William R. Reinus

Ultrasonographic evaluation of the rotator cuff and biceps tendon.

Ultrasonography of the rotator cuff and biceps tendon was investigated in 106 patients who had been referred for arthrography of the shoulder. Both the sensitivity and the specificity of ultrasound in detecting a tear of the rotator cuff were 91 per cent. The predictive value of a negative sonogram was 95 per cent and the predictive value of a positive sonogram was 84 per cent. Ultrasonography proved to be superior to arthrography in the examination of the normal and abnormal biceps tendon. Sonographically detectable effusions from the tendon sheath of the biceps were present in 19 per cent of this population of patients. This finding was statistically highly associated (90 per cent) with rotator cuff tears and other soft-tissue abnormalities of the shoulder. Based on these results, it appears that ultrasonography can be used as the initial imaging test for many patients with suspected abnormalities of the rotator cuff or biceps tendon.

A MULTIDISCIPLINARY STUDY INVESTIGATING RADIOTHERAPY IN EWING'S SARCOMA: END RESULTS OF POG #8346

PURPOSE To determine if involved field radiation (IF) is equivalent to standard whole bone radiation (SF) in local tumor control; to establish patterns of failure following treatment; and to determine response, event-free survival (EFS), and overall survival rates from multidisciplinary therapy in Ewings sarcoma. METHODS AND MATERIALS Between 1983 and 1988, 184 children with Ewings sarcoma were enrolled onto Pediatric Oncology Group 8346 (POG 8346). A total of 178 (97%) met eligibility criteria; 6 had pathology other than Ewings sarcoma. Induction chemotherapy of cyclophosphamide/doxorubicin (adriamycin )(C/A) x 12 weeks was followed by local treatment either surgery or radiation therapy and C/A, dactinomycin, and vincristine for 50 weeks. Resection was advised for patients with small primary tumors if accomplished without functional loss. Forty patients were randomized to receive SF, whole bone radiation to 39.6 Gy plus a 16.2 Gy boost (total 55.8 Gy) or IF to 55.8 Gy, and the remainder were assigned to IF radiation. RESULTS Of 178 eligible patients, 141 (79%) had localized disease and 37 (21%) had metastases at presentation. Their 5-year EFS was 51% (SE 5%) and 23% (SE 7%) respectively. The response rate to induction chemotherapy was 88% (28% complete, 60% partial), but after radiotherapy the response rate increased to 98%. Thirty-seven of the localized patients underwent resection, of whom 16 (43%) required postoperative radiotherapy; the 5-year EFS of these surgical patients was 80% (SE 7%). The remaining 104 localized patients were eligible for randomization or assignment to receive radiotherapy; the 5-year EFS of these patients was 41% (SE 5%), with no significant difference in EFS between those randomized to SF vs. IF. Site of primary tumor correlated with 5-year EFS: distal extremity 65% (SE 8%), central 63% (SE 10%), proximal extremity 46% (SE 8%), and pelvic-sacral 24% (SE 10%) (p=0.004). Initial tumor size did not correlate significantly with EFS. Patterns of failure among the 141 localized patients revealed 23% of patients experienced a local failure, while 40% had a systemic failure. The 5-year local control rate for the surgical patients +/- postoperative radiotherapy was 88% (SE 6%), while for the patients undergoing radiotherapy alone it was 65% (SE 7%). There was no difference in local control between those randomized to SF vs. IF. The 5-year local control rate for the patients with pelvic-sacral tumors was 44% (SE 15%), significantly worse than the local control rates for those with central tumors 82% (SE 8%), distal extremity 80% (SE 8%), or proximal extremity 69% (SE 9%) (p=0.023). However, quality of radiotherapy correlated with outcome. Patients who had appropriate radiotherapy had a 5-year local control of 80% (SE 7%), while those with minor deviations had 5-year local control of 48% (SE 14%), and those with major deviations had a local control of only 16% (SE 15%) (p=0.005). The local failure was within an irradiated volume in 62% of patients, outside the irradiated volume in 24% of cases, while the precise location could not be determined in the remaining 14%. CONCLUSIONS As most failures in Ewings sarcoma are systemic, improved EFS requires more effective systemic chemotherapy. Adequate IF radiotherapy requires treatment to appropriate volumes as defined by MRI imaging and full radiation doses. Pretreatment review of radiologic images with a musculoskeletal radiologist to determine appropriate tumor volumes, as well as use of conformal radiotherapy techniques are important for improved outcome.

