Burkitt's lymphoma of the scapula

Burkitt's lymphoma may involve the maxilla or mandible, but to date, there has been no reference in the literature to scapular involvement by this tumor. This article describes the case of a 9-year-old child who presented with a huge tumor involving the right shoulder with osteolytic and sclerotic lesions in the scapula. The histopathological findings were suggestive of Burkitt's lymphoma, and the immunohistochemical findings discard a lymphoblastic lymphoma or plasmablastic lymphoma. In addition, in situ hybridization for Epstein-Barr virus encoded small nuclear RNA (EBER) was positive. Although the child also presented a cervical lymphadenopathy, the fact that Burkitt's lymphoma is generally extranodal, the marked swelling of the shoulder, and the extensive involvement of the bone strongly argue that this tumor had its origin in the scapula. This case demonstrates the importance of including Burkitt's lymphoma in the differential diagnosis of lymphoma involving bones in children.

Releases of subscapularis contracture: an anatomic and clinical study

Correction of anterior subscapularis contracture is an important step in soft-tissue balancing at the time of total shoulder replacement (TSR). An anatomic and clinical investigation was undertaken to investigate the effect of steps involved in subscapularis release. In 14 cadaveric shoulders studied, the subscapularis insertion consisted of three regions: a thick superior tubular tendon (STT), a flat middle tendon, and an inferior portion where the muscle fibers insert directly into the humerus. In 16 consecutive patients undergoing primary TSR for osteoarthritis, measurements of subscapularis length were taken after different releases. An average of 0.9 cm (confidence interval, 0.7-1.1 cm) of excursion was added after anterior capsular release, and an additional 0.7 cm (confidence interval, 0.5-0.9 cm) of excursion was obtained after STT release. Incision of the STT is an alternative means of gaining subscapularis length when balancing the soft tissues in patients with osteoarthritis undergoing TSR.

The course of the suprascapular nerve in the supraspinatus fossa and its vulnerability in muscle advancement

Twenty-four cadaveric shoulders were evaluated to assess damage to the suprascapular nerve in relation to Debeyre's advancement of the supraspinatus muscle for rotator cuff repair. In all cases the neurovascular pedicle was tethered at the suprascapular notch and at the periosteum of the supraspinatus fossa. The medial motor branches were directed to the trigonum spinae or the superior angle of the scapula (group 1). The dorsal branches crossed the muscle at the bottom of the supraspinatus fossa (group 2) or directly entered the muscle (group 3). The lateral group remained in the supraspinatus fossa (group 4) or entered the infraspinatus fossa (group 5). The mean distance between the scapular notch and the point of entry of the medial branches into the muscle was 2.9 cm. Branches of group 1 and the main nerve are at risk of injury when detaching muscle from bone. This risk is minimized by subperiosteal detachment. Branches of group 1 are tensioned when advancing the muscle 1 cm laterally.

Non-Hodgkin's lymphoma with left suprascapular neuropathy on magnetic resonance imaging

Magnetic resonance imaging is gaining importance in the diagnosis of nerve and muscular disorders. The ability of magnetic resonance imaging to delineate the different muscles and the nerve in any plane has made the differentiation between the changes of neuropathy, denervation, and nerve entrapment possible. Although findings on magnetic resonance imaging are non-specific, their use, coupled with clinical symptoms and electromyographic findings, allow an accurate diagnosis to be made without resorting to invasive biopsies.

[Sprengel deformity in a nine-year-old boy: diagnosis and therapy]

Sprengel deformity is a congenital malformation with usually unilateral elevation and medial rotation of the scapula. An omovertebral bone is generally present. Associated skeletal malformations are frequently present. Though functional impairment is mild, the cosmetic and psycho-social impairment can be considerable. The prognosis of early surgical therapy is good. The presented case also justifies surgical correction in the older child.

