Explore the vast range of titles available.

Background Fractures of the proximal humerus are associated with a profound temporary and sometimes permanent, impairment of function and quality of life. The treatment of comminuted fractures of the proximal humerus like selected three-or four-part fractures and split fractures of the humeral head is a demanding and unresolved problem, especially in the elderly. Locking plates appear to offer improved fixation; however, screw cut-out rates ranges due to fracture collapse are high. As this may lead to higher rates of revision surgery, it may be preferable to treat comminuted fractures in the elderly primarily with a prosthesis or non-operatively. Results from case series and a small-sample randomized controlled trial (RCT) suggest improved function and less pain after primary hemiarthroplasty (HA); however these studies had some limitations and a RCT is needed. The primary aim of this study is to compare the Constant scores (reflecting functional outcome and pain) at one year after primary HA versus non-operative treatment in elderly patients who sustained a comminuted proximal humeral fracture. Secondary aims include effects on functional outcome, pain, complications, quality of life, and cost-effectiveness. Methods/Design A prospective, multi-center RCT will be conducted in nine centers in the Netherlands and Belgium. Eighty patients over 65 years of age, who have sustained a three-or four part, or split head proximal humeral fracture will be randomized between primary hemiarthroplasty and conservative treatment. The primary outcome is the Constant score, which indicates pain and function. Secondary outcomes include the Disability of the Arm and Shoulder (DASH) score, Visual Analogue Scale (VAS) for pain, radiographic healing, health-related quality of life (Short-form-36, EuroQol-5D) and healthcare consumption. Cost-effectiveness ratios will be determined for both trial arms. Outcome will be monitored at regular intervals over the subsequent 24 months (1, 3 and 6 weeks, and 3, 6, 12, 18, and 24 months). Data will be analyzed on an intention to treat basis, using univariate and multivariable analyses. Discussion This trial will provide level-1 evidence on the effectiveness of the two mostly applied treatment options for three-or four part and split head proximal humeral fractures in the elderly. These data may support the development of a clinical guideline for treatment of these traumatic injuries. Trial registration Netherlands Trial Register (NTR): NTR2040

Background The optimal surgical management of dislocated three- and four-part fractures of the proximal humerus in elderly patients remains unclear. Most used techniques are hemiarthroplasty and angle-stable locking compression plate osteosynthesis. In the current literature there is no evidence available presenting superior results between hemiarthroplasty and angle-stable locking compression plate osteosynthesis in terms of speed of recovery, pain, patient satisfaction, functional outcome, quality of life or complications. Methods/Design A randomized controlled multicenter trial will be conducted. Patients older than 60 years of age with a dislocated three- or four-part fracture of the proximal humerus as diagnosed by X-rays and CT-scans will be included. Exclusion criteria are a fracture older than 14 days, multiple comorbidity, multitrauma, a pathological fracture, previous surgery on the injured shoulder, severely deranged function caused by a previous disease, \"head-split\" proximal humerus fracture and unwillingness or inability to follow instructions. Participants will be randomized between surgical treatment with hemiarthroplasty and angle-stable locking compression plate osteosynthesis. Measurements will take place preoperatively and 3 months, 6 months, 9 months, 12 months and 24 months postoperatively. Primary outcome measure is speed of recovery of functional capacity of the affected upper limb using the Disabilities of Arm, Shoulder and Hand score (DASH). Secondary outcome measures are pain, patient satisfaction, shoulder function, quality of life, radiological evaluation and complications. Data will be analyzed on an intention-to-treat basis, using univariate and multivariate analyses. Discussion Both hemiarthroplasty and angle-stable locking compression plate osteosynthesis are used in the current treatment of dislocated three-and four-part fractures of the proximal humerus. There is a lack of level-1 studies comparing these two most-used surgical treatment options. This randomized controlled multicenter trial has been designed to determine which surgical treatment option provides the fastest recovery of functional capacity of the affected upper limb, and will provide better outcomes in pain, satisfaction, shoulder function, quality of life, radiological evaluation and complications. Trial registration number The trial is registered in the Netherlands Trial Registry ( NTR2461 )

