Ganglion Cysts of the Proximal Tibiofibular Joint: Low Risk of Recurrence After Total Cyst Excision.

BACKGROUND: Peroneal nerve neuropathy due to compression from tumors or tumor-like lesions such as ganglion cysts is rare. Few case series have been published and reported local recurrence rates are high, while secondary procedures are frequently employed. QUESTIONS/PURPOSES: (1) What are the demographics of patients with ganglion cysts of the proximal tibiofibular joint, and what proportion of them present with intraneural cysts and peroneal nerve palsy? (2) What Musculoskeletal Tumor Society (MSTS) scores do patients with this condition achieve after decompression surgery with removal of the ganglion cyst, but no arthrodesis of the tibiofibular joint? (3) What proportion of patients experience local recurrence after surgery? METHODS: Between 2009 to 2018, 30 patients (29 primary cases) were treated for chronic peroneal palsy or neuropathy due to ganglion cysts of the proximal tibiofibular joint at two tertiary orthopaedic medical centers with total resection of the cystic lesion. MRI with contrast and electromyography (EMG) were performed preoperatively in all patients. The minimum follow-up for this series was 1 year (median 48 months, range 13 to 120); 14% (4 of 29) were lost to follow-up before that time. The MSTS score was recorded preoperatively, at 6 weeks postoperatively, and at most-recent follow-up. RESULTS: A total of 90% of the patients were male (26 of 29 patients) and the median age was 67 years (range 20 to 76). In all, 17% (5 of 29) were treated due to intraneural ganglia. Twenty-eight percent (8 of 29) presented with complete peroneal palsy (foot drop). The mean MSTS score improved from 67 ± 12% before surgery to 89 ± 12% at 6 weeks postoperative (p < 0.001) and to 92 ± 9% at final follow up (p = 0.003, comparison with 6 weeks postop). All patients improved their scores. A total of 8% (2 of 25 patients) experienced local recurrence after surgery. CONCLUSION: Ganglion cysts of the proximal tibiofibular joint occurred more often as extraneural lesions in older male patients in this small series. Total excision was associated with improved functional outcome and low risk of neurologic damage and local recurrence, and we did not use any more complex reconstructive procedures. Tendon transfers may be performed simultaneously in older patients to stabilize the ankle joint, while younger patients may recover after decompression alone, although larger randomized studies are needed to confirm our preliminary observations. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Controversial issues in kyphoplasty and vertebroplasty in malignant vertebral fractures.

BACKGROUND: Kyphoplasty (KP) and vertebroplasty (VP) have been successfully employed in the treatment of pathological vertebral fractures. METHODS: A critical review of the medical literature was performed and controversial issues were analyzed. RESULTS: Evidence supports KP as the treatment of choice to control fracture pain and the possible restoration of sagittal balance, provided that no overt instability or myelopathy is present, the fracture is painful and other pain generators have been excluded, and positive radiological findings are present. Unilateral procedures yield similar results to bilateral ones and should be pursued whenever feasible. Biopsy should be routinely performed and 3 to 4 levels may be augmented in a single operation. Higher cement filling appears to yield better results. Radiotherapy is complementary with KP and VP but must be individualized. CONCLUSIONS: In cases of painful cancer fractures, if overt instability or myelopathy is not present, unilateral KP should be pursued, whenever feasible, followed by radiotherapy. The technological advances in hardware and biomaterials, as well as combining KP with other modalities, will help ensure a safe and more effective procedure. Address.

Embolization of hypervascular bone metastases reduces intraoperative blood loss: a case-control study.

