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Background The aims of this study are to (1) determine whether fixation of metastatic long bone fractures with an intramedullary nail (IMN) influences the incidence of lung metastasis in comparison to arthroplasty or ORIF (Arthro/ORIF); and (2) assess this relationship in primary tumor types; and (3) to assess survival implications of lung metastasis after surgery. Methods Retrospective cohort study investigating 184 patients (107 IMN, and 77 Arthro/ORIF) surgically treated for metastatic long bone fractures. Patients were required to have a single surgically treated impending or established pathologic fracture of a long bone, pre-operative lung imaging (lung radiograph or computed tomography) and post-operative lung imaging within 6 months of surgery. Primary cancer types included were breast (n = 70), lung (n = 43), prostate (n = 34), renal cell (n = 37). Statistical analyses were conducted using two-tailed Fisher’s exact tests, and Kaplan-Meier survival analyses. Results Patients treated with IMN and Arthro/ORIF developed new or progressive lung metastases following surgery at an incidence of 34 and 26%, respectively. Surgical method did not significantly influence lung metastasis (p = 0.33). Furthermore, an analysis of primary cancer subgroups did not yield any differences between IMN vs Arthro/ORIF. Median survival for the entire cohort was 11 months and 1-year overall survival was 42.7% (95% CI: 35.4–49.8). Regardless of fixation method, the presence of new or progressive lung metastatic disease at follow up imaging study was found to have a negative impact on patient survival (p Conclusions In this study, development or progression of metastatic lung disease was not affected by long bone stabilization strategy. IM manipulation of metastatic long bone fractures therefore may not result in a clinically relevant increase in metastatic lung burden. The results of this study also suggest that lung metastasis within 6 months of surgery for metastatic long bone lesions is negatively associated with patient survival. Level of evidence III, therapeutic study

Background The incidence of intramedullary infection is increasing with increased use of intramedullary fixation for long bone fractures. However, appropriate treatment for infection after intramedullary nailing is unclear. The purpose of this study was to report the results of our treatment protocol for infection after intramedullary nailing: intramedullary nail removal, local debridement, reaming and irrigation, and antibiotic-loaded calcium sulfate implantation with or without segmental bone resection and distraction osteogenesis. Methods We retrospectively reviewed the records of patients with an infection after intramedullary nailing treated from 2014 to 2017 at our center. Patients with follow-up of less than 24 months, received other treatment methods, or those with serious medical conditions were excluded from the analysis. Patients met the criteria were treated as described above, followed by distraction osteogenesis in 9 cases to repair bone defect. The infection remission rate, infection recurrence rate, and post-operative complication rates were assessed. Results A total of 19 patients were included in the analysis. All of patients had satisfactory outcomes with an average follow-up of 38.1 ± 9.4 months (range, 24 to 55 months). Eighteen patients (94.7%) achieved infection remission; 1 patient (5.3%) developed a reinfection that resolved after repeat debridement. Nine patients with bone defects (average size 4.7 ± 1.3 cm; range, 3.3 to 7.6 cm) were treated with bone transport which successfully restored the length of involved limb. The mean bone transport duration was 10.7 ± 4.0 months (range, 6.7 to 19.5 months). The majority of patients achieved full weight bearing and became pain free during the follow-up period. Postoperative complications mainly included prolonged aseptic drainage (7/19; 36.8%), re-fracture (1/19; 5.3%) and joint stiffness, which were successfully managed by regular dressing changes and re-fixation, respectively. Conclusion Intramedullary nail removal, canal reaming and irrigation, and antibiotic-loaded calcium sulfate implantation (with or without distraction osteogenesis) is effective for treating infections after intramedullary nailing.