There is no information on the sensory innervation at the flexor muscle origin at the medial epicondyle of the humerus and it is not known if substance P receptors (Neurokinin 1-receptors, NK1-R) are present in tendon insertions in general. In the present investigation, we have studied the muscle origin in patients suffering from medial epicondylalgia and tennis elbow. Immunohistochemistry and antibodies to substance P (SP) and CGRP as well as the general nerve marker PGP 9.5 were used. Specific immunoreactions were observed in nerve bundles and as free nerve fibers. The immunoreactive structures were partly seen in association with some of the blood vessels. The observations constitute a morphological correlate for the occurrence of nerve mediated effects in this region. By using immunohistochemistry and antibodies to NK1-R, the distribution of this receptor was studied at the insertion of the proximal tendon of the extensor carpi radialis brevis muscle at the lateral epicondyle. Specific immunoreactions were seen as varicose fibers occurring as single fibers or grouped into bundles, indicating that SP has effects in the nerves in this region. The results give further evidence for a possible neurogenic involvement in the pathophysiology of tennis elbow and in medial epicondylalgia.

Background There are several options for reconstruction of proximal humerus resections after wide resection for malignant tumors in children. The clavicula pro humero technique is a biologic option that has been used in the past, but there are only scant case reports and small series that comment on the results of the procedure. Because the longevity of children mandates a reconstruction with potential longevity not likely to be achieved by other techniques, the clavicula pro humero technique may be a potential option in selected patients. Questions/purposes (1) How successful is the clavicula pro humero procedure in achieving local tumor control? (2) What is the frequency of nonunion? (3) What are the complications of the procedure? (4) What scores do patients achieve (on the Musculoskeletal Tumor Society (MSTS) and the Toronto Extremity Salvage Score (TESS) after this procedure? Methods Four university hospitals performed the clavicula pro humero technique in eight children aged 8 to 18 years between June 2006 and February 2014. During that period, general indications for this approach included all reconstructions of the proximal humerus for malignant tumors in children older than 8 years. All patients were followed for a mean of 40 months (range, 25–86 months); one patient was lost to followup before 2 years. The tumor resections removed the rotator cuff muscles in all patients, glenohumeral joint in five, and deltoid muscle in three. The median length of the bone defect after resection was 20 cm (range, 7–25 cm). It was reduced to 9 cm (range, 0–17 cm) or 27% (range, 0%–64%) of the total humerus length after clavicular rotation. Direct osteosynthesis (one patient), induced membrane technique (one patient), or vascularized fibular autograft (six patients) was used to complete the defect after rotation of the clavicle if necessary. Presence of union (defined as bone healing before 10 months, as assessed by disappearance of the osteotomy on AP and lateral view radiographs), and complications were determined by chart review performed by a surgeon not involved in patient care. Function assessed by the MSTS and the TESS scores were determined by the patients with their families. Results None of the patients had tumor recurrence. One patient died of pulmonary metastases before the 2-year followup. Proximal and distal bone unions were achieved before 10 months without an additional surgical procedure in two and six of seven patients, respectively. Fourteen local complications occurred resulting in nine revision operations. The main complication was aseptic proximal pseudarthrosis (five patients); other complications included one proximal junction fracture, one clavicle fracture complicated by clavicle osteolysis, one distal junction fracture, one necrosis of the skin paddle of the fibular autograft, one glenoclavicular ossification, and one distal pseudarthrosis complicated by a fracture of this distal junction. Function, as assessed by the MSTS score, was a median of 23 of 30 (range, 11–27). The median TESS score was 82% (range, 75%–92%). Shoulder ROM (median; range) in abduction, front elevation, and external and internal rotations were 70°(30°–90°), 75°(30°–85°), 10°(0°–20°), and 80°(80°–100°), respectively. Three of the seven patients reported dissatisfaction with the cosmetic appearance. Conclusions The clavicula pro humero technique achieved oncologic local control after resection and reconstruction of proximal humerus tumors in children. Although union times are approximately 2 years and some patients underwent augmentation with other grafts, it eventually provides a solid, painless, biologic, and stable reconstruction and creates a mobile acromioclavicular joint and generally good function. Nonunion of the proximal junction is the main complication of this technique. We cannot directly compare this technique with other reconstruction options, and longer followup is needed, but this may be a useful reconstruction option to consider in select pediatric patients with sarcomas of the proximal humerus. Level of Evidence Level IV, therapeutic study.

