Raffi Avedian

The use of calcium sulfate in the treatment of benign bone lesions. A preliminary report.

Bone grafts are widely used by surgeons to correct bone defects resulting from a variety of causes, including tumors, trauma, and infection. Autogenous bone remains the ideal material for grafting because it is not antigenic and it has both osteoinductive and osteogenic properties1. The harvesting of autogenous bone, however, can be associated with substantial complications. The common problems that have been reported include pain at the donor site, palsy of the lateral femoral cutaneous nerve, injury of the superior gluteal artery, pelvic fracture, hematoma, infection, and gait disturbances2. Furthermore, the amount of autogenous bone graft available for harvesting is limited and may be insufficient to fill large osseous defects. The quality of the harvested autogenous bone is also variable1. Because of the complications associated with harvesting autogenous bone and its limited supply, many surgeons have sought bone-graft-substitute materials. A bone-graft substitute that has regained popularity recently is calcium sulfate, more commonly known as plaster of Paris. Plaster of Paris is derived from the common mineral gypsum, which contains calcium sulfate dihydrate (CaSO4 • 2 H2O). Calcium sulfate was first used by Dreesman2 to obliterate bone cavities caused by tuberculosis. In 1959, Peltier3 became the first American to report on the use of calcium sulfate as a bone-graft substitute. He and Jones found that calcium sulfate is …

Factors associated with recurrence of primary aneurysmal bone cysts: is argon beam coagulation an effective adjuvant treatment?

BACKGROUND Our goal was to assess the effectiveness and safety of argon beam coagulation as an adjuvant treatment for primary aneurysmal bone cysts, to reevaluate the adjuvant effectiveness of the use of a high-speed burr alone, and, secondarily, to identify predictors of aneurysmal bone cyst recurrence. METHODS We retrospectively reviewed the records of ninety-six patients with primary aneurysmal bone cysts who were managed at our institution from January 1, 1983, to December 31, 2008. Forty patients were managed with curettage, a high-speed burr, and argon beam coagulation; thirty-four were managed with curettage and a high-speed burr without argon beam coagulation; and the remaining twenty-two were managed with curettage with argon beam coagulation alone, curettage with no adjuvant treatment, or resection of the entire lesion. Demographic, clinical, and radiographic data were viewed comparatively for possible predictors of recurrence. Kaplan-Meier survival analysis with a log-rank test was performed to measure association and effectiveness. RESULTS The median age at the time of diagnosis was fifteen years (range, one to sixty-two years). The median duration of follow-up was 29.5 months (range, zero to 300 months). The overall rate of recurrence of aneurysmal bone cyst after surgical treatment was 11.5%. The rate of recurrence was 20.6% after curettage and high-speed-burr treatment alone and 7.5% after curettage and high-speed-burr treatment plus argon beam coagulation. The five-year Kaplan-Meier survival estimate was 92% for patients managed with curettage and adjuvant treatment with a high-speed burr and argon beam coagulation, compared with 73% for patients managed with curettage and a high-speed burr only (p = 0.060). CONCLUSIONS Surgical treatment of aneurysmal bone cyst with curettage and adjuvant argon beam coagulation is effective. Postoperative fracture appears to be a common complication of this treatment and needs to be studied further. Treatment with curettage and high-speed burr alone may not reduce recurrence.

Sarcoma Resection With and Without Vascular Reconstruction: A Matched Case-control Study.

OBJECTIVE To examine the impact of major vascular resection on sarcoma resection outcomes. SUMMARY BACKGROUND DATA En bloc resection and reconstruction of involved vessels is being increasingly performed during sarcoma surgery; however, the perioperative and oncologic outcomes of this strategy are not well described. METHODS Patients undergoing sarcoma resection with (VASC) and without (NO-VASC) vascular reconstruction were 1:2 matched on anatomic site, histology, grade, size, synchronous metastasis, and primary (vs. repeat) resection. R2 resections were excluded. Endpoints included perioperative morbidity, mortality, local recurrence, and survival. RESULTS From 2000 to 2014, 50 sarcoma patients underwent VASC resection. These were matched with 100 NO-VASC patients having similar clinicopathologic characteristics. The rates of any complication (74% vs. 44%, P = 0.002), grade 3 or higher complication (38% vs. 18%, P = 0.024), and transfusion (66% vs. 33%, P < 0.001) were all more common in the VASC group. Thirty-day (2% vs. 0%, P = 0.30) or 90-day mortality (6% vs. 2%, P = 0.24) were not significantly higher. Local recurrence (5-year, 51% vs. 54%, P = 0.11) and overall survival after resection (5-year, 59% vs. 53%, P = 0.67) were similar between the 2 groups. Within the VASC group, overall survival was not affected by the type of vessel involved (artery vs. vein) or the presence of histology-proven vessel wall invasion. CONCLUSIONS Vascular resection and reconstruction during sarcoma resection significantly increases perioperative morbidity and requires meticulous preoperative multidisciplinary planning. However, the oncologic outcome appears equivalent to cases without major vascular involvement. The anticipated need for vascular resection and reconstruction should not be a contraindication to sarcoma resection.