BACKGROUND: Small case series suggest that preoperative transcatheter arterial embolization minimizes bleeding and facilitates surgery for hypervascular metastatic bone tumors. However, control groups would make our confidence in clinical recommendations stronger, but small patient numbers make prospective trials difficult to conduct on this topic. QUESTIONS/PURPOSES: In this case-control study, we asked whether (1) patients who undergo embolization have less estimated blood loss and/or shorter operative time than patients who do not have embolization; (2) larger tumor size, greater initial tumor vascularity, and longer interval from embolization to surgery are associated with greater estimated blood loss and packed red blood cell transfusion volume; and (3) embolization does not affect renal function in patients with normal preoperative renal function. METHODS: We retrospectively reviewed records of patients with hypervascular bone metastases treated at our institution between 1998 and 2008. Twenty-seven patients with renal cell carcinoma and 12 with thyroid carcinoma who underwent embolization before 41 surgical procedures were matched to 41 patients who did not have embolization with respect to age, diagnosis, tumor size and potential vascularity, and procedure type; matching was performed without knowledge of outcomes. In univariate and multivariate analyses, age, tumor size, use of embolization, surgery type and risk, embolization-to-surgery interval, and degree of devascularization were evaluated for correlations with estimated blood loss, packed red blood cell transfusion volume, operative time, and postembolization renal function. RESULTS: Overall, patients who had embolization had less mean estimated blood loss (0.90 versus 1.77 L; p = 0.002), packed red blood cell transfusion volume (2.15 versus 3.56 U; p = 0.020), and operative time (3.13 versus 3.91 hours; p < 0.001). Larger tumor size correlated with greater estimated blood loss (r = 0.451; p = 0.003), packed red blood cell transfusion volume (r = 0.50; p = 0.002), and operative time (r = 0.595; p < 0.001). Neither the interval for embolization to surgery nor the degree of devascularization correlated with estimated blood loss or transfusion volume. In open rodding with intralesional curettage, transcatheter arterial embolization was associated with reduced estimated blood loss, transfusion volume, and operative time. Packed red blood cell transfusion volume was not reduced by embolization in intramedullary nailing procedures with the patient numbers available. Among patients with normal preoperative renal function who had embolization, creatinine levels remained normal. Mild transient, reversible renal function change occurred in one patient with preoperatively abnormal renal function. CONCLUSIONS: This study suggests that preoperative embolization probably reduces estimated blood loss, particularly for large tumors and during open femoral procedures.

Double approach operation for large extracompartmental proximal thigh tumors.

Resection of large femoral triangle tumors that invade the bone (or vice versa) still remains a challenge. A lateral-only approach would hinder dissection of the mass, away from the femoral vessels, while an iliofemoral-only type of approach would make bone resection and megaprosthetic reconstruction very arduous. The authors describe a two-stage, one-position operation via a double surgical approach: the first stage is comprised by an iliofemoral approach and dissection of the femoral vessels, followed by proximal femoral resection and reconstruction stage. One illustrative case is presented along with the authors overall experience. We believe that this operation facilitates wide tumor resection in a safe and step-wise manner, as not to add to the morbidity of the procedure.

Effect of graded posterior element and ligament removal on annulus stress and segmental stability in lumbar spine stenosis: a finite element analysis study.

The study aimed to investigate the impact of posterior element and ligament removal on the maximum von Mises stress, and maximum shear stress of the eight-layer annulus for treating stenosis at the L3-L4 and L4-L5 levels in the lumbar spine. Previous studies have indicated that laminectomy alone can result in segmental instability unless fusion is performed. However, no direct correlations have been established regarding the impact of posterior and ligament removal. To address this gap, four models were developed: Model 1 represented the intact L2-L5 model, while model 2 involved a unilateral laminotomy involving the removal of a section of the L4 inferior lamina and 50% of the ligament flavum between L4 and L5. Model 3 consisted of a complete laminectomy, which included the removal of the spinous process and lamina of L4, as well as the relevant connecting ligaments between L3-L4 and L4-L5 (ligament flavum, interspinous ligament, supraspinous ligament). In the fourth model, a complete laminectomy with 50% facetectomy was conducted. This involved the same removals as in model 3, along with a 50% removal of the inferior/superior facets of L4 and a 50% removal of the facet capsular ligaments between L3-L4 and L4-L5. The results indicated a significant change in the range of motion (ROM) at the L3-L4 and L4-L5 levels during flexion and torque situations, but no significant change during extension and bending simulation. The ROM increased by 10% from model 1 and 2 to model 3, and by 20% to model 4 during flexion simulation. The maximum shear stress and maximum von-Mises stress of the annulus and nucleus at the L3-L4 levels exhibited the greatest increase during flexion. In all eight layers of the annulus, there was an observed increase in both the maximum shear stress and maximum von-Mises stress from model 1&2 to model 3 and model 4, with the highest rate of increase noted in layers 7&8. These findings suggest that graded posterior element and ligament removal have a notable impact on stress distribution and range of motion in the lumbar spine, particularly during flexion.