Background Central chondrosarcoma of bone is graded on a scale of 1 to 3 according to histological criteria. Clinically, these tumors can be divided into low-grade (Grade 1) and high-grade (Grade 2, Grade 3, and dedifferentiated) chondrosarcomas. Although en bloc resection has been the most widely used treatment, it has become generally accepted that in selected patients with low-grade chondrosarcomas of long bones, curettage is safe and effective. This approach requires an accurate preoperative estimation of grade to avoid under- or overtreatment, but prior reports have indicated that both imaging and biopsy do not always give an accurate prediction of grade. Questions/purposes (1) What is the concordance of image-guided needle preoperative biopsy and postoperative grading in central (intramedullary) chondrosarcomas of long bones, and how does this compare with the concordance of image-guided needle preoperative biopsy and postoperative grading in central pelvic chondrosarcomas? (2) What is the concordance of preoperative image-guided needle biopsy and postoperative findings in differentiating low-grade from high-grade central chondrosarcomas of long bones, and how does this compare with the concordance in central pelvic chondrosarcomas? Methods Between 1997 and 2014, in our institution, we treated 126 patients for central chondrosarcomas located in long bones and the pelvis. Of these 126 cases, 41 were located in the pelvis and the remaining 85 cases were located in long bones. This study considers 39 (95%) and 40 (47%) of them, respectively. We included all cases in which histological information was complete regarding preoperative and postoperative tumor grading. We excluded all cases with incomplete data sets or nondiagnostic preoperative biopsies. To evaluate the needle biopsy accuracy, we compared the histological tumor grade, obtained from the preoperative biopsy, with the final histological grade obtained from the postoperative surgical specimen. The weighted and nonweighted kappa statistics were used to evaluate the agreement. Results Concordance between the preoperative biopsy and the final pathological analysis in terms of histological grade was much higher in long-bone chondrosarcoma than in pelvic chondrosarcoma (83% [33 of 40] versus 36% [14 of 39]; odds ratio, 8, 48). Likewise, the weighted kappa coefficients were higher in long-bone chondrosarcoma than in pelvic chondrosarcoma for the determination of histological grade (0.63; 95% confidence interval [CI], 0.34–0.91 versus 0.12; -0.32 to 0.57; p < 0.001). When categorizing the lesions as low grade or high grade, concordance between the preoperative biopsy and the final pathological analysis was much higher in long-bone chondrosarcoma than in pelvic chondrosarcoma (90% [36 of 40] versus 67% [26 of 39]; odds ratio, 4, 5). Likewise, the weighted kappa coefficients were higher in long-bone chondrosarcoma than in pelvic chondrosarcoma (0.73; 95% CI, 0.51–0.94 versus 0.26; 0.04–0.48; p < 0.001). Conclusions Image-guided needle biopsy, when performed by a specialist radiologist and evaluated by an experienced bone pathologist, is a useful tool in determining the histological grade of long-bone chondrosarcomas allowing identification of true low-grade tumors. The histological grade should be correlated with imaging and the clinical presentation, but under these circumstances, experienced tumor surgeons may use this information in planning surgical treatment. The same appears not to be true for pelvic lesions, in which histological grade established by needle biopsy should be interpreted with caution. Level of Evidence Level III, diagnostic study.

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.

