Orthopaedic Opinion Research Articles

Case report of high-grade pleomorphic sarcoma (rhabdomyosarcoma): a missed diagnosis in the non-healing post-traumatic wound of the elderly

Rhabdomyosarcoma (RMS) is known to be common childhood soft tissue sarcoma (STS). RMS is infrequent in adults. STS constitute <1% of all adult solid malignant sarcomas and RMS accounts for 3% of all STS. The tumor is divided into three main subtypes-embryonal, alveolar, and pleomorphic (most common in adults). The most common primary sites are extremities. It’s an aggressive lesion with a high rate of metastasis. The patient presented with a non-healing wound over a posterior-medial aspect of the right leg with features suggestive of cellulitis. The patient gave a history of fall 5 months ago for which he took treatment at a local doctor, he continued to have severe pain for which an orthopedic opinion was taken and advised conservative management for an un-displaced fracture of the fibula. He later developed swelling over the lower-middle part of his right leg 3 months ago for which an ultrasound was done suggestive of a large amount of fluid suspicious of hematoma secondary to A-V malformation, an attempt for drainage of fluid was made leading to an evacuation of blood clots further procedure was abandoned and the patient transferred to our center. CT-angio demonstrated it as a heterogeneously attenuating solid cystic lesion. After appropriate consents-wound exploration was done with the evacuation of soft gelatinous material with pus discharge and blood clots. HPE-suggestive of high-grade pleomorphic rhabdomyosarcoma. The patient was advised amputation but denied any further treatment. Post-operative recovery was uneventful with no recurrence for the first 6 months after which the patient did not follow up. Post-traumatic mass at extremities should be evaluated with a high index of suspicion of STS. In case of doubt, either a preoperative biopsy or an intraoperative frozen section is a safe practice.

Fibrous dysplasia mimicking skeletal involvement in Lymphoma.

We present the case of a 19-year-old male with nodular sclerosing classical Hodgkin lymphoma, who had an incidental finding of fibrous dysplasia of the bone. This caused 18-F-fluorodeoxyglucose (18-F-FDG) avidity on positron emission tomography-computed tomography (PET-CT) scan leading to incorrect initial staging. This patient presented with a 4-month history of enlarging cervical lymph nodes, without B symptoms. He had no prior medical history. His initial diagnostic 18-F-FDG PET-CT demonstrated moderately avid left cervical and superior mediastinal lymphadenopathy and two partially sclerotic, partially lytic bone lesions. These were moderately avid, one in the proximal right humerus (SUV 6.1) and the second in the posterior distal humerus (SUV 8.1). There was no other avid lymphadenopathy (see Figure 1). He had a magnetic resonance imaging (MRI) scan and an orthopaedic opinion was sought; the lesions were felt likely to be skeletal involvement of his Hodgkin lymphoma. Therefore, his staging was 4A, with an international prognostic score of 2, and treatment was commenced following a RATHL approach starting with ABVD chemotherapy. The interim PET-CT scan following cycle 2 of ABVD demonstrated a complete metabolic response within the cervical and mediastinal lymphadenopathy, but persistent avidity within the right humeral shaft lesions which were essentially unchanged in size with a mild reduction in 18-F-FDG avidity (see Figure 2). He did report some aching in the right arm. This discrepant radiological response prompted further investigation. The bone lesions were evaluated with a CT and MRI scan, and his case was discussed again with the orthopaedic team who at that point felt the radiological appearances were suggestive of fibrous dysplasia. He had a biopsy of the bone lesion and histological examination confirmed the diagnosis of fibrous dysplasia with no evidence of Hodgkin lymphoma or other primary bone malignancy. The patient's staging was therefore amended to stage 2A early favourable (ESR 4 mm/h at diagnosis), and treatment was changed to combined modality chemo-radiotherapy. He had already completed 2 cycles of ABVD and so proceeded to receive 20 Gy in 10 fractions of consolidation radiotherapy. His end-of-treatment PET-CT scan is awaited but clinically he remains in complete remission. He will require surveillance imaging of the bony lesions. Fibrous dysplasia of the bone (FD) is an uncommon genetic disorder causing benign fibroosseous bone lesions. It is diagnosed predominantly in children and young adults. It has a wide spectrum of presentations but is often asymptomatic and can be found incidentally. Malignant transformation can rarely occur. Radiological features can vary from classical ground glass lesions to cystic or sclerotic lesions. FD lesions can show a large variability in 18-F-FDG uptake on PET-CT, and avidity in FD may change over time. There are several other case reports of FD mimicking skeletal involvement in lymphoma. In conclusion, discrepant responses to treatment should be further investigated. Careful interpretation of 18-F-FDG avid bone lesions is required to avoid misdiagnosis or overtreatment. FD should be considered within the differential diagnosis, especially in younger patients. Orla Gildea: conception, literature review and writing—original draft preparation Claire Burney: supervision and writing—review and editing Julian Kabala: resources, visualisation The authors declare no conflict of interest. Self. N/A. Uploaded. N/A. Not applicable to this article as no new data were created or analysed.

