Doris E. Wenger

Acetabular Labral Tears Rarely Occur in the Absence of Bony Abnormalities

We evaluated the percentage of patients with acetabular labral tears who have a structural hip abnormality detectable by conventional radiography. Records from our institution from 1996 through 2002 were reviewed to identify all patients with labral tears. Patients were excluded who had classic hip dysplasia, advanced osteoarthritis, or a history of pelvic or femoral osteotomy. The hip radiographs were evaluated for abnormalities of Tönnis angle, center-edge angle of Wiberg, acetabular version, femoral neck-shaft angle, congruency between the femoral head and acetabulum, anterior femoral head-neck offset, and presence of femoral head osteophytes. Twenty-seven of the 31 patients (87%) had at least one abnormal finding and 35% had more than one abnormality. Ten patients had a retroverted acetabulum, 16 had coxa valga, 11 had an abnormal femoral head-neck offset, and 14 had osteophytes on the femoral head. Four of 31 patients (13%) had no identifiable structural abnormalities. To our knowledge, this is the first study to document that the majority of patients with labral tears have a structural hip abnormality detectable with conventional radiographs. Familiarity with these structural abnormalities is important for early detection and accurate diagnosis, and may impact optimal treatment planning and prognosis.

Quantitative Assessment of Classic Anteroinferior Bony Bankart Lesions by Radiography and Computed Tomography

Background An anteroinferior osseous defect of the glenoid rim is sometimes encountered in patients with recurrent anterior dislocations of the shoulder. A defect of more than 21% of the glenoid length is reported to cause instability after Bankart repair. Hypothesis We can estimate the critical size of glenoid defects by using radiography or computed tomography. Study Design A controlled laboratory study. Methods Osseous defects of 0%, 9%, 21%, 34%, and 46% of the glenoid length were created stepwise in 12 cadaveric scapulae, and plain radiographs simulating the axillary and West Point views and computed tomographic images were obtained. The maximum width of the remnant glenoid was measured under each condition and expressed as a percentage of the width of the intact glenoid. Results A 21% defect appeared to be 18.6% of the intact glenoid on the West Point view. With computed tomography, a 21% defect resulted in loss of 50% of the width on a single slice across the lower one-fourth of the glenoid. Conclusions We can estimate the size of a glenoid defect by using the West Point radiographic view or computed tomogram. Clinical Relevance These images gave decisive information as to whether an osseous glenoid defect required bone grafting to achieve stability after Bankart repair.

Secondary chondrosarcoma in osteochondroma: report of 107 patients.

Secondary chondrosarcomas are rare; recognition and diagnosis are difficult. Slow growth and late recurrence require long-term followup to understand the clinical course. In the current study, 107 patients had secondary chondrosarcoma arising in a solitary osteochondroma (61 patients) or multiple exostoses (46 patients). All histologic slides were reviewed without knowledge of the outcome, and radiologic studies were available for review in 71 cases. Patients with secondary chondrosarcoma were one to two decades younger than those with primary chondrosarcoma. Male preponderance and a predilection for flat bones were observed. The radiologic signs of sarcomatous degeneration included irregularity of the margin, inhomogeneous mineralization, and an associated soft tissue mass. The tumors generally were well-differentiated. Only 10 tumors were classified as Grade 2. Five-year and 10-year local recurrence rates were 15.9% and 17.5%, respectively, and 5- and 10-year mortality rates were 1.6% and 4.8% for patients having initial treatment at the authors’ institution. Metastasis developed in five patients: in the lung in four patients and in the groin region in one patient. Most patients who died of tumor died of local recurrence. Wide excision had the lowest local recurrence rate. With successful surgical treatment, patients may have long-term disease-free survival.

