Proximal femoral multiple myeloma pathological fractures, impending and actual fractures - a patient survival study.

INTRODUCTION: The femur is a common site for Multiple Myeloma (MM) involvement. This study explores the impact of preventive surgery for anticipated femoral pathological fractures (IFF), based on Mirels classification, versus treatment of pathological femur fracture (PFF) on MM patient mortality and morbidity. METHODS: Retrospective cohort of 33 patients undergoing surgery due to femoral MM involvement (2004-2015), 18 patients with PFF, 15 patients with IFF, followed up until deceased or to July 2016. Demographic data, oncological, pathological, radiation, surgical reports, outpatient clinical records, and imaging studies were studied. Exclusion criteria included patients who had surgery at other medical centers. RESULTS: The mean age was 70.4 ± 13.6 and 62.6 ± 12.2 years (p = 0.1) in the PFF and the IFF cohorts, respectively, primarily women (55.6% and 46.7%, respectively). The average Mirels' score was 10.4 ± 1.2. Post-operative complications were observed in 25% of patients, with no difference between IFF & PFF. We did not find a difference in mortality between IFF and PFF cohorts (p = 0.59). CONCLUSION: The femur is commonly involved in MM. This study found that actual fractures, compared to imminent fractures, do not affect MM morbidity or mortality. Our study shows that proximal femoral MM behaves differently from proximal femoral metastatic disease regarding the impact of surgery on life span. Due to the fracture healing potential of MM, an IFF can probably be treated initially conservatively unless it progresses to an actual fracture needing surgery. Future, more extensive studies are required before revolutionizing the proximal femoral Multiple Myeloma-related involvement treatment paradigm.

Femoral metastatic pathological fractures, impending and actual fractures - A patient survival study.

INTRODUCTION: The skeleton is a common site for metastases. Prostate, breast, lung, renal and thyroid carcinomas account for 80 % of the original cancers, with the femur being the most affected long bone. With improved oncological treatments, prolonged patient survival leads to an increased prevalence of osseous metastases. This study examines the impact of preventive surgery for impending femoral pathological fracture (IFF), versus treatment of pathological femur fracture (PFF) on patient mortality and morbidity. METHODS: Retrospective cohort of 174 patients undergoing surgery due to femoral metastases (2004-2015). Eighty-two patients were with PFF, and 92 were with IFF based on the Mirels' score. The followed-up period was until 2016. Demographic data, oncological, pathological, radiation, surgical reports, outpatient clinical records, and imaging studies were examined. Exclusion criteria included primary tumours and Multiple Myeloma. RESULTS: The mean age was 64.8 ± 13.3 and 60.2 ± 11.9 years (p = 0.02) in the PFF and the IFF cohorts, with 62.1 % women and 57 % men. The breast was the most common source of femoral metastases. The average Mirels' score was 10 ± 1.2. There was an association between tumour origin and survival. Carcinoma of the lung had the worst survival, while the prostate had the most prolonged survival. Survival rates differed between IFF and PFF (p = 0.03). Postoperative complications occurred in 26 % of the patient, with no difference between IFF & PFF. CONCLUSION: Breast and lung are the most common tumours to metastasize the femur. Our study revalidates that pathological femoral fractures impede patient survival compared to impending fractures and should undergo preventive surgery. Postoperative complications do not differ between IFF and PFF but remain relatively high. Overall, patients with proximal femoral metastatic disease survive longer than previously published, probably due to improved treatment modalities.

Magnetic resonance arthrography of the hip: prevalence of diagnoses not suspected by the referring physician and correlation with clinical examination and pain score.

