Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Published in
Clinical Orthopaedics and Related Research®
Volume 467 | Issue 11 | Nov, 2009
Articles

Biopsy of Soft Tissue Masses: Evidence-based Medicine for the Musculoskeletal Tumor Society

Bruce T. Rougraff MD, Albert Aboulafia MD, J. Sybil Biermann MD, John Healey MD The literature contains a number of controversies regarding key questions: (1) When is a biopsy indicated? (2) How should the biopsy be placed? (3) How should the biopsy be performed and which has the greatest diagnostic accuracy? (4) Who should perform the biopsy? (5) What clinical parameters present the greatest diagnostic difficulty? Using PubMed and Google Scholar we performed English-language literature searches of clinical studies reporting biopsy of soft tissue masses. Thirty-two studies met the inclusion criteria but were only able to address three of the five questions the authors had hoped to evaluate. Available evidence suggests open biopsy has the highest diagnostic accuracy over core needle biopsy, which was higher than fine needle aspiration. There was no evidence to address who is best suited to perform the biopsy (general surgeon, orthopaedic surgeon, radiologist, pathologist) in terms of accuracy of diagnosis. Frozen section at the time of biopsy may improve diagnostic accuracy. Diagnostic difficulty was associated with myxoid and round cell neoplasms, infections, and tumors located in the paraspinal region. The limited number of references addressing these issues demonstrated the need for more Level I research in the area of biopsy of soft tissue masses.,[object Object]

Early Equivalence of Uncemented Press-fit and Compress® Femoral Fixation

German L. Farfalli MD, Patrick J. Boland MD, Carol D. Morris MD, Edward A. Athanasian MD, John H. Healey MD Bone ingrowth promises more durable biologic fixation of megaprostheses. The relative performance of different types of fixation is unknown. We compared the fixation of two forms of biologically fixed femoral components: an intramedullary uncemented press-fit stem (UCS; Group 1, 50 patients) and a Compress® uncemented fixation (CPS; Group 2, 41 patients). In Group 1, the overall Kaplan-Meier prosthetic survival rates were 85% at 5 and 71% at 10 years. Most failures were long-term developments. Aseptic loosening was the primary cause of failure. Stem diameters less than 13.5 mm and a diaphyseal/stem coefficient greater than 2.5 mm were associated with decreased prosthetic survival. In Group 2, the overall rate of CPS survival was 88% at 5 years. Failure of femoral fixation or fracture during the first year was the main reason for revision. Five-year survival rates were similar between the groups and we observed no difference in the functional success of the implants. We found no failures after 1-year followup in Group 2 (CPS). Any difference in prosthetic survival can only be proven by longer-term study or a randomized trial.,[object Object]

Compress® Periprosthetic Fractures: Interface Stability and Ease of Revision

Wakenda K. Tyler MD, John H. Healey MD, Carol D. Morris MD, Patrick J. Boland MD, Richard J. O’Donnell MD [object Object],[object Object]

Compressive Osseointegration of Tibial Implants in Primary Cancer Reconstruction

Richard J. O’Donnell MD Compressive osseointegration technology, which provides immediate, mechanically compliant endoprosthetic fixation, has been adapted for massive proximal tibial reconstructions in an attempt to avoid aseptic failure encountered with conventional stems. A retrospective review of 16 patients with resected tumors was undertaken to determine whether compressive osseointegration can provide durable anchorage of tibial implants. Medical records, radiographs, and clinical examinations were reviewed to assess surgical, local disease control, and prosthetic outcomes. The average age was 18 years (range, 12–42 years). Diagnoses included osteosarcoma (12), Ewing sarcoma (two), chondrosarcoma (one), and undifferentiated sarcoma (one). Minimum followup was 2 years (mean, 4.5 years; range, 2–10.3 years); no patient was lost to followup. There were no local recurrences. Four patients developed metastatic disease; one patient died of his primary tumor, and another died from a chemotherapy-related malignancy. Complications included one early deep infection that ultimately resulted in prosthetic loosening and the need for an above-knee amputation. There were two late deep infections; prosthetic retention was achieved with débridement and antibiotics. One patient developed aseptic loosening and underwent revision; the other 15 implants provided stable osseointegration at last followup. Compressive osseointegration technology can thus achieve acceptable short-term endoprosthetic fixation results and may reduce the risk of aseptic loosening reported with conventional tibial stems.,[object Object]

Megaprosthesis versus Condyle-sparing Intercalary Allograft: Distal Femoral Sarcoma

Melissa N. Zimel MD, Amy M. Cizik MPH, Timothy B. Rapp MD, Jason S. Weisstein MD, Ernest U. Conrad MD Although functionally appealing in preserving the native knee, the condyle-sparing intercalary allograft of the distal femur may be associated with a higher risk of tumor recurrence and endoprosthetic replacement for malignant distal femoral bone tumors. We therefore compared the risk of local tumor recurrence between patients in these two types of reconstruction groups. We retrospectively reviewed 85 patients (mean age, 22 years; range, 4–82 years), 38 (45%) of whom had a condyle-sparing allograft and 47 (55%) of whom had endoprostheses. The minimum followup for both groups was 2 years (mean, 7 years; range, 2–19 years). Local recurrences occurred in 11% (five of 47) of the patients having implants versus 18% (seven of 38) of the patients having allografts. Using time to local recurrence as an end point, the Kaplan-Meier survivorship of the implant group was similar to that of the condyle-sparing allograft group at 2, 5, and 10 years (93% versus 87% at 2 years, 87% versus 81% at 5 years, and 87% versus 81% at 10 years, respectively). The condyle-sparing allograft procedure offers the potential advantage of retaining the native knee in a young patient population while incurring no greater risk of local recurrence as those offered the endoprosthetic procedure.,[object Object]

