Osteolysis after cervical disc arthroplasty.

PURPOSE: Cervical disc arthroplasty (CDA) has become an increasingly popular treatment for cervical degenerative disc disease. One potential complication is osteolysis. However, current literature on this topic appears limited. The purpose of this study is to elucidate the incidence, aetiology, consequence, and subsequent treatment of this complication. METHODS: A systematic literature review was performed according to the PRISMA guidelines. Studies discussing the causes, incidence and management of osteolysis after a CA were included. RESULTS: A total of nine studies were included. We divided these studies into two groups: (1) large case series in which an active radiological evaluation for osteolysis was performed (total = six studies), (2) case report studies, which discussed symptomatic cases of osteolysis (total = three). The incidence of asymptomatic osteolysis ranged from 8 to 64%; however, only one study reported an incidence of < 10% and when this case was excluded the incidence ranged from 44 to 64%. Severe asymptomatic bone loss (exposure of the implant) was found in less than 4% of patients. Bone loss from osteolysis appeared to occur early (< 1 year) after surgery and late (> 1 year) as well. Symptomatic patients with osteolysis often required revision surgery. These patients required removal of implant and conversion to fusion in the majority of the cases. CONCLUSIONS: Osteolysis after CDA is common; however, the majority of cases have only mild or asymptomatic presentations that do not require revision surgery. The timing of osteolysis varies significantly. This may be due to differences in the aetiology of osteolysis.

Radiographic outcomes of impaction-grafted standard-length humeral components in total shoulder and ream-and-run arthroplasty: is stress shielding an issue?

BACKGROUND: The purpose of this study was to evaluate humeral stress shielding in shoulder arthroplasties performed with a smooth, standard-length humeral stem fixed with impaction autografting. METHODS: Two-year outcomes were evaluated for 48 ream-and-run arthroplasties and 78 total shoulder arthroplasties (TSAs) performed at a single institution. Postoperative radiographs were analyzed for adaptive changes, calcar osteolysis, and component shift or subsidence. Radiographic outcomes were analyzed for associations with patient demographic characteristics, humeral stem filling ratios, and glenoid loosening; clinical outcomes were assessed using the Simple Shoulder Test. RESULTS: At 2 years after surgery, the ream-and-run procedures showed partial calcar osteolysis in 9 cases (19%). The TSAs showed partial calcar osteolysis in 19 cases (24%) and complete calcar osteolysis in 2 (3%). Humeral component subsidence or component shift was observed in 3 ream-and-run procedures (6%) and in 8 TSAs (10%). These radiographic findings were not significantly associated with patient demographic characteristics, canal-filling ratios, or clinical outcomes. CONCLUSION: When inserted with impaction autografting, a smooth, standard-length humeral stem offers a secure bone-preserving approach for humeral component fixation in shoulder arthroplasty. These results with a conventional prosthesis can serve as a basis for comparison for new component designs and fixation methods.

Balloon kyphoplasty and additional anterior odontoid screw fixation for treatment of unstable osteolytic lesions of the vertebral body C2: a case series.

BACKGROUND: Unstable osteolytic lesions of the occipitocervical junction are rare and may occur in hematological malignancy or vertebral hemangioma, among others. Different case reports have been published about vertebroplasty for treatment of spinal metastases of the upper cervical spine. Only few cases concern balloon kyphoplasty of C2. We present a consecutive case series including four patients with an osteolytic lesion of the dens axis and describe a technical note for balloon kyphoplasty of C2 and an additional anterior odontoid screw fixation. METHODS: Four consecutive patients with an osteolytic lesion of the vertebral body of C2 were treated by anterior balloon kyphoplasty and additional anterior odontoid screw fixation of the dens axis. The radiological imaging showed a lytic process of the vertebral body C2 with no vertebral collapse but involvement of more than 50% of the vertebral body in all patients. RESULTS: Two cases of potentially unstable osteolytic lesions of C2 by myeloma, one case with metastatic osteolytic lesion of C2 by adenocarcinoma of the colon and one patient with vertebral hemangioma located in C2 were presented to our clinic. In all cases, surgical treatment with an anterior balloon kyphoplasty of C2 and an additional anterior, bicortical odontoid screw placement was performed. Control x-rays showed sufficient osteosynthesis and cement placement in the vertebral body C2. DISCUSSION: Anterior balloon kyphoplasty and anterior odontoid screw placement is a safe treatment option for large osteolytic lesions of C2. The additional odontoid screw placement has the advantage of providing more stabilization and may prevent late complications, like odontoid fractures. For patients with potentially unstable or large osteolytic lesions of the dens without spinal cord compression or neurological symptoms we recommend the placement of an anterior odontoid screw when performing a balloon kyphoplasty. LEVEL OF EVIDENCE: - IV: retrospective or historical series.

