The supracondylar femoral nail in tibia.

We have found the intramedullary supracondylar femoral nail to be useful in special situations involving the tibia: proximal tibial fractures and nonunions, intercalary resections for tumors in the proximal or distal tibial diaphysis, and tibio-talo-calcaneal arthrodeses. We report on ten such cases.

Locked intramedullary nailing for difficult nonunions of the humeral diaphysis.

Antegrade intramedullary nailing and bone grafting was carried out for 27 patients with resistant atrophic nonunion of the humeral diaphysis. The initial fracture was open in 12 cases and closed in 15. There were ten proximal humeral fractures, 13 mid-shaft fractures and four distal humeral shaft fractures. Most had previous attempts at internal fixation with bone grafting. Fifteen cases united, but 12 remained ununited necessitating further surgical treatment. The failures were all in the more complex cases. Lack of rigidity and compression may be the problem.

Modular megaprosthesis for proximal femoral tumors.

Fifteen patients with proximal femoral tumors had resection and limb salvage with an uncemented Kotz (HMRS) megaprosthesis. There were five osteosarcomas, four chondrosarcomas, one hemangioendothelioma, three fibrosarcomas, and two Ewing's sarcomas. The mean follow-up was 6.7 (range 3-10) years. Two patients died of causes not related to the prosthesis. The postoperative Musculoskeletal Tumor Society score (MSTS) score was 19 (range 12-26) for the remaining 13 patients. There were one aseptic loosening, two infections, and one local recurrence. The most frequent complication was hip dislocation at 20%. Reconstruction of proximal femoral tumors with a modular megaprosthesis is a good procedure, but hip instability remains a major problem.

Modular megaprosthesis for distal femoral tumors.

We treated 48 patients with distal femoral tumors by resection and limb salvage with an uncemented megaprosthesis (Howmedica Modular Replacement System). Diagnoses included: 32 osteosarcomas, five chondrosarcomas, six giant cell tumors of the bone, three fibrosarcomas, and two Ewing's sarcomas. The mean follow-up was 5.6 years (2-10 years). The overall complication rate was 39%. Seven patients died of their disease, but none from complications related to the surgery. Five patients were revised to arthrodesis, and one required amputation because of complications. The mean postoperative Musculoskeletal Tumor Society score (MSTS) score was 21 (6-28) for the remaining 35 patients. The most frequent complications were infection (14.6%) and aseptic loosening (4.8%). Ten-year survival of the prosthesis was 65%.

Treatment of nonunion around the olecranon fossa of the humerus by intramedullary locked nailing.

Nonunion of fractures of the olecranon fossa of the humerus presents a difficult surgical problem. The distal fragment is usually small and osteoporotic and stable fixation is not easy to achieve. We describe a modification of the technique of locked nailing by which the distal aspect of the nail is placed in the subchondral region of the trochlea. Good results were obtained in seven out of eight patients with this technique.

Reimplantation of autoclaved tumour bone in limb salvage surgery.

This is a prospective clinical study of 7 patients with malignant bone tumours who were treated by resection of the tumour, followed with reconstruction by reimplantation of the resected autoclaved tumour bone. There were 3 male and 4 female patients between 10 and 36 years of age. All the tumours were Stage IIB. Five of the 7 were in the region of the knee joint. Histologically, 5 were osteosarcomas, 1 a recurrent chondrosarcoma and 1 a recurrent Ewing's sarcoma. All the patients were treated by en bloc resection of the tumour with wide margins. The resected length ranged from 13 cm to 28 cm. After removal of soft tissue and cartilage, the resected bone segment was autoclaved for 5 min at 132 degrees C and 29 pounds per square inch pressure (0.2 mega Pascal). This autoclaved segment of bone was then reimplanted and fixed with an appropriate implant. The average follow-up was 20 months with a range of 14 to 27 months. None of the tumours recurred and, at the most recent follow-up, all the patients were alive, 6 with no evidence of disease and one with a lung metastasis. Six of the 7 patients were available for radiological assessment. Solid bone union was seen in 4 patients, delayed union in 1 and nonunion in 1. This method of reconstruction using an autoclaved tumour bone graft is useful in countries where facilities for allograft or tumour prostheses are not available owing to financial, technical or sociocultural reasons.

Giant cell tumours of the hand.

A study of seven cases of giant cell tumours of the hand is reported. All tumours were treated by an en bloc excision of the tumour or by whole ray resection. En bloc resection of the tumour and reconstruction with a fibular graft where necessary should be considered as the treatment of choice in giant cell tumour of the hand.

Giant cell tumour of metacarpal with pulmonary and skeletal metastases.

A case of giant cell tumour of the left fifth metacarpal with pulmonary and skeletal metastases is reported with follow-up of 14 years. The pulmonary metastases were treated by chemotherapy, but the size of the metastatic nodules continued to increase, and no further treatment was given. The pulmonary metastatic nodules started to regress 8 years after the diagnosis without any treatment, and had disappeared after 14 years. The skeletal metastases were unchanged at the latest follow-up. Both pulmonary and skeletal metastases have been asymptomatic for the 14 years after they were diagnosed. It is suggested that pulmonary metastases of benign giant cell tumour has a good long-term prognosis and these patients should be kept under observation only, avoiding extensive lobectomy, chemotherapy or radiotherapy.

Massive subacromial bursitis with rice bodies. Report of three cases, one of which was bilateral.

Multiple cartilaginous-like bodies (rice bodies) in joints or bursae may be the presenting sign of a more extensive underlying rheumatic condition. Three patients with massive subacromial bursae with rice bodies are described, one of whom had bilateral occurrence. In all patients, excision of the bursa and rice bodies relieved the symptoms. The underlying rheumatic condition continued its course, generally sparing the involved shoulder joint. Review of these cases reinforces the need to provide a thorough examination for systemic rheumatologic disease in patients diagnosed with this lesion.

Pitfalls in the diagnosis of the simple wrist ganglion.

ABSTRACT; A wrist mass, often found to be a ganglion, is a common clinical problem. Any mass is difficult to diagnose by physical examination alone. Reported entities appearing to be wrist ganglions areanomalous extensor muscle bellies, lipomas, neuromas of the posterior interosseous nerve, synovial cysts of rheumatoid arthritis, aneurysm of the radial artery, and others. In addition, the authors are aware of entities not previously reported. This retrospective review of four malignancies and a plexiform neuroma that appeared to be simple wrist masses serves to increase the clinician's awareness of the pitfalls to be avoided in the diagnosis of the wrist mass.