Biopsy of bone and soft-tissue lesions

Diagnosis and management of primary malignant tumors in the upper extremity

Bone and soft tissue sarcomas of the upper extremity are relatively uncommon. In many cases, they are discovered incidentally during evaluation of traumatic injuries or common ailments such as rotator cuff tendonitis or tennis elbow. Thus, it is important for all orthopedic surgeons to understand the differential diagnosis, workup, and treatment for upper extremity lesions. An appreciation of the clinical and radiographic features of primary malignant lesions aids in identifying patients that need referral to an orthopedic oncologist and a multidisciplinary team.

Managing NON-DIAGNOSTIC biopsies in musculoskeletal tumours in a specialist centre: Deciding on the algorithm

INTRODUCTION

Core needle biopsy is an effective method of obtaining tissue diagnosis. However, a diagnostic dilemma arises when lesional tissue is non-diagnostic which obviates considering radiological guided re-biopsy (RB) or an open surgical biopsy but the question raised is which serves as a better diagnostic tool.

PATIENT AND METHODS

We retrospectively reviewed data from a prospectively collected database of 4516 core needle biopsies performed in our specialist musculoskeletal tumour centre over a 6-year period. Our aim was to evaluate the management of non-diagnostic biopsies (NDB) and establish a safe and accurate diagnostic strategy in the presence of a NDB.

RESULTS

Two hundred fifteen (4.8%) NDB cases with complete follow-up were identified. Of these 157 (73%) were treated definitively on the basis of imaging and 58 (27%) had a RB, 48 (83%) of which led to a positive histological diagnosis. The remaining 10 were again non-diagnostic giving a total of 167 patients being treated definitively without a tissue diagnosis. The sensitivity and specificity for multidisciplinary team (MDT) assessment as a diagnostic tool was 0.75 and 0.88 respectively while that for RB was 0.91 and 0.9.

CONCLUSION

Re-biopsy after first non-diagnostic core needle biopsy offers high sensitivity and specificity, especially in the presence of malignancy. In the absence of tissue diagnosis, however, MDT assessment is also highly accurate and a safe strategy in managing this complex group of patients.

LEVEL OF EVIDENCE

Diagnostic Level III.

Imaging of the lesions in the lateral muscle compartment of the forearm, alias mobile wad of Henry: Demographics, radiological anatomy and surgical relevance

INTRODUCTION

Mobile wad of Henry (MOH) is a preferred surgical term used to describe the lateral compartment muscles of the forearm consisting of brachioradialis, extensor carpi radialis longus and brevis. The lesions in this compartment are uncommon. In this paper, we describe the largest series of the MOH lesions including their demographics, imaging appearances and importance of surgical anatomy whilst managing MOH lesions via radiological or surgical interventions.

METHODS

A retrospective search of oncology database for lesions in MOH at our tertiary orthopaedic oncology institute was performed for the last 12 years (2007-2019) after obtaining institutional review board approval. We further analyse data to obtain further clarity of various neoplasms occurring at this particular anatomical site.

RESULTS

We identified 28 patients with MOH lesions with an age range of 8 to 84 years and a male predominance. Imaging-wise, majority of lesions were benign following characteristics of lipomatous tumours, lipomas being the commonest. Other relatively uncommon benign lesions were nodular fasciitis, myositis ossificans and brachioradialis muscle injury; whereas aggressive MOH soft tissue neoplasms included synovial sarcoma and fibrohistiocytoma.

CONCLUSION

Although majority of MOH lesions are benign, one needs to be aware of spectrum containing uncommon benign and aggressive MOH lesions. When posed with dilemma, the MOH lesions require multidisciplinary approach with close collaboration of the radiologist, the surgeon and the pathologist to decide further management.

Biopsy Path Contamination in Primary Bone Sarcomas

Objective

To determine the incidence of contamination of the biopsy pathway in patients with primary bone sarcomas, as well as the clinical characteristics that influenced this outcome.

Materials and Methods

The anatomopathological reports of the patients who were treated by the Orthopedic Oncology Sector of the Orthopedic and Traumatology Department of this institution were retrospectively evaluated.

Results

Of the 148 patients included for evaluation in the present study, only 1 presented contamination by neoplastic cells in his biopsy pathway.

Conclusion

The bone biopsy procedure in patients with primary bone sarcomas presents great safety regarding pathway contamination when performed in specialized centers that treat this type of pathology.

Does muscle biopsy change the treatment of pediatric muscular disease?

BACKGROUND

Muscle biopsy is performed to confirm the diagnosis of neuromuscular disease and guide therapy. The purpose of our study was to determine if muscle biopsy changed patient diagnosis or treatment, which patients were most likely to benefit from muscle biopsy, and complications resulting from muscle biopsy.

MATERIALS AND METHODS

An IRB-approved retrospective chart review of all patients less than 18 years old undergoing muscle biopsy between January 2010 and August 2016 was performed. Demographics, patient presentation, diagnosis, treatment, hospital course, and follow-up were evaluated. Descriptive and comparative (student's t test, Mann-Whitney U, and Fisher's exact test) statistical analysis was performed. Medians were reported with interquartile range (IQR).

RESULTS

90 patients underwent a muscle biopsy. The median age at biopsy was 5 years (2, 10). 37% (n = 34) had a definitive diagnosis. 39% (n = 35) had a change in their diagnosis. 37% (n = 34) had a change in their treatment course. In the 34 patients who had a change in their treatment, the most common diagnosis was inflammatory disease at 44% (n = 15). In the 56 patients who did not have a change in treatment, the most common diagnosis was hypotonia at 30% (n = 17). There was no difference in patients who had a change in treatment based on pathology versus those that did not. The median length of follow-up was 3 years (1, 5).

CONCLUSIONS

Muscle biopsy should be considered to diagnose patients with symptoms consistent with inflammatory or dystrophic muscular disease. The likelihood of this altering the patient's treatment course is around 40%.

Are Biopsy Tracts a Concern for Seeding and Local Recurrence in Sarcomas?

