JAAOS, Volume 26, No. 22

Lipomatous Soft-tissue Tumors

Lipomatous soft-tissue tumors are the most common neoplasms encountered by physicians. They range from benign lipomas to high-grade liposarcomas. Unplanned excisions of sarcomas are commonly due to the presumptive diagnosis of lipoma and can be avoided by understanding their diagnostic magnetic resonance imaging appearance. Magnetic resonance images should be obtained for all soft-tissue masses that are deep to fascia or those >5 cm in subcutaneous tissue. Atypical lipomatous tumors present as large deep fatty masses and have a propensity for local recurrence and a small risk of malignant transformation. Well-differentiated liposarcomas are histologically identical to atypical lipomatous tumors but have a markedly worse prognosis secondary to their anatomic location. Masses that lack isointense signal to subcutaneous fat on MRI may represent a sarcoma and require a biopsy before definitive treatment. Large deep lipomatous masses and liposarcomas should be sent to a sarcoma referral center for definitive treatment.

      • Subspecialty:
      • Musculoskeletal Oncology

    Symptomatic, Unstable Os Acromiale

    Management of a persistently symptomatic, unstable os acromiale remains controversial. An unstable os acromiale is an easy diagnosis to miss and should be specifically evaluated for in patients with shoulder pain and a high degree of clinical suspicion. Surgical options include open or arthroscopic excision and open reduction and internal fixation. Open excision of large fragments has had poor results. Arthroscopic treatment is commonly used for small fragments (preacromion), and the technique has also been used in larger fragments (meso-os), but concerns persist over postoperative weakness secondary to shortening of the deltoid lever arm. Open reduction and internal fixation through a transacromial approach has been shown to have predictable union rates but can be complicated by symptomatic implant. Recent biomechanical studies have expanded our understanding of optimal fixation constructs, which may also decrease implant-related issues. Ultimately, the choice of which procedure to use will be dictated by patient factors such as age, activity level, and the nature of rotator cuff pathology.

    Level of Evidence:

    Level V

        • Subspecialty:
        • Shoulder and Elbow

      Management of Midshaft Clavicle Fractures in Adults

      Fractures of the clavicle are common injuries that occur across all age groups but are most frequently seen in the young, active patient population. Among the different types of clavicle fractures, those occurring in the middle third of the clavicular shaft are the most common. Historically, most of these fractures were treated by closed means even when notable displacement was present. Recently, there has been a renewed interest in assessing the best treatment option for these patients. Although nonsurgical treatment is a reliable method for treating many of these fractures, more recent data suggest that fractures with notable displacement (>2 cm of shortening or >100% displacement) and/or comminution have better short-term outcomes and lower rates of nonunion with surgical management. Current surgical options include superior plating, anterior-inferior plating, dual plating, and intramedullary nail fixation.

          • Subspecialty:
          • Shoulder and Elbow

        Utility of Routine Postoperative Radiographs After Fixation of Lower Extremity Fractures

        Introduction: The goal of this study was to investigate the clinical utility of radiographs at all time points after internal fixation of lower extremity fractures.

        Methods: A retrospective chart review was conducted at a level I trauma center. Four hundred eighty-five patients with 586 fractures of the femur, tibia, and ankle were included. Data were analyzed to investigate the effect of radiographs on changes in management at all postoperative time points for each fracture type.

        Results: Each fracture received, on average, 4.8 radiographs after fixation for a total cost of $938,469. The management of 31% (179 of 586) of fractures deviated from the expected postoperative course. Of the 179 fractures with a deviation, 93 (31%) resulted from radiographic findings alone and occurred (1) in the immediate postoperative period (2%) and (2) in the period from consideration of advancement to full weight bearing up until confirmation of fracture union (98%). Notable cost savings can be realized by using the findings to eliminate nonclinically indicated imaging at both the institutional and national levels.

        Conclusion: Routine radiographs in isolation contribute to changes in management (1) in the immediate postoperative period in select cases and (2) during the period when advancement to full weight bearing is being considered up until clinical fracture union.

        Level of Evidence: Level III

            • Subspecialty:
            • Trauma

          Peroneal Tendon Tears: We Should Consider Looking at the Muscle Instead

          Introduction: The purpose of this study was to determine whether tears of the peroneus brevis (PB) tendon correlate with increased fatty infiltration of the PB muscle on MRI compared with musculature without clinical evidence of peroneal pathology.

          Methods: Ankle MRI scans of patients with PB tendon tearing (tear group) were compared with those of patients without clinical evidence of peroneal pathology (control group). Two reviewers graded the PB muscle belly according to the Goutallier classification.

          Results: Thirty patients were included in each group. The mean Goutallier scores for the tear and control groups were 0.52 (±0.72) and 0.05 (±0.15), respectively (P = 0.0019). The level of interobserver agreement between reviewers was moderate (intraclass correlation coefficient = 0.75; 95% confidence interval, 0.57 to 0.85).

          Discussion: Patients with PB tendon tear demonstrate markedly higher grades of fatty degeneration compared with patients without peroneal pathology. The Goutallier classification may become a valuable instrument for assessing the severity of a PB tear.

          Level of Evidence: Level III—diagnostic study

              • Subspecialty:
              • Foot and Ankle

            Novel Surgical Approach to Segmental Bone Transport Using a Magnetic Intramedullary Limb Lengthening System

            Posttraumatic bone defects (BDs) remain a difficult complication for orthopaedic surgeons. Surgical goals in these reconstructive cases are to create stable limb fixation, maintain limb length, and provide adequate soft-tissue coverage. Historically, surgical approaches in these cases have required the use of an external fixator, which is associated with several postoperative complications. A plate-assisted bone segment transport (PABST) technique using a magnetic limb lengthening system eliminates the need for an external fixator and is effective for these reconstructive cases. A 51-year-old male patient presented as a category I trauma after a motorcycle collision. Osseous injury was defined as Gustilo-Anderson type IIIB distal tibia and fibula fracture (AO 42-C2). After fixation failure, the PABST technique was performed using a magnetic intramedullary limb lengthening system. Radiographic union was achieved 18 months postoperatively. This innovative surgical technique is effective in treating posttraumatic BDs without the need for limb shortening or the use of an external fixator. PABST has the potential to decrease postoperative complications in BD reconstructive cases using all-internal technology designed for limb lengthening. PABST, in this instance, uses a magnetic intramedullary nail that is controlled with a hand-held external remote to allow for precise, adjustable, and bidirectional bone segment transport.

                • Subspecialty:
                • General Orthopaedics