Large enchondroma of the thoracic spine: a rare case report and review of the literature.

BACKGROUND: Enchondroma, a subtype of chondroma, originates from the medullary cavity of the bone and produces an expansile growth pattern. Enchondroma located in the spine is rare and a few cases of large thoracic enchondroma have been reported. The authors document a rare case of large enchondroma in the thoracic spine of a 49-year-old woman, and discuss its clinical, radiological and histopathological characteristics. CASE PRESENTATION: The patient presented with rapidly progressive and severe pain on her upper back. Magnetic resonance imaging revealed an expansile lesion at the posterior elements of T3 that was hypointense on T1-weighted images and mixed iso- to hyperintense on T2-weighted images. Administration of gadolinium-diethylenetriamine pentaacetic acid (Gd-DTPA) resulted in heterogeneous enhancement. During surgery, a large tumor of 4.2cm × 4.7cm × 2.1cm was resected along with the lamina and spinous process. Histological examination revealed that the tumor consisted of mature hyaline cartilage with typical chondrocytes, indicating that it was an enchondroma. CONCLUSIONS: Despite its benign-growing nature, enchondroma should be examined closely for signs of enchondromatosis and enchondrosarcoma. Complete surgical resection is the treatment of choice for immediate relief of symptoms and avoidance of recurrence.

Cochlear Implantation in Patients With Osteolytic Labyrinthitis: A Case Series.

OBJECTIVE: To describe the rare process of osteolytic labyrinthitis, previously referred to as labyrinthine sequestrum, which involves progressive obliteration of the bony and membranous labyrinth with eventual supplantation with soft tissue and, in some cases, bony sequestrum. PATIENTS: Three patients with diverse presentations of osteolytic labyrinthitis from two tertiary care academic medical centers. INTERVENTIONS: Case series report analyzing the relevant clinical, radiologic, pathologic, and surgical data on our patients with osteolytic labyrinthitis and comparing these index cases to the existing literature. MAIN OUTCOME MEASURES: We describe the varying image findings seen in osteolytic labyrinthitis on computed tomography and magnetic resonance imaging. Also, we report successful surgical intervention and hearing rehabilitation with cochlear implantation in patients with osteolytic labyrinthitis. RESULTS: Our three patients presented with profound sudden sensorineural hearing loss and vertigo consistent with labyrinthitis. None of the three patients had a history of chronic otitis media. Imaging workup revealed varying degrees of erosion to the otic capsule bone demonstrating the spectrum of disease seen in osteolytic labyrinthitis. Although two cases showed osteolytic changes to the semicircular canals and vestibule, the first case revealed frank bony sequestrum within the obliterated labyrinth. The three cases were taken for surgical debridement and cochlear implantation. CONCLUSIONS: We propose the new term, osteolytic labyrinthitis-previously referred to as labyrinthine sequestrum-to describe the rare spectrum of disease characterized by destruction of the osseous and membranous labyrinth and potential supplantation with bony sequestrum. Cochlear implantation is a viable option in selected patients with osteolytic labyrinthitis.

Rare localizations of bone sarcoidosis: two case reports and review of the literature.

Sarcoidosis is a multisystem disease of unknown origin. Granulomatous bone involvement has an overall incidence of 1-13%. This incidence is probably underestimated in certain patient series because bone involvement is often asymptomatic. The small bones of hands and feet are the most common localizations, while skull, knee, rib, pelvic and sternal localizations are rarely reported. Here we describe some interesting cases of chronic sarcoidosis with unusual bone localizations observed at our regional referral centre for sarcoidosis. We also review the literature to underline the complexity of the disease, the problem of differential diagnosis with respect to malignancies and the need for appropriate and effective therapy of this rare localization.