BACKGROUND

A biopsy is the final step in the diagnosis of sarcomas. Complete resection of the biopsy tract traditionally has been recommended in musculoskeletal oncology guidelines, as that tract is considered potentially seeded with tumor cells. However, to our knowledge, the frequency and implications of contamination of the biopsy tract-specifically with respect to the likelihood of local recurrence-and the factors that affect cell seeding are not well described.

QUESTIONS/PURPOSES

We asked: (1) How often are biopsy tracts contaminated with pathologically detectable tumor cells at the time of tumor resection? (2) What factors, in particular biopsy type (open versus percutaneous), are associated with tumoral seeding? (3) Is biopsy tract contamination associated with local recurrence?

METHODS

This is a retrospective study of a database with patient data collected from a single center between 2000 and 2013. We treated 221 patients with sarcomas. A total of 27 patients (12%) were excluded and 14 (6%) were lost to followup. One hundred eighty patients finally were included in the analysis who either had biopsies at our center (112) or biopsies at outside institutions (68). Of those performed at our center, 15 (13%) were open and 97 (87%) were percutaneous; of those at outside centers, those numbers were 47 (69%) and 21 (31%) respectively. Median followup was 40 months (range, 24-152 months). During the study period, we generally performed percutaneous biopsies as a standard practice for the diagnosis of bone and soft tissue sarcomas and open biopsies were done when the percutaneous procedure failed to provide a histologic characterization. The mean age of the population was 48 years (range, 7-87 years); 60% were male; 42% had bone sarcomas. Nineteen patients had preoperative radiotherapy and 56 had postoperative radiotherapy. Fifty-seven patients received neoadjuvant chemotherapy and 73 had adjuvant chemotherapy. We determined what proportion of biopsy tracts were contaminated by pathologic analysis of the biopsy tract specimen; during the period in question, our routine practice was to excise the biopsy tract whenever possible at the time of the definitive resection. Using the logistic regression test and Mantel-Haenszel test, we compared open with percutaneous biopsies in terms of the proportion of those that were contaminated at our site and for outside referral biopsies separately, because we do not assume the level of expertise was the same (our site is a referral tumor center). We compared the local recurrence-free survival between patients with and without contamination and between open and percutaneous biopsies using the Kaplan Meier test, again separating those performed at our site from those referred for purposes of this analysis.

RESULTS

Twenty-one of 180 biopsy tracts were contaminated (12%). Twenty of 62 (32%) of the open biopsies and one of 118 (0.8%) of the percutaneous core needle biopsies had cell seeding (odds ratio [OR], 56; 95% CI, 7-428; p < 0.001. One of 97 (1%) percutaneous biopsies performed in our center, and none of the 21 (0%) percutaneous biopsies performed in other centers had contaminated biopsy tracts (p = 0.047). Two of 15 (13%) open biopsies performed at our center and 18 of 41(38%) open biopsies performed at other centers had contaminated biopsy tracts (OR, 4; 95% CI, 1-7; p = 0.001). Four of 74 (5%) bone sarcomas and 18 of 106 (17%) soft tissue sarcomas had biopsy tract contamination (OR, 3; 95% CI, 1-10; p = 0.023). The local recurrence-free survival was longer for patients without contaminated tracts (mean, 107 months; 95% CI, 74-141 months) than for those with biopsy tract seeding (mean, 11 months; 95% CI, 1-20 months; p < 0.001).

CONCLUSIONS

Open biopsies were associated with an increased risk of tumoral seeding of the biopsy site, and tumoral seeding was associated with an increased risk of local recurrence. However, it is possible that other factors, such as increased complexity of the tumor or a difficult location, influenced the decision to obtain an open biopsy. Even so, based on these results, we believe that higher risk of local recurrence may be caused by an incomplete biopsy tract resection. In our opinion, the percutaneous biopsy with neoadjuvant or adjuvant therapy is the preferred method of biopsy at our center.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Utility of Examination of Biopsy Tracts in Osteosarcoma Resection Specimens

OBJECTIVES

To determine the utility and necessity of submitting tissue sections from the biopsy tracts of osteosarcoma resection specimens.

METHODS

The prevalence of residual tumor in representative sections of osteosarcoma biopsy tracts was assessed in a series of 97 osteosarcoma resection specimens.

RESULTS

No residual tumor cells were identified in 97 sampled biopsy tracts (0%; 95% confidence interval, 0%-2.5%).

CONCLUSIONS

Pathologists do not need to submit sections of resected biopsy tracts unless there is clinical or gross evidence that would warrant further examination.

TUMOR CONTAMINATION IN THE BIOPSY PATH OF PRIMARY MALIGNANT BONE TUMORS

Objective: To study factors possibly associated with tumor contamination in the biopsy path of primary malignant bone tumors. Method: Thirty-five patients who underwent surgical treatment with diagnoses of osteosarcoma, Ewing's tumor and chondrosarcoma were studied retrospectively. The sample was analyzed to characterize the biopsy technique used, histological type of the tumor, neoadjuvant chemotherapy used, local recurrences and tumor contamination in the biopsy path. Results: Among the 35 patients studied, four cases of contamination occurred (11.43%): one from osteosarcoma, two from Ewing's tumor and one from chondrosarcoma. There was no association between the type of tumor and presence of tumor contamination in the biopsy path (p = 0.65). There was also no association between the presence of tumor contamination and the biopsy technique (p = 0.06). On the other hand, there were associations between the presence of tumor contamination and local recurrence (p = 0.01) and between tumor contamination and absence of neoadjuvant chemotherapy (p = 0.02). Conclusion: Tumor contamination in the biopsy path of primary malignant bone tumors was associated with local recurrence. On the other hand, the histological type of the tumor and the type of biopsy did not have an influence on tumor contamination. Neoadjuvant chemotherapy had a protective effect against this complication. Despite these findings, tumor contamination is a complication that should always be taken into consideration, and removal of the biopsy path is recommended in tumor resection surgery.

