M. A. J. van de Sande

Proximal migration can be measured accurately on standardized anteroposterior shoulder radiographs

During the last decade, investigators of several studies have stressed the importance of early diagnosis and treatment of rotator cuff tears to improve outcome of surgical repair. Proximal migration of the humeral head is thought to be indicative for rotator cuff disorders. We wanted to assess the accuracy of proximal migration measurement on anteroposterior radiographs. Computed tomography scans and anteroposterior radiographs of 43 shoulders in 26 patients were taken using the same protocol. Proximal migration was measured as the acromiohumeral interval and the upward migration index. The mean absolute difference for the upward migration index was only 0.06 (standard deviation, 0.07), this was less then 5% of the mean upward migration index measured on computed tomography reformations. The correlation coefficient and Bland-Altman plot showed a strong correlation between computed tomography and radiographic measurements, especially for the upward migration index (correlation coefficient, 0.82). Our results indicate that measurement of subacromial space on anteroposterior radiographs, controlled for positioning, scaling, and individual differences by using the upward migration index, presents an accurate measurement for proximal migration. Level of Evidence:Diagnostic study, Level I (testing of previously developed diagnostic criteria on consecutive patients-with universally applied reference “gold” standard). See the Guidelines for Authors for a complete description of levels of evidence.

Intercalary allograft reconstructions following resection of primary bone tumors: a nationwide multicenter study.

BACKGROUND Favorable reports on the use of massive allografts to reconstruct intercalary defects underline their place in limb-salvage surgery. However, little is known about optimal indications as reports on failure and complication rates in larger populations remain scarce. We evaluated the incidence of and risk factors for failure and complications, time to full weight-bearing, and optimal fixation methods for intercalary allografts after tumor resection. METHODS A retrospective study was performed in all four centers of orthopaedic oncology in the Netherlands. All consecutive patients reconstructed with intercalary (whole-circumference) allografts after tumor resection in the long bones during 1989 to 2009 were evaluated. The minimum follow-up was twenty-four months. Eighty-seven patients with a median age of seventeen years (range, 1.5 to 77.5 years) matched inclusion criteria. The most common diagnoses were osteosarcoma, Ewing sarcoma, adamantinoma, and chondrosarcoma. The median follow-up period was eighty-four months (range, twenty-five to 262 months). Ninety percent of tumors were localized in the femur or the tibia. RESULTS Fifteen percent of our patients experienced a graft-related failure. The major complications were nonunion (40%), fracture (29%), and infection (14%). Complications occurred in 76% of patients and reoperations were necessary in 70% of patients. The median time to the latest complication was thirty-two months (range, zero to 200 months). The median time to full weight-bearing was nine months (range, one to eighty months). Fifteen grafts failed, twelve of which failed in the first four years. None of the thirty-four tibial reconstructions failed. Reconstruction site, patient age, allograft length, nail-only fixation, and non-bridging osteosynthesis were the most important risk factors for complications. Adjuvant chemotherapy and irradiation had no effects on complication rates. CONCLUSIONS We report high complication rates and considerable failure rates for the use of intercalary allografts; complications primarily occurred in the first years after surgery, but some occurred much later after surgery. To reduce the number of failures, we recommend reconsidering the use of allografts for reconstructions of defects that are ≥15 cm, especially in older patients, and applying bridging osteosynthesis with use of plate fixation.

The management of diffuse-type giant cell tumour (pigmented villonodular synovitis) and giant cell tumour of tendon sheath (nodular tenosynovitis)

Giant cell tumours (GCT) of the synovium and tendon sheath can be classified into two forms: localised (giant cell tumour of the tendon sheath, or nodular tenosynovitis) and diffuse (diffuse-type giant cell tumour or pigmented villonodular synovitis). The former principally affects the small joints. It presents as a solitary slow-growing tumour with a characteristic appearance on MRI and is treated by surgical excision. There is a significant risk of multiple recurrences with aggressive diffuse disease. A multidisciplinary approach with dedicated MRI, histological assessment and planned surgery with either adjuvant radiotherapy or systemic targeted therapy is required to improve outcomes in recurrent and refractory diffuse-type GCT. Although arthroscopic synovectomy through several portals has been advocated as an alternative to arthrotomy, there is a significant risk of inadequate excision and recurrence, particularly in the posterior compartment of the knee. For local disease partial arthroscopic synovectomy may be sufficient, at the risk of recurrence. For both local and diffuse intra-articular disease open surgery is advised for recurrent disease. Marginal excision with focal disease will suffice, not dissimilar to the treatment of GCT of tendon sheath. For recurrent and extra-articular soft-tissue disease adjuvant therapy, including intra-articular radioactive colloid or moderate-dose external beam radiotherapy, should be considered.

