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Scheider P, Farr S. Outcomes and complications of surgical treatment modalities for simple bone cysts of the humerus in children and adolescents. INTERNATIONAL ORTHOPAEDICS 2024; 48:1619-1626. [PMID: 38570348 DOI: 10.1007/s00264-024-06158-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 03/19/2024] [Indexed: 04/05/2024]
Abstract
PURPOSE The aim of this study was to evaluate and compare different surgical treatment modalities for simple bone cysts (SBC) of the humerus regarding their effectiveness and recurrence rate. METHODS In this retrospective study, patients who received surgical treatment for previously untreated primary SBCs of the humerus were analyzed. Demographic data, cyst-specific as well as treatment-specific parameters, complications, treatment failures, and recurrence rates were collected and correlated with different treatment modalities. Observed procedures were categorized as open procedure (n=20) or osteosynthesis alone (n=3). For the open procedure group, four subgroups could be defined. RESULTS Twenty-three patients were included. The mean age at diagnosis was 11.6 ± 2.5 years, and the mean postoperative follow-up was 3.9 ± 2.6 years (range 1.0-10.3). After surgical intervention, a total of five (21.7%) patients showed at least one recurrence. Fracture occurred in three (13.0%) cases. The incidence of treatment failure was significantly higher in the curettage, allograft, adjuvants group, with five (83.3%) of six cases showing recurrence, than in the other subgroups (≤ 25.0%) including the osteosynthesis alone group (p=.024). For the open procedure group, the failure-free survival rates were 80.0% after two years and 50.4% after five years. For the three cases treated by osteosynthesis alone, no failures were observed. CONCLUSION Open procedures showed similar failure rates except for the subgroup using curettage, allograft, and adjuvants which showed significantly higher treatment failure. Promising results were observed in the group which received solely osteosynthesis without cyst excision or filling, as no treatment failure was observed here.
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Affiliation(s)
- Philipp Scheider
- Department of Pediatric Orthopaedics and Foot and Ankle Surgery, Orthopaedic Hospital Speising, Speisingerstraße 109, 1130, Vienna, Austria.
| | - Sebastian Farr
- Department of Pediatric Orthopaedics and Foot and Ankle Surgery, Orthopaedic Hospital Speising, Speisingerstraße 109, 1130, Vienna, Austria
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van Geloven TPG, van der Heijden L, Laitinen MK, Campanacci DA, Döring K, Dammerer D, Badr IT, Haara M, Beltrami G, Hobusch GM, Kraus T, Scheider P, Soto-Montoya C, Umer M, Saeed J, Funovics PT, Fiocco M, van de Sande MAJ, de Witte PB. As simple as it sounds? The treatment of simple bone cysts in the proximal femur in children and adolescents: Retrospective multicenter EPOS study of 74 patients. J Child Orthop 2024; 18:85-95. [PMID: 38348433 PMCID: PMC10859114 DOI: 10.1177/18632521231221553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 12/03/2023] [Indexed: 02/15/2024] Open
Abstract
Purpose Simple bone cysts are among the most prevalent benign cystic tumor-like lesions in children. Proximal femoral simple bone cysts may require specific treatment because of increased fracture risk. With limited literature available on this specific localization, consensus regarding optimal treatment is lacking. We present a large international multicenter retrospective cohort study on proximal femoral simple bone cysts. Methods All consecutive pediatric patients with proximal femoral simple bone cyst from 10 tertiary referral centers for musculoskeletal oncology were included (2000-2021). Demographics, primary treatment, complications, and re-operations were evaluated. Primary outcomes were time until full weight-bearing and failure-free survival. Results Overall, 74 simple bone cyst patients were included (median age 9 years (range = 2-16), 56 (76%) male). Median follow-up was 2.9 years (range = 0.5-21). Index procedure was watchful waiting (n = 6), percutaneous procedure (n = 12), open procedure (n = 50), or osteosynthesis alone (n = 6). Median time until full weight-bearing was 8 weeks (95% confidence interval = 0.1-15.9) for watchful waiting, 9.5 (95% confidence interval = 3.7-15.3) for percutaneous procedure, 11 (95% confidence interval = -0.7 to 13.7) for open procedure, and 6.5 (95% confidence interval = 5.9-16.1) for osteosynthesis alone (p = 0.58). Failure rates were 33%, 58%, 29%, and 0%, respectively (p = 0.069). Overall failure-free survival at 1, 2, and 5 years was 77.8% (95% confidence interval = 68.2-87.4), 69.5% (95% confidence interval = 58.5-80.5), and 62.0% (95% confidence interval = 47.9-76.1), respectively. Conclusion A preferred treatment for proximal femoral simple bone cysts remains unclear, with comparable failure rates and times until full weight-bearing. Watchful waiting may be successful in certain cases. If not feasible, osteosynthesis alone can be considered. Treatment goals should be cyst control, minimizing complications and swift return to normal activities. Therefore, an individualized balance should be made between undertreatment, with potentially higher complication risks versus overtreatment, resulting in possible larger interventions and accompanying complications. Level of evidence Level IV, retrospective multicentre study.