Contrast-enhanced color Doppler ultrasonography increases diagnostic accuracy for soft tissue tumors

Resolution of ultrasonography (US) has undergone marked development. Additionally, a new-generation contrast medium (Sonazoid) used for US is newly available. Contrast-enhanced US has been widely used for evaluating several types of cancer. In the present study, we evaluated the ability of color Doppler US (CDUS) and Sonazoid to differentiate between benign and malignant soft tissue tumors. A total of 180 patients (87 male, 93 female) were enrolled in the present study. The patient ages ranged from 1 to 91 years (mean 58.1±20.0 years). The maximum size, depth, tumor margins, shape, echogenicity and textural pattern were measured on gray-scale images. CDUS was used to evaluate the intratumoral blood flow with and without Sonazoid. Peak systolic flow velocity (Vp), mean flow velocity (Vm), resistivity index (RI) and pulsatility index (PI) of each detected intratumoral artery were automatically calculated with power Doppler US (PDUS). The present study included 118 benign and 62 malignant tumors. Statistical significances were found in size, depth, tumor margin and textural pattern but not in shape or echogenicity on gray-scale images. Before Sonazoid injection, CDUS findings showed 55% sensitivity, 77% specificity and 69% accuracy, whereas contrast-enhanced CDUS showed 87% sensitivity, 68% specificity and 74% accuracy. There were no statistically significant differences between malignant and benign tumors regarding the mean Vp, Vm, RI and PI values determined on PDUS. In conclusion, contrast-enhanced CDUS proved to be a reliable diagnostic tool for detecting malignant potential in soft tissue tumors.

Neoplasm seeding in biopsy tract of the musculoskeletal system. A systematic review

To identify, through a systematic literature review, the characteristics of neoplasm seeding in biopsy performed on the musculoskeletal system. We performed a search on PubMed, MEDLINE, LILACS and SciELO from August to October 2010. We included articles that addressed the neoplasm seeding in biopsy performed on the musculoskeletal system. The search was limited to English, Spanish and Portuguese as publication languages, but it was not limited by year of publication. We retrieved 2858 articles, but only seven were selected based on inclusion and exclusion criteria. Other four papers were found in the references of selected articles, totalizing 11 articles that were used to perform this systematic review. Issues may be raised in the literature: age and gender don't seem to influence the occurrence of neoplasm seeding; without resection of the biopsy tract, the possibility of local recurrence is very real; the influence of the type of tumor in the occurrence of neoplasm seeding is uncertain; it is impossible to conclude whether the closed biopsy technique has a lower chance of neoplasm seeding; it is likely that adjuvant chemotherapy has a protective effect against neoplasm seeding; an unfavorable prognosis is expected according to neoplasm seeding results.

Role of intraoperative pathology consultation in skeletal tumors and tumor-like lesions

Early and accurate detection of bone tumors and their staging are important since some of them are highly malignant. Intraoperative pathological consultation in bone tumors and tumor-like conditions is quite complex; however, it allows improvement in prognosis and limb salvage. Present study was conducted on 52 patients who underwent surgical procedure after clinical and radiological diagnosis of bone tumors/tumor-like conditions. Fresh unfixed tissue was quickly inspected grossly, followed by preparation of imprint smears and frozen section which were evaluated by two pathologists separately and compared subsequently with reports of paraffin-embedded sections. Clinical reasons for intraoperative consultation were to make diagnosis in 65.4% of cases and to determine resection margin status in 21.1% while in 13.5% of cases, it was for both indications. Diagnostic yield of imprint smears was 87.8% (13 malignant, 22 benign, and 1 tumor-like) and of frozen section was 90.2% (16 malignant, 19 benign, and 2 nonneoplastic) while paraffin sections could diagnose specific tumors in 95.1% (18 malignant, 18 benign, and 3 nonneoplastic). Although frozen section had better sensitivity (88.2%), it had less specificity (94.7%) as compared to imprint smears (76.5% and 100%, resp.). Imprint cytology and frozen section together provide a quick, safe, and reliable intraoperative provisional tissue diagnosis in skeletal tumors and tumor-like conditions.

Accuracy of core needle biopsy for musculoskeletal tumours

PURPOSE

To evaluate the sensitivity and specificity of core needle biopsy in determining musculoskeletal tumours in our hospital.

METHODS

Records of 134 patients who underwent core needle biopsy followed by definitive surgery were retrospectively reviewed. Results of the core needle biopsy were compared with those of the final histology. Histology was classified into benign versus malignant, and bony versus soft-tissue lesions. The sensitivity and specificity of core needle biopsy were calculated.

RESULTS

Based on final histology, there were 33 bone tumours (3 benign and 30 malignant), 74 soft-tissue tumours (6 benign and 68 malignant), 11 schwannomas (7 benign and 4 malignant), and 16 inflammatory/necrotic (benign) lesions. For 118 (88%) tumours, the biopsy results matched the final histological results. For 7 tumours, biopsy results were non-diagnostic, as the amount of tissue obtained was insufficient. For 9 tumours, biopsy results did not match the final histological results; 5 considered benign but turned out to be malignant, one considered malignant but turned out to be benign, and 3 were correctly identified as malignant but incorrectly subtyped. The sensitivity and specificity of core needle biopsy were 95% (97/102) and 97% (31/32), respectively, assuming that the 7 non-diagnostic tumours were correctly diagnosed.

CONCLUSION

Core needle biopsy is an accurate and reliable diagnostic tool for musculoskeletal tumours if performed by skilled persons and adequate tissue is obtained.

Sports activity after total joint arthroplasty: recommendations for the counseling physician

Sports activity after total joint arthroplasty (TJA) has become an increasingly important topic, as many younger patients seeking TJA have higher postoperative expectations with regard to return to athletic activity. Our current knowledge of this area is largely based on retrospective clinical studies and surveys of surgeon recommendations. The decision to participate in sports after TJA depends on the patient's general health, prior athletic experience, type of TJA, and desired sporting activity. Ultimately, patients should discuss these factors with their physician in order to make an educated decision regarding sports activity after TJA. This article summarizes the best available evidence to help guide physicians in their conversation with patients regarding safe and appropriate sports activity after TJA.