Age-related changes of the glenoid labrum in normal shoulders

A growing number of labral changes are described in the literature. The purpose of this study was to evaluate the glenoid and labrum of normal shoulders at different ages and characterize any apparent age-dependent changes. We analyzed 32 normal cadaveric shoulders with a mean age of 57 years (range, 18-89 years). There were 22 male and 10 female cadavers, with 14 right and 18 left specimens. The shoulders were studied macroscopically, histologically, and radiologically. The radiologic evaluation consisted of an analysis of the subchondral mineralization of the glenoid with the use of computed tomographic osteoabsorptiometry. Macroscopically, there were no statistically significant differences among the age groups. Histopathologically, the labrum showed a significant qualitative and quantitative increase (P <.01) in lesions across all regions with increasing age. In younger individuals, lesions at the 12-o'clock position were the most prevalent, with the incidence increasing with age. The anterosuperior position was the region with the next highest prevalence. This was also the area of the highest stress distribution on the glenoid. Our studies demonstrated clear histopathologic changes of the glenoid labrum that are significantly age-related at specific sites. The earliest changes are seen close to the area of highest stress distribution of the glenoid, which could explain the progressive labral changes with increasing age. Arthroscopically detected changes of the glenoid labrum should be evaluated in the context of age-related changes in normal shoulders.

Scrape and fine-needle aspiration cytology of elastofibroma

BACKGROUND

Cytological findings of elastofibroma have rarely been reported and, to the best of our knowledge, have been illustrated in only 4 patients in the English language literature.

MATERIALS AND METHODS

We retrospectively reviewed fine-needle aspiration biopsy (FNAB) and scrape smears in 5 cases of elastofibroma.

RESULTS

All the lesions were typically located between the rib cage and the scapula. The cytological smears consisted of mature adipocytes, fibroblasts, collagen fibers, globular bodies and characteristic "braid-like" or "fern-like" structures, revealing degenerative elastic fibers. All the smears were specifically diagnosed as elastofibroma in combination with clinical and radiological findings.

CONCLUSION

FNAB smears of elastofibromas may be hypocellular due to their densely fibrous nature and therefore diagnostic material may often be overlooked. Careful evaluation of the background of the smears coupled with full knowledge of the clinical and radiological findings, including magnetic resonance imaging, is required to establish the correct diagnosis.

Glenoid shape in atraumatic posterior instability of the shoulder

Glenoid shape is related closely to shoulder stability and its abnormality is thought to affect the humeral head position in shoulders with atraumatic instability. However, it is unclear how the glenoid shape in shoulders with atraumatic instability is different from the glenoid shape in normal shoulders. The current authors investigated glenoid shape of 45 healthy individuals (20 males and 25 females; average age, 22 years) and 20 patients with atraumatic posterior instability with multidirectional laxity (six males and 14 females; average age, 19 years) using three-dimensional magnetic resonance imaging. The tilting angles of the glenoid bone were measured in five consecutive planes perpendicular to the long axis of the glenoid and cross sections were divided into three types (concave, flat, convex). In healthy individuals, the average tilting angles from the bottom to the top of the glenoid bone were 3.0 degrees +/- 3.6 degrees, 1.0 degrees +/- 3.2 degrees, -1.0 degrees +/- 2.0 degrees, -2.3 degrees +/- 3.9 degrees, and -6.9 degrees +/- 3.7 degrees anteriorly, and tilting angles of patients were -6.1 degrees +/- 4.0 degrees, -4.0 degrees +/- 3.6 degrees, -4.8 degrees +/- 3.2 degrees, -5.5 degrees +/- 2.7 degrees, and -7.5 degrees +/- 3.1 degrees. The type of cross section also was different on the bottom plane where the concave shape accounted for 78% of healthy individuals whereas it accounted for 0% of patients. The loss of tilting angles and concavity of the inferior glenoid would correlate with the direction of the head translation in posterior instability.

