Brian E. McGrath

Malignant fibrous histiocytoma: an institutional review.

Background: A thorough understanding of malignant fibrous histiocytoma (MFH), the most common subtype of soft tissue sarcoma, will lead to improved histologic-specific protocols. Methods: 126 patients with histologically confirmed MFH were analyzed. The median follow-up was 42 months (range 1–233 months). Results: Overall survival was 58% at 5 years and 38% at 10 years. Grade significantly influenced prognosis, with 10-year survival of 90%, 60%, and 20% for low, intermediate, and high grade tumors, respectively (p = 0.0007). Distant metastases at initial presentation (p = 0.0002) and size of the primary tumor (p = 0.0007) influenced outcome. Neither anatomic site nor depth of the primary tumor were significant prognostic factors. Positive microscopic margins were associated with a decreased disease-free survival (p = 0.006). Conclusions: Tumor grade, size, and distant metastases at initial presentation remain the most important prognostic factors for MFH. Resection with negative microscopic margins decreased the incidence of local recurrence.

Primary Extremity Sarcoma: What Is the Appropriate Follow-Up?

Background: Our objective was to evaluate the effectiveness of follow-up tests for detecting first local and distant recurrences in patients with primary extremity soft tissue sarcoma.Methods: We retrospectively analyzed all adult cases of primary extremity soft tissue sarcoma (n 5 174) treated between 1982 and 1992. Patients were observed every 3 months for 2 years, every 4 months the third year, every 6 months the next 2 years, and annually, thereafter. Each visit consisted of taking the patient’s history, a physical examination, a complete blood count, a blood chemistry panel, and a chest x-ray. For high-grade tumors, the primary site was imaged annually when clinically appropriate.Results: Of 141 patients who were assessable, 29 patients developed local recurrence and 57 developed distant recurrence. All but one of the local recurrences was detected on the basis of an abnormal physical examination. Of the 29 patients who developed local recurrence, 25 were resected. Distant metastases were detected because of symptoms in 21 cases. Of the 36 asymptomatic lung recurrences, 30 were detected by follow-up chest x-ray. Of the 36 asymptomatic lung recurrences, 24 patients underwent metastasectomy. The positive and negative predictive values of surveillance chest x-ray were 92% and 97%, respectively. Laboratory testing never led to the detection of recurrence.Conclusions: Close surveillance by clinical assessment and chest x-ray is appropriate for follow-up observation of patients with primary extremity soft tissue sarcoma.

Ewing's sarcoma of the pelvis: Long-term survival and functional outcome

Fifty patients with Ewings sarcoma of the pelvis were treated using a multidisciplinary approach; followup of surviving patients averaged 137 months (range, 40-276 months). The addition of surgical resection to the multidisciplinary treatment for all patients was associated with improved survival compared with survival of patients treated with chemotherapy and radiation therapy alone; the addition of surgery to the treatment regimen of 37 patients without metastases also was associated with improved survival. There were no significant differences between the surgical and nonsurgical groups in terms of tumor size, stage of disease, patient age, duration of symptoms before diagnosis, or anatomic site. Surgery was used more often in recently treated patients, but the year of diagnosis and treatment did not significantly affect overall survival, secondary to large confidence intervals. The Short Form-36 and the Musculoskeletal Tumor Society functional evaluation instruments showed a superior level of function in the nonsurgical group, but this difference was not statistically significant. There have been many advances in the treatment of patients with Ewings sarcoma during the past 3 decades, resulting in improved survival for patients with Ewings sarcoma of the pelvis. The addition of surgery significantly improved survival and did not show a significant difference in functional outcome.

Evaluation of suspected osteoid osteoma.