Inter-Specimen Analysis of Diverse Finite Element Models of the Lumbar Spine.

Over the past few decades, there has been a growing popularity in utilizing finite element analysis to study the spine. However, most current studies tend to use one specimen for their models. This research aimed to validate multiple finite element models by comparing them with data from in vivo experiments and other existing finite element studies. Additionally, this study sought to analyze the data based on the gender and age of the specimens. For this study, eight lumbar spine (L2-L5) finite element models were developed. These models were then subjected to finite element analysis to simulate the six fundamental motions. CT scans were obtained from a total of eight individuals, four males and four females, ranging in age from forty-four (44) to seventy-three (73) years old. The CT scans were preprocessed and used to construct finite element models that accurately emulated the motions of flexion, extension, lateral bending, and axial rotation. Preloads and moments were applied to the models to replicate physiological loading conditions. This study focused on analyzing various parameters such as vertebral rotation, facet forces, and intradiscal pressure in all loading directions. The obtained data were then compared with the results of other finite element analyses and in vivo experimental measurements found in the existing literature to ensure their validity. This study successfully validated the intervertebral rotation, intradiscal pressure, and facet force results by comparing them with previous research findings. Notably, this study concluded that gender did not have a significant impact on the results. However, the results did highlight the importance of age as a critical variable when modeling the lumbar spine.

Is vertebral augmentation the right choice for cancer patients with painful vertebral compression fractures?

Cancer-related fractures of the spine are different from osteoporotic ones, not only in pathogenesis but also in natural history and treatment. Higher class evidence now supports offering balloon kyphoplasty to a patient with cancer, provided that the pain is significant in intensity, has a positional character, and correlates to the area of the fractured vertebrae. Absence of clinical spinal cord compression and overt instability are paramount. Because of the frequent disruption of the posterior vertebral body cortex in these patients, the procedure should be performed by experienced operators who could also quickly perform an open decompression if cement extravasation occurs. Patients will benefit from vertebral augmentation, even in chronic malignant fractures. A biopsy should be routinely performed and a combination with radiation treatment would be beneficial in most cases.

Comparing effects of kyphoplasty, vertebroplasty, and non-surgical management in a systematic review of randomized and non-randomized controlled studies.

PURPOSE: To determine if differences in safety or efficacy exist between balloon kyphoplasty (BKP), vertebroplasty (VP) and non-surgical management (NSM) for the treatment of osteoporotic vertebral compression fractures (VCFs). METHODS: As of February 1, 2011, a PubMed search (key words: kyphoplasty, vertebroplasty) resulted in 1,587 articles out of which 27 met basic selection criteria (prospective multiple-arm studies with cohorts of ≥ 20 patients). This systematic review adheres to preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. RESULTS: Pain reduction in both BKP (-5.07/10 points, P < 0.01) and VP (-4.55/10, P < 0.01) was superior to that for NSM (-2.17/10), while no difference was found between BKP/VP (P = 0.35). Subsequent fractures occurred more frequently in the NSM group (22 %) compared with VP (11 %, P = 0.04) and BKP (11 %, P = 0.01). BKP resulted in greater kyphosis reduction than VP (4.8º vs. 1.7°, P < 0.01). Quality of life (QOL) improvement showed superiority of BKP over VP (P = 0.04), along with a trend for disability improvement (P = 0.08). Cement extravasation was less frequent in the BKP (P = 0.01). Surgical intervention within the first 7 weeks yielded greater pain reduction than VCFs treated later. CONCLUSIONS: BKP/VP provided greater pain relief and fewer subsequent fractures than NSM in osteoporotic VCFs. BKP is marginally favored over VP in disability improvement, and significantly favored in QOL improvement. BKP had a lower risk of cement extravasation and resulted in greater kyphosis correction. Despite this analysis being restricted to Level I and II studies, significant heterogeneity suggests that the current literature is delivering inconsistent messages and further trials are needed to delineate confounding variables.

