Validation of diagnostic codes for subtrochanteric, diaphyseal, and atypical femoral fractures using administrative claims data.

Administrative claims databases have large samples and high generalizability. They have been used to evaluate associations of atypical femoral fractures with bisphosphonates. We developed and assessed accuracy of claims-based algorithms with hospital and physician diagnosis codes for these fractures. Medical records and radiology reports of all adults admitted at University of Alabama at Birmingham Health System from 2004 to 2008 with International Classification of Diseases, Ninth Revision hospital discharges and surgeons' fracture repair codes for subtrochanteric femoral fractures and random sample of other femoral fractures were reviewed. We identified 137 persons with suspected subtrochanteric femoral fractures and randomly selected 50 persons with either suspected diaphyseal femoral fractures or hip fractures other than subtrochanteric and diaphyseal femoral fractures (typical hip fractures). Eleven patients had radiographic features indicative of atypical femoral fractures. The positive predictive value (PPV) of claims-based algorithms varied with primary or secondary positions on discharge diagnoses and the sources of diagnosis codes. The PPV for fractures ranged 69-89% for subtrochanteric femoral, 89-98% for diaphyseal femoral, and 85-98% for typical hip fractures. The PPV of administrative codes for defining a femoral fracture as atypical was low and imprecise. Claims-based algorithms combining hospital discharges with surgeon's diagnosis codes had high PPV to identify the site of subtrochanteric or diaphyseal femoral fractures vs typical hip fractures. However, claims-based data were not accurate in identifying atypical femoral fractures. These claims algorithms will be useful in future population-based observational studies to evaluate associations between osteoporosis medications and subtrochanteric and diaphyseal femoral fractures.

The outcome of composite bone graft substitute used to treat cavitary bone defects.

Although autogenous bone graft remains the gold standard graft material, it is associated with an unacceptably high incidence of morbidity. Furthermore, operative time, blood loss, and length of hospitalization are often increased. In order for a graft substitute to replicate the optimal bone healing properties of autogenous graft, 3 essential elements must be present: scaffolding for osteoconduction, growth factors for osteoinduction, and progenitor cells for osteogenesis. A composite graft that combines a synthetic scaffold with osteoprogenitor cells from bone marrow aspirate (BMA) may potentially deliver the advantages of autogenous bone grafts without the procurement morbidity. Sixty consecutive patients with cavitary bone defects were treated with a composite of b-tricalcium phosphate (beta-TCP), Vitoss (Orthovita, Malvern, Pennsylvania), and BMA. The cavitary defects were measured on orthogonal views by experienced musculoskeletal radiologists. Radiographically, resorption and trabeculation increased steadily with time. This differential was slightly more noticeable in large defects with a central trabeculation occurring in advance of the peripheral region. The majority of patients progressed to unrestricted activities by 6 weeks and had returned to their usual activities by 12 weeks. No significant difference in graft incorporation rate was noted based on age, size of defect, or use of adjuvant local treatment. The use of a composite graft (ultraporous beta-TCP+BMA) in the treatment of cavitary lesions appears to be safe and effective.

Synovial sarcoma: clinicopathologic features, treatment, and prognosis.

Synovial sarcoma is a characteristic subtype of soft tissue sarcomas with a predilection for young people. There may be a long delay in diagnosis or misdiagnosis, because of its insidious growth, varied presentation on imaging studies and associated joint pain, which can be confused with trauma. Diagnosis requires a tissue sample in the form of a needle or open biopsy. The needle biopsy may not be representative of the tumor, particular if it is biphasic, and it may be necessary to proceed to open biopsy. Ideally, the biopsy should be performed by the surgeon who will be performing the definitive surgical resection. Although treatment is predicated on surgery, adjuvant radiation and/or chemotherapy may be beneficial, particularly in high risk patients. Significant prognostic factors include: size > 5 cm, deep-seated location, adequacy of surgical margins, and history of recurrence. In the future, multi-institutional prospectively randomized, controlled studies will be needed to better define the role of adjuvant chemotherapy. Currently, outcome may be optimized by early suspicion and detection with referral to an orthopedic oncology specialist prior to the biopsy.

Lumbar discography: current concepts and controversies.

Lumbar provocation discography is an invasive diagnostic procedure to identify pain originating from within the lumbar discs. Specific morphological changes within the disc, classified as radial fissures, can be imaged following the injection of radiopaque contrast into the nucleus pulposus. The reproduction of concordant low back and/or referred somatic pain to the lower extremity under controlled conditions and the demonstration of annular radial tears are part of a spectrum of internal disc disruption that is separate from disc degeneration. A review of the validity and technique of lumbar discography as well as recently described causes of false positive responses are presented.