Osteolytic lesions: osteitis fibrosa cystica in the setting of severe primary hyperparathyroidism.

A 58-year-old female patient presented with several weeks history of significant bilateral knee pain. Initial knee radiographs demonstrated lucencies of the bony cortex while extensive osteolytic lesions on a routine chest radiograph were suggestive of multiple myeloma or bony metastases. Biochemical investigation revealed primary hyperparathyroidism with renal insufficiency. A parathyroid adenoma was demonstrated on a neck ultrasound and sestamibi scan and subsequently confirmed by histology. We illustrate a case of primary hyperparathyroidism with osteitis fibrosa cystica and brown tumours which were initially mistaken for malignant disease.

Management of acetabular bone loss.

Acetabular bone loss is a common complication associated with revision total joint replacement. Successful surgical management is enhanced by a systematic classification of bony defects. A variety of implants, fixation strategies, surgical techniques, and graft materials are required to address the spectrum of reconstructive complications encountered at revision surgery.

Schnitzler's syndrome (urticaria and macroglobulinemia) dramatically improved with corticosteroids.

The authors report the case of a 65-year-old man who had an evolving case of Schnitzler's syndrome with lytic bone lesions which was unresponsive to several drugs, and which dramatically improved with small quantities of corticosteroids. Schnitzler's syndrome, first described in 1974, is defined by chronic non-pruritic urticaria, osteocondensation, and monoclonal IgM dysproteinemia without features of lymphoproliferative disease, and is associated with fever, deterioration of the general health and biological signs of inflammation. Only 22 cases of Schnitzler's syndrome have been reported hitherto and there is no known effective treatment, H1 and H2 blockers, dapsone, colchicine, chloroquine, cyclophosphamide, chlorambucil and azathioprine having proven useless in the few patients treated. Corticosteroids may be effective, however, especially against the urticaria.

Painful conditions of the acromioclavicular joint.

The acromioclavicular (AC) joint may be affected by a number of pathologic processes, most commonly osteoarthritis, posttraumatic arthritis, and distal clavicle osteolysis. The correct diagnosis of a problem can usually be deduced from a thorough history, physical examination, and radiologic evaluation. Asymptomatic AC joint degeneration is frequent and does not always correlate with the presence of symptoms. Selective lidocaine injection enhances diagnostic accuracy and may correlate with surgical outcome. Nonoperative treatment is helpful for most patients, although those with osteolysis may have to modify their activities. In appropriately selected patients, open or arthroscopic distal clavicle resection is necessary to relieve symptoms. Recent biomechanical and clinical data emphasize the importance of capsular preservation and minimization of bone resection; however, the optimal amount of distal clavicle resection remains elusive. Patients with AC joint instability have poor results after distal clavicle resection.

Clinical course of bone metastasis from prostatic cancer following endocrine therapy: examination with bone x-ray.

X-ray findings of bone metastatic lesions from 81 cases of stage D2 prostatic cancer were examined before and following endocrine therapy. Untreated lesions were classified into five types; osteoblastic (15%), mixed, but mainly osteoblastic (31%), mixed, but mainly osteolytic (17%), osteolytic (10%), and undetermined with a positive bone scan (27%). Patients with two mixed types had a tendency of widely speeded areas of metastasis and elevated serum prostatic acid phosphatase. Temporal enlargement of sclerotic lesion immediately after the start of therapy did not indicate disease progression. In many cases, changes from osteolytic to osteoblastic patterns were noticed in the same lesion regardless of the effects of endocrine therapy. Remodeling to the sclerotic pattern appeared as curative changes. From these findings, it was concluded that the natural course of bone lesions showed a tendency to change from the osteolytic to osteoblastic type and relapse was often accompanied by an increase of the osteolytic type lesion. Evaluation of therapeutic effects based on remodeling, changes in number and areas of lesions, and the appearance of new lesion correlated well with prognosis.

