Unilateral hypertrophy of tensor fascia lata: a soft tissue tumor simulator.

OBJECTIVE: To describe the imaging findings in eight cases of unilateral tensor fascia lata (TFL) hypertrophy presenting as soft tissue masses. DESIGN: Imaging studies and medical charts of eight patients were reviewed retrospectively. The imaging studies included five radiographs, five computed tomography (CT) and six magnetic resonance imaging (MRI) examinations. RESULTS: The majority of patients (seven of eight) presented with a palpable proximal anterior thigh mass. One patient was asymptomatic and incidentally diagnosed. There were six females and two males. Ages ranged from 27 to 86 years old (mean 61). MRI and CT showed unilateral enlargement of the TFL muscle in all cases. CONCLUSION: TFL muscle hypertrophy is an uncommon clinical entity, which can simulate a soft tissue tumor. The characteristic appearance on CT or MRI allows a confident diagnosis of muscle hypertrophy to be made, avoiding unnecessary biopsy or surgical intervention.

Distal upper extremity function following proximal humeral resection and reconstruction for tumors: contralateral comparison.

BACKGROUND: Most functional analyses after limb salvage operations about the shoulder have focused on proximal function with the assumption that distal function is largely unaffected. This analysis examines distal function objectively. METHODS: Objective laboratory data regarding distal upper extremity strength after reconstructive procedures for tumors near the shoulder joint was collected over a 16-year period. Thirty-two patients were able to participate fully in the data collection at an average most recent follow-up duration of > 3.5 years. RESULTS: Statistically significant reductions on the involved side compared with the uninvolved side in grip, forearm pronation, forearm supination, elbow flexion, and elbow extension strength were documented (p < 0.05). The magnitude of reduction in strength diminishes distally, with the greatest effect in this group of patients being observed in elbow extension, followed by elbow flexion, forearm supination, and forearm pronation. Grip strength consistently showed the least amount of strength reduction compared with the uninvolved side, even within resection and reconstruction groups. Subjective patient rating of dexterity was no less than 3 of 5. Ninety percent of patients rated their dexterity 4 of 5 (52%) or 5 of 5 (38%). CONCLUSIONS: Despite the insistence of "normal" function in the distal upper extremity after limb salvage procedures, complete normality is not maintained. However, the degree of maintenance of distal function appears to be high, especially for grip strength and forearm pronation strength, and patient satisfaction is acceptable.

Immunologic responses in human recipients of osseous and osteochondral allografts.

A multiinstitutional study was carried out to evaluate immunologic responses for human recipients of massive frozen (-80 degrees C) osseous and osteochondral allografts. Allografts were used to reconstruct skeletal defects associated with a variety of traumatic degenerative and neoplastic disorders. Serum samples were obtained before surgery and from 1 month to 4 years after surgery. Sera were tested by microcytotoxicity against T cells from 60 donors for human leukocyte antigen Class I antibodies and against beta 2-microglobulin treated B cells from 40 donors for human leukocyte antigen Class II antibodies. Panels were selected to represent the majority of known human leukocyte antigen specificities. Of the 84 cases evaluated, 62 (74%) received blood transfusions and 28 of 44 (64%) female recipients had been previously pregnant. Sensitization before transplant was shown in 33 of 84 (39%) patients. After grafting, 49 of 84 (58%) recipients showed evidence of sensitization to Class I antigens and 46 of 84 (55%) recipients showed evidence to sensitization to Class II antigens. Overall sensitization was 67%.

Intercalary spacers in the treatment of segmentally destructive diaphyseal humeral lesions in disseminated malignancies.

During a 10-year period, 17 patients with segmentally destructive bone lesions of the humeral diaphysis in disseminated malignancies resulting in impending fracture (8 patients), pathologic fracture (6 patients), or failure of attempted internal fixation techniques (3 patients) were treated with resection of the involved diaphyseal segment and reconstruction with a cemented modular intercalary humeral spacer. Fourteen patients had metastatic cancer, 2 had multiple myeloma, and 1 had lymphoma. Breast and renal carcinoma were the most common pathologic diagnoses. The involved site was within the middle 1/3 in 8 patients, in the proximal-middle junction in 5, in the middle-distal junction in 2, and within the proximal and distal 1/3 in 1 patient each. Early pain relief was successful in 88% of patients. Early in the postoperative hospital course, patients generally were able to use the ipsilateral hand to assist feeding. Radiographic analysis revealed that the limited selection of stem lengths led to 76% of the distal stems and 47% of the proximal stems being shorter than the ideal length. The complication rate independent of disease progression was 29%. The most common complication was temporary radial nerve injury (3 patients). There were 3 implant failures, most commonly due to disengagement of the male-female junction. Two periprosthetic fractures occurred, 1 proximally (due to tumor progression) and 1 distally. Suggestions are given for modification of the implants to improve the major problems of limited versatility in intramedullary stem length and inadequate mating at the junction.