Primary Ewing's sarcoma involving the bones of the head and neck

Ewings sarcoma is a rare tumor of the bone. In the Intergroup Ewings Sarcoma Study (IESS) approximately 4% of the primary bone tumors arose in the bones of the head and neck. The mean age of patients was 10.9 years; boys slightly dominated the group. Signs and symptoms were local in distribution, with a mass or swelling most frequent. As in other sites, we categorized the dominant histologic pattern as diffuse or filigree, the latter carrying a more unfavorable prognosis. The radiographic appearance may be atypical as compared to Ewings sarcoma at other sites. Prognosis of head and neck Ewings is significantly better than Ewings sarcoma overall. The gnathic bones were commonly affected, yet there was no associated mortality. No patient with primary disease in the bones of the head and neck who survived for 5 years on any of the IESS protocols has subsequently died.

Expansile Skeletal Hyperphosphatasia: A New Familial Metabolic Bone Disease†‡

We describe a new familial metabolic bone disease characterized by expanding hyperostotic long bones, early onset deafness, premature tooth loss, and episodic hypercalcemia. The condition affects a mother and daughter studied at the age of 36 years and 11 years, respectively. Both individuals lost all hearing in early childhood and suffered premature shedding of teeth. Skeletal pains began just before puberty. Swelling and aching of most middle phalanges in the hands is an especially troublesome manifestation. The mother also had episodes of symptomatic hypercalcemia first documented in late childhood and subsequently during intercurrent illness and postpartum lactation. Radiographs show hyperostosis and/or osteosclerosis predominantly in the skull and appendicular skeleton. Long bones also are expanded considerably, especially the middle phalanges in the fingers. The mothers skeletal abnormalities are more severe. Biochemical parameters of bone turnover, including serum alkaline phosphatase (ALP) activity, are elevated substantially. In the proposita, dynamic histomorphometry of nondecalcified sections of iliac crest revealed rapid skeletal remodeling. In the mother, who had been treated with bisphosphonates, electron microscopy (EM) showed disorganized collagen bundles as well as necrotic and apoptotic bone cells but no osteocytic osteolysis. Measles virus gene transcripts were not detected in peripheral blood monocytes. Karyotyping was normal, 46,XX. Hyperphosphatasia with bone disease previously has been reported as either a sporadic or autosomal recessive condition. Expansile skeletal hyperphosphatasia (ESH) is probably inherited as an autosomal dominant trait with a high degree of penetrance.

Practical selection criteria for noncontrast cranial computed tomography in patients with head trauma

STUDY OBJECTIVE To study patients with acute trauma retrospectively for clinical predictors of positive cranial computed tomography. METHODS We reviewed the medical records and noncontrast computed tomography scans of 373 consecutive head trauma patients presenting to a trauma Level I emergency department. Potential criteria for patient selection were analyzed statistically, using both univariate and multivariate models. RESULTS Our data suggest that relying on four variables--positive neurologic examination, intoxication, and a history of amnesia or focal neurologic deficit--as screening criteria for computed tomography would have saved 58.6% of the scans performed on these patients. Together, these criteria had a sensitivity of 90.1% and a negative predictive value of 98.1% for abnormal computed tomography. Four patients with positive scans would not have been detected using this strategy. None of these patients deteriorated clinically or required operative intervention. CONCLUSION Our data suggest that it may be possible to effectively screen patients with head trauma for cranial computed tomography using clinical criteria and so reduce the current number of scans performed by more than half. However, a prospective study is required to confirm our results.

Lead arthropathy: a cause of delayed onset lead poisoning

Patients who suffer gun shot wounds often have retained bullet fragments within their bodies. These are usually of no clinical consequence. We describe three patients with retained bullets within their hip joints. One of these patients, who had extensive ground intra-articular bullet fragments and secondary osteoarthritis of the hip, presented with signs, symptoms, and laboratory data consistent with lead intoxication. The bullet and metallic fragments were removed surgically with good clinical response. Two patients whose bullets were implanted entirely within the femoral head and whose joints showed smaller degrees of lead fragmentation had no symptoms of lead intoxication. The degree of intra-articular fragmentation of the bullet and the surface area of lead exposed to synovial fluid are emphasized as decisive factors with respect to appropriate therapy.