A technique of computed tomography with intravenous contrast has proven useful in the differentiation between osteoid osteoma and other similar appearing lucent lesions of bone in 6 cases. The clinical evaluation of benign appearing radiolucent lesions of long bones has been greatly improved by the use of modern imaging techniques. The differential diagnosis often is narrowed to osteoid osteoma and osteomyelitis based on plain radiographs, computed tomography, or magnetic resonance imaging. The enhancement of the lucent center of the lesion was plotted against time. The rapid uptake of contrast medium by the osteoid osteoma was in sharp contrast to the much slower enhancement in osteomyelitis. The establishment of a preoperative diagnosis enabled the surgeon to excise the lesion without a biopsy. Histologic review verified the preoperative diagnosis in all cases.

The efficacy of direct current stimulation for lumbar intertransverse process fusions in an animal model.

Study Design. Posterolateral lumbar intertransverse process fusion using a rabbit model with autologous bone graft and direct current stimulation was compared with fusion achieved by using autologous bone graft alone. Objectives. To determine the efficacy of direct current electrical stimulation for the posterolateral lumbar intertransverse process fusion technique by using a 20-&mgr;A current and the more recently developed 60-&mgr;A current delivered by an implantable direct current stimulator. Summary of Background Data. Previous studies have demonstrated a positive effect of direct current electrical stimulation on posterior spinal fusion techniques. However, until recently, the environment of an intertransverse fusion was not well simulated. The current research examined the posterolateral lumbar intertransverse process fusion technique with direct current electrical stimulation using a rabbit model. This appears to parallel human fusion techniques more closely and allows for lower cost and technical ease. Methods. In this study, 44 adult New Zealand white rabbits underwent an L5–L6 intertransverse process fusion. All the fusions used an autologous bone graft obtained from bilateral posterior iliac crests. A device was implanted in all the rabbits subcutaneously, and they were divided randomly into three groups: a sham or nonfunctioning group, a 20-&mgr;A low-current stimulator group, and a 60-&mgr;A higher-current stimulator group. Spinal fusion was evaluated radiographically, histologically, and manually as well as by biomechanical testing 5 weeks after surgery. Results. Radiographic grades, manual palpation, biomechanical strength, and stiffness showed an increasing trend from sham or inactive stimulator groups to low-current and then to high-current stimulator groups. Histologic analysis revealed that the higher-current stimulator showed that, statistically, the healing response of the host tissue to the autograft had increased significantly, as compared with the sham. Conclusions. Direct current electrical stimulation is efficacious in improving both the healing rate and strength in this posterolateral lumbar fusion model. In addition, it appears that this effect is enhanced by increasing the stimulation current from 20 &mgr;A to 60 &mgr;A.

Observations on a retrieved patellar tendon autograft used to reconstruct the anterior cruciate ligament a case report

Torn anterior cruciate ligaments are commonly replaced with central-third bone-patellar tendon-bone autografts1. Many animal models have been used to study the revascularization process of patellar tendon autografts after reconstruction2-8. However, only biopsy material, usually superficial, from successfully functioning human anterior cruciate reconstructions have been evaluated9-13. We are reporting a case in which the entire knee joint was retrieved at autopsy on a twenty-six-year-old athlete in whom a torn anterior cruciate ligament had been replaced with a central-third bone-patellar tendon-bone autograft eighteen months earlier. To our knowledge, this is the first such analysis of a retrieved patellar tendon autograft that had been used to replace the anterior cruciate ligament. A twenty-six-year-old man tore an anterior cruciate ligament while playing basketball. Because of recurrent instability, surgery was performed three years later. Preoperative radiographs revealed normal findings. Examination with the patient under anesthesia revealed a result of 2+ on the Lachman test and a positive pivot shift. Arthroscopic examination confirmed a complete rupture of the anterior cruciate ligament, a torn lateral meniscus, and a bucket-handle tear of the medial meniscus. The lateral meniscal tear was resected, and the torn medial meniscus was excised. A central-third bone-patellar tendon-bone autograft was used to replace the torn anterior cruciate ligament under arthroscopic visualization with use of a two-incision technique. A 5 to 6-mm-deep groove was fashioned through an anterior approach with use of a curved rasp in the posterolateral aspect of the intercondylar notch. The autograft was passed through a tibial tunnel, and the patellar bone segment was secured to the posterior cortex of the distal part of the femur with a single small-fragment AO screw. The patellar tendon portion of the graft was positioned on the femoral side in the posterolateral rasped groove in the …

A randomized clinical trial to evaluate two doses of an intra-articular injection of LMWF-5A in adults with pain due to osteoarthritis of the knee.

