Aims

The early mortality in patients with hip fractures from bony metastases is unknown. The objectives of this study were to quantify 30- and 90-day mortality in patients with proximal femoral metastases, and to create a mortality prediction tool based on biomarkers associated with early death.

Aims. The aim of this study was to assess the reliability of using MRI scans to calculate the Spinal Instability Neoplastic Score (SINS) in patients with metastatic spinal cord compression (MSCC). Methods. A total of 100 patients were retrospectively included in the study. The SINS score was calculated from each patient’s MRI and CT scans by two consultant musculoskeletal radiologists (reviewers 1 and 2) and one consultant spinal surgeon (reviewer 3). In order to avoid potential bias in the assessment, MRI scans were reviewed first. Bland-Altman analysis was used to identify the limits of agreement between the SINS scores from the MRI and CT scans for the three reviewers. Results. The limit of agreement between the SINS score from the MRI and CT scans for the reviewers was -0.11 for reviewer 1 (95% CI 0.82 to -1.04), -0.12 for reviewer 2 (95% CI 1.24 to -1.48), and -0.37 for reviewer 3 (95% CI 2.35 to -3.09). The use of MRI tended to increase the score when compared with that using the CT scan. No patient having their score calculated from MRI scans would have been classified as stable rather than intermediate or unstable when calculated from CT scans, potentially leading to suboptimal care. Conclusion. We found that MRI scans can be used to calculate the SINS score reliably, compared with the score from CT scans. The main difference between the scores derived from MRI and CT was in defining the type of bony lesion. This could be made easier by knowing the site of the primary tumour when calculating the score, or by using inverted T1-volumetric interpolated breath-hold examination MRI to assess the bone more reliably, similar to using CT. Cite this article: Bone Joint J 2021;103-B(5):971–975

Concepts in glenoid tracking and treatment strategies of glenoid bone loss are well established. Initial observations in our practice in Singapore showed few patients with major bone loss requiring glenoid reconstructions. This led us to investigate the incidence of and the extent of bone loss in our patients with shoulder instability. Our study revealed bony Bankart lesions were seen in 46% of our patients but glenoid bone loss measured only 6–10% of the glenoid surface. In the same study we found that arthroscopic labral repair with capsular plication and Mason-Ellen suturing (Hybrid technique) was sufficient to stabilise patients with bipolar bone defects and minor glenoid bone loss. This led us to develop the concept of minor bone loss and a new algorithm. Our algorithm and strategies to deal with major bone loss will also be discussed, and techniques & outcomes of Arthroscopic Bony Bankart repair, Arthroscopic Glenoid Reconstruction and Arthroscopic Remplissage procedures will be shown

The aim of this study was to determine the position of the glenoid’s “Bare Spot” in a large number of cadaver specimens. The “Bare Spot” area of the glenoid has been used to determine the presence and size of a bony lesion at arthroscopic assessment of a patient following gleno-humeral dislocation; it has been assumed that this spot is placed centrally on the face of the glenoid. Fifty cadavers were obtained from the Anatomy Department and none had known bone or joint pathology. Both shoulders were dissected open. In two there was evidence of bone pathology and one had a rotator cuff tear on one side. The size of the glenoid and the “Bare Spot” was measured with a micrometer and the position of the “Bare Spot” was measured from its centre to the anterior and posterior glenoid rims and to the antero-inferior glenoid rim (were bony lesions most often occur). The “Bare Spot” was present in 88 of 100 shoulders. Its diameter was 4.5mm with a range from 2.4mm to 9 mm and inter-quartile range from 3.35mm to 6.1mm. The “Bare Spot” is often present and is centrally placed in the antero-posterior plane, but the antero-inferior glenoid rim is further away. This is of vital importance in planning surgery as inappropriate soft tissue surgery may be performed if the “Bare Spot” is assumed to be centrally placed in the glenoid