Soft tissue extension increases the risk of local recurrence after curettage with adjuvants for giant-cell tumor of the long bones

Background and purpose Risk factors for local recurrence of giant-cell tumor of bone (GCTB) have mostly been studied in heterogeneous treatment groups, including resection and intralesional treatment. The aim of the study was the identification of individual risk factors after curettage with adjuvants in GCTB. Methods Of 147 patients treated for primary GCTB between 1981 and 2009, 93 patients were included in this retrospective single-center study. All patients were treated with curettage and polymethylmethacrylate (PMMA) with (n = 75) or without (n = 18) phenol. Mean follow-up was 8 (2–24) years. Recurrence-free survival was assessed for treatment modalities. Age, sex, tumor location, soft tissue extension, and pathological fractures were scored for every patient and included in a Cox regression analysis. Results The recurrence rate after the first procedure was 25/93. Recurrence-free survival for PMMA and phenol and for PMMA alone was similar. Eventually, local control was achieved using 1 or multiple intralesional procedures in 85 patients. Resection was required in 8 patients. A higher risk of local recurrence was found for soft tissue extension (HR = 5, 95% CI: 2–12), but not for age below 30, sex, location (distal radius vs. other), or pathological fracture. Interpretation Curettage with adjuvants is a feasible first-choice treatment option for GCTB, with good oncological outcome and joint preservation. Soft tissue extension strongly increased the risk of local recurrence, whereas age, sex, location, and pathological fractures did not.

The vascularised fibular graft for limb salvage after bone tumour surgery: a multicentre study

Vascularised fibular grafts (VFGs ) are a valuable surgical technique in limb salvage after resection of a tumour. The primary objective of this multicentre study was to assess the risk factors for failure and complications for using a VFG after resection of a tumour. The study involved 74 consecutive patients (45 men and 29 women with mean age of 23 years (1 to 64) from four tertiary centres for orthopaedic oncology who underwent reconstruction using a VFG after resection of a tumour between 1996 and 2011. There were 52 primary and 22 secondary reconstructions. The mean follow-up was 77 months (10 to 195). In all, 69 patients (93%) had successful limb salvage; all of these united and 65 (88%) showed hypertrophy of the graft. The mean time to union differed between those involving the upper (28 weeks; 12 to 96) and lower limbs (44 weeks; 12 to 250). Fracture occurred in 11 (15%), and nonunion in 14 (19%) patients. In 35 patients (47%) at least one complication arose, with a greater proportion in lower limb reconstructions, non-bridging osteosynthesis, and in children. These complications resulted in revision surgery in 26 patients (35%). VFG is a successful and durable technique for reconstruction of a defect in bone after resection of a tumour, but is accompanied by a significant risk of complications, that often require revision surgery. Union was not markedly influenced by the need for chemo- or radiotherapy, but should not be expected during chemotherapy. Therefore, restricted weight-bearing within this period is advocated.

Giant cell tumours of the small bones of the hands and feet: Long-term results of 30 patients and a systematic literature review.