Objective The Low Molecular Weight Fraction of 5% human serum Albumin (LMWF-5A) is being investigated as a treatment for knee pain from osteoarthritis. Methods This was a multicenter randomized, vehicle-controlled, double-blind, parallel study designed to evaluate the safety and efficacy of two doses of an intra-articular injection of LMWF-5A. Patients with symptomatic knee osteoarthritis were randomized 1∶1∶1∶1 to receive a single 4 mL or 10 mL intra-articular knee injection of either LMWF-5A or vehicle control (saline). The primary efficacy endpoint was the difference between treatment groups in the Western Ontario and McMaster Universities (WOMAC) pain change from baseline over 12 weeks. Safety was examined as the incidence and severity of adverse events (AEs). Results A total of 329 patients were randomized and received treatment. LMWF-5A resulted in a significant decrease in pain at 12 weeks compared to vehicle control (−0.93 vs −0.72; estimated difference from control: −0.25, p = 0.004); an injection volume effect was not observed (p = 0.64). The effect of LMWF-5A on pain was even more pronounced in patients with severe knee OA (Kellgren Lawrence Grade IV): the estimated difference from control was −0.42 (p = 0.02). Adverse events were generally mild and were similar in patients who received vehicle control (47%) and LMWF-5A (41%). Conclusions This clinical trial demonstrated that LMWF-5A is safe and effective at providing relief for the pain of moderate to severe OA of the knee over 12 weeks when administered by intra-articular injection into the knee. Trial Registration ClinicalTrials.gov NCT01839331

Clinical importance of late recurrence in soft‐tissue sarcomas

Soft‐tissue sarcomas (STS) represent a diverse histologic group of malignancies at risk for local and distant failure. We studied the impact of late (5 or more years) vs. early recurrence (less than 5 years) on subsequent outcome.

Large, deep high-grade extremity sarcomas: when is a myocutaneous flap reconstruction necessary?

The surgical treatment of large, deep high-grade extremity soft tissue sarcomas frequently produces a significant tissue defect. In addition, the management of the surgical wound is often further complicated by preoperative radiation or adjuvant therapies. The use of either pedicled or free myocutaneous flaps allows for more rapid and predictable wound healing in this situation. Myocutaneous flaps provide well-vascularized coverage of lost tissue volume, exposed vital structures, and prosthetic reconstruction materials. When harvested from unirradiated sites, flap coverage can overcome the detrimental effects of radiation therapy and chemotherapy on postoperative wound healing. Reconstruction of the soft tissue defect may also improve patient satisfaction with aesthetic issues. The use of innervated myocutaneous flaps can even address the functionality of the extremity following resection of major muscle groups. Myocutaneous flaps are an extremely versatile option for reconstruction in the treatment of large, deep high-grade extremity soft tissue sarcomas.

Transient peroneal nerve palsies from injuries placed in traction splints

Two patients thought to have distal femur fractures presented to the emergency department (ED) of a level 1 trauma center with traction splints applied to their lower extremities. Both patients had varying degrees of peroneal nerve palsies. Neither patient sustained a fracture, but both had a lateral collateral ligament injury and one an associated anterior cruciate ligament tear. One patient had a sensory and motor block, while the other had loss of sensation on the dorsum of his foot. After removal of the traction splint both regained peroneal nerve function within 6 hours. Although assessment of ligamentous knee injuries are not a priority in the trauma setting, clinicians should be aware of this possible complication in a patient with a lateral soft tissue injury to the knee who is placed in a traction splint that is not indicated for immobilization of this type of injury.