Faculty Bibliography

BACKGROUND:Pediatric supracondylar humeral fractures (SCHFs) are among the most common elbow injuries in children and frequently require operative fixation. Although after-hours surgery is often unavoidable due to emergency presentation patterns, many centers now reserve nighttime intervention for urgent indications such as vascular compromise. Concerns nevertheless persist regarding the potential impact of after-hours surgery on surgical efficiency, technical decision-making, and postoperative outcomes. METHODS:A systematic search of PubMed, Scopus, the Cochrane Library, and Google Scholar was conducted from database inception through December 15, 2025. Comparative studies evaluating operative treatment of pediatric SCHFs performed during daytime working hours versus after-hours were included. Outcomes assessed comprised perioperative characteristics (operative time, time to surgery), intraoperative decision-making (medial pin fixation, open reduction), and postoperative complications (pin migration, alignment-related complications, infection, and iatrogenic postoperative nerve injury). RESULTS:Seven studies encompassing 913 pediatric patients met the inclusion criteria. Operative time did not differ significantly between daytime and after-hours surgery ( P =0.11). Time to surgery was shorter in the after-hours group ( P <0.001). No significant differences were observed in rates of medial pin fixation ( P =0.70) or open reduction ( P =0.80). Postoperative complications, including pin migration, infection, and iatrogenic postoperative nerve injury, were comparable between groups, whereas alignment-related complications were more frequent in the after-hours group ( P =0.04). CONCLUSIONS:Operative fixation of pediatric SCHFs showed broadly comparable perioperative efficiency, technical outcomes, and complication rates when performed during daytime or after-hours, although alignment-related complications were more frequent in the after-hours group. These findings suggest that surgical timing alone may not be the primary determinant of outcome.

INTRODUCTION/BACKGROUND:Ewing sarcoma (EWS) is an aggressive small round blue cell malignancy driven by EWSR1::ETS fusions, with poor survival outcomes in metastatic and relapsed disease. While multimodal chemotherapy remains the cornerstone of therapy, emerging agents hold potential to overcome resistance and improve outcomes. METHODS:A systematic search of PubMed, Scopus, and Google Scholar through February 2026 identified 1,166 records. Following duplicate removal and two-stage screening, 87 preclinical and clinical studies were included. Data were extracted and synthesized narratively, with emphasis on therapeutic class, mechanism of action, side effects, and translational relevance. RESULTS:Across therapeutic classes, several promising avenues emerged. Direct EWS-FLI1 targeting (TK216, trabectedin combinations, CRISPR-based approaches) demonstrated preliminary clinical and robust preclinical efficacy. IGF-1R inhibitors (linsitinib, ganitumab, and figitumumab) showed biological activity, though limited survival benefit in trials. CD99-directed therapies, including monoclonal antibodies and siRNA-nanoparticle conjugates, achieved synergy with chemotherapy in xenografts. PARP inhibitors exhibited preclinical efficacy, particularly in combination regimens, though monotherapy responses were modest in clinical cohorts. Kinase inhibitors targeting WEE1, DNA-PK, and Aurora A kinase, as well as multikinase TKIs (cabozantinib, regorafenib, and anlotinib), revealed varying degrees of cytotoxicity and disease stabilization. Epigenetic therapies, including LSD1, HDAC, and EZH2 inhibitors, attenuated EWS-FLI1 transcriptional programs and enhanced chemosensitivity. Immunotherapeutic approaches (immune checkpoint inhibitors, IGF-1R antibodies, Vigil vaccine) have so far yielded limited responses, though selected strategies showed potential benefit in subsets. Novel agents such as verteporfin, evofosfamide, and proteasome inhibitors further expanded the spectrum of vulnerabilities. CONCLUSIONS:Targeted and molecular therapies in EWS show significant promise, particularly in rational combinations that exploit the tumor's dependence on EWS-FLI1-driven transcriptional dysregulation, DNA damage repair deficiencies, or survival signaling. Future research must prioritize biomarker-driven patient selection, integration of multiomics approaches, and multicenter prospective trials to translate these strategies into clinically meaningful improvements in EWS survival.