Giant cell tumours (GCTs) of the small bones of the hands and feet are rare. Small case series have been published but there is no consensus about ideal treatment. We performed a systematic review, initially screening 775 titles, and included 12 papers comprising 91 patients with GCT of the small bones of the hands and feet. The rate of recurrence across these publications was found to be 72% (18 of 25) in those treated with isolated curettage, 13% (2 of 15) in those treated with curettage plus adjuvants, 15% (6 of 41) in those treated by resection and 10% (1 of 10) in those treated by amputation. We then retrospectively analysed 30 patients treated for GCT of the small bones of the hands and feet between 1987 and 2010 in five specialised centres. The primary treatment was curettage in six, curettage with adjuvants (phenol or liquid nitrogen with or without polymethylmethacrylate (PMMA)) in 18 and resection in six. We evaluated the rate of complications and recurrence as well as the factors that influenced their functional outcome. At a mean follow-up of 7.9 years (2 to 26) the rate of recurrence was 50% (n = 3) in those patients treated with isolated curettage, 22% (n = 4) in those treated with curettage plus adjuvants and 17% (n = 1) in those treated with resection (p = 0.404). The only complication was pain in one patient, which resolved after surgical removal of remnants of PMMA. We could not identify any individual factors associated with a higher rate of complications or recurrence. The mean post-operative Musculoskeletal Tumor Society scores were slightly higher after intra-lesional treatment including isolated curettage and curettage plus adjuvants (29 (20 to 30)) compared with resection (25 (15 to 30)) (p = 0.091). Repeated curettage with adjuvants eventually resulted in the cure for all patients and is therefore a reasonable treatment for both primary and recurrent GCT of the small bones of the hands and feet.

Hemicortical Resection and Inlay Allograft Reconstruction for Primary Bone Tumors A Retrospective Evaluation in the Netherlands and Review of the Literature

BACKGROUND Selected primary tumors of the long bones can be adequately treated with hemicortical resection, allowing for optimal function without compromising the oncological outcome. Allografts can be used to reconstruct the defect. As there is a lack of studies of larger populations with sufficient follow-up, little is known about the outcomes of these procedures. METHODS In this nationwide retrospective study, all patients treated with hemicortical resection and allograft reconstruction for a primary bone tumor from 1989 to 2012 were evaluated for (1) mechanical complications and infection, (2) oncological outcome, and (3) failure or allograft survival. The minimum duration of follow-up was twenty-four months. RESULTS The study included 111 patients with a median age of twenty-eight years (range, seven to seventy-three years). The predominant diagnoses were adamantinoma (n = 37; 33%) and parosteal osteosarcoma (n = 18; 16%). At the time of review, 104 patients (94%) were alive (median duration of follow-up, 6.7 years). Seven patients (6%) died, after a median of twenty-six months. Thirty-seven patients (33%) had non-oncological complications, with host bone fracture being the most common (n = 20, 18%); all healed uneventfully. Other complications included nonunion (n = 8; 7%), infection (n = 8; 7%), and allograft fracture (n = 3; 3%). Of ninety-seven patients with a malignant tumor, fifteen (15%) had residual or recurrent tumor and six (6%) had metastasis. The risk of complications and fractures increased with the extent of cortical resection. CONCLUSIONS Survival of hemicortical allografts is excellent. Host bone fracture is the predominant complication; however, none of these fractures necessitated allograft removal in our series. The extent of resection is the most important risk factor for complications. Hemicortical resection is not recommended for high-grade lesions; however, it may be superior to segmental resection for treatment of carefully selected tumors, provided that it is possible to obtain adequate margins. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Subacromial space measurement: a reliable method indicating fatty infiltration in patients with rheumatoid arthritis.

Proximal migration of the humeral head is thought to indicate fatty infiltration of the rotator cuff muscles or rotator cuff tears. We sought to evaluate the influence of these rotator cuff abnormalities on the subacromial space. Using anteroposterior radiographs, ultrasound, and computed tomography, we analyzed 54 shoulders in 29 patients with rheumatoid arthritis. The upward migration index was defined as proximal migration of the humeral head relative to its size. The mean muscle density from computed tomography images was used to indicate fatty infiltration. Fatty infiltration of the infraspinatus muscle showed the strongest correlation with proximal migration. After correcting for age, cuff tears, and rheumatoid disease, the partial correlation coefficient between both remained strong. A subdivision in proximal migration is proposed to screen for rotator cuff abnormalities. A large amount of fatty infiltration was indicated by an upward migration index less than 1.25, a medium amount by an upward migration index between 1.25 to 1.35, and a small amount by an upward migration index greater than 1.35. Measurement of proximal migration using the upward migration index provides a reliable screening method indicating fatty infiltration of the rotator cuff.Level of Evidence: Diagnostic study, Level I. See the Guidelines for Authors for a complete description of levels of evidence.