Alendronate improves bone mineral density in primary biliary cirrhosis: A randomized placebo-controlled trial

Bone loss is a well‐recognized complication of primary biliary cirrhosis (PBC). Although it has been suggested that alendronate might improve bone mineral density (BMD) in PBC, no randomized placebo‐controlled trial has been conducted. The primary aim of this study was to compare the effects of alendronate versus placebo on BMD and biochemical measurements of bone turnover in patients with PBC‐associated bone loss. We conducted a double‐blinded, randomized, placebo‐controlled trial. Patients with a PBC and BMD t score of less than −1.5 were randomized to receive 70 mg per week of alendronate or placebo over 1 year. BMD of the lumbar spine and proximal femur were measured at entry and at 1 year. Changes from baseline in BMD and biochemical measurements of bone turnover were assessed. Thirty‐four patients were enrolled. Seventeen patients were randomized to each arm. After 1 year, a significantly larger improvement (P = .005) in spine BMD was observed in the alendronate group (0.09 ± 0.03 g/cm2 SD from baseline) compared with the placebo group (−0.003 ± 0.02 g/cm2 SD from baseline). A larger improvement (P = .046) was also observed in the femoral BMD of alendronate patients versus placebo. BMD changes were independent of concomitant estrogen therapy. The rate of adverse effects was similar in both groups. In conclusion, in patients with PBC‐related bone loss, alendronate significantly improves BMD compared with placebo. Although in this study oral alendronate appears to be well tolerated in patients with PBC, larger studies are needed to formally evaluate safety. (HEPATOLOGY 2005;42:762–771.)

Malignant fibrous histiocytoma of bone

Malignant fibrous histiocytoma of bone, a relatively rare primary malignant neoplasm occurring in bone, is a distinct clinicopathologic entity formerly included in the category of osteosarcoma or fibrosarcoma. A series of patients treated at the Mayo Clinic for malignant fibrous histiocytoma of bone was studied to determine whether the prognosis for this disease is different from that of osteosarcoma and whether treatment should be different.

MRI Findings of 26 Patients with Parsonage-Turner Syndrome

OBJECTIVE The objective of our study was to describe the MRI features of patients with Parsonage-Turner syndrome. Familiarity with the MRI features associated with this entity is important because radiologists may be the first to suggest the diagnosis. Twenty-six patients with Parsonage-Turner syndrome were treated at our institution between 1997 and 2005. We retrospectively reviewed the MR images of patients with clinical or electromyographic evidence (or both) of acute brachial neuritis without a definable cause. CONCLUSION MRI of the brachial plexus and shoulder in patients with Parsonage-Turner syndrome showed intramuscular denervation changes involving one or more muscle groups of the shoulder girdle. The supraspinatus and infraspinatus muscles were the most commonly involved. MRI is sensitive for detecting signal abnormalities in the muscles of the shoulder girdle of patients with Parsonage-Turner syndrome. MRI may be instrumental in accurately diagnosing the syndrome.

Molecular Testing for Lipomatous Tumors: Critical Analysis and Test Recommendations Based on the Analysis of 405 Extremity-based Tumors

Ancillary molecular testing has been advocated for diagnostic accuracy in the differentiation of lipomas from atypical lipomatous tumors/well-differentiated liposarcomas (ALT/WDL); however, the implications and specific indications for use are not well-established in the current literature. Herein, we extend previous findings by quantitatively evaluating the impact of molecular testing of lipomatous neoplasms in our routine clinical practice, how it modifies the historical perspective of their clinical course, and the effect of distinct surgical procedures in modulating the risk of local recurrence for these tumors after molecular classification. On the basis of these analyses, we suggest a specific set of basic recommendations for complementary molecular assessment in the diagnosis of lipomatous tumors. Four hundred and five lipomatous neoplasms located in the trunk and extremities were analyzed histologically and for the presence of 12q13-15 amplification on paraffin-embedded tissues by assessing MDM2/CPM amplification. Survival analyses were calculated with Kaplan-Meier and compared with the log-rank. Multivariate analysis was evaluated by the Cox regression method. The 405 tumors were histologically classified as ordinary lipoma (n=324), intramuscular lipoma (n=29), and ALT/WDL (n=52). The level of agreement between the histologic diagnosis and the molecular diagnosis was high (96%) but pathologists showed a tendency to overestimate cytologic atypia and the diagnosis of ALT/WDL (precision, 79%; accuracy, 88%). Molecular assessment led to a major diagnostic reclassification in 18 tumors (4%). Eleven of the tumors histologically classified as ALT/WDL were reclassified as ordinary lipoma (n=5) and intramuscular lipoma (n=6); none of which recurred. Seven ordinary lipomas were reclassified as ALT/WDL, 6 of which were larger than 15 cm and deeply located; 2 recurred locally. After molecular data, the 5-year local recurrence rates for ordinary lipoma, intramuscular lipoma, and ALT/WDL were 1%, 12%, and 44%, respectively. Multivariate analyses after molecular assessment showed tumor type and type of resection to be associated with the risk of local recurrence. Complementary molecular testing refines the histologic classification of lipomatous tumors and better estimates the impact of surgical procedures on the risk of local recurrence. Pathologists tend to overestimate the degree of cytologic atypia and the indiscriminate use of molecular testing should be avoided, especially for extremity-based tumors. Molecular testing should be considered for “relapsing lipomas,” tumors with questionable cytologic atypia (even if widely excised), or for large lipomatous tumors (>15 cm) without diagnostic cytologic atypia.