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Affiliation(s)
- Thomas PG van Geloven
- Department of Orthopedic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Lizz van der Heijden
- Department of Orthopedic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Minna K Laitinen
- Bone Tumor Unit, Orthopedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Domenico A Campanacci
- Orthopedic Oncology and Reconstructive Surgery, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Kevin Döring
- Division of Orthopedics, Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Dietmar Dammerer
- Department of Orthopaedics and Traumatology, University Hospital of Krems, Krems, Austria
| | - Ismail T Badr
- Orthopedic Surgery, Menoufia University, Shebin El-Kom, Egypt
| | - Mikko Haara
- Pediatric Surgery and Orthopedics, New Children’s Hospital Helsinki, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Giovanni Beltrami
- Pediatric Orthopedics, Azienda Ospedaliero Universitaria Meyer, Florence, Italy
| | - Gerhard M Hobusch
- Division of Orthopedics, Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Tanja Kraus
- Pediatric Orthopedic Unit, Orthopedics and Traumatology, University of Graz, Graz, Austria
| | - Philipp Scheider
- Trauma Surgery, University Clinic of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Masood Umer
- Orthopedic Surgery, The Aga Khan University Hospital, Karachi, Pakistan
| | - Javeria Saeed
- Orthopedic Surgery, The Aga Khan University Hospital, Karachi, Pakistan
| | - Phillipp T Funovics
- Division of Orthopedics, Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Marta Fiocco
- Medical Statistics Section, Department of Biomedical Data Science, Leiden University Medical Center, Leiden, The Netherlands
- Mathematical Institute, Leiden University, Leiden, The Netherlands
| | | | - Pieter Bas de Witte
- Department of Orthopedic Surgery, Leiden University Medical Center, Leiden, The Netherlands
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Xie Y, Song Z, Tang Z, Xu Z, Rao Z, Wen J, Xiao S. Percutaneous calcium sulfate injection versus localized scrape bone grafting: clinical effect comparison in titanium elastic nail treatment of pathological fracture of proximal humerus caused by unicameral bone cysts in children. Front Pediatr 2024; 11:1334950. [PMID: 38264502 PMCID: PMC10803614 DOI: 10.3389/fped.2023.1334950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 12/19/2023] [Indexed: 01/25/2024] Open
Abstract
Objective A retrospective study was conducted to compare the mid-term clinical efficacy between percutaneous calcium sulfate injection (PCSI) and localized scrape bone grafting (LSBG) in using titanium elastic nails treat humerus pathologic fractures caused by unicameral bone cysts in children. Methods Humerus pathologic fracture patients with unicameral bone cysts in our pediatric orthopedic department from January 2015 to January 2020 were retrospectively analyzed. Patients were divided into two groups, namely the PCSI group and the LSBG group, based on the type of bone grafting material they received. Preoperative assessments were made in both groups using the Cyst Index and Cyst activity. During the perioperative phase, assessments were made regarding operative time, bleeding, postoperative VAS scores, and the frequency of reoperation within 2 years. Clinical outcomes were evaluated using the Capanna scale at the last follow-up, and the occurrence of re-fractures during the follow-up period. Results A total of 22 patients were included, with a mean follow-up duration of 33.5 ± 5.8 months. No significant differences were found between the two groups in terms of Cyst Index and Cyst activity before the operation. The operative time, bleeding, and postoperative VAS scores in the PCSI group were found to be lower than those in the LSBG group (P < 0.05). The PCSI group also showed a higher frequency of reoperation within 2 years compared to the LSBG group (P < 0.05). However, no significant differences were observed between the two groups in terms of Capanna scale scores at the last follow-up and the incidence of re-fractures during follow-up. Conclusions Both titanium elastic nails (TEN) combined with PCSI or LSBG were found to be safe and effective treatments for humerus pathologic fractures caused by unicameral bone cysts in children. PCSI is considered as a less invasive option with shorter operative times, less bleeding, and reduced postoperative pain, although it comes with the risk of multiple injections. On the other hand, LSBG is considered as a more invasive option for the treatment of active bone cysts but is associated with a lower recurrence rate.
