Pathological fractures of the proximal humerus treated with a proximal humeral locking plate and bone cement.

Bone loss secondary to primary or metastatic lesions of the proximal humerus remains a challenging surgical problem. Options include preservation of the joint with stabilisation using internal fixation or resection of the tumour with prosthetic replacement. Resection of the proximal humerus often includes the greater tuberosity and adjacent diaphysis, which may result in poor function secondary to loss of the rotator cuff and/or deltoid function. Preservation of the joint with internal fixation may reduce the time in hospital and peri-operative morbidity compared with joint replacement, and result in a better functional outcome. We included 32 patients with pathological fractures of the proximal humerus in this study. Functional and radiological assessments were performed. At a mean follow-up of 17.6 months (8 to 61) there was no radiological evidence of failure of fixation. The mean revised musculoskeletal Tumour Society functional score was 94.6% (86% to 99%). There was recurrent tumour requiring further surgery in four patients (12.5%). Of the 22 patients who were employed prior to presentation all returned to work without restrictions. The use of a locking plate combined with augmentation with cement extends the indications for salvage of the proximal humerus with good function in patients with pathological and impending pathological fractures.

Synchronous bifocal alveolar rhabdomyosarcoma: a case report.

We report a case of bifocal rhabdomyosarcoma involving the hand and thigh in an 11-year-old female. We highlight the importance of a thorough clinical examination and an aggressive surgical approach in which each lesion is treated as a separate primary.

Phosphate-32 colloid radiosynovectomy in hemophilia: outcome of 125 procedures.

Radiosynovectomy offers a potentially effective, minimally invasive option for patients with chronic hemarthrosis and synovitis. The long-term outcome of patients with hemophilia who were treated with phosphate-32 chromic phosphate radiosynovectomy was evaluated. One hundred twenty-five procedures in 81 patients were done. Two- to 10-year followup by age and joint included joint bleeding and quality-of-life assessment. In addition, a relative cost comparison, scintigraphic imaging, and evaluation of biodistribution of the radionuclide were done. Of 125 procedures, 54% resulted in complete cessation of bleeding into the treated joint after the procedure, and 73% of patients reported improved mobility of the treated joint. Of patients 18 years old and younger, 79% had a greater than 75% reduction in bleeding incidence, and of patients older than 40 years, only 56% had a similar reduction. Seventy-nine percent of patients surveyed had a significant improvement in quality of life attributable to the treated joint. No evidence of significant leakage was observed. Billing records analysis indicated that radiosynovectomy costs less than 5% of surgical synovectomy. Phosphate-32 chromic phosphate radiosynovectomy is a clinically useful, safe, and cost-effective outpatient procedure in the treatment of patients with chronic hemarthrosis and synovitis.

Limb salvage for chronic tibial osteomyelitis: an outcomes study.

BACKGROUND: The decision to undergo a limb salvage procedure is difficult and multifaceted. This study reviews the outcomes of patients with chronic tibial osteomyelitis who underwent limb salvage and hopes to enhance our understanding of the impact this complex procedure has on the patient's ability to have a functional and fulfilling life. METHODS: Forty-six patients, with at least 18 months follow-up, who had undergone limb salvage for chronic, refractory tibial osteomyelitis were evaluated. A modification of the Limb Extremity Outcomes Instrument was utilized emphasizing inquiries pertaining to quality of life. RESULTS: Thirty-nine (85%) of the 46 patients were able to ambulate independently without pain. All patients younger than 45 years of age had successful outcomes. Thirty-one percent of the patients with a positive smoking history were failures, and 71% of all failures were smokers. CONCLUSION: Limb salvage seems to be a satisfactory option for patients with chronic tibial osteomyelitis. A history of smoking and advanced age may have adverse affects and are relative contraindications.

Radiosynovectomy's clinical applications and cost effectiveness: a review.

It is apparent that from the work of the authors and many others, including the work of Rivard, Sledge, Zuckerman, among others, that radiosynovectomy has an important role to play in providing effective treatment of affected joints associated with rheumatoid arthritis and other forms of arthritis as well as the hemophiliac joint. The treatment offers relief from the effects of recurrent joint effusion with an approximately 60% to 66% favorable response and from recurrent hemarthrosis in the hemophiliac joint with an approximately 75% to 80% favorable response. The impact of providing radiosynovectomy as an alternative to surgical synovectomy is seen, where postoperative side effects such as joint stiffness are avoided, improved quality of life is repeatedly documented, and the cost savings in health care dollars, particularly evident in the hemophiliac joint in this relatively small population, are potentially enormous. With almost two million people in the United States suffering from rheumatoid arthritis, the potential savings in health care dollars is also enormous. As with any use of in vivo radiopharmaceuticals, the potential for radiation-induced damage exists. However, with a 25 plus year record of use, more optimally configured radiopharmaceuticals, and the addition of maneuvers to minimize potential joint leakage, the risk of radiation induced damage appears to be minimal. It appears as though radiosynovectomy is an effective as well as cost-effective alternative to surgical synovectomy and is becoming the procedure of choice particularly in the hemophiliac patient with recurrent hemarthrosis and synovitis who has failed medical therapy. It is also the procedure of choice in patients for whom surgery is contraindicated because of the presence of clotting factor inhibitors.

The impact on treatment planning of MRI of the spine in patients suspected of vertebral metastasis: an efficacy study.

The objective of this study was to determine the efficacy of spinal MRI in suspected spinal metastasis. The effect of spinal MRI on treatment planning choices (radiation, chemotherapy, steroids, or surgery) in 130 patients with suspected spinal metastatic involvement was evaluated. In a retrospective group of 100 patients, 47 (47%) had therapy changes associated with MR findings. Forty out of 78 (51%) of patients presenting with symptoms (back pain, weakness, paresthesia, or sphincter dysfunction) had MR associated therapy choices. Seven out of 22 (32%) of patients without spinal symptoms had therapy changes. Twelve out of 30 (40%) of patients evaluated prospectively had therapy choices directed by MR findings. Overall, 59 out of 130 (45%) of patients had therapy choices associated with findings in spinal MRI. MRI results influenced the addition or modification of radiation therapy treatment in 33% of the patients suspected of metastatic disease to the spine.

Hemarthrosis and synovitis associated with hemophilia: clinical use of P-32 chromic phosphate synoviorthesis for treatment.

PURPOSE: To evaluate the clinical usefulness of phosphorus-32 chromic phosphate synoviorthesis in patients with hemophilia, recurrent hemarthrosis, and synovitis. MATERIALS AND METHODS: Forty-four P-32 colloid synoviorthesis procedures were performed in 38 patients with these abnormalities. P-32 colloid was injected intramuscularly in a dose of 1.0 mCi (37.0 MBq) in adult knees and 0.5 mCi (18.5 MBq) in adult elbows. A thin-window Geiger-Müller counter was used to survey treated joints, lymph nodes, and liver in order to detect leakage from the joint. Follow-up extended to a maximum of 4 years after treatment. RESULTS: No evidence of clinically significant leakage was seen. Twenty-two of 28 treatments (78%) with longer than 6 months follow-up were associated with improvement in range of motion and frequency of hemorrhage. Of 15 treatments with longer than 2 years follow-up, 10 (67%) were associated with improvement in range of motion; 12 (80%), with improvement in frequency of hemorrhage; and 12 (80%) with improvement in quality-of-life activities. CONCLUSION: P-32 colloid synoviorthesis is a clinically useful out-patient procedure in patients with hemophilia, recurrent hemarthrosis, and synovitis in whom hemostatic therapy has failed.