Recent Intraarticular Steroid Injection May Increase Infection Rates in Primary Tha

We retrospectively determined the rate of therapeutic intraarticular steroid injection within 1 year before total hip arthroplasty (THA) for osteoarthritis and whether the injection of the steroid increased the risk of infection. In a retrospective matched cohort study, 224 primary THAs (217 patients) implanted within 1 year of intraarticular steroid injection (Group 1) were compared with 224 primary THAs (220 patients) in patients who had not received an injection (Group 2). The mean time between injection and THA was 112 days (SD, 81 days). In Group 1, there were three deep and 11 superficial infections compared with one deep and eight superficial infections in Group 2. The hazard ratios of deep and superficial infections were 3 (95% CI, 0.3, 29.8) and 1.5 (95% CI, 0.6, 3.6), respectively. Intraarticular steroid injection within 1 year of THA did not affect postoperative rates of infection. However, the mean time from steroid injection to THA was 44 days (SD, 23 days) in the few patients who had deep infection develop. While not statistically significant, this raises a concern of increased risk of deep infection when receiving a steroid injection within 6 weeks of THA. Caution should be used before giving an intraarticular steroid injection within 2 months before THA.Level of Evidence: Therapeutic study, Level III. See Guidelines for Authors for a complete description of levels of evidence.

Does local recurrence impact survival in low-grade chondrosarcoma of the long bones?

We hypothesized local recurrence of Grade 1 chondrosarcoma in the long bones of the extremity negatively influences survival. To explore that notion, we retrospectively reviewed 164 patients treated surgically for Grade 1 chondrosarcoma of the long bones. Local recurrence occurred in 21 (13%) patients. Four patients had progression of tumor grade on recurrence, and six patients had more than one local recurrence. Seven of the 21 patients with local recurrences had metastasis. Six of the 21 patients with local recurrences died secondary to chondrosarcoma. Local recurrence, progression of grade at recurrence, and distant metastases all were associated with a decrease in overall survival. The difference in survival was not apparent until after 5 years and was more pronounced after 10 years. Recurrence may be regarded as a declaration of an aggressive phenotype and should be treated as such. Level of Evidence: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Malignant fibrous histiocytoma of bone: A clinicopathologic study of 81 patients

BACKGROUND. Malignant fibrous histiocytoma of bone, a relatively rare primary malignant neoplasm occurring in bone, is a distinct clinicopathologic entity formerly included in the category of osteosarcoma or fibrosarcoma. A series of patients treated at the Mayo Clinic for malignant fibrous histiocytoma of bone was studied to determine whether the prognosis for this disease is different from that of osteosarcoma and whether treatment should be different. METHODS. The bone tumor files of the Mayo Clinic were reviewed for examples of malignant fibrous histiocytoma of bone. Clinical records and histologic slides were reviewed for 81 patients. Roentgenograms of 13 patients were available for review. RESULTS. Patients with malignant fibrous histiocytoma of bone ranged in age from 6 to 81 years. The region most commonly affected was the knee. Seventy-eight percent of the lesions arose de novo and 22% in preexisting conditions. Histologically, most of the tumors were classified as the storiform pleomorphic type, although other histologic subtypes were identified. The prognosis depended on the types of surgical margins involved. Patients with wide or radical margins had a better prognosis than patients in whom the margins were contaminated. Some patients who received radiation therapy alone became long term survivors. CONCLUSIONS. The overall prognosis for patients with malignant fibrous histiocytoma was not found to be significantly different from that described for patients with osteosarcoma in recent series. However, at least in this small series, some patients with malignant fibrous histiocytoma had a good response to radiation therapy. Osteosarcoma is generally considered radioresistant.