Bruce T. Rougraff

A comparison of tricompartmental and unicompartmental arthroplasty for the treatment of gonarthrosis.

An historical prospective study was performed to compare two surgical management alternatives in the treatment of patients with knee arthritis. There were 120 unicompartmental and 81 tricompartmental knee arthroplasties in 98 and 66 patients, respectively. All living patients were available for follow-up observation, and survivorship data on all arthroplasties were obtained. The average follow-up interval was 78 months (range, eight-162 months) in the unicompartmental series and 68 months (range, two- 186 months) in the tricompartmental group. Patients receiving the unicompartmental arthroplasty were treated with nonmetal-backed polyethylene tibial components. Prosthetic survivorship was 92% at ten years in the unicompartmental patient group. There were no statistically significant differences in aseptic loosening between these two patient groups. In appropriately selected patients unicompartmental arthroplasty was associated with better range of motion and ambulatory function than patients being treated with tricompartmental knee replacement.

Complete quadriceps tendon ruptures.

Forty-four patients with 53 quadriceps tendon ruptures were studied retrospectively with an average follow up of 67.2 months (range: 24 to 155). The type of repair was not associated with differences in functional outcome, patient satisfaction, range of motion, or isokinetic testing. Patients with a delay in surgical treatment in comparison to those immediately repaired had significantly worse functional results (P < .05), lower satisfaction scores (P < .05), and lower isokinetic data for both the injured and uninjured extremities, however, their range of motion and comparative extensor power results were nearly identical. On reviewing all patients, the ultimate range of motion was within an average of 2 degrees of the uninjured side in nearly all patients. Based on the results of this study, all surgical methods can be expected to give comparable results as long as treatment is begun within 1 week of the injury. Regaining range of motion comparable to the uninjured side was not a problem in this series despite a delay in treatment.

Unicompartmental knee arthroplasty. A multicenter investigation with long-term follow-up evaluation.

Nonmental-backed, cemented, unicompartmental knee arthroplasty has a survivorship rate in this multicenter investigation at ten years of 91.4% (+/- 2.8). High levels of patient weight were associated with increased need for revision arthroplasty. Overall, men had a lower revision rate (2.4%) compared with women (3.9%). Valgus postoperative alignment was minimally associated with progression of disease as a cause for revision. No difference in revision rates between medial and lateral compartmental arthroplasty was noted. The theoretical clinical benefits of the use of metal-backed tibial components will need to be reevaluated in light of these findings.

Inhibition of proliferation and induction of apoptosis by doxycycline in cultured human osteosarcoma cells

Matrix metalloproteinases (MMPs) play a major role in the phenomena of growth, invasion, and metastasis of malignant disease. We studied the effects of doxycycline, a synthetic tetracycline that has been shown to suppress MMP activity in other solid tumors, on osteosarcoma (OSA) cell proliferation and MMP activity in vitro. OSA cells from 6 patients and from one established human tumor cell line (U2OS) (American Type Culture Collection) were cultured in the presence or absence of doxycycline. Doxycycline (10 microg/ml) suppressed OSA cell proliferation threefold to sevenfold in all cultures. MMP activity was assessed by gelatin zymography and was diminished by approximately 50% in all cultures. We examined the hypothesis that induction of apoptosis is one of the mechanisms by which doxycycline inhibits OSA cell proliferation. Ethidium bromide-stained gels of DNA from cells grown in the presence of 5 microg/ml and 10 microg/ml of doxycycline revealed laddering consistent with apoptosis after 24 hours in culture. The demonstration that doxycycline suppresses cell proliferation and MMP activity and induces apoptosis in human OSA cells in vitro suggests that this well-tolerated oral agent may be effective in the in vivo treatment of OSA.

Oncologic Outcomes of Primary Bone Sarcomas of the Pelvis

Although many studies have been performed for evaluation of surgical techniques and surgical morbidity in cases of primary pelvic sarcoma, few have addressed the long term oncologic outcomes for these patients. Therefore, the outcome of 41 patients with primary pelvic bone sarcomas were followed for 2-13 years (average, 6 years; median, 5 years). There were 18 chondrosarcomas (15 low grade and 3 high grade tumors), 11 osteosarcomas (1 low grade and 10 high grade tumors), 5 high grade malignant fibrous histiocytomas of bone, 5 Ewings sarcomas, 1 undifferentiated sarcoma, and 1 low grade angiosarcoma of bone. Fifteen of the 17 patients with low grade tumors survived (88%), whereas only 6 of the 24 patients with high grade tumors survived (25%). Local disease recurred in 1 of the 24 (4%) patients with high grade tumors and in none of the patients with low grade tumors. Reoperations for complications were required in 33% of the patients. A difference could not be demonstrated in the quality of surgical margins or in the surgical morbidity, patient survival, and rate of local recurrence between patients treated with hemipelvectomy (8) and those treated with pelvic resection (32). Patients with low grade pelvic sarcomas have a good prognosis after pelvic resection, but those with high grade sarcomas continue to have a poor prognosis.