BACKGROUND: Magnetic resonance arthrography (MRA) of the hip is the most sensitive imaging modality for intra-articular pathologies such as labral tears. PURPOSE: To evaluate the prevalence of non-suspected pathologies revealed by hip MRA and correlate them to physical examination/pain level. MATERIAL AND METHODS: All hip MRAs (2011-2013) were retrospectively evaluated for intra- and extra-articular pathologies in consensus by two readers. A clinical score (0-7)/pain score (0-10) was calculated for each patient based on orthopedic test results extracted from referral forms/a telephone questionnaire. Patients were divided into four groups according to MRA findings: intra-articular expected (targeted) pathology only; intra-articular targeted and additional non-targeted (unexpected) pathology; non-targeted pathology; and no pathology. Pathologies prevalence/clinical score/pain score were compared between the groups. RESULTS: A total of 229 MRAs were included (127 men, 102 women; mean age, 36.5 ± 14.17 years): 111(48.4%) patients had solely intra-articular targeted pathology. Significant non-targeted pathologies were detected in 76 (33%) patients (targeted and non-targeted, 51; non-targeted only 25). No significant pathology was detected in 42 patients (18%). Mean physical examination score was 2.77 ± 1.77, range 0-7. There was no significant difference or correlation (r = 0.017, P = 0.804) between the clinical scores of the different MRA pathology groups. Pain score (143 patients) was significantly higher in the non-targeted pathology group compared to the targeted and non-targeted group (P = 0.04) and to the no pathology group (P = 0.04). There was no correlation between the physical examination score and the pain score (r = 0.017, P = 0.804). CONCLUSION: Unsuspected non-targeted pathologies were detected in 33% of hip MRA. Physical examination/pain level could not differentiate between patients.

Peripartum changes of the sacroiliac joints on MRI: increasing mechanical load correlating with signs of edema and inflammation kindling spondyloarthropathy in the genetically prone.

The purpose of this study is to characterize the MRI changes of the sacroiliac joints (SIJs) during pregnancy and following labor and to correlate them with clinical symptoms. Ninety-three pelvic and hip MRIs of pregnant and ≤6 months postpartum women were retrospectively evaluated (Berlin method), for the presence of acute and structural SIJ changes. A telephone questionnaire focusing on pain characterization, co-morbidities, and clinical outcome was conducted with 52 subjects. Findings were correlated with pregnancy week/postpartum time and clinical parameters. SIJ-bone marrow edema (BME) and subchondral sclerosis were a prevalent peripartum finding (46/26 % subjects, respectively), and their frequency increased with pregnancy age. Also, BME, joint fluid, capsulitis, and enthesitis total score were correlated with pregnancy age/postpartum time (r = 0.2-0.31, P = 0.013-0.036). Significant correlation was noted between BME and subchondral sclerosis scores (r = 0.485, P < 0.0001). A sizable proportion of women showed diffuse SIJ BME (7.6 %) and this correlated with slower resolution of symptoms. Indeed, in half of the cases in which MRI was performed due to pregnancy-induced low-back pain (LBP) and diffuse BME was found-spondyloarthropathy ensued. In conclusion, pregnancy and puerperium are associated with a host of acute findings in and around the SIJ, including BME, capsulitis, and enthesitis, reflecting most probably, mechanical load and hormonal changes. While the vast majority of symptoms abate within weeks to several months postpartum, 3.8 % of women go on to develop spondyloarthropathy. Diffuse SIJ BME and the presence of risk factors for spondyloarthropathy are predictive of a chronic course.

Biomechanical properties of bone treated by magnetic resonance-guided focused ultrasound - an in vivo porcine model study.

The magnetic resonance-guided focused ultrasound (MRgFUS) system uses MR imaging for real-time aiming of thermal ablation of bone and soft tissue tumors. Past clinical studies showed no increase in fracture rate after MRgFUS treatment. The purpose of this study was to determine the effect of MRgFUS treatment on mechanical properties of bone and correlate the effect to histological findings of treated bone. Four fully grown mini-pigs were treated by MRgFUS. Six consecutive right normal ribs were treated in each animal, and the left corresponding ribs served as controls. The animals were sacrificed at pre-set intervals (0, 2, 6 and 12weeks after treatment), and the treated and control bones were extracted. Mechanical properties of each bone were examined using three points bending studies for comparing treated bones to the corresponding controls. Histologic properties using Masson and hematoxylin-eosin stains were also compared. The ratio between treated and control biomechanical properties showed reduction in bone biomechanical properties at 6weeks post-MRgFUS treatment. The mean±SD yield load ratio and maximum ratios were 0.69±0.11 and 0.71±0.13, respectively (both p=0.031). These findings showed some recovery trend at 12weeks after treatment. Histological analysis showed a reduction in mean osteon size at 2weeks after treatment (0.58×10(-3)±0.1×10(-3)mm and 0.16×10(-3)±0.017×10(-3)mm) in control vs. treated bones, respectively (p=0.005). Treatment with the MRgFUS system resulted in a ~30% reduction in mechanical strength at 6weeks post-treatment. The reduction showed a reversible trend, with a 25%-20% decrease in strength at 12weeks post-treatment.

