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A glomus tumor is a benign mesenchymal tumor comprised of cells that resemble the perivascular modified smooth muscle cells of the glomus body. Glomus tumors typically appear in the superficial lesions of the soft tissue in the extremities, such as the subungual region. However, their occurrence in the bone is rare, with only about 30 cases reported to date. Half of these cases involved the distal phalanges of the fingers or toes, with only three reported cases involving the long bones. Here, we present the first case, a primary glomus tumor in the humerus of a 14-year-old female. An osteolytic and cystic lesion was detected after a pathological fracture occurred during exercise. Despite the tumor's large size, no pathological findings indicated malignancy. The fracture healed through conservative treatment, while the tumor was effectively managed with curettage. Appropriate medical care can be provided to patients by focusing on pathological findings., (© 2024. The Author(s), under exclusive licence to International Skeletal Society (ISS).)

The individual Geoffroy's side-necked turtle, Phrynops cf. P. geoffroanus, was diagnosed postmortem with osteosarcoma associated with the forelimb through morphological and histological analysis. Osteosarcoma stands as the most prevalent primary malignant bone tumor in tetrapods. The tumor presents itself as a large mass in the distal epiphysis, characterized by spicular outgrowths and a rugose external texture. Histologically, the afflicted humerus displayed a high degree of vascularity and exhibited an extensive bone resorption process involving the medullary and endosteal regions. Notably, a clear transition between the bone marrow and cortical bone was absent, indicative of a remodeling process featuring Haversian bone system apposition. Additionally, the diaphyseal region displayed the progression of neoplastic bone tissue along the bone. For comparative purposes, we describe a humeral thin section from a healthy specimen revealing compact primary bone interrupted by cyclical growth marks which differs from the continuous growth observed in the neoplastic humerus. To assess the neoplastic bone growth rate at the mid-diaphysis level, phylogenetic eigenvector maps (PEM) were employed, utilizing osteocyte density and vascular density as explanatory variables. The findings indicated that the osteosarcoma exhibited a slow-growing nature, suggesting that the turtle had to live with this condition for years. As the neoplasia continued to expand, it likely led to disadvantages for the pathological Phrynops individual due to humeral deformity. Furthermore, malignancy was associated with angiogenesis and the invasion of the medullary region by neoplastic bone tissue, raising the likelihood of metastasis as an additional factor contributing to the individual's sickness. The presence of numerous vascular canals in the diaphyseal thin section suggested a low-grade central osteosarcoma. It is worth noting that osseous neoplasms are rarely documented in Testudines, making this case of osteosarcoma in a South American freshwater chelid specimen a unique and rare occurrence., (© 2024 American Association for Anatomy.)

We present a case of a 58-year-old male who presented following 4 months of progressively worsening right upper extremity pain. Initial pathology demonstrated pleomorphic chondroblasts with increased mitotic activity indicating an intermediate grade (Grade 2) clear cell chondrosarcoma of the proximal humerus. Following surgical resection, the primary lesion demonstrated aggressive behavior and early metastasis to the cervical and thoracic spine. The patient unfortunately expired 30 months after initial presentation. Although clear cell chondrosarcoma has been historically regarded as low grade, we present a unique example of an aggressive clinical course of clear cell chondrosarcoma., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Rationale: Primary leiomyosarcoma of the bone (LMSB) is a rare aggressive sarcoma with limited treatment options. Histopathologic and immunohistochemical features are similar to their more common uterine and soft tissue counterparts. However, its broader spectrum of histopathologic features and rarity make diagnostic challenges., Patient Concerns: We present a case of LMSB in a 20-year-old female who presented with left shoulder aching pain for 3 months. An osteolytic intramedullary lesion was found in the left proximal humeral epi-metaphysis., Diagnoses: Initial open biopsy showed a giant cell tumor of bone with aneurysmal bone cyst (ABC)-like changes. However, an open biopsy followed by extended curettage showed LMSB with ABC-like changes., Interventions: Wide excision of the lesion and bipolar hemiarthroplasty followed by concomitant chemoradiation therapy was conducted. The mass was completely removed without significant problems., Outcomes: Complete mass excision and symptomatic improvements were achieved, and no subsequent relapses were observed., Lessons: The authors encountered a rare case of LMSB. Most occurrences are in the lower extremity and trunk, respectively. ABC-like changes in bone tumors can lead to misdiagnosis. In this case, the ABC-like changes developed from the underlying LMSB as a secondary alteration. A careful examination of the underlying bone tumor is crucial to avoid misdiagnosing it as ABC or exhibiting ABC-like changes. Moreover, there has been no case report of LMSB with secondary ABC-like changes in bone., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Endoprostheses (EPC) are often utilized for reconstruction of the proximal humerus with either hemiarthroplasty (HA) or reverse arthroplasty (RA) constructs. RA constructs have improved outcomes in patients with primary lesions, but no studies have compared techniques in metastatic disease. The aim of this study is to compare functional outcomes and complications between HA and RA constructs in patients undergoing endoprosthetic reconstruction for proximal humerus metastases., Methods: We retrospectively reviewed our institutional arthroplasty database to identify 66 (56% male; 38 HA and 28 RA) patients with a proximal humerus reconstruction for a non-primary malignancy. The majority (88%) presented with pathologic fracture, and the most common diagnosis was renal cell carcinoma (48%)., Resultss: Patients with RA reconstructions had better postoperative forward elevation (74° vs. 32°, p < 0.01) and higher functional outcome scores. HA patients had more complications (odds ratio 13, p < 0.01), with instability being the most common complication., Conclusions: Patients with nonprimary malignancies of the proximal humerus had improved functional outcomes and fewer complications after undergoing reconstruction with a reverse EPC compared to a HA EPC. Preference for reverse EPC should be given in patients with good prognosis and ability to complete postoperative rehabilitation., (© 2024 Wiley Periodicals LLC.)

Background: The distribution of subchondral bone density in a joint represents stress that is applied to the joint. Knowing this information is important for understanding the pathophysiology of osteoarthritis (OA). In the elbow, however, this has not been studied before., Questions/purposes: (1) Is advanced-stage elbow OA associated with more radially distributed subchondral bone density than earlier stages? (2) What demographic (age and sex) and radiographic (osteophyte location and carrying angle) factors are associated with increased radial shift in subchondral bone density?, Methods: Between March 2001 and December 2021, we treated 301 patients for elbow OA. We considered patients with plain radiographs and conventional CT scans as potentially eligible. Thus, 68% (206 patients) were eligible; a further 27% (80 patients) were excluded because of a history of any injury or surgery or known inflammatory joint disease, leaving 42% (126 patients) for analysis here. Their mean ± standard deviation age was 60 ± 10 years. Early OA with minimal joint space narrowing and osteophyte formation was found in 33% (42 of 126) of patients, and advanced OA was found in the remaining 67% (84 of 126). Three-dimensional distal humerus subchondral bone models were derived from CT images, and in the central intra-articulating portion, we measured the subchondral bone density in two different sites: where it articulates with the radius (SBD rad ) and with the ulna (SBD ulna ). We further defined the SBD ratio as the percent ratio of SBD rad to SBD ulna . We also evaluated osteophyte severity based on its size at the radiocapitellar and ulnotrochlear joints, and alignment through measuring the carrying angle on radiographs. To assess interobserver reliability, two orthopaedic surgeons took measurements independently from each other. All measurements had excellent intraoberver and interobserver reliabilities. Then, we compared the subchondral bone parameters between early and advanced OA and performed a multivariable analysis of the factors associated with subchondral bone parameters, including age, sex, osteophyte location, and carrying angle., Results: Radial versus ulna subchondral bone density (SBD ratio ) was modestly higher in patients with advanced OA (118% ± 17%) than in patients with early OA (109% ± 17%, mean difference 9% [95% CI 2.3% to 15.3%]; p = 0.01). With increasing radial deviation in subchondral bone density, cubitus valgus had a modest association (β = 0.46 ± 0.23; p = 0.04) and severe osteophytes at the radiocapitellar joint had a large association (β = 9.51 ± 3.06; p = 0.002)., Conclusion: According to subchondral bone density distribution, stress concentration was more radially deviated in patients with the advanced stages of elbow OA than in those with the early stages. We also found that an increase in carrying angle is associated with radial deviation of stress. A future study that examines longitudinal changes in the subchondral bone density might be required to confirm changes in stress concentration with OA progression., Clinical Relevance: This study gives us insight into the potential pathophysiology of elbow OA in relation to elbow alignment. Although debridement of osteophytes in the ulnotrochlear joint is the most frequently performed procedure in patients with advanced elbow OA, our finding suggests that some patients with an increased carrying angle might benefit from management of the radiocapitellar joint as well, or from being informed of the future development of OA in the radiocapitellar joint, because stress at this site can be increased with the advancement of OA., Competing Interests: All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2023 by the Association of Bone and Joint Surgeons.)

