Jesse T. Torbert

Endoprosthetic reconstructions: Results of long-term followup of 139 patients

Our primary goal in doing this study was to determine the effect of prosthesis location, patient age, periprosthetic infection, and primary versus revision placement on endoprosthetic survival. We also examined our endoprosthetic survival rates and reasons for failure. We retrospectively studied 139 endoprosthetic reconstructions performed between 1984 and 2002, including 57 distal femur, 27 proximal femur, 26 proximal tibia, 17 proximal humerus, 4 distal humerus, 3 total scapula, 3 total femur, and 2 total humerus reconstructions. Location of reconstruction and presence of periprosthetic infection significantly affected endoprosthetic survival. Survival was not affected by patient age or primary versus revision placement. Overall, Kaplan-Meier event-free endoprosthetic survival was 86%, 80%, and 69% at 3, 5, and 10-year followup. The trend for endoprosthetic survival from best to worst was proximal femur, proximal humerus, distal femur, proximal tibia, and distal humerus. Reasons for failure included mechanical failure (eight patients), tumor recurrence (eight patients), aseptic loosening (six patients), dislocation (two patients), periprosthetic infection (two patients), and endoprosthetic malalignment (one patient). Our periprosthetic infection rate was 2.2%. The local recurrence rate in patients treated for primary malignant tumors was 6.8%, similar to previous limb-salvage and amputation studies. Overall, we have found that endoprosthetic reconstruction is a reliable limb-salvage technique. Level of Evidence: Therapeutic study, Level IV-2 (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Intralesional curettage for grades II and III giant cell tumors of bone.

Grade III Campanacci lesions are traditionally treated with wide resections based on their postulated aggressiveness and potential for local recurrence and metastasis. The purpose of this study was to determine if there was a difference in local recurrence rates of Grade II and III lesions treated with intralesional curettage, burring, phenol cauterization, and polymethylmethacrylate application. Sixty-three patients (26 Campanacci Grade II and 37 Grade III lesions) met the inclusion criteria. No pathologic fractures, including intraarticular fractures, were included in this study. Followup averaged 108 months (range, 25–259 months). The overall local recurrence rate was 6% (4 of 63 patients), with no observed difference between Grade II and III lesions. The average Musculoskeletal Tumor Society functional score was 27.9/30 (93%). The mean range of motion of the adjacent joint was 97%. Patients with radiographic signs of osteoarthritis before treatment did not show substantial progression, and only one patient developed radiographic signs of degenerative arthritis postoperatively. Our distal metastatic rate was 3.2%. These data support the use of intralesional curettage and burring with adjuvant phenol and polymethylmethacrylate even in Grade III lesions, in the absence of pathologic fracture, regardless of the presence or extent of extraosseous extension. Level of Evidence: Therapeutic study, Level III-1 (retrospective cohort). See the Guidelines for Authors for a complete description of levels of evidence.

Clinical utility of percutaneous biopsies of musculoskeletal tumors

Percutaneous biopsies are frequently used for musculoskeletal lesions. We suspect published accuracy rates (80-97%) overestimate clinical utility. We retrospectively reviewed 120 consecutive percutaneous biopsies performed by interventional radiologists at our institution. Patients underwent core biopsy, fine-needle aspiration (FNA), or both. The biopsy interpretations were considered clinically useful if they allowed proper treatment to proceed and not useful if they were nondiagnostic or if surgical specimens disagreed with percutaneous specimen. Patients were categorized by biopsy type, tissue type, and tumor type. Ninety of 120 percutaneous biopsies were clinically useful, 27 were nondiagnostic, and three were incorrect; in these latter 30 patients we proceeded to open biopsy. Patients with both biopsies had clinically useful results (80.6%) more often than FNA or core alone(68.0% and 66.7%, respectively). Biopsies of bone lesions were clinically useful more often than those of soft tissue. Myxoid histology was associated with decreased clinical accuracy. Clinical utility was independent of tumor type. No single characteristic predicted increased probability of open biopsy. The clinical utility rate was acceptable, but below published accuracy rates. The combination of both biopsies was better than FNA alone. Myxoid findings rarely helped to guide definitive treatment. Treatment decision making requires balancing biopsy results with clinical data.Level of Evidence: Diagnostic study, level IV. See Guidelines for Authors for a complete description of levels of evidence.