Concomitant findings and clinical significance of a fluid crescent between the iliacus muscle and iliac bone on MRI.

BACKGROUND: Some routine magnetic resonance imaging (MRI) examinations show a thin line of fluid signal intensity along the iliac crest ("fluid crescent") between the iliacus muscle and the iliac bone. This fluid crescent has not been described before. PURPOSE: To evaluate the clinical context and significance of the fluid crescent. MATERIAL AND METHODS: MRI examinations of the abdomen and pelvis performed over 1 year were retrospectively reviewed twice for the presence of a fluid crescent. The relationship between the presence of a fluid crescent and associated abnormal findings, including ascites, iliopsoas compartment, and bone and soft tissue pathologies, was evaluated. RESULTS: Forty-one out of 254 MRI studies (male:female ratio, 136:118; mean age, 42 years) demonstrated a fluid crescent (16%). Thirty-eight of them had associated MRI pathologies: edema of the hip muscles = 24, ascites = 11, iliac bone = 21, and iliopsoas compartment = 7. Correlations between the presence of a fluid crescent and pathological findings were highly significant (P < 0.0001), except for the presence of fluid in the hip joint. CONCLUSION: A fluid crescent is an abnormal MRI finding strongly associated with iliopsoas compartment pathology, ascites, hip muscle edema, and pelvic bone abnormalities. The nature of this fluid crescent is yet to be determined.

Delay in diagnosis of femoral hematogenous osteomyelitis in adults: an elusive disease with poor outcome.

BACKGROUND: Hematogenous osteomyelitis of long bone is rare in adults, especially in the immune competent host. Only a few cases have been described to date. OBJECTIVES: To present a case series of femoral hematogenous osteomyelitis in adults, a rare condition that is difficult to diagnose and may cause major morbidity and mortality. METHODS: We reviewed three cases of femoral hematogenous osteomyelitis that occurred between 2007 and 2009. The course of the disease, physical findings, imaging modalities, laboratory analysis, culture results and functional outcomes were recorded. RESULTS: In all cases the diagnosis was delayed after symptoms were first attributed to radicular-like pain or lateral thigh pain due to an inflammatory non-infectious source. In all cases infection was caused by an unusual or fastidious bacterium. The pathogen was Haemophilus aphrophilus in one case, and Streptococcus specimens were found in the other two. Pathological fracture occurred in two of the cases despite culture-specific antibiotic treatment and a non-weight bearing treatment protocol. It took five surgical interventions on average to reach full recovery from infection, but residual disability was still noted at the last follow-up. CONCLUSIONS: Clinicians should be aware that although femoral hematogenous osteomyelitis is a rare condition in adults, its ability to mimic other pathologies can result in delayed diagnosis and major morbidity. In our series the pathogen was different in each case and was cultured only from the infected site. Pathological fracture is a devastating complication but we do not recommend prophylactic stabilization at this point.

The value of hip aspiration in pediatric transient synovitis.

INTRODUCTION: Hip transient synovitis (TS) is a common pediatric orthopaedic problem. Although a self-limiting illness, it often makes the patient temporarily disabled and poses a diagnostic difficulty because of its similarity to septic arthritis in clinical manifestations. The aim of this study was to evaluate the use of a single ultrasound-guided hip aspiration as a treatment modality for TS. METHODS: Between the years 1984 and 1989, 112 children with TS were treated through bed rest and using nonsteroidal anti-inflammatory drugs (group 1). Between the years 1990 and 1999, 119 children diagnosed with TS were treated using hip aspiration, bed rest, and nonsteroidal anti-inflammatory drugs (group 2). Recovery parameters were compared between these patient groups. RESULTS: Twenty-four hours after admission, limping was noted in 92% and 10% of the patients in groups 1 and 2, respectively, (P < 0.001). Refusal to bear weight was observed in 14% and 1% in groups 1 and 2, respectively, (P < 0.001), and hip joint pain was reported in 81% and 6% in groups 1 and 2, respectively, (P < 0.001). Larger joint effusions were found to be the reason behind the inability to bear weight. CONCLUSIONS: Pain due to TS may be because of capsule stretching owing to the accumulation of joint effusion. Ultrasound-guided hip aspiration relieves pain and limitation in movement and provides rapid differential diagnosis from septic arthritis of the hip joint.