Background Tumors of the appendicular skeleton commonly affect the proximal humerus, but there is no consensus regarding the best reconstructive technique after proximal humerus resection for tumors of the shoulder. Questions/purposes We wished to perform a systematic review to determine which surgical reconstruction offers the (1) best functional outcome as measured by the Musculoskeletal Tumor Society (MSTS) score, (2) longest construct survival, and (3) lowest complication rate after proximal humerus resection for malignant or aggressive benign tumors of the shoulder. Methods We searched the literature up to June 1, 2013, from MEDLINE, EMBASE, and the Cochrane Library. Only studies reporting results in English, Dutch, or German and with followups of 80% or more of the patients at a minimum of 2 years were included. Twenty-nine studies with 693 patients met our criteria, seven studies (24%) were level of evidence III and the remainder were level IV. Studies reported on reconstruction with prostheses (n = 17), osteoarticular allografts (n = 10), and allograft-prosthesis composites (n = 11). Owing to substantial heterogeneity and bias, we narratively report our results. Results Functional scores in prosthesis studies ranged from 61% to 77% (10 studies, 141 patients), from 50% to 78% (eight studies, 84 patients) in osteoarticular graft studies, and from 57% to 91% (10 studies, 141 patients) in allograft-prosthesis composite studies. Implant survival ranged from 0.38 to 1.0 in the prosthesis group (341 patients), 0.33 to 1.0 in the osteoarticular allograft group (143 patients), and 0.33 to 1.0 in allograft-prosthesis group (132 patients). Overall complications per patient varied between 0.045 and 0.85 in the prosthesis group, 0 and 1.5 in the osteoarticular graft group, and 0.19 and 0.79 in the prosthesis-composite graft group. We observed a higher fracture rate for osteoarticular allografts, but other specific complication rates were similar. Conclusions Owing to the limitations of our systematic review, we found that allograft-prosthesis composites and prostheses seem to have similar functional outcome and survival rates, and both seem to avoid fractures that are observed with osteoarticular allografts. Further collaboration in the field of surgical oncology, using randomized controlled trials, is required to establish the superiority of any particular treatment.

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 10 5 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.

Background Dermatofibrosarcoma protuberans (DFSP) is a rare, low-to-intermediate grade malignant soft tissue sarcoma that is prone to local recurrence after surgery but rarely metastasizes to distant sites. However, in this case, the tumor metastasized to the humerus and presented as a solitary lesion. Case presentation A 42-year-old male patient presented with pain and limited mobility in the left upper limb, with a history of surgery for DFSP in the popliteal fossa. Imaging examinations revealed bone destruction in the proximal humerus and a soft tissue mass, with the lesion measuring 11.0 × 8.5 × 7.0 cm. Aspiration biopsy confirmed that the lesion in the humerus was a metastatic tumor. After two months of palliative treatment, follow-up examinations showed a reduction in the size of the lesion.Seven months after the treatment, the humeral lesion had progressed, and multiple new bone metastases were found. Conclusions Metastasis of DFSP is rare, and bone metastasis is even rarer. We need to integrate medical history, perform comprehensive diagnosis through immunohistochemistry, molecular pathology monitoring, and imaging examinations. Additionally, this case reminds us that when encountering patients who primarily complain of bone pain during the initial diagnosis, we should thoroughly inquire about their medical and surgical history, conduct a comprehensive analysis, and make an integrated judgment. When necessary, perform a core biopsy first to determine the origin of the lesion. This approach allows us to provide patients with as comprehensive a range of treatment options as possible, thereby improving their quality of life.

Background Staphylococcus aureus is a major pathogen responsible for both community-acquired and hospital-acquired infections. However, disseminated infections complicated by pulmonary abscesses and osteomyelitis are rare in otherwise healthy children. Case presentation We report a case of a previously healthy 12-year-old boy who presented with a 7-day history of cough and a 5-day history of fever and progressive swelling of the left upper limb after self-manipulating a right forearm furuncle. Physical examination and imaging revealed multifocal pulmonary abscesses and osteomyelitis of the left humerus. Blood cultures confirmed the presence of methicillin-resistant Staphylococcus aureus (MRSA). Despite initial empirical antibiotic therapy, the patient’s symptoms persisted, necessitating four surgical interventions. The first two surgeries involved debridement with antibiotic-loaded calcium sulfate implantation. Nineteen months later, due to nonunion of the proximal humerus, the patient underwent open reduction and internal fixation with autologous iliac bone grafting, followed by subsequent removal of the internal fixation two years later. This staged approach, starting with infection control followed by delayed reconstruction, led to successful bone union, with complete resolution of the pulmonary abscesses on follow-up imaging. Conclusion This case highlights the potential for rapid hematogenous dissemination of Staphylococcus aureus leading to complex multi-organ involvement even in healthy pediatric patients. Prompt diagnosis, multidisciplinary management, and combined surgical and antibiotic therapy are critical for favorable outcomes. Clinical trial number Not applicable.