Evaluacion de la biopsia transpedicular guiada por TAC

OBJETIVO: Valorar la utilidad de la biopsia transpedicular percutánea guiada por Tomografía Axial Computarizada en conjunto con la sistematización de estudios como pruebas diagnósticas de la etiología de la destrucción vertebral. MÉTODOS: Estudio de serie de casos prospectivo transversal de 21 pacientes a los que se les realizó biopsia transpedicular percutánea guiada por Tomografía Axial Computarizada y estudios de laboratorio y gabinete de marzo a julio del 2011, para evaluar su utilidad en el diagnóstico de destrucción vertebral. RESULTADOS: Fueron 21 pacientes, 14 hombres y 7 mujeres, con edad media de 59,2 años, cuyos niveles más afectados estuvieron en L1, L2 y L3. El reporte de la biopsia tuvo una precisión diagnóstica del 90,4%. En 2 casos se realizó correlación clínica entre biopsia y sistematización de estudios para obtener el diagnóstico. CONCLUSIÓN: La biopsia guiada por Tomografía Axial Computarizada es una técnica sencilla, útil, de bajo costo y eficaz en el estudio de la destrucción vertebral; la sistematización de estudios permite corroborar el diagnóstico de la biopsia.

Some general considerations about the clinicopathologic aspects of soft tissue tumors in children and adolescents

Soft tissue tumors in children and adolescents are an important group of neoplasms, pseudoneoplasms, and tumefactive malformations with some distinctive clinicopathologic, genetic, syndromic, and therapeutic implications. In addition to the basic pathologic examination, there is the availability of diagnostic adjuncts in various settings based upon the histopathologic features that facilitate and/or corroborate a diagnosis. Immunohistochemistry, cytogenetics, molecular genetics, and an ever-increasing array of new technologies are available to address specific diagnostic questions and even potential therapeutic strategies. This review focuses upon some of the unique aspects of soft tissue tumors in children, including the classification, approach to the diagnosis, grading, clinical and pathologic staging, therapy-related changes, pathogenesis, and risk factors.

[Diagnosis of malignant bone and soft tissue tumors]

Primary sarcoma of bone is a rare entity but nevertheless a significant cause of mortality in children and adolescents. The focus of the preoperative evaluation is to set up a histological diagnosis, define local tumor extent and develop a therapy regimen. In addition to patient history and clinical findings a radiograph in two orthogonal planes is still of great importance. MRI plays a major role in the further clarification of the diagnosis, while CT is valuable in the diagnosis of tumors of the axial skeleton as well as in systemic staging. A PET-CT can be performed to obtain an overview of further tumor sites. Open bone biopsy is the final diagnostic step and should be carried out at the institution where the definitive treatment will be performed. Complications such as fracture, neural lesions and spread of tumor cells are relatively rare if the biopsy is performed appropriately; however, patients should be instructed to strictly avoid weight-bearing on the affected extremity.

Ewings sarcoma of the hand-a case report

Ewings sarcoma of the hand is relatively rare. Ewings sarcoma can present with minimal pain and swelling of the affected digit. The Erythrocyte sedimentation rate and C-reactive protein may be high. Radiologically, Ewings sarcoma can present with a plethora of features from permeative bone destruction to expansile lesions with or without periosteal reaction. Because of these features, this can be confused with Tuberculosis especially in a country like ours where Tuberculosis is endemic. This leads to starting of inappropriate treatment and delay in diagnosis. We report a case of an 18 year old boy who was initially diagnosed as Tuberculous dactylytis of the proximal phalanx of the little finger. He was started on anti-tuberculous treatment and did not respond to it. Subsequent investigation in our centre which also included an open biopsy, confirmed the diagnosis of Ewings sarcoma. He was treated with ray excision, and chemotherapy. This case is being presented for its rarity and also to emphasize the fact that an open biopsy in suspected cases would be appropriate to confirm the diagnosis. This would prevent delay in diagnosis of rare conditions like Ewings sarcoma.

Musculoskeletal oncology training during residency

PURPOSE

To evaluate the efficacy of a musculoskeletal oncology training module during residency.

METHODS

24 orthopaedic residents with differing years of experience were recruited. 12 of them received musculoskeletal oncology training for 6 months. The remaining 12 were controls who did not attend the training and had no clinical experience in a musculoskeletal oncology unit but had at least 3 years of postgraduate surgical training. Upon completion, residents in both groups were assessed by a knowledge test and then an objective structured clinical examination (OSCE).

RESULTS

Residents who attended the training module had better mean knowledge test scores (48 vs 25 out of 58, p<0.0001) and OSCE scores (32 vs 22 out of 42, p<0.004), compared to those who did not attend. No residents who attended the training module marked an inappropriate biopsy site that would have compromised definitive surgery, compared to 5 (42%) of the untrained residents who marked an inappropriate biopsy site that may have resulted in an unnecessary amputation. All residents who attended the training module agreed that such a module should be included in the orthopaedic residency programme.

CONCLUSION

Residents who attended the training module were more aware of the biopsy principles and risks. A training module for musculoskeletal oncology should be included in the orthopaedic residency programme.

Radiology of the resurfaced hip

Hip resurfacing arthroplasty is an increasingly common procedure for osteoarthritis. Conventional radiographs are used routinely for follow-up assessment, however they only provide limited information on the radiological outcome. Various complications have been reported in the scientific literature although not all are fully understood. In an effort to investigate problematic or failing hip resurfacings, various radiological methods have been utilized. These methods can be used to help make a diagnosis and guide management. This paper aims to review and illustrate the radiographic findings in the form of radiography, computerized tomography (CT), magnetic resonance imaging (MRI), and ultrasound of both normal and abnormal findings in hip resurfacing arthroplasty. However, imaging around a metal prosthesis with CT and MRI is particularly challenging and therefore the potential techniques used to overcome this are discussed.

Indications and results of hip resurfacing

The best indication for hip resurfacing is a young active patient with severe hip arthritis, good hip morphology and reasonable bone quality. With revision of either component for any reason as the endpoint, there were 68 revisions in our series of 3,095 consecutive Birmingham Hip Resurfacings (BHR) (1997-2009), including all diagnoses in all ages. This equates to a revision rate of 2.2% and survivorships of 99, 97 and 96% at five, ten and 13 years, respectively. In patients under 55 years with osteoarthritis, the survivorship is 99 and 98% at ten and 13 years. These results provide medium-term evidence that BHR when performed well in properly selected patients offers excellent outcomes and implant survivorship. Small changes to implant materials and design can affect joint function and survivorship significantly as seen from the withdrawal of certain resurfacing devices recently from clinical use. The clinical history of one device cannot be extrapolated to other devices.