Selective computed tomography-guided perisciatic injection as a diagnostic tool in multiple hereditary exostoses.

Multiple osteochondromas, also known as multiple hereditary exostoses, is an autosomal-dominant disease. Multiple osteochondromas are characterized by the development of cartilage-capped bony tumors, known as osteochondromas. Osteochondromas can cause limb deformities, limb-length discrepancies, angular deformations, bursitis, and impingement of adjacent tendons or neurovascular structures. They have also been reported as a cause of sciatic pain. Sometimes, more than 1 location of neural compression exists, thereby presenting a difficult diagnostic challenge for treating physicians. This article describes a patient with multiple hereditary exostoses and accompanying severe sciatic pain who was referred for a revision decompressive spine surgery. The patient's functional impairment was such that he was unable to sit for a few minutes. A selective computed tomography-guided perisciatic nerve injection was performed to differentiate between lateral spinal stenosis and peripheral nerve compression or impingement by an existing large pelvic osteochondroma. The patient reported substantial relief and regained the ability to sit pain free immediately postoperatively. Excision of a proximal femur osteochondroma was performed based on the results of a selective perisciatic nerve injection, resulting in successful resolution of his sciatic pain and functional impairment. The current case is an example of the diagnostic challenge in treating patients with multiple anatomic lesions that can cause symptoms and demonstrate how selective computed tomography-guided perisciatic nerve injection can aid clinicians in obtaining an accurate diagnosis and choosing the most appropriate surgical management.

Uncemented arthroplasty for metastatic disease of the hip: preliminary clinical experience.

Improved longevity among patients with metastatic bone disease led to increasing incidence of pathologic and impending fractures around the hip. Cemented hip arthroplasty is considered to be the standard of care for this condition. The purpose of this study is to evaluate the outcome of uncemented hip arthroplasty in those patients. We performed a retrospective review of clinical and radiologic data of 57 consecutive patients (60 hips) who underwent an uncemented hip arthroplasty due to metastatic hip disease. Mean follow-up was 18.6 months (range, 5-60 months); overall 1-year survival and mortality rates were 58.5% and 38.3%, respectively. Multiple myeloma and metastatic prostate carcinoma patients had better outcome over other metastasis origin. At last follow-up, no prosthesis failure or operation-related major complication has been recorded.

Quantification of human serum procollagen C-proteinase enhancer (hsPCPE) glycopattern.

BACKGROUND: Procollagen C-proteinase enhancer 1 (PCPE1), a glycoprotein secreted from differentiating osteoblast, enhances the rate-limiting step of collagen type I fibrillar formation. It is expressed and secreted by cells that produce collagen type I and has the potential to be a marker for bone pathologies. METHODS: We developed an assay to quantify PCPE glycopattern based on isoelectric focusing (IEF) and detection with a bio-imaging camera (coefficient of variation within and between assays, 15% and 20%, respectively). RESULTS: PCPE was quantified in 39 serum samples from healthy subjects (17 females and 22 males). The concentration in the serum was 305(274) ng/ml, median(IQR). The level of the PCPE isoforms and their relative distribution were altered in patients with bone disorders. CONCLUSIONS: The data generated by our system, support our hypothesis that combined data on PCPE concentration and isoforms may be useful for the diagnosis and follow-up of bone diseases. Further research, on larger cohorts of both normal subjects and patients, must be done.

Osteoid osteoma--the CT vessel sign.