Aim: The aim of the present study was to evaluate the functional results of the Latarjet procedure. Moreover we analysed the prevalence of glenohumeral OA after this intervention. Patients and Methods: Forty patients were included in the study. All the patients were clinically evaluated according to the system of Rowe, Duplay and Constant. X-ray evaluation was useful to detect bony lesions, to evaluate the position and the evolution of the graft, and according to the system of Samilson the grade of glenohumeral OA. Results: At follow-up none of the patients had recurrent dislocation. Only two patients reported occasional subluxation, and 1 case had a positive apprehension test. The average score for strenght according to the system of Constant was 16 points (min/max: 9/22) for the operated shoulder and 19 points (min/max: 12/24) for the uninvolved side. Pre-op radiographs demonstrated a bony lesion in 37 cases (90%): in 35 cases was discovered a lesion of the glenoid rim and in 36 shoulder was detected an Hill-Sachs lesion. In only one case was detected a Samilson grade 1 degeneration. Post-op radiographs showed a correct positioning of the coracoid graft in 32 cases, too lateral in 5 cases and too medial in 3 cases. Glenohumeral OA: 2 cases Samilson grade 2; 1 case Samilson grade 1. Conclusion: Our data confirm that Latarjet technique is an efficient procedure in chronic anterior shoulder instability in sportsmen so to allow to more than 80% of our patients to return to sport activities

Purpose of the study: Depending on the series, fractures of the anteroinferior glenoid labrum have been reported in 3% to 90% of patients with anterior shoulder instability. These fractures disrupt the physiological glenoid concavity and shorten the effective length of the glenoid arch. Indications for treatment depend on the size of the fragment and range from osteosynthesis to resection or suture. We hypothesized that these lesions could be treated arthroscopically (Bankart procedure with fragment suture). The purpose of this work was to analyze clinical and radiological outcome observed in nine patients with anterior instability associated with significant glenoid fracture. Material and methods: This was a monocentric study of a continuous series of nine glenoid fractures associated with anteromedial dislocation in nine patients (three women and six men), mean age 35.5 years (range 17–75 years). Preoperatively, all of the fractures were considered to involve more than 25% of the glenoid surface. After detaching the capsulolabral lesion with the bony fragment and avivement of the anterior border, the Bankart procedure was performed with anchors and resorbable sutures. The shoulder was strapped for six weeks with passive rehabilitation (pendulum movements) initiated early. Results: Mean follow-up was 27 months (range 12–48 months). There were no cases of recurrent instability. Seven patients were very satisfied and two were satisfied. Eight patients were able to resume their sports activities at the same level. Apprehension developed in all patients. At last follow-up, joint motion was normal for eight of the nine patients, the Duplay score was 100 for eight patients and 45 for one. All bony lesions healed in an anatomic position (six analyzed with plain x-rays and three with CT scan). Discussion and conclusion: This short series demonstrates that glenoid fractures can be treated arthroscopically with concomitant treatment of the capsulolabroligament complex in order to reconstruct the glenoid arch, an essential element for restoring shoulder stability. It is thus necessary to identify bony lesions preoperatively to determine the most appropriate therapeutic approach. A long-term follow-up will be useful to assess the rate of recurrent instability and validate this therapeutic option

Aim: Traumatic shoulder dislocation in patients older than 50 years is an unusual injury with specific anatomic lesions and different treatment considerations than these encountered in younger patients. We present our experience in treating such kind of injuries. Patients-methods: Between January December 2002 9 patients-4 males, 5 females – with ages ranging between 50–72 years (mean age 64 y.), have been treated in our department suffering from first traumatic shoulder dislocation. Rehabilitation program and overall recovery progress was observed in an outpatient basis while postoperative outcome was evaluated using ASES and UCLA rating scores. Results: In 4 patients rotator cuff tear was found and reconstructed by suturing the lesion. One (1) of these patients, who had a coexisted bony Bankart lesion, presented 1 ½ month postoperative with recurrence of dislocation. Bony Bankart lesion prevented reduction in 2 patients and was reconstructed using open stabilization in one and arthroscopic to the other. HAGL lesion was detected in another patient and treated with open reduction and shoulder stabilization. Finally 2 patients with shoulder dislocation and coexisted greater tuberosity fracture were treated with closed reduction. Conclusions: Ttraumatic shoulder dislocation in patients older than 50 years consists a distinct entity which if inadequately treated leaves the shoulder with severe functional impairment. Recurrent shoulder dislocation is an unusual complication in such patients but on the other hand rotator cuff tears and glenoid bony lesions are frequently encountered necessitating treatment. Postoperative patients should be examined in small intervals with a high degree of suspicion for the above mentioned coexisted lesions