BACKGROUND:Synthetic composites of calcium phosphate and calcium sulfate have been used for grafting after intralesional curettage of benign bone tumors. However, there are limited studies on the outcomes of children who were grafted with these materials. QUESTIONS/PURPOSES/OBJECTIVE:(1) What proportion of patients with benign pediatric bone lesions who were treated with synthetic calcium phosphate and calcium sulfate bone substitute as a bone void filler experienced radiographic graft resorption by 1 year after treatment? (2) What proportion of patients thus treated experienced recurrence of the tumor or fracture at a minimum follow-up time of 1 year? METHODS:Between 2020 and 2023, a total of 42 patients were surgically treated for benign lytic bone tumors or bone cysts at a single tertiary academic children's hospital. Two were excluded from analysis (one because it was a recurrent aneurysmal bone cyst initially treated with curettage and bone grafting, and one who was treated with aspiration and corticosteroid injection of the cyst at the family's request), leaving 40 who were treated with curettage and grafting using synthetic calcium phosphate and calcium sulfate bone substitute. All had at least 12 months of follow-up (mean ± SD 32 ± 15 months) and were analyzed in this retrospective study. Of the patients, 30% (12 of 40) were female, and the mean age of the cohort was 12 ± 4 years. During this time, adjunctive internal fixation hardware was generally used when there was a pathologic fracture, and based on those indications, 23% (9 of 40) received hardware. To answer our first study question about the proportion of lesions that demonstrated graft resorption by 1 year after treatment, we annotated the lesions and assessed for percent resorption at 6 weeks, 12 weeks, 6 months, 9 months, and 12 months. To answer our second study question, we used a Kaplan-Meier survivorship estimator to determine survivorship free from recurrence and survivorship free from fracture. RESULTS:Eighty-eight percent (35 of 40) developed complete resorption of the graft by 1 year after surgery; 45% (18 of 40) demonstrated this finding by 4 months after surgery. Thirteen percent (5) of patients developed local recurrence. Survivorship free from local recurrence was 88% (95% confidence interval [CI] 77% to 99%) at 1 year, and survivorship free from fracture was 100% (95% CI not estimable) at 1 year. Of those that recurred, there were three aneurysmal bone cysts, one unicameral bone cyst, and one chondroblastoma. CONCLUSION/CONCLUSIONS:The bone substitute was associated with gradual resorption, low recurrence rates, and no fractures in this cohort. With the right indications, patients can start weightbearing at 6 weeks without hardware augmentation. Close monitoring is crucial, especially for aneurysmal bone cysts that have a higher risk of recurrence. Further research may be needed to compare the effectiveness and cost-efficiency of bone substitutes and alternative graft options. LEVEL OF EVIDENCE/METHODS:Level IV, therapeutic study.

INTRODUCTION/BACKGROUND:While the number of absolute and relative contraindications to total joint arthroplasty (TJA) has gradually decreased, active cancer patients have traditionally been challenging surgical candidates. We sought to compare perioperative and two-year postoperative clinical outcomes of patients with and without active cancer. METHODS:Patients over 18 years with active cancer undergoing primary, unilateral TJA from 2017 to 2023 at a single urban academic center were reviewed for a minimum two-year follow-up. Cancer status, type, and stage were confirmed manually. 68 cancer patients were propensity-matched 3:1 to 204 non-cancer patients from a pool of 9,382 based on age, sex, BMI, smoking status, race, and ASA class. Demographic, perioperative, and clinical data were analyzed using t-tests, Chi-square, and ANOVA. Subgroup analyses compared cancer patients receiving active therapy versus those not on treatment. RESULTS:There were no significant demographic differences between groups, except Charlson Comorbidity Index (P < 0.001). The most common cancers were breast (22%) and prostate (20%). There were no differences in discharge disposition (P = 0.20), operative time (P = 0.87), or length of stay (P = 0.29). The all-cause revision rate (including infection) was higher in patients with active cancer (7.4% vs. 2.5%), though not statistically significant (P = 0.15; Power = 46.5%). Of the various causes for revision, infection was significantly more likely in cancer patients than other causes compared (4.4% vs. 0%, P = 0.003). When analyzing only the active cancer group, those receiving cancer therapy had higher revision rates, though this was not statistically significant (11.1% vs. 6.0%, P = 0.487). DISCUSSION/CONCLUSION/CONCLUSIONS:Despite often being excluded from arthroplasty studies, active cancer patients demonstrated comparable overall outcomes after primary TJA. Although infection-related revisions were more common, they were effectively treated. With proper preoperative optimization and multidisciplinary care, TJA can be safely performed in selected active cancer patients.