Congenital undescended scapula (Sprengel deformity): a case study

This study describes a congenital deformity of the shoulder joint in a 5-year-old female, associated with an undescended scapula and the presence of an omovertebral bone. Dissections on 16 cadavers were done to identify structures in danger of injure before operating on the patient. Surgeons need to take specific note of the dorsal scapular nerve.

Outcomes of scapula stabilization in obstetrical brachial plexus palsy: a novel dynamic procedure for correction of the winged scapula

Among the late consequences of obstetrical brachial plexus palsy is winging of the scapula, a functional and aesthetic deformity. This article introduces a novel surgical procedure for the dynamic correction of this clinical entity that involves the dynamic transfer of the contralateral trapezius muscle and/or rhomboid muscles and anchoring to the affected scapula. In more severe cases of scapula winging, the contralateral latissimus dorsi muscle may also need to be transferred to achieve dynamic scapula stabilization. The outcomes of this novel surgical procedure were analyzed in relation to the effect on abduction, external rotation, growth of the scapula, and distance of the scapula from the posterior midline. The results were analyzed in 26 patients who underwent this procedure and had adequate follow-up. The mean patient age was 6.39 years. Fourteen (54 percent) had a diagnosis of Erb palsy, and 12 (46 percent) had a diagnosis of global paralysis. All 26 patients had an additional secondary procedure performed prior to or simultaneously with the scapula stabilization procedure. In 19 patients, the contralateral trapezius was transferred and anchored to the medial border of the winged scapula alone, but in seven cases the underlying rhomboid major was transferred along with the trapezius muscle to provide sufficient scapula stabilization. In five cases in which the scapula winging was severe, the contralateral latissimus dorsi muscle was transferred at a second stage. After this procedure, all patients demonstrated improved scapula symmetry. The mean increase in abduction was 18 degrees (p < 0.001), the mean increase in external rotation was 19 degrees (p < 0.001), and the mean increase in anterior flexion was 12 degrees (p = 0.015). The improvement of the relative position of the winged scapula on the posterior thorax was analyzed by measuring the distance of the inferior angle of both scapulae from the midline, then calculating the difference between normal and affected sides and comparing this value before and after the scapula stabilization procedure. This value preoperatively was 3.24 cm; postoperatively it decreased to 0.36 cm (p < 0.001), demonstrating a statistically significant improvement.

Perthes lesion (a variant of the Bankart lesion): MR imaging and MR arthrographic findings with surgical correlation

OBJECTIVE

The aim of this study was to evaluate the use of MR imaging in the characterization of the Perthes lesion by correlating MR findings with findings at arthroscopy.

CONCLUSION

The use of a combination of axial and abduction-external rotation position sequences on MR images can be helpful in the diagnosis of a Perthes lesion. A fluid-filled joint with capsular distension, caused by either a large amount of effusion or MR arthrography, was found to be helpful in outlining Perthes lesions. Adding the abduction-external rotation position to the protocol in patients in whom Perthes lesion is suspected will increase diagnostic accuracy and may reveal a Perthes lesion not visible on axial images, as was the case in 50% of the patients in our series.

Congenital high scapula

Congenital high scapula is also known as Sprengel's deformity. The elevation of the scapula is accompanied by its rotation to a varus position. A series of 19 cases is presented, with 4 bilateral cases. A modified Woodward procedure was performed in all the surgical cases using the basic Woodward technique modified by correcting the tilting of the glena. The operative results were judged on cosmetic and functional criteria. The age of the patients and the presence of an omovertebral bone did not influence the results. Associated cervical spine anomalies were of negative prognosis. Results in this series showed only three fair or poor results; the other cases (79%) were all improved cosmetically and functionally with normal shoulder abduction following reorientation of the scapulo-humeral joint.