Ulnar nerve injuries in Guyon canal: a report of 32 cases.

PURPOSE: In this study, the surgical outcomes of 32 patients with ulnar nerve injuries in the Guyon canal are presented. Outcomes were analyzed in relation to various factors such as age, surgical timing, zone of injury, and type of nerve reconstruction. METHODS: Between 1990 and 2007, 32 patients with injury in Guyon canal were managed surgically. Twelve patients had ulnar nerve injury proximal to its bifurcation (zone I); 14 patients had isolated motor branch injury (zone II); and six patients had isolated sensory branch injury (zone III). End-to-end repair was achieved in 12 (38%) of 32 patients, while nerve grafting was performed in 20 (62%) cases. The mean follow-up period was 22 months. RESULTS: Good and excellent motor function was restored in 25 (96%) of 26 cases with motor branch injury. Good and excellent sensory results were achieved in 15 (83%) of 18 cases with sensory branch injury. Outcomes were significantly better for those who had early repair (<4 weeks) when compared with those who had repair 4 weeks after injury (P < 0.05). There were no significant differences between outcomes after end-to-end repair or nerve grafting (P > 0.05) and between outcomes from repair of injuries in different zone (P > 0.05). CONCLUSIONS: Early diagnosis and surgical treatment with careful dissection of the ulnar nerve branches within the canal is very important. Adequate exposure is usually required to repair the nerve in the Guyon canal. Nerve grafting in this level could give analogous results as the end-to-end repair.

Vertebrectomy and expandable cage placement via a one-stage, one-position anterolateral retroperitoneal approach in L5 tumors.

Spinal reconstruction of the L5 vertebrae after tumor resection remains a challenge. Complex resection followed by circumferential fixation in the same setting, or in staged fashion, is often employed. The added operative time associated with this method potentially increases morbidity and mortality in an inherently high-risk procedure and anatomy in the lumbosacral area makes reconstruction more challenging. The authors describe a technique involving L5 vertebrectomy, placement of an expandable cage, and anterolateral L4-S1 screw fixation via a one-stage, one-position, anterolateral retroperitoneal approach. Two illustrative cases are presented along with the authors overall experience in L5 tumor operations. We believe that this is a feasible reconstructive option after tumor resection in lower lumbar metastatic spine disease. The approach may be also utilized in combined anteroposterior (two-stage) procedures in primary malignant tumors or oligometastatic disease.

Comparison of polymethylmethacrylate versus expandable cage in anterior vertebral column reconstruction after posterior extracavitary corpectomy in lumbar and thoraco-lumbar metastatic spine tumors.

Single-stage posterior corpectomy for the management of spinal tumors has been well described. Anterior column reconstruction has been accomplished using polymethylmethacrylate (PMMA) or expandable cages (EC). The aim of this retrospective study was to compare PMMA versus ECs in anterior vertebral column reconstruction after posterior corpectomy for tumors in the lumbar and thoracolumbar spine. Between 2006 and 2009 we identified 32 patients that underwent a single-stage posterior extracavitary tumor resection and anterior reconstruction, 16 with PMMA and 16 with EC. There were no baseline differences in regards to age (mean: 58.2 years) or performance status. Differences between groups in terms of survival, estimated blood loss (EBL), kyphosis reduction (decrease in Cobb's angle), pain, functional outcomes, and performance status were evaluated. Mean overall survival and EBL were 17 months and 1165 ml, respectively. No differences were noted between the study groups in regards to survival (p = 0.5) or EBL (p = 0.8). There was a trend for better Kyphosis reduction in favor of the EC group (10.04 vs. 5.45, p = 0.16). No difference in performance status or VAS improvements was observed (p > 0.05). Seven patients had complications that led to reoperation (5 infections). PMMA or ECs are viable options for reconstruction of the anterior vertebral column following tumor resection and corpectomy. Both approaches allow for correction of the kyphotic deformity, and stabilization of the anterior vertebral column with similar functional and performance status outcomes in the lumbar and thoracolumbar area.

