To evaluate the occurrence of partial or total loss of the reverse-flow sural flap used for coverage failures in the lateral, medial, and central regions of the ankle, as well as factors related to flap loss. A retrospective cohort study was conducted including data from 32 patients who underwent surgery with reverse sural flaps between February 2012 and September 2023 at the Institute of Orthopedics and Traumatology, HC/FMUSP. In the group of patients requiring coverage in the medial region, 40% had partial flap loss and 30% suffered total loss. In the lateral region, 20% experienced partial loss and 13.3% total loss. In the central area, 57.14% had partial coverage loss, with no cases of total loss. The reverse sural flap proved to be favorable for coverage of defects in the lateral region of the ankle, but showed higher rates of partial or total loss when used for coverage of defects in the medial region of the ankle. A negative effect was observed in the presence of patient comorbidities, in trauma-related cases, and in the early approach to flap construction. Level of Evidence II; Retrospective cohort study. Avaliar a ocorrência de perda parcial ou total do retalho sural de fluxo reverso utilizado nas falhas de cobertura na região lateral, medial e central do tornozelo, assim como fatores relacionados à perda do retalho. Foi realizado um estudo de coorte retrospectiva incluindo os dados de 32 pacientes submetidos à cirurgia com retalhos surais reversos entre fevereiro de 2012 a setembro de 2023 no Instituto de Ortopedia e Traumatologia do HC/FMUSP. No grupo de pacientes com necessidade de cobertura na região medial, 40% tiveram perda parcial do retalho e 30% sofreram perda total. Na região lateral, foram 20% de perdas parciais e 13,3% de perdas totais. E na área medial, 57,14% tiveram perda parcial da cobertura, sem nenhum caso de perda total. O retalho sural reverso se mostrou favorável para a cobertura de falhas na região lateral no tornozelo e mostrou maiores taxas de perdas parciais ou totais quando foi utilizado para a cobertura das falhas na região medial do tornozelo. Houve um efeito negativo na presença de comorbidades do paciente, nos casos causados por trauma e na abordagem precoce da confecção do retalho. Nível de Evidência II; Estudo de coorte retrospectiva.
There are different treatments for cut-out failure after intramedullary nailing in hip fractures. Salvage with hip arthroplasty is an accepted method in frail elderly patients and in cases of articular cartilage damage or compromised bone stock precluding re-osteosynthesis. However, this is not without complications (10-66%) due to its complexity. A single-center retrospective case series of patients treated with salvage arthroplasty using an uncemented modular diaphyseal fixation stem (Arcos® system, Zimmer Biomet). Minimum follow-up was 1 year. Fourteen cases were recorded, nine after Gamma3® nailing and five after Intertan® nailing. The posterolateral approach was the most commonly used (10 cases). Eight total hip replacements, three double mobility replacements, and six bipolar hemiarthroplasties were implanted. At 30 days, 92.9% were able to walk indoors with technical support. During the first year, six patients (42.8%) had complications related to the implant: three periprosthetic fractures, one acetabular erosion, and three dislocations. No patients died during hospitalization or at 30 days; one patient (7.1%) died within a year. Prosthetic salvage after cut-out with uncemented modular diaphyseal stems is a complex surgery with a significant risk of complications, especially dislocation and periprosthetic fracture. These implants allow the deficient proximal areas to be by-passed and restore the length, version, and offset, making them a possible alternative in selected patients, although not without complications. Level IV.