INTRODUCTION/BACKGROUND:Distal radius fractures are the most common fractures seen in the emergency department in children in the USA. However, no established or standardised guidelines exist for the optimal management of completely displaced fractures in younger children. The proposed multicentre randomised trial will compare functional outcomes between children treated with fracture reduction under sedation versus children treated with simple immobilisation. METHODS AND ANALYSIS/METHODS:Participants aged 4-10 years presenting to the emergency department with 100% dorsally translated metaphyseal fractures of the radius less than 5 cm from the distal radial physis will be recruited for the study. Those patients with open fractures, other ipsilateral arm fractures (excluding ulna), pathologic fractures, bone diseases, or neuromuscular or metabolic conditions will be excluded. Participants who agree to enrol in the trial will be randomly assigned via a minimal sufficient balance algorithm to either sedated reduction or in situ immobilisation. A sample size of 167 participants per arm will provide at least 90% power to detect a difference in the primary outcome of Patient-Reported Outcomes Measurement Information System Upper Extremity computer adaptive test scores of 4 points at 1 year from treatment. Primary analyses will employ a linear mixed model to estimate the treatment effect at 1 year. Secondary outcomes include additional measures of perceived pain, complications, radiographic angulation, satisfaction and additional procedures (revisions, refractures, reductions and reoperations). ETHICS AND DISSEMINATION/BACKGROUND:Ethical approval was obtained from the following local Institutional Review Boards: Advarra, serving as the single Institutional Review Board, approved the study (Pro00062090) in April 2022. The Hospital for Sick Children (Toronto, ON, Canada) did not rely on Advarra and received separate approval from their local Research Ethics Board (REB; REB number: 1000079992) on 19 July 2023. Results will be disseminated through publication in peer-reviewed journals and presentations at international conference meetings. TRIAL REGISTRATION NUMBER/BACKGROUND:NCT05131685.

» Multifactorial Pathogenesis: Legg-Calvé-Perthes disease (LCPD) may result from a complex interplay of genetic, epigenetic, and environmental factors, culminating in avascular necrosis of the femoral head in children aged 4 to 10 years.» Genetic Contributions: Mutations in COL2A1 weaken cartilage integrity, and polymorphisms in IL6 drive inflammatory responses, exacerbating bone resorption and necrosis.» Role of Epigenetics: Epigenetic mechanisms, such as altered DNA methylation and miRNA dysregulation, may modulate disease progression by linking genetic susceptibility to environmental influences.» Environmental Amplifiers: Key environmental risk factors, including maternal smoking, low birth weight, and socioeconomic deprivation, may exacerbate the genetic and epigenetic predisposition to LCPD.» Future Directions: Advancements in genetic screening and epigenetic therapies, such as miRNA modulators and DNA methylation inhibitors, combined with preventive measures like improved prenatal care and reduced smoke exposure, may offer promising avenues for optimizing outcomes in LCPD.

OBJECTIVES/OBJECTIVE:Despite the success rate of the Pavlik method in the treatment of developmental dislocation of the hip, there is a subset of hips that do not reduce with harness use. The purpose of this study was to determine the outcomes after closed reduction (CR), open reduction (OR) and combined open reduction and pelvic osteotomy (OR+PO) in patients with infantile hip dislocations who initially failed the Pavlik method. METHODS:This was a retrospective cohort study of patients with infantile hip dislocations who failed the Pavlik method and subsequently underwent a secondary procedure for persistent hip dislocation. The primary outcome measure was the Severin classification of the involved hip 3 years after the secondary procedure. Other outcomes assessed included rates of redislocation, residual acetabular dysplasia and proximal femoral growth disturbance. RESULTS:Twenty-three patients were included; seven subsequently underwent CR, three underwent isolated OR and 13 proceeded directly to OR+PO. The overall successful outcome rate at final follow-up (as determined by radiographic Severin class I or II) was 11/23 (48%). However, patients undergoing OR+PO had significantly higher rates of successful outcomes (77%) compared with CR (15%) and OR (0%), P  < 0.05. The rate of residual acetabular dysplasia and proximal femoral growth disturbance was significantly lower in patients treated with OR+PO compared with CR and isolated OR, P  < 0.05. CONCLUSION/CONCLUSIONS:Patients with dislocated hips who failed Pavlik harness treatment had better radiographic outcomes 3 years after OR+PO in comparison to patients undergoing CR or isolated OR.

PURPOSE OF REVIEW/OBJECTIVE:The pathogenesis of dedifferentiated chondrosarcoma is controversial, and no genetic abnormality has consistently been identified in the disease. Focusing on the diagnostic challenges encountered in dedifferentiated chondrosarcoma, the following review aims at summarizing the tumor's active neoplastic pathways while highlighting therapeutic modalities that could potentially be explored to enhance patient survivorship. RECENT FINDINGS/RESULTS:Owing to the challenging examination of small needle biopsy sampling as well as the disease's overlapping morphological and immunohistochemical features with other bone and soft-tissue sarcomas, the diagnosis of dedifferentiated chondrosarcoma can be problematic. While combined doxorubicin- and cisplatin-based regimens remain the first-line systemic chemotherapy in the disease, ~50% of tumors carry EXT1/2 or IDH1/2 mutations, advancing EXT or IDH inhibitors as potential alternative therapies, respectively. Despite systemic chemotherapy, dedifferentiated chondrosarcoma remains an aggressive tumor with dismal prognosis and limited survival. A multidisciplinary collaboration across multiple cancer centers is warranted to yield an accurate diagnosis, understand the disease's underlying pathogenesis, develop adequate treatment, and improve patient survivorship.