Diagnostic delay in soft tissue tumors: a single-center study of a university cancer center with a focus on health services research.

BACKGROUND: Lumps and soft tissue tumors (STT) are frequent reasons for consulting a physician. Most STT are benign, and lumps are not always associated with a tumor. MRI is the most advanced imaging modality to assist a provisional diagnosis of STT. Only a small fraction of STT is malignant, these soft tissue sarcomas are known for their aggressive growth. The study aims to analyze the influence of the MRI report on the speed of treatment of patients with suspected STT. METHODS: This was a retrospective, longitudinal, single-center study from 2011-2020. We included adult patients who had biopsies or resections of masses suspicious for STT in MRI exams. MRI reports were classified as benign (I), intermediate/unclear (II), or malignant (III). For these cohorts, time was statistically analyzed from MRI scan to first contact with the University cancer center (UCC) and surgery. Furthermore, distance in kilometers from the patients´ home to the UCC was examined and compared to age and suspected malignancy. RESULTS: Three hundred two patients (♀130; ♂172) were included. Histologic analyses revealed 286 tumors. The average age of the patients was 54.7(SD: 16.2) years. Malignant tumors were more often suspected in older patients (p = 0.0098). Patients with a benign diagnosed tumor in MRI contacted the UCC after an average of 31.3 (SD: 47.8) days. In contrast, patients with suspicion of a malignant tumor contacted the UCC significantly earlier, after 14.1 days (SD: 17.1); p = 0.0098. Likewise, the time between first contact and biopsy/resection was 32.8 days (SD: 35.7) for suspiciously benign tumors, and potentially malignant tumors were treated significantly faster 14.8 (SD: 16.0) days; (p = 0.028). Patients traveled on average 47.5 km (range: 0.5-483) to contact a specialized physician at the UCC. Suspected degree of malignancy or patient´s age had no statistical influence on traveled distance. DISCUSSION: The treatment speed depended to a great extent on the suspected malignancy of the STT in the MRI report. The provisional diagnoses from the radiologist highly influenced the time delay between MRI scan and first contact to the UCC and surgical treatment. No discrimination of age or distance to the UCC was observed in this study.

Lateral femoral notch sign and posterolateral tibial plateau fractures and their associated injuries in the setting of an anterior cruciate ligament rupture.

INTRODUCTION: ACL injury is one of the most common injuries of the knee joint in sports. As accompanying osseous injuries of the ACL rupture a femoral impression the so-called lateral femoral notch sign and a posterolateral fracture of the tibial plateau are described. However, frequency, concomitant ligament injuries and when and how to treat these combined injuries are not clear. There is still a lack of understanding with which ligamentous concomitant injuries besides the anterior cruciate ligament injury these bony injuries are associated. MATERIALS AND METHODS: One hundred fifteen MRI scans with proven anterior cruciate ligament rupture performed at our center were retrospectively evaluated for the presence of a meniscus, collateral ligament injury, a femoral impression, or a posterolateral impression fracture. Femoral impressions were described according to their local appearance and posterolateral tibial plateau fractures were described using the classification of Menzdorf et al. RESULTS: In 29 cases a significant impression in the lateral femoral condyle was detected. There was a significantly increased number of lateral meniscal (41.4% vs. 18.6% p = 0.023) and medial ligament (41.4% vs. 22.1%; p = 0.040) injuries in the group with a lateral femoral notch sign. 104 patients showed a posterolateral bone bruise or fracture of the tibial plateau. Seven of these required an intervention according to Menzdorf et al. In the group of anterior cruciate ligament injuries with posterolateral tibial plateau fracture significantly more lateral meniscus injuries were seen (p = 0.039). CONCLUSION: In the preoperative planning of ACL rupture accompanied with a positive femoral notch sign, attention should be paid to possible medial collateral ligament and lateral meniscus injuries. As these are more likely to occur together. A posterolateral impression fracture of the tibial plateau is associated with an increased likelihood of the presence of a lateral meniscal injury. This must be considered in surgical therapy and planning and may be the indication for necessary early surgical treatment.