Arthrographic evaluation of the carpal triangular fibrocartilage complex

One hundred sixty-two patients had analyses for correlation of triangular fibrocartilage abnormalities (TFCC), with duration and location of pain and other possible associated radiographic, scintigraphic, and arthrographic abnormalities. Results indicated that TFCC perforations did not correlate with any pain complex or other associated radiographic, arthrographic, or scintigraphic abnormality. No association with carpal instability or with ulnar variance could be identified. No definition between perforations that were posttraumatic and those that were the results of a degenerative process could be made. Several small defects on both the proximal and distal surfaces of the TFCC were identified. They do not appear to have been reported previously in the literature. Their significance is discussed.

Posteroanterior wrist radiography: Importance of arm positioning

Proper interpretation of wrist radiography requires a standardized radiographic technique. We obtained posteroanterior (PA) radiographs of the wrist in nine patients in three different arm positions to study the effect of arm position on ulnar styloid process orientation. An appearance simulating a normal anteroposterior (AP) wrist radiograph was present in six of nine PA radiographs when the arm was positioned next to the trunk, and the elbow was flexed to a 90% angle. The orientation of the ulnar styloid was not helpful in differentiating either pronated from supinated wrist positions or AP from PA projections. We concluded that radiographic screening of the carpus should be performed with standardized wrist positioning and nomenclature as described in modern radiographic technological texts. Supplemental projections should be exposed and interpreted with an understanding of the position of the arm and the direction of the incident radiographic beam at the time of examination.

Quantitative analysis of the plain radiographic appearance of aneurysmal bone cysts.

RATIONAL AND OBJECTIVESTo quantitate radiographic features that distinguish the plain radiographic appearance of aneurysmal bone cyst (ABC) from other solitary lesions of bone. MATERIALS AND METHODS Seven hundred nine cases of focal bone lesions, including 32 ABCs were analyzed according to demographic, anatomic, and plain radiographic features. Vector analysis of groups of features was performed to determine those that are most sensitive and specific for the appearance of ABC in contrast with other lesions in the data base. RESULTS Aneurysmal bone cysts most consistently are medullary-based, either eccentric or centric (94%), show lysis (100%), cortical thinning (97%), enlargement of the host bone (100%), and geographic bone destruction (94%). They have well-defined edges (84%), no fallen fragment (100%), no evidence of periosteal reaction (75%), and no visible matrix (91 %). Although they typically occur in the metadiaphysis of long bones, the anatomic location and demographic data did not significantly affect the sensitivity or specificity for detection of ABCs. The vector analysis-generated differential diagnoses include giant cell tumor, unicameral bone cyst, nonossifying fibroma, enchondroma, and fibrous dysplasia as the major lesions. CONCLUSIONS A relatively specific set of radiographic features can be defined, which will assist in the radiographic interpretation and improve on current textbook descriptions.

QUANTITATIVE ANALYSIS OF THE PLAIN RADIOGRAPHIC APPEARANCE OF BRODIE'S ABSCESS

RATIONALE AND OBJECTIVES The authors quantitate the radiographic features that distinguish the plain radiographic appearance of Brodies abscess (BA) from other solitary lesions of bone. METHODS Plain radiographs of 709 solitary bone lesions were reviewed, including 21 BAs. These were analyzed according to demographic, gross anatomic, and structural features. Vector analysis of groups of features was performed to determine those that are most sensitive and specific for the radiographic appearance of BA relative to other lesions of bone. RESULTS Brodies abscesses, in our series, are most commonly medullary-based (86%) lytic lesions (100%), with a geographic pattern of destruction (100%), well-defined edges (90%), marginal sclerosis (86%), and no bone enlargement (95%). In general, they have no periosteal reaction (71%), cortical break (95%), or visible matrix (90%). They typically are localized to the diaphysis or metaphysis (86%) of tubular bones, particularly in the lower extremity (63%). By vector analysis, the radiographic and demographic description of BA that provided the greatest sensitivity (67%-76%) while maintaining high prevalence (20%-21%) included a well-defined lytic lesion with a geographic pattern of destruction, and no bone enlargement or matrix or cortical break arising in patients younger than 40 years old. Although BAs commonly are small lesions with maximum diameters < 50 mm, size criteria did not greatly affect the sensitivity or specificity for detection of BA in our database. The differential diagnosis generated by vector analysis includes osteoid osteoma, nonossifying fibroma, giant cell tumor, eosinophilic granuloma chondroblastoma, and fibrous dysplasia, as the major lesions. CONCLUSIONS Although BA can present with a variety of radiographic features, a relatively specific set of radiographic characteristics can be defined to assist in plain-film diagnosis and to help refine the differential diagnosis of similar-appearing lesions.