regional node metastases (11%), and 4 with soft tissue metastases (11%). Survival was the same for those with pulmonary and only extrapulmonary metastases. The 10 patients with complete resection or complete chemotherapy response of all detectable lesions had longer mean survival (34 months) than the 25 patients who had partial/no resection or response (20 months) (P = 0.02). Conclusions:Soft tissue sarcoma patients presenting with metastatic disease have a low survival rate, but complete eradication of tumor correlated with longer survival. Longer-term studies especially those tracking the outcome of complete responders and those completely resected will help determine the efficacy of chemotherapy.

Decreased ratios of lateral to medial patellofemoral forces and pressures after lateral retinacular release and gender knees in total knee arthroplasty

PurposeTo demonstrate that lateral to medial patellofemoral force and pressure ratios could be a surrogate marker of retinacular tension and patellar tracking.MethodsThe patellofemoral forces of six knees from three fresh-frozen half-body female cadavers were evaluated with a capacitive sensor under simulated operative conditions in six staged clinical scenarios: native knees, knee arthroplasty without patellar resurfacing, resurfaced knee and patella, resurfaced knee and patella with lateral release, gender-specific knee arthroplasty with patella resurfacing, and gender-specific knee arthroplasty with lateral release. Maximum force and peak pressure were simultaneously recorded during three to four ranges of motion. Average values were compared between lateral and medial patellofemoral compartments as an objective measure of patellar tracking for the different settings.ResultsSignificant differences in lateral and medial force and pressure differentials were seen in most scenarios despite clinically normal patellar tracking. Lateral to medial ratios of maximum force and peak pressure significantly increased after TKA (2.9, 2.1) and after patella resurfacing (2.8, 2.6) compared to the native knee (1.6, 1.8). Addition of a lateral release in resurfaced knees decreased the ratio of lateral to medial patellofemoral forces and pressures as did gender knee arthroplasty (1.5 and 1.1, 2 and 1.3, respectively). Pressure and force values most closely resembled the native knee in the resurfaced knee/resurfaced patella with lateral release and in the gender knee arthroplasty scenarios.ConclusionsUse of lateral to medial patellofemoral force ratios as a surrogate objective marker for patellar tracking was validated in this study by decreasing ratios observed after lateral release in TKA and with gender-specific implants.

Primary reverse total shoulder arthroplasty outcomes in patients with subscapularis repair versus tenotomy

BACKGROUND Reverse total shoulder arthroplasty (RTSA) is now performed at nearly the same rate as anatomic total shoulder arthroplasty in the United States. Repair of the subscapularis is of vital importance in total shoulder arthroplasty; however, its utilization in RTSA has recently been questioned. METHODS This is a retrospective comparative study from prospectively collected data comparing the outcomes and complications after primary RTSA with or without subscapularis repair. The study includes 202 patients who underwent primary RTSA at a single institution by a single surgeon using the same implant between 2007 and 2012. Average clinical follow-up was greater than 3 years in both groups. Outcome scores, clinical range-of-motion and strength measurements, and complications including dislocations are reported. RESULTS At an average follow-up of greater than 3 years, there were no significant differences in clinical range of motion, strength, and rates of complications including dislocations. External rotation was 24° in the subscapularis repair group and 26° in the no-repair group. There were no differences in the American Shoulder and Elbow Surgeons shoulder score. Subjective measures included the Shoulder Pain and Disability Index; University of California, Los Angeles shoulder rating scale; Simple Shoulder Test; and normalized Constant outcome scores. There were 0 dislocations (0%) in the subscapularis repair group and 3 dislocations in the no-repair group (2.6%), which were not significantly different. CONCLUSION Primary RTSAs with or without subscapularis repair have similar clinical outcome scores, range of motion, strength, and rates of complications including dislocations at 3 years of follow-up.

Reverse total shoulder arthroplasty in wheelchair-dependent patients.

BACKGROUND Wheelchair-dependent patients have a high incidence of shoulder pathology, often causing severe impairment. This study reports outcomes of wheelchair-dependent lower extremity-impaired patients with symptomatic shoulder arthritis or severe rotator cuff pathology treated with reverse total shoulder arthroplasty (RTSA). METHODS Data for 19 wheelchair-dependent patients who had an RTSA for symptomatic arthritis or rotator cuff pathology, or both, were obtained from the University of Florida Shoulder Arthroplasty Database. Included were 16 of 19 shoulders with adequate follow-up averaging 40 months. Functional outcome scores included the Simple Shoulder Test, University of California Los Angeles Shoulder Rating Scale, Shoulder Pain and Disability Index, American Shoulder and Elbow Surgeons score, Constant score, and 12-item Short Form (SF-12) health survey. Objective measures were active elevation, external rotation, and internal rotation. Radiographs were evaluated for lucent lines, notching, and prosthetic loosening. RESULTS All measured parameters, except the SF-12, significantly improved at the final follow-up. Functional outcome scores included Shoulder Pain and Disability Index, 45; Simple Shoulder Test, 7; American Shoulder and Elbow Surgeons, 73; University of California Los Angeles Shoulder Rating Scale, 30; Constant, 70; and SF-12, 33. Active elevation was 112°, and active external rotation was 29°. Most patients (83%) were satisfied. The complication rate was 25%; baseplate failure and dislocation occurred early, and periprosthetic humeral fracture secondary to infection occurred late. The notching rate was 42%. CONCLUSIONS Shoulder pain and dysfunction due to arthritis and rotator cuff pathology can result in the loss of independence in wheelchair-dependent patients. We investigated whether RTSA can sustain the increased loads placed by these patients during transfers. Wheelchair-dependent patients can benefit from an RTSA for shoulder pain and dysfunction but must accept worsened impairment during the immediate postoperative period and a higher complication rate than the general population treated with an RTSA.

Fixation of chondral fracture of the weight-bearing area of the lateral femoral condyle in an adolescent

AbstractPurely chondral fractures of the distal femur associated with patellar dislocation are uncommon, and treatment varies from fixation to debridement and marrow stimulation techniques. The unusual case reported here involves an adolescent who underwent fixation of a purely chondral fracture involving a large weight-bearing portion of the lateral femoral condyle. Chondral fracture healing was confirmed on follow-up magnetic resonance imaging and arthroscopic examination. This case suggests that fixation of purely chondral fractures can be successful in weight-bearing areas of the knee. Level of evidence V.

Physical Examination of the Shoulder

This article summarizes the overall assessment of the shoulder joint and seeks to help direct clinicians to diagnose shoulder pathology using standard and specific physical examinations. The history and standard examination can prompt the examiner to focus on specific tests to further evaluate the shoulder and limit the differential diagnoses. An appropriate and directed shoulder physical examination allows the clinician to focus on further diagnostic strategies and treatment options for the patient.