Additional lateral extra-articular tenodesis in revision ACL reconstruction does not influence the outcome of patients with low-grade anterior knee laxity.

INTRODUCTION: There is limited evidence on the indications of lateral extra-articular tenodesis (LET) in revision ACLR. The aim of this study was to evaluate the influence of the LET in patients with revision ACLR with preoperative low-grade anterior knee laxity. METHODS: Between 2013 and 2018, 78 patients who underwent revision ACLR with preoperative low-grade anterior knee laxity [≤ 5 mm side-to-side difference (SSD)] were included in the retrospective cohort study. An additional modified Lemaire tenodesis was performed in 23 patients during revision ACLR and patients were clinically examined with a minimum of 2 years after revision surgery. Postoperative failure of the revision ACLR was defined as SSD in Rolimeter® testing ≥ 5 mm or pivot-shift grade 2/3. RESULTS: In total, failure of the revision ACLR occurred in 11.5% (n = 9) of the cases at a mean follow-up of 28.7 ± 8.8 (24-67) months. Patients with an additional LET and revision ACLR did not show a significantly reduced failure rate (13% vs. 11%) or an improved clinical outcome according to the postoperative functional scores or pain in regards to patients with an isolated revision ACLR (Tegner 5.7 ± 1.3 vs. 5.9 ± 1.5, n.s.; IKDC 77.5 ± 16.2 vs. 80.1 ± 14.9, n.s., Lysholm 81.9 ± 14.2 vs. 83.8 ± 14.5, n.s.; VAS 1.9 ± 2.2 vs. 1.2 ± 1.7, n.s.). CONCLUSIONS: An additional LET in patients with revision ACLR with low-grade anterior knee laxity does not influence patient-related outcomes or failure rates. Subjects with preoperative low-grade anterior knee laxity may not benefit from a LET in revision ACLR. LEVEL OF EVIDENCE: III.

Patella height is not altered by descending medial open-wedge high tibial osteotomy (HTO) compared to ascending HTO.

PURPOSE: The primary purpose of the study was to gain insight into geometric changes of the patellar height (PH) and posterior tibial slope (PTS) after a biplanar ascending medial open-wedge high tibial osteotomy (HTO) compared to biplanar descending medial open-wedge HTO in patients with genu varum. METHODS: Sixty-four patients (mean age 45.2 ± 8.7 years, females n = 24, males n = 40) with varus malalignment and medial gonarthrosis were retrospectively studied. Patients received either a biplanar ascending or descending medial open-wedge HTO. Radiographic analysis included the assessment of standing total leg axis, PH, and PTS prior to and after surgery. RESULTS: In the ascending HTO group, PH decreased significantly by 4.0% (p = 0.037, Caton-Deschamps index) after an average leg axis valgus-producing correction of 7.1° ± 2.8°. In the descending HTO group, with an average leg axis correction of 7.0° ± 3.7°, there were no significant PH changes. There were no significant differences between the ascending and descending HTO groups regarding PTS or leg axis. The mean post-operative leg axis between ascending (1.6° ± 1.9°) and descending HTO (1.9° ± 2.4°) was not significantly different. CONCLUSION: Compared to the biplanar ascending medial open-wedge HTO, the descending HTO did not influence patella height or increase the posterior tibial slope. In order to respect patellofemoral and slope-related knee kinematics, a biplanar descending medial open-wedge HTO has proven useful to control patella height and posterior tibial slope. These findings underscore the importance of the preoperative patella height assessment in the osteotomy planning and subsequent choice of the biplanar osteotomy direction. LEVEL OF EVIDENCE: IV.

Unravelling Local Atomic Order of the Anionic Sublattice in M(Al1-x Gax )4 with M=Sr and Ba by Using NMR Spectroscopy and Quantum Mechanical Modelling.

The quasibinary section of the intermetallic phases MAl4 and MGa4 with M=Sr and Ba have been characterised by means of X-ray diffraction (XRD) studies and differential thermal analysis. The binary phases show complete miscibility and form solid solutions M(Al1-x Gax )4 with M=Sr and Ba. These structures crystallise in the BaAl4 structure type with four- and five-bonded Al and/or Ga atoms (denoted as Al(4b), Al(5b), Ga(4b), and Ga(5b), respectively) that form a polyanionic Al/Ga sublattice. Solid state 27 Al NMR spectroscopic analysis and quantum mechanical (QM) calculations were applied to study the bonding of the Al centres and the influence of Al/Ga substitution, especially in the regimes with low degrees of substitution. M(Al1-x Gax )4 with M=Sr and Ba and 0.925≤x≤0.975 can be described as a matrix of the binary majority compound in which a low amount of the Ga atoms has been substituted by Al atoms. In good agreement with the QM calculations, 27 Al NMR investigations and single crystal XRD studies prove a preferred occupancy of Al(4b) for these substitution regimes. Furthermore, two different local Al environments were found, namely isolated Al(4b1) atoms and Al(4b2), due to the formation of Al(4b)-Al(4b) pairs besides isolated Al(4b) atoms within the polyanionic sublattice. QM calculations of the electric field gradient (EFG) using superlattice structures under periodic boundary conditions are in good agreement with the NMR spectroscopic results.

[Treatment of Injuries to the Posterior Cruciate Ligament]. / Therapie von Verletzungen des hinteren Kreuzbandes.

Compared to the anterior cruciate ligament injury, the rupture of the posterior cruciate Ligament (PCL) is the rarer condition. A high healing potential is attributed to the PCL in the literature, which is why conservative therapy is also considered important in addition to surgical treatment 1. Posterior cruciate ligament rupture is often associated with concomitant injuries. Among other things, up to 70% of cases are associated with accompanying injuries to the posterolateral corner 2. The detection of concomitant injuries has a significant influence on the outcome, as isolated surgical PCL stabilization does not lead to satisfactory results in these cases.

Influence of variable hinge positioning on coronal and sagittal alignment in uniplanar medial open-wedge high tibial osteotomy.

Purpose: There is a high risk of increasing the posterior tibial slope (PTS) during medially opening-wedge high tibial osteotomy (mowHTO). Most recently, the idea of intentional simultaneous coronal and sagittal correction, using uniplanar cutting techniques has emerged. This study aims to examine the influences of variable hinge positioning and osteotomy gap height on the sagittal and coronal plane. Methods: Twenty uniplanar mowHTOs were performed in standardised (left) solid-foam proximal tibia models. In the different models, hinge position was rotated stepwise by 10°, between 90° (cutting straight medial to lateral) and 0° (cutting straight anterior to posterior) (n = 10). Additionally, gap heights of 5 and 10 mm were produced and analysed. Logistic regression analysis was performed to calculate a predictive regression formula for the relation between gap height, hinge rotation and the changes of medial proximal tibia angle (MPTA), medial and lateral PTS. Results: Between cutting angles of 90 and 20°, the MPTA was mainly influenced by the gap height (0.95° MPTA per 1 mm gap height), but not by the cutting angle. Between 20 and 0°, the MPTA was decreased by 3.6° per 10° of rotation, but not by the gap height. Between cutting angles of 90 and 10°, the PTS was increased linearly by 0.97° per 10° of rotation and by 0.61° per 1 mm gap height. Conclusion: In mowHTO with lateral hinge positions, the MPTA is mainly influenced by gap height. Changes of PTS can be avoided by a straight lateral hinge position. In posterior hinge locations (0-20°), changes of MPTA are mainly caused by hinge rotation, but not by gap height. Level of Evidence: Level III, Case-control study.

Analysis of postoperative complications 5 years after osteosynthesis of patella fractures-a retrospective, multicenter cohort study.

PURPOSE: The study aims to investigate the influence of patient- and fracture-specific factors on the occurrence of complications after osteosynthesis of patella fractures and to compare knee joint function, activity, and subjective pain levels after a regular postoperative course and after complications in the medium term. METHODS: This retrospective, multicenter cohort study examined patients who received surgery for patella fracture at level 1 trauma centers between 2013 and 2018. Patient demographics and fracture-specific variables were evaluated. Final follow-up assessments included patient-reported pain scores (NRS), subjective activity and knee function scores (Tegner Activity Scale, Lysholm score, IKDC score), complications, and revisions. RESULTS: A total of 243 patients with a mean follow-up of 63.4 ± 21.3 months were included. Among them, 66.9% of patients underwent tension band wiring (TBW), 19.0% received locking plate osteosynthesis (LPO), and 14.1% underwent screw osteosynthesis (SO). A total of 38 patients (15.6%) experienced complications (TBW: 16.7%; LPO: 15.2%; SO: 11.8%). Implant-related complications of atraumatic fragment dislocation and material insufficiency/dislocation, accounted for 50% of all complications, were significantly more common after TBW than LPO (p = 0.015). No patient-specific factor was identified as a general cause for increased complications. Overall, particularly following complications such as limited range of motion or traumatic refracture, functional knee scores were significantly lower and pain levels were significantly higher at the final follow-up when a complication occurred. Implant-related complications, however, achieved functional scores comparable to a regular postoperative course without complications after revision surgery. CONCLUSION: The present study demonstrated that implant-related complications occurred significantly more often after TBW compared to LPO. The complication rates were similar in all groups.

The value of magnetic resonance imaging in the preoperative diagnosis of tibial plateau fractures: a systematic literature review.

PURPOSE: The outcome of a tibial plateau fracture (TPF) depends on the fracture reduction achieved and the extent of soft-tissue lesions, including lesions in the ligaments, cartilage, and menisci. Sub-optimal treatment can result in poor knee function and osteoarthritis. Preoperative planning is primarily based on conventional X-ray and computed tomography (CT), which are unsuitable for diagnosing soft-tissue lesions. Magnetic resonance imaging (MRI) is not routinely performed. To date, no literature exists that clearly states the indications for preoperative MRI. This systematic review aimed to determine the frequency of soft-tissue lesions in TPFs, the association between fracture type and soft-tissue lesions, and the types of cases for which MRI is indicated. METHODS: A systematic review of the literature was based on articles located in PubMed/MEDLINE and the Cochrane Central Register of Controlled Trials (CENTRAL), supplemented by searching the included articles' reference lists and the ePublication lists of leading orthopedic and trauma journals. RESULTS: A total of 1138 studies were retrieved. Of these, 18 met the eligibility criteria and included a total of 877 patients. The proportion of total soft-tissue lesions was 93.0%. The proportions of soft-tissue lesions were as follows: medial collateral ligament 20.7%, lateral collateral ligament 22.9%, anterior cruciate ligament 36.8%, posterior cruciate ligament 14.8%, lateral meniscus 48.9%, and medial meniscus 24.5%. A weak association was found between increasing frequency of LCL and ACL lesions and an increase in fracture type according to Schatzker's classification. No standard algorithm for MRI scans of TPFs was found. CONCLUSION: At least one ligament or meniscal lesion is present in 93.0% of TPF cases. More studies with higher levels of evidence are needed to find out in which particular cases MRI adds value. However, MRI is recommended, at least in young patients and cases of high-energy trauma.

The influence of 3D printing on inter- and intrarater reliability on the classification of tibial plateau fractures.

PURPOSE: Tibial plateau fractures continue to be a challenging task in clinical practice and current outcomes seem to provide the potential for further improvement. Especially presurgical understanding of the orientation of fracture lines and fracture severity is an essential key to sufficient surgical treatment. The object of this study was to evaluate the reliability of modern axial CT-based classification systems for tibial plateau fractures. In addition, the diagnostic-added value of 3D printing on the classification systems was investigated. METHODS: 22 raters were asked to classify 22 tibial plateau fractures (11 AO B- and 11 AO C-fractures) with the AO, the 10-Segment and the Revisited Schatzker classification in a three-step evaluation: first only using CT scans, second with 3D volumetric reconstructions and last with 3D-printed fracture models. Inter- and intraobserver agreement and the subjective certainty were analyzed. Statistics were done using kappa values, percentage match and a univariant one-way analysis of variance. RESULTS: The AO classifications interobserver percentage match and kappa values improved for all raters and recorded an overall value of 0.34, respectively, 43% for the 3D print. The 10-Segment classification interobserver agreement also improved with the 3D-printed models and scored an overall kappa value of 0.18 and a percentage match of 79%. Equally the Revisited Schatzker classification increased its values to 0.31 and 35%. The intraobserver agreement showed a moderate agreement for the AO (0.44) and Revisited Schatzker classification (0.42) whereas the 10-Segment classification showed a fair agreement (0.27). Additionally, the raters changed their classification in 36% of the cases after evaluating the fracture with the 3D-printed models and the subjective certainty regarding the decisions improved as categories of self-reliant diagnostic choices were selected 18% (p < 0.05) more often after using the 3D-printed models. CONCLUSION: Based on the measured outcomes it was concluded that the new classification systems show an overall slight to fair reliability and the use of 3D printing proved to be beneficial for the preoperative diagnostics of tibial plateau fractures. The 10-Segment classification system showed the highest percentage match evaluation of all classification systems demonstrating its high clinical value across all levels of user experience.

Influence of the Fluoroscopy Setting towards the Patient When Identifying the MPFL Insertion Point.

(1) The malposition of the femoral tunnel in medial patellofemoral ligament (MPFL) reconstruction can lead to length changes in the MPFL graft, and an increase in medial peak pressure in the patellofemoral joint. It is the cause of 36% of all MPFL revisions. According to Schöttle et al., the creation of the drill canal should be performed in a strictly lateral radiograph. In this study, it was hypothesized that positioning the image receptor to the knee during intraoperative fluoroscopy would lead to a relevant mispositioning of the femoral tunnel, despite an always adjusted true-lateral view. (2) A total of 10 distal femurs were created from 10 knee CT scans using a 3D printer. First, true-lateral fluoroscopies were taken from lateral to medial at a 25 cm (LM25) distance from the image receptor, then from medial to lateral at a 5 cm (ML5) distance. Using the method from Schöttle, the femoral origin of the MPFL was determined when the femur was positioned distally, proximally, superiorly, and inferiorly to the image receptor. (3) The comparison of the selected MPFL insertion points according to Schöttle et al. revealed that the initial determination of the point in the ML5 view resulted in a distal and posterior shift of the point by 5.3 mm ± 1.2 mm when the point was checked in the LM25 view. In the opposite case, when the MPFL insertion was initially determined in the LM25 view and then redetermined in the ML5 view, there was a shift of 4.8 mm ± 2.2 mm anteriorly and proximally. The further positioning of the femur (distal, proximal, superior, and inferior) showed no relevant influence. (4) For fluoroscopic identification of the femoral MPFL, according to Schöttle et al., attention should be paid to the position of the fluoroscopy in addition to a true-lateral view.

Clinical Routine and Necessary Advances in Soft Tissue Tumor Imaging Based on the ESSR Guideline: Initial Findings.

Soft tissue sarcomas are malignant diseases with a complex classification and various histological subtypes, mostly clinically inconspicuous appearance, and a rare occurrence. To ensure safe patient care, the European Society of Musculoskeletal Radiology (ESSR) issued a guideline for diagnostic imaging of soft tissue tumors in adults in 2015. In this study, we investigated whether implementation of these guidelines resulted in improved MRI protocol and report quality in patients with soft tissue sarcomas in our cancer center. All cases of histologically confirmed soft tissue sarcomas that were treated at our study center from 2006 to 2018 were evaluated retrospectively. The radiological reports were examined for their compliance with the recommendations of the ESSR. Patients were divided into two groups, before and after the introduction of the 2015 ESSR guidelines. In total, 103 cases of histologically confirmed sarcomas were studied. The distribution of, age, gender, number of subjects, performing radiology, and MRI indication on both groups did not show any significant differences. Only using the required MRI sequences showed a significant improvement after the introduction of the guidelines (p = 0.048). All other criteria, especially the requirements for the report of findings, showed no improvement. The guidelines of the European Society for Musculoskeletal Radiology are not regularly followed, and their establishment did not consistently improve MRI quality in our study group. This poses a risk for incorrect or delayed diagnosis and, ultimately, therapy of soft tissue tumors. However, this study is the first of its kind and involves a limited collective. A European-wide multicenter study would be appreciated to confirm these results.

A comparison between Asians and Caucasians in the dimensions of the femoral isthmus based on a 3D-CT analysis of 1189 adult femurs.

INTRODUCTION: For successful intramedullary implant placement at the femur, such as nailing in unstable proximal femur fractures, the use of an implant that at least reaches or exceeds the femoral isthmus and yields sufficient thickness is recommended. A number of complications after intramedullary femoral nailing have been reported, particularly in Asians. To understand the anatomical features of the proximal femur and their ethnic differences, we aimed to accurately calculate the femoral isthmus dimensions and proximal distance of Asians and Caucasians. METHODS: In total, 1189 Asian and Caucasian segmented 3D CT data sets of femurs were analyzed. The individual femoral isthmus diameter was precisely computed to investigate whether gender, femur length, age, ethnicity or body mass index have an influence on isthmus diameters. RESULTS: The mean isthmus diameter of all femurs was 10.71 ± 2.2 mm. A significantly larger diameter was found in Asians when compared to Caucasians (p < 0.001). Age was a strong predictor of the isthmus diameter variability in females (p < 0.001, adjusted r2 = 0.299). With every year of life, the isthmus showed a widening of 0.08 mm in women. A Matched Pair Analysis of 150 female femurs showed a significant difference between isthmus diameter in Asian and Caucasian femurs (p = 0.05). In 50% of the cases the isthmus was found in a range of 2.4 cm between 16.9 and 19.3 cm distal to the tip of the greater trochanter. The female Asian femur differs from Caucasians as it is wider at the isthmus. CONCLUSIONS: In absolute values, the proximal isthmus distance did not show much variation but is more proximal in Asians. The detailed data presented may be helpful in the development of future implant designs. The length and thickness of future standard implants may be considered based on the findings.

Influence of Medial Osteotomy Height and Hinge Position in Open Wedge High Tibial Osteotomy: A Simulation Study.

(1) Background: In treating medial unicompartmental gonarthrosis, medial open wedge high tibial osteotomy (mOWHTO) reduces pain and is intended to delay a possible indication for joint replacement by relieving the affected compartment. This study aimed to investigate the influence of the osteotomy height with different hinge points in HTO in genu varum on the leg axis. (2) Methods: Fifty-five patients with varus lower leg alignment obtained full-weight bearing long-leg radiographs were analyzed. Different simulations were performed: Osteotomy height was selected at 3 and 4 cm distal to the tibial articular surface, and the hinge points were selected at 0.5 cm, 1 cm, and 1.5 cm medial to the fibular head, respectively. The target of each correction was 55% of the tibial plateau measured from the medial. Then, the width of the opening wedge was measured. Intraobserver and interobserver reliability were calculated. (3) Results: Statistically significant differences in wedge width were seen at an osteotomy height of 3 cm below the tibial plateau when the distance of the hinge from the fibular head was 0.5 cm to 1.5 cm (3 cm and 0.5 cm: 8.9 +/- 3.88 vs. 3 cm and 1.5 cm: 11.6 +/- 4.39 p = 0.012). Statistically significant differences were also found concerning the wedge width between the distances 0.5 to 1.5 cm from the fibular head at the osteotomy height of 4 cm below the tibial plateau. (4 cm and 0.5 cm: 9.0 +/- 3.76 vs. 4 cm and 1.5 cm: 11.4 +/- 4.27 p = 0.026). (4) Conclusion: A change of the lateral hinge position of 1 cm results in a change in wedge width of approximately 2 mm. If hinge positions are chosen differently in preoperative planning and intraoperatively, the result can lead to over- or under-correction.

Lipomatous Tumors: A Comparison of MRI-Reported Diagnosis with Histological Diagnosis.

Lipomatous tumors are among the most common soft tissue tumors (STTs). Magnetic resonance imaging (MRI) is a state-of-the-art diagnostic tool used to differentiate and characterize STTs. Radiological misjudgment can lead to incorrect treatment. This was a single-center retrospective study. Two hundred and forty lipomatous tumors were included. MRI diagnoses were categorized as benign, intermediate, or malignant and were compared with histological diagnoses. Tumor volumes were measured by MRI and from surgical specimens. The tumor was correctly categorized 73.3% of the time. A total of 21.7% of tumors were categorized as more malignant in MRI reports than they were by histology, and vice versa for 5.0% of tumors. Volume measured by MRI was not different from actual tumor size in pathology. Atypical lipomatous tumors (ALTs) and liposarcomas (LPSs) were larger when compared with lipomata and occurred in older patients. Based on the MRI-suspected tumor entity, surgical treatment can be planned. Large lipomatous tumors in elderly patients are more likely to be ALTs. However, a safe threshold size or volume for ALTs cannot be determined.

Clinical Presentation and MRI Characteristics of Appendicular Soft Tissue Lymphoma: A Systematic Review.

Appendicular soft tissue lymphoma (ASTL) is rare and is frequently misinterpreted as soft tissue sarcoma (STS). Studies investigating magnet resonance imaging (MRI) characteristics of ASTL are scarce and showed heterogenous investigation criteria and results. The purpose of this study was to systematically review clinical presentations and MRI characteristics of ASTL as described in the current literature. For that purpose, we performed a systematic literature review in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Patient demographics, clinical presentation and MRI imaging characteristics of ASTL were investigated, resulting in a total of nine included studies reporting a total of 77 patients. Signal intensity of lymphoma compared to muscle tissue was mostly described as isointense (53%) or slightly hyperintense (39%) in T1-weighted images and always as hyperintense in proton-and T2-weighted images. Multicompartmental involvement was reported in 59% of cases and subcutaneous stranding in 74%. Long segmental involvement was present in 80% of investigated cases. Involvement of neurovascular structures was reported in 41% of cases and the presence of traversing vessels in 83% of patients. The presence of these findings should lead to the inclusion of ASTL in the differential diagnosis of soft tissue masses.

Diagnostic and Therapeutic Pathways of Intramuscular Myxoma.

Intramuscular myxomas (IMMs) are benign tumors. Evidence regarding diagnostic and therapeutic pathways is rare, and guidelines do not exist due to their low incidence. The aim of this study was a retrospective analysis at a university cancer center and the interdisciplinary re-evaluation of the individual diagnostic and therapeutic procedures. Overall, 38 patients were included in the study. IMMs occurred mostly in middle-aged women. At the time of first consultation, 57.9% had few symptoms or were asymptomatic. In 92.1% of the cases, the tumor was localized in the extremities. The lower extremity was affected in 73.7%. The average size of IMMs was 5.0 cm. The proximally located tumors in the gluteus, thighs, and upper arms were significantly larger (p = 0.02) than the distally-located tumors in the forearms and lower legs. An MRI was performed in 97.4%. Based on imaging, an IMM was suspected in 5.6% by radiologists and in 54.1% by musculoskeletal surgeons. An incision biopsy was performed in 68.4% and led in 100.0% to the right histopathological diagnosis. In total, 89.5% of IMMs were resected. Postoperative complications requiring revision occurred in 8.8%. Recurrences or degenerations of IMMs were not reported in any of these cases.

Lower Failure Rates and Improved Patient Outcome Due to Reconstruction of the MCL and Revision ACL Reconstruction in Chronic Medial Knee Instability.