Background Hereditary multiple osteochondromas (HMO) is a genetic condition characterized by the presence of multiple osteochondromas, usually at the lateral side of the most active growth plate of a long bone. These lesions may persist, be asymptomatic during childhood, and may increase in number and size until growth plates close. Therefore, diagnosis of HMO in children and young people can be challenging; while short stature can be more evident at the onset of puberty, asymptomatic ostheocondromas can progress into different degrees of orthopedic deformity. Moreover, multiple complications may arise due to the presence of osteochondromas, including tendon and compression muscle pain, neurovascular disorders, obstetric problems, scoliosis and malignant transformation into secondary peripheral chondrosarcoma in adulthood. Case presentation We report the case of a girl admitted to our Institute for growth delay. While laboratory tests, including growth hormone stimulation test, were normal, left hand X-ray revealed multiple osteochondromas, suggestive for HMO. The genetic test for EXT1 and EXT2 genes confirmed the radiological diagnosis, with a mutation inherited from the mother who displayed the same radiological abnormalities along with recurrent limb pain episodes. Conclusions HMO is a genetic condition whose diagnosis can be challenging, especially in females. Every pediatricians should consider a skeletal dysplasia in case of unexplained growth delay and a skeletal survey might be fundamental in reaching a diagnosis.

Background Morel-Lavallee lesions (MLLs) are rare internal degloving injuries typically caused by blunt traumatic injuries and most commonly occur around the hips and in association with pelvic or acetabular fractures. MLL is often overlooked in the setting of poly-trauma; therefore, clinicians must maintain a high degree of suspicion and be familiar with the management of such injuries, especially in obese poly-trauma patients. Case presentation We present a 30-year-old female pedestrian struck by a motor vehicle who sustained multiple long bone fractures, a mesenteric hematoma, and full-thickness abdominal skin friction burn which masked a significant underlying abdominal MLL. The internal degloving caused significant devascularization of the overlying soft tissue and skin which required surgical drainage of hematoma, abdominal wall reconstruction with tangential excision, allografting, negative pressure wound therapy, and ultimately autografting. Conclusion MLL is a rare, often overlooked, internal degloving injury. Surgeons must maintain a high index of suspicion when dealing with third degree friction burns as they may mask underlying injuries such as MLL, and a delay in diagnosis can lead to increased morbidity.

BMC musculoskeletal disorders 18(1), 468 (2017). doi:10.1186/s12891-017-1813-9, Published by BioMed Central, London

Background Radiotherapy for long bone metastases (RTLB) can be complicated by fractures, which considerably increase morbidity and mortality. The aim of this study was to analyze the risk factors for impending fractures following radiotherapy for long bone metastases (RTLB) using CT scan-based virtual simulation. Methods Forty-seven (47) patients were treated with RTLB (18 lung, 11 breast, 10 prostate and 8 other cancers) for a period of 18 months. Two doctors analyzed the CT images prior to radiation therapy. The impending fractures were then monitored and the correlation between bone scan parameters and fracture occurrence was analyzed. Results The male gender ratio was 0.57 and the mean age 62.8 (33–93) years. The average size of the metastatic lesions was 32 (8–87) x 2 (6–81) x 52 (7–408) mm with cortical involvement (CI) in 66% of cases. The site was in the upper third of the bone in 92% of cases (28 femoral, 17 humeral and two tibial). Ten fractures occurred: two during RTLB, seven after one month and one after 6.6 months. The fractured lesions measured 48 (17–87) x 34 (12–66) x 76 (38–408) mm. The predictive parameters for fracture were osteolytic (39% vs. 10%; p = 0.02) and permeative lesions (42% vs. 0%; p