Incidence of intravascular uptake during fluoroscopically guided lumbar disc injections: a prospective observational study.

BACKGROUND: Although there are many in vivo studies evaluating lumbar disc injections, no studies have described the occurrence of intravascular uptake of contrast on discography. This phenomenon, however, has been well documented for other fluoroscopically-guided, contrast-enhanced spinal injections. OBJECTIVES: To document the phenomenon and incidence of intravascular uptake during fluoroscopically-guided, contrast-enhanced lumbar disc injections. DESIGN: A prospective, observational, community-based study. METHODS: The incidence of fluoroscopically-confirmed intravascular uptake of contrast material was documented in 160 patients representing a subset of individuals presenting to a small private community hospital for evaluation and treatment of lower back pain. These patients underwent fluoroscopically-guided lumbar disc injections for therapeutic and/or diagnostic purposes. RESULTS: A total of 280 discs from L1-2 to L5-S1 were studied. The degree of disc degeneration of the evaluated discs was scored using the Adams' scoring criteria for intervertebral disc degeneration. The incidence of intravascular uptake as well as any correlation between stage of disc degeneration and intravascular uptake was statistically evaluated. A total of 40 out of 280 discs (14.3%) demonstrated intravascular uptake. Detection of intravascular uptake usually required real-time fluoroscopy. There was no statistical correlation between the degree of disc degeneration and the incidence of intravascular uptake. No disc infections or other adverse sequelae occurred. CONCLUSION: This is the first study, to our knowledge, that addresses the incidence of intravascular uptake during lumbar disc injections in patients with low back pain. The presence of intravascular uptake may have implications both clinically and diagnostically in regards to interpretation of lumbar discography and adverse events related to loss of injected medications into the vascular system.

Minimally invasive surgery for ablation of osteoid osteoma of the spine.

STUDY DESIGN: Compare the effectiveness of two different techniques for the management of osteoid osteoma of the spine. OBJECTIVE: To describe the technique, feasibility, and indications of two different minimally invasive surgical methods for the treatment of osteoid osteoma of the spine. SUMMARY OF THE BACKGROUND DATA: Current treatment of osteoid osteoma of the spine is usually conventional surgical excision. The successful treatment of osteoid osteoma of the appendicular skeleton by percutaneous radiofrequency probe ablation is known; however, there have been only a few cases reported utilizing this method to treat osteoid osteoma of the spine. The high success rate of percutaneous transpedicle vertebral biopsy and diskectomy led us to believe this technique can also be applicable for the treatment of osteoid osteoma of the spine. METHODS: Two patients with symptomatic osteoid osteoma of the spine underwent two different surgical managements with local anesthesia. In one patient, the osteoid osteoma was localized in the apex of the right L4 superior articular process joint. Under computed tomography guidance he underwent radiofrequency coagulation with the use of a radiofrequency generator at 90 degrees for 240 seconds. The lesion in the second patient was located in the right pedicle of the T9 vertebra close to the exiting nerve root and was cored out by means of a special percutaneous instrument designed for percutaneous biopsy under fluoroscopic guidance. RESULTS: Both patients experienced immediate relief of pain, resumed their regular activities, and also remained free of symptoms after the 2.5- and 3-year follow-up. CONCLUSION: Minimally invasive surgery can successfully be applied in the treatment of osteoid osteoma of the lumbar spine. When the nidus is not adjacent to the neural elements radiofrequency thermal ablation can be an effective and safe treatment of osteoid osteoma in the spine.

Effectiveness and pitfalls of percutaneous transpedicle biopsy of the spine.

Seventy-one percutaneous transpedicle biopsy specimens were taken from 68 patients with cervical, thoracic, lumbar, or sacral vertebral lesions, with the patients under local anesthesia. Sixty-one procedures were done with fluoroscopic guidance and seven procedures were done with computed tomography guidance. Twenty-one patients were diagnosed as having infectious spondylodiscitis, three had tuberculosis, two had coccidiomycosis, two had brucellosis, one had blastomycosis, one had an echinococcus cyst, six had primary neoplasms, 14 had metastatic neoplasms, five had osseous repair for insufficiency fractures, seven had osteoporotic fractures, and one had Paget's disease of bone. In the four remaining patients, the biopsy initially was negative but it was proven to be false-negative because of faulty biopsy technique. The percutaneous transpedicle approach for biopsy is safe, efficacious, and cost-effective. False-negative results and complications can be avoided when adhering to the technical details of this procedure.