Lack of radiographic loosening signs in a hip resurfacing that failed by stem fracture

Fracture of the femoral stem is a rare manifestation of femoral component loosening in hip resurfacing. The patient had undergone successful hip resurfacing 3 years prior to presentation, presenting with complaints of groin pain, but without radiographic evidence of loosening. At 6 years post-operatively, the patient again presented with groin pain. Radiographs demonstrated a mid-stem fracture. Analysis of the retrieved implant and resected femoral head following conversion to total hip arthroplasty indicated that component failure and fracture appeared to be secondary to failed fixation and implant loosening not related to osteonecrosis or acute femoral neck fracture. The case report highlights the difficulty in diagnosing femoral component loosening in hip resurfacing in the absence of gross implant subsidence or stem radiolucency.

Good results with cemented total hip arthroplasty in patients between 40 and 50 years of age

BACKGROUND AND PURPOSE

Total hip arthroplasties in young patients have lower long-term survival rates than in older patients. We evaluated the use of a unique treatment protocol in patients aged between 40 and 50 years. In all cases we used a cemented THA, and for acetabular deficiencies we also used impacted bone grafts together with a cemented cup.

METHODS

In 140 consecutive patients who were between 40 and 50 years of age at index surgery, 168 cemented total hip prostheses were evaluated after a mean follow-up time of 10 (2-19) years. Acetabular deficiencies were reconstructed with wire meshes and impacted bone grafts with a cemented cup (70 hips). During follow-up, 18 patients died (27 hips); in this group 3 hips (3 patients) had been revised. None of the patients were lost to follow-up. In all surviving patients, clinical assessment was performed with hip-score questions and all radiographs were evaluated.

RESULTS

All clinical questionnaires showed an improved clinical hip score. 29 hips (17%) were revised after a mean of 8 (0.3-18) years. Kaplan-Meier survival analysis showed a survival of 88% (95% CI: 82-94) after 10 years with revision of either component for any reason. Survival with endpoint revision for aseptic loosening of either component was 94% (95% CI: 90-99) after 10 years.

INTERPRETATION

Cemented implants in young patients have satisfying long-term results. Reconstruction of acetabular deficiencies with impacted bone grafts show promising results.

Diagnosis of bone metastases in urological malignancies--an update

The spread of urological malignancies to bone is a poor prognostic factor. Early detection of metastatic bony lesions assists with tailoring patient management and potentially improving quality of life. Newer therapies such as zolderonic acid for prostate cancer have reinvigorated the importance of clinicians treating bony disease. An array of biochemical and imaging options are available and the order, sensitivity and cost of such investigations need to be understood to maximise clinical benefit. Furthermore, the ideal time to investigate for bony metastases has often been controversial. Although simple history and examination, serum calcium and alkaline phosphatase and plain radiography with bone scintigraphy remain at the forefront of diagnosing bony disease, evolving diagnostic modalities, such as positron emission tomography and newer bone markers need to be considered. The aim of this review is to clarify the role of various investigations and to give clinicians a current analysis of the timing of such investigations in the context of evolving diagnostic modalities and accepted guidelines for urological malignancy.

[Surgical treatment of musculoskeletal soft tissue sarcomas]

Treatment of soft tissue sarcomas requires an individual plan which considers interdisciplinary recommendations and the various clinical situations. Anatomical region, histological grading and typing, and tumor size necessitate adjusted methods of reconstruction. The biopsy should be performed at the institution where the patient is treated. In general surgical resection of the tumor will be the treatment of choice. Adjuvant therapies are applied according to anatomical region and size and grading of the tumor. Surgery alone is recommended only in small (<5 cm), superficial, low-grade sarcomas. Sarcomas larger than 5 cm in diameter should be treated by surgery and radiotherapy, achieving excellent results, although in high-grade sarcomas more than 50% of patients still will experience metastatic disease. In case of locally recurrent disease, surgical revision with tumor-free resection margins followed by radiotherapy should be the aim. This applies even for patients who had had radiotherapy after the first excision. In this case brachytherapy is a good modality of tissue-sparing treatment.

[Uncemented arthroplasty of the hip]

Prognosis of cemented total hip replacement seems to be excellent for elderly patients. In younger age the outcome is less favourable and early revision is more common. Thus, different concepts with better prognosis and preservation of bone stock for possible revisions were needed. After more than 30 years of application with excellent short-term and long-term results, uncemented total hip arthroplasty is nowadays generally regarded as the standard procedure for younger patients. New bone-preserving implants, such as surface replacement or short-stemmed femoral shaft prostheses, have been introduced especially for younger patients. Some of these new procedures are still under development, and the long-term results of new implant concepts have to be evaluated over the next decades. Regarding recently published scientific studies an overview about non-cemented total hip arthroplasty is given and current concepts and developments are presented.

[Musculoskeletal tumors: significance of morphological diagnostics]

Musculoskeletal tumors, particularly bone neoplasms, are very rare. Diagnosis and treatment require an interdisciplinary concept as well as wide experience of all physicians involved. The final histopathologic diagnosis should not be confirmed without information regarding the patient's age, exact localization, and radiological findings. The requirements of additional diagnostic procedures (molecular pathology) have to be taken into consideration when planning a biopsy.

Hypertrophy of the abductor digiti minimi muscle simulating a localised soft tissue mass

Soft tissue tumours of the foot are rare and often present a difficult clinical and diagnostic situation. We report of a 15-year-old male with a painless swelling at the lateral margin of the left foot. After X-ray and MRI an excisional biopsy was performed. Histology revealed true muscle hypertrophy without myopathic or degenerative changes, consistent with the diagnosis of congenital hypertrophy of the abductor digiti minimi muscle. At a follow-up of one and a half year there was no recurrence and the patient was satisfied with the shape and the appearance of the foot.