The Friedman-Eilber Resection Arthroplasty of the Pelvis

Adam J. Schwartz MD, Piya Kiatisevi MD, Fritz C. Eilber MD, Frederick R. Eilber MD, Jeffrey J. Eckardt MD It has been argued that internal hemipelvectomy without reconstruction of the pelvic ring leads to poor ambulation and inferior patient acceptance. To determine the accuracy of this contention, we posed the following questions: First, how effectively does a typical patient ambulate following this procedure? Second, what is the typical functional capacity of a patient following internal hemipelvectomy? In the spring of 2006, we obtained video documentation of eight patients who had undergone resection arthroplasty of the hemipelvis seen in our clinic during routine clinical followup. The minimum followup in 2006 was 1.1 years (mean, 8.2 years; range, 1.1–22.7 years); at the time of last followup in 2008 the minimum followup was 2.9 years (mean, 9.8 years; range, 2.9–24.5 years). At last followup seven of the eight patients were without pain, and were able to walk without supports. The remaining patient used narcotic medication and a cane or crutch only occasionally. The mean MSTS score at the time of most recent followup was 73.3% of normal (range 53.3–80.0%; mean raw score was 22.0; range 16–24). All eight patients ultimately returned to gainful employment. These observations demonstrate independent painless ambulation and acceptable function is possible following resection arthroplasty of the hemipelvis.,[object Object]

Periacetabular Reconstruction with a New Endoprosthesis

Lawrence R. Menendez MD, FACS, Elke R. Ahlmann MD, Yuri Falkinstein MD, Daniel C. Allison MD, MBA Reconstruction of the Type II pelvic resection is challenging. Currently available reconstructive options have inherent problems including graft and implant failure, pain, poor function, and high major complication rates. The periacetabular reconstruction (PAR) endoprosthesis was designed to be secured with internal fixation and bone cement to the remaining ilium and support a reconstructed acetabulum. This construct potentially avoids the complications of graft or hardware failure, while maintaining early mobilization, comfort, limb lengths, and function. We retrospectively reviewed 25 patients who underwent Type II pelvic resection and reconstruction with the PAR endoprosthesis, analyzing function, complications, and survivorship. The minimum followup was 13 months (mean, 29.4 months; range, 13 to 108 months). We compared the PAR data with the literature for the Mark II saddle endoprosthesis. The PAR’s average MSTS score was 20.8 (67%), major complications occurred in 14 (56%), and implant survivorship was 84% at 2 years and 60% at 5 years. The rate of failure at the ilium-saddle interface was lower and implant survivorship higher than those in the published literature for the Mark II saddle. We recommend use of the PAR endoprosthesis for reconstruction of large defects following Type II pelvic resection. The modified saddle design provides greater inherent stability, allowing for faster rehabilitation and improved longevity without increased complications and is an improvement over the currently available saddle prostheses.,[object Object]

Soft-tissue Sarcoma Metastases Identified on Abdomen and Pelvis CT Imaging

David M. King MD, Donald A. Hackbarth MD, Chris M. Kilian BA, Guillermo F. Carrera MD The current standard of care for patients with extremity soft-tissue sarcomas is to obtain imaging of the chest for staging and surveillance. Our institutional standard of care has been to obtain CT scans of the chest, abdomen, and pelvis to evaluate for metastatic disease. Cost and radiation risk led us to question the utility of the additional scans. We presumed abdomen and pelvic CT scans would not benefit this patient population. We retrospectively reviewed our sarcoma databases from 2000 to 2008. We included 124 patients with 15 types of extremity soft tissue sarcomas evaluated with CT of the C/A/P. Primary outcomes were (1) location of metastatic disease in relation to (2) sarcoma type. Twenty patients (16%) presented with or developed abdomen/pelvis metastases and 10 of the 15 types of soft tissue sarcomas had abdominal or pelvic metastases. A larger number of patients demonstrated metastatic disease in the abdomen and pelvis than anticipated. We believe routine imaging of the abdomen and pelvic with CT for both staging and surveillance of all types of soft tissue sarcoma should be considered.,[object Object]

Joint Preservation after Extensive Curettage of Knee Giant Cell Tumors

Miguel A. Ayerza MD, Luis A. Aponte-Tinao MD, German L. Farfalli MD, Carlos A. Lores Restrepo MD, D. Luis Muscolo MD Curettage is the most attractive procedure for surgically treating a giant cell tumor because it preserves joint function. However, since many giant cell tumors compromise subchondral bone this technique can jeopardize the articular surface with subsequent fractures or collapse. We asked whether intralesional curettage of a giant cell tumor close to the knee that combined morselized bone and cortical structural allograft would preserve joint function. We retrospectively reviewed 22 patients treated with that approach. The minimum followup was 2 years (average, 48 months; range, 24–80 months). The distal femur was involved in 12 patients and proximal tibia in 10. Complications and failures were recorded and functional results evaluated with Musculoskeletal Tumor Society score. We determined survivorship using the Kaplan-Meier technique using removal of the implant as the endpoint. The survival was 85% and the average functional score 28 points. Three of the 22 patients had a local tumor recurrence and one had a partial subchondral collapse not requiring further treatment. Among the remaining patients, none had fracture, infection, or knee instability. The combination of fragmented and cortical allograft allows reconstructing the bone defect and ligaments created after extensive curettage of a knee giant cell tumor obtaining normal joint function and a high survival rate with minimal complications in a high percentage of the patients.,[object Object]