Langerhans' cell histiocytosis (histiocytosis X) of bone. A clinicopathologic analysis of 263 pediatric and adult cases.

BACKGROUND: Langerhans' cell histiocytosis (LCH) of bone is a disorder of histiocytic proliferation with variable and often unpredictable behavior. METHOD: The authors evaluated the clinical and pathologic features of 263 patients (172 children, 91 adults) with biopsy-proven LCH examined during an 80-year period at the Mayo Clinic. Only patients with bone involvement pathologically and/or radiographically were included in the study. Clinical follow-up was available for 245 patients and ranged from 3 months to 50 years (mean, 12 years; median, 10 years). Chi-square tests were used to determine associations between age, gender, extent of osseous involvement, visceral disease, and pathologic features. Survival analyses were performed by univariate and multivariate Cox regression methods. RESULTS: Age at presentation ranged from 2 months to 71 years with a clear predominance in children. The most common presenting complaint was pain, often worse at night. The skull was the most frequent osseous site in children and adults. Diabetes insipidus was documented in 40 patients. Forty-four children developed skeletal recurrence and/or new bone lesions, 19 of whom had diabetes insipidus. Fourteen children and 3 adults died either directly or indirectly from LCH. One adult patient developed systemic amyloidosis. All but two of these pediatric patients were 3 years of age or younger at presentation. All children with hepatosplenomegaly (7 patients) and/or thrombocytopenia (9 patients) died. Nine of the 14 children who died presented initially with three or more bone lesions. CONCLUSIONS: The clinical behavior of LCH of bone is often unpredictable; however, young age at diagnosis, hepatosplenomegaly, thrombocytopenia, and polyostotic (> or = 3 bones involved) disease are associated with a poor prognosis (P < 0.005). Recrudescence in children, but not in adults, strongly correlates with the presence of diabetes insipidus (P < 0.0005).

Massive osteolysis.

Massive osteolysis is rare, peculiar, and enigmatic. The clinical, radiographic, and histologic features were reviewed in 11 cases. The patients were generally young (mean age, 20.7 years), and males outnumbered females. More than half the patients had involvement of either the femur or the ribs alone or including the vertebrae. On the basis of radiographic studies, the disease process is capable of originating either in bone or adjacent soft tissues. Histologically, the authors were unable to identify pathognomonic features. Other than excision of all involved tissue, surgical treatment was generally ineffective. Radiation therapy may be successful in eradicating the disease in selected cases.

Osteosarcoma of the hand. A clinicopathologic study of 12 cases.

BACKGROUND: The incidence of osteosarcoma of the hand is about 0.18% of all osteosarcomas. METHODS: This study describes the clinicopathologic profile of 12 patients (3 Mayo Clinic and 9 consultation) with osteosarcoma of the hand (13 tumors). RESULTS: The patients (six male patients, five female, one unknown) were from 16 to 81 years of age (average, 45). Seven tumors were in phalanges and six in metacarpals. Nine tumors were classified as conventional, one as low-grade intraosseous, one as osteoblastoma-like, one as high-grade surface, and one as periosteal osteosarcoma. Recurrent disease developed in all patients in whom the initial operation resulted in intralesional excision or a marginal margin but not in the five patients in whom the initial operation achieved wide margins. Only one patient died of metastatic disease. CONCLUSIONS: The findings in this review support the conclusion that surgical treatment with a wide margin provides good results in patients with osteosarcoma of the hand.

Biopsy of soft-tissue tumors.

