Background: Several viable options have been discussed in the literature for management of bone defects that result from resection of proximal tibial sarcomas. Pedicled vascularized fibular graft alone as a reconstructive technique can be considered as an alternative method that needs to be evaluated regarding adequacy, safety, and applicability for these situations. Methods: This is a retrospective case series study of 23 patients (14 male and nine female) aged from 7 yr to 40 yr with proximal tibial sarcomas that were managed from 1999 through 2017 by a knee-sparing limb salvage technique. Routine clinical and radiographic examinations were performed with histopathologic diagnosis that found 16 patients who had conventional osteosarcoma, three patients who had parosteal osteosarcoma, three patients who had Ewing sarcoma, and one patient who had fibrosarcoma. One patient had initial lung metastasis. Results: The average functional score from the revised Musculoskeletal Tumor Society rating scale (MSTS) was 26 (86.6%). Local recurrence occurred in two patients who were managed by amputation. Overall survival in our study was 91.4% with mortality of two patients. Conclusions: Pedicled vascularized fibular graft alone as a novel reconstructive technique after knee-sparing limb salvage surgery for juxtaarticular proximal tibial sarcoma is an effective technique with overall good oncologic and functional results. Level of Evidence: Level IV

Hospital Santa Rita, Monterrey, Mexico Financial Disclosures: The authors report no conflicts of interest.

Background: Tibial plateau fractures are considered to be one of the most common fractures with an increasing incidence of motor vehicle accidents. Posteromedial fracture, in particular, is considered a more challenging case. Combination of posteromedial fragment fracture with central articular depression or medial condyle fracture make it much more difficult to reduce and adequately fix the fractured fragments. The aims of this study were to describe a new extensile medial approach for the management of different types of tibial plateau fractures with posteromedial fragments and to evaluate results using this approach. Methods: Between January 2015 and January 2017, 15 patients with Schatzker IV, V, or VI fractures, in combination with a posteromedial fragment, were operated for open reduction of the fracture with restoration of the articular surface alignment. Fixation was done by double plate osteosynthesis. Complete healing time and knee-function scores were recorded in the follow-up period. Results: The average age of patients was 41.8 yr; the mean follow-up period was 30 mo. One patient had superficial wound dehiscence and was treated conservatively. No patients with knee instability or loss of reduction were reported. Conclusions: The posteromedial approach offers a very good access to view, reduce, and fix difficult posteromedial fractures together with comminuted tibial plateau fractures without the need for dissection of the neurovascular bundle in the fossa or soft-tissue injury. Level of Evidence: Level IV.

Aneurysmal bone cyst of the clavicle is rarely reported in the literature. The average age of diagnosis in the reported cases is 12 years with female gender and medial third location predilection. We reported a case of a 5-year-old male child who presented with an incidental finding of right clavicular lesion on chest radiograph. Further evaluation revealed an aneurysmal bone cyst in the lateral end of the right clavicle. On the initial follow-up visit (after 6 months of observation), the lesion size increased to four-folds of the initial size. Complete subperiosteal resection was done with no recurrence noticed up to 4 months postoperatively. This study illustrates the importance of listing the aneurysmal bone cyst in the differential diagnosis of expansile clavicular lesions in young children.

Junqueira, Jader Joel Machado MDa; Hatanaka, Diná Mie MDb; Teruya, Alexandre MDc; Higuchi, Eunice Harue MDd Author Information

Internal hemipelvectomy (IH) is a newer surgical choice for pelvic tumors. It involves resection of the tumor, reconstruction of the pelvis without sacrificing the neurovascular structures, and preservation of the lower limb. We aimed to describe first experience with IH in primary pelvic tumors in Peru. Four patients aged 17 to 49 years old at the time of diagnosis were included. 75% were chondrosarcomas, and 25% were chondroblastomas. The IH types were 50% type II, 25% type I-A, and 25% type III. The neoplasm sizes differed from 5cm to more than 20 cm. Postoperative complications were right hip arthrosis, transient urinary incontinence, and abdominal eventration. Fifty percent had local recurrence, with a recurrence mean time of 24 months. As a first attempt at this technique in Peru, IH had promising results with a 100% overall survival at 30 months. However, more studies are required to analyze the factors associated with a high rate of recurrence (50%).