Purpose of the study: The purpose of this retrospective study was to analyze clinical datao n pigmented villon-odular synovitis (PVSN) of the knee as well as outcome after treatment in order to define the diagnostic stages, the surgical treatment, and follow-up modalities for this rare benign proliferative disease of the synovial which predominantly affects the knee joint. Material and methods: Between 1996 and 2004, 28 patients were managed in our department, 13 men and 15 women, diffuse PVNS in 20 and localized PVNS in 8. IN the localized forms, symptoms were similar to those observed in knees with intra-articular foreign bodies or a meniscal lesion (75%) was present for 14 months on average at the first consultation. Mean age at onset of therapeutic management was 40 years (range 20–62). Localized arthroscopic or open resection was performed. For the diffuse forms, symptoms had been present for 15 months on average at the first consultation. Patients sought medical care because of spontaneous hemarthrosis or diffuse knee pain with no specific signs. Mean age at onset of therapeutic management was 38 years (range 15–59). Bony lesions were observed in 20%. Synoviorthesis or surgical synovectomy were performed. Mean follow-up was 97 months (range 12–309). Outcome was analyzed separately for the localized and diffuse forms. Results: For the localized PVNS, there were no complications after surgical treatment but the relapse rate reached 12.5%. For diffuse PVNS, the cumulative rate of relapse was 50%, recurrence being noted on average 37 months after treatment. A stiff joint developed in 14% after open synovectomy. Surgical treatment was necessary in four cases (total arthroplasty in three) seen late after development of bony lesions; the clinical outcome was good with good gain in flexion. Discussion: MRI is essential for the topographic diagnosis and to guide surgery. For diffuse PVNS seen at an advanced stage or after several recurrences, adjuvant synoviorthesis can be useful 4 to 8 months after surgery. Conclusion: Appropriate treatment of PVNS of the knee depends on the presentation but usually involves a surgical procedure. The risk of recurrence for diffuse PVNS warrants annual MRI for four years

The management of bony lesions associated with glenohumeral instability has been open to debate. Invariably a significant period of time elapses between injury and surgery during which the bony fragment may atrophy and reduce both in size and in quality. Histomorphometric bone analyses were prospectively performed on the glenoid bone fragments harvested during the modified Latarjet operation. The main purpose of the study was to assess the viability of the bone. Biopsies were obtained from 21 patients that had given informed consent. Median age was 21 years (range 16–50). All were male patients. The most important sports identified were rugby (64%) and water sports (surfing, water polo, water skiing, surfing (21%)). Mean glenoid bone loss on CT scan was 17% (range 10–50%). Thirty-three percent had bone loss greater than 20%. Gross morphology of glenolabral fragments identified a single large fragment (11/21); dominant large fragment plus smaller fragments (7/21); multiple fragments (4/21). Single large fragments comprised 52% of the study. Mean volume and mass of bony fragments were 2.18 ml (range 1–3 ml) and 1.64 gms (range 0.43–2.8 g), respectively. Histology of the specimens revealed no bone in three of the 21 specimens. Bony necrosis was present in 8/18 (44%) of the specimens. From a histopathological point of view, reattachment of these devitalized bone fragments by screws or anchors may result in predictable operative failure and recurrent instability. We can therefore not support the practice of “repair” of bony Bankart lesions based on the above findings