Distal femoral extension osteotomy and patellar tendon advancement or shortening in ambulatory children with cerebral palsy: A modified Delphi consensus study and literature review.

In children with cerebral palsy, flexion deformities of the knee can be treated with a distal femoral extension osteotomy combined with either patellar tendon advancement or patellar tendon shortening. The purpose of this study was to establish a consensus through expert orthopedic opinion, using a modified Delphi process to describe the surgical indications for distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening. A literature review was also conducted to summarize the recent literature on distal femoral extension osteotomy and patellar tendon shortening/patellar tendon advancement. A group of 16 pediatric orthopedic surgeons, with more than 10 years of experience in the surgical management of children with cerebral palsy, was established. The group used a 5-level Likert-type scale to record agreement or disagreement with statements regarding distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening. Consensus for the surgical indications for distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening was achieved through a modified Delphi process. The literature review, summarized studies of clinical outcomes of distal femoral extension osteotomy/patellar tendon shortening/patellar tendon advancement, published between 2008 and 2022. There was a high level of agreement with consensus for 31 out of 44 (70%) statements on distal femoral extension osteotomy. Agreement was lower for patellar tendon advancement/patellar tendon shortening with consensus reached for 8 of 21 (38%) of statements. The literature review included 25 studies which revealed variation in operative technique for distal femoral extension osteotomy, patellar tendon advancement, and patellar tendon shortening. Distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening were generally effective in correcting knee flexion deformities and extensor lag, but there was marked variation in outcomes and complication rates. The results from this study will provide guidelines for surgeons who care for children with cerebral palsy and point to unresolved questions for further research. level V.

334 FASTTRAX - A FRACTURE RESPONSE SERVICE FOR NURSING HOME RESIDENTS

Abstract Background Nursing Home Residents (NHR) are the frailest group of older people and require a gerontologically attuned approach to care. The new FastTrax fracture response service has been developed as a result of a Quality Improvement (QI) project to evaluate the need for this service. The data leading to the development of this pathway is presented here. FastTraX ensures NHR receive optimal orthopaedic and gerontological care without necessity for emergency department (ED) presentation. Methods A retrospective, medical chart review was completed on all NHRs who presented over12-months to a level-4 hospital ED following a fall/injury. Included patients were nursing home residents with suspected fracture discussed with the on-call orthopaedic service. Patients who required more complex imaging other than plain film or with known/suspected head trauma were excluded. Data collected included demographics, clinical and imaging details, and care outcomes. Results In 2021, there were sixty-nine (mean age 80.3, 82.6% female) NHR presentations to the ED with fracture/ injury where orthopaedic opinion was sought following x-ray. Just-under half, 49.2 % (34/69) of patients were admitted, all of whom had confirmed fractures. However, 32.3% (11/34) of admitted NHRs were conservatively treated with an average length-of-stay of 3.6 days before discharge to NH. 6/34 (17.6%) of admitted NHRs died, and 5 of those deaths occurred post-operatively. Of the 50.7% (35/69) discharged directly back to NH from ED, 45.7% (16/35) of those had no fracture, whereas 54.2% (19/35) were discharged for conservative management. Therefore, potentially only 29/69 (33%) ED presentations required definitive orthopaedic/gerontological intervention necessitating admission and two-thirds are potentially avoidable. Conclusion The new FastTraX fracture response service is an Advanced-Nurse Practitioner (rANP) co-ordinated integrated service combining use of on-site mobile radiological diagnostics in the NH, a fast-track ambulatory orthopaedic-consult clinic, and specialist gerontological care delivered in timely response to support NH staff in avoiding ED transfer where appropriate.

Poster Presentation

Poster Presentation

Indications for gastrocsoleus lengthening in ambulatory children with cerebral palsy: a Delphi consensus study.