Outcomes after Excision of Pigmented Villonodular Synovitis of the Knee

Vivek Sharma MD, Edward Y. Cheng MD Pigmented villonodular synovitis (PVNS) has a high but variable recurrence rate. Prior studies do not compare recurrence-free survival (RFS) for various surgical approaches or salvage surgery for relapse. We therefore determined: (1) RFS after excision; (2) RFS after salvage surgery for relapse; (3) factors associated with relapse. We retrospectively reviewed the medical records of 49 patients with previously untreated PVNS of the knee (12 localized, 37 diffuse) who were treated with synovectomy from 1991 to 2008; there were 22 males and 27 females, with mean age of 35.2 years (range, 10–73). Minimum followup was 1 year (mean, 6.2 years; range, 1–13). Twenty-one patients had a relapse. The RFS for index surgery was 75% and 53%; and for salvage surgery was 71% and 52% at 2 and 5 years respectively. The RFS was 95% for open versus 62% for arthroscopic synovectomy at 2 years, 71% and 41% at 5 years. The RFS was 91% for localized and 70% for diffuse PVNS at 2 years, 73% and 48% at 5 years. Diffuse disease (RR = 4.49) and arthroscopic synovectomy (RR = 3.30) were associated with relapse. Recurrence was frequent after synovectomy. Reexcision can salvage relapses as successfully as excision for primary disease; however, morbidity was associated with additional surgeries.,[object Object]

The Linear Cutting Stapler May Reduce Surgical Time and Blood Loss with Muscle Transection: A Pilot Study

Daniel C. Allison MD, MBA, Elke R. Ahlmann MD, Anny H. Xiang PhD, Lawrence R. Menendez MD, FACS Because of skeletal muscle’s density and vascularity, its transection with standard electrocautery can be tedious. In a pilot study we asked whether a linear cutting stapling device decreased surgical time, blood loss, transfusion rates, and complications in patients undergoing above-knee amputation when compared to traditional electrocautery. We retrospectively reviewed 11 patients with above-knee amputation cases using a linear cutting stapling device over a 10-year period and compared those to 13 patients in whom we used electrocautery. The patients treated with the linear cutting stapling device had an average of 97 minutes of surgical time, 302 cc blood loss, and 1.55 units transfusion, compared to an average 119 minutes, 510 cc, and 2.15 units, respectively, with the electrocautery cases. Despite the trends, these parameters, as well as major complications, were similar in these two small groups. In skeletal muscle transection, we believe the linear cutting stapler is a reasonable and potentially cost-effective technical alternative to electrocautery, possibly resulting in less blood loss and shorter surgical time with similar rates of complications.,[object Object]

Is Vertical-center-anterior Angle Equivalent to Anterior Coverage of the Hip?

Takashi Sakai MD, PhD, Takashi Nishii MD, PhD, Kazuomi Sugamoto MD, PhD, Hideki Yoshikawa MD, PhD, Nobuhiko Sugano MD, PhD We investigated whether the vertical-center-anterior (VCA) angle measured on the false-profile view of the hip represents true anterior coverage by computer simulation using three-dimensional (3-D) computed tomography (CT) in 100 hips without osteoarthritic changes. True anterior coverage angle on the sagittal plane was measured in the pelvic coordinate system. Two types of VCA angle were measured on the digital reconstructed radiographs: the anterior point of the VCA angle was defined as the foremost aspect of the acetabulum, denoted VCA-1, whereas the anterior edge of the dense shadow of the subchondral bone of the acetabulum was defined as VCA-2. In the normal hips, VCA-1 was consistent with anterior coverage angle (r = 0.88, Spearman rank test), whereas VCA-2 underestimated the anterior coverage (r = 0.72). In the dysplastic hips, VCA-2 did not always indicate true anterior coverage (r = 0.64), whereas VCA-1 overestimated the anterior coverage (r = 0.002). Although VCA-1 in normal hips shows true anterior coverage, the VCA angle does not indicate true anterior coverage in dysplastic hips, and VCA angle measurement in dysplastic hips should be used carefully.,[object Object]

Inferior Survival of Hydroxyapatite versus Titanium-coated Cups at 15 Years

Maiken Stilling MD, Ole Rahbek MD, PhD, Kjeld Søballe MD, DMSc Hydroxyapatite (HA) particles have long been suspected to disintegrate from implant surfaces, become entrapped in joint spaces of orthopaedic bearing couples, and start a cascade leading to progressive polyethylene (PE) wear, increased osteolysis, and aseptic loosening. We compared cup revision at 15 years’ followup in a randomized group of patients with 26 cementless THA components with titanium (Ti) versus first-generation HA coating. We also assessed radiographic PE wear and osteolysis to the 12-year followup or end point revision at a minimum of 5 years (mean, 10.9 years; range, 5–12.6 years). Two Ti-coated cups (17%) and eight HA-coated cups (57%) were revised at 15 years’ followup. Femoral head penetration rate was 0.46 mm/year (standard deviation, 0.26) with the HA-coated cups (n = 12) and 0.38 mm/year (standard deviation, 0.14) with the Ti-coated cups (n = 10); we observed a wide variance of linear wear with the HA-coated cups. We also observed a positive association between high wear rate and revision, and between a high volume of osteolysis and revision. Our findings suggest inferior survival of medium-thickness spray-dried HA-coated cups with individual cases of excessive PE wear and premature cup failure. These findings apply to first-generation modular cups and may not apply to other cup designs and new HA-coating technologies.,[object Object]

