David G. Mohler

External beam radiation therapy enhances local control in pigmented villonodular synovitis.

PURPOSE Pigmented villonodular synovitis (PVNS) is a rare proliferative disorder of the synovium with locally aggressive behavior. We reviewed our experience using radiation therapy in the treatment of PVNS. MATERIALS AND METHODS Seventeen patients with 18 sites of PVNS were treated with radiation between 1993 and 2007. Cases were retrospectively reviewed for patient information, treatment parameters, complications, and outcome. Seven sites were primary presentations and 11 were recurrent with an average of 2.5 prior surgical interventions. The most common location was the knee joint (67%). Cytoreductive surgery was performed before radiation therapy in 16/18 sites with all having proven or suspected residual disease. Radiation was delivered using 4-15 MV photons with an average total dose 34 Gy (range, 20-36 Gy). Seventeen of 18 sites (94%) had postradiotherapy imaging. RESULTS With average follow-up of 46 months (range, 8-181 months), initial local control was achieved in 75% (12/16) of the sites with prior cytoreductive surgery (mean time to recurrence, 38 months). Ultimate local control was 100% after repeat resection (mean follow-up, 61 months). Two additional sites without prior cytoreductive surgery showed growth after radiotherapy (mean time to documented growth, 10.5 months). Seventeen of the 18 involved joints (94%) were scored as excellent or good PVNS-related function, one site (5%) as fair function, and no site with poor function. No patient required amputation; and there were no Grade 3/4 treatment-related complications. CONCLUSION Postoperative external beam radiation is effective in preventing disease recurrence and should be offered following maximal cytoreduction to enhance local control in PVNS.

Complete pelvic ring failure after posterior iliac bone graft harvesting.

STUDY DESIGN Case report. OBJECTIVE To present a rare complication of posterior iliac bone graft harvesting. SUMMARY OF BACKGROUND DATA Although iliac bone graft harvesting is a common procedure in spinal surgery, it is not without complications. One such complication is fracture of the ilium that is seen most often in older women with osteopenia. METHOD In this case a severe complication of posterior iliac bone graft harvesting was identified in a patient with steroid-induced osteoporosis that led to multiple pelvic fracture, nonunions, and eventual failure of the entire pelvic ring. Imaging studies showed osteoporotic bone and multiple nonunions of the pelvis with structural collapse. RESULTS Staged sequential platings of the iliac wings were performed to stabilize the pelvis. The initial fixation of the left iliac wing apparently united after hardware failure. The right iliac wing was successfully fixed with plates supplemented with bone cement and allograft. Anterior fixation was planned. CONCLUSIONS Care should be taken when considering autograft harvesting in patients with risk factors for osteoporosis. The outcome could be debilitating.

Adamantinoma Arising in the Distal Fibula Treated with Distal Fibulectomy: A Case Report and Review of the Literature:

Adamantinoma is a rare primary bone tumor occurring in the mandible and the long tubular bones. The diaphysis of the tibia is the most common site of extragnathic presentation. Fibular involvement is rare and usually has coexisting tibial involvement. Adamantinoma arising in the distal fibular metaphysis has not been previously reported. This is a case of a teenage boy presenting with a cystic lesion of the distal fibula, initially diagnosed and treated as a unicameral bone cyst. Aggressive behavior ultimately led to a diagnosis of adamantinoma. He was treated with distal fibulectomy without surgical reconstruction with good functional outcome.

Sarcoma Resection With and Without Vascular Reconstruction: A Matched Case-control Study.

OBJECTIVE To examine the impact of major vascular resection on sarcoma resection outcomes. SUMMARY BACKGROUND DATA En bloc resection and reconstruction of involved vessels is being increasingly performed during sarcoma surgery; however, the perioperative and oncologic outcomes of this strategy are not well described. METHODS Patients undergoing sarcoma resection with (VASC) and without (NO-VASC) vascular reconstruction were 1:2 matched on anatomic site, histology, grade, size, synchronous metastasis, and primary (vs. repeat) resection. R2 resections were excluded. Endpoints included perioperative morbidity, mortality, local recurrence, and survival. RESULTS From 2000 to 2014, 50 sarcoma patients underwent VASC resection. These were matched with 100 NO-VASC patients having similar clinicopathologic characteristics. The rates of any complication (74% vs. 44%, P = 0.002), grade 3 or higher complication (38% vs. 18%, P = 0.024), and transfusion (66% vs. 33%, P < 0.001) were all more common in the VASC group. Thirty-day (2% vs. 0%, P = 0.30) or 90-day mortality (6% vs. 2%, P = 0.24) were not significantly higher. Local recurrence (5-year, 51% vs. 54%, P = 0.11) and overall survival after resection (5-year, 59% vs. 53%, P = 0.67) were similar between the 2 groups. Within the VASC group, overall survival was not affected by the type of vessel involved (artery vs. vein) or the presence of histology-proven vessel wall invasion. CONCLUSIONS Vascular resection and reconstruction during sarcoma resection significantly increases perioperative morbidity and requires meticulous preoperative multidisciplinary planning. However, the oncologic outcome appears equivalent to cases without major vascular involvement. The anticipated need for vascular resection and reconstruction should not be a contraindication to sarcoma resection.

