Calcaneal chondroblastoma with pathologic fracture and recurrence.

Chondroblastomas account for <2% of all bone tumors. The calcaneus is the fifth most common location of occurrence. Males in their second decade of life are most often affected, presenting with an insidious onset of localized pain, swelling, and tenderness. The finding of associated pathologic fracture has been rare. Imaging studies can aid in the formulation of the differential diagnosis and surgical plan. The definitive diagnosis requires histologic examination. Curettage and bone grafting is curative in >80% of cases. Local recurrence rates of ≤38% have been reported, most often because of inadequate resection, and have been associated with malignant conversion and metastasis. Adjuvant therapies can help minimize the incidence of local recurrence. Long-term follow-up examinations are recommended, given the protracted interval that can exist between recurrence and the potential for malignant conversion and metastasis. We present the case of a young, healthy, active male with a calcaneal chondroblastoma and associated pathologic fracture whose initial treatment consisted of curettage, hydrogen peroxide lavage, and allogeneic bone grafting. Recurrence developed at 15 months postoperatively and was treated with repeat curettage, high-speed burring, and reconstruction with steel Steinman pins and polymethylmethacrylate, resulting in no pain or recurrence at the 5-month follow-up point.

Glenoid component failure after total shoulder arthroplasty with migration of the component into posterior subcutaneous tissue: a case report.

Glenoid component loosening is the most frequently cited complication related to total shoulder arthroplasty (TSA). The mechanism behind glenoid loosening remains an area of active investigation. Distant migration of the implant following loosening has not been described. Both glenoid implant removal and revision have demonstrated successful results following symptomatic loosening. This report presents the case of a 61-year-old female who experienced a complete glenoid component dissociation following TSA with migration of the implant into the subcutaneous tissue of the posterior shoulder. The patient underwent implant removal without glenoid revision and has experienced an excellent outcome at midterm follow-up. Although glenoid component loosening remains the most common complication associated with TSA, this particular scenario and the subsequent management have not been previously reported.

Ipsilateral diaphyseal femur fracture after resection arthroplasty.

Resection arthroplasty of the hip is most commonly used for recalcitrant infections in the setting of prior hemiarthroplasty and total hip arthroplasty. Reported complications of this procedure include shortening of the extremity and ambulation difficulties requiring assistive devices. We report a case of an unusual finding of an ipsilateral femoral shaft fracture after a ground level fall 4 months after a resection arthroplasty for a septic hip. A closed reduction with internal fixation using an intramedullary nail was performed, and 3 months postoperatively, the patient was ambulating with device assistance.

Features of grade 3 giant cell tumors of the distal radius associated with successful intralesional treatment.

PURPOSE: The goal of this study was to identify radiographic and anatomic features of Campanacci grade 3 distal radius giant cell tumors that are associated with an acceptable rate of local recurrence after intralesional treatment. METHODS: We retrospectively reviewed 15 grade 3 distal radius giant cell tumors treated with intralesional curettage, cryosurgery, and cementation (CCC) (n = 9) or with wide en bloc excision and reconstruction (WEE) (n = 6). Success was defined as local control after CCC without conversion to wide excision, and as a recurrence rate comparable with rates in the scientific literature. Preoperative radiographic evaluation and intraoperative determination of tumor extension guided the choice of treatment. Tumor width on x-rays and tumor volume on magnetic resonance imaging were measured. Outcome was assessed with postoperative motion and grip strength, and the Disabilities of the Shoulder, Arm and Hand, the visual analog pain score, and a satisfaction questionnaire. RESULTS: Local recurrence occurred in 2 of 9 patients after primary CCC, in none with repeat CCC, and in none of the 6 with WEE. No patient treated with secondary CCC had unresectable recurrence requiring conversion to WEE. Patients with a single site of cortical perforation who received CCC treatment achieved local control with intralesional treatment alone. Average tumor volume was 12 cm(3) (range, 9-17 cm(3)) with CCC and 43 cm(3) (range, 29-57 cm(3)) with WEE. Postoperative motion and strength, Disabilities of the Shoulder, Arm and Hand score, and visual analog pain scale score were acceptable in all and superior with CCC. All patients were highly satisfied. CONCLUSIONS: Tumor volume measured with magnetic resonance imaging and anatomically defined limits of soft tissue extension may help identify grade 3 lesions that can be treated with with CCC with an acceptable rate of local recurrence. We propose subclassification of Campanacci grade 3 lesions. Under this classification, tumors with extension assessed by preoperative imaging and confirmed by intraoperatively to be limited to a single site of palmar cortical perforation are classified as grade 3(p), where (p) denotes a single site bound by the pronator quadratus. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Predictive value of magnetic resonance imaging in determining presence of residual disease after marginal excision of unsuspected soft tissue sarcomas of the hand.