Hip Arthroplasty after Previous Arthrodesis

Erik D. Peterson MD, Joseph P. Nemanich MD, Aaron Altenburg MD, Miguel E. Cabanela MD Total hip arthroplasty after previous arthrodesis has been associated with increased complications and decreased survivorship of the prosthesis. We evaluated pain, function, and the factors influencing survivorship of total hip arthroplasties after previous arthrodesis between 1985 and 2000 and compared these results with those obtained in prior years with the same procedure and in the same institution. We retrospectively reviewed 30 patients who had previous spontaneous or surgical arthrodesis. The minimum followup was 2 years (mean, 10.4 years; range 2–20.5 years). Seven failures were identified (23%). The overall survival free of failure was 86% at 5 years and 75% at 10 years. At last followup, 27 of the 30 patients (91%) had no or slight pain, 26 (87%) had a limp, and 18 (61%) needed a gait aid. Surgical arthrodesis, age younger than 50 years at the time of arthroplasty, and length of arthrodesis less than 30 years independently predicted failure. Conversion of arthrodesis to hip arthroplasty reliably decreases pain and improves function, but many patients will limp and require a gait aid. Our outcomes were similar to those after revision rather than after primary hip arthroplasty.,[object Object]

Predictors of Health-related Quality-of-life Change after Total Hip Arthroplasty

José M. Quintana PhD, Antonio Escobar PhD, Urko Aguirre MSc, Iratxe Lafuente MSc, Juan C. Arenaza MD Various parameters have been considered as possible predictors of health-related quality-of-life outcomes after THA in patients with hip osteoarthritis. We hypothesized the preintervention health status is the main and more homogeneous predictor of changes of the different aspects of health-related quality-of-life outcomes, mental health status has an important influence on results, whereas other sociodemographic or clinical factors had only a punctual influence. All patients who fulfilled the selection criteria completed the Medical Outcomes Study SF-36 and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) before and 6 months after the intervention. Seven hundred eighty-eight patients completed the questionnaire before the intervention and 590 completed it (74.9%) at 6 months. The preintervention score in each SF-36 and WOMAC domain and the SF-36 mental health domain predicted changes after the intervention. Female gender, having comorbidities, contralateral hip osteoarthritis, or back pain predicted less improvement on some SF-36 domains. Older age, the presence of contralateral hip osteoarthritis, or back pain predicted less improvement on some of the WOMAC domains. Preintervention health status, measured by the WOMAC or SF-36, and mental health status uniformly predicted health-related quality-of-life changes, whereas some clinical parameters predicted some domains. SF-36 and WOMAC seem to be appropriate tools for predicting THA outcomes.,[object Object]

Acetabular Polyethylene Wear and Acetabular Inclination and Femoral Offset

Nick J. Little MSc, MRCS, Constant A. Busch MD, FRCS, John A. Gallagher MD, FRACS, Cecil H. Rorabeck MD, FRCSC, Robert B. Bourne MD, FRCSC [object Object],[object Object]

Improved Early Clinical Outcomes of RP/PS Mobile-Bearing Total Knee Arthroplasties

Tae Kyun Kim MD, PhD, Hyung Joon Cho MD, Yeon Gwi Kang BS, Sung Ju Kim MS, Chong Bum Chang MD, PhD The rotating-platform posterior-stabilized (RP/PS) prosthesis was developed to take advantage of the benefits of the traditional RP mobile-bearing system and the posterior-stabilized design. This nonconsecutive cohort study compared the clinical outcomes of TKAs performed using a RP/PS mobile system or a floating-platform (FP) system. The clinical outcomes of 93 TKAs with a RP/PS prosthesis were compared with the same number of TKAs with a FP mobile-bearing prosthesis at 6, 12, and 24 months after surgery. Clinical outcomes differed between the FP and RP/PS groups as a function of length of followup. In the FP group, most outcomes peaked at 12 months and then deteriorated, whereas in the RP/PS group, outcomes stabilized or continued to improve between 12 and 24 months. The RP/PS group had greater maximum flexion throughout followup and better clinical outcomes 24 months after surgery. Patient satisfaction was superior in the RP/RS group. This study suggests the RP/PS prosthesis provides better functional outcomes, including greater maximum flexion and better patient satisfaction. We propose the RP/PS mobile-bearing system is a more attractive option than the FP mobile-bearing system for patient populations of elderly women similar to patients enrolled in our study.,[object Object]

Limited Quadricepsplasty for Contracture during Femoral Lengthening

Saurabh Khakharia MD, Austin T. Fragomen MD, S. Robert Rozbruch MD Extension contracture of the knee is a common complication of femoral lengthening. Knee flexion exercises to stretch the contracture with physical therapy can be effective but take a prolonged amount of time to work and place increased stress across the patellofemoral joint. We developed a minimal-incision limited quadricepsplasty surgical technique to treat knee extension contracture secondary to femoral lengthening and retrospectively reviewed 16 patients treated with this procedure. The mean age of the patients was 23 years. Range of motion of the knee and quadriceps strength were recorded preoperatively, after femur lengthening but before additional surgery, after quadricepsplasty, and at each followup. The mean femoral lengthening performed was 4.4 cm. We compared range of motion and time to regain knee flexion with those of historical controls. The minimum followup after quadricepsplasty was 6 months (mean, 38 months; range, 6–84 months). The mean range of motion was 129° preoperatively, 29° after the distraction phase of femoral lengthening, and 108° after limited quadricepsplasty, and at final followup, the mean knee flexion was 125°. There were no major complications. Limited quadricepsplasty improved knee flexion after a knee extension contracture developed secondary to femoral lengthening. In comparison to historical controls who did not have quadricepsplasty, the patients with limited quadricepsplasty had quicker return of knee flexion, although there was no difference in knee flexion achieved ultimately.,[object Object]

