Nonossifying Fibroma Involving Epiphysis of Long Bone-Case Report and Review of the Literature.

Nonossifying fibroma (NOF) is a common benign bone neoplasm and is usually observed in the first 2 decades of life. Most NOFs occur in the metaphysis of long bones of the lower extremities and migrate toward the diaphysis during skeletal maturation. Epiphyseal involvement by NOF has been rarely reported, with only one case found in the English literature. The authors report the second case of NOF involving the epiphysis of a long bone, the proximal tibia of a 21-year-old woman. Clinicians and pathologists should be aware of the rare possibility of epiphyseal involvement of long bones by this condition. Pathologists should select appropriate immunohistochemistry markers to rule out alternative diagnoses.

Extramedullary Hematopoiesis Adjacent to Vertebral Fracture in a Patient with Pernicious Anemia: Support for a Mechanical Extrusion Mechanism.

CASE: A 68-year-old woman presented with a paraspinal mass of indeterminate imaging characteristics. Workup and computed tomography-guided Fine Needle Aspiration (FNA) aspiration revealed extramedullary hematopoiesis (EMH) adjacent to a prior compression fracture in the setting of pernicious anemia. CONCLUSION: The combination of findings suggests a possible relationship of the compression fracture and the EMH because of traumatic extravasation of marrow contents, with the patient's underlying anemia possibly providing an underlying predisposition to EMH.

Low-grade Fibromyxoid Sarcoma With Heterotopic Bone Formation: Case Report and Review of the Literature.

Low-grade fibromyxoid sarcoma is an uncommon soft tissue malignant neoplasm with deceptively bland histologic appearance, and a tendency for late recurrence and metastasis. Cases with significant heterotopic ossification are exceedingly rare. In the literature, only 9 cases of low-grade fibromyxoid sarcoma with bone formation proven by histopathology have been described in detail in the literature. We report the case of a 42-year-old male presenting with a 20-year history of a painless tumor in his left upper thigh. Computed tomography images showed coarse punctate central and peripheral calcifications, and the mass was resected. The tumor cells were immunohistochemically positive for MUC4, and also positive for FUS (16p11.2) gene rearrangement by fluorescence in situ hybridization. Besides, immunohistochemistry showed focal weak to moderate staining for TLE-1. At histology, heterotopic ossification was also observed. A diagnosis of low-grade fibromyxoid sarcoma (grade 1, stage T4) was rendered, and prior reports of these tumors with bone formation have not concomitantly described TLE-1 staining. This paper aims to characterize the radiologic, pathologic, and clinical features of low-grade fibromyxoid sarcoma showing heterotopic ossification reported in the literature, and further review the morphologic spectrum of this malignant neoplasm.

Blinded Ultrasound Examination of the Subscapularis Following Anatomic Shoulder Arthroplasty.

BACKGROUND: The subscapularis tendon is commonly released during shoulder arthroplasty, and its integrity and repair postoperatively have been shown important to help maximize patient function. However, diagnosing subscapular tendon failure can be difficult with magnetic resonance imaging secondary to metal artifact as well as very costly. PURPOSE: The purpose of this study was to assess the utility of ultrasound imaging in evaluating subscapularis integrity at specific time points following shoulder arthroplasty, in a blinded fashion. Secondarily, we report on the correlation between the condition of the subscapularis and quality-of-life outcome measures. STUDY DESIGN: Prospective case series. METHODS: Ultrasounds were completed preoperatively and postoperatively at 1 week as well as at 1, 3, and 6 months. Each was read by a single musculoskeletal radiologist and categorized as "intact," "torn," or "unclear." Clinical outcome was evaluated using the Western Ontario Osteoarthritis Shoulder (WOOS) index at these same time points. RESULTS: The final study group consisted of 35 procedures in 33 patients (19 females and 14 males, mean age 66 ± 9 years). Three patients had postoperative subscapularis failures that were confirmed in the operating room at the time of repair. Of 24 sonographs categorized as "unclear" in the postoperative period, the majority (n = 12, 50%) were taken at 1 week. Compared to preoperative scores, patients had lower WOOS scores at 1, 3, and 6 months postoperatively (P < .001). Correlation analysis did not reveal an association between the ultrasound readings and the WOOS scores postoperatively. CONCLUSION: The utility of ultrasound examination of the subscapularis tendon following shoulder arthroplasty is limited by timing and may be most useful when used by the physician within clinical context. Significant improvement was noted in disease-specific quality-of-life scores regardless of the status of the subscapularis tendon as read on ultrasound.

The Effect of Early Range of Motion on Quality of Life, Clinical Outcome, and Repair Integrity After Arthroscopic Rotator Cuff Repair.