Competing Interests: The author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

Chondroblastoma is a rare benign cartilaginous tumor that accounts for approximately 1% of bone tumors, but it can be associated with lung metastasis in extremely rare cases, leading to a poor prognosis and death. Herein, we report the case of a 19-year-old male patient who presented with an aggressive chondroblastoma of the proximal humerus and bilateral lung metastasis. The patient was treated with wide local resection, partial metastasectomy, and denosumab. Denosumab treatment was effective in controlling metastatic progression and preventing local recurrence., (Copyright: © Saudi Medical Journal.)

Purpose: To evaluate whether there is a mismatch between Risser staging and the proximal humerus ossification system (PHOS); and to analyze the correlation in the skeletal maturity stages between the two humeral epiphyses., Methods: Data from patients aged 10 to 18 years with adolescent idiopathic scoliosis (AIS) seen between 2018 to 2021 were analyzed. In an anteroposterior (AP) spine radiograph the ossification process was evaluated using the Risser classification method and bilateral PHOS (if both humeral epiphyses were visualized). A mismatch between methods was defined as a Risser 0-1 (relatively skeletally immature) with a PHOS 4-5 (skeletally mature), or a Risser 2-5 (relatively skeletally mature) with a PHOS 1-3 (skeletally immature). The McNemar test was used to calculate the significance of the mismatch., Results: A mismatch between Risser and PHOS stages was observed in 28.5% of 105 patients, which was statistically significant (p < 0.001). Of the 49 patients with a Risser 0-1, 55.1% (n = 27) had a PHOS 4-5. None of the patients with a Risser 2-5 had a PHOS 1-3. In the 47 patients in whom both humeri were visualized, the absolute correlation between the left and right PHOS values was 95.7%., Conclusion: Of AIS patients who are relatively skeletally immature according to Risser staging, more than half may be skeletally mature when measured with PHOS. In patients with a Risser 0-1, it is recommended to measure skeletal maturity in an AP spine radiograph using the PHOS method, which may more accurately guide treatment decision-making, without the need to visualize both humeral epiphyses in this radiographic projection., Level of Evidence: IV., (© 2024. The Author(s), under exclusive licence to Scoliosis Research Society.)

Background: Functional humeral bracing of midshaft humeral fractures has been widely accepted as a gold standard for nonoperative treatment. Despite reported high union rates, there is no proven superiority of any orthosis. Here we aim to compare the outcomes after the use of custom-made thermoplastic vs. commercial humeral brace with regard to time to union, nonunion rates, types of nonunion, and conversion to surgery., Methods: Patients with humeral fractures treated between 2018 and 2021 were identified retrospectively by electronic records. Only diaphyseal humerus fractures (AO 12) were included in the study. Proximal (AO 11) or distal (AO 13) fractures, open fractures, pathologic fractures, bilateral fractures, multiple fractures, and patients lost to follow-up were excluded. Patients attending one center received a custom-made thermoplastic splint, whereas those at the other center had an off-the-shelf humeral brace applied. Radiologic union was defined as healing of at least 3 of 4 cortices determined from follow-up radiographs. Data calculations were performed using the χ 2 test., Results: A total of 53 patients treated with a thermoplastic brace and 43 with a commercial brace were identified. A total of 52 men were included, and the cohort's mean age was 60.1 years (standard deviation: 16.1 years). Both groups had similar gender and age distributions. More patients achieved union with a thermoplastic brace (79.2%) than those with a commercial brace (76.7%), which was statistically significant (χ 2 , P = .04). Although time to union was similar both clinically and radiologically, patients with a commercial brace converted to surgical treatment more frequently (11 vs. 14 cases)., Conclusion: Thermoplastic custom-made braces provide better fracture stability, allowing for statistically significantly higher rates of fracture union during a similar treatment period to commercially available splints. Patients wearing a commercial splint were significantly more likely to develop hypertrophic nonunion requiring surgery., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.)

The pathophysiology of lateral epicondylitis (LE) remains not fully elucidated, as it involves a complex interaction of anatomical structures. The primary objective of the research is to identify a potential relationship between LE and the ulnohumeral angle (UHA), which demonstrates the coronal alignment of the elbow. Patients diagnosed with LE between September 1st, 2020, and September 1st, 2023, were retrospectively examined. Demographic information and UHA measurements of patients meeting the inclusion criteria and a control group with similar criteria were collected. Measurements were independently conducted by 2 orthopedists at a 2-week interval and compared. Among 413 patients meeting the inclusion criteria and the control group comprising 420 patients, there were no significant differences in age, gender, and side (P = .447, P = .288, P = .159, respectively). The mean UHA for the LE group was 13.49 ± 4.24, while for the control group, it was 12.82 ± 9.19, showing a significant difference (P = .026). The inter-observer and intraobserver reliability of the angle measurements were both above 0.80. We hypothesize that the increase in UHA in patients with LE reflects an adaptive change secondary to compressive forces acting on the lateral aspect of the elbow. This study is the first to describe the relationship between LE and UHA based on anatomical-biomechanical foundations, suggesting a cause-and-effect relationship. Further studies are warranted to delve deeper into this relationship., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Case: We present 2 cases of severe hemodynamic collapse during prophylactic stabilization of impending pathologic humerus fractures using a photodynamic bone stabilization device. Both events occurred when the monomer was infused under pressure into a balloon catheter., Conclusion: We suspect that an increase in intramedullary pressure during balloon expansion may cause adverse systemic effects similar to fat embolism or bone cement implantation syndrome. Appropriate communication with the anesthesia team, invasive hemodynamic monitoring, and prophylactic vent hole creation may help mitigate or manage these adverse systemic effects., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C331)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Abstract: Myeloid sarcoma is a neoplastic mass formed by the infiltration of primitive or immature myeloid cells into organs and tissues outside the bone marrow. It may occur before, at the same time, or manifest as the recurrence of acute myeloid leukemia, myelodysplastic syndromes, and chronic myeloproliferative syndromes. It may involve any organ or tissue, including skin, soft tissue, lymph nodes, and gastrointestinal tract and bone. Isolated humerus involvement is extremely rare. Herein, we present the FDG PET/CT findings of a rare case of isolate myeloid sarcoma in the right humerus, which showed only increased bone density with moderate FDG uptake., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Biological reconstruction by replanting the resected tumor-bearing segment is preferred by some surgeons when caring for a patient with a bone sarcoma. Frozen autografts are advantageous because they are cost-effective, provide an excellent fit, permit the maintenance of osteoinductive and osteoconductive properties, and are not associated with transmission of viral disease. The pedicle frozen autograft technique, in which only one osteotomy is made for the freezing procedure, keeping the affected segment in continuity with the host bone and soft tissue instead of two osteotomies, maintains the affected segment with the host bone and soft tissue. This could restore blood flow more rapidly in a frozen autograft than in a free-frozen autograft with two osteotomies., Questions/purposes: (1) In what proportion of patients was union achieved by 6 months using this technique of frozen autografting? (2) What complications were observed in a small series using this approach? (3) What was the function of these patients as determined by Musculoskeletal Tumor Society (MSTS) score? (4) What proportion of patients experienced local recurrence?, Methods: Between 2014 and 2017, we treated 87 patients for primary sarcomas of the femur, tibia, or humerus. Of those, we considered patients who could undergo intercalary resection and showed a good response to neoadjuvant chemotherapy as potentially eligible for this technique. Based on these criteria, 49% (43 patients) were eligible; a further 9% (eight) were excluded because of inadequate bone quality (defined as cortical thickness less than 50% by CT assessment). We retrospectively studied 32 patients who were treated with a single metaphyseal osteotomy, the so-called pedicle freezing technique, which uses liquid nitrogen. There were 20 men and 12 women. The median age was 18 years (range 13 to 48 years). The median follow-up duration was 55 months (range 48 to 63 months). Patients were assessed clinically and radiologically regarding union (defined in this study as bony bridging of three of four cortices by 6 months), the proportion of patients experiencing local recurrence, the occurrence of nononcologic complications, and MSTS scores., Results: Three percent (one of 32) of the patients had nonunion (no union by 9 months). The median MSTS score was 90%, with no evidence of metastases at the final follow-up interval. Nine percent (three of 32) of our patients died. The local recurrence rate was 3.1% (one of 32 patients). The mean restricted disease-free survival time at 60 months (5 years) was 58 months (95% CI 55 to 62 months). Twenty-five percent of patients (eight of 32) experienced nononcologic complications. This included superficial skin burns (two patients), superficial wound infection (two patients), deep venous thrombosis (one patient), transient nerve palsy (two patients), and permanent nerve palsy (one patient)., Conclusion: This treatment was reasonably successful in patients with sarcomas of the femur, tibia, and humerus who could undergo an intercalary resection, and this treatment did not involve the epiphysis and upper metaphysis. It avoids a second osteotomy site as in prior reports of freezing techniques, and union was achieved in all but one patient. There were few complications or local recurrences, and the patients' function was shown to be good. This technique cannot be used in all long-bone sarcomas, but we believe this is a reasonable alternative treatment for patients who show a good response to neoadjuvant chemotherapy, those in whom intercalary resection is feasible while retaining at least 2 cm of the subchondral area, and in those who have adequate bone stock to withstand the freezing process. Experienced surgeons who are well trained on the recycling technique in specialized centers are crucial to perform the technique. Further study is necessary to see how this technique compares with other reconstruction options., Level of Evidence: Level IV, therapeutic study., Competing Interests: Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2023 by the Association of Bone and Joint Surgeons.)