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Affiliation(s)
- Yuyin Xie
- Department of Pediatric Orthopedics, Hunan Provincial People’s Hospital, the First Affiliated Hospital of Hunan Normal University, Changsha, Hunan, China
| | - Zhenqi Song
- Department of Pediatric Orthopedics, Hunan Provincial People’s Hospital, the First Affiliated Hospital of Hunan Normal University, Changsha, Hunan, China
| | - Zhongwen Tang
- Department of Pediatric Orthopedics, Hunan Provincial People’s Hospital, the First Affiliated Hospital of Hunan Normal University, Changsha, Hunan, China
| | - Zheng Xu
- Department of Pediatric Orthopedics, Hunan Provincial People’s Hospital, the First Affiliated Hospital of Hunan Normal University, Changsha, Hunan, China
| | - Zhouzhou Rao
- Key Laboratory of Translational Cancer Stem Cell Research, Department of Physiology, Hunan Normal University School of Medicine, Changsha, Hunan, China
| | - Jie Wen
- Department of Pediatric Orthopedics, Hunan Provincial People’s Hospital, the First Affiliated Hospital of Hunan Normal University, Changsha, Hunan, China
- Department of Anatomy, Hunan Normal University School of Medicine, Changsha, Hunan, China
| | - Sheng Xiao
- Department of Pediatric Orthopedics, Hunan Provincial People’s Hospital, the First Affiliated Hospital of Hunan Normal University, Changsha, Hunan, China
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Ruiz-Arellanos K, Larios F, Inchaustegui ML, Gonzalez MR, Pretell-Mazzini J. Treatment and Outcomes of 4,973 Unicameral Bone Cysts: A Systematic Review and Meta-Analysis. JBJS Rev 2024; 12:01874474-202401000-00002. [PMID: 38181108 DOI: 10.2106/jbjs.rvw.23.00159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2024]
Abstract
» Unicameral bone cysts (UBCs) can increase the risk of pathologic fractures of both long and short bones. Although multiple treatments exist, data are conflicting regarding optimal management. » We sought to analyze treatment strategies for UBCs and their rates of successful treatment. » Success rates were analyzed according to treatment modality, with emphasis on filling techniques and/or decompression associated with curettage, and injection compounds. » Curettage with bone substitute and cyst decompression was identified as a highly successful technique for UBC treatment. » Decompressing the cyst wall after injection, regardless of the specific compound used, had a greater potential to enhance healing rates. » The management decision should be individually guided within the patient's context.
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Affiliation(s)
| | - Felipe Larios
- Facultad de Medicina Universidad Peruana Cayetano Heredia, Lima, Perú
| | | | - Marcos R Gonzalez
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Juan Pretell-Mazzini
- Miami Cancer Institute, Division of Orthopedic Oncology, Baptist Health System South Florida, Plantation, Florida
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Deventer N, Deventer N, Gosheger G, de Vaal M, Budny T, Luebben T, Frommer A, Vogt B. Evaluation of different treatment modalities for fractured and non-fractured simple bone cyst: A single-center review of 68 patients. Medicine (Baltimore) 2021; 100:e26703. [PMID: 34397806 PMCID: PMC8341315 DOI: 10.1097/md.0000000000026703] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 07/07/2021] [Indexed: 12/04/2022] Open
Abstract
Simple bone cysts (SBCs) occur most frequently in the proximal aspect of the humerus and femur in growing age and are associated with intercurrent pathological fractures in up to 87%. Therapeutic management of SBCs remains controversial. The aim of this study was to examine the outcome of conservative and various surgical treatment modalities considering the specific anatomic location and integrity of the SBC.In this retrospective study, we analyzed 68 cases of SBCs who underwent a conservative or surgical treatment between 2009 and 2020 with a mean follow-up of 30.1 months. The epidemiological characteristics, complications, clinical, and radiographic outcome after conservative or surgical treatment were assessed.The study includes 50 male (73.5%) and 18 female (26.5%) patients with a mean age of 9.1 years. The most common locations were the proximal humerus (69.2%, n = 47) and femur (16.2%, n = 11). In 43 cases (63.2%; upper limb n = 40, lower limb n = 3) a pathological fracture occurred. Fifty patients (73.5%; upper limb n = 40, lower limb n = 10) underwent a conservative treatment. In 11 cases (16.2.1%; upper limb n = 4, lower limb n = 7) an intralesional curettage and defect reconstruction with bone substitute without stabilization were performed. Five patients (7.3%; upper limb n = 4, lower limb n = 1) received an osteosynthesis, in two cases (2.9%; upper limb 1; lower limb 1) combined with an intralesional curettage and defect reconstruction with bone substitute. All 32 pathological fractures treated conservatively (upper limb n = 31, lower limb n = 1) healed within 6 weeks; 17/43 patients (39.5%) suffered at least one second