Minimally invasive sacroiliac fixation in oncologic patients with sacral insufficiency fractures using a fluoroscopy-based navigation system.

STUDY DESIGN: Surgical technique article with retrospective case series. SUMMARY OF BACKGROUND DATA: Sacral insufficiency fractures are commonly encountered in oncologic patients and constitute a cause for persistent lower back and pelvic pain. OBJECTIVE: The aim of this study is to describe the modified technique of navigated percutaneous sacroiliac (SI) fixation using multiple long screws per level that cross both SI joints and engage bilateral iliac bones; furthermore to evaluate its safety and efficacy in oncologic patients with sacral insufficiency fractures. METHODS: Six oncologic patients (3 male, 3 female, mean age: 58.8 y) with sacral insufficiency fractures who had undergone additional radiation therapy were operated with navigated percutaneous fixation. Two patients had failed preoperative sacroplasty and 1 had failed SI pinning. Eighteen SI screws were placed (15 at S1 level and 3 at S2). In the majority of cases the screws were long enough to engage bilateral ilium and sacrum. Additionally, 1 patient underwent percutaneous iliolumbar instrumentation and in 4 patients we performed concomitant sacroplasty or polymethylmethacrylate screw augmentation. The patients were followed for 18.8 months in average (range: 12-30 mo). Outcome was assessed using the Karnofsky Performance Status score (KPS), pain scale (0-10) and detailed neurologic examination. RESULTS: In 1 case, a revision of a screw was required due to radiculopathy. There was no perioperative morbidity or mortality. No hardware failure was encountered. There was significant improvement in KPS (P=0.04) and pain levels (P=0.02). CONCLUSIONS: These preliminary data suggest that navigated percutaneous SI screw fixation is a safe and effective intervention in terms of pain control and performance status improvement in oncologic patients with sacral insufficiency fractures. For optimal fixation, multiple long screws that engage both iliac bones may be inserted through the S1 level in a safe manner. The technique may be combined with sacroplasty or closed posterior instrumentation to augment the screw fixation. Further investigation is needed to compare this technique with other treatment modalities.

Fixation of femoral neck fractures using divergent versus parallel cannulated screws.

Controversy exists regarding the optimal method of internal fixation in femoral neck fractures. Biomechanical data suggest that calcar fixation is superior to central screws placement. We propose a divergent technique for placing 3 cannulated stainless steel screws engaging the calcar femorale. Fifty two patients admitted to our institution for a femoral neck fracture were treated with the divergent screw technique, over a 7-year period. Four patients were deceased and 4 were lost to follow-up. Of the remaining 44 patients there were 10 males and 34 females, aged from 33 to 78 years (mean, 58 years). All patients were operated on by the same surgeon and were followed-up for a minimum of 2 years (mean: 33.6 months, range: 2-6 years). Twenty four patients sustained a non-displaced fracture (Garden I-II) and 20 sustained a displaced fracture (Garden III-IV) of the femoral neck. Mean Harris hip score (HHS) was 89.6 points. Avascular necrosis was evident in 4 patients (9%) with displaced fractures. Non-unions or failed internal fixations were not encountered. There was a significant difference in the HHS, in favor of the divergent group (P = 0.006), while more complications were encountered in the parallel group including 6 cases with non-union. In conclusion, parallel screw placement is not critical for an excellent clinical outcome. Our proposed fixation method using 3 screws that diverge and lie in different coronal planes (1 engaging the calcar femorale) with a free-hand technique may offer enhanced fixation. Biomechanical data along with larger clinical studies are needed to establish our proposed method.