Background. Revision surgery for a failed metal on metal (MoM) hip arthroplasty is often unpredictable and challenging due to associated massive soft tissue and bony lesions. We present the analysis and early outcomes of revision surgery in failed MoM hip arthroplasties at our institution. Methods. We have retrospectively analysed the findings and outcomes of revision surgery in 61 failed MoM hip arthroplasties performed between 2009 and 2014. These patients were identified in the special MoM hip surveillance pathway. All these patients underwent clinical assessment and relevant investigations. Intra-operative and histopathological findings were analysed. Results. There were 24 male and 37 female patients with an average age 63.67 yrs. Of the 61 patients, 39 were revised for pseudocysts, 10 for painful hip with raised metal ion levels and the remaining cases for aseptic loosening, malposition and periprosthetic fracture. Average follow up was 12 months. Pre-op and Post-op Oxford hip scores were recorded. One death and one intra-operative periprosthetic fracture was observed. There were no dislocations but one post-op infection was observed. Conclusions. A dedicated MoM pathway helps to identify early failures. A thorough knowledge of failure mechanisms combined with appropriate early and effective surgical intervention may help achieve good clinical outcomes

Heterotopic ossification (HO) is the formation of bone at extra-skeletal sites. Genetic diseases, traumatic injuries, or severe burns can induce this pathological condition and can lead to severe immobility. While the mechanisms by which the bony lesions arise are not completely understood, intense inflammation associated with musculoskeletal injury and/or highly invasive orthopaedic surgery is thought to induce HO. The incidence of HO has been reported between 3% and 90% following total hip arthroplasty. While the vast majority of these cases are asymptomatic, some patients will present decreased range of motion and painful swelling around the affected joints leading to severe immobility. In severe cases, ectopic bone formation may be involved in implant failure, leading to costly and painful revision surgery. The effects of surgical-related intraoperative risk factors for the formation of HO can also play a role. Prophylactic radiation therapy, and anti-inflammatory and biphosphonates agents have shown some promise in preventing HO, but their effects are mild to moderate at best and can be complicated with adverse effects. Irradiation around surgery could decrease the incidence of HO. However, high costs and the risk of soft tissue sarcoma inhibit the use of irradiation. Increased trials have demonstrated that nonsteroidal anti-inflammatory drugs (NSAID) are effective for the prevention of HO. However, the risk of gastrointestinal side effects caused by NSAID has drawn the attention of surgeons. The effect of the selective COX-2 inhibitor, celecoxib, is associated with a significant reduction in the incidence of HO in patients undergoing THA. Bone morphogenetic proteins (BMP) such as BMP2 identified another novel druggable target, i.e., the remote application of apyrase (ATP hydrolyzing agent) in the burn site decreased HO formation and mitigated functional impairment later. The question is if apyrase can be safely administered through other, such as systematical, routes. While the systemic treatments have shown general efficacy and are used clinically, there may be great benefit obtained from more localised treatment or from more targeted inhibitors of osteogenesis or chondrogenesis. In the surgical setting, prophylaxis for HO is regularly indicated due to the considerable risk of functional impairment. Heterotopic ossification is a well-known complication of total hip arthroplasty, especially when the direct lateral approach is used. Possible intraoperative risks are the size of incision, approach, duration of surgery and gender that can be associated with higher rates of HO or increase of the severity of HO. Like inflammation and tissue damage/ischemia are likely to be the key in the formation of HO, kindness to the soft tissues, tissue preserving surgery, pulse lavage to remove bone inducing factors and avoiding damage to all tissues should be erased as a comorbidity. Incision length, tissue dissection and subsequent localised trauma and ischemia, blood loss, anesthetic type and length of surgery may all contribute to the local inflammatory response. Data suggest that the surgeon may control the extent and nature of HO formation by limiting the incision length and if possible the length of the operation. Currently resection of HO is generally suggested after complete maturation (between 14–18 months), since earlier intervention is thought to predispose to recurrence. Reliable indicators of maturation of HO are diminishing activity on serial bone scans and/or decreasing levels of alkaline phosphatase. Although usually asymptomatic, heterotopic bone formation can cause major disability consisting of pain and a decreased range of motion in up to 7% of patients undergoing THA. Patients benefit from early resection of the heterotopic ossification with a proper and reliable postoperative strategy to prevent recurrence of HO with clinical implications

Aims

We first sought to compare survival for patients treated surgically for solitary and multiple metastases in the appendicular skeleton, and second, to explore the role of complete and incomplete resection (R0 and R1/R2) in patients with a solitary bony metastasis in the appendicular skeleton.

1. A case of multiple pseudo-cystic tuberculosis in an American Indian infant is described. 2. The extensive lesions in the skull of this infant are considered to be of particular interest. 3. The possible significance of a bony lesion present at birth is discussed

Because of bony lesions, revision surgery in the acetabulum is not always easy. We have a revision cross that we use to strengthen the bone cement and give extra stability in the presence of defects. So far, two surgeons have performed operations on 60 patients. Follow-up times range from six months to five years. One patient has been lost because of sepsis. We conclude that this is an effective way to augment revisions

Purpose. The hip region is the second most common site for tuberculosis following the spine in children. The aim is to describe the variable radiological patterns of presentation and their resemblance to pyogenic infection, tumours and other benign conditions of bone in children. Methods. The clinical and radiological records of 29 children aged 10 months–13 years with confirmed tuberculosis of the hip region seen between 1990 and 2011 were reviewed retrospectively. Clinical features were pain, limp and flexion, adduction contractures. Abscesses and sinuses were seen in 4 children. The ESR ranged between 7–110 mm/hr. Mantoux was positive in 20 children. All cases were histologically confirmed. Treatment involved biopsy, currettage of bone defects, limited synovectomy and adductor tenotomy. Patients were immobilised for 4 weeks on a spica cast or traction. Antituberculous treatment was administered for 9–12 months. Results. Radiologically 9 lesions were extra-articular and 20 involved the joint synovium and articular surface. Extra-articular lesions were seen in the pubis, greater and lesser trochanter, ilium, proximal femur and peri-acetabular regions. Intra-articular lesions were seen in the femoral head, neck and acetabulum. Dislocations and subluxations occurred in 8 patients; various lesions mimicked pyogenic arthritis, idiopathic chondrolysis, chondrobastoma, Perthes disease, eosinophilic granuloma and osteoid osteoma. Follow up ranged between 8 months and 5 years. Good range of movement was seen in 20 children. Nine children had flexion adduction contractures, four of these had ankylosed hips and five required abduction extension osteotomies. Other changes seen were coxa vara (2) coxa magna (1) and avascular necrosis (3). Conclusion. The variable radiological picture of tuberculosis of the hip region can mimic various osteoarticular conditions in children. Biopsy is essential and should be taken from the bony lesion and not the synovium alone. NO DISCLOSURES

MRI arthography (MRA) is commonly used in the investigation of shoulder instability. However many surgeons are now using CT arthography (CTA) as their primary radiological investigative modality. They argue that CTA is cheaper, and give satisfactory soft tissue images in the “soft tissue window” mode. They believe that CTA give superior images when looking at bone loss and bony defects, and as such is more useful in deciding whether a patient requires an open procedure or not. In this study we aimed to compare the results of MRA and CTA in the investigation of shoulder instability. We reviewed the operative and arthographic findings in all patients who had surgery for shoulder instability in our unit over a 4 year period. We compared the results of the arthograms with the definitive findings found at the time of surgery. All arthograms were performed by standard techniques and were reported by musculoskeletal radiology consultants. All surgery was performed by experienced consultant shoulder surgeons. In total 48 CTAs and 50 MRAs were performed. We found that there was no significant difference between the two wrt sensitivity (p=0.1) and specificity (p=0.4) when looking at labral pathology. However CTA was more sensitive at picking up bony lesions (p< 0.05). This study supports the view that CT arthography is the superior radiological modality in identifying pathology when investigating patients with shoulder instability. It is cheaper and better tolerated by patients than MRA and gives useful information on whether a patient needs an open or arthroscopic stabilisation procedure

1 . A specific mechanism of injury can produce a tear of the articular disc of the wrist without any associated bony lesion. 2. Torn discs have been found associated with Colles's fractures and with dislocation of the inferior radio-ulnar joint. 3. The injury gives rise to clear-cut symptoms and definite physical signs. 4. Operation in fourteen cases has shown five types of tear of the disc. 5. Arthrographs of the wrist are helpful in establishing the diagnosis. 6. In isolated tears removal ofthe disc relieves the symptoms and does not prejudice function. 7. If there is other joint injury, removal of the disc cannot be expected to give as satisfactory a result

