Jasvir S. Khurana

Surgical treatment and recurrence rate of aneurysmal bone cysts in children.

High recurrence rates have been reported after surgical treatment of aneurysmal bone cysts, ranging from 10–59%, and greater (five of seven) in children younger than 10 years. No previous study has focused specifically on recurrence as a function of age in a large pediatric study. The purpose of the current study was to review the outcome of current surgical techniques in the treatment of primary aneurysmal bone cysts in children and to determine if recurrence rates were higher in younger children, as proposed by some authors. This study included 45 children with primary aneurysmal bone cysts with more than 2 years followup after their first treatment using our current four-step surgical technique. The subjects were studied and classified on the basis of their age group (≤ 10 years of age or >10 years of age). The recurrence rate, and other parameters were determined after surgical treatment. Of the 45 children with primary aneurysmal bone cysts, 13 children were 10 years or younger and 32 were older than 10 years. Persistence or recurrence of the lesion requiring additional surgery occurred in three children in the younger age group and in five children in the older age group. The difference in persistence or recurrence rates based on age was not statistically significant. However, the persistence or recurrence rates are lower than previously reported (82% overall success rate after initial surgery).

Negative scintigraphy with positive magnetic resonance imaging in bone metastases.

We report three patients with known primary tumor in whom radionuclide skeletal imaging for metastatic disease was normal with or without clinical symptomatology referable to this area. Magnetic resonance imaging (MRI) of the spine demonstrated focal areas of abnormal signal intensity in the vertebral bodies of these patients. In all three patients, biopsy confirmed metastatic disease. All the patients received radiation or chemotherapy depending upon the etiology. These preliminary data suggest that MR imaging may be useful in evaluating patients with known primary tumor in whom clinical suspicion persists despite a negative radionuclide bone scan.

Percutaneous needle biopsy of the spine

The results of 75 percutaneous needle biopsies of the spine were analyzed. There were 8 cervical, 25 thoracic, 27 lumbar, and 15 sacral biopsies. An accurate diagnosis was made in 92% of all cases. Metastatic disease yielded the best accuracy rate (96%). The lowest accuracy rate (82%) was noted with benign primary tumors and fractures. The results were better in female patients than male (97% vs. 86%). Larger needles gave slightly better accuracy (97%). No relationship between accuracy and spine level was found. There were two complications: one pneumothorax and an episode of self-limited hemorrhage. Percutaneous needle biopsy is a safe and reliable method of obtaining a diagnosis in many different spine lesions.

Postoperative infusional continuous regional analgesia. A technique for relief of postoperative pain following major extremity surgery.

A new technique using postoperative infusional continuous regional analgesia (PICRA) for postoperative pain relief was investigated in 23 surgical patients treated by amputation (12 patients) or by limb-salvage resection operations (11 patients). Bupivacaine was delivered into peripheral nerve sheaths via catheters placed therein at the time of surgery. Only patients in whom the nerves were easily accessible were treated. Catheters were placed in the axillary sheath, the lumbosacral trunk, and the femoral nerve sheaths of patients treated with shoulder girdle and pelvic procedures (resections and amputations), and within the sciatic nerve sheath of those treated with lower extremity procedures. The anesthetic agent was delivered at controllable rates. Regional analgesia was obtained in the operative site with minimal motor or sensory decrease. To assess the efficacy of this technique, the results of this study group were compared with those of a matched group of 11 patients treated with similar surgical procedures but who received epidural morphine. Eleven of the 23 patients on PICRA required no supplemental narcotic agents. The mean level of the narcotic agents required by the remaining 13 PICRA patients was approximately one third of that required by the matched group of 11 patients receiving epidural morphine. Overall, the patients on PICRA had an 80% reduction of narcotic requirements when compared to the historical controls. The technique is reliable and can be performed by the surgeon, requiring about a ten-minute increase in operating time. It has potentially wide application in orthopedics in procedures in which the major nerves are easily accessible (e.g., pelvic fractures and revision hip surgery) and for patients with intractable pain of the extremities.

Subtalar arthralgia caused by juxtaarticular osteoid osteoma.

Juxtaarticular osteoid osteomas in the ankle are frequently misdiagnosed because their symptoms mimic arthritis and may precede roentgenographic findings. In addition, these tumors are rare compared to arthritis and other sources of ankle pain. Four cases of osteoid osteoma of the talus or calcaneus are reported, indicating some of the problems encountered with their identification, and suggestions are made for appropriate investigations to aid in the early and correct diagnosis. The use of plain tomograms, thin-section computed tomograms, and radionuclide scans aid an early and correct diagnosis. Arthroscopy and arthrotomy are often inappropriate.

Skeletal metastases in liposarcoma detectable only by magnetic resonance imaging.

Diffuse, asymptomatic skeletal metastases occurred in a 46-year-old patient with liposarcoma. These metastases were detected by magnetic resonance imaging (MRI) but not by roentgenograms or radionuclide scans. Pathologic confirmation from the MRI-detected area was obtained. This observation suggests a possible explanation for the present discrepancy between the incidence of skeletal involvement in antemortem and postmortem studies in metastatic liposarcoma. MRI may be an extremely sensitive tool for detection of bone and bone marrow metastasis.

Pyogenic vertebral osteomyelitis of the posterior elements

Three cases of pyogenic vertebral osteomyelitis involving only the posterior elements are presented. This unusual location creates difficulty in distinguishing vertebral osteomyelitis from neoplasms and arthridites. All three patients had involvement of the articular facet, a helpful indication against neoplasms. However, vertebral osteomyelitis should be differentiated from erosive arthridites.

Case report 510

This 26-year-old white man complained of a dull ache in the hip over a 4-months period. There was no history of trauma, unusual athletic activity, vigorous massage, or other cause of local contusion was obtained. He had experienced no fever or weight loss. Physical examination revealed a tender mass measuring approximately 5 x 5 cm anterior to the left hip. The overlying skin appeared normal. Laboratory evaluation including serum calcium, phosphate, and erythrocyte sedimentation rate was within normal limits. Plain radiographs showed a large, densely-ossified para-articular mass adjacent to the ilium

Chondroblastoma of the rib. A case report and review of the literature

Chondroblastoma, a rare bone tumor usually found in the epiphyseal region of long bones, appeared in the rib of a 49-year-old man. Review of the literature reveals that the most common locations for this tumor are the knee and proximal humerus. The most common age group is the second decade. Eighteen cases of chondroblastoma of the rib have been reported in the literature; the patients were older than typical patients with epiphyseal chondroblastoma and had an excellent prognosis after resection of the tumor.

Malignancy supervening on an intramedullary nail

A primary, malignant, fibrous histiocytoma of bone occurring in association with a Hansen Street intramedullary nail occurred in a 39-year-old man. The physical and chemical characteristics of materials, in relation to the generation of secondary neoplasia are reviewed, but the problem of coincidence is difficult to exclude.