Segmental Resection and Replantation Have a Role for Selected Advanced Sarcomas in the Upper Limb

Soo Bong Hahn MD, Yun Rak Choi MD, Ho Jung Kang MD, Kyoo Ho Shin MD Although limb salvage surgery for primary sarcoma of the upper limb is a standard procedure, it often is technically challenging. We asked whether segmental resection and replantation would provide (1) local control and long-term survival and (2) useful limb function in patients who had advanced primary malignant and aggressive tumors of the upper limbs. We retrospectively reviewed six patients treated with this procedure when a wide resection around the tumor could not be achieved with other limb-salvage procedures. Diagnoses included osteosarcoma (two), Ewing’s sarcoma (one), leiomyosarcoma (one), and giant cell tumor (two). Four patients had displaced pathologic fractures. Minimum followup was 40 months (mean, 164 months; range, 40–214 months). All but one patient remained disease-free; the patient with Ewing’s sarcoma died from the disease 40 months after surgery. The average functional score at last followup was 20 points. The mean grasping and pinching power of the operative hand were 66% and 72% of the contralateral side, respectively. Two patients had complications: one had wound dehiscence that subsequently healed and one had radial nerve palsy that recovered spontaneously by 3 months. Segmental resection and replantation may have a role in selected cases for treatment of advanced primary sarcoma or aggressive giant cell tumor of the upper limb as partial limb salvage.,[object Object]

Arthroscopically Assisted Removal of Intraosseous Ganglion Cysts of the Distal Tibia

Lorenz Büchler MD, Harish Hosalkar MD, MBMS (Orth), FCPS (Orth), DNB (Orth), Martin Weber MD Intraosseous ganglia of the distal tibia are rare. We evaluated the feasibility of surgically treating these lesions with an arthroscopically assisted technique. Five patients with symptomatic distal tibial ganglia underwent surgical curettage and excision with this technique. All patients underwent débridement of the chondral lesion and hypertrophied synovial lining when present, probing of the portal to the ganglion, and subsequently thorough curettage with bone grafting performed through a cortical window made from a separate small incision. Biopsy confirmed the diagnosis in all patients. All patients had eventual relief of symptoms with good integration of bone graft at final followup. There were no recurrences at a minimum followup of 19 months (mean, 38.6 months; range, 19–69 months). Mean time for return to full function was 15.4 weeks (range, 8–17 weeks). There were no intraoperative or postoperative complications. The mean American Orthopaedic Foot and Ankle Society scores increased from 73 points (range, 67–77 points) preoperatively to 94 points (range, 90–100 points) postoperatively. Arthroscopically assisted surgical treatment of ganglia of the distal tibia in the appropriate patient is a reasonably simple technique that relieves symptoms and helps the patient to regain normal gait and full function with no recurrence (in our small series).,[object Object]

Cyclooxygenase-2 Overexpression Predicts Poor Survival in Patients with High-grade Extremity Osteosarcoma: A Pilot Study

Hiroshi Urakawa MD, Yoshihiro Nishida MD, PhD, Takahiro Naruse MD, PhD, Hiroatsu Nakashima MD, PhD, Naoki Ishiguro MD, PhD Several lines of evidence suggest cyclooxygenase-2 (COX-2) overexpression may be a causal factor for tumor growth and metastasis. However, there is no evidence COX-2 expression in a primary tumor correlates with clinical outcome of osteosarcoma. We examined expression levels of COX-2 immunohistochemically in 51 patients with extremity osteosarcoma who completed standard therapy and obtained complete initial regression of the tumor. Correlation of the positivity of staining with prognosis was analyzed. COX-2 was expressed in most of the cases. We found no correlation between COX-2 staining intensity and variables such as gender, age, anatomic site, necrosis after chemotherapy, and surgical stage. Strong COX-2 expression was associated with low metastasis-free survival. Age older than 20 years and strong COX-2 expression independently predicted increased risk of metastasis. Among seven patients with resectable lung metastasis, all three with greater COX-2 expression in the metastatic lesion than that in a primary site died of the disease. Our preliminary data suggest COX-2 overexpression in the primary tumor correlates with the occurrence of distant metastasis in patients with osteosarcoma and also may affect postmetastatic survival.,[object Object]

Prognostic Factors for Survival in Patients with Epithelioid Sarcoma: 441 Cases from the SEER Database

Muhammad Umar Jawad MD, Jason Extein BS, Elijah S. Min BS, Sean P. Scully MD, PhD Current stratification of prognosis in patients with epithelioid sarcoma (ES) is based largely on data reported by individual centers with a limited number of patients. We sought to identify the important prognostic parameters using the Surveillance, Epidemiology, and End Results (SEER) database. We identified 441 patients with ES in the database and extracted information regarding patient demographics and clinical characteristics. Kaplan-Meier, log-rank, and Cox regression were used for analysis. Disease-specific survival declined until 100 months after diagnosis after which survival was unrelated to epithelioid sarcoma. The overall incidence of ES during 2005 was 0.041 per 100,000. The reported incidence has increased since 1973, with an annual percentage change of 5.217%. On multivariate analysis, only age younger than 16 years, local stage of disease, or negative nodes and surgical resection of the tumor predicted better disease-specific survival. We observed no increase in survival by comparing decades of diagnosis since 1986. The SEER database shows only age younger than 16 years, negative nodes, or local stage of disease and operability of primary disease independently predict survival in patients with ES.,[object Object]