Glomus Tumor of the Plantar Arch: A Case Report with Magnetic Resonance Imaging Findings

A 55-year-old woman with a 12-year history of a painful nodule in the subcutaneous fat layer of the plantar arch was evaluated with magnetic resonance imaging, followed by excisional biopsy. Pathology revealed a glomus tumor, which is extremely rare in the plantar surface of the foot. The magnetic resonance imaging studies are presented. The literature on glomus tumors in the foot is reviewed. This entity should be considered in the differential diagnosis of solitary plantar nodules when marked sensitivity to temperature or pressure is exhibited.

Intercalary Tibial Allografts Following Tumor Resection: The Role of Fibular Centralization

Options to reconstruct intercalary tibial defects include allografts, vascularized bone transfers, autogenous cortical grafts, endoprostheses, and Ilizarov bone transport. Five patients underwent intercalary bulk allograft reconstruction following en bloc resection of tibial sarcomas. Two patients underwent immediate fibular centralization and iliac crest bone grafting in addition to the allograft. Two patients who underwent fibular centralization during primary reconstruction united uneventfully. The remaining three patients developed nonunion, of which one was successfully salvaged by fibular centralization. A combined allograft transplant and fibular centralization with iliac crest bone grafting is an effective procedure to reconstruct the tibial diaphysis, as well as a salvage procedure for allograft nonunion.

Augmented amputations of the lower extremity.

Ten patients who had amputations of a lower extremity for high-grade sarcomas underwent bone augmentation with either allograft or autograft between 1988 and 1996. There were eight transfemoral amputations and two transtibial amputations. The transferred segments consisted of one proximal tibia and six distal tibia autografts, two allografts, one autograft talar dome and first metatarsal, and one with a patellar cap of a supracondylar amputation. The average length of followup was 54 months. There were no nonunions of any of the grafts. There were three wound problems requiring additional operations. One autograft resorbed, and one autograft had a late infection. There was one local recurrence. Augmentation to provide length resulted in a 42% increase in bone length in those performed purely for length. All patients were able to use standard prostheses. Functional outcome was appropriate to the amputation level. Half of the patients avoided more proximal levels of amputation because of the ability to augment the osteotomy. The use of nonvascularized structural autografts or allografts is a simple procedure that can produce a superior residual limb in patients undergoing amputation. Its use should be considered in patients for whom traditional amputation techniques will result in poor function, difficulty in fitting a prosthesis, or greater than necessary anatomic loss.

Failure of medullary tubes. A materials analysis.

The objective of this study is to determine the effects of autoclaving on the stress, strain, ultimate tensile strength (UTS), fracture strain, modulus, and yield stress of nylon medullary tubes. There are three reports describing nylon medullary tube failure in the literature. All cases involved the use of nylon medullary tubes during open reduction internal fixation of fractured long bones. We demonstrated increased brittleness and decreased strength with increased exposure of medullary tubes to autoclaving, most dramatically after 100 autoclave cycles. Visual inspection of tubes is a clear indication of material degradation after repeated autoclaving. Furthermore, there is a significant difference in ultimate tensile strength (P < 0.0001) between tubes exposed to less than 100 sterilization cycles compared to tubes exposed to greater than 100 cycles. Likewise, there is a significant decrease in yield stress (P < 0.0004) between the same groups. We recommend disposal and replacement of nylon medullary tubes before they are exposed to 100 autoclaving cycles in order to avoid failure of the device.

Angiosarcoma of the hand associated with chronic exposure to polyvinyl chloride pipes and cement : A case report

Angiosarcoma of the liver has been reported to be causally related to chronic exposure to polyvinyl chloride7,14,15,25. Skin contact with products that contain polyvinyl chloride is known to cause a spectrum of vascular dysplasias8,21. We report the case of a patient who had angiosarcoma of the hand after having been exposed to polyvinyl chloride over a period of eleven years. The patient had lesions involving the nail-folds of three digits (the thumb and the long and ring fingers) as well as several soft-tissue masses in the palm. He also had metastases to the lungs. The treatment included amputation through the distal third of the forearm followed by chemotherapy. The metastatic lesions in the lungs were excised. Six years after treatment, the patient was alive with evidence of recurrent disease. We believe that angiosarcoma of the hand can result from chronic skin contact with pipes and cement containing polyvinyl chloride. The use of gloves to minimize skin contact with the material is recommended for those who work with these products on a routine basis. Otherwise healthy individuals who are found to have angiosarcoma of the hand should be questioned about exposure to products containing polyvinyl chloride. A thirty-six-year-old right-hand-dominant man was seen because of mild, persistent pain in the region of the metacarpal of the little finger. He apparently had been injured during a game of softball. He had not noted the presence of any mass. The patient had worked in the landscaping business for eleven years. His job involved the installation of watering systems that employed pipes and cement containing polyvinyl chloride. During the first three years of his employment, he spent approximately twenty hours per week handling pipes, cement, and primer. After he was promoted to the …

Multiple Fracture of Medullary Tube During Intramedullary Nailing of Long Bone Fractures

Intramedullary nailing is an accepted treatment for the fixation of femoral and tibial shaft fractures. There is a low but significant incidence of intraoperative complications during intramedullary nailing. During this procedure, a medullary tube may be used to exchange the bent olive-tipped reaming guidewire for the straight guidewire. A review of the literature found only one report of a fracture of the medullary tube. Two cases in which the medullary tube fractured into multiple pieces are presented.