Background Unicameral bone cyst (UBC) is the most common benign lytic bone lesion seen in children. The aim of this study is to investigate clinical factors affecting pathological fracture and healing of UBC. Methods We retrospectively reviewed 155 UBC patients who consulted Nagoya musculoskeletal oncology group hospitals in Japan. Sixty of the 155 patients had pathological fracture at presentation. Of 141 patients with follow-up periods exceeding 6 months, 77 were followed conservatively and 64 treated by surgery. Results The fracture risk was significantly higher in the humerus than other bones. In multivariate analysis, ballooning of bone, cyst in long bone, male sex, thin cortical thickness and multilocular cyst were significant adverse prognostic factors for pathological fractures at presentation. The healing rates were 30% and 83% with observation and surgery, respectively. Multivariate analysis revealed that fracture at presentation and history of biopsy were good prognostic factors for healing of UBC in patients under observation. Conclusion The present results suggest that mechanical disruption of UBC such as fracture and biopsy promotes healing, and thus watchful waiting is indicated in these patients, whereas patients with poor prognostic factors for fractures should be considered for surgery.

Successful management of intramedullary long bone osteomyelitis remains a challenge for both surgeons and patients. Patients are often immune-compromised and have endured multiple surgeries. Treatment principles include antibiotic administration (systemically +/- locally), surgical debridement of the infection site and stabilization. Since their description in 2002, antibiotic coated nails have become part of the armamentarium for the treatment of osteomyelitis allowing both local elution of antibiotics and stabilization of a debrided long bone. Limitations to their utilization have remained, in part from the technical difficulty of fabrication and MRI artifacts. We describe a new surgical technique of fabrication that has the advantages of being simple, reproducible, with an end product free of MRI artifacts.

Background Fusobacterium species are uncommon causes of osteomyelitis. These organisms are normal flora of the oral cavity. Therefore, they mostly cause osteomyelitis of the head and neck. Hematogenous osteomyelitis at distant sites other than the head and neck has rarely been reported in pediatric or immunocompromised patients. Here, we report the first case of osteomyelitis of a long bone combined with a muscle abscess due to Fusobacterium nucleatum in an otherwise healthy adult. Case presentation A 59-year-old Korean man was admitted for pain and swelling of the right lower leg, which had been persistent for two weeks. Magnetic resonance imaging showed osteomyelitis of the right fibula with a surrounding muscle abscess of the right lower leg. Incision and drainage was performed, and repetitive tissue cultures grew F. nucleatum. In this patient, it was presumed that recurrent periodontitis caused hematogenous seeding of F. nucleatum to a distant site leading to osteomyelitis with a muscle abscess. The patient was successfully treated with intravenous ampicillin-sulbactam for three weeks and oral amoxicillin-clavulanate for eight weeks. He also underwent repeated surgical drainage. He has no evidence of recurrence after seven months of follow-up. Conclusions Clinicians should be aware that F. nucleatum could be the etiologic agent of hematogenous osteomyelitis of a long bone in an immunocompetent patient.