Results of a Minimally Invasive Technique for Treatment of Unicameral Bone Cysts

Gökçe Mik MD, Alexandre Arkader MD, Alexander Manteghi BS, John P. Dormans MD Unicameral bone cysts are benign bone lesions commonly seen in pediatric patients. Several treatment methods have been described with variable results and high recurrence rates. We previously reported short-term success of a minimally invasive technique that includes combining percutaneous decompression and grafting with medical-grade calcium sulfate pellets. The purpose of this study was to review the additional long-term results with a minimum followup of 24 months (average, 37 months; range, 24–70 months). We identified 55 patients with an average age of 10.8 years (range, 1.3–18 years). Forty-one of 55 lesions occurred in the humerus and femur. Forty-four of 55 (80%) patients had a partial or complete response after initial surgery; of these, seven obtained a partial or complete response after a repeat surgery (cumulative healing rate, 94%). Two patients underwent a third surgery (cumulative healing rate, 98%). One underwent a third repeat surgery (cumulative healing rate, 100%). There were no major complications associated with the procedure. Two patients had a superficial infection that resolved with oral antibiotics. Although some patients required a repeat procedure, complete or partial response at a minimum 24 months’ followup was achieved in all patients.,[object Object]

Ethanol Sclerotherapy Reduces Pain in Symptomatic Musculoskeletal Hemangiomas

Eileen A. Crawford MD, Rachel L. Slotcavage MD, Joseph J. King MD, Richard D. Lackman MD, Christian M. Ogilvie MD

Hemangiomas, benign vascular lesions, require intervention if causing pain or functional limitations. Functional deficits are common after excision, favoring minimally invasive treatments. To determine whether ethanol sclerotherapy reduces pain and lesion size and to assess complications in symptomatic musculoskeletal hemangiomas, we retrospectively reviewed 19 patients (six males, 13 females; mean age, 34 years) meeting criteria of confirmed hemangioma, treatment with ethanol sclerotherapy, and minimum of 6 weeks of followup. Fourteen were primary lesions and five were recurrent; all were painful. Thirty-eight sclerotherapy procedures were performed, with each patient undergoing a maximum of three procedures. Mean followup was 24 months (range, 2–95 months). Four patients reported full pain relief, 11 had partial relief, and four had no relief. With recurrent lesions, one patient had full pain relief, one had partial relief, and three had no relief. For patients with lesions larger than 5 cm, two had full relief, six had partial relief, and three had no relief. Lesion shrinkage occurred in 12 patients. Temporary complications included paresthesiae (three), tendon contracture (one), skin breakdown (one), and deep vein thrombosis (one). Ethanol sclerotherapy afforded prompt pain relief in 15 of 19 patients with hemangioma, making it a reasonable option for initially avoiding surgical excision. However, the short followup of our patients requires additional long-term studies to assess the duration of the results.,[object Object]

Bone Stress Injuries Are Common in Female Military Trainees: A Preliminary Study

Maria H. Niva MD, PhD, Ville M. Mattila MD, PhD, Martti J. Kiuru MD, PhD, MSc, Harri K. Pihlajamäki MD, PhD Although bone stress injuries are common in male military trainees, it is not known how common they are in female trainees. It also is unclear whether asymptomatic bone stress injuries heal if intensive training is continued. We prospectively followed 10 female trainees of a military Reserve Officer Course. The subjects underwent clinical and MRI examinations of the pelvis, thighs, and lower legs at the beginning, once during, and at the end of their 3-month course. We identified two to five injuries in every female trainee, all of whom already had the injuries at the beginning of the officer course. None of these injuries increased their severity despite vigorous training. Two-thirds were asymptomatic and low grade. Femoral and tibial shafts were the most common locations. Higher-grade injuries were more likely symptomatic, but regardless of the MRI findings, female trainees expressed only mild to moderate symptoms. Asymptomatic, low-grade bone stress injuries of the femoral and tibial shaft are common in female recruits undergoing heavy physical training. Because these injuries seem to remain constant or even disappear despite continued heavy physical activity, we do not recommend routine screening of asymptomatic trainees. As some bone stress fractures may have severe consequences (eg, in the femoral neck), symptomatic bone stress injuries should be examined and treated.

Predictors of Prognosis for Elderly Patients with Poststroke Hemiplegia Experiencing Hip Fractures

Mingli Feng MD, Jian Zhang MD, Huiliang Shen, Huaijian Hu MD, Li Cao Hip fracture is an important cause of mortality and disability in elderly patients, particularly in those with poststroke hemiplegia, but little information is available regarding differences of general characteristics between patients with and without hemiplegia who experience hip fractures, factors predicting recovery of prefracture ambulatory status, and mortality of patients with poststroke hemiplegia with hip fractures. We retrospectively reviewed 1379 consecutive prospectively followed patients with hip fractures treated from January 2000 to May 2006. Of the 1379 patients, 101 (7.3%) had poststroke hemiplegia. All patients were followed a minimum of 1 year if they survived more than a year or until death if they died within a year after surgery (mean, 19.5 months; range, 4–49 months). According to the American Society of Anesthesiologists (ASA) rating, the patients with hemiplegia were sicker than patients without hemiplegia, more likely to have three or more comorbidities, lower cognitive ability, weaker prefracture ambulatory status, more days of hospitalization, and higher mortality rate. Gender, ASA rating, number of comorbidities, and prefracture ambulatory status predicted mortality of hip fractures in elderly patients with poststroke hemiplegia, and the ASA rating, number of comorbidities, and cognitive ability predicted recovery of prefracture ambulatory status for these patients.,[object Object]

Do Successful Surgical Results after Operative Treatment of Long-bone Nonunions Correlate with Outcomes?

Kenneth A. Egol MD, Konrad Gruson MD, Allison B. Spitzer BA, Michael Walsh PhD, Nirmal C. Tejwani MD

There has been increased emphasis on validated, patient-reported functional outcomes after orthopaedic interventions for various conditions. The few reports on these types of outcomes after treatment of fracture nonunions are limited to specific anatomic sites, limited by small numbers, and retrospective. To determine whether successful healing of established long-bone nonunions resulted in improved functional outcomes and reduction in patient-reported pain scores, we prospectively followed 80 patients. These patients had a mean of 1.4 surgical procedures before enrollment and a mean of 18 months had elapsed from previous surgery until enrollment. Baseline data and functional scores were obtained before intervention. Seventeen of the 80 patients (21%) had positive intraoperative cultures. At a mean of 18.7 months (range, 12–36 months), 72 (90%) nonunions had healed. Patients with healed nonunions scored better on the Short Musculoskeletal Functional Assessment. Pain scores among all patients improved compared with baseline, but to a greater degree in patients who achieved healing by final followup. Our data suggest improvement in pain scores is seen in all patients after surgery, whereas successful internal fixation leads to improved function.,[object Object]

Is Locking Nailing of Humeral Head Fractures Superior to Locking Plate Fixation?

G. Gradl MD, PhD, A. Dietze MD, M. Kääb MD, PhD, W. Hopfenmüller MD, PhD, T. Mittlmeier MD, PhD The optimal surgical treatment of displaced proximal humeral fractures is controversial. New implants providing angular stability have been introduced to maintain the intraoperative reduction. In a multi-institutional study, we prospectively enrolled and followed 152 patients with unilateral displaced and unstable proximal humeral fractures treated either with an antegrade angular and sliding stable proximal interlocking nail or an angular stable plate. Fractures were classified according to the Neer four-segment classification. Clinical, functional, and radiographic followups were performed 3, 6, and 12 months after surgery. Absolute and relative (to the contralateral shoulder) Constant-Murley scores were used to assess postoperative shoulder function. Using age, gender, and fracture type, we identified 76 pairs (152 patients) for a matched-pairs analysis. Relative Constant-Murley scores 12 months after treatment with an angular and sliding stable nail and after plate fixation were 81% and 77%, respectively. We observed no differences between the two groups. Stabilization of displaced proximal humeral fractures with either an angular stable intramedullary or an extramedullary implant seems suitable with both surgical treatment options.,[object Object]

Improved Tendon Radioprotection by Combined Cross-linking and Free Radical Scavenging

Aaron Seto MS, Charles J. Gatt MD, Michael G. Dunn PhD Allograft safety is a great concern owing to the risk of disease transmission from nonsterile tissues. Radiation sterilization is not used routinely because of deleterious effects on the mechanical integrity and stability of allograft collagen. We previously reported several individual cross-linking or free radical scavenging treatments provided some radioprotective effects for tendons. We therefore asked whether a combination of treatments would provide an improved protective effect after radiation exposure regarding mechanical properties and enzyme resistance. To address this question we treated 90 rabbit Achilles tendons with a combination of cross-linking (1-ethyl-3-[3-dimethyl aminopropyl] carbodiimide [EDC]) and one of three scavenging regimens (mannitol, ascorbate, or riboflavin). Tendons then were exposed to one of three radiation conditions (gamma or electron beam irradiation at 50 kGy or unsterilized). Combination-treated tendons (10 per group) had increases in mechanical properties and higher resistance to collagenase digestion compared with EDC-only and untreated tendons. Irradiated tendons treated with EDC-mannitol, -ascorbate, and -riboflavin combinations had comparable strength to native tendon and had averages of 26%, 39%, and 37% greater, respectively, than those treated with EDC-only. Optimization of a cross-linking protocol and free radical scavenging cocktail is ongoing with the goal of ensuring sterile allografts through irradiation while maintaining their structure and mechanical properties.

Rheologic Behavior of Osteoarthritic Synovial Fluid after Addition of Hyaluronic Acid: A Pilot Study

Pierre Mathieu MD, Thierry Conrozier MD, Eric Vignon MD, Yves Rozand MD, Marguerite Rinaudo PhD Viscosupplementation is a symptomatic treatment of osteoarthritis (OA) intended to restore rheologic homeostasis of the synovial fluid by injecting hyaluronic acid intraarticularly. Despite the long history of this therapy, little is known about its mechanisms of action and differences between commercial preparations. We investigated the rheologic behavior of OA synovial fluid with time, when stored at 4°C, before and after the addition of two hyaluronic acid commercial preparations (linear and cross-linked). Thirteen OA synovial fluids were stored at 4°C and assayed using steric exclusion chromatography, which allows hyaluronic acid to be separated from the remaining pool of proteins and its molecular weight and concentration to be determined without any pretreatment and calibration. The synovial fluid rheology also was studied in vitro, before and after addition of two viscosupplements, over 6 weeks. The non-Newtonian behavior of synovial fluid throughout followup appears to be the result of loose interactions between proteins and hyaluronic acid. When mixed with the linear hyaluronic acid, synovial fluid becomes less non-Newtonian whereas the non-Newtonian behavior was reinforced when mixed with the cross-linked hyaluronic acid. The rheology was nearly unchanged for all synovial fluids over 6 weeks. Our preliminary trial shows it is possible to study synovial fluid, stored at 4°C, over a long time and suggests the enzymatic degradation of hyaluronic acid is negligible under these experimental conditions.

