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In an effort to produce best practice guidelines for spine immobilization in the austere environment, the Wilderness Medical Society convened an expert panel charged with the development of evidence-based guidelines for management of the injured or potentially injured spine in an austere (dangerous or compromised) environment. Recommendations are made regarding several parameters related to spinal immobilization. These recommendations are graded on the basis of the quality of supporting evidence and balance between the benefits and risks or burdens for each parameter according to the methodology stipulated by the American College of Chest Physicians. A treatment algorithm based on the guidelines is presented. This is an updated version of original WMS Practice Guidelines for Spine Immobilization in the Austere Environment published in Wilderness & Environmental Medicine 2013;24(3):241–252.

mTOR inhibitors are emerging as important anti-neoplastic agents with a wide range of clinical applications. The topoisomerase I inhibitor irinotecan is a potent DNA damaging drug, with a broad spectrum of anticancer activities. mTOR appears to enhance cancer cell survival following DNA damage, thus the inhibition of mTOR after irinotecan could theoretically show synergistic activities in patients. Both mTOR inhibitors and irinotecan have been used as single agents in soft tissue sarcomas with limited efficacy. We completed a phase I trial of the combination of the mTOR inhibitor, temsirolimus, and irinotecan in patients with advanced soft tissue sarcoma. Seventeen patients were recruited. The Phase II recommended dose is 20 mg of temsirolimus and 80 mg/m2 of irinotecan administered on weekly basis for three out of four weeks. Most frequently encountered toxicities include cytopenias, fatigue, and gastrointestinal toxicities. Two patients (one with leiomyosarcoma and one with high grade undifferentiated sarcoma) had stable disease for more than 12 months.

Summary: Metastatic disease to the pelvis and lower extremity is a significant contributor to morbidity in patients with metastatic cancer. When indicated, surgical prevention of pathologic fractures and treatment of established fractures can preserve patient mobility, dramatically increase pain control, and prevent associated co-morbidities. Forty percent of bony metastases occur in the pelvis and 25% in the femur. Because of the limited life expectancy and debilitated nature of patients undergoing palliative surgery for metastatic disease, the surgical construct should allow immediate unrestricted weight bearing. All areas of the bone should be imaged and all significantly involved portions of the bone should be addressed with the reconstruction. Postoperative radiation therapy should be considered. With appropriate technique and implant selection, outcomes of surgical management are generally very good.

Summary: Proximal tibia resection with endoprosthetic reconstruction is a complex limb sparing procedure for tumors of the proximal tibia. Recent advances in implants and surgical techniques have made this option preferable to amputation for many patients. Long-term survival and recurrence rates are similar between limb salvage and limb ablation in the proximal tibia. Appropriate indications for limb salvage are imperative to mitigate disastrous outcomes such as loss of limb or life. A comprehensive perioperative evaluation should include a detailed history and physical, laboratory, and radiographic testing, along with a biopsy confirmed diagnosis before the definitive procedure. Once a patient has been appropriately evaluated, there are three steps critical to a successful procedure: proximal tibia resection, reconstruction of the proximal tibia and knee joint with a prosthetic component, and extensor mechanism reconstruction utilizing a gastrocnemius flap to improve implant coverage and enhance the patellar tendon repair. Proximal tibia resection with prosthetic reconstruction can be associated with significant complications; however, these can be minimized with appropriate preoperative planning and a meticulous technique.

An observational cohort study was performed on 90 hip arthroplasties performed in 84 patients for metastatic disease of the hip. Significant improvement was noted with both 3-month and 6-month function scores vs preoperative function scores (P < .001). Complications included 1 intraoperative femur fracture, 2 cases of deep venous thrombosis, 1 peroneal nerve palsy, 1 deep infection, and 5 dislocations. Eight (8.8% of 90 procedures, 9.4% of 84 patients) patients died during the initial hospital stay. Although the risk of mortality after hip arthroplasty for metastatic diseases is perhaps higher than previously expected, improvement in postoperative function scores in surviving patients was significant and perioperative morbidity in this complex patient population was acceptably low.

Two children presented with painful lytic lesions in the lower extremity. The lesions were located within cortical bone, and surrounded by sclerosis of the medullary bone and periosteal new bone formation. The lesions were painful, and nonsteroidal anti-inflammatory agents relieved the pain. CT-guided core biopsies were performed followed by radiofrequency treatment. Pathologic evaluation of the specimens revealed features consistent with benign intracortical chondroma. In one case radiofrequency treatment appears to have cured the tumor. The other patient required operative intervention.

Metastatic bone disease has a significant effect on a patient's mortality and health-related quality of life. An aging US population and improved survival rates of patients with cancer have led to an increase in the incidence of symptomatic bony metastatic lesions that may require orthopaedic care. Skeletal-related events in neoplastic disease include pain, pathologic fracture, hypercalcemia, and neural compression, including spinal cord compression. The clinical evaluation and diagnostic study of a patient with a skeletal lesion of unknown etiology should be approached carefully. In patients with widespread metastatic disease, the treatment of a skeletal-related event may be limited to stabilization of the pathologic fracture or local disease control. The treatment of metastatic bone disease is guided by the nature of the skeletal-related event, the responsiveness of the lesion to adjuvant care, and the overall condition and survival expectations of the patient. Impending pathologic fractures are often more easily treated, with less morbidity and easier recovery for patients, than completed fractures. Quality of life is the most important outcome measure in these patients. When surgery is indicated, the approach, choice of fixation, and use of adjuvant should allow for immediate and unrestricted weight bearing. Because metastatic lesions to the skeleton have a limited capacity for spontaneous healing, surgical fixation should be durable for the life expectancy of the patient. In the epiphyseal region of long bones, replacement arthroplasty is generally preferred over internal fixation. Metaphyseal and diaphyseal regions can generally be addressed with intramedullary nailing or plate fixation with adjuvant. The specific treatment of acetabular lesions is dictated by the anatomy and the degree of bone loss. Spinal stability and neural compromise are important considerations in choosing a strategy for managing spine tumors. Effective surgical approaches to metastatic disease of the spine may include vertebral augmentation or open decompression and realignment of the spinal column with internal fixation. Radiation therapy is an important adjunctive modality in the treatment of metastatic bone disease. Medical management consists of symptom control, cytotoxic chemotherapy, and targeted therapy. Emerging technologies, including radiofrequency ablation, cementoplasty, and advances in intraoperative imaging and navigation, show promise in the treatment of metastatic bone disease.

Met behulp van kwalitatieve en kwantitatieve analyse van het looppatroon evalueerden wij bij 41 patienten met degeneratieve arthritis de gevolgen van een totale heupartroplastiek (tha). Patienten met unilaterale en bilaterale degeneratieve heupaandoeningen werden geevalueerd, met als doel het benoemen van de kenmerken van het preoperatieve