PURPOSE: Diagnosis of a soft tissue sarcoma of the hand is at times made only in retrospect after marginal excision of a presumed benign soft tissue mass. Magnetic resonance imaging (MRI) helps determine the presence of residual disease and the extent of contamination caused by marginal excision of unsuspected soft tissue sarcomas and assists in the planning of definitive treatment with surgery and radiotherapy when required. We sought to determine the accuracy of MRI in detecting residual sarcoma after marginal excision. METHODS: We retrospectively studied case records and imaging studies for all patients with soft tissue sarcomas of the hand evaluated and treated at our institution from 1996 to 2005. We included in this study 33 patients who underwent definitive surgery at our center after prior marginal excision. MRI scans done before definitive wide resection were classified as positive or negative for residual tumor. A musculoskeletal radiologist, blinded to the sarcoma type, findings on histopathology, and surgery, reviewed 19 scans to see whether the accuracy could be improved. RESULTS: There were 8 epithelioid sarcomas, 6 synovial sarcomas, 4 malignant fibrous histiocytomas, 2 leiomyosarcomas, 2 liposarcomas, 2 myxofibrosarcomas, and one each of 9 other diagnoses. A total of 11 were low-grade and 22 were high-grade tumors, with 4 superficial and 29 deep tumors. Pathology examination after definitive wide resection or partial hand amputation showed that 15 patients had residual tumor, 9 gross and 6 microscopic. The sensitivity of MRI in detecting residual soft tissue sarcoma of the hand was 60%, specificity was 78%, positive predictive value was 69%, and negative predictive value was 70%. The sensitivity of MRI in detecting gross residual soft tissue sarcoma of the hand was 89%, specificity was 79%, positive predictive value was 62%, and negative predictive value was 95%. Even when an experienced musculoskeletal radiologist reassessed 19 MRI scans, the accuracy did not improve. CONCLUSIONS: Magnetic resonance imaging does not reliably detect residual gross or microscopic soft tissue sarcoma after marginal excision of unsuspected soft tissue sarcomas of the hand, with residual tumor not readily distinguished from postoperative change. The absence of disease on MRI should not be used as the sole criterion in determining whether a repeat resection should be performed. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic III.

Bisphosphonate delivery to tubular bone allografts.

Large structural allografts used for reconstruction of bone defects after revision arthroplasty and tumor resection fracture up to 27% of the time from osteolytic resorption around the fixation screw holes and tendon or ligament attachment sites. Treating structural allografts before implantation with bisphosphonates may inhibit local osteoclastic processes and prevent bone resorption and the development of stress risers, thereby reducing the long-term fracture rate. Taking advantage of allografts' open-pore structure, we asked whether passive soaking or positive-pressure pumping was a more efficient technique for delivering bisphosphonates. We treated matched pairs of ovine tibial allografts with fluids containing Tc-99m pamidronate and toluidine blue stain to facilitate indicator distribution analysis via microSPECT-microCT imaging and light microscopy, respectively. Surfactants octylphenoxy polyethoxy ethanol or beractant were added to the treatment fluids to reduce flow resistance of solutions pumped through the allografts. Indicator distribution after 1 hour of soaking produced a thin ring around periosteal and endosteal surfaces, while pumping for 10 minutes produced a more even distribution throughout the allograft. Flow resistance was reduced with octylphenoxy polyethoxy ethanol but unaffected with beractant. Pumped allografts displayed a more homogeneous indicator distribution in less time than soaking while surfactants enhanced fluid movement.

Proximal femoral replacement for metastatic bone disease.

Between 1994 and 2000, 13 patients (8 women and 5 men; 14 hips) underwent proximal femoral replacement secondary to metastatic disease. Average patient age was 62 years (range: 46-77 years). The most common diagnosis was renal cell carcinoma. Seven pathologic fractures were noted. Patients ambulated with full weight bearing postoperatively and wore an abduction brace for 3-4 months. Ten patients died of their diseases at 0.5-3.5 years postoperatively. No dislocations, infections, or reoperations occurred. Proximal femoral replacement provides excellent pain relief and good restoration of function when more simple reconstructive options are not feasible.

Floating Lateral Mass Fractures of the Cervical Spine.

STUDY DESIGN: Level I trauma center case series. OBJECTIVE: The purpose of this study was (i) to characterize the floating lateral mass (FLM) fracture with the mechanism of injury, anatomical injury pattern, associated vascular injuries, neurological deficits, and key radiographic features; and (ii) to better understand the most effective method of treatment. SUMMARY OF BACKGROUND DATA: An uncommon and poorly described subset of unilateral lateral mass fractures is FLM with fractures of the adjacent pedicle and lamina. METHODS: Prospectively collected trauma registries were assessed to identify all patients with FLM fractures involving C3 to C7 between January 1, 2007 and December 31, 2012. RESULTS: After institutional review board approval, 60 consecutive cases were identified from the trauma registries. The mean follow-up was 9 months (range 0-42 months). The most common level was C6. The most common mechanism of injury was a high speed motor vehicle accident (45%). Radiographic rotational displacement manifested as an anterolisthesis. CT showed facet joint widening at the level above and below in 63%. Vertebral artery injuries occurred in 22%. Neurological deficits occurred as radiculopathy in 38% and spinal cord injury in 18%. All eight patients, who were treated nonoperatively, developed subluxation despite external immobilization and six patients required surgery. Of the 58 patients treated operatively, 31 (53%) patients underwent a 2 level Anterior Cervical Discectomy and Fusion (ACDF) alone. Nine (15%) patients had one level ACDF, with 83% demonstrating radiographic failure. Posterior fusion alone or combined with ACDF/corpectomy was performed in 6 patients (10%) and 7 patients (12%), respectively. CONCLUSION: A FLM fracture results from a high energy injury and involves two motion segments. Vertebral artery injuries and neurological deficits frequently occur. Magnetic Resonance demonstrates a significant disc injury in 81% of patients, usually at the lower level. Two level ACDF or Posterior Spinal Instrumented Fusion are effective means of treatment. LEVEL OF EVIDENCE: 3.

Conventional Chondrosarcoma Diagnosed After Total Knee Arthroplasty: A Case Report.

CASE: Three years after a total knee arthroplasty, the patient presented with persistent pain and an enlarging intra-articular periprosthetic mass. Attempts at nonoperative treatment and arthroscopic debridement were unsuccessful. A biopsy revealed a large, intermediate-grade chondrosarcoma involving the joint space. The patient was treated with an above-the-knee amputation, but eventually died as a result of widespread metastatic disease. CONCLUSION: To our knowledge, this is the first reported case of chondrosarcoma involving the joint space that was diagnosed after total knee arthroplasty. This case demonstrates the need for increased awareness when there are suspicious clinical findings and the importance of diagnosing and/or treating tumors prior to or shortly after total joint arthroplasty.

Medicaid status is associated with higher surgical site infection rates after spine surgery.

STUDY DESIGN: The Spine End Results Registry (2003-2004) is a registry of prospectively collected data of all patients undergoing spinal surgery at the University of Washington Medical Center and Harborview Medical Center. Insurance data were prospectively collected and used in multivariate analysis to determine risk of perioperative complications. OBJECTIVE: Given the negative financial impact of surgical site infections (SSIs) and the higher overall complication rates of patients with a Medicaid payer status, we hypothesized that a Medicaid payer status would have a significantly higher SSI rate. SUMMARY OF BACKGROUND DATA: The medical literature demonstrates lesser outcomes and increased complication rates in patients who have public insurance than those who have private insurance. No one has shown that patients with a Medicaid payer status compared with Medicare and privately insured patients have a significantly increased SSI rate for spine surgery. METHODS: The prospectively collected Spine End Results Registry provided data for analysis. SSI was defined as treatment requiring operative debridement. Demographic, social, medical, and the surgical severity index risk factors were assessed against the exposure of payer status for the surgical procedure. RESULTS: The population included Medicare (N = 354), Medicaid (N = 334), the Veterans' Administration (N = 39), private insurers (N = 603), and self-pay (N = 42). Those patients whose insurer was Medicaid had a 2.06 odds (95% confidence interval: 1.19-3.58, P = 0.01) of having a SSI compared with the privately insured. CONCLUSION: The study highlights the increased cost of spine surgical procedures for patients with a Medicaid payer status with the passage of the Patient Protection and Affordable Care Act of 2010. The Patient Protection and Affordable Care Act of 2010 provisions could cause a reduction in reimbursement to the hospital for taking care of patients with Medicaid insurance due to their higher complication rates and higher costs. This very issue could inadvertently lead to access limitations. LEVEL OF EVIDENCE: 3.

Scapular osteochondromas treated with surgical excision.

A retrospective review was performed of all osteochondroma excisions at our institution from 1994 to 2007. Postoperative functional assessment was completed with use of the Disabilities of the Arm, Shoulder and Hand (DASH) survey and a self-report questionnaire. Eight osteochondromas were excised at a mean patient age of 21.63 years. Presenting reports included pain, mass, pseudowinging, and snapping of the scapula. Physical examination identified pseudowinging, palpable mass, and pain with shoulder motion. The lesions arose from the ventral surface of the scapula in 5 patients, the dorsal surface in 2, and the inferior acromion in 1. The resected specimen averaged 10.8cm(3). A reactive bursa was found and resected in 4 patients. At mean of 4.17 years postresection, no signs of recurrence were found in 7 patients (88%). The single patient with a recurrence had undergone 2 additional surgical procedures. Six patients (75%) reported no/mild pain with routine and strenuous activities. One patient reported moderate and 1 patient reported moderate/severe pain with routine and strenuous activities. Four patients reported post-resection function as excellent, 2 as good, 1 as average/good, and 1 as average/poor. Six patients (75%) reported feeling very satisfied with the results, 1 reported feeling satisfied, and 1 reported feeling unsatisfied. The average DASH score was 11.7 (range, 0.00-46.67). No winging or pseudowinging was identified in those available for examination, and no difference was identified in range of motion comparing the operative to the nonoperative upper extremity. Near normal functional outcomes can be expected following excision of scapular osteochondromas.

Renal cell carcinoma metastases to bone after a 33-year remission.

Renal cell carcinoma accounts for 2% of all cancers. Metastases to bone occur 35% to 40% of the time, second in prevalence of metastases only to the lungs. These metastases are highly destructive, hypervascular tumors known to be difficult to manage. This article reports a unique case in which a patient was disease free for 33 years from initial nephrectomy for treatment of primary renal cell carcinoma to discovery of metastatic disease to the pelvis. Search for an unknown primary was performed, consisting of a complete blood count, chemistry, alkaline phosphatase, calcium, serum and urine protein electrophoresis, immunoglobulin levels, prostate specific antigen, liver function tests, bone scan, and chest, abdomen, and pelvis computed tomography scans. This workup was negative for any other primary source of malignancy, and the patient's remaining kidney was found to be free from any tumor burden. The patient successfully underwent excisional biopsy of the lesion, which proved to be vascular in nature, consistent with the final pathology of renal cell carcinoma. The longest amount of time from completion of treatment for the primary renal cell carcinoma to discovery of the first metastatic disease has previously been reported at 22.3 years. Mean interval between primary treatment and discovery of metastases has been defined as 3.0+/-5.4 years. This article highlights the need for advanced medical workup as well as maintaining a high clinical suspicion in patients with remote histories of primary malignancies who present with bony lesions.

Infiltrative MRI pattern and incomplete initial surgery compromise local control of myxofibrosarcoma.

UNLABELLED: Myxofibrosarcoma (MFS) has a high local failure rate of up to 79%. We conducted a retrospective analysis on all patients with the diagnosis of myxofibrosarcoma seen between 1990 and 2004 to assess whether improved imaging with MRI reduced local recurrence, increased survival, and whether radiotherapy following resection influenced outcome. Twenty-one patients were treated for MFS with a median followup of 52 months (range, 18-122). All patients were surgically treated, with 19 receiving limb-sparing surgery. All patients with high grade disease, positive margins, or a pre-referral procedure received radiation therapy. The local recurrence rate was 57% for patients with a prior outside procedure (8 of 14), while patients with no prior surgery had a rate of 14% (1 of 7). Prior marginal excision and diffuse fascial spread on MRI predicted an increased local recurrence rate. The disease-free survival at 5 years was 43% (SE, 22%) for low-grade disease and 39% (SE, 18%) for high- grade disease. Magnetic resonance imaging observations suggest a unique pattern of diffuse spread along fascial planes that could be responsible for the high local recurrence. Radiation did not compensate for positive margins, nor did it reduce recurrence after negative margins. LEVEL OF EVIDENCE: Therapeutic study, level IV (case series).

Limb salvage of infected knee reconstructions for cancer with staged revision and free tissue transfer.

UNLABELLED: Periprosthetic infections of oncologic reconstructions have an amputation rate between 37% and 87%. Eleven patients with an infected knee reconstruction following limb salvage surgery for cancer were treated with the staged protocol. All patients underwent prosthetic removal and implantation of an antibiotic-impregnated cement spacer, i.v. antibiotic therapy, repeat debridement and spacer change, and delayed prosthetic reconstruction and free tissue transfer. At the time of reconstruction, the median bone defect was 185 mm. The mean soft tissue defect was 112 cm2. Coverage was obtained with a free musculocutaneous flap. All limbs were spared without amputation or flap loss. The mean functional outcome as measured by the Musculoskeletal Tumor Society lower extremity score was 23 of 30. Infections of large prosthetic reconstructions about the knee can be salvaged successfully with repetitive debridement, staged prosthetic reimplantation, and free tissue transfer. Free tissue transfer improves the soft tissue envelope and allows restoration of joint motion. LEVEL OF EVIDENCE: Case Series. Level IV.

Outcomes of re-excision after unplanned excisions of soft-tissue sarcomas.

BACKGROUND AND OBJECTIVES: Unplanned excisions of soft-tissue sarcomas of the extremities occur commonly. Our goal was to evaluate the presence of residual disease, the treatment outcomes as they relate to local and distant recurrence and 5-year survival, and the limb functional outcomes in patients with unplanned sarcoma excision who were treated with re-excision and adjuvant therapy. METHODS: Between 1993 and 1999, 42 patients presented to our institution after unplanned excision of soft-tissue sarcomas. Of those 42 patients, 38 without gross residual disease or metastatic lesions formed the basis of this review. All 38 patients underwent revision wide excision; most (31) also received adjuvant therapy (radiation and/or chemotherapy). Clinical data were obtained from analysis of patient records and radiographic studies. Univariate analysis was performed with logistical regression, and multivariate analysis was performed with Cox modeling. RESULTS: The overall 5-year survival rate was 91.3% and the disease-free 5-year survival rate was 82.2%. Univariate analysis showed that stage-III disease (American Joint Committee on Cancer classification of soft-tissue sarcomas), lesions below the fascia, a histologic high-grade, and the development of organ metastasis were statistically significant factors for mortality. Stage-III disease also was significant for mortality on multivariate analysis. Only stage-III disease was significant for the development of local recurrence. Eighty-four percent of the patients had good to excellent functional outcomes. CONCLUSIONS: Re-excision with adjuvant therapy proved to be a safe and effective method for treating the disease and preserving limb function.