Extensor Carpi Ulnaris Tenodesis Versus No Stabilization After Wide Resection of Distal Ulna Giant Cell Tumors.

BACKGROUND: The necessity of stabilizing the residual ulnar stump after distal ulna tumor resection remains controversial. The authors retrospectively compared the outcome of patients who underwent wide resection of distal ulna giant cell tumors (GCTs) and reconstruction with tenodesis of the extensor carpi ulnaris (ECU) or without reconstruction. METHODS: Between 2007 and 2015, 9 patients (6 females, 3 males; mean age, 36.8 years; range, 24-65 years) who underwent distal ulna resection for GCT of bone were retrospectively reviewed. The mean resection length was 8.1 cm. Five patients had no reconstruction, whereas 4 patients had stabilization of the ulnar stump using ECU tenodesis. With a mean follow-up of 3.6 years (2-9 years), the functional outcome using the quick Disability of Arm, Shoulder and Hand (DASH) score; Musculoskeletal Tumor Society score and grip strength; as well as the oncological outcome were evaluated. RESULTS: Musculoskeletal Tumor Society functional scores were more than 24 in 7 patients and 20 to 24 in 2 patients (mean, 27.6 or 92%). Quick DASH scores ranged from 0 to 27.3 (mean, 11.1). In both groups, similar scores were observed ( P > .5). No patient had instability or pain related to the stump. There was no ulnar translation or subluxation of the radiocarpal joint. Grip strength in the operated hand, controlled for handedness, was 11% less than in the contralateral hand, although there was no difference between groups ( P > .4). All patients were disease-free at the latest follow-up. CONCLUSIONS: The distal ulna may be widely resected with or without stabilization of the residual ulnar stump, yielding satisfactory local disease control and functional outcome.

Detection of somatostatin receptors in human osteosarcoma.

BACKGROUND: The location of osteosarcoma in the metaphysis as well as the age of the patients during the most rapid tumour growth suggest that factors related to skeletal growth are involved in the pathogenesis of this tumour. In this aspect this study aims to detect somatostatin receptors in human osteosarcomas and correlate this finding with the clinical outcome of the tumour. PATIENTS AND METHODS: Immunohistochemical staining for the presence of somatostatin receptors as well as overall survival and disease free survival rates were retrospectively studied in twenty-nine osteosarcoma patients. RESULTS: Four osteosarcomas with several aggressive biologic behaviour expressed somatostatin receptors. In these four young patients the event free rate was 0% and the overall survival rate was 50% at 4, 3 years. In contrast the event free survival rate of the twenty-five patients with negative somatostatin receptor status was 72% with an overall survival rate of 76% at 4,3 years. CONCLUSION: The present study demonstrates the existence of somatostatin receptors in human osteosarcoma. Tumours expressing somatostatin receptors seemed to be aggressive with a very low disease free and overall survival rate compared to osteosarcoma with negative receptor status.

Total Scapulectomy and Shoulder Reconstruction Using a Scapular Prosthesis and Constrained Reverse Shoulder Arthroplasty.

Malignant tumors of the scapula are rare, and limb salvage surgery after tumor resection is challenging. The authors present a series of 6 patients who were treated by total scapulectomy and reconstruction with a custom-made scapular prosthesis and a constrained reverse shoulder arthroplasty. Postoperative oncologic and functional outcomes were assessed. The mean follow-up was 37 months (range, 9-84 months). Clear surgical margins were achieved in all patients. At the last follow-up, 4 patients showed no evidence of disease and 2 had died of systemic metastatic disease. Although shoulder function was limited, all shoulders were painless and stable and the patients retained satisfactory hand, wrist, and elbow function. [Orthopedics. 2018; 41(6):e888-e893.].

Is early vertebroplasty/kyphoplasty justified in multiple myeloma given the rapid vertebral fracture progression?

COMMENTARY ON: Xiao R, Miller JA, Margetis K, et al. Radiographic progression of vertebral fractures in patients with multiple myeloma. Spine J 2016:16:822-32 (in this issue).