Early histologic appearance of human patellar tendon autografts used for anterior cruciate ligament reconstruction.

Abstract Nine patients underwent second-look arthroscopy and biopsy between 3 and 8 weeks after anterior cruciate ligament (ACL) reconstruction using autogenous patellar tendon. All nine biopsies were taken from the central region of the graft. Every biopsy revealed viable cells in two different patterns. As early as 3 weeks after ACL reconstruction, there were areas that were very similar to patellar tendon control specimens with low nuclear counts, mature collagen, and elongated, metabolically quiescent nuclear morphology. Other areas were hypercellular and associated intimately with neovascular invasion. Vascularity of the grafts was present as early as 3 weeks after reconstruction and increased in prevalence over the next 5 weeks. All specimens had areas of acellularity and degeneration. From these data, the authors conclude that the transplantation of nonvascularized, autogenous patellar tendon is characterized by early viability of the graft both from original fibroblasts and by new cells that arise from neovascularity that is present as early as 3 weeks after ACL reconstruction.

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.

Tumors masquerading as hematomas.

Suboptimal patient management can occur when malignant soft tissue tumors with internal hemorrhage masquerade as simple hematomas. We retrospectively reviewed 31 patients with malignancies who had diagnostic delays averaging 6.7 months (range, 1.0-49.3 months). The diagnoses included soft tissue sarcomas (27), metastatic cancers (three), and lymphoma (one). History of subcutaneous ecchymosis was positive in only five patients (three of whom had trauma), negative in 18, and unknown in eight. Ecchymosis was present in two patients, absent in 20, and unknown in nine. Previous treatments included observation and reassurance (21), aspiration (11), incision and drainage (10), unplanned resections (seven), physical therapy (seven), medication administration (six), and arthroscopy (one). Interpretations of initial MRI (21) and ultrasound (four) did not raise suspicion of underlying cancers. Traumatic hemorrhage usually causes subcutaneous ecchymosis. However, intratumoral hemorrhage often is contained by a pseudocapsule, which prevents fascial plane tracking and subcutaneous ecchymosis, thus providing a diagnostic clue. Magnetic resonance imaging and ultrasound studies may not accurately diagnose questionable lesions. Diagnostic delay or inappropriate treatment may result if patients do not receive appropriate followup, biopsy (usually open), or referral whenever the diagnosis is in doubt.Level of Evidence: Level IV, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Soft-tissue lumps and bumps.

Soft-tissue masses of the extremities and torso are a common problem encountered by the orthopaedic surgeon. Although these soft-tissue masses are often benign, the orthopaedic surgeon must be able to recognize the features key to differentiating benign and malignant masses. An understanding of the epidemiology and clinical presentation of soft-tissue masses is needed in order to outline a practical approach to evaluation and surgical management.

Local progression after operative treatment of metastatic kidney cancer.

The cases of 78 patients with osseous metastases from kidney cancer were reviewed to determine the rate of local progression after operative resection as compared with more traditional intralesional procedures. Group I consisted of 41 (53%) patients who were treated with intralesional procedures involving internal fixation with or without curettage or polymethylmethacrylate. Of the 41 patients, additional operations were recommended for 17 (41%) of the patients who had local osseous progression. Fourteen additional procedures including nine wide resections with reconstruction, three amputations, and two mass excisions were done. Group II consisted of 37 (47%) patients who were treated with marginal or wide resection with or without reconstruction. In this group, only one patient required additional operative intervention for local osseous progression. Median survival of patients in Group I was 20 months compared with 35 months for patients in Group II. This study shows that despite shorter average survival, patients who undergo intralesional surgery are at high risk of reoperation for local progression. Resectional surgery should be considered in patients with skeletal metastases from kidney cancer to lessen the risk of reoperation for local progression.