We reviewed 277 patients with soft-tissue sarcoma (STS) treated between 1975 and 1995 to study the incidence, distribution, time of appearance, and radiological findings of skeletal metastases. Of these, 28 (10.1%) had metastases within a mean period of 18.6 months after admission. The incidence of skeletal metastases differed among the histological subtypes of sarcoma; alveolar soft-part sarcoma, dedifferentiated liposarcoma, angiosarcoma, and rhabdomyosarcoma tended to show higher incidences. The regional bones close to the primary tumour were affected in 13 (46.4%) of the 28 patients, and the axial bones in 18 (64.3%). Radiologically, the metastatic bony lesions predominantly showed osteolytic changes, and there were pathological fractures in 21 of 44 lesions

Background. Bone lesions in Ewing's sarcoma (ES/PNET) have been traditionally diagnosed with bone Scan. PET-scan is emerging as a promising investigative modality for detection of metastatic lesions. In this prospective study, we compare the utility of both to detect the metastatic sites. Methods. One hundred and seventy five histologically proven cases of ESPNET from 2004-2009 were prospectively staged with bone scan and PET-scan with Breath- hold CT scan- thorax. The diagnostic value of PET-scan to pick up metastatic lesions was compared with bone scan. Results. The site of primary disease was axial in 62(35.4 %) patients, appendicular in 94(53.7 %) patients, and extraskeletal in 19 (10.8 %) patients. 24(13.7 %) patients were metastatic at presentation, while 151(86.2 %) patients had localized disease. In all patients with localized disease, bone scan did not detect any lesion other than that detected on PET-scan. In metastatic patients, PET-scan detected 12 patients with lymph node involvement which were not detected by bone scan, 10 patients were found to have lung metastasis by PET scan with breath-hold CT thorax, bony metastases were seen in two patients where the number and site of lesions were same in both PET and bone scan. In 19 patients with extraskeletal PNET, PET scan detected primary lesion in all while the bone scan was non-avid in any of these. Conclusion. PET- Scan was able to detect all the bony lesions picked up by bone scan at baseline in newly diagnosed patients of PNET/ES. Furthermore, PET-scan was able to detect extra-skeletal sites of metastases. We conclude that PET scan may obviate the need of bone scan in the diagnostic work up of patients with Ewing's sarcoma

The Latarjet procedure utilises the coracoid as a vascularised bone autograft to augment the glenoid in patients with shoulder dislocation, especially where there is a bony lesion affecting the glenoid. A modification of the Latarjet procedure, pioneered in Cape Town, South Africa, rotates the coracoid so that its curved under-surface matches that of the glenoid. The aim of this study was to measure the radii of curvature of the glenoid and the coracoid to see how well the curved under-surface of the coracoid matches the glenoid’s surface curvature. An initial study of 210 cadaveric scapulae was performed in which the radii of curvature of the surface of the glenoid and the curved under-surface of the coracoid were measured. We found that the curves are very similar. The glenoid’s surface had a median curvature of 30mm (inter-quartile range from 25mm to 30mm) and the coracoid had a median curvature of 22.5mm (inter-quartile range from 20mm to 25mm). The curvature of the glenoid in these dry specimens was slightly larger than the corresponding coracoid curvature. In life this difference would be minimised by articular cartilage, labrum and the attachment of capsule (another Cape Town modification). A further parallel CT based study was set up at Derbyshire Royal Infirmary in England. The same radii of curvature where measured and compared using 3D CT reconstruction on a further 20 scapulae from living patients. These measurements also support the cadaveric similarities with a mean glenoid curvature of 23.9mm and coracoid of 25.4mm respectively. Using a paired t-test no statiscally significant difference was found between the corresponding data (p=0.2488). This study confirms the native anatomy of the coracoid is perfectly suited for this modification of the Latar-jet procedure