Biopsy is an integral part of the overall management of patients with soft-tissue sarcoma. The types of biopsy are fine needle, trocar, open incision or en bloc excision. There are advantages and disadvantages of each. Open biopsy requires strict adherence to a number of surgical principles. Proper execution requires determination of appropriate biopsy site, meticulous technique, and close collaboration with an experienced pathologist. Failure to adhere to these principles may result in untoward consequences for patients.

Aneurysmal bone cyst. A clinicopathologic study of 238 cases.

Aneurysmal bone cyst (ABC) is a nonneoplastic expansile bone lesion that mainly affects children and young adults. Primary ABC is relatively rare, with an incidence one half that of giant cell tumor of bone. In 238 patients with ABC studied in the Mayo Clinic files, more than 80% of the lesions were in long bones, flat bones, or the spinal column. Of the lesions initially treated at the Mayo Clinic, 95% were typical ABC; the rest were "solid" variants. Except for the absence of obvious cavernous channels and spaces, there was no significant histologic difference between solid variant and typical ABC. Radiographically, ABC is an eccentric expansile lesion commonly located at the metaphysis of long bones. Computed tomography and magnetic resonance imaging may show multiple internal septations or fluid levels. In the 153 patients treated, 19% had recurrence after curettage (intralesional excision). Recurrence was most common during the first 2 postoperative years.

Enterocutaneous fistula complicating total hip arthroplasty. A case report.

This is a case report of an enterocutaneous fistula complicating total hip arthroplasty, an extremely rare but potentially fatal complication. A 76-year-old woman survived but required extensive prolonged surgical treatment.

Solitary congenital fibromatosis (infantile myofibromatosis) of bone.

Congenital fibromatosis is a rare and benign myofibroblastic tumor that may occur in either a solitary or multicentric form. The soft-tissue form of this entity is well recognized. This report analyzes the clinical and pathologic features of 14 cases of congenital fibromatosis in which the tumor existed as a solitary lesion in bone. Most of the tumors (71%) were in patients who were 2 years old or younger. All but one tumor involved the craniofacial bones. Radiographically, they were purely lucent lesions in which a sclerotic rim was visible in each skull lesion. The myofibroblastic appearance closely resembled the microscopic features seen in the soft-tissue counterpart. For appropriate surgical management, it is imperative to recognize that this tumor occurs as a solitary lesion in bone and that it is distinct from other, more aggressive fibrous lesions.

Resection of malignant bone tumors about the shoulder. A preliminary report of reconstruction with a new modular spacer.

Reconstruction after resection of malignant bone tumors about the shoulder is difficult. Twelve patients had reconstruction using a new titanium modular spacer. This modular system allows the surgeon to reconstruct variable lengths of the proximal humerus. Although the patient has no active shoulder motion, excellent hand and elbow function is preserved. The spacer serves as a temporary device in the young active patient. A more definitive reconstructive procedure can be performed after the completion of chemotherapy and a sufficient disease-free interval.

Soft tissue sarcoma. Integration of brachytherapy, resection, and external irradiation.

Between December 1981 and August 1988, 63 patients with clinically localized nonretroperitoneal soft tissue sarcomas underwent 65 brachytherapy procedures in conjunction with conservative resection with (61 tumors) or without (four tumors) external beam irradiation. Implant doses of 1500 to 2000 cGy were combined with 4500 to 5000 cGy of external irradiation. External irradiation was given preoperatively for larger lesions near bone or neurovascular structures, whereas it was used postoperatively for smaller, more resectable lesions or those that had previously been inadequately excised. There were 47 high-grade tumors, 34 tumors greater than 5 cm, and nine patients with recurrent lesions (five with previous irradiation). With mean follow-up of 20 months, conclusions on local control are tentative, but only two of 56 tumors (4%) with brachytherapy as part of initial management had recurred locally and three of nine recurrent tumors had re-recurred locally. Only one of five local recurrences was within the implanted volume. Only two of 40 implantations (5%) performed at initial resection followed by postoperative external irradiation led to wound complications, whereas four of 16 implantations (25%) performed at resection after preoperative external irradiation were associated with wound problems. This technique does not increase local morbidity and may enhance local tumor control in comparison with either external radiation or brachytherapy alone as an adjuvant to conservative resection.

Metastatic bone disease. A study of the surgical treatment of 166 pathologic humeral and femoral fractures.