Functional outcome and quality of life after the surgical treatment for diffuse-type giant-cell tumour around the knee: A retrospective analysis of 30 patients

We retrospectively reviewed 30 patients with a diffuse-type giant-cell tumour (Dt-GCT) (previously known as pigmented villonodular synovitis) around the knee in order to assess the influence of the type of surgery on the functional outcome and quality of life (QOL). Between 1980 and 2001, 15 of these tumours had been treated primarily at our tertiary referral centre and 15 had been referred from elsewhere with recurrent lesions. The mean follow-up was 64 months (24 to 393). Functional outcome and QOL were assessed with range of movement and the Knee injury and Osteoarthritis Outcome Score (KOOS), the Musculoskeletal Tumour Society (MSTS) score, the Toronto Extremity Salvage Score (TESS) and the SF-36 questionnaire. There was recurrence in four of 14 patients treated initially by open synovectomy. Local control was achieved after a second operation in 13 of 14 (93%). Recurrence occurred in 15 of 16 patients treated initially by arthroscopic synovectomy. These patients underwent a mean of 1.8 arthroscopies (one to eight) before open synovectomy. This achieved local control in 8 of 15 (53%) after the first synovectomy and in 12 of 15 (80%) after two. The functional outcome and QOL of patients who had undergone primary arthroscopic synovectomy and its attendant subsequent surgical procedures were compared with those who had had a primary open synovectomy using the following measures: range of movement (114º versus 127º; p = 0.03); KOOS (48 versus 71; p = 0.003); MSTS (19 versus 24; p = 0.02); TESS (75 versus 86; p = 0.03); and SF-36 (62 versus 80; p = 0.01). Those who had undergone open synovectomy needed fewer subsequent operations. Most patients who had been referred with a recurrence had undergone an initial arthroscopic synovectomy followed by multiple further synovectomies. At the final follow-up of eight years (2 to 32), these patients had impaired function and QOL compared with those who had undergone open synovectomy initially. We conclude that the natural history of Dt-GCT in patients who are treated by arthroscopic synovectomy has an unfavourable outcome, and that primary open synovectomy should be undertaken to prevent recurrence or residual disease.

Modular total shoulder system with short stem. A prospective clinical and radiological analysis

Between 1994 and 2001, a short-stemmed modular shoulder prosthesis was inserted in 62 shoulders in patients with rheumatoid arthritis (RA) or osteoarthrosis (OA). We reviewed 53 patients with 60 shoulders (45 RA/15 OA) with at least 24 months follow-up. In 22 shoulders, we used a total shoulder prosthesis including a glenoid polyethylene component, whereas 38 shoulders only had a humeral component. In six shoulders, the humeral component was cemented. The average follow-up was 47 (24–99) months. There were no intraoperative complications but one wound infection and one patient with proximal migration of the humeral component. Hospital for Special Surgery Score increased from 44 (19–72) to 63 (21–93) points and Shoulder Function Assessment score (SFA) from 24 (12–46) to 42 (11–66) points. The VAS score for pain at rest improved from 4.3 to 1.9. Nonprogressive radiolucent lines were seen adjacent to nine glenoid and one humeral components. Fifty-six patients were satisfied with the result.RésuméEntre 1994 et 2001 une prothèse modulaire avec tige court a été insérée dans 62 épaules dans les malades avec polyarthrite rhumatoïde (RA) ou ostéoarthrose (OA). Nous avons examiné 53 malades avec 60 épaules (45 RA/15 OA) avec au moins 24 mois suivez. Dans 22 épaules nous avons utilisé une prothèse de l’épaule totale y compris un composant glenoid du polyéthylène, alors que 38 épaules avaient un composant humérale seulement. Dans six épaules le composant huméral a été cimenté. La suite moyenne était 47 (24–99) mois. Il n’y avait pas de complications intraopérative mais une infection de plaie et un patient avec migration proximal du composant huméral. Le Score de HSS augmenté de 44 (19–72) à 63 (21–93) points et score de SFA de 24 (12–46) à 42 (11–66) points. Les Score VAS améliorer de 4,3 à 1,9 en paix. Les lignes radiotransparent non-progressives ont été vues adjacent à neuf composants glénoïdes et un composant huméral. Cinquante-six malades ont été satisfaits avec le résultat.