James O. Johnston

The use of methylmethacrylate as an adjunct in the internal fixation of malignant neoplastic fractures.

1. The advantages of managing malignant pathological fractures in long bones by operative internal fixation is recognized. When conventional fixation is used, failures have resulted because of extensive cortical bone lysis about the fracture site with consequent instability. 2. Thirty-one actual and two incipient malignant pathological fractures in thirty patients were managed by internal fixation augmented by replacement of locally resected tumor and pathological bone by methylmethacrylate. 3. This method achieves immediate solid fracture immobilization with consequent alleviation of pain, early active joint motion, and early weight-bearing with minimum, if any, support. 4. True fracture healing probably does not occur. However, in only one patient did failure of fixation result.

Giant Cell Tumor of Bone: Curettage and Cement Reconstruction

A retrospective review was conducted of all consecutive giant cell tumors treated by the senior author (JOJ) between 1975 and 1990 using the technique of aggressive curettage through a large bone window followed by acrylic cement reconstruction. Steinmann pins were used as reinforcement bars within the methacrylate in large lesions. Thirty-eight patients with a mean followup of 5.2 years (range, 2-16 years) were identified. Three (8%) recurrences are reported. There were no infections or mechanical failures of the construct. Functional results were good to excellent in 84% of patients. Ninety-five percent of patients reported good or excellent stability, no deformity, and emotional acceptance of the procedure. The recurrence rate with this protocol (8%) approached that associated with wide resection or amputation (0%-5%), and was lower than that seen with simple curettage and bone grafting (27%-55%). Acrylic cement reconstruction is a safe and effective procedure that provides local adjuvant therapy and immediate stability for early rehabilitation. The authors emphasize the importance of aggressive curettage of the lesion through a large bone window and suggest the use of reinforcement bars within the cement for large defects.

Limb salvage and prosthetic joint reconstruction for low-grade and selected high-grade sarcomas of bone after wide resection and replacement by authoclaved autogeneic grafts

Wide resection is an acceptable alternative to amputation for the management of primary sarcomas of the long bones or pelvis. The resected bone can be debrided of gross tumor tissue, autoclaved, and then replaced over intramedullary fixation to reconstruct the limb anatomically. The procedure can be

Tumoral calcinosis: radiologic-pathologic correlation

ObjectiveTumoral calcinosis is a frequently misdiagnosed disorder. This study details the radiologic and pathologic characteristics of tumoral calcinosis that distinguish it from most other entities.DesignRadiologic and pathologic findings, and medical records of 12 patients with tumoral calcinosis were reviewed and compared with equivalent information about 5 patients with other calcified lesions.PatientsThe 12 patients ranged in age from 15 months to 62 years. Six had idiopathic tumoral calcinosis and 6 had secondary tumoral calcinosis.Results and conclusionsA consistent radiologic finding for tumoral calcinosis was a dense calcified mass that was homogeneous except for a “chicken wire” pattern of lucencies, which correlated histologically with thin fibrous septae. Other characteristics of tumoral calcinosis included fluid-calcium levels, demonstrated in four patients, and smooth osseous erosions adjacent to the mass, demonstrated in three patients. Five cases of tumoral calcinosis were originally confused with other calcified lesions; however, the radiologic findings were characteristic of tumoral calcinosis in retrospect.

Synovial chondromatosis of the hip joint presenting as an intrapelvic mass: a case report.