OBJECTIVE: To evaluate whether the presence of a feeding vessel in proximity to osteoid osteomas of long bones on multidetector CT (MDCT) can be an adjuvant clue for the diagnosis of osteoid osteoma. MATERIALS AND METHODS: Forty-nine CT scans of patients with radiological and clinical diagnosis of osteoid osteoma of long bones and a control group of 20 CT scans of patients with cortical-based lesions other then osteoid osteoma were analyzed. Two radiologists evaluated the CT images in consensus for the presence of a blood vessel in the same axial slices in which the nidus of osteoid osteoma was seen and to determine the incidence. RESULTS: In 39 cases (79.6%) of osteoid osteoma, a blood vessel either entered the nidus (23 patients) or was seen in proximity to it (16 patients). This was significantly different (P < 0.05) from the cortical-based lesions, in which only two CT scans (10%) showed a blood vessel in the lesion's proximity. CONCLUSION: In the majority of osteoid osteoma lesions in long bones, a blood vessel can be seen on MDCT either entering the nidus itself or in its proximity. The role of this vessel in the lesion pathogenesis and whether it improves diagnostic accuracy need further evaluation.

Total hip arthroplasty in patients with Down's syndrome.

Patients with Down's syndrome (DS) have an increased incidence of coxarthrosis which may become symptomatic with prolonged life expectancy. We present seven consecutive patients (nine hips) with DS who had primary total hip arthroplasty (THA). Average clinical and radiological follow-up was 9.9 ± 6.4 years (range 2-22.25). Harris hip scores (HHS) improved significantly (p < 0.01) from 41.1 (range 18.5-65) to 80.2 (range 67.5-91) at latest follow-up. Two patients required revision arthroplasty for stem loosening at 16 (osteolysis) and six years (trauma) following THA, respectively. Six of the THAs required a constrained liner. No dislocations or deep infections were encountered. We contend that THA is a reliable surgical intervention in patients with DS and may be performed in symptomatic patients.

[Percutaneous CT guided radio-frequency ablation of osteoid osteoma and osteoblastoma].

BACKGROUND: Osteoid osteoma (OO) is a benign osteoblastic bone lesion that causes severe local pain mainly at night, and usually responds to oral administration of NSAID. The lesion is located around the proximal thigh in more than 50% of the cases. Osteoblastoma is similar to OO in their histopathology features, but emerges frequently in the spine, and has a larger diameter than OO. Percutaneous CT-guided radiofrequency ablation (RFA) is becoming the treatment of choice for osteoid osteoma and non-aggressive osteoblastoma in the last decade. METHODS: During the period 2005-2009, 38 patients were diagnosed with osteoid osteoma (n = 34), and osteoblastoma (n = 4). A total of 34 patients were treated with RFA using a water-cooled, variable ablation size tip. Two patients underwent an open procedure, and 2 had spontaneous remission. RESULTS: Thirty three patients (97%) reported complete remission of their pain after a single treatment; one patient needed a second RFA treatment, and reported full remission of his symptoms after the 2nd treatment. CONCLUSIONS: Percutaneous CT-guided radiofrequency ablation of osteoid osteoma and non-aggressive osteoblastoma is simple, safe, and reliable. Meticulous placement of the probe inside the tumor, and the usage of water-cooled, variable ablation size tip, improves the overall outcome and decrease complication rates.

Pain palliation in patients with bone metastases using MR-guided focused ultrasound surgery: a multicenter study.

BACKGROUND: Noninvasive thermal ablation using magnetic resonance (MR)-guided focused ultrasound (MRgFUS) has been shown to be clinically effective in uterine fibroids, and is being evaluated for ablation of breast, liver, and brain lesions. Recently MRgFUS has been evaluated for palliation of pain caused by bone metastases. We present the clinical results of a multicenter study using MRgFUS for palliation of bone metastases pain. METHODS: A multicenter study to evaluate the safety and efficacy of MRgFUS palliative treatment of bone metastases was conducted in patients suffering from painful metastatic bone lesions for which other treatments were either ineffective or not feasible. Thirty-one patients with painful bone metastases underwent the MRgFUS procedure in three medical centers. Treatment safety was evaluated by assessing the device-related complications. Effectiveness of pain palliation was evaluated using the visual analog pain score (VAS), and measurable changes in the intake of opioid analgesics. RESULTS: Thirty-six procedures were performed on 31 patients. Mean follow-up time was 4 months. 25 patients underwent the planned treatment and were available for 3 months post-treatment follow-up. 72% of the patients (18/25) reported significant pain improvement. Average VAS score was reduced from 5.9 prior to treatment to 1.8 at 3 months post treatment. 67% of patients with recorded medication data reported a reduction in their opioid usage. No device-related severe adverse events were recorded. CONCLUSION: The results suggest that MRgFUS has the ability to provide an accurate, effective, and safe noninvasive palliative treatment for patients with bone metastases.