Solitary Osteochondroma of the Proximal Femur and Femoral Acetabular Impingement

Although osteochondromas can be present within the context of multiple hereditary exostosis, these tumors are overwhelmingly found as isolated lesions. Increased exostotic load associated with multiple hereditary exostosis can lead to limb-length discrepancy, increased femoral anteversion, valgus angulation, and acetabular dysplasia. Despite these observations, the relationship of more common isolated exostoses near the proximal femur and their role in femoral acetabular impingement has never been depicted. Although solitary osteochondromas have been linked with bursal inflammation and pain, compression on neurovascular structures, and malignant degeneration, they have not previously been associated with femoral acetabular impingement. This article presents a novel case of a proximal femoral osteochondroma of the greater trochanter leading to the development and associated symptoms and radiographic findings consistent with hip impingement. A 24-year-old man presented with groin and lower extremity pain thought to be due to an exostosis of the proximal femur. Following surgical excision and persistence of anterior groin pain, the patient was found to display a presentation and radiographic findings consistent with femoral acetabular impingement. He successfully underwent a hip arthroscopy, femoroacetabular osteochondroplasty, and labral repair. Postoperatively, his symptoms improved significantly, and he returned to normal activity. The presence of a proximal femoral exostosis can be associated with the development of femoral acetabular impingement. Awareness of this relationship may lead to a better understanding of patient symptoms and expectations associated with treatment.

Surgical Intervention of Nonvertebral Osseous Metastasis

BACKGROUND Nonvertebral osseous metastases can result in pain and disability. The goals of surgical intervention are to reduce pain and to improve function if nonsurgical treatment fails. The indications for proceeding with surgical intervention depend on anatomic location, amount of local destruction, extent of skeletal and visceral disease and, most important, the patients performance status and life expectancy. METHODS This article reviews the evaluation and treatment of metastatic nonvertebral osseous lesions from the perspective of the orthopedic surgeon, based mainly on an assessment of the surgical literature. RESULTS This article summarizes the approaches to preoperative evaluation, patient selection, and medical optimization. Guidelines for estimating osseous stability and fracture risk are discussed, and surgical implants and their relation to postoperative outcomes are examined. This review also describes less invasive ablative procedures currently available. CONCLUSIONS The surgical management of nonvertebral osseous metastases involves multidisciplinary collaboration. The surgical construct must be a stable, reliable, and durable intervention that is individually tailored and matched to a patients prognosis and performance status.

Is MR-guided High-intensity Focused Ultrasound a Feasible Treatment Modality for Desmoid Tumors?

BackgroundMR-guided high-intensity focused ultrasound is a noninvasive treatment modality that uses focused ultrasound waves to thermally ablate tumors within the human body while minimizing side effects to surrounding healthy tissues. This technology is FDA-approved for certain tumors and has potential to be a noninvasive treatment option for extremity soft tissue tumors. Development of treatment modalities that achieve tumor control, decrease morbidity, or both might be of great benefit for patients. We wanted to assess the potential use of this technology in the treatment of extremity desmoid tumors.Questions/purposes(1) Can we use MR-guided high-intensity focused ultrasound to accurately ablate a predetermined target volume within a human cadaver extremity? (2) Does MR-guided high-intensity focused ultrasound treatment stop progression and/or cause regression of extremity desmoid tumors?MethodsSimulated tumor volumes in four human cadavers, created by using plastic markers, were ablated using a commercially available focused ultrasound system. Accuracy was determined in accordance with the International Organization of Standards location error by measuring the farthest distance between the ablated tissue and the plane corresponding to the target. Between 2012 and 2014, we treated nine patients with desmoid tumors using focused ultrasound ablation. Indications for this were tumor-related symptoms or failure of conventional treatment. Of those, five of them were available for MRI followup at 12 months or longer (mean, 18.2 months; range, 12–23 months). The radiographic and clinical outcomes of five patients who had desmoid tumors treated with focused ultrasound were prospectively recorded. Patients were assessed preoperatively with MRI and followed at routine intervals after treatment with MRI scans and clinical examination.ResultsThe ablation accuracy for the four cadaver extremities was 5 mm, 3 mm, 8 mm, and 8 mm. Four patients’ tumors became smaller after treatment and one patient has slight progression at the time of last followup. The mean decrease in tumor size determined by MRI measurements was 36% (95% confidence interval, 7%–66%). No patient has received additional adjuvant systemic or local treatment. Treatment-related adverse events included first- and second-degree skin burns occurring in four patients, which were managed successfully without further surgery.ConclusionsThis preliminary investigation provides some evidence that MR-guided high-intensity focused ultrasound may be a feasible treatment for desmoid tumors. It may also be of use for other soft tissue neoplasms in situations in which there are limited traditional treatment options such as recurrent sarcomas. Further investigation is necessary to better define the indications, efficacy, role, and long-term oncologic outcomes of focused ultrasound treatment.Level of EvidenceLevel IV, therapeutic study.