Oral nutritional supplementation (ONS) is commonly prescribed in malnourished older adults after hip fracture, but formulations are heterogeneous, and their comparative association with mortality remains unclear. We aimed to evaluate whether HMB-containing ONS was associated with lower mortality than non-HMB ONS and to explore whether supplement formulation combined with treatment persistence was associated with differential mortality patterns. This was a formulation-specific subanalysis of a previously described prospective cohort of older adults with hip fracture and malnutrition or significant nutritional risk. Only patients with known ONS formulation were included (n = 107): 59 received HMB-containing ONS, and 48 received non-HMB ONS, including standard, diabetes-specific, and renal-oriented formulations. Mortality at 3, 6, and 12 months was analyzed using crude comparisons and multivariable logistic regression adjusted for sex, age, and Charlson comorbidity index. A 6-month adjusted Cox model was used as the main time-to-event analysis. Exploratory analyses assessed mortality according to supplement formulation and treatment persistence. Overall mortality was 14.0% at 3 months, 23.4% at 6 months, and 29.9% at 12 months. At 6 months, mortality was lower among patients receiving HMB-containing ONS than among those receiving non-HMB ONS (13.6% vs. 35.4%; p = 0.011), and the association remained significant after adjustment (OR 0.267; 95% CI 0.091-0.784; p = 0.016). Associations at 3 and 12 months were directionally consistent but not statistically significant. In the adjusted Cox model, prescription of HMB-containing ONS was associated with a lower hazard of death within 6 months (HR 0.358; 95% CI 0.145-0.885; p = 0.026). Exploratory analyses showed a 6-month mortality gradient according to formulation and persistence, ranging from 0.0% in patients receiving HMB-ONS for ≥3 months to 41.2% in those receiving non-HMB ONS for <3 months. In this formulation-specific subanalysis of malnourished older adults with hip fracture, an association between HMB-containing ONS and lower 6-month mortality was observed compared with non-HMB ONS. Exploratory findings suggested a clinically relevant mortality gradient according to both supplement formulation and treatment persistence, although these results should be interpreted cautiously. Larger prospective studies are warranted to confirm these findings.
We present the case of a 16-year-old female polytrauma patient who sustained a rare and highly unstable pelvic ring injury following a high-energy motor vehicle collision with partial ejection. The injury pattern was classified as Tile C3, combining a right anterior crescent-type fracture with anterior sacroiliac (SI) joint dislocation, a left-sided Denis II sacral fracture, a distal T-shaped sacral fracture, and bilateral pubic rami fractures. Neurological deficits included right L5 and left S1-S2 involvement. Initial management adhered to damage control principles, including pelvic binder application, preperitoneal packing, and temporary external fixation. Due to cranial migration of the right hemipelvis and neurovascular compression, urgent anterior open reduction and SI joint plating were performed via an ilioinguinal approach. Definitive fixation, performed on day five, included percutaneous dual iliosacral screws for the Denis II fracture and bilateral retrograde pubic ramus screws, while the distal T-shaped sacral fracture was treated conservatively. The patient achieved stable fixation without implant failure, enabling early mobilization. At 12 months, radiographs demonstrated consolidation of the pelvic ring injuries with maintained alignment and no implant failure. She walked independently with an ankle-foot orthosis for persistent right foot drop, although residual L5-S1 motor weakness and altered reflexes persisted. Functional scores demonstrated marked recovery (Majeed 70/80; Iowa 85/100). This case highlights the importance of individualized, staged surgical strategies in managing complex pelvic fractures with combined rotational and vertical instability, especially in the presence of neurological injury and visceral trauma.
Osteosarcomas (OS), the most common primary malignant bone tumours, are classified as low-grade (characterised by MDM2 amplification) or high-grade (with complex karyotypes). Accurate diagnosis is essential for treatment and prognosis. This study evaluates pre-analytical variables associated with the success or failure of epigenetic analyses in osteosarcoma samples and proposes a standardised preparation protocol. Retrospective cohort study of adult patients with OS diagnosed at our sarcoma reference centre (CSUR) over the past 20 years. Pre-analytical variables: year of diagnosis, histological subtype, tissue type, site of origin, sample type (core needle biopsy or surgical specimen with or without chemotherapy), decalcification method (none, EDTA, or nitric acid), and FISH availability. Five 5-μm sections were obtained from each paraffin block. DNA methylation profiling was performed using the Infinium MethylationEPIC v2.0 platform (Illumina). Univariate and multivariate analyses were performed to identify failure predictors. A total of 103 samples from 79 patients were analysed: 58 conventional OS, 14 extraskeletal, 24 parosteal, and 7 dedifferentiated OS. Of the 95 formalin-fixed, paraffin-embedded (FFPE) samples, 43 (45.2%) were suitable for epigenetic analysis, whereas all frozen samples were adequate (100%). Decalcification affected success rates, although not significantly: nitric acid was associated with the highest failure rate (68.97%), followed by EDTA (57.14%) and non-decalcified samples (46.15%). FFPE samples are suitable for epigenetic studies, although performance depends on pre-analytical factors. Frozen tissue remains the gold standard. Nitric acid should be avoided. A protocol is proposed that prioritises frozen tissue, documents decalcification methods, excludes strong acids, incorporates quality control measures, and favours samples less than five years old.
Learning curves for robotic total knee arthroplasty (TKA) have been widely described during the initial adoption of robotic technology. However, it remains unclear whether robotic surgical proficiency is platform-specific or transferable between systems based on different modelling paradigms. The purpose of this study was to evaluate whether an experienced robotic surgeon demonstrates a measurable learning curve when transitioning from imageless to CT-based robotic TKA. A senior surgeon with experience exceeding 1000 robotic knee arthroplasties performed using imagel-ess platforms transitioned to a CT-based robotic TKA system. The first 25 consecutive CT-based robotic TKAs were prospectively analysed. Operative time and postoperative radiographic alignment (HKA, LDFA, MPTA, tibial slope) were assessed. Learning curve dynamics were evaluated using cumulative sum (CUSUM) and segmented regression analyses. Radiographic outliers were defined as deviations greater than 2° from the planned target. Operative time decreased from 65 min in the first case to a steady-state mean of 55 ± 3 min (95% CI 53.8-56.2) by case 3, corresponding to a 15.4% reduction. Continuous CUSUM demonstrated an inflection point at case 2, confirmed by segmented regression (p < 0.05). Mean postoperative alignment was 0.7° ± 1.2° for HKA, 88.5° ± 1.1° for LDFA, 87.8° ± 1.2° for MPTA, and 4.8° ± 0.7° for tibial slope. No radiographic outliers (> 2°) were observed after case 2. In an experienced robotic surgeon, transition from imageless to CT-based robotic TKA was not associated with a clinically relevant learning curve. Operative efficiency stabilised rapidly and radiographic alignment accuracy was maintained from the earliest procedures. These findings suggest that robotic TKA proficiency may be transferable across platforms, although confirmation through multicentre comparative studies remains necessary. Level IV.
Forefoot problems are highly relevant in the general population. It leads to a loss of autonomy and increases the risk of falls. Treatment needs to consider the underlying cause, and conservative measures are generally instituted before surgical intervention. Nonsurgical approaches must be focused on pressure relief and deformity correction. Corrective devices may be indicated for reducible deformities. Physiotherapy based on exercises and the use of specific orthoses are indicated. The new concept with an emphasis on strengthening the intrinsic muscles of the foot appears to be quite effective in correcting less severe deformities and preventing the deformities from worsening.
The objective of the Continuous Update Project of the RICA Pathway (Enhanced Recovery After Surgery in Adults) is to maintain updated and consensual recommendations based on scientific evidence, facilitating their implementation and evaluation. The project was developed between November 2021 and October 2025, focusing on elective major surgery in adults. Evidence was evaluated using the GRADE methodology, with reviews in PubMed, Embase, and the Cochrane Library, including systematic reviews, meta-analyses, randomized clinical trials, consensus guidelines, and multicenter studies. The project was structured into a coordinating group, a consulting group, and various reviewing groups, and the recommendations were evaluated and accepted by consensus. 106 recommendations were approved, compared to 135 in the 2021 edition. 83% of these presented high or moderate evidence, and 76% had a strong grade of recommendation in favor. The recommendations were grouped into sets of measures ("bundles") to improve their applicability.
To establish age- and time-specific recommendations for the treatment of traumatic anterior shoulder instability (TASI) and for return-to-sport (RTS) decision-making through a formal consensus process among European experts. The European Society of Sports Medicine, Knee Surgery and Arthroscopy-European Shoulder Associates (ESSKA-ESA) formal consensus methodology was followed. A steering group formulated 35 clinically relevant questions, 23 of which addressed treatment and RTS and are reported in Part 2. A structured literature review was conducted. Statements were drafted and graded based on the level of scientific support. Then, the rating group reviewed and refined the statements, followed by validation from the reader group for cultural adaptability. Recommendations were tailored by age group (adolescents, young adults and older adults) and timing of instability (first-time vs. recurrent). The final global median (range) of the 23 questions was 9 (8-9). Eleven questions achieved strong agreement, 11 relative agreement and 1 uncertain agreement. The grades of recommendations were: A in 0 (0%) statements, B in 30 (35.3%) statements, C in 24 (28.2%) statements and D in 31 (36.5%) statements (each statement could have more than one grade of recommendation). Bone loss and soft tissue lesions were key factors in decision-making. The consensus emphasized individualized thresholds for surgical versus conservative management, highlighting the role of bone augmentation in subcritical (bone loss 10%-15%) (especially in bipolar bone loss) and critical defects (bone loss >20%), lesion-specific soft tissue repair and the limited role of immobilization. RTS criteria included pain-free full range of motion, shoulder stability, strength and sport-specific readiness, typically achieved between 4 and 6 months depending on the procedure and sport demands. This ESSKA-ESA European Formal Consensus delivers practical, evidence- and experience-based recommendations for treatment and RTS following TASI according to age- and time-specific (first time and recurrent) scenarios. By integrating recurrence status, bone loss, soft tissue injury and sport type, the consensus provides a clinically valuable framework for individualized decision-making. Level II.
The pubic symphysis is a key joint for the stability of the pelvic ring. Pubic symphysis instability may lead to chronic pain and significant functional limitation, particularly in athletes and young subjects. Although conservative management is the first-line approach, refractory cases may require surgical intervention. The present study aimed to describe a surgical technique used in two soccer players who underwent pubic symphysis reconstruction through a Pfannenstiel approach with an autologous semitendinosus tendon graft passed through bone tunnels in the pubic bones in a figure- eight configuration and fixed with non-absorbable sutures. This technique's goal is to preserve the physiological mobility of the pubic symphysis. At 6 months, both patients showed an improvement of more than 30 points in the modified Harris Hip Score. Moreover, they achieved satisfactory functional recovery, returning to sports at 6 and 8 months, respectively. Radiographic evaluation demonstrated improved pelvic stability over a 5-year follow-up period. The technique proved to be safe, with low morbidity, and good clinical outcomes, allowing pelvic mobility preservation and return to sports. Despite the small number of cases, this surgical approach appears to be reproducible, with biomechanical advantages over pubic symphysis arthrodesis and a low complication rate. A sínfise púbica é uma articulação fundamental para a estabilidade do anel pélvico. A instabilidade desta articulação pode causar dor crônica e limitação funcional significativa, especialmente em atletas e indivíduos jovens. Embora o tratamento conservador seja a primeira linha de manejo, casos refratários podem exigir abordagem cirúrgica. Este estudo propõe apresentar uma descrição de técnica cirúrgica utilizada em dois pacientes atletas de futebol que foram submetidos à reconstrução da sínfise púbica com via de acesso de Pffanestiel, passagem de enxerto autólogo do 'tendão semitendinoso através de túneis ósseos nos ossos do púbis, configurados em oito e fixados com fios de sutura inabsorvíveis. A técnica visou preservar a mobilidade fisiológica da sínfise púbica. Após 6 meses, houve melhora de mais de 30 pontos do Escore de Harris Modificado para o Quadril e retorno funcional satisfatório às atividades físicas com retorno ao esporte após 6 e 8 meses, respectivamente. Houve melhora da estabilidade pélvica radiológica durante o seguimento de 5 anos. A técnica demonstrou ser segura, com baixa morbidade e bons resultados clínicos, permitindo a preservação da mobilidade pélvica e o retorno ao esporte. Apesar do baixo número de casos, esta alternativa cirúrgica é reprodutível, com vantagens biomecânicas em comparação com a artrodese da sínfise púbica e baixo índice de complicações.
Paediatric flexible flatfoot is the most common orthopaedic deformity encountered in paediatric practice. Although most cases are asymptomatic and resolve spontaneously, a subgroup of patients develops pain, functional impairment, and progressive deformity, requiring surgical treatment after failure of conservative management. Evans and Cotton osteotomies remain the standard procedures for correcting hindfoot valgus and restoring the medial longitudinal arch, both requiring a structural interposition material to maintain correction. Traditionally, autografts, allografts, and xenografts have been used; however, these options are associated with donor-site morbidity, graft resorption, disease transmission, and potential loss of correction over time. Porous titanium wedges have recently emerged as a synthetic alternative, offering immediate structural stability, osseointegration, and resistance to resorption while eliminating donor-site complications. This review evaluates the current evidence regarding surgical management of paediatric flexible flatfoot, comparing radiological outcomes, functional results, and complication profiles among available interposition materials, and discussing their role in contemporary reconstructive foot surgery.
distal biceps tendon rupture is an uncommon injury, with an incidence of two to three cases per 100,000 people annually. It predominantly affects men between the ages of 40 and 60, commonly in the dominant arm and during eccentric contractions. Surgical treatment is preferred as it allows better restoration of supination and flexion strength. Proper anatomical positioning has been shown to optimize forearm supination strength. a 45-year-old male developed an injury to the posterior interosseous nerve secondary to improper positioning of the distal biceps tendon during reinsertion. A revision surgery was performed. this case provides clinical evidence of a specific complication rarely described: posterior interosseous nerve entrapment due to incorrect tendon reinsertion. The value of proper anatomical positioning to avoid neurological sequelae is emphasized, as well as the importance of timely surgical reintervention to restore function. la ruptura del tendón distal del bíceps es una lesión infrecuente, con una incidencia de dos a tres personas por cada 100,000 personas al año, que afecta principalmente a hombres entre los 40 y 60 años, comúnmente en el brazo dominante y durante contracciones excéntricas. El tratamiento quirúrgico es preferido, ya que permite restaurar mejor la supinación y fuerza de flexión. Se ha demostrado que el posicionamiento anatómico adecuado optimiza la fuerza en la supinación del antebrazo. hombre de 45 años que desarrolló una lesión del nervio interóseo posterior secundario a un posicionamiento inadecuado del tendón distal del bíceps derecho en su reinserción, por lo cual se le somete a una cirugía de revisión. Se documenta la evolución clínica, el tratamiento quirúrgico de reintervención y el seguimiento. este caso aporta evidencia clínica sobre una complicación específica poco descrita: el atrapamiento del nervio interóseo posterior debido a una reinserción incorrecta del tendón. Se enfatiza el valor de realizar un posicionamiento anatómico adecuado para evitar secuelas neurológicas, así como la importancia de la reintervención quirúrgica oportuna para restaurar la función.
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Complications after open reduction and internal fixation (ORIF) of ankle fractures are not uncommon, negatively impacting the postoperative outcome. Tibiotalocalcaneal (TTC) arthrodesis has been shown to be a viable treatment option in these cases. The aim of this study was to describe the operative technique and the outcome of patients presenting failed osteosynthesis of the ankle joint managed with TTC using a retrograde femoral IM nail. This is a retrospective observational study of adult patients (18 years or older) operated on for failure in osteosynthesis of the ankle joint (malleolar or tibial pilon fractures) using a retrograde femoral nail to perform TTC arthrodesis, with a minimum follow-up of 24 months. Patient demographics, initial injury characterization, comorbidities, initial treatment, time from initial injury to TTC arthrodesis, time to union, secondary procedures, and complications were recorded. Patients were evaluated clinically and radiographically at 12 and 24 months using, respectively, a modified version of the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scores and full-weight-bearing anteroposterior and lateral radiographs. During the study period, 17 patients were treated with TTC arthrodesis using a retrograde femoral nail. The initial injury was a pilon fracture in 4 patients and a malleolar ankle fracture in 13 patients. The time between the initial injury and TTC arthrodesis ranged from 8 to 52 months, with a mean of 14.7 months. Complete radiographic fusion of the tibiotalar joint occurred uneventfully in all patients, whereas in four (23.5%) cases, complete radiographic fusion of the subtalar joint was not observed, although these patients were considered to have a satisfactory outcome due to a functional, painless, and properly aligned hindfoot after TTC arthrodesis. The mean time to union was 8 months, with a range of 5 to 10 months. Secondary procedures were performed in 2 patients. Four patients experienced minor complications. There were no statistically significant differences between patients who sustained a tibial pilon fracture and a malleolar ankle fracture in all variables analysed. The modified AOFAS score at 24 months ranged from 64 to 94, with a mean of 81 points. The use of a femoral retrograde IM nail for TTC arthrodesis is a viable option for patients with sequelae of tibial pilon and ankle malleolar fractures due to fixation failure.
Achondroplasia is the most common skeletal dysplasia associated with disproportionate short stature, with an estimated prevalence of 4.6 per 100 000 births. It is caused by a pathogenic variant in the gene encoding fibroblast growth factor receptor 3 (FGFR3), which disrupts endochondral ossification of the growing skeleton. To provide an updated overview of the therapeutic approach to achondroplasia, including currently approved treatments and those under investigation. The approval of vosoritide in 2021 has brought a major shift in the management of these patients. Updated follow-up guidelines have been published, along with initial outcomes in treated patients, with the aim of determining not only the impact on growth and final height but also on associated comorbidities, such as foramen magnum stenosis, and body proportions. We also review other emerging therapeutic strategies currently under development. The availability of targeted therapies has modified the traditional approach to the management of achondroplasia, which makes ongoing updates on approved and investigational treatments essential.
This study intended to evaluate the reliability of diagnosing meniscal RAMP lesions on magnetic resonance imaging (MRI) using a newly developed identification checklist. The primary objective was to standardise MRI interpretation to reduce operator-dependent variability and enhance diagnostic agreement. In total, 1350 knee MRI scans were initially reviewed, with 200 matching the predefined inclusion and exclusion criteria. Four sports medicine surgeons were divided into two groups: one using the developed RAMP lesion identification checklist and the other interpreting the MRI scans without it. Interobserver reliability was assessed using Cohen's kappa coefficient at two distinct time points. After 1 month, both groups reassessed the MRI scans using the checklist. The Intraclass Correlation Coefficient (ICC) was also calculated to determine the overall diagnostic consistency between the groups. The introduction of the checklist significantly improved interobserver reliability. In the initial evaluation, the group using the checklist exhibited a higher level of diagnostic agreement (Cohen's kappa = 0.779, 89% agreement) compared to the group without the checklist (Cohen's kappa = 0.057, 60.5% agreement). After 1 month, when both groups used the checklist, diagnostic concordance improved substantially (Cohen's kappa = 0.698, 85% agreement). The ICC between the groups indicated strong diagnostic consistency (0.759), further highlighting the checklist's effectiveness. The RAMP lesion identification checklist significantly enhances the reliability of MRI-based diagnoses by standardising the interpretation process and reducing observer variability. This protocol offers significant value in the preoperative setting by enhancing diagnostic consensus and surgeon confidence, ultimately allowing for more comprehensive surgical planning. However, further validation studies comparing MRI findings with direct arthroscopic evaluations are necessary to confirm its clinical utility. Level 3.
To characterize the prevalence and patterns of psychoactive substance use among fatal traffic crash victims across four Brazilian metropolitan areas and to identify the demographic and temporal factors independently associated with substance positivity. Cross-sectional study of 524 fatal traffic crash victims from Recife (n = 272), Curitiba (n = 96), Vitória (n = 93), and Belém (n = 63), March 2022-June 2024. Standardized blood toxicological screening for alcohol, cocaine (benzoylecgonine), benzodiazepines, amphetamines, and cannabis was performed at a single reference laboratory. Multivariable logistic regression identified independent predictors of alcohol and any substance positivity. Overall, 46.0% of victims tested positive for at least one substance. Alcohol was detected in 38.0%, with mean blood alcohol concentration (BAC) of 1.83 g/L (SD = 0.88); no significant difference across cities (p = 0.095). Cocaine or metabolites were detected in 9.9%, with uniform regional distribution (p = 0.392). Vitória showed markedly higher benzodiazepine positivity (9.7% vs. 1.0-4.4%; p = 0.019). Cannabis was not detected. Night time (OR = 2.45, 95%CI 1.63-3.67) and weekend crashes (OR = 2.05, 95%CI 1.38-3.04) were the strongest independent predictors of alcohol positivity. After adjustment, Vitória showed significantly higher odds of any substance positivity compared to Recife (OR = 1.73, 95%CI 1.01-2.98, p = 0.046). Psychoactive substances were involved in nearly half of fatal traffic crashes across four Brazilian cities. Temporal factors-night time and weekend crashes-were the primary independent predictors of substance involvement. Vitória's elevated benzodiazepine positivity persisted after adjustment, suggesting distinct regional prescribing patterns. These findings support temporally targeted enforcement strategies and region-specific pharmaceutical interventions.
Pheochromocytomasand paragangliomas (PPGLs) are rare catecholamine-secreting tumors that can affect systemic physiology, including bone metabolism. Although they are typically associated with genetic syndromes such as MEN2 and von Hippel-Lindau disease, PPGLs are not commonly linked to primary bone tumors. However, recent findings suggest a novel cancer syndrome involving both PPGLs and giant cell tumor of bone (GCTB) through H3F3A mutations. We report a rare case of a 53-year-old woman with multicentric GCTB, initially diagnosed at age 24, who subsequently developed bilateral pheochromocytomas. Following multiple recurrences of skeletal tumors and eventual leg amputation, imaging and biochemical evaluation revealed bilateral adrenal tumors with markedly elevated catecholamine levels. Genetic analysis identified mosaicism for a pathogenic H3F3A (G35W) variant in both adrenal and bone tumors. Surgical resection of both adrenal glands normalized catecholamine levels and resolved hypertension. The patient has remained tumor-free and normotensive for five years following adrenalectomy. This case supports the existence of a shared pathogenic mechanism linking PPGLs and GCTBs, likely mediated by postzygotic H3F3A mutations. Recognition of this association is crucial for early diagnosis, genetic counseling, and management of similar cases.
To compare the interobserver and intraobserver reliability of glenopolar angle (GPA) measurement in scapular fractures using conventional radiography (2D) and three-dimensional computed tomography (3D-CT). This retrospective observational study included 33 patients with fractures of the scapular body or neck treated between 2016 and 2023. Anteroposterior radiographs and 3D-CT scans obtained at the time of diagnosis were included. The GPA was measured by eight independent evaluators, and data were analyzed using the intraclass correlation coefficient (ICC), according to the criteria proposed by Koo and Li, with SPSS software. The mean interobserver ICC for GPA measurement was 0.959 (95% CI: 0.934-0.977) for radiography and 0.971 (95% CI: 0.953-0.984) for 3D-CT, indicating excellent reliability for both methods. Individual intraobserver reliability ranged from 0.598 to 0.869, with five evaluators demonstrating good reliability and three showing moderate reliability. The sample consisted predominantly of males (93.9%), with a mean age of 39.6 years (range: 19-78 years), and 24.2% of patients underwent surgical treatment. GPA measurements obtained by radiography and 3D-CT demonstrated high interobserver reliability, with slight superiority of 3D-CT. Both methods are valid, although 3D-CT may be preferable in cases requiring greater angular precision. Level of Evidence: III; Retrospective observational study. Comparar a confiabilidade inter e intraobservador da aferição do ângulo glenopolar (AGP) em fraturas da escápula utilizando radiografias convencionais (2D) e tomografias computadorizadas com reconstrução tridimensional (TC-3D). Estudo observacional retrospectivo conduzido com 33 pacientes com fraturas do corpo ou colo da escápula atendidos entre 2016 e 2023. Foram incluídas radiografias anteroposteriores e TC-3D obtidas no momento do diagnóstico. O AGP foi aferido por oito avaliadores independentes e os dados foram analisados por meio do coeficiente de correlação intraclasse (CCI), conforme os critérios de Koo e Li, utilizando o software SPSS. A média do CCI interobservador para a aferição do AGP foi de 0,959 (IC95%: 0,934–0,977) para a radiografia e de 0,971 (IC95%: 0,953–0,984) para a TC-3D, indicando excelente confiabilidade para ambos os métodos. A confiabilidade intraobservador individual variou de 0,598 a 0,869, com cinco avaliadores apresentando boa confiabilidade e três com confiabilidade moderada. A amostra foi composta majoritariamente por homens (93,9%), com média de idade de 39,6 anos (19–78 anos), sendo 24,2% tratados cirurgicamente. As aferições do AGP por radiografia e TC-3D demonstraram alta confiabilidade interobservador, com leve superioridade da TC-3D. Ambos os métodos são válidos, sendo a TC-3D preferível em casos com necessidade de maior precisão angular. Nível de evidência: III; Estudo comparativo retrospectivo.