fracture. After intralesional curettage and defect reconstruction with bone substitute local recurrence was observed in 5/13 cases (38.5%). Spontaneous consolidation, at least partially, was observed in three cases (4.4%) following conservative treatment after fracture. No relevant secondary angular or torsional deformity was observed after treatment.The majority of SBCs can be treated conservatively, especially in the upper extremity. However, if a fracture is completely dislocated, joint affecting, unstable or open, surgical treatment is necessary. Load-dependent pain or the inability to mobilize timely after fracture can necessitate surgical treatment in SBCs affecting the lower extremity. Spontaneous resolution, especially after fracture, can be seen in rare cases.
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Affiliation(s)
- Niklas Deventer
- Department of Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Muenster, Germany
| | - Nils Deventer
- Department of Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Muenster, Germany
| | - Georg Gosheger
- Department of Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Muenster, Germany
| | - Marieke de Vaal
- Department of Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Muenster, Germany
| | - Tymoteusz Budny
- Department of Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Muenster, Germany
| | - Timo Luebben
- Department of Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Muenster, Germany
| | - Adrien Frommer
- Department of Pediatric Orthopaedics, Deformity Reconstruction and Foot Surgery, University Hospital Muenster, Muenster, Germany
| | - Bjoern Vogt
- Department of Pediatric Orthopaedics, Deformity Reconstruction and Foot Surgery, University Hospital Muenster, Muenster, Germany
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Wang X, Han J, Li Y, Liu Y, Luo J. Comparative efficacy and safety profile for the treatment of humeral bone cysts in children: curettage and mixed bone grafting either with or without elastic intramedullary nailing. J Orthop Surg Res 2021; 16:241. [PMID: 33823909 PMCID: PMC8022413 DOI: 10.1186/s13018-020-02130-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 11/29/2020] [Indexed: 11/25/2022] Open
Abstract
Purpose The primary aim of our study was to evaluate the comparative efficacy and safety profile of curettage and mixed bone grafting without instrument or with elastic intramedullary nailing in the treatment of humeral bone cyst in children. Methods Our retrospective study included a total of 48 children harboring humeral bone cyst in our hospital from August 2012 to February 2019. The patients enrolled were divided into elastic nailing group with the application of elastic intramedullary nailing (n = 25) and control group without using instrument (n = 23) during the management of curettage and mixed bone grafting. The following medical outcomes of the two groups were monitored and recorded: the amount of intraoperative blood loss, operation time and postoperative full weight-bearing time, in addition to postoperative clinical effects after 1 year, the function and pain level of shoulder joint before and 1, 3, 6, 9, 12, and 16 months after operation. Follow-up radiographic outcomes were reviewed to observe bone healing, local recurrence and internal fixation loosening, and other postoperative complications. Results The clinical curative effect of the elastic nailing group was higher than that of the control group 16 months after operation (96.00% > 73.91%, P < 0.05). The intraoperative blood loss and postoperative full weight-bearing time in the elastic nailing group were less than those in the control group (P < 0.05), but the operation time was statistically insignificant between the two groups (P > 0.05). Before operation, the shoulder joint function of the two groups was comparable (P > 0.05), while the function showed remarkably better outcome in the elastic nailing group than control group 1 to 16 months after operation (P < 0.05). Before operation, the pain level of the two groups was comparable (P > 0.05), while 1 to 16 months after operation, the pain level of the elastic nailing group was significantly lower than that of the control group (P < 0.05). Patients in both groups were followed up for 16 months. Mixed bone grafting fusion was indicated by imaging CT and X-ray during the follow-up period, with an average fusion time of 11.3 ± 1.2 months (range, 8–16 months). Three months after operation, there was 1 case of incomplete pathological fracture in the control group, while no related complications occurred in the elastic nailing group. Moreover, no tumor recurrence was observed in the two groups. The two groups were comparable in terms of the incidence of complications (P > 0.05). Conclusion Children with humeral cyst treated with curettage and mixed bone grafting with the additional use of elastic intramedullary nailing exerted superior results to those without using instrument as there are beneficial outcomes and safety profile and no complications.