PURPOSE: To compare the effect of early versus delayed motion protocols on quality of life, clinical outcomes, and repair integrity in patients who have undergone arthroscopic single-tendon rotator cuff repair. METHODS: This was a prospective, randomized, investigator-blinded clinical trial. Seventy-three patients from a single surgeon's practice who underwent arthroscopic repair of a single-tendon rotator cuff tear were randomized to either an early motion protocol (starting 2 to 3 days after surgery) or a delayed motion protocol (starting 28 days after surgery). The primary outcome measure was the Western Ontario Rotator Cuff index (WORC). Secondary outcome measures included clinical outcome scores, integrity of the repair on 6-month magnetic resonance imaging scans, pain scores, physical examination data, and ultrasonography. Study participants were followed up at 3, 6, and 12 weeks; 6 months; and 1 year postoperatively. RESULTS: There was no statistically significant difference in WORC scores at 6 months (529 ± 472 in delayed group vs 325 ± 400 in early group, P = .08). Mixed-effects analysis indicated the early group maintained lower WORC scores throughout the postoperative period (estimated difference of 191, P = .04). The proportions of patients with tears on the 6-month postoperative magnetic resonance imaging scan were comparable (31% in delayed group vs 34% in early group, P = .78). CONCLUSIONS: There was no difference between the delayed and early motion groups in WORC scores at 6 months after surgery. Early motion was associated with lower WORC scores throughout the postoperative period; however, both groups had a similar trajectory of improvement, suggesting both protocols have the same effect on patient-reported improvement. Although failure rates were similar between the groups, the sample size was not sufficient to support a statement regarding the relation between tear morphology and the rehabilitation protocol. LEVEL OF EVIDENCE: Level II, lesser-quality randomized controlled trial.

Radiographic interpretation of distal radius fractures: visual estimations versus digital measuring techniques.

PURPOSE: Distal radius fractures are a common injury. In the emergency room, trainees regularly assess these fractures using visual estimation. Our hypothesis is that assessment of radiographic parameters has sufficient accuracy for rendering treatment consistent with formal measurements. METHODS: This study compared visual measurements made by 25 orthopaedic residents and attending physicians to formal measurements made by a single fellowship trained musculoskeletal radiologist in a series of patients with distal radius fractures. A search was performed utilizing the ICD-9 code for distal radius fracture in all patients presenting to a single institution emergency department. Participants used visual estimation to rate 25 radiographs. Parameters estimated included radial inclination, radial height, volar tilt, and the presence of intra-articular displacement. Analysis using Lin concordance coefficients, Bland Altman plots, and the Kappa statistic evaluated the agreement between visual estimation and formal measurements. The proportion of raters whose estimates would have resulted in a course of treatment that conflicted with the formal reading quantified the potential impact of visual estimation on treatment. RESULTS: Concordance coefficients were poor for radial inclination (ρc = 0.13), radial height (ρc = 0.24), and volar tilt (ρc = 0.46). The Kappa statistic for intra-articular displacement was 0.4. Analysis performed according to level of training did not result in substantial improvements in these statistics. Treatment based on visual estimates conflicted with formal readings 34 % of the time for radial inclination, 38 % of the time for radial height, 27 % of the time for volar tilt, and 31 % of the time for intra-articular displacement. DISCUSSION: Visual estimation is not an adequate form of measurement for evaluation of patients with distal radius fractures. Physicians should be mindful of these results when developing treatment plans based solely upon visual estimation.

Osteoid osteoma: a pictorial review.

Osteoid osteoma is a small, benign osteoblastic bone tumor most commonly found in long bones, such as the femur or tibia. Osteoid osteomas account for roughly 10% of all benign bone tumors and characteristically present with dull aching pain, worse at night, and often relieved with NSAIDS. They typically present in young individuals, most commonly between the ages of seven and 25 years and in a male to female ratio of 3:1. An understanding of its classic radiographic appearance is necessary for diagnosis.

Overuse injuries of the foot: imaging presentations of common pathologies.

Overuse injuries of the foot are common, resulting in frequent visits to the primary care physician and orthopaedic surgeon. Radiologic workup often ensues. Morton's neuroma, plantar fasciitis and Haglund's syndrome are three such entities with classic MRI appearances.

Tennis leg: mechanism of injury and radiographic presentation.

As summer is upon us, we thought a discussion of tennis leg would be beneficial to our fellow clinicians. Tennis leg is a relatively common clinical condition, classically manifesting as acute, sports-related pain in the mid-calf. First described in 1883, the pathogenesis has been debated--tennis leg was first attributed to rupture of the plantaris tendon, though more recent investigations have implicated rupture of the medial head of the gastrocnemius at its myotendinous junction. For simplicity, many authors use the term tennis leg to describe all such acute muscle injuries in the superficial calf.

Effects of radiation on bone.

Ionizing radiation produces its deleterious biologic effects by both direct (DNA strand breaks) and indirect processes (formation of free oxygen radicals). Mitotically active cells are more susceptible to the detrimental effects of ionizing radiation. These effects are most severe locally within the treatment field but can also occur systemically, possibly reflecting hormonal influences and inflