Malignant lymphoma of bone: a review of 119 patients.

BACKGROUND: Lymphoma of bone is uncommon. As a result of this, many aspects of primary lymphoma of bone (PLB) are controversial: the definition, treatment strategies, response criteria, and prognostic factors. QUESTIONS/PURPOSES: We sought to determine the following in an analysis from a single center over a four-decade period: (1) 5-year disease-free survival of patients with PLB as well as those with systemic lymphoma with bone involvement; and (2) whether prognostic factors (sex, site of tumor, age) were associated with 5-year survival. METHODS: A total of 119 patients with lymphoma involving the musculoskeletal system were retrospectively evaluated. Among these, 94 patients who had a minimum followup of 6 months (mean, 67 months; range, 6 months to 34 years) were further analyzed for the skeletal site of involvement, the orthopaedic intervention(s) needed, and survival. The overall median age was 45 years (range, 7-87 years). The female-to-male ratio was 1:1.53. There were 70 (65 unifocal, five multifocal) patients with PLB. The femur was the most frequent site involved. Appendicular skeleton involvement was substantially higher in patients with PLB. Thirty-four (36%) patients had at least one surgical intervention. Fourteen patients (41%) needed more than one major surgical intervention. RESULTS: The disease-free 5-year survival for patients with PLB was 81% and for the patients with systemic lymphoma with bone involvement, it was 44%. The disease-free 5-year survival of the patients with PLB younger than 60 years old and 60 years old or older was 90% and 62%, respectively. Age was the only prognostic factor on survival of patients with PLB. CONCLUSIONS: Orthopaedic intervention was usually needed for pathologic fractures, avascular necrosis, spinal cord compression, or for the lesions of the weightbearing bones compromising stability or joint motion. The potential for long-term survival suggests the use of implants and techniques that have the best chance of long-term success.

Intra-articular injection of hyaluronic acid is not superior to saline solution injection for ankle arthritis: a randomized, double-blind, placebo-controlled study.

BACKGROUND: Intra-articular injections of hyaluronic acid are potentially useful to treat ankle osteoarthritis, yet their effectiveness has not been proven. Both single and multiple-dose treatments for ankle arthritis with use of various hyaluronic acid products have been recommended, but few high-quality studies have been published. The aim of this study was to compare the effectiveness of a single intra-articular injection of hyaluronic acid with a single intra-articular injection of normal saline solution (placebo) for osteoarthritis of the ankle. METHODS: Sixty-four patients with ankle osteoarthritis who met all study criteria were randomly assigned to a single intra-articular injection of 2.5 mL of low-molecular-weight, non-cross-linked hyaluronic acid or a single intra-articular injection of 2.5 mL of normal saline solution. The primary outcome measure was the change from baseline in the American Orthopaedic Foot & Ankle Society (AOFAS) clinical rating score at the six-week and twelve-week follow-up examination. Secondary outcome measures included the Ankle Osteoarthritis Scale score and patient-reported pain with use of a visual analog pain scale. RESULTS: Of the sixty-four patients randomized and treated, eight patients withdrew, leaving fifty-six patients who completed the entire study. There was one mild adverse event (1.6%) among the sixty-four patients. At six weeks and twelve weeks, the mean AOFAS scores in the hyaluronic acid group had improved from baseline by 4.9 and 4.9 points, respectively, whereas the mean AOFAS scores in the placebo group initially worsened by 0.4 point at six weeks and then improved by 5.4 points at twelve weeks. While the change at twelve weeks from baseline was substantial for both groups, the between-group differences were not significant. CONCLUSIONS: We found that a single intra-articular injection of low-molecular-weight, non-cross-linked hyaluronic acid is not demonstrably superior to a single intra-articular injection of saline solution for the treatment of osteoarthritis of the ankle.

Advance in the treatment of aneurysmal bone cyst of the sacrum.

OBJECTIVE: The objective of this study was the review of 11 patients with two different treatment methods used historically for aneurysmal bone cyst in the sacrum. The outcome of both procedures is reported. In addition, the treatment technique of CT-guided percutaneous injections of demineralized bone matrix mixed with bone marrow concentrate is described. MATERIALS AND METHODS: From 1997 to 2008, 11 patients with sacral aneurysmal bone cyst were treated at the Rizzoli Institute, Bologna, Italy. The first seven patients had surgical curettage without bone grafting, chemical adjuvants, or arterial embolization. The last four patients had arterial embolization. The last patient did not respond to arterial embolization and was treated by CT-guided injection of demineralized bone matrix mixed with bone marrow concentrate. RESULTS: Curettage was successful in five out of seven patients. Two patients suffered complications, and two cases had recurrence. Arterial embolization was successful in three of four patients. The patient treated with injection had a good clinical and radiographic result. CONCLUSION: Both surgical and arterial embolization are effective for aneurysmal bone cyst in the sacrum. However, these treatments may lead to complications and recurrence. The use of CT-guided injections of demineralized bone matrix mixed with bone marrow concentrate may be a safe and effective alternative for treatment of these destructive and problematic lesions.

Outcomes of suture button repair of the distal tibiofibular syndesmosis.

BACKGROUND: Recently, a suture button device has been advocated as a simple and effective method of repairing the syndesmosis. Proponents of the device have cited earlier weightbearing and elimination of the need for device removal as potential advantages over metallic screws. However, the available reports generally have short followup. With longer followup, some concerns about the suture button device have surfaced. MATERIALS AND METHODS: We reviewed the clinical and radiographic results of 24 patients with acute injuries to the distal tibiofibular syndesmosis who were treated with suture button fixation. Average followup was 20 months. The primary outcomes measure was the AOFAS ankle hindfoot score. Secondary outcomes measures included a calibrated measurement of the tibiofibular clear space and tibiofibular overlap. RESULTS: The average AOFAS score was 94 points. Syndesmotic parameters returned to normal after surgery and remained normal throughout the followup period. One in four patients required removal of the suture endobutton device due to local irritation or lack of motion. Osteolysis of the bone and subsidence of the device into the bone was observed in four patients. Three patients developed heterotopic ossification within the syndesmotic ligament, one mild, one moderate, and one who had a nearly complete syndesmotic fusion. CONCLUSION: The suture button device is an effective way to repair the syndesmosis. In our series, the reduction of the syndesmosis was maintained throughout the followup period. However, reoperation for device removal was more common than anticipated. Osteolysis of the bone near the implant and subsidence of the device may occur.

Alloprosthetic composite is a suitable reconstruction after periacetabular tumor resection.

BACKGROUND: Resection of a tumor of the pelvis is most disabling when the acetabulum is excised and a durable reconstruction of the defect is hard to achieve. All available methods are associated with frequent complications. Few large series have been published, and fewer have focused entirely on complete resections of the acetabulum. The use of an allograft-prosthetic composite allows customization on the operating table. However, while such composites restore anatomy and function of the pelvis the use of pelvic allografts is controversial and the durability is unknown. QUESTIONS/PURPOSES: We therefore examined (1) the frequency of allograft and prosthetic failure, (2) positive and negative factors influencing the survival of the allograft prosthetic composite, and (3) function of patients with this reconstruction. PATIENTS AND METHODS: We retrospectively evaluated 35 patients who had resection of the entire acetabulum and reconstruction with an allograft-prosthetic composite. Function was scored by the Musculoskeletal Tumor Society system. Followup in 24 survivors averaged 120 months (range, 61-188 months). RESULTS: Greater than 75% of the allografts were still in place at last followup, and the original prosthetic reconstruction was still in place in 56%. Infection was an important negative factor for allograft survival. The average functional score was 72%, with better mean scores for patients who had reconstruction with a stemmed cup and an artificial ligament (average 89%). CONCLUSIONS: An allograft-prosthetic composite provides a versatile substitution of the pelvis and hip, with functional scores approximately 75% of normal.

Approach to the management of soft tissue tumors of the foot and ankle.

To properly treat soft tissue tumors, the foot and ankle surgeon must start with an adequate fund of knowledge and follow a systematic approach. Some malignant soft tumors have a predilection for the foot and ankle, and they may mimic common musculoskeletal conditions, leading to a trap for the unwary clinician. This review will familiarize the practitioner with the common soft tissue tumors that occur in the foot and ankle along with their presentations. A systematic approach to the workup is outlined, which is designed to establish the diagnosis with a significant degree of certainty before the surgical treatment of the tumor is planned. A practical and reliable method of distinguishing benign tumors from those that are potentially malignant is presented. Finally, the techniques for surgical management of the common soft tissue tumors are summarized.

Metastases to bones of the foot: a case series, review of the literature, and a systematic approach to diagnosis.

Metastatic lesions to the bones of the foot are rare but pose a challenge to the treating surgeon because of variation in presentation. Cases may present as a painful or swollen toe or as an infection resistant to antibiotics, or they may mimic inflammatory arthropathy. As such, diagnosis may be delayed. Also, with the advent of new therapies for certain cancers, patients living longer have time to develop metastases. The incidence of metastases to the foot is changing. The senior author (HD) has managed 3 consecutive cases of tumorous lesions metastasizing to the foot. Patients included 1 man and 2 women, with an average age of 76.7 years (range, 57-88 years). Open biopsy was performed in 2 cases, whereas true-cut needle biopsy was performed in 1 case. The average follow-up was 16.2 months (range, 8.5-29 years). The pattern and incidence of foot metastases may be changing. Early and accurate diagnosis may help improve patient survival. A working protocol is presented here that can help in diagnosing such lesions.

Adult onset flatfoot associated with an intramuscular hemangioma of the posterior tibialis muscle.

A 30-year-old man was referred for a painful mass in the left calf and planovalgus deformity of the left foot. The pain had been present for 15 years but recently had become severe. On examination there was a visible, exquisitely tender mass in the medial distal aspect of the lower leg. There was valgus deformity of the hindfoot, abduction of the forefoot, and complete loss of the longitudinal arch which was passively correctable to neutral. Magnetic resonance imaging showed a 3.035.5312.0-cm complex mass in the calf with a "bag of worms" appearance consistent with a vascular tumor. An incisional biopsy resulted in diagnosis of benign intermuscular hemangioma. A marginal resection of the mass was later performed. During operative resection, the tumor was found to involve the entire posterior tibialis muscle to the musculotendinous junction. The patient began full weight bearing 4 weeks postoperatively and was placed in an ankle-foot orthosis for correction of the planovalgus. At 19 months postoperative, he reported no pain and mild weakness of the left foot, and he had returned to full-time work. There was no recurrence of the tumor. Intermuscular hemangioma of the calf may cause acquired spasticity and equinus deformity of the foot. In addition, intramuscular hemangiomas have been reported to cause muscle weakness and tendon rupture. In this patient, the authors believe that the posterior tibialis muscle was weakened and elongated secondary to the replacement of the muscle tissue by the tumor, ultimately leading to the planovalgus deformity.

Progressive ORF virus infection in a patient with lymphoma: successful treatment using imiquimod.

Orf virus is a parapoxvirus that infects small ruminants worldwide. We present the case report of a 73-year-old woman with non-Hodgkins lymphoma who developed progressive orf virus lesions that were unresponsive to surgical debridement and to cidofovir therapy. The patient's orf virus infection was successfully treated with topical imiquimod despite progression of her malignancy.

The use of cement in osteoarticular allografts for proximal humeral bone tumors.

In a proximal humerus resection for a bone tumor, the use of an osteoarticular allograft is considered the best restoration of shoulder function. We retrospectively reviewed the outcomes of 31 patients who had an intraarticular resection of the proximal humerus for a bone tumor. Twenty-three of the allografts were filled with cement. The average followup was 5.3 years. Of the 31 patients with more than 24 months followup, seven had revision surgery or removal of the allograft. Kaplan-Meier analysis showed that the probability of survival of the reconstruction was 78% at 5 years. Fracture was the main complication in 11 patients (37%) of whom seven were in the noncemented group. Four of these patients had successful surgery for conversion to an allograft-prosthetic composite, whereas one patient had a new allograft. Allografts that were filled with cement had four fractures (18%); three were subchondral fractures discovered by routine CT scans. None of these patients had pain or needed revision surgery. Osteochondral allograft in proximal humerus replacement is a reliable reconstructive technique if the allograft is augmented by filling the intramedullary space with cement. Moreover, cement augmented allografts are less expensive and technically easier than allograft-prosthetic composites.