Introduction: The humerus is a common site of metastases and primary tumors. For some patients with a segmental defect and/or diaphyseal cortical destruction a cemented intercalary device may provide a more reliable construct, however data on their use is limited., Methods: We reviewed 43 (28 male and 15 female) patients treated with an intercalary humeral spacer at a single tertiary referral center between 1989 and 2022. Humeral lesions were most commonly secondary to metastatic disease (n = 29, 68%), with 25 (58%) patients presenting with a pathologic fracture. Mean age and body mass index were 66 years and 27.9 kg/m 2 . First generation taper joint device were used in 22 patients and second-generation lap device in 21 patients., Results: Following reconstruction the 2-year overall survival was 30%. Mechanical complications occurred in 11 patients, most commonly aseptic loosening (n = 6, 14%). With death as a competing risk, the cumulative incidence of mechanical failure was 28% at 2-years postoperative. Following the procedure, mean Musculoskeletal Tumor Society scores was 70% and mean shoulder elevation was 87°., Conclusion: Reconstruction of the humeral diaphysis with an intercalary endoprosthesis provides restoration of function of the upper extremity, however, is associated with one in four patients having mechanical failure., (© 2023 Wiley Periodicals LLC.)

The bony shoulder girdle consists of the clavicle, humerus, and scapula, which work synergistically to form a complex articulation that is essential for use of the upper extremity. The shoulder girdle is the most common location for primary and secondary bone tumors in the upper extremity, and following resection of these tumors, reconstruction of the upper extremity is challenging. Compared with those in the lower extremity, reconstructive techniques in the upper extremity have historically been unreliable and fraught with complications and poor functional outcomes. Newer reconstructive techniques using reverse total shoulder arthroplasty and functional muscle flaps have shown promise to improve outcomes while reducing complications for proximal humerus reconstructions. Despite these advancements, reconstruction following scapulectomy remains challenging and is still associated with more frequent complications and compromised function.

Background: There is no agreement on the best choice of proximal humeral reconstruction following tumor resection in pediatric patients. We reviewed the functional outcomes, oncologic outcomes, and surgical complications in pediatric patients after proximal humeral reconstruction with cemented osteoarticular allograft., Methods: Eighteen patients aged 8-13 years who underwent proximal humeral osteoarticular allograft reconstruction following resection of primary bone sarcoma were included. The mean follow-up period was 88 ± 31.7 months. At the last follow-up assessment, limb function was evaluated based on shoulder range of motion, Musculoskeletal Tumor Society score, and Toronto Extremity Salvage Score. Tumor recurrence and postoperative complications were extracted from the patients' medical records., Results: Mean active forward flexion of the shoulder was 38° ± 18°. Mean active abduction was 48° ± 18°. Mean active external rotation was 23° ± 9°. The mean Musculoskeletal Tumor Society score was 73.4% ± 11.2%. The mean Toronto Extremity Salvage Score was 75.6% ± 12.9%. Local recurrence occurred in 1 patient. Metastasis developed after the operation in 2 additional patients. We recorded 6 postoperative complications in this series, including 1 superficial infection, 1 late-onset deep infection, 1 allograft fracture, 2 cases of nonunion, and 2 cases of shoulder instability. Two complications required allograft removal., Conclusion: In pediatric patients, reconstruction of the proximal humerus with cemented osteoarticular allograft results in acceptable oncologic and functional outcomes while the postoperative complication rate seems to be lower than that of other available techniques., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

The spontaneous disappearance of a segment of bone in a short period without the existence of a tumoral disease that justifies it is an exceptional event. We report the case of an older adult in whom the upper epiphysis of the right humerus and part of the acromion disappeared in a period of 3 weeks in the absence of a malignant tumor. Bone biopsy revealed osteoclasts, lymphatic vessels, and blood vessels. This disorder was first reported in 1838 and in 1955 it was established as a specific disease by Gorham and Stout. Since then, it has been named in their honor.

Background: A vascularized fibula graft (VFG) is the vascular autograft most frequently used to restore large segmental long bone defects, particularly in the upper limb. Because the use of a vascularized fibula involves an operation in an uninvolved extremity with potential morbidity, it is important to document that this type of reconstruction is successful in restoring function to the humerus. However, the long-term results of VFG after intercalary resection of the humeral diaphysis for bone tumors are still unknown., Questions/purposes: (1) What was the complication rate of reconstruction? (2) What was the functional result after surgical treatment, as assessed by the Musculoskeletal Tumor Society (MSTS) score, the American Shoulder and Elbow Society (ASES) score, and Constant score? (3) What was the survivorship of these grafts free from revision and graft removal at 5, 10, and 15 years?, Methods: Between 1987 and 2021, 127 patients were treated at our institution with en bloc resection for a primary malignant or an aggressive benign bone tumor of the humerus; we excluded patients treated with extra-articular resection or amputation. Of those, 14% (18 of 127) were treated with intercalary resection of the humeral diaphysis for primary bone tumors and reconstruction with VFG, with or without a bulk allograft, and were analyzed in this retrospective study. Generally, our indications for reconstruction with VFG are intercalary resection of the humerus for primary malignant or aggressive benign bone tumors in patients with long life expectancy and high functional demands, in whom adequate bone stock of the proximal and distal epiphysis can be preserved. In 13 patients, VFG was used alone, whereas in five patients, a massive allograft was used. Our policy was to use VFG combined with a massive allograft in patients undergoing juxta-articular joint-sparing resections in which proximal osteotomy was performed close to the anatomic neck of the humerus to obtain more stable fixation and better tendinous reattachment of the rotator cuff and deltoid. All 18 patients who were treated with a VFG were available for follow-up at a minimum of 2 years (median follow-up 176 months, range 26 to 275 months), and although three have not been seen in the past 5 years and are not known to have died, they had 172, 163, and 236 months of follow-up, and were included. The median age at surgery was 25 years (range 2 to 63 years), the median humeral resection length was 15 cm (range 8 to 21 cm), and the median fibular length was 16 cm (range 12 to 23 cm). Complications and functional scores were ascertained by chart review that was performed by an individual not involved in patient care. Functional results were assessed with the MSTS score (range 0 to 30), the ASES score (range 0 to 100), and the Constant score (range 0% to 100%). Survivorship was estimated using a Kaplan-Meier survivorship estimator, which was suitable because there were few deaths in this series., Results: Seven patients underwent a revision procedure (one radial nerve transient palsy because of screw impingement, four nonunions in three patients with one humeral head avascular necrosis, treatment for screw-related pain in one patient, and two VFG fractures), and one patient underwent VFG removal. Donor site complications were observed in four patients (one ankle valgus deformity and three claw toes-the first toe in two patients and the other toes in the third). At the final clinical control, at a median follow-up of 176 months (range 26 to 275 months), the median MSTS score was 30 of 30 (range 28 to 30), the median ASES score was 98.3 (range 93 to 100), and the median Constant score was 93.5% (range 79% to 100%). Revision-free survival was 71% (95% CI 53% to 96%) at 5 years and 57% (95% CI 37% to 88%) at 10 and 15 years; VFG removal-free survival was 94% (95% CI 83% to 100%) at 5, 10, and 15 years., Conclusion: VFG appears to be an effective reconstructive option after humeral intercalary resection for primary bone tumors. These are complex procedures and should be performed by an experienced team of surgeons who recognize that complications may occur frequently in the first years after the procedure. The frequency of mechanical complications observed in the first 5 years postoperatively may be lessened by using long spanning-plate fixation, and if successful, this reconstruction provides a long-term, durable reconstruction with excellent functional results., Level of Evidence: Level IV, therapeutic study., Competing Interests: Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Association of Bone and Joint Surgeons.)