The Effect of Applicant Publication Volume on the Orthopaedic Residency Match

BACKGROUND Research is an important factor used in evaluating applicants to orthopaedic training programs. Current reports regarding the publication rate among prospective residents are likely inaccurate. It is unknown whether research productivity is weighted more heavily at programs affiliated with research-driven institutions. OBJECTIVE To establish accurate baseline data on publication rate among matched applicants to orthopaedic residency programs and to compare publication rates between applicants who matched at research-focused institutions and those who matched elsewhere. DESIGN We performed a literature search for each U.S. resident in the 2013-2014 intern class. Number of publications: (1) in total, (2) in orthopaedic journals, and (3) as first/last author were recorded. Publication rate at the top 25 programs (according to medical school and departmental National Institutes of Health [NIH] funding and U.S. News ranking) was compared statistically against all others. RESULTS Average number of publications per intern for all programs was 1.28 ± 0.15. Number of total and first/last author publications was significantly greater for programs affiliated with medical schools and departments in the top 25 for NIH funding, and at schools in the top 25 U.S. News rankings. Publication rate in orthopaedic journals was significantly higher for programs affiliated with departments in the top 25 for NIH funding and at top 25 U.S. News medical schools. CONCLUSIONS The average matched applicant to an orthopaedic residency program publishes in the peer-reviewed literature less frequently than previously reported. Matched applicants at research-focused institutions tended to have more publications than those who matched at other programs.

Principles of Musculoskeletal Biopsy

The appropriate treatment of any musculoskeletal tumor is based on a correct diagnosis. In some instances, a patients history and imaging studies provide sufficient information to guide definitive treatment. However, in many cases, a biopsy may be necessary. A biopsy, although technically simple, must be conducted in a thoughtful manner in order to obtain an accurate tissue sample while avoiding complications. Some potential complications include inaccurate sampling, improperly placed incision that complicates future surgeries, and healthy tissue contamination that can add morbidity to the definitive surgery or preclude the chance of limb salvage. This chapter will review the considerations for planning and performing a biopsy of musculoskeletal tumors.

Successful Surgical and Medical Treatment of Rhizopus Osteomyelitis Following Hematopoietic Cell Transplantation

Mucormycosis has been reported in otherwise healthy individuals; however, it is primarily seen in immunocompromised patients, such as those with diabetes mellitus, malignancy, or chronic graft-versus-host disease, and has a high mortality rate. Because most cases of mucormycosis are associated with contiguous rhinocerebral infection, only 5 cases of isolated musculoskeletal Rhizopus infection have been reported in the literature. One patient underwent hematopoietic cell transplant, which resulted in a fatal outcome.This article describes the successful treatment of isolated Rhizopus osteomyelitis in a patient who underwent hematopoietic cell transplant using a combined surgical and medical approach. A 33-year-old woman with pre-B cell acute lymphoblastic leukemia underwent hematopoietic cell transplant with few complications but developed chronic graft-versus-host disease 8 months posttransplant. She was treated with high-dose steroids for 6 weeks before she was admitted for severe right tibial pain in the absence of trauma. Early detection, aggressive therapies, and a multidisciplinary surgical and medical team allowed for the microbiologically confirmed resolution of the infection. Treatment included multiagent antimicrobial therapy with amphotericin B, daptomycin, and ertapenem. Several surgical irrigation and debridement procedures were also performed, with the eventual placement of amphotericin-impregnated polymethylmethacrylate cement beads and small fragment titanium screws. The patient continued taking postoperative antifungal treatment for 7 months after discharge. Six months following the discontinuation of antifungal therapy, the teams multidisciplinary approach achieved a continued resolution of the patients infection and a return to a fully ambulatory and radiographically proven recovery without limb loss.

MR guided focused ultrasound treatment of soft tissue tumors of the extremities — preliminary experience

Soft tissue tumors are a heterogeneous group of tumors arising from connective tissues. These tumors may be benign, benign but locally aggressive, or malignant. Surgery either alone or in combination with adjuvant therapies such as radiation or chemotherapy can potentially cure a patient with a soft tissue tumor. The morbidity and complications associated with treatment can have significant and lasting adverse effects on limb function and quality of life. In some situations, patients develop local recurrence of disease and require further surgery, which can result in further treatment-associated morbidity. We have adapted MR guided focused ultrasound (MRgFUS) techniques to the treatment of benign and malignant soft tissue tumors of the extremities with the goal of safely and effectively performing MRgFUS ablation on human subjects. This presentation describes the use of MRgFUS for the treatment of desmoid fibromatosis, arteriovenous malformations, and malignant sarcomas.