Post-traumatic fibro-osseous lesion of the ribs and scapula (sclerosing xanthofibroma)

Fibrous lesions of bone may be difficult to classify. Their etiology is controversial, most being considered to be developmental lesions rather than true neoplasms. We describe a patient with post-traumatic fibro-osseous lesion of the ribs, also known as sclerosing xanthofibroma; a lesion believed to be a reactive response to intramedullary hemorrhage following chest wall trauma. Clinically, the lesions in our patient were thought to be metastatic disease because of their multifocal appearance. An extensive clinical and laboratory metastatic evaluation with surgical resection of one of the lesions using intraoperative gamma probe was undertaken. In addition to the multiple rib involvement, our case also showed a lesion in the scapula. The pathologic and radiologic features of this entity are reviewed along with the summary of the differential diagnosis.

Comparative radiologic study of bone density and cortical thickness of donor bone used in mandibular reconstruction

OBJECTIVE

The aim of this study was to compare the total cancellous bone density, bone-implant interface density, and cortical thickness of 6 donor bone types commonly used in oral and maxillofacial reconstruction.

METHODS

A total of 120 bones from 20 Korean adults-including iliac bones, fibulas, cranial bones, scapulas, ribs, and clavicles-were selected. The implant recipient site was determined by the shape, contour, and anatomical limitations of the bones. The serial cross-sectional images of each bone were then acquired through computed tomography. Total cancellous bone density, bone-implant interface density around the imaginary implant fixture, and the cortical thickness along both sides of the imaginary fixture on each cross-sectional image were evaluated and compared.

RESULTS

The cancellous bone density of each donor bone type had a statistically significant difference. The cranial bone showed the highest cancellous bone density, followed by the iliac bone, clavicle, scapula, rib, and fibula (P <.05). The bone-implant interface density of the cranial bone, clavicle, fibula, and scapula each belonged to the same Duncan's group, whereas the rib and iliac bone showed lower bone-implant interface density. In average cortical thickness, the scapula and fibula had a thicker cortex surrounding the imaginary implant than the other bones, and the rib had the thinnest cortex.

CONCLUSION

Although more extensive testing is needed to explain the clinical implications of these results, the findings of this study may help clinicians choose the most appropriate donor bone.

Long-term results of total shoulder arthroplasty following bone-grafting of the glenoid

BACKGROUND

The marked loss of glenoid bone volume or alteration of glenoid version can affect glenoid component fixation in patients undergoing total shoulder arthroplasty. The purpose of this study was to evaluate the long-term results associated with the use of bone-grafting for restoration of glenoid volume and version at the time of total shoulder arthroplasty.

METHODS

Twenty-one shoulders received an internally fixed, corticocancellous bone graft for the restoration of peripheral glenoid bone stock at the time of total shoulder arthroplasty between 1980 and 1989. Grafting was indicated when glenoid bone stock was insufficient to maintain adequate version or fixation of the prosthesis. Seventeen shoulders were available for follow-up; the average duration of follow-up for the thirteen shoulders that did not have prosthetic failure within the first two years was seventy months. Total shoulder arthroplasty was performed because of osteoarthritis in five shoulders, chronic anterior fracture-dislocation in five, capsulorrhaphy arthropathy in three, inflammatory arthritis in two, recurrent dislocation in one, and failure of a previous arthroplasty in one. All patients had some form of anterior or posterior instability preoperatively. There were five anterior and twelve posterior glenoid defects. Bone from the resected humeral head was used for grafting in fifteen shoulders, and bicortical iliac-crest bone was used in two.

RESULTS

The average glenoid version after grafting was 4 degrees of retroversion, with an average correction of 33 degrees. The graft failed to maintain the original correction in three shoulders due to nonunion, dissolution, or shift. Five total shoulder replacements failed, necessitating glenoid revision at two to ninety-one months postoperatively. The failures were associated with recurrent massive cuff tears (one shoulder), persistent instability (two shoulders), improper component placement (one shoulder), and loss of graft fixation (one shoulder). There were no humeral component failures. According to the criteria of Neer et al., the functional result was rated as excellent in three shoulders, satisfactory in six, and unsatisfactory in eight.

