Epithelioid sarcoma (ES) of the hand is a rare, aggressive cutaneous malignancy with high rates of recurrence, metastases and mortality. With an incidence rate of 0.4 cases/y per one million population, which compromise for approximately 1–1.4% of all soft tissue sarcoma, ES accounts for 10% of soft tissues sarcomas of the hand and foot. Its aggressiveness and propensity to spread and metastases without being noticed, makes it unique and potentially lethal. Missed or delayed diagnosis are often encountered as this tumor can mimic variety of different entities and due to the infrequent nature of this lesion, treatment options are still controversial. The authors provide systemic review of the current literature on epidemiology, etiology, pathogenesis, management and outcomes of this disease as well as a case presentation and a proposed treatment algorithm. The choice of treatment option depends on disease characteristics, staging at presentation, regional lymph node involvement, comorbidities and performance status of the patient. Emphasis on a multidisciplinary coordinated care is crucial as early diagnosis and treatment can decrease morbidity and mortality rates.

Background: Surgeons disagree about the best surgical treatment for simple, displaced olecranon fractures. Although the tension band wiring technique and plate fixation are the most common surgical options for fixation, studies comparing both are limited. To date, there have been no randomized trials comparing patient-reported outcomes and complications at more than 5 years of follow-up. Questions/purposes: (1) Does tension band wiring or plate fixation result in better ROM and patient-reported outcome scores for simple displaced olecranon fractures? (2) What is the risk of complications associated with each technique? Methods: Between November 2012 and October 2017, 68 patients were treated for acute, displaced olecranon fracture in a hand and upper extremity surgery unit at a tertiary-care center. Patients 18 years or older with traumatic, nonpathologic, simple olecranon fractures who presented within 2 weeks of injury were considered potentially eligible. Based on that, 74% (50) of patients met the inclusion criteria; 16% (11) of patients declined to participate in the study, and another 10% (seven) were excluded because they did not meet the prespecified inclusion criteria. Patients were randomized on a 1:1 basis to either tension band wiring or plate fixation and were evaluated at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year after surgery. At the final follow-up interval, 16% (eight) were lost to follow-up: 4% (two) in the tension band wiring group and 12% (six) in the plate fixation group. The median follow-up time was 8 years (IQR 7 to 9 years). We evaluated complications at a minimum of 6 years after surgery. The primary outcome measure was the 1-year postoperative DASH score. Additional outcome measures included the patient-reported Oxford Elbow Score, ROM, and the proportion of patients in each group who reported hardware-related symptoms and had subsequent implant removal or postoperative infection. Results: No differences were observed in the DASH score (tension band wiring 18 [range 3 to 65] versus plate fixation 24 [range 3 to 52], median difference -6 [95% CI -12.7 to 14.9]; p = 0.73), Oxford Elbow Score (tension band wiring 36 [range 10 to 48] versus plate fixation 39 [range 17 to 47], median difference -3; p = 0.53), or all ROM measurements (p > 0.05) between the groups at 1 year of follow-up. The odds of having surgery for symptomatic implant removal were lower for plate fixation than for tension band wiring (one of 19 versus eight of 23, OR 9.6 [95% CI 1.08 to 85.7]; p =0.02); the odds of infection, however, were higher in the plate group (three of 19 versus 0 of 23; p = 0.048). Conclusion: No differences were observed between the two techniques in terms of ROM or patient-reported outcomes. Surgeons should consider that although the risk of implant removal is higher in tension band wiring, patients older than 85 years undergoing plate fixation for simple olecranon fractures are at a greater risk of postoperative infection. Level of Evidence: Level I, therapeutic study.

This systematic review and meta-analysis compare the incidences of complications, reoperations and hardware removal between anterior and dorsal plating after corrective osteotomy for dorsally angulated distal radial malunions. A total of 403 patients were included; 253 patients underwent anterior corrective osteotomy and 150 underwent dorsal corrective osteotomy. Mean follow-up was 30 months. Anterior plating was associated with fewer reoperations (9% vs. 28%), less hardware removal (3% vs. 18%) and comparable major complications (5% vs. 6%) compared to dorsal plating. The adjusted model showed a significant reduction (approximately 85%) in the odds of reoperation and hardware removal in the anterior group. There was no difference in major or minor complications between the groups. Surgeons should be fully aware of the increased risks when using dorsal plate fixation after corrective osteotomy for dorsally angulated distal radial malunions.

OBJECTIVES: This study investigates whether the intraoperative administration of intravenous tranexamic acid (TXA), known for its hemostatic and potential anti-inflammatory properties, affects the incidence of heterotopic ossification (HO) following surgery for elbow fracture dislocations. METHODS: Design: Prospective, randomized clinical trial. Setting: Hand and Upper Extremity Surgery Unit. Patient Selection Criteria: Patients aged 18–75 years with acute traumatic elbow fracture dislocations requiring surgical management from June 1, 2016, to October 31, 2022, were eligible. Inclusion criteria included traumatic nonpathological elbow fracture dislocations. Patients were randomized 1:1 to receive either intraoperative TXA or no additional treatment. Outcome Measures and Comparisons: The primary outcome was the occurrence of HO, defined by new bone formation observed in radiographic exams during postoperative follow-ups. Secondary outcomes included the presence of clinically relevant HO, reoperation rate due to symptomatic HO, and time to HO reoperation. Compared were patients who received TXA with controls. RESULTS: Out of 47 patients with elbow fracture dislocations who completed the follow-up, 23 (49%) received TXA prophylaxis while 24 (51%) were controls. The average age was 51.2 years (range, 18–77 years) with a mean follow-up of 12.9 months (range, 6.11–34.2). In the TXA group, 11 (47.8%) were men and 12 (52.2%) were women, while in the control group, 14 (58.3%) were men and 10 (41.7%) were women. HO was observed in 30% of patients, primarily around the radial head (71%). In this study, 43.5% of patients in the TXA group developed HO compared with 16.7% in the control group. The differences in HO formation suggest a potentially higher risk in the TXA group (relative risk = 2.6, 95% 1.0 to 8.5, P = 0.06). Clinically relevant HO led to reoperation in 2 of 10 (20%) patients in the TXA group, while none of the patients in the control group required reoperation, resulting in an overall reoperation rate of 14.3% in the study cohort. CONCLUSIONS: This prospective trial identified a possible increased risk of HO formation in patients receiving TXA, however, with the sample size available a statistically significant difference was unable to be detected. These findings highlight the need for further research emphasizing larger prospective comparative studies to assess TXA's impact on HO. A deeper understanding of this relationship will enable clinicians to balance TXA's potential risks and benefits more effectively, optimizing outcomes in orthopedic surgery. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.