A totally asymptomatic twenty-four-year-old white housewife who appeared well was found on routine pelvic examination to have a firm, ovoid, seemingly immobile mass, about twelve centimeters long and six centimeters in diameter, lying along the inner left side of the pelvis. The patient had delivered a child normally six years previously, and no mass had been observed on pelvic examination as recently as two years before the present observation. Needle biopsy performed prior to her referral to Kaiser Foundation Hospital, Oakland, showed a somewhat myxomatous cartilaginous tissue with some rather aggressive-appearing chondrocytes. Orthopaedic examination demonstrated a full range of painless motion, without crepitation or limp, in the left hip. Palpation of the hip area was unrevealing. Results of laboratory studies, including a complete blood count, serum calcium, phosphorus, and alkaline phosphatase, were considered to be normal, as was a strontium-85 scan. Although the mass could not be visualized on roentgenograms, scalloping and indentation ofthe femoral head were seen (Fig. 1). The left hipjoint and the inner aspect ofthe left side ofthe pelvis were explored through an anterior approach. Numerous irregular cartilaginous bodies about one centimeter in diameter filled thejoint. They appeared to arise from an area at thejunction ofthe synovium and articular cartilage anteriorly. There was a keel-like ridge along the anterior aspect of the femoral neck. A small opening in the medial portion of the hip capsule communicated with a thumb-sized, thin-walled iliopectineal bursa, which was filled with loose cartilaginous bodies that had obviously escaped from the joint. Slightly proximal to this, outside the medial aspect of the capsule, was a mass twelve centimeters in length and six centimeters in diameter, composed of coalesced loose cartilaginous bodies (Fig. 2). At the periphery of the mass, the bodies were loosely connected and tended to separate from it. Just distal to the obturator foramen was a mass similar in size and shape, but more tightly organized. A third mass, also of the same size and tightly organized, lay within the pelvis proximal to the obturator foramen; it was this mass which had been palpated preoperatively. The three masses were easily shelled out and removed, as were the intra-articular loose bodies and the iliopectineal bursa. The histological appearance of the three masses was as previously described. There has been no evidence of recurrence during the ensuing nineteen months.

Compliant prestress fixation in tumor prostheses: interface retrieval data.

This article reports the first available human retrieval data following the use of a new fixation system for tumor prostheses. The compliant prestress (CPS) fixation system obviates the need for long intramedullary stems. The CPS was designed to provide a stable, high-pressure, motion-free bone-implant interface that would prevent aseptic loosening and allow osseointegration at the bone-implant interface. At 10 months, the fourth patient in the human trial required amputation. Backscatter electron microscopy revealed a buttress of new bone had formed along 70% of the bone-metal interface, with excellent bony ingrowth (average: 42%) into the transverse, porous-coated titanium interface.

Limb salvage procedure for neoplasms about the knee by spherocentric total knee arthroplasty and autogenous autoclaved bone grafting.

Spherocentric total joint arthroplasty was performed for treatment of neoplasm in 15 patients. The average follow-up period was 30 months. In nine of the patients concomitant autoclaved autologous bone implants were also prepared from the resected specimens. The results were satisfactory in ten patients and unsatisfactory in five. One patient had an infection that required amputation. One patient with osteosarcoma had a recurrence at 20 months and was treated by amputation. Poor results were caused by stem failure in two patients and by component loosening in one patient. Total joint arthroplasty combined with autoclaved bone implantation is a useful limb salvage procedure for resected neoplasms about the knee.

The Management of Comminuted Unstable Intertrochanteric Fractures

A modification of the medial displaced osteotomy and fixation technique of Dimon and Hughston for the operative management of unstable comminuted intertrochanteric fractures of the hip using a sliding compression screw-plate combination was performed in seventy-two patients who were followed more than twelve months after operation. Sixty-seven fractures progressed to rapid union with good valgus reduction maintained. Sixty patients were allowed full weight-bearing on the affected extremity within eight days of the operation. The average time to fracture union in this group was three and one-half months.

Pigmented villonodular synovitis of the shoulder after anterior capsulolabral reconstruction

Pigmented villonodular synovitis (PVNS) is a proliferative disorder of the synovium affecting joints, bursae, or tendon sheaths. PVNS is further classified into diffuse and localized forms and rarely affects the shoulder. We report a case of nodular synovitis of the shoulder after arthroscopic and open anterior capsulolabral reconstruction. The histopathology and treatment of a nodular form of PVNS of the shoulder is discussed.

Latissimus Dorsi Tendinosis and Tear: Imaging Features of a Pseudotumor of the Upper Limb in Five Patients

OBJECTIVE The objective of our study was to determine the imaging appearances of a pseudotumor of the upper limb, latissimus dorsi tendinosis and tear, in five patients and to correlate those imaging findings with clinical history and histopathology. CONCLUSION Tears or reactive tendinosis of the latissimus dorsi tendon at its insertion on the proximal humerus may present as a pseudotumor. Awareness of the imaging findings may allow accurate diagnosis and conservative management.