PurposeEquinus is the most common deformity in cerebral palsy (CP) and gastrocsoleus lengthening (GSL) is the most commonly performed surgery to improve gait and function in ambulatory children with CP. Substantial variation exists in the indications for GSL and surgical technique. The purpose of this study was to review surgical anatomy and biomechanics of the gastrocsoleus and to utilize expert orthopaedic opinion through a Delphi technique to establish consensus for surgical indications for GSL in ambulatory children with CP.MethodsA 17-member panel, of Fellowship-trained paediatric orthopaedic surgeons, each with at least 9 years of clinical post-training experience in the surgical management of children with CP, was established. Consensus for the surgical indications for GSL was achieved through a standardized, iterative Delphi process.ResultsConsensus was reached to support conservative Zone 1 surgery in diplegia and Zone 3 surgery (lengthening of the Achilles tendon) was contraindicated. Zone 2 or Zone 3 surgery reached general agreement as a choice in hemiplegia and under-correction was preferred to any degree of overcorrection. Agreement was reached that the optimum age for GSL surgery was 6 years to 10 years and should be avoided in children aged under 4 years. Physical examination measures with the child awake and under anaesthesia were important in decision making. Gait analysis was supported both for decision making and for assessing outcomes, in combination with patient reported outcomes (PROMS).ConclusionsThe results from this study may encourage informed practice evaluation, reduce practice variability, improve clinical outcomes and point to questions for further research.Level of EvidenceV

Orthopaedic Trainee Opinion on the Current Procedure-based Assessment Compared to its Predecessor: A UK Trauma Centre Perspective.

BackgroundProcedure-based assessments (PBAs) were introduced as a formative assessment of surgical performance. UK trainees are currently expected to complete at least 20 PBAs each training year. A new PBA tool was introduced in August 2016 in order to address several criticisms with its predecessor. These included mandatory written feedback and increasing the number of global levels of assessment.ObjectivesOur study sought to identify the impact of these modifications to the PBA tool on its perceived utility as a formative assessment of surgical skill.Study design & methodsOrthopaedic trainee registrars (ST3-ST8) holding a UK National Training Number (NTN) at a major UK trauma centre were invited to take part in the study. Each trainee completed an anonymous questionnaire that was designed to elicit the view of trainees towards the old and new PBA.ResultsTwelve trainees took part in the study. Most of them admitted receiving good quality feedback from their trainer using both tools (75% old PBA; 83% ew PBA). Most trainees (58%) felt that written feedback did not encourage verbal feedback from their trainer. Overall, trainees felt the new PBA global rating scale levels had made it a more accurate measure of surgical performance and allowed them to better appreciate the gradual improvement in their surgical skills throughout their training.ConclusionsFifty per cent of the trainees believed that the new PBA overall was a better formative assessment of surgical skill than its predecessor. A significant factor has been the introduction of a new global rating score rather than efforts to improve feedback. Further work should look to identify whether these views match those of other UK-based trainees on a larger scale.

A lifestyle management programme focused on exercise, diet and physiotherapy support for patients with hip or knee osteoarthritis and a body mass index over 35: A qualitative study.

The Lifestyle Management Programme (LMP) is an exercise and weight management programme with physiotherapy support for people with hip or knee osteoarthritis (OA) and a body mass index (BMI) over 35. This qualitative study explored views and experiences of the LMP among patients and professionals, and offers insight for future programmes. Five referring clinicians and six delivering professionals participated in focus groups. Three referring GPs and nine patients who attended the LMP took part in semi-structured interviews. Topics included: referral, reasons for taking up and continuing the programme or not, and experiences and outcomes. Framework method was used to analyse the qualitative data. Overall, patients and professionals valued the multidisciplinary nature of the LMP. However, professionals explained feeling guilty about delaying patients on the orthopaedic waiting list and believed that the programme should be redirected to those with less severe OA and a lower BMI. Referring clinicians differed in their interpretation of the referral criteria and expressed varying levels of autonomy when making referrals. Patients referred after a consultation with their general practitioner appeared to be more satisfied with the referral process. Patients were also encouraged by the opportunity to improve health, their likelihood of surgery and social benefits. However, patients were discouraged by inconvenience, cost, lack of readiness to change and embarrassment. In conclusion, shared decision-making about lifestyle management without delaying orthopaedic opinion is preferable, and more psychological support may increase participation. Importantly, the programme may be better focused on rehabilitation for patients with a lower BMI and less severe symptoms.

Clinical audit drives quality improvement in a successful Musculoskeletal Interface Service (MIS)

Purpose: Musculoskeletal Interface services (MIS) were established to increase the management of musculoskeletal problem in primary care and reduce the need for onward referrals to secondary care for orthopaedic opinion (Roddy 2013). It is recognized that the burden of MSK disease is increasing with around 7.5 million working days being lost due to Musculoskeletal (MSK) conditions. Established services need to continually reflect on service provision in terms of clinical and cost effectiveness. Our large MIS (20,000 referrals per year) uses an audit cycle to continually improve clinical services. Clinical audit is a recognized methodology to improve service quality and redesign (NHS England).