Competing Interests: The author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

Background: Large metastatic lesions of the diaphysis can cause considerable pain and result in difficult surgical challenges. Resection and cemented intercalary endoprosthetic reconstruction offer one solution to the problem, but it is an extensive operation that might not be tolerated well by a debilitated patient. The risk of aseptic loosening and revision after intercalary endoprosthetic replacement has varied in previous reports, which have not examined the risk of revision in the context of patient survival., Questions/purposes: (1) In a small case series from one institution, what is the survivorship of patients after cemented intercalary endoprosthetic replacement for diaphyseal metastasis, and what is the cumulative incidence of revision for any reason? (2) What are the complications associated with cemented intercalary reconstruction? (3) What is the functional outcome after the procedure as assessed by the MSTS93 score?, Methods: We retrospectively studied 19 patients with diaphyseal long bone metastases who were treated with resection and cemented intercalary endoprosthetic reconstruction by five participating surgeons at one referral center from 2006 to 2017. There were 11 men and eight women with a median age of 59 years (range 46 to 80 years). The minimum follow-up required for this series was 12 months; however, patients who reached an endpoint (death, radiographic loosening, or implant revision) before that time were included. One of these 19 patients was lost to follow-up but was not known to have died. The median follow-up was 24 months (range 0 to 116 months). Eight of the 19 patients presented with pathologic fractures. Ten of 19 lesions involved the femur, and nine of 19 were in the humerus. The most common pathologic finding was renal cell carcinoma (in 10 of 19). Survival estimates of the patients were calculated using the Kaplan-Meier method. A competing risks estimator was used to evaluate implant survival, using death of the patient as the competing risk. We also estimated the cumulative incidence of aseptic loosening in a competing risk analysis. Radiographs were analyzed for radiolucency at the bone-cement-implant interfaces, fracture, integrity of the cement mantle, and component position stability. Complications were assessed using record review that was performed by an individual who was not involved in the initial care of the patients. Functional outcomes were assessed using the MSTS93 scoring system., Results: Patient survivorship was 68% (95% CI 50% to 93%) at 1 year, 53% (95% CI 34% to 81%) at 2 years, and 14% (95% CI 4% to 49%) at 5 years; the median patient survival time after reconstruction was 25 months (range 0 to 116 months). In the competing risk analysis, using death as the competing risk, the cumulative incidence of implant revision was 11% (95% CI 2% to 29%) at 1 year and 16% (95% CI 4% to 36%) at 5 years after surgery; however, the cumulative incidence of aseptic loosening (with death as a competing risk) was 22% (95% CI 6% to 43%) at 1 year and 33% (95% CI 13% to 55%) at 5 years after surgery. Other complications included one patient who died postoperatively of cardiac arrest, one patient with delayed wound healing, two patients with bone recurrence, and one patient who experienced local soft tissue recurrence that was excised without implant revision. Total MSTS93 scores improved from a mean of 12.6 ± 8.1 (42% ± 27%) preoperatively to 21.5 ± 5.0 (72% ± 17%) at 3 months postoperatively (p < 0.001) and 21.6 ± 8.5 (72% ± 28%) at 2 years postoperatively (p = 0.98; 3 months versus 2 years)., Conclusion: Resection of diaphyseal metastases with intercalary reconstruction can provide stability and short-term improvement in function for patients with advanced metastatic disease and extensive cortical destruction. Aseptic loosening is a concern, particularly in the humerus; however, the competing risk analysis suggests the procedure is adequate for most patients, because many in this series died of disease without undergoing revision., Level of Evidence: Level IV, therapeutic study ., Competing Interests: All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2023 by the Association of Bone and Joint Surgeons.)

French bulldogs (FBD) are reported to be at an increased risk of developing humeral condylar fractures (HCF). Spaniel breeds have been reported to be at increased risk of HCF due to a high prevalence of humeral intracondylar fissures (HIF), which can predispose to fracture. The aims of this retrospective, single center, observational study were twofold. First, to compare the signalment, fracture configuration, and etiology of populations of FBD and spaniel breeds presenting with HCF at a single hospital. Second, to evaluate the computed tomographic (CT) findings of the contralateral elbow joints of FBD and spaniel breeds presenting with HCF for concomitant pathology. FBDs were overrepresented for HCF, most commonly presenting when skeletally immature, with a median age of 3.7 months. Fractures of the lateral condyle were the most common configuration for both breed groups. Sclerosis at the fracture site was identified in 62% of FBD and 95% of spaniels undergoing CT scans. Humeral intracondylar fissures and intracondylar sclerosis were commonly observed in the contralateral elbows of FBD (44% and 50%, respectively) and spaniel breeds (58% and 95%, respectively). Medial coronoid pathology, elbow incongruency, and periarticular osteophytes were not identified in the contralateral elbows of FBD but were identified in 29%, 4%, and 20% of spaniels, respectively. The high prevalence of HIF in the FBD group may be a predisposing factor for HCF in this breed., (© 2023 The Authors. Veterinary Radiology & Ultrasound published by Wiley Periodicals LLC on behalf of American College of Veterinary Radiology.)

Basal cell carcinoma (BCC) is the most common skin cancer, and most of the reports have involved the head and neck, but it is rare for it to be highly invasive, with an invasion of long bone being extremely rare. A 73 year old woman presented with a giant BCC on her right arm. Magnetic resonance imaging suggested the involvement of the right humerus. Biopsy confirmed the nodular type of BCC. The patient underwent BCC excision including hemicortical humerus excision with fibula allograft and latissimus dorsi flap with a split-thickness skin graft. Excluding a transient radial nerve palsy, the patient's postoperative course was otherwise uncomplicated. Although BCC invasion into the long bone is extremely rare, the gold standard treatment is, as a rule, en bloc surgical resection with a wide variety of reconstructive techniques. This treatment is only possible through the collaboration of general surgery, orthopedics, and plastic surgery.