Musculoskeletal desmoid tumors.

Desmoid tumors are benign tumors that exhibit varying degrees of local aggressiveness and diverse growth patterns. Magnetic resonance imaging remains the modality of choice for assessment of the nature and size of the soft-tissue lesion and involvement of surrounding structures. Treatment strategies include surgery, chemotherapy, hormonal therapy, and radiation therapy, either individually or in combination. Despite the benign nature of these tumors, multidisciplinary care is needed to provide combined treatment options. Chemotherapy in low doses is an excellent first-round treatment in any patient in whom contemplated local treatment may produce local morbidity and adjacent tissue injury.

Skeletal Trauma and Common Orthopedic Problems

Our understanding of the biology of fracture healing has evolved over the decades and basic science research as well as clinical outcomes studies continue to add to the existing knowledge. This review outlines the physiology and pathology of healing of fractures including those in children as well as fracture configurations with basic modalities of fixation and treatment.

Inaccuracies in the Assessment of Femoral Anteversion in Proximal Femoral Replacement Prostheses

Accurately judging anteversion of proximal femoral replacement prostheses (PFRPs) during insertion can be difficult and may affect performance/stability. We designed a gravity goniometer jig, which attaches directly to the prosthesis, to improve rotational placement. Our hypotheses were that surgeons cannot accurately estimate anteversion in the context of a PFRP and that our jig would improve rotational placement. In our model, a 15-centimeter PFRP was placed in a saw-bones femur set in a lateral position. The prosthesis could rotate into anteversion/retroversion while the femur was fixed. Orthopedic residents and surgeons made 2 attempts to place the prosthesis into 15 degrees of anteversion; first without, then with the jig. Each attempt was recorded by photograph and angle-measuring jig. Nineteen surgeons and 28 residents participated. Without the jig, the mean PFRP anteversion was 18.3 degrees (range, 1 degrees -50.5 degrees ; SD, 9.6) compared to 14.3 degrees (range, 12.5 degrees -15.5 degrees ; SD, 0.7) using the jig (P = .006). Without a jig, the mean anteversion of resident-placed endoprosthesis was 18.4 degrees (range, 3 degrees -36 degrees ; SD, 8.1) compared to 18.1 degrees (range, 1 degrees -50.5 degrees ; SD, 12.1) (P = .91) recorded for attending physicians. The angle measurements from the jig and photographs were statistically equal. The placement of the PFRP into proper anteversion was more accurate with the aid of the jig. Simple jigs, such as the one developed for this study, may improve rotational placement of PFRPs.

Recurrence and Bleeding in Hibernomas.

Hibernomas are rare, benign, soft tissue tumors of brown fat. Despite being benign, we have experienced recurrent hibernomas and cases of significant bleeding at our institution. The current literature contains case reports of recurrence, and one large series that describes pathologic variants but contains little clinical data. We could not find data on bleeding. We hypothesized that recurrence is related to the resection type and/or the pathologic variant. We also postulated that atypical histologic findings correlate with excessive bleeding during excision. We sought to confirm that the MRI features of hibernomas could distinguish them from lipomas yet place them among lipomatous tumors. We retrospectively reviewed all hibernomas at our institution over 10 years. There were six hibernomas. Two were removed with a marginal excision and four with an intralesional excision. Two recurred after intralesional surgery. Histologic findings were typical for all patients. An MRI was available on only one patient and showed a fatty tumor that was distinguishable from a lipoma. Recurrences occurred after intralesional but not after marginal excisions. Histology could not predict recurrence. Hibernomas have the potential for significant bleeding during surgical excision, as seen in two of our cases. Level of Evidence: Prognostic study, Level IV (case series). See the Guidelines for Authors for a complete description of levels of evidence.

A Rare Case of Ewing???s Sarcoma and Osteosarcoma at Different Sites 10 Years Apart

Ewings sarcoma of bone and osteosarcoma are rare tumors. A combination of high-grade osteosarcoma and Ewings sarcoma of bone in anatomically unrelated sites is unique, especially in the absence of previous radiation or retinoblastoma. We present a patient with a rare case of Ewings sarcoma of the scapula that showed no evidence of recurrence (after 10 years of continued followup) and who subsequently presented with a primary osteosarcoma of the femur.