De novo osteogenic sarcoma in patients older than forty: benefit of multimodality therapy.

UNLABELLED: The treatment of primary osteogenic sarcoma is well established in younger patients; however, controversy surrounds the treatment of this disease in the older population. To confirm multimodality therapy results in longer survival than surgery alone, 58 patients older than 40 years with primary osteogenic sarcoma were assessed retrospectively for the benefits of multimodality treatment versus surgery alone. We then asked whether specific patient and tumor characteristics and treatment modalities affected the rates of survival. Finally, we questioned whether pulmonary metastatectomy increased survival. The 5-year and 10-year overall survival for the group was 58% and 44%, respectively. Multimodality therapy increased survival compared with surgery alone in patients with high-grade disease. On multivariate analysis, considerable prognostic factors for improved overall survival for the entire group were age younger than 60 years, volume less than 100 cm, normal alkaline phosphatase, localized disease, negative surgical margins, and absence of recurrence. Pulmonary metastatectomy improved survival in selected patients. LEVEL OF EVIDENCE: Therapeutic study, Level III-1 (retrospective cohort study). See the Guidelines for Authors for a complete description of levels of evidence.

Cell proliferation of cultured human cancer cells are affected by the elevated tumor pressures that exist in vivo.

Elevated interstitial fluid pressure (IFP) is observed in most solid tumors. However, the study of the cellular processes of tumors and the development of chemotherapy are routinely studied using in vitro culture systems at atmospheric pressure. Using a new pressurized cell culture system, we investigated the influence of hydrostatic pressure on population dynamics of three primary osteosarcoma (HOS, U2OS, SaOS2) and two metastatic tumor cell lines (MCF7 breast, H1299 lung) that invade bone. Values of IFP in normal human bone and muscle, and in osteosarcoma tumors obtained during their surgical biopsy established the hydrostatic pressure range for the in vitro cell studies. The IFP values were obtained from a retrospective review of patient records. IFP from confirmed osteosarcoma was 35.9+/- 16.2 mmHg. Tumor IFP was significantly higher than muscle IFP (p < 0.001) and bone IFP (p < 0.003). The in vitro study measured the cell-line proliferation using hydrostatic pressures of 0, 20, 50 and 100 mmHg. The findings suggest that hydrostatic pressure either increases or decreases tumor proliferation rates depending on cell type. Furthermore, cell death was not associated with apoptosis.

Brachytherapy tubes and free tissue transfer after soft tissue sarcoma resection.

Irradiation commonly is used after resection of soft tissue sarcomas to decrease the local recurrence rate. Brachytherapy spares more normal tissue than external beam irradiation and permits irradiation to the tumor bed in the immediate postoperative period. After vascular anastomosis and irradiation, flap survival can be affected by vascular coagulation in the immediate postoperative period and later by vascular fibrosis secondary to irradiation effects. The purpose of the current retrospective study was to evaluate the survival of free tissue transfer when combined with brachytherapy after resection of soft tissue sarcomas. Thirty-six patients had wide resection of extremity tumors, free flap coverage, and brachytherapy 5 days after surgery. Followup averaged 54 months. There were three major and four minor complications. The major complications included two patients with free flaps who required revision of anastomosis before radiation therapy (they had brachytherapy 5 days after the second surgery without additional complications) and one patient who had a deep wound infection develop 2 months after the index procedure and required a second flap. Minor complications included one hematoma, one partial skin graft loss, and two superficial infections. Brachytherapy can be done safely at the site of microvascular anastomosis in the immediate postoperative period.