Abstract: Renal cell carcinoma (RCC) with isolated humeral metastasis as the initial presentation is rare. We reported FDG PET/CT findings of isolated humeral metastasis from RCC in a 63-year-old man with right upper arm pain as the initial presentation. The bone scanning in an outside hospital showed that the focus with increased uptake of the right humerus was possibly malignant. FDG PET/CT showed that the right humeral mass had intense activity, and there was an additional FDG lesion in the lower pole of the right kidney. The mass of the right humerus was later confirmed as humeral metastasis from RCC by pathological examination., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Osteosarcoma is the most common bone sarcoma and is typically found in the distal femur, proximal tibia, and proximal humerus. While several factors are known to influence survival, less is known regarding the influence of primary tumor location. This study describes the clinical features and prognosis of mandibular osteosarcoma. The SEER database was utilized to identify cases of mandibular osteosarcoma diagnosed between 2004 and 2015. Sex, age, grade, histological subtype, tumor size, tumor extension, presence of metastasis at diagnosis, and therapeutic intervention were determined. Osteosarcomas originating from other sites were assessed for comparison. There were 164 cases of mandibular osteosarcoma identified, representing 5.5% of all surveyed osteosarcomas. The 2-, 5-, and 10-year overall survival rates were 79.9%, 65.6% and 58.5%, respectively. Survival was worse for patients with older age, larger tumor size, metastatic disease, and absence of surgical resection. Compared to other sites, mandibular osteosarcomas were significantly smaller tumors and were far less likely to metastasize. Mandibular osteosarcoma manifested at an older age than the more common extremity osteosarcomas and presented with smaller tumors. Rates of metastasis of jaw osteosarcoma were much lower than osteosarcoma found in the extremities, while mortality rates were comparable., (Copyright © 2022 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Authors have commonly observed lamellar periosteal new bone formation at the cranial aspect of the humeral diaphysis in mediolateral radiographs of the humerus for large breed dogs with no evidence of pain or lameness. The aim of this retrospective, analytical study was to investigate the appearance and prevalence of "humeral periosteal reaction-like lesions" (HPRLL) in dogs and identify any predispositions. Mediolateral radiographs of humeri were evaluated and the presence and extent of "humeral periosteal reaction-like lesions" at the cranial aspect of the humerus were recorded. Macroscopic and histological examination of the humeri were performed for one dog with HPRLL. A total of 2877 mediolateral radiographs of 1727 dogs were included and focal or extended periosteal reaction-like lesions were found in 643 humeri of 387 dogs. Body weight ≥ 30 kg and age ≥ 7 years had a statistically significant, positive effect (P < 0.001) on the presence of HPRLL. German Shepherd dogs and Rottweilers were overrepresented in the group with HPRLL (P < 0.01). At the level of the HPRLL, the enthesis of the superficial pectoral muscles (M. pectoralis descendens and M. pectoralis transversus) to the Crista tuberculi majoris and Crista humeri were macroscopically and histologically identified. The authors propose that higher mechanical loads to the enthesis in large breed dogs may lead to physiological, age-related remodeling processes of the muscular attachment. The finding should not be confused with a pathological condition such as bone neoplasia., (© 2022 The Authors. Veterinary Radiology & Ultrasound published by Wiley Periodicals LLC on behalf of American College of Veterinary Radiology.)

(1) Background: Some of the goals of orthopedic surgical oncology are saving limbs and function. The humerus is the third most frequent site in primary tumors and one of the most involved sites for metastases. Prosthetic replacement with modular megaprosthesis is one of the treatment choices, but there are several types of complications, such as problems with function and pain. The aim of our study is to assess functional outcomes and shoulder instability in the reconstruction of proximal humerus metastases. (2) Methods: This is a retrospective observational study. Twenty-eight patients, with proximal humerus metastases, admitted to the department of Orthopaedics and Traumatology of our University Hospital between 2014 and 2022 were recruited. Each patient underwent resection and prosthetic replacement surgery with modular megaprosthesis. Clinical evaluation was assessed through MSTS score, WOSI index, and DASH score. (3) Results: Twenty patients were included in the study. Fairly good results, especially regarding pain, function, and emotional acceptance, were obtained in all three tests: DASH, MSTS, and WOSI. Patients who reported shoulder instability actually have worse outcomes than those who report having stable shoulders. In addition, patients with a resection >10 cm have worse outcomes than those who had a resection of 10 cm. No significant differences were found between the deltopectoral approach group and the lateral approach group. (4) Conclusions: Reconstructive surgery with megaprosthesis of the proximal humerus in patients with metastases can be considered a treatment option, especially in patients with pathological fractures or injuries with a high risk of fracture and good life expectancy. This study shows how this type of surgery affects instability, but in terms of functionality, pain, and patient satisfaction, it gives satisfactory results.

Abstract: Lung adenocarcinoma with humeral metastasis as the initial presentation is rare. We reported FDG PET/CT findings of solitary humeral metastasis from adenocarcinoma of the lung in a 57-year-old man with the right upper arm pain as the initial presentation. MRI showed bone destruction of the right humerus with a soft tissue mass, suggesting the possibility of malignancy. FDG PET/CT showed that the right humeral mass had strong activity, and there were additional FDG lesions in the right armpit, left apical lung, and left adrenal gland, which was later confirmed as humeral metastasis from lung adenocarcinoma by pathological examination., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Medical screening using ultrasonography (US) has been performed on young baseball players for early detection of osteochondritis dissecans (OCD) of the humeral capitellum. Deep learning (DL) and artificial intelligence (AI) techniques are widely adopted in the medical imaging research field., Purpose/hypothesis: The purpose of this study was to calculate the diagnostic accuracy using DL for US images of OCD. We hypothesized that using DL for US imaging would improve the prediction accuracy of OCD., Study Design: Cohort study (Diagnosis); Level of evidence, 2., Methods: A total of 40 elbows (mean age of patients, 12.1 years) that were suspected of having OCD at a medical checkup and later confirmed by radiographs and magnetic resonance imaging were included in the study. The affected elbows were used as the OCD group and the contralateral elbows as the control group. From US videos, 100 images per elbow were captured from different angles, and 4000 images of the elbows were prepared for both groups. Of these, 80% were randomly selected by DL models and used as training data; the remaining were used as test data. Transfer learning was conducted using 3 pretrained DL models. The confusion matrix and the area under the receiver operating characteristic curve (AUC) were used to evaluate the model, and the visualization of the areas deemed important by the DL models was also performed. Furthermore, OCD regions were detected using an automatic image recognition model based on DL., Results: Classification of the OCD image by the DL model was performed; the best accuracy score was 0.87; the recall was 1.00. AUC was high for all DL models. Visualization of important features showed that AI predicted the presence of OCD by focusing on the irregularity or discontinuity of the surface of subchondral bone. In the detection of OCD task, the mean average precision was 0.83., Conclusion: The DL on US images identified OCD with high accuracy. The important features detected by the DL models correspond to the areas used by clinicians in screening the US images. The OCD was also detected with high accuracy using the object detection model. The AI model may be used in medical screening for OCD.

The proximal humerus is a common location for primary tumors, benign lesions, and metastatic disease. Advances in neoadjuvant and adjuvant therapy have allowed for limb-salvage surgery in most of the cases. There are numerous of options for surgical management of proximal humerus lesions and the decision to pursue one over another depends on factors such as age, comorbidities, pathology, location within the proximal humerus, planned resection margins/size of defect, and bone quality. Long-term outcomes for these techniques tend to be retrospective comparative studies, with recent studies highlighting the improved outcomes of reverse total shoulders., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Chondrosarcoma are malignant tumours in which neoplastic cells produce cartilage. The most commonly affected sites are pelvis, femur, humerus and ribs. Scapula involvement is relatively rare. Surgery remains the primary modality of treatment for chondrosarcoma. Radiotherapy is used as an adjuvant therapy in high grade tumours and in cases of residual disease. Present study reports a rare case of scapular chondrosarcoma in a 37 year old male, managed with multimodality treatment and discusses briefly the prognostic parameters and treatment modalities. Only few studies have discussed about scapular chondrosarcoma and more studies with larger number of patients are needed to develop an evidence-based treatment and follow-up protocol for these patients., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier Ltd.)