Scintigraphic patterns of injury in amateur weight lifters.

PURPOSE: Weight lifting is now a standard part of training in most sports. An increasing number of amateur athletes are doing strength training, mostly in unsupervised situations. A series of injuries in amateur weight lifters was analyzed by bone scintigraphy, with the aim of depicting specific patterns that would accurately identify the primary lesions. METHODS: Twelve patients (10 men and 2 women) were studied whose ages ranged from 18 to 35 years. Patients were referred for bone scintigraphy with clinical diagnoses based on history, physical examination, and appropriate radiologic investigations. Diagnoses were confirmed by surgery, arthroscopy, arthrography, local steroid injection, and outcome. RESULTS: Most of the injuries were in athletes undertaking free-weight training. Most injuries were in the upper limbs, particularly around the shoulder. Scintigraphic patterns of supraspinatus and bicipital tendons and also rotator cuff lesions were identified. Clavicular osteolysis, avulsion injuries, muscle damage, and vertebral lesions were also noted. Several abnormalities revealed by scintigraphy were clinically unsuspected. CONCLUSIONS: Scintigraphic manifestations of several injuries, particularly around the shoulder, have a specific pattern. Recognition of these patterns can enhance the performance of bone scintigraphy. Scintigraphy also has the potential to detect clinically unsuspected disease.

Total knee arthroplasty for neuropathic joint disease after severe bone destruction eroded the tibial tuberosity.

This article describes a patient in whom total knee arthroplasty was performed for neuropathic joint disease secondary to diabetes mellitus after severe bone destruction eroded the tibial tuberosity. At initial examination, radiographs of the knee showed bone destruction in the medial and anterior regions of the tibia, and fine bone fragments were seen in the joint. Conservative therapy was performed using a brace. However, bone destruction gradually advanced, and 10 months after the initial examination, radiographs of the knee showed bone destruction in the lateral condyle of the femur and advanced bone destruction of the anterior tibia; the tibial tuberosity was missing. It is rare for the tibial tuberosity in the anterior tibia to disappear. If this happens, reconstruction is difficult and total knee arthroplasty becomes complicated. For the bone defect in the tibia, cement was used to recreate the shape of the anterior surface of the tibia. It was possible to minimize the volume of bone resection and morphologically reconstruct the tibial tuberosity. The patient recovered quickly. At postoperative week 5, the patient was able to walk using a cane. Thirty-six months after total knee arthroplasty, knee extension was 0°, flexion was 120°, extension lag was 5°, knee score improved from 40 points to 94 points, and functional score improved from 20 points to 75 points. However, long-term implant stability needs to be carefully monitored.

Multifocal osteolytic lesions within lumbar spine in a middle-aged Chinese woman: a benign metastasizing leiomyoma?

STUDY DESIGN: Case report. OBJECTIVE: To describe a case presented as osteolytic lesions involving 2 inconsecutive lumbar, which was pathologically proved to be of smooth muscular origin. SUMMARY OF BACKGROUND DATA: Smooth muscle tumor of uncertain malignant potential (STUMP) could be diagnosed when the neoplasm showed some malignant behavior, whereas its histologic image revealed very low malignance. A 47-year-old woman presented with low back pain and numbness of the left lower extremity attributable to osteolytic lesions in the second and fourth lumbar vertebral bodies, which was subsequently diagnosed as STUMP. A benign metastasizing leiomyoma was highly suspected. METHODS: Clinical, pathologic, and radiologic characters of the patient with STUMP confined within the lumbar spine were retrospectively reviewed. A mini review was also conducted. RESULTS: We describe the first spine-confined case of STUMP. CONCLUSION: Significant new information in the growing literature of this rare and newly identified diagnosis has addressed the need for orthopedists to consider the STUMP diagnosis.

Aneurysmal bone cyst of the acromion treated by selective arterial embolization.

Aneurysmal bone cysts are rarely located in the scapula and are especially rare in the acromion. We present an 8-year-old boy with a large aneurysmal bone cyst of the acromion that achieved curative treatment with one selective transcatheter arterial embolization. Five years after the procedure, healing of the lesion and remodeling of the acromion was observed without any evidence of recurrence.