Background: There is little long-term information and no prior report that used independently collected data describing the effectiveness and complications of intraarticular injections of stem cells. Methods: This study reviewed the records of 2964 patients who received stem-cell injections in the hip, knee, or shoulder and 2971 patients who had injections of steroids or viscosupplementation (comparison group). Results: Pain improved initially in 2104 (71%) of patients who received stem cells. At a mean follow-up of 5.6 yr, 563 (15%) patients continued to report less pain, and the mean time of pain reduction was 17 mo (range, 1 to 84 mo). The mean cost of stem-cell care was $6000 (range, $1200 to $13,000). There were 115 (8%) complications using autologous stem cells, 113 (8%) with donor cells, and 13 (9%) when both were used. Stem-cell complications included six tumors, 14 infections, 48 syncopal, arrhythmia, seizure, or vasovagal reactions, 42 chronic culture-negative effusions, 18 injection site rashes, 44 instances of systemic viral like syndrome or herpes zoster-like reactions, 31 new allergies, and 39 instances of acute and severe worsening of pain and function. There were 82 hospitalizations. For the comparison group, there were 61 (2%) complications and eight hospitalizations. Conclusions: The frequency (8%) and severity of complications with stem cell-injections is higher than for steroid or viscosupplementation injections (2%). Stem-cell joint injections are a costly and speculative treatment and should only be used with a deep understanding of the risk. Practitioners providing stem cell joint injections must include long-term follow-up as part of their care. Additional validated scientific studies are needed. Level of Evidence: Level II.

Background: Computer-assisted navigation has the potential to improve the accuracy of cup positioning during total hip arthroplasty (THA) and prevent leg-length discrepancy (LLD). The purpose of this study was to compare acetabular cup position and postoperative LLD after primary THA using posterolateral approach. Methods: Between August 2016 to December 2017, 57 THAs using imageless navigation were matched with 57 THA without navigation, based on age, gender, and BMI. Postoperative weight-bearing radiographs were assessed for anteversion, inclination, and LLD. Functional LLD was measured in comparison to the contralateral side. The proportion of cups within Lewinnek’s safe zone and LLD greater than 5 mm were assessed. Results: The mean age was 54.9±9.6 yr and 57.6±12.5 yr in control and navigated groups, respectively. Mean cup orientation in the navigated group was 20.6±3.3 degrees (17 to 25) of anteversion and 41.9±4.8 degrees (30 to 51) of inclination, versus 25±11.1 degrees (10 to 31) and 45.7±8.7 degrees (29 to 55) in the control group; these were statistically significant (P=0.005 and P<0.001, respectively). In the navigated group, significantly more acetabular cups were placed within Lewinnek’s safe zone (anteversion: 77% vs. 47%, P=0.005; inclination: 91% vs. 67%, P<0.001). There was no significant difference in mean LLD in the navigation and control groups (3.2±1.5 mm vs. 4.6±3.4 mm, P=0.36), although fewer LLDs of greater than 5 mm were reported in the navigated group (7.1%) than in the control group (31.6%, P=0.007). Conclusions: The use of imageless computer-assisted navigation improved the accuracy of acetabular cup components and LLD. Level of Evidence: Level III.

Gajewski, Christopher R. MDa; Vaz, Jason A. MD, FRCPCb; Williams, Brendan A. MDa,c; Muhly, Wallis T. MDa,b; Lawrence, J. Todd R. MD, PhDa,c Author Information

Background: Drop-foot syndrome is a disorder in which the dorsiflexor muscles are weakened or completely paralyzed, leading to foot slapping after the initial contact and foot-dragging during the swing phase. Passive and hybrid passive ankle-foot orthoses (AFOs) are often prescribed as an intervention for this disorder; however, the effects of these AFOs on kinetic parameters during the gait of drop-foot patients seem unclear. This study aimed to compare the affected lower limb joints of ankle, knee, and hip kinetics parameters (moments and powers) during walking in drop-foot patients using an innovative AFO storing-restoring hybrid passive AFO, named “Comfort Gait” and posterior leaf spring (PLS) AFO. Methods: Ten drop-foot patients were recruited in the current study to walk at a comfortable self-selected speed while wearing two different AFO selections. Kinetic parameters with a motion capture system were obtained for these patients. Results: The results of this study revealed a significant increase in the peak values of kinetic parameters of the lower limb of the affected side (ankle, knee, and hip moments and powers) with the innovative designed AFO when compared to PLS AFO (P<0.05). Conclusions: The significant increase of kinetic parameters in drop foot with use of the Comfort Gait as compared to the PLS AFO might suggest the effectiveness of this innovative AFO in improving the gait of foot drop patients more than the use of PLS AFO. Level of Evidence: Level II