CONCLUSIONS

Despite the finding that eight shoulders had an unsatisfactory functional result at the time of longterm follow-up, corticocancellous grafting of the glenoid successfully restored glenoid version and volume in fourteen of the seventeen shoulders in the present study. Patients with glenoid deficiency often have associated glenohumeral instability, which may affect the results of total shoulder arthroplasty. Bone-grafting of the glenoid is a technically demanding procedure that can restore bone stock in patients with structural defects.

Inflammatory arthritis in canids: spondyloarthropathy

Spondyloarthropathy was observed in 25 (2.8%) of 895 preserved canid museum specimens and was catalogued by species. The associated skeletal alterations in canids are indistinguishable grossly and physiologically from those in humans with spondyloarthropathy of the reactive type. Rate of affliction was independent of captive or wild-caught status or gender. In canids, spondyloarthropathy was much more common than osteoarthritis (0.3%), which predominantly is limited to captive animals. Animal well-being may be enhanced by recognition of the condition and initiation of specific treatment.

Scapulohumeral osteoarthritis in 20 Shetland ponies, miniature horses and falabella ponies

This paper describes the clinical and diagnostic features of 20 cases of scapulohumeral osteoarthritis in Shetland ponies, miniature horses and falabella ponies. The history and clinical signs were similar in all the cases Radiographically they all had consistent changes which consisted predominantly of articular osteophytes and periarticular enthesiophytes. Six of the cases had radiographic evidence of dysplasia of the scapulohumeral joint, although it was uncertain whether this was a primary or a secondary finding. No specific treatment appeared to be advantageous. At follow up, six of the ponies had to be euthanased owing to continuing severe lameness; the other 14 ponies remained lame, but were maintained at pasture by the occasional use of oral non-steroidal anti-inflammatory drugs. No definitive aetiology for the condition was identified, but it is proposed that an underlying dysplasia, or lack of collateral support may predispose the scapulohumeral joint of miniature horse breeds to the disease.

Elastofibroma dorsi: elaboration of cytologic features and review of its pathogenesis

Elastofibroma is a slow-growing soft tissue lesion characteristically found between the inferior scapula and chest wall. Because it behaves clinically in a benign manner, fine-needle aspiration (FNA) represents the simplest and quickest method of obtaining a definitive diagnosis, thus obviating more invasive means of obtaining a tissue diagnosis. However, due to the nature of this lesion a correct diagnosis can inadvertently be missed. Herein we describe the findings of a recent FNA that obtained abundant diagnostic material and elaborate upon the spectrum of cytologic features of the elastic fibers that can be identified. These features should be recognized, since aspiration biopsy in elastofibromas can lead to hypocellular smears. In addition, we discuss recent developments in the pathophysiology of elastic fibers and their application toward understanding the generation of an elastofibroma.

[Subscapular elastofibroma]

Elastofibroma dorsi (EF) is a rare and benign connective-tissue tumour, typically localized between the lower part of the scapula and the chest wall. Two case stories of EF are presented. The etiology, symptoms, diagnostics and treatment are discussed.

Solitary osseous hemangioma outside the spinal and craniofacial bones

Bone hemangioma is mainly seen in the skull and spine, and rarely occurs in other bones. We report herein four cases of osseous hemangioma arising in rare sites: In two cases, on a rib; a faintly painful mass in one case located on the scapula; and progressive pain in one case located on the ischium. The tumors presented clinically as incidental lesions on radiographs. All cases had an aggressive appearance, such as defect of the cortex, a soft-tissue mass, and a sunburst-like appearance. Markedly high signal intensity on T2-weighted magnetic resonance images was a characteristic finding. Open biopsy resulted in severe blood loss, but needle biopsy was performed safely under computed tomography guidance. It is important to note that bone hemangiomas may be misdiagnosed as malignant tumors.