Humeral head arthroplasty and meniscal allograft resurfacing of the glenoid

BACKGROUND

Biological glenoid resurfacing with prosthetic humeral head replacement has been suggested as a means to avoid the potential complications of polyethylene use in younger patients with glenohumeral arthritis. The purposes of this report were (1) to describe a technique that was developed to facilitate biological resurfacing of the glenoid with use of meniscal allograft tissue and (2) to report the effectiveness of hemiarthroplasty in conjunction with meniscal allograft glenoid resurfacing.

METHODS

Thirty patients (thirty shoulders) with glenohumeral arthritis were treated with hemiarthroplasty and lateral meniscal allograft resurfacing of the glenoid. Clinical assessments were performed at regular intervals with use of visual analog scales for pain, shoulder comfort, and function and with use of patient self-assessments including the American Shoulder and Elbow Surgeons score and the Simple Shoulder Test. A detailed radiographic analysis was performed to evaluate glenohumeral subluxation, glenoid bone loss, and the glenohumeral joint space.

RESULTS

Twenty-seven patients (twenty-seven shoulders) were followed for a minimum of two years. The mean duration of follow-up was three years. For the Simple Shoulder Test and the visual analog scale measures for level of pain, pain at rest, and pain with strenuous activity, the results at the final follow-up evaluation were significantly better than the preoperative results. Similarly, all ten functions of the American Shoulder and Elbow Surgeons questionnaire were significantly improved at the time of the latest follow-up. Over the time frame of the study, there was radiographic evidence of glenohumeral joint-space narrowing.

CONCLUSIONS

Lateral meniscal allograft resurfacing of the glenoid can protect the glenoid from erosion, can minimize glenohumeral subluxation, and is associated with significant pain relief and improved function for two to five years when used in conjunction with hemiarthroplasty in younger patients with glenohumeral arthritis. However, the progressive decrease in glenohumeral joint space noted radiographically raises concern for both the long-term functional outcome and the durability of the glenoid bone-sparing effect.

Differentiating benign and malignant soft tissue masses by magnetic resonance imaging: role of tissue component analysis

BACKGROUND

There is a variable degree of accuracy in discriminating benign from malignant soft tissue masses based on signal intensity and morphologic characteristics by magnetic resonance imaging (MRI). The aim of this study was to determine the utility of detailed component pattern assessment, in addition to morphologic study, for differentiating benign from malignant soft tissue masses by MRI.

METHODS

The imaging features of 118 histologically proven soft tissue masses were analyzed according to: (1) signal characteristics: (a) high T1 matrix; (b) low T2 matrix; (c) fibrous tissue signal; (d) calcification; (e) myxoid signal tissue; (f) fatty signal tissue; (g) cystic signal; (h) necrotic signal; (i) septations; (j) vascular signal void signal; (k) fat rim; and (l) hemorrhage; and according to (2) morphologic assessment: (a) lesion size (maximal diameter) in centimeters (cm); (b) lesion depth in cm; (c) margins; (d) peritumoral edema; (e) bone involvement; (f) marginal capsule or pseudocapsule; and (g) neurovascular bundle involvement. Univariate and multivariate analyses followed by stepwise logistic regression of combination of imaging features were performed. The predictive value of each imaging feature and various combinations of imaging features were determined.

RESULTS

In univariate analysis, T2 low signal matrix, fibrous tissue, calcification, necrosis, septum, fat rim sign, peritumoral edema, and hemorrhage showed statistically significant differences between benign and malignant masses (p < 0.05). The positive predictive value of necrosis for malignancy was 84.8%, and its specificity was 90.9%. In multivariate analysis, the best model for predicting malignant masses was the combination of necrosis, maximal mass diameter, peritumoral edema, and absent fibrosis, absent calcification, and lack of fat rim. The combination of these parameters resulted in the most correct diagnoses of malignancy, with a sensitivity of 84.2%, specificity of 64.0%, and accuracy of 74.8%, whereas the accuracy of models consisting of component character and morphologic feature were 74.3% and 70.9%, respectively.

CONCLUSION

MRI is useful in determining whether a soft tissue mass is malignant or not. Traditional morphologic assessment was reinforced by detailed component characterization analysis. The parameters favoring malignancy were large lesion size, peritumoral edema, necrosis, and absent calcification, absent fibrosis, and lack of fat rim.

The role of intra-operative pathological evaluation in the management of musculoskeletal tumours

A tissue biopsy is usually a critical aspect in guiding appropriate initial management in patients with musculoskeletal tumours. We have previously outlined the role of intra-operative frozen section in both the determination of adequacy of a biopsy and for its diagnostic utility. In this article, the options and techniques for intra-operative pathological evaluation, namely frozen section, fine needle aspiration cytology and touch imprint cytology are reviewed. Frozen section examination may be applicable in the following Sections, including (1) at core biopsy, (2) at surgical margins, (3) at confirming diagnosis prior to definitive treatment or to evaluate tumour spread, and (4) at establishing a diagnosis of a metastasis prior to intramedullary nailing. There are also situations in which frozen section is inappropriate. Pitfalls associated with frozen sections are also highlighted. There are also cost implications, which we have quantified, of performing frozen sections. In our experience that the use of intra-operative pathological evaluation reduces the non-diagnostic rate of bone and soft tissue sarcoma biopsies, eliminates the need for re-biopsy hence alleviating stress, and is a useful addition to the armamentarium in evaluating musculoskeletal tumours.

Computer-assisted femoral head resurfacing

Femoral head resurfacing is re-emerging as a surgical option for younger patients who are not yet candidates for total hip replacement. However, this procedure is more difficult than total hip replacement, and the mechanical jigs typically used to align the implant produce significant variability in implant placement and take a significant amount of time to position properly. We propose that a computer-assisted surgical (CAS) technique could reduce implant variability with little or no increase in operative time. We describe a new CAS technique for this procedure and demonstrate in a cadaver study of five paired femurs that the CAS technique in the hands of a novice surgeon markedly reduced the varus/valgus variability of the implant relative to the pre-operative plan (2 degrees standard deviation for CAS versus 5 degrees for a mechanical jig operated by an expert surgeon). We also show that the mechanical jig resulted in significantly retroverted implant placement. There was no significant difference in operative time between the two techniques.