BACKGROUND: Concomitant lesion of the medial collateral ligament (MCL) is associated with a greater risk of anterior cruciate ligament (ACL) graft failure. PURPOSE: The aim of this study was to compare two medial stabilization techniques in patients with revision ACL reconstruction (ACLR) and concomitant chronic medial knee instability. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: In a retrospective study, we included 53 patients with revision ACLR and chronic grade 2 medial knee instability to compare medial surgical techniques (MCL reconstruction [n = 17] vs repair [n = 36]). Postoperative failure of the revision ACLR (primary aim) was defined as side-to-side difference in Rolimeter testing ≥5 mm or pivot-shift grade ≥2. Clinical parameters and postoperative functional scores (secondary aim) were evaluated with a mean ± SD follow-up of 28.8 ± 9 months (range, 24-69 months). RESULTS: Revision ACLR was performed in 53 patients with additional grade 2 medial instability (men, n = 33; women, n = 20; mean age, 31.3 ± 12 years). Failure occurred in 5.9% (n = 1) in the MCL reconstruction group, whereas 36.1% (n = 13) of patients with MCL repair showed a failed revision ACLR (P = .02). In the postoperative assessment, the anterior side-to-side difference in Rolimeter testing was significantly reduced (1.5 ± 1.9 mm vs 2.9 ± 2.3 mm; P = .037), and medial knee instability occurred significantly less (18% vs 50%; P = .025) in the MCL reconstruction group than in the MCL repair group. In the logistic regression, patients showed a 9-times elevated risk of failure when an MCL repair was performed (P = .043). Patient-reported outcomes were increased in the MCL reconstruction group as compared with MCL repair, but only the Lysholm score showed a significant difference (Tegner, 5.6 ± 1.9 vs 5.3 ± 1.6; International Knee Documentation Committee, 80.3 ± 16.6 vs 73.6 ± 16.4; Lysholm, 82.9 ± 13.6 vs 75.1 ± 21.1 [P = .047]). CONCLUSION: MCL reconstruction led to lower failure rates in patients with combined revision ACLR and chronic medial instability as compared with MCL repair. MCL reconstruction was superior to MCL repair, as lower postoperative anterior instability, an increased Lysholm score, and less medial instability were present after revision ACLR. MCL repair was associated with a 9-times greater risk of failure.

Musculoskeletal Soft-Tissue Sarcoma: Quality Assessment of Initial MRI Reports Shows Frequent Deviation from ESSR Guidelines.

Soft-tissue sarcomas (STS) are a rare subtype of soft-tissue mass and are frequently misinterpreted as benign lesions. Magnetic resonance imaging (MRI) is the primary recommended type of diagnostics. To assess the quality of primary radiology reports, we investigated whether recommended MRI report elements were included in compliance with European Society of Musculoskeletal Radiology (ESSR) guidelines. A total of 1107 patients were evaluated retrospectively, and 126 radiological reports on patients with malignant STS were assessed for ESSR quality criteria. One or more required sequences or planes were missing in 67% of the reports. In all 126 cases, the report recognized the mass as anomalous (100%). Sixty-eight percent of the reports mentioned signs of malignancy. The majority of reports (n = 109, 87%) articulated a suspected diagnosis, 32 of which showed a mismatch with the final diagnosis (25%). Thirty-two percent of the reports had a misinterpretation of the masses as benign. Benign misinterpretations were more common in masses smaller than 5 cm (65% vs. 27%). Thirty percent of the reports suggested tissue biopsy and 6% recommended referral to a sarcoma center. MRI reports showed frequent deviations from ESSR guidelines, and protocol guidelines were not routinely met. Deviations from standard protocol and reporting guidelines could put patients at risk for inadequate therapy.

The concept of direct approach to lateral tibial plateau fractures and stepwise extension as needed.

Malreduction after tibial plateau fractures mainly occurs due to insufficient visualization of the articular surface. In 85% of all C-type fractures an involvement of the posterolateral-central segment is observed, which is the main region of malreduction. The choice of the approach is determined (1) by the articular area which needs to be visualized and (2) the positioning of the fixation material. For simple lateral plateau fractures without involvement of the posterolateral-central segment an anterolateral standard approach in supine position with a lateral plating is the treatment of choice in most cases. For complex fractures the surgeon has to consider, that the articular surface of the lateral plateau only can be completely visualized by extended approaches in supine, lateral and prone position. Anterolateral and lateral plating can also be performed in supine, lateral and prone position. A direct fixation of the posterolateral-central segment by a plate or a screw from posterior can be only achieved in prone or lateral position, not supine. The posterolateral approach includes the use of two windows for direct visualization of the fracture. If visualization is insufficient the approach can be extended by lateral epicondylar osteotomy which allows exposure of at least 83% of the lateral articular surface. Additional central subluxation of the lateral meniscus allows to expose almost 100% of the articular surface. The concept of stepwise extension of the approach is helpful and should be individually performed as needed to achieve anatomic reduction and stable fixation of tibial plateau fractures.