Background: The research on surgical outcomes of hemiarthroplasty and reverse total shoulder arthroplasty using allograft-prosthesis composites for the proximal humeral oncologic condition is still scarce. Therefore, this study aimed to compare surgical outcomes of shoulder joint reconstruction with hemiarthroplasty and reverse total shoulder arthroplasty using allograft-prosthesis composites for tumors of the proximal humerus., Methods: Eleven patients underwent hemiarthroplasty or reverse total shoulder arthroplasty using allograft-prosthesis composites for tumors of the proximal humerus between July 2011 and April 2018 were reviewed. Radiographic analysis for bone union of allograft-host bone junction, implant loosening, stress shielding and shoulder dislocation or subluxation was performed. Functional outcomes were evaluated using visual analog scales for pain, range of motion, Simple Shoulder Test score and Musculoskeletal Tumor Society score. Furthermore, oncologic outcome and complications were also assessed, respectively., Results: There were five patients with hemiarthroplasty (mean age, 23.2 years) and six patients with reverse total shoulder arthroplasty (mean age, 46.8 years, P = 0.05). Radiographically, there were no events associated with implant loosening, stress shielding and shoulder dislocation or subluxation in the two groups. There were no differences in functional outcomes between the two groups. There was no local recurrence in entire cohort. In the hemiarthroplasty group, one patient was required revision surgery to reverse total shoulder arthroplasty at postoperative 6 years due to rotator cuff dysfunction. In the reverse total shoulder arthroplasty group, one patient showed the fracture occurred at allograft-host bone junction at postoperative 6 months., Conclusions: Surgical outcomes of hemiarthroplasty with allograft-prosthesis composites were not inferior to reverse total shoulder arthroplasty when applied in properly selected patients. The authors recommended that hemiarthroplasty with allograft-prosthesis composites could be used for young age patients without glenoid metastasis involvement, and reverse total shoulder arthroplasty with allograft-prosthesis composites could be used for patients with old age or metastatic bone tumors., (© The Author(s) 2022. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Prosthetic reconstruction after wide resection of tumors of the proximal humerus presents a unique challenge. The shoulder is a complex articulation, and patients have high expectations for postoperative function. The goal of this study is to compare functional outcomes, oncologic outcomes, and complication rates for 2 reconstructive methods. Forty patients with proximal humeral tumors were reviewed retrospectively. Proximal humeral endoprosthesis (PHE) was used for 21 patients, and reverse shoulder arthroplasty (RSA) was used for 19 patients. Clinical results, oncologic outcomes, and complication rates were assessed. The functional outcomes of the patients were assessed with the Musculoskeletal Tumor Society scoring system (MSTS), the shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, and shoulder range of motion. The mean follow-up was 62±15 months. Shoulder dislocations occurred among 8 patients with PHE and 1 patient with RSA ( P =.021). The other complication rates were similar for the 2 groups ( P <.05). At the latest follow-up, the mean MSTS score was 68±10.3 for those with PHE and 76±7.7 for the patients with RSA ( P =.72). However, the QuickDASH score was significantly better ( P =.031) for those with RSA (mean, 19±6.3) compared with patients with PHE (mean, 30±4.8). Additionally, shoulder active abduction and forward flexion were significantly greater for the RSA group ( P =.04 and P =.03, respectively). Five patients had local recurrence. Prosthetic reconstruction after oncologic re-section of the proximal humerus is associated with significant limitation of shoulder range of motion and a high rate of revision surgery. However, in this study, RSA was associated with fewer dislocations, improved Quick-DASH score, and greater abduction and forward flexion compared with PHE. [ Orthopedics . 2022;45(6):e335-e341.].

Objectives: To estimate, using CT imaging, differences in the regional bone density of the humeral condyle in Labrador retriever elbows with and without medial coronoid process disease., Materials and Methods: The elbows of Labrador Retrievers that had undergone CT were reviewed. Scans were divided into three categories: elbows without medial coronoid process disease; elbows with medial coronoid process disease involving fragmentation of the radial incisure; elbows with medial coronoid process disease involving fragmentation of the medial coronoid apex. A templating technique was employed to define the weight-bearing regions of the medial and lateral portion of the humeral condyle and estimates of volumetric bone density (defined by Hounsfield unit measurement) were compared across the three groups., Results: CT evaluation was performed on 122 elbows in 81 dogs. There was a higher mean Hounsfield unit measurement in the medial and lateral portions of the humeral condyles in elbows with medial coronoid process disease involving fragmentation of the medial coronoid apex compared with elbows with medial coronoid process disease involving fragmentation of the radial incisure., Clinical Significance: Dogs with apical fragmentation of the medial coronoid process exhibited significantly higher estimated bone mineral density within the medial portion of the humeral condyle when compared to dogs with radial incisure fragmentation. The medial portion of the humeral condyle may be associated with the pathogenesis of apical but not radial incisure medial coronoid process fragmentation in Labrador Retrievers., (© 2022 British Small Animal Veterinary Association.)

Background: For patients with malignant limb tumors, salvage surgery can be achieved using endoprosthesis or biological reconstructions like allograft or autograft. In carefully selected patients, resected bone can be recycled after sterilization using methods like autoclaving, irradiation, pasteurization or freezing with liquid nitrogen. We evaluated the clinical outcome and complications of malignant limb tumors treated with intercalary resection and frozen autograft reconstruction., Methods: We reviewed 33 patients whose malignant bone tumors were treated by wide resection and reconstruction with recycling liquid nitrogen-treated autografts between 2006 and 2017. Limb function, bone union at the osteotomy site and complications were evaluated. Functional outcome was assessed using the Musculoskeletal Tumor Society (MSTS) scoring system., Results: The cohort comprised 16 males and 17 females, with a mean age of 35.4 years (14-76 years). The most common tumor was osteosarcoma (7 cases). Tumors were located in the humerus (5), ulna (1), femur (10) and tibia (17). The mean follow-up was 49.9 months (range 12-127 months). Of the 33 patients, 16 remained disease-free, and 3 were alive with disease. The mean size of the defect after tumor resection was 11.6 cm (range 6-25 cm). Bone union was achieved in 32 patients, with a mean union time of 8.8 months (range 4-18 months). Complications included 1 graft nonunion, 2 infections (1 superficial, 1 deep infection), 1 leg length discrepancy, 2 graft fractures and 3 local recurrences. The mean MSTS score was 87.2% (range 70-100%)., Conclusion: Liquid nitrogen-treated tumor-bearing autograft is an effective option for biological reconstruction after meta-/diaphyseal tumor resection of long bones. This method has excellent clinical outcomes and is especially recommended for patients with no severe osteolytic bone tumors., (© 2022. The Author(s).)

Objective: The purpose of this study was to describe a surgical technique of bone resection with periosteal preservation and reconstruction in patients with high-grade bone malignant tumors and to determine its effect on local recurrences, and time and quality of bone union in bone autografting reconstruction., Patients and Methods: We retrospectively reviewed 11 cases of high-grade malignant bone tumors in children aged 4 to 16 years, who were treated with chemotherapy and tumor resection while preserving partially the adjacent periosteum. Tumors were located in the lower limb in eight cases; three tumors were in the humerus. The mean length of the bone defect after resection was 15.8 cm (range, 6-34.5 cm). Reconstruction was provided by non-vascularized autograft in eight cases (lower limb) and polymethyl methacrylate spacer in three cases (upper limb). Patients were followed up for a mean of 71 months., Results: At the last follow-up, no patients had local recurrence. Three patients were dead because of metastasis. Bone union was good in time and quality in all children who had bone autografting. In cases of PMMA reconstruction, there was periosteal bone formation around the spacer. According to the MSTS functional score, patients with lower limb localizations had a mean score of 27.75 points and patients with upper limb localizations had a score of 24/30., Conclusion: Preservation of the periosteum in bone resection for malignant tumors could be a good adjuvant alternative for bone reconstruction, without increasing the risk of local recurrence. However, patients must be carefully selected., (© 2022. The Author(s).)

Background: The purpose of this study was to investigate the feasibility of using a three-dimensional (3D)-printed arthrodesis prosthesis for reconstruction of the proximal humeral defect after tumor resection., Methods: A novel proximal humeral prosthesis was designed to restore bone continuity and shoulder arthrodesis and was fabricated via 3D printing technology. Ten patients with primary malignancies in the proximal humerus underwent intra-articular resection and replacement with this prosthesis from 2017 to 2019. Baseline and operative data, oncological and prosthetic survival, and functional status were summarized., Results: This cohort consisted of 9 males and 1 female with a mean age of 32.1 ± 16.1 years. Diagnoses included 5 cases of osteosarcoma, 3 cases of chondrosarcoma and 1 each case of undifferentiated pleomorphic sarcoma and malignant myoepithelioma. The mean operative duration, intraoperative hemorrhage and postoperative length of hospitalization were 151.5 ± 61.0 min, 410.0 ± 353.4 ml and 5.3 ± 1.9 d, respectively. The mean follow-up duration was 29.3 ± 6.4 months, with a minimum of 24 months for the surviving patients. Two patients experienced local recurrence, and four patients developed distant metastases. Detachment of the taper occurred in two patients. One was managed conservatively, and the other received amputation due to concurrent tumor recurrence. The mean MSTS-93 and ASES scores and ranges of forwards flexion and abduction were 24.9 ± 3.1, 79.4 ± 8.3, 71.3 ± 19.4°, and 61.3 ± 16.4°, respectively. The functional outcomes were independent of the preservation of the axillary nerve. Histological study of the glenoid component showed evidence of bone ingrowth at the bone-prosthesis porous interface., Conclusion: Application of the 3D-printed arthrodesis prosthesis might be a safe and efficacious method for functional reconstruction in patients who underwent resection of the proximal humerus, especially for those without preservation of the axillary nerve., (© 2022. The Author(s).)