Older adults are predisposed to osteomyelitis either because of an increased incidence of associated disorders (e.g., peripheral vascular disease, diabetes mellitus, malnutrition and poor dentition) or because of surgical procedures that are frequently performed in the elderly population (e.g., dental extractions, open-heart surgery, and prosthetic joint replacement or osteosynthesis). Two types of haematogenous osteomyelitis that are seen in the elderly are vertebral and long bone osteomyelitis. The most common pathogen is Staphylococcus aureus. Osteomyelitis secondary to contiguous foci of infection can occur in older adults without vascular insufficiency (secondary to pressure ulcers) or with vascular insufficiency due to diabetes mellitus or peripheral vascular disease from atherosclerosis. Chronic osteomyelitis may be defined as osteomyelitis that has a duration of more than 6 weeks or that recurs or is not cured after the initial infection. Chronic osteomyelitis may be associated with certain surgical procedures (e.g., sternal osteomyelitis after open-heart surgery or implant-related infections after orthopaedic and traumatological procedures), poor dentition or dental extraction (mandibular osteomyelitis), and, more commonly, with systemic disorders (e.g., peripheral vascular disease and diabetes mellitus). Acute osteomyelitis can in some cases be cured with antimicrobial therapy alone but surgical management is often required and includes extensive debridement, obliteration of dead spaces, stabilisation, adequate soft tissue coverage, and restoration of an effective blood supply. Chronic osteomyelitis may be caused by S. aureus or coagulase negative staphylococci, but is often due to gram-negative organisms. Because of the presence of infected bone fragments without a blood supply (sequestra), cure with antibiotic therapy alone is rare, if ever, possible and adequate surgical debridement is the cornerstone of therapy. Bone repair and bone mineral density may be significantly retarded and may be corrected by eliminating risk factors, supplementing the diet with calcium, bisphosphonates, and/or vitamin D, and treating with testosterone and/or estrogen when deficient. Sodium fluoride treatment and anabolic steroids may be used as alternatives. Septic arthritis is a medical emergency, and prompt recognition and rapid and aggressive treatment are critical to ensuring a good prognosis. The treatment of septic arthritis includes appropriate antimicrobial therapy and joint drainage. Adverse effects of prescribed antibacterials occur more often in the elderly patient than in young adults. The physician can help to minimise the incidence of adverse effects and improve outcomes by being aware of the principles of clinical pharmacology, the characteristics of specific drugs, and the special physical, psychological and social needs of older patients, Figure ​Figure1,1, ​,2,2, ​,3,3, ​,44. Figure 1 Septic knee prosthesis. The arrow shows the bone loss, due to infection and loosening of the implant. Figure 2 X-ray after septic prosthesis removal and antibiotic-loaded spacer implant Figure 3 Total knee re-implantation after 3 months. Note the filling of the bone defect in medial aspect of the tibial plateau Figure 4 Control after 2 years

There is general agreement that early internal stabilization in long bone fractures in severely injured patients is advantageous. Intramedullary reaming and nailing, however, include increased intramedullary pressure. This may cause intravasation of bone marrow contents, leading to bone marrow embolisation and altered cardiopulmonary function. Possible beneficial effects of attenuation of the intramedullary pressure increase by the use of a reamer-irrigator-aspirator (RIA) system were studied with the hypothesis that the RIA technique would cause lower numbers of pulmonary embolisms and lesser cardiopulmonary affection than after traditional reaming (TR).

Background The "ideal" timing and modality of fracture fixation for unstable thoracolumbar spine fractures in multiply injured patients remains controversial. The concept of "damage control orthopedics" (DCO), which has evolved globally in the past decade, provides a safe guidance for temporary external fixation of long bone or pelvic fractures in multisystem trauma. In contrast, "damage control" concepts for unstable spine injuries have not been widely implemented, and the scarce literature in the field remains largely anecdotal. The current practice standards are reflected by two distinct positions, either (1) immediate "early total care" or (2) delayed spine fixation after recovery from associated injuries. Both concepts have inherent risks which may contribute to adverse outcome. Presentation of hypothesis We hypothesize that the concept of "spine damage control" – consisting of immediate posterior fracture reduction and instrumentation, followed by scheduled 360° completion fusion during a physiological "time-window of opportunity" – will be associated with less complications and improved outcomes of polytrauma patients with unstable thoracolumbar fractures, compared to conventional treatment strategies. Testing of hypothesis We propose a prospective multicenter trial on a large cohort of multiply injured patients with an associated unstable thoracolumbar fracture. Patients will be assigned to one of three distinct study arms: (1) Immediate definitive (anterior and/or posterior) fracture fixation within 24 hours of admission; (2) Delayed definitive (anterior and/or posterior) fracture fixation at > 3 days after admission; (3) "Spine damage control" procedure by posterior reduction and instrumentation within 24 hours of admission, followed by anterior 360° completion fusion at > 3 days after admission, if indicated. The primary and secondary endpoints include length of ventilator-free days, length of ICU and hospital stay, mortality, incidence of complications, neurological status and functional recovery. Implications of hypothesis A "spine damage control" protocol may save lives and improve outcomes in severely injured patients with associated spine injuries.