Upper extremity compartmental anatomy: clinical relevance to radiologists

Malignant tumors of the upper extremity are uncommon, and their care should be referred to specialized facilities with experience treating these lesions. The Musculoskeletal Tumor Society (MSTS) staging system is used by the surgeon to determine appropriate surgical management, assess prognosis, and communicate with other healthcare providers. Magnetic resonance imaging (MRI) is employed pre-operatively to identify a lesion's compartment of origin, determine extent of spread, and plan biopsy and resection approaches. Involvement of neurovascular structures may result in devastating loss of upper extremity function, requiring amputation. Violation of high-resistance compartmental barriers necessitates more extensive surgical resection. Biopsy may be performed by the radiologist using imaging guidance. Knowledge of compartmental anatomy allows the radiologist or surgeon to use an easily excisable biopsy approach and prevent iatrogenic spread to unaffected compartments. Case examples are presented to illustrate the importance of compartmental anatomy in the management of benign and malignant upper extremity tumors.

Outcome of prosthetic joint infection in patients with rheumatoid arthritis: the impact of medical and surgical therapy in 200 episodes

BACKGROUND

Prosthetic joint infection in patients with rheumatoid arthritis is a serious complication of total joint arthroplasty. Little information is available on the outcome of medical and surgical treatments of prosthetic joint infection in patients with rheumatoid arthritis.

METHODS

We conducted a retrospective analysis of all patients with rheumatoid arthritis and a total hip or total knee arthroplasty infection evaluated at Mayo Clinic (Rochester, MN) between 1 January 1969 and 31 December 1995.

RESULTS

A total of 200 first episodes of prosthetic joint infection in 160 patients with rheumatoid arthritis were diagnosed during the study period. Thirty-seven percent of prosthetic joint infection episodes were due to Staphylococcus aureus. Of these episodes, 23% and 19% were treated with debridement and retention of components and 2-stage exchange, respectively. The type of surgical procedure was the only analyzed clinical variable that was associated with treatment failure (P < .001). Rates of 5-year survival free of treatment failure for patients with prosthetic joint infection episodes treated with debridement and retention of components, 2-stage exchange, and resection arthroplasty were 32% (95% confidence interval [CI], 21%-49%), 79% (95% CI, 66%-93%), and 61% (95% CI, 49%-74%), respectively.

CONCLUSIONS

S. aureus is the most common pathogen among patients with rheumatoid arthritis with prosthetic joint infection. Two-stage exchange was used in only 19% of the prosthetic joint infection episodes among patients with rheumatoid arthritis during the study period, but it was associated with the best outcome. The variable most strongly associated with the outcome was the type of surgical procedure.

Lumbar vertebral hemangioma causing cauda equina syndrome: a case report

STUDY DESIGN

Case report.

OBJECTIVES

To report a case of lumbar hemangioma causing neurogenic claudication and early cauda equina, managed with hemostatic vertebroplasty and posterior decompression.

SUMMARY OF BACKGROUND DATA

This is the first report to our knowledge of a lumbar hemangioma causing neurogenic claudication and early cauda equina syndrome. Most hemangiomas causing neurologic symptoms occur in thoracic spine and cause spinal cord compression. Vertebroplasty as a method of hemostasis and for providing mechanical stability in this situation has not been discussed previously in the literature.

METHODS

L4 hemangioma was diagnosed in a 64-year-old woman with severe neurogenic claudication and early cauda equina syndrome. Preoperative angiograms showed no embolizable vessels. Posterior decompression was performed followed by bilateral transpedicular vertebroplasty. The patient received postoperative radiation to prevent recurrence.

RESULTS

Complete relief of neurogenic claudication and cauda equina with less than 100 mL of blood loss.

CONCLUSION

A lumbar hemangioma of the vertebral body, although rare, can cause neurogenic claudication and cauda equina syndrome. Intraoperative vertebroplasty can be an effective method of hemostasis and provide stability of the vertebra following posterior decompression.

The impact of previous surgical manipulation of subcutaneous sarcoma on oncologic outcome

We prospectively followed 106 consecutive patients referred for surgical treatment of nonmetastatic subcutaneous soft tissue sarcoma to assess whether prior surgical manipulation had an impact on local control and/or disease-free survival. 10 patients had no previous surgical treatment; 11 had only a previous biopsy, 75 had a previous attempted excision, and 10 were referred after the tumor had recurred locally. Histologic grade was inversely associated with overall survival and disease-free survival. Of the 75 patients with previous attempted excision, 22 (29%) had gross residual disease, 27 (36%) had microscopic residual disease, and 26 (35%) had no identifiable residual disease. The 5-year metastasis-free survival was 88%. Local control was obtained in 100% of patients without previous surgical manipulation, 89% of those with previous surgery, and 60% of those who were referred after a local relapse had been recognized. Cox proportional hazards analysis revealed that larger tumor size negatively impacted disease-free survival in those patients who were treated with previous attempted excision. Of those patients with tumors 4 cm or larger and a previous unplanned sarcoma excision, disease-free survival was lower than in those patients referred without previous attempted excision.

LEVEL OF EVIDENCE

Prognostic study, Level I-2 (prospective study). See the Guidelines for Authors for a complete description of levels of evidence.

Lower extremity compartmental anatomy: clinical relevance to radiologists

A thorough understanding of compartmental anatomy is necessary for the radiologist participating in the care of a patient with a lower extremity musculoskeletal malignancy. Localization of tumor to compartment of origin and identification of extracompartmental spread preoperatively are needed to correctly stage a tumor and determine the appropriate surgical management. An understanding of the locations of fascial boundaries, extracompartmental tissues, and neurovascular structures of the thigh and lower leg facilitates this diagnostic process. For the radiologist planning to biopsy a suspicious musculoskeletal lesion, consultation with the referring orthopaedic surgeon is recommended in order to jointly select an appropriate percutaneous biopsy approach. Adequate preprocedural planning ensures selection of an approach which prevents iatrogenic tumor spread beyond the compartment of origin, protects neurovascular structures, and allows complete resection of the biopsy tract and scar at the time of surgical resection without jeopardizing a potential limb-sparing procedure. Cross-sectional anatomic review and case examples demonstrate the importance of a detailed understanding of compartmental anatomy when approaching the patient with a lower extremity musculoskeletal tumor.