Background: Although most unicameral bone cysts (UBCs) are either successfully treated or have healed by the time of skeletal maturity, a small proportion of patients will have persistent UBCs beyond the age of skeletal maturity. More reliable methods are needed to treat persistent UBCs in the humerus because these cysts are associated with a high risk of fracture due to thinning of the humeral cortex. In this study, we evaluated whether inserting a fibular strut allograft into the humerus would be associated with healing of the cyst and union of associated pathologic fractures in skeletally mature patients with a UBC of the proximal humerus., Questions/purposes: (1) How effective is inserting a fibular strut allograft in the healing of proximal humerus UBCs in skeletally mature patients with bone cysts and associated fractures? (2) What are the functional results of this procedure? (3) What complications are associated with this procedure?, Methods: Between 2005 and 2018, we surgically treated 23 skeletally mature patients with persistent humeral UBCs and any of the following indications: a progressive cyst that was not responsive to aspiration and 2 to 3 steroid injections, a cyst with a pathologic fracture, and a cyst at high risk of fracture. Of those, patients with a cyst located in the proximal humerus and a defect length more than 6 cm (n = 18) were considered eligible to be treated with insertion of a fibular strut allograft through a hole created in the greater tuberosity. A further two patients were excluded because they were treated by other surgical methods. From the remaining 16 patients, two patients were lost to follow-up before 2 years and could not be analyzed in this study. Another two patients had incomplete datasets, leaving 12 for analyses in this retrospective study. Three patients presented with a pathologic fracture. Complete filling of the cysts with bone within 24 months was regarded as healing, and after 24 months it was classified as delayed healing. Cyst consolidation with small residual areas of osteolysis was considered healed with residual radiographic appearance. Fracture union was determined by the clear observation of at least three of four cortical views bridged by bone in the radiographic follow-up 3 months after the operation. Fractures in which the cortices were not bridged by bone after 3 months were regarded as a delayed union. The functional outcome of the patients was assessed by the Musculoskeletal Tumor Society (MSTS) scoring system, with a total score ranging from 0 to 30. A higher score was indicative of less pain and better function. MSTS scores were obtained through a chart review by an orthopaedist who was not involved in the care administered., Results: At a median (range) follow-up of 57 months (33 to 87), the cyst was completely healed in nine patients and healed with residual cyst in the remaining three. Union was observed within 3 months in all patients who presented with a pathologic fracture. The median MSTS score of the patients was 30 (28 to 30). No postoperative complications such as persistent pain or re-fracture were observed., Conclusion: The primary goal of treating a UBC of the proximal humerus is to prevent fracture of the affected bone; insertion of a fibular strut graft in this study met this goal. Therefore, we believe a fibular strut allograft insertion is worth consideration when treating proximal humeral UBCs in skeletally mature patients. Further studies will be needed to determine whether this approach has benefits compared with other treatment options., Level of Evidence: Level IV, therapeutic study., Competing Interests: Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2021 by the Association of Bone and Joint Surgeons.)

Background: There is no agreement about the best reconstructive option following resection of proximal humerus tumors. The purpose of this study was to compare the functional outcomes of endoprosthesis reconstruction versus nail cement spacer reconstruction after wide resection of proximal humeral tumors., Methods: This retrospective comparative study included 58 patients with proximal humerus tumors who had undergone tumor resection and reconstruction with modular endoprosthesis (humeral hemiarthroplasties) or cement spacer. Medical records were reviewed for the epidemiological, clinical, radiological, and operative data. Lung metastasis, local recurrence, and complication were also reviewed. The functional outcome was evaluated using the Musculoskeletal Tumor Society scoring (MSTS) system., Results: Nineteen patients with a mean age of 33.4 ± 17.5 years underwent reconstruction by modular endoprosthesis, and 39 patients with a mean age of 24.6 ± 14.3 years underwent reconstruction by cement spacer. The mean MSTS score was 24.8 ± 1.1 in the endoprosthesis group and 23.9 ± 1.4 in the spacer group, P = 0.018. Complications were reported in 5 (26.3%) patients in the endoprosthesis group and 11 (28.2%) patients in the spacer group, P = 0.879. There were no statistically significant differences in the functional outcomes in both patient groups with or without axillary or deltoid resection., Conclusions: Both endoprostheses and cement spacers are durable reconstructions with almost equal functional outcomes with no added advantage of the expensive endoprosthesis., (© 2022. The Author(s).)

Background/aim: The effectiveness of clavicula pro humero (CPH) reconstruction for pediatric proximal humerus sarcoma has been reported in a small number of cases. We aimed to investigate the effectiveness of biological CPH reconstruction for malignant bone tumors of the proximal humerus in children and adults., Patients and Methods: This was a retrospective cohort study that included eight patients who underwent CPH reconstruction due to a malignant bone tumor around the proximal humerus. Postoperative parameters, including complications, postoperative upper limb function, and the period until bone fusion, were investigated., Results: Three patients had non-union and fracture of the clavicular segment. Among them, one patient underwent revision surgery for internal fixation and bone grafting. Five patients achieved bone fusion, and the overall mean Musculoskeletal Tumor Society score was 70%, which is comparable to previous reports., Conclusion: CPH reconstruction is an effective technique for malignant bone tumors of the proximal humerus in all ages., (Copyright © 2022 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Anterior glenohumeral instability is an increasingly common injury among young military servicemen. First-time dislocations occurring in combination with anterior labral tears and humeral avulsion of glenohumeral ligament lesions, although rare, significantly contribute to further shoulder dysfunction with recurrent instability and pain. Tears of the pectoralis major are also a type of injury more common in the military population, with operative management resulting in decreased strength. We present a unique case of a young, active duty male that sustains an anterior shoulder dislocation with a concomitant pectoralis major tendon rupture while bench press weight lifting in preparation for the Army Special Forces selection. To the best of our knowledge, this is the first case presented in the literature describing management of a simultaneous anterior shoulder dislocation, humeral avulsion of glenohumeral ligament lesion, and pectoralis major tendon rupture treated with a single operation. After aggressive rehabilitation, the patient was able to successfully pass Special Forces selection and has near full function of the operative shoulder with remarkable satisfaction scores., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Case: Multifocal synchronous primary skeletal chondrosarcomas of an extremity are rarely reported. In this study, we report 2 such cases. The first case is a 32-year-old woman who presented with extensive right femoral and tibial diaphysis lesions. The second case is a 36-year-old woman with lesions in the left proximal humerus, the coracoid process of scapula and sternum. Both patients underwent limb salvage surgery and were disease-free at the 38- and 20-month follow-up., Conclusion: Athough rare, the possibility of multifocal chondrosarcoma should be kept in mind during the workup of a patient with chondrosarcoma., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B795)., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

»: The most common type of humeral avulsion of the glenohumeral ligament (HAGL) is a purely ligamentous avulsion involving the anterior inferior glenohumeral ligament (IGHL), but other variants are seen, including posterior lesions and those with an osseous avulsion., »: A central lesion between the intact anterior and posterior bands of the IGHL is gaining recognition as a distinct clinical entity., »: HAGL lesions are most commonly seen in patients with anterior instability without a Bankart tear or in those with persistent symptoms despite having undergone a Bankart repair., »: Magnetic resonance imaging is the most sensitive imaging modality. An arthrogram is helpful with subacute and chronic lesions when the joint is not distended. Arthroscopy is the gold standard for diagnosis., »: While some have reported success with nonoperative management, surgical repair with either arthroscopic or open techniques has provided a high rate of successful outcomes; however, the literature is limited to mostly Level-IV and V evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSREV/A795)., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

The study goal was to evaluate the distances from the radial (RN), the musculocutaneous (MN) and axillary nerves (AN) and the medial neurovascular bundle of the upper arm to a minimally invasive applied plate and to define its relation to the RN during different degrees of malrotation during MIPO. The sample involved ten upper extremities. Application of a PHILOS plate was performed through a Delta-split. Intervals between the AN, MN, RN and the medial vascular bundle were defined at various positions. The humeral shaft was artificially fractured at a height of about the mean of the plate. The distal fragment was brought into 15° and 30° internal (IR) as well as external rotation (ER) and here, the plate's relation to the RN was evaluated. The medial neurovascular bundle intersected the plate at its distal part in two specimens. Regarding the distances from the RN to the plate during different rotation positions the distances became significantly longer during ER, respectively shorter during IR. The medial neurovascular bundle and the RN were identified as the main structures at risk. Care must be taken during distal screw placement and malrotation exceeding 15° must be avoided during MIPO., (© 2022. The Author(s).)