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Affiliation(s)
- Xuan Wang
- Department of Pediatric Orthopedics, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Qiaoxi District, Shijiazhuang, 050051, Hebei, China
| | - Jiuhui Han
- Department of Pediatric Orthopedics, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Qiaoxi District, Shijiazhuang, 050051, Hebei, China.
| | - Yazhou Li
- Department of Pediatric Orthopedics, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Qiaoxi District, Shijiazhuang, 050051, Hebei, China
| | - Yuchang Liu
- Department of Pediatric Orthopedics, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Qiaoxi District, Shijiazhuang, 050051, Hebei, China
| | - Junzhong Luo
- Department of Pediatric Orthopedics, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Qiaoxi District, Shijiazhuang, 050051, Hebei, China
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Williams AK, Crawford B, Federman NC, Bernthal N, Arkader A. What's New in Pediatric Orthopaedic Tumor Surgery. J Pediatr Orthop 2021; 41:e174-e180. [PMID: 33027233 DOI: 10.1097/bpo.0000000000001689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pediatric Orthopaedic Oncology is a developing subspecialty within the field of Pediatric Orthopaedics. Traditionally, the field of Orthopaedic Oncology has been focused on the skeletally mature individual, and the research tends to be all encompassing rather than truly evaluating isolated populations. The purpose of this review is to summarize the most clinically relevant literature in the field of Pediatric Orthopaedic Oncology over the last 6 years. METHODS We evaluated the PubMed database utilizing keywords for pediatric orthopaedic oncology: sarcoma, osteosarcoma, Ewing sarcoma, bone cyst. In additionally, we further broadened our search by searching for relevant articles in the contents sections of major orthopaedic surgery journals that routinely publish both pediatric and orthopaedic oncology literature. In keeping with "What's New," we selected the most clinically relevant articles published in the last 6 years from January 1, 2014 through February 2020. Basic science and systemic therapies literature was widely reviewed and the research and clinical trials most relevant to pediatric sarcoma and neoplastic processes found in the pediatric population were included. RESULTS Our search yielded 60 articles that met general criteria, from which 14 were determined to be most relevant to the goals of this paper. Of the papers presented in this review, there were papers related to management of benign tumors/tumor-like conditions, bone cysts, limb salvage procedures, and amputation procedures. Ultimately included in the review were 5 studies related to limb salvage, 4 related to bone cysts, 1 related to multiple hereditary exostoses, 2 related to osteofibrous dysplasia, 1 related to chondroblastoma, and 1 discussing cementation in skeletally immature patients. They were level III, IV, and V studies. Basic science and systemic therapies literature was widely reviewed and the research and clinical trials most relevant to pediatric sarcoma and neoplastic processes found in the pediatric population were included. Our search of the basic science and systemic therapies literature yielded 19 sources were found to be pertinent to our aims and 18 of those sources were published between 2015 and 2020. CONCLUSIONS There are many, varied, and creative procedures in the realm of limb salvage, though there remains a lack of high-level evidence to support some of the more novel procedures. In regards to benign bone tumors, despite a more solid base of literature, there still does not seem to be consensus as to the best treatment. In particular, there continue to be many schools of thought on the treatment of benign bone cysts. Research in the basic science arena and systemic therapies are advancing in exciting ways in regards to pediatric sarcoma. Orthopaedic oncologic research specific to the pediatric population overall continues to be impeded by low sample sizes and inadequate levels of evidence, which limits the ability of surgeons to draw definitive conclusions from the literature.
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Affiliation(s)
- Amy K Williams
- Department of Orthopaedic Surgery, Miller Children's Hospital, Long Beach
| | | | - Noah C Federman
- Pediatric Hematology and Oncology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | | | - Alexandre Arkader
- Department of Orthopaedic Surgery, Children's Hospital of Philadelphia, Philadephia, PA
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