Total hip arthroplasty for primary osteoarthrosis in younger patients in the Finnish arthroplasty register. 4,661 primary replacements followed for 0-22 years

BACKGROUND

Many studies have found a higher risk of revision after hip arthroplasty in younger patients. We evaluated the population-based survival of total hip arthroplasty (THA) in patients under 55 years of age and the factors affecting survival.

METHODS

The Finnish Arthroplasty Register was established in 1980, and 74,492 primary THAs were entered into the register between 1980 and 2001. 4,661 of these were evaluated, all of which had been performed for primary osteoarthrosis on patients under 55 years of age.

RESULTS

Proximally circumferentially porous-coated uncemented stems implanted between 1991 and 2001 had a 10-year survival rate of 99 (95% CI 98.5-99.6)% with aseptic loosening as endpoint. The risk of stem revision due to aseptic loosening was higher in cemented stems than in proximally porous-coated (RR 5.5, p < 0.001) or HA-coated (RR 6.6, p = 0.01) uncemented stems implanted during the same period. According to Cox regression analysis of cups implanted 1991-2001, the risk of revision for all-polyethylene cemented cups was 3.0 times as high as that for press-fit porous-coated uncemented cups with aseptic loosening as endpoint (p = 0.01). However, when the endpoint was defined as any revision (including exchange of liner), there was no longer any difference between these two concepts, the 10-year survival rates being 94 (92.1-95.5)% for press-fit porous-coated uncemented cups and 93 (88.5-97.6)% for all-polyethylene cemented cups (p = 0.9).

INTERPRETATION

Modern uncemented stems seem to have better resistance to aseptic loosening than cemented stems in younger patients. Thus, for younger patients, uncemented proximally circumferentially porous- and HA-coated stems are the implants of choice. Press-fit porous- and HA-coated uncemented cups may have better endurance against aseptic loosening than cemented cups in younger patients. However, when all revisions (including exchange of liner) are taken into account, the survival of modern uncemented cups is no better than that of all-poly cemented cups.

The effectiveness of metal on metal hip resurfacing: a systematic review of the available evidence published before 2002

Background

Conventional total hip replacement (THR) may be felt to carry too high a risk of failure over a patient's lifetime, especially in young people. There is increasing interest in metal on metal hip resurfacing arthroplasty (MoM) as this offers a bone-conserving option for treating those patients who are not considered eligible for THR. We aim to evaluate the effectiveness of MoM for treatment of hip disease, and compare it with alternative treatments for hip disease offered within the UK.

Methods

A systematic review was carried out to identify the relevant literature on MoM published before 2002. As watchful waiting and total hip replacement are alternative methods commonly used to alleviate the symptoms of degenerative joint disease of the hip, we compared MoM with these.

Results

The data on the effectiveness of MoM are scarce, as it is a relatively new technique and at present only short-term results are available.

Conclusion

It is not possible to make any firm conclusions about the effectiveness of MoM based on these early results. While the short-term results are promising, it is unclear if such results would be replicated in more rigorous studies, and what the long-term performance might be. Further research is needed which ideally should involve long-term randomised comparisons of MoM with alternative approaches to the clinical management of hip disease.

Total hip arthroplasty with the Lord prosthesis. A long-term follow-up study

BACKGROUND

The Lord prosthesis has been used rather extensively for total hip arthroplasty. In 1981, we began a prospective study for the purpose of determining the long-term results associated with the use of this prosthesis. In the present report, we describe the results for the living patients after a mean duration of follow-up of 17.5 years (range, fifteen to twenty years).

METHODS

One hundred and two patients (116 hips) with a mean age of sixty-two years at the time of the index arthroplasty were included in the study. Eighty-nine hips were in women, and twenty-seven were in men. The Lord femoral prosthesis (with a 32-mm head) and the Lord threaded cup were used in all patients. The protocol included radiographic analysis, recording of complications, and a clinical evaluation. The patients were evaluated at one to four years, five to nine years, and fifteen to twenty years.

RESULTS

One patient (one hip) refused to participate and forty-two patients (forty-five hips) died with the femoral component in place, leaving fifty-nine patients (seventy hips) available for clinical assessment. One femoral component was revised because of mechanical loosening, and one was revised because of a stem fracture. One stem appeared to be loose radiographically. Kaplan-Meier survivorship analysis with revision of the femoral component because of mechanical loosening, stem fracture, or radiographic loosening as the end point revealed a cumulative survival rate of 98% (95% confidence interval, 95.3% to 100.7%) (with twenty-eight hips at risk) at 17.5 years. Seventeen acetabular components were revised because of mechanical loosening, and sixteen were considered to be radiographically loose. Kaplan-Meier survivorship analysis with revision of the acetabular component because of mechanical or radiographic loosening as the end point revealed a cumulative survival rate of 65% (95% confidence interval, 53% to 72%) (with twenty-two hips at risk) at 17.5 years.

CONCLUSIONS

We believe that the survival rate of the Lord femoral component after 17.5 years of follow-up was excellent. However, there was a substantial rate of proximal femoral bone loss. The results associated with the threaded cup were rather poor, and many patients had a loose implant but few symptoms. We recommend that patients with these implants be followed closely so that revision can be performed before substantial destruction of the acetabulum has occurred.

LEVEL OF EVIDENCE

Therapeutic study, Level II-1 (prospective cohort study). See Instructions to Authors for a complete description of levels of evidence.

Biopsy of hand, wrist, and forearm tumors

This article describes three biopsy methods currently used for treating masses arising in the hand, wrist, and forearm: open biopsy, fine needle aspiration, and core needle biopsy. The forearm, wrist, and hand comprise a complex and diverse anatomic region, and biopsy is emphasized as the most important element in the diagnosis of the musculoskeletal tumor. Biopsy methods for assessing true neoplasms, bony protuberances, cysts,infection and abscesses, foreign bodies, reactive granulomas, tenosynovial proliferation,and skin and fascial lesions are discussed.