Design and processing capabilities of additive manufacturing (AM) to fabricate complex geometries continues to drive the adoption of AM for biomedical applications. In this study, a validated design methodology is presented to evaluate AM as an effective fabrication technique for reconstruction of large bone defects after tumor resection in pediatric oncology patients. Implanting off-the-shelf components in pediatric patients is especially challenging because most standard components are sized and shaped for more common adult cases. While currently reported efforts on AM implants are focused on maxillofacial, hip and knee reconstructions, there have been no reported studies on reconstruction of proximal humerus tumors. A case study of a 9-year-old diagnosed with proximal humerus osteosarcoma was used to develop a patient-specific AM prosthesis for the humerus following tumor resection. Commonly used body-centered cubic (BCC) structures were incorporated at the surgical neck and distal interface in order to increase the effective surface area, promote osseointegration, and reduce the implant weight. A patient-specific prosthesis was fabricated using electron beam melting method from biocompatible Ti-6Al-4V. Both computational and biomechanical tests were performed on the prosthesis to evaluate its biomechanical behavior under varying loading conditions. Morphological analysis of the construct using micro-computed tomography was used to compare the as-designed and as-built prosthesis. It was found that the patient-specific prosthesis could withstand physiologically-relevant loading conditions with minimal permanent deformation (82 μm after 105 cycles) at the medial aspect of the porous surgical neck. These outcomes support potential translation of the patient-specific AM prostheses to reconstruct large bone defects following tumor resection., Competing Interests: TransMachine Additive (NC, USA) provided support on EBM fabrication of the patient-specific implant in this study. This does not alter our adherence to PLOS ONE policies on sharing data and materials. There are no patents, products in development or marketed products associated with this research to declare.

Purpose: To evaluate with computed tomography (CT) the incidence of implant-related osteolysis after implantation of two types of all-suture anchors during remplissage for the management of Hill-Sachs lesions in shoulder instability., Methods: Single-cohort, observational study with a minimum of 12 months follow-up. Twenty-five participants (19 males and 6 females; mean age 37.4 years [SD: 11.6]) with Hill-Sachs lesions requiring remplissage were evaluated with a CT performed a mean of 14.1 [3.74] months after surgery. Fifty-five all-suture anchors (19 2.3 mm Iconix and 36 1.7 mm Suturefix) were used. The volume of the bone defects was measured in the CT. Every anchor was classified into one of four groups: (1) no bone defect. (2) Partial bone defect (bone defects smaller than the drill used for anchor placement). (3) Tunnel enlargement (bone defect larger than the drill volume but smaller than twice that volume). (4) Cystic lesion (bone defect larger twice the drill volume)., Results: No bone defect was identified in only two anchors (3.6%, 95% CI 0.4-12.5%). A partial bone defect was found in eight anchors (14.5%, 95% CI 6.5-26.7%). In 35 anchors (63.6%, 95% CI 49.6-76.2%), there was enlargement of the bone defect that was smaller than 200% the size of the drill used. Ten anchors caused bone defects larger than twice the size of the drill used (18.2%, 95% CI 9.1-30.9%). The defect size was a mean of 89 mm 3 (SD: 49 mm 3 , minimum 0 mm 3 , maximum 230 mm 3 )., Conclusion: When using all-suture anchors in arthroscopic remplissage during instability surgery, relevant bone osteolytic defects are common at 1-year-follow-up. Cystic defects larger than twice the volume of the resected bone during implantation develop in one in six anchors and significant tunnel widening will develop in another three out of five anchors. This bone loss effectively increases the size and depth of the Hill-Sachs lesions but does not seem to affect short-term clinical outcomes., Level of Evidence: Level IV.

Background: Arthroscopic rotator cuff surgery is an effective treatment for rotator cuff tears with the considered use of double-row repair techniques becoming popular in the last decade. We aim to compare the effects of double- and single-row arthroscopic rotator cuff repairs (ARCR) on repair integrity (RI) and acromiohumeral distance (AHD)., Methods: In this observational study, we retrospectively identified 98 patients with degenerative rotator cuff tear treated with arthroscopic rotator cuff repair between 2016 and 2019. We excluded 22 patients with partial-thickness tears, 15 with associated subscapularis or SLAP tears, 13 with massive tears, and 5 patients lost to follow-up; we included 43 patients who had ARCR for full-thickness cuff tear and clinical, radiologic follow-up. Of these 43 patients, 23 are grouped as double-row repair group (DRG) and 20 as single-row repair group (SRG). A minimum of 12 months after the surgery, bilateral shoulder MRIs were obtained. Contralateral shoulders without asymptomatic rotator cuff tears served as a control group (CG). The operating surgeon and two other surgeons experienced in arthroscopy blindly measured the AHD and determined the RI at the control MRIs in all groups. Functional assessments relied on UCLA and qDASH Scores., Results: The mean age was 57.89 (45-78) years, and the mean follow-up time was 28,65 (21-43) months. The mean AHD of the CG was 9.7 ± 0.96 mm, the preoperative AHD of DRG was 8.62 ± 1.45 mm, and SRG was 9.71 ± 0.95 mm. The postoperative mean AHD of DRG 9.61 ± 1.83 mm and SRG was 10.21 ± 1.97 mm. AHD differences between the preoperative and postoperative groups were significant (P=0.009). The increase of the AHD in the double-row group was significantly higher than the single-row group (P=0.004). There was a high correlation between the RI and DASH scores (P=0.005). RI did not correlate with the repair method (P=0.580)., Conclusion: Although double-row repairs can maintain greater AHD than single-row repairs in the clinical setting, this difference did not affect functional results. Regardless of the surgical intervention, functional results are favourable if RI is achieved., Level of Evidence: Level III, Retrospective Cohort Study.

An enthesis refers to the interface at which a tendon or a ligament integrates into the periosteum. Its morphology can be influenced by intrinsic factors such as sex, age, and extrinsic factors such as levels of activity, which will in turn impact on bone remodeling and lead to morphological changes. In bioarcheology, entheseal changes have had a long tradition of being used for the reconstruction of past activities. The literature has shown that in some cases of osteoarthritis, entheseal changes are associated with osteoarthritic manifestations. This work aims to evaluate the relationship between the degree of entheseal changes and the severity of osteodegenerative processes. The studied materials consisted of 30 humeri and 30 femora from the osteological collection at St George's University of London. Intensities of both entheseal changes and osteodegenerative processes were macroscopically assessed and scored. The difference in scores of entheseal changes between osteoarthritic groups and nonosteoarthritic groups is statistically significant at a confidence level of 95% (α = .05) for both the humeri and femora. Results show a positive correlation between the degree of entheseal changes and the severity of osteodegenerative processes in the femora, suggesting that enthesis may play a role in osteoarthritis. Findings from this work supports the proposed hypothesis that the degree of entheseal changes and the severity of osteoarthritic manifestation are related. This work contributes to current knowledge that osteoarthritis is a disease involving the whole joint; the enthesis could potentially be a target for the diagnosis of osteoarthritis., (© 2020 American Association for Anatomy.)