Patrick Bettiol

Chordomas are rare, locally aggressive spinal tumors. En bloc resection may improve local control but can cause substantial morbidity. Thermal ablation may provide a less invasive adjunct or alternative in selected cases. We systematically reviewed reports of radiofrequency ablation (RFA), cryoablation, laser interstitial thermal therapy, high-intensity focused ultrasound, and similar thermal techniques for spinal or sacral chordoma to characterize their clinical applications and reported clinical and radiographic outcomes across pre-resection, primary non-operative, and palliative settings. Eligible studies reported at least one ablation-related clinical or radiographic outcome. Data were descriptively synthesized, and risk of bias was assessed using the Joanna Briggs Institute criteria. Thirteen studies including 33 patients and 34 ablated sites were identified. Cryoablation was used in 21 patients, RFA in 11 patients, and laser interstitial thermal therapy in one patient. Ablation was used as a pre-resection adjunct, primary treatment for unresectable disease, or palliation for recurrent or metastatic lesions. Most reports described pain improvement, short-term local stability, and few major complications. We also report an L4 chordoma treated with CT-guided RFA and vertebroplasty before staged en bloc spondylectomy, without a new neurologic deficit or local recurrence at 18 months. Thermal ablation may be a technically feasible adjunct, primary non-operative option, or palliative strategy for carefully selected spinal and sacral chordomas. In the presented mobile-spine case, planned pre-spondylectomy RFA was feasible before staged en bloc resection; however, limited follow-up and sparse heterogeneous literature preclude conclusions regarding long-term local control, recurrence reduction, survival, or routine use. Ablation should not replace oncologically appropriate en bloc resection when that procedure can be safely achieved and should be considered selectively within multidisciplinary chordoma care.

Background: Scar formation is a normal part of the proliferative phase in wound healing where collagen is remodelled to better approximate normal skin. When collagen is not effectively redistributed, excessive scarring may occur. Recently, CO₂ laser has emerged as an adjunct in improving scar quality via remodelling and redistribution of dermal collagen fibres. Due to the paucity of literature related to its use in the hands and upper extremities, we created a study to examine its effects on hypertrophic scars focused on the hands and upper extremities. Methods: Patients treated with CO₂ laser for hypertrophic scars of the hand and upper extremity were included. The Vancouver Scar Scale (VSS) and Patient and Observer Scar Assessment Scale (POSAS) were used to assess the progression of scar quality. Unpaired t-tests were performed to determine statistical difference between pre- and post-treatment scores on each scale. Pearson correlation coefficients were used to understand the relationship between number of treatments and scar quality. Results: Of the 90 patients enrolled, 54 patients completed serial scar assessment forms. All patient and observer-reported POSAS domains showed improvement ( P < 0.05) apart from Itching. All VSS domains showed improvement ( P < 0.05). There was moderate correlation between overall patient-reported opinion of scar quality and Discoloration, Stiffness and Thickness, and strong correlation between overall patient opinion and Irregularity (r = 0.715). All observer-reported domains were strongly correlated (r = 7.56–8.74) with overall observer opinion of scar quality. Conclusion: The results of this study may further substantiate CO₂ laser as a treatment modality for excessive scarring in a variety of surgical subspecialties. Lay Summary: Complex trauma and burns that impact the skin sometimes result in abnormal healing of the skin called, “hypertrophic scarring”. In our study we assessed how using focused CO₂ laser therapy impacts patients and health care provider assessment of wound progression. Our results were based upon patient reported and healthcare provider observations based upon two standardized forms the Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scale (POSAS). What we found is that after CO₂ Laser Therapy, our 64 patients with 77 treated scars received on average almost 3 treatments and these treatments helped them with physical function and improved aesthetic appearance of their scars. The health care providers also found that the treatments improved functional and aesthetic end points. Overall, our study helps substantiate the body of evidence that using CO₂ laser therapy improves aesthetics and function of hypertrophic scars in the upper extremity.

Implant failure leading to revision total joint arthroplasty can occur through a variety of different mechanisms which are typically associated with a soft tissue response adjacent to the implant that provide insight into the underlying etiology of implant failure. The objective of this study was to elucidate mechanisms of implant failure as they relate to histological classification and findings of adjacent periprosthetic tissue. Histological analysis of soft tissue adjacent to the implant was performed in 99 patients with an average age of 64 years old and grouped into four categories based on the study conducted by Morawietz et al.: Modes of failure were categorized into five groupings based on the study conducted by Callies et al.: Instability (N = 35), Aseptic Loosening (N = 24), Hardware and/or Mechanical Failure (N = 15), Septic (N = 13), and Other failures (N = 12). We calculated odds ratios and conducted regression analysis to assess the relationship between modes of failure and histological findings as well as modes of failure and comorbidities. Hardware/mechanical failure was independently correlated with histological findings of anucleate protein debris, histiocytes, Staphylococcus epidermidis, and synovitis. Furthermore, hardware/mechanical failure was independently correlated with osteosarcoma as a co-morbidity. Septic failure was associated with histological findings of Enterococcus, granulation tissue, and tissue necrosis as well as comorbidities of Crohn’s disease, deep venous thrombosis, lung disease, and rheumatoid arthritis. Infection was 5.8 times more likely to be associated with Type II histology. Aseptic loosening was associated with histologic findings of synovitis. Our findings support the existing literature on periprosthetic tissue analysis in revision total joint arthroplasty which may improve surgeon understanding of the patholophysiological mechanisms that contribute to implant failure and revision surgery.