Investigating the Immunologic Effects of CoCr Nanoparticles

Bamikole Ogunwale MBChB, MRCS, Andreas Schmidt-Ott PhD, R. M. Dominic Meek MD, FRCS (Tr & Orth), James M. Brewer BS, PhD The increase in metal-on-metal hip arthroplasties has led to concern regarding the effect of raised serum and tissue metal ion levels. Our aim was to determine changes in the integrity and function of cells of the immune system after exposure to CoCr nanoparticles in specific cell culture experiments. Nanometer-sized particles of CoCr were made from a manufacturer’s forged CoCr used for metal-on-metal articulations. Primary, murine dendritic cells and T and B lymphocytes then were exposed to these CoCr particles under cell culture conditions and then assayed for viability and proliferation/activation. CoCr nanoparticles did not directly activate dendritic cells or regulate B cells. Although nanoparticles were not directly toxic to resting T cells, Signals 1- and 2-dependent T cell proliferation were reduced. This may explain the observed reduction in CD8+ T cells observed in patients with metal-on-metal implants.

Physician Collective Bargaining

Anthony Hunter Schiff JD, MPH Current antitrust enforcement policy unduly restricts physician collaboration, especially among small physician practices. Among other matters, current enforcement policy has hindered the ability of physicians to implement efficient healthcare delivery innovations, such as the acquisition and implementation of health information technology (HIT). Furthermore, the Federal Trade Commission and Department of Justice have unevenly enforced the antitrust laws, thereby fostering an increasingly severe imbalance in the healthcare market in which dominant health insurers enjoy the benefit of largely unfettered consolidation at the cost of both consumers and providers. This article traces the history of antitrust enforcement in healthcare, describe the current marketplace, and suggest the problems that must be addressed to restore balance to the healthcare market and help to ensure an innovative and efficient healthcare system capable of meeting the demands of the 21st century. Specifically, the writer explains how innovative physician collaborations have been improperly stifled by the policies of the federal antitrust enforcement agencies, and recommend that these policies be relaxed to permit physicians more latitude to bargain collectively with health insurers in conjunction with procompetitive clinical integration efforts. The article also explains how the unbridled consolidation of the health insurance industry has resulted in higher premiums to consumers and lower compensation to physicians, and recommends that further consolidation be prohibited. Finally, the writer discusses how health insurers with market power are improperly undermining the physician-patient relationship, and recommend federal antitrust enforcement agencies take appropriate steps to protect patients and their physicians from this anticompetitive conduct. The article also suggests such steps will require changes in three areas: (1) health insurers must be prohibited from engaging in anticompetitive activity; (2) the continuing improper consolidation of the health insurance industry must be curtailed; and (3) the physician community must be permitted to undertake the collaborative activity necessary for the establishment of a transparent, coordinated, and efficient delivery system.

Case Report: Rhodococcus erythropolis Osteomyelitis in the Toe

M. Roy MRCS, S. Sidhom FRCS (T&O), K. G. Kerr MD, FRCPath, J. L. Conroy FRCS (T&O) The Rhodococcus species rarely cause musculoskeletal infections, with only two cases reported in the literature. We report the case of a 53-year-old woman who had an infection develop after first metatarsophalangeal joint fusion. A year after surgery, she continued to have pain and swelling with nonunion. She underwent revision of the arthrodesis and tissue samples from surgery revealed Rhodococcus erythropolis. The patient’s symptoms improved with oral antibiotics. One year after the revision surgery, the fusion had united. We believe this is the first report of a case of a musculoskeletal infection caused by Rhodococcus erythropolis.

Case Report: Femoral Neuropathy Secondary to Total Hip Arthroplasty Wear Debris

Samo K. Fokter MD, PhD, Alenka Repše-Fokter MD, PhD, Iztok Takač MD, PhD Femoral nerve palsy after THA is well known, but delayed palsy is rare. We describe a 58-year-old man who had progressive thigh pain, weakness, and numbness develop 13 years after cementless arthroplasty of his left hip. Plain radiographs showed substantial liner wear. MRI of the lumbar spine was unrevealing and EMG showed a peripheral neurogenic process involving the left femoral nerve. The large intrapelvic cystic mass was confirmed by an abdominopelvic CT scan. Percutaneous aspiration of the cyst was performed. Cultures of the fluid were negative and cytopathologic examination showed necrotic debris without malignant cells. Biopsy revealed necrosis and abundant foreign body granulation tissue with polarizable debris. During surgical removal of the cyst, a defect of the inner acetabular wall was noted. After subsequent revision arthroplasty with allograft bone, the patient’s clinical symptoms improved and his EMG returned to normal.

Thigh Pain in a 73-year-old Man

Tonya L. Dixon MPH, Mark J. Kransdorf MD, Murli Krishna MD, Mary I. O’Connor MD
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