A retrospective study of the surgical treatment of 166 metastatic lesions of the humerus and femur in 147 patients was performed. There were 106 women and 41 men whose average age was 62 years. Two-thirds of the patients were treated for complete fractures, while one-third were treated for impending fractures. Breast, lung, and kidney carcinoma accounted for the majority of the primary lesions. One-half of the patients died within nine months of surgery, while one-quarter were alive 19.1 months after surgery. The patients with breast cancer had the best prognosis, while the patients with lung cancer had the worst. The probability of implant failure increased linearly with time to 33% at 60 months. The probability of failure for the femoral lesions was greater, with 44% at 60 months. The average survival in the patients with failed fixation in the femoral lesions was 34.5 months with a mean interval to failure at 17.7 months. The failure rate was high (23%) in proximal femoral lesions treated with a compression screw or nail plate. Common reasons for failure included poor initial fixation, improper implant selection, and progression of disease within the operative field. Bone cement augmentation should be used with the fixation device when possible. Complications due to hip-screw cut-out from the head may also be reduced by applying bone cement around the screw threads.

Metastatic diaphyseal fractures of the shaft of the humerus. The structural strength evaluation of a new method of treatment with a segmental defect prosthesis.

The surgical treatment of extensive metastatic diaphyseal lesions of the humerus with pathologic fractures is difficult. Patients with failed internal fixation often have large segments of bone loss. Rigid fixation often is not possible in these cases. Four patients were treated with a titanium segmental defect (SD) prosthesis with good clinical results. A comparative in vitro analysis of fixation with the SD prosthesis, a Rush rod, and a dynamic compression plate (DCP) augmented with methylmethacrylate was performed. The SD prosthesis performed better than the Rush rod and DCP in both the nondestructive four-point bending test and the destructive torsional test. The reconstructed humeri using the SD prosthesis had a torsional strength approaching that of an intact specimen. Hence, the SD prosthesis is a useful adjunct device in treating patients with extensive destructive lesions of the humerus secondary to metastatic disease and hematologic malignancies and in patients with malignant diseases who have had failed attempts at internal fixation.

Chondrosarcoma of the spine.

Twenty patients were diagnosed as having chondrosarcoma of bone that originated in the spine and, except for one, were treated surgically at the Mayo Clinic. The patients' ages ranged from eighteen to seventy years. Pain in the area of involvement was the first symptom in nearly all patients. Nearly one-half of the patients had detected a mass before being diagnosed. In addition, nine patients had neurological symptoms and signs when they were first seen. All patients had a surgical biopsy of the lesion, often combined with decompressive laminectomy. Five patients received postoperative radiation therapy in various dosages. No patient received adjunctive chemotherapy. All but five patients died of local progression of the disease. The five-year survival rate was 55 per cent. The median length of survival was six years. Although it is rare, chondrosarcoma of the spine can usually be identified on radiographs. Preoperative assessment must include computed tomography, magnetic resonance imaging, and, possibly, arteriography to assess the precise extent of the disease. Although surgical ablation often is technically difficult, a wide excision should be attempted. If this is not obtainable, postoperative radiation therapy should be considered.

Wedge resection of the symphysis pubis for the treatment of osteitis pubis.

Ten patients had a wedge resection of the symphysis pubis for the treatment of symptoms of osteitis pubis that had been recalcitrant to non-operative treatment for at least six months. Preoperatively, the average duration of symptoms was thirty-two months. The symptoms included a waddling gait and crepitus, pain, and tenderness over the symphysis pubis. The early radiographic signs of the disease were rarefaction of the adjacent pubic bones and widening of the symphysis pubis. Later signs included sclerosis and narrowing of the symphyseal joint space. Pathological examination of the resected joint revealed chronic inflammatory reaction in all patients. At an average of fourteen months postoperatively, all of the patients had marked improvement and were fully active. However, at an average of ninety-two months postoperatively, three of the ten patients were not satisfied with the result. One patient needed bilateral sacro-iliac arthrodesis for pain that was caused by instability.

Adamantinoma of the radius. A case report.

Adamantinoma is a rare, primary, malignant bone tumor; only one such case involving the radius has been reported. A second case is documented. This patient was treated by en bloc excision and reconstruction with microvascular fibula transfer. Although adamantinoma is not considered to be a high-grade lesion, aggressive treatment is warranted for lesions of the radius.