Orthopaedic surgeons’ opinions surrounding the management of proximal humerus fractures: an international survey

The purpose of this study was to survey surgeons' preferences surrounding the management and evaluation of proximal humerus fractures internationally. A questionnaire was developed using previous literature and input from practicing orthopaedic surgeon opinion leaders. Between November 13, 2014 and December 31, 2014, the questionnaire was posted on the membership section of three major orthopaedic and shoulder surgery association websites. Survey responses were anonymous. The survey was completed by 134 unique practicing orthopaedic surgeons. The majority of respondents (72%) practiced in North America while 28% practiced internationally. For displaced two-part fractures, a preference for open reduction and internal fixation (ORIF) with locking plates was identified (75%). No consensus was reached for preferred treatment of three- and four- part fractures: 37% chose ORIF with locking plates, 26% chose hemi-arthroplasty (HA), and 29% chose reverse shoulder arthroplasty (RSA). Preferred treatment types for three- and four-part fractures were marginally significantly different depending on place of practice (North America vs. international, p=0.058). A significantly larger proportion of surgeons who had completed an upper extremity fellowship (35%) chose RSA for the treatment of three and four-part fractures, compared to those who had not (9%, p=0.002). No consensus was observed regarding what outcome measure is best to assess function following proximal humerus fractures. The management of more complex, displaced proximal humerus fractures remains controversial. Additionally, there are conflicting opinions on what outcome measure is best to assess function following the treatment of proximal humerus fractures.

Augmentation Techniques for Meniscus Repair.

Menisci display exquisitely complex structure and play an essential weight-bearing role in the knee joint. A torn meniscus is one of the most common knee injuries which can result in pain and mechanical abnormalities. Tear location is one aspect which determines the endogenous healing response; tears that occur in the peripheral densely vascularized zone of the meniscus have the potential to heal while the healing capacity is more limited in the less vascularized inner zones. Meniscectomy was once widely performed, but led to poor radiographic and patient-reported mid- and long-term outcomes. After the advent of arthroscopy, orthopaedic opinion in the 1980s has been swaying toward salvaging or repairing the torn meniscus tissue to prevent osteoarthritis rather than performing meniscectomy. Meniscus repair in young active individuals has been shown to be effective, reproducible, and reliable if indications are met; however, only a small proportion of all tears are considered repairable with available technologies. Biological augmentation techniques and meniscus tissue engineering strategies are being devised to enhance the likelihood and rate of healing in meniscus repair. Preclinical and clinical studies have shown that introduction of cellular elements of the blood, bone marrow, and related growth factors have the potential to enhance meniscus repair. This article reviews the current state of clinical management of meniscus tears (primary repair) as well as augmentation techniques to improve healing by meniscus wrapping with extracellular matrix materials, trephination, synovial rasping and abrasion, fibrin/blood clot placement, and platelet-rich plasma injections. In addition, the rationale for using polymer/autologous blood component implants to improve meniscus repair will be discussed.

Interprosthetic fractures of the lower extermity

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An Unusual Cause of Dysphagia

A 71-year-old male presented in ENT department with dysphagia for last three weeks, more to solids than liquids. He had a hard bony bulge in the posterior pharyngeal wall on palpation and hence was referred for an Orthopaedic opinion. Lateral radiograph of the cervical spine (Fig. 1) revealed diffuse ossification of the anterior longitudinal ligament (straight line, Fig. 1). This ossification was extending almost half the width of the cervical body from its anterior body at C1 and C2 vertebra level (dashed line, Fig. 1) and there was severe narrowing of the airway (Fig. 1, arrows). He was diagnosed as Diffuse Idiopathic Skeletal Hyperostosis (DISH) or Forestier's disease, which is characterized by ossification of longitudinal ligaments (esp. anterior longitudinal ligament) (Fig. 2, arrows) along with sparing of sacroiliac joints (Fig. 3, arrows). It usually affects males aged greater than 50 years and is usually an incidental radiological finding and only symptomatic lesions need specific treatment. This patient was advised diet modification and surgical removal of the ossified mass if the dysphagia persisted. The most common differential of the DISH is Ankylosing Spondylitis (AS). These two entities can be differentiated on the basis of age at presentation and the involvement of a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x

Pediatrics in the austere environment

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Fractures in rickets due to vitamin D deficiency

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An update on distal biceps tendon ruptures

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Submuscular plating for pediatric femoral fractures. Indications and technique

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The benefit of digital production of implant

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Proximal interphalangeal joint arthroplasty

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Trendelenburg sign in nondegenerate and degenerate hips

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