Lymph node metastasis in soft tissue sarcoma in an extremity.

For patients with soft tissue sarcoma in an extremity, the outcome is thought to be poor if lymph node metastasis develops. The purpose of this study was to examine the impact of lymphatic involvement from soft tissue sarcoma on patient survival. Thirty-nine (3.7%) of 1066 patients who had surgery for soft tissue sarcoma in an extremity had lymph node metastases develop. Three (20%) of 15 patients with epithelioid sarcoma, four (19%) of 21 patients with rhabdomyosarcoma, two (11.1%) of 18 patients with clear cell sarcoma, and two (11.1%) of 18 patients with angiosarcoma had lymphatic involvement. Thirty patients who had resection of involved lymph nodes had an estimated 5-year survival of 57%, whereas nine patients treated without surgery all died within 30 months. An estimated 4-year survival of 71% for patients with isolated lymph node metastases was significantly better than 21% for patients with synchronous systemic and lymph node involvement. There was no difference in outcome for patients with isolated lymphatic involvement compared with patients with American Joint Committee on Cancer Stage III extremity sarcomas. These results suggest that long-term survival is possible after surgical resection of lymphatic metastases from soft tissue sarcoma. The American Joint Committee on Cancer should consider separating isolated nodal metastases from systemic involvement in patients with Stage IV sarcoma.

Treatment of septic arthritis of the hip joint by repeated ultrasound-guided aspirations.

Arthrotomy of the hip joint followed by a variable period of drainage or continuous irrigation and drainage is considered the accepted treatment of septic arthritis of the hip joint (SAHJ). The authors reviewed the results of a cohort of children with SAHJ with repeated aspirations of the hip joint. Thirty-four children diagnosed with SAHJ were treated with repeated aspirations of the hip joint. The aspirations were performed under ultrasound guidance and topical anesthesia or under sedation. After the aspiration the joint was irrigated using the same needle, and the procedure was repeated daily. Six of the patients were operated on and then treated with aspirations because of drain dislodgement or clogging. Twenty-eight of the patients were treated primarily with repeated aspirations. Four of those patients did not improve and underwent arthrotomies, and 24 were treated only by repeated aspirations and healed completely. The mean number of aspirations was 3.6 (range 3-5), and 75% of the patients resumed walking after 24 hours. The mean follow-up time was 7.4 years (range 3-18). No complications were seen. Repeated aspiration is a safe and efficacious method of treatment for SAHJ. This method of treatment is not associated with surgery and its complications and prevents scarring of the skin and the need for general anesthesia. Faster return to normal activity was noted in this series.

Management of periprosthetic femoral fractures after total knee arthroplasty using a distal femoral allograft.

This study is a review and discussion of 12 consecutive patients who were revised with a distal femoral allograft for periprosthetic supracondylar fractures of the femur associated with poor bone quality by the same surgeon between 1990 and 2001. Two were lost to follow-up. The average age was 65 years, and the mean follow up was 6 years. Charts were reviewed to identify complications and graft survivorship. Functional assessment consisted of the modified Hospital for Special Surgery (HSS) knee score and the MOS 36-ITEM Short Form Health Survey. Radiographs were evaluated by 3 independent observers to determine graft union, resorption, and component loosening. The average postoperative HSS score and SF-36 were 75 and 88, respectively. Mean flexion was 100 degrees. Nine patients achieved union and were able to fully bear weight. Three patients required more surgery as a result of postoperative complications. Radiographs showed no migration, no loosening, and good interface union in 9 of the 10 patients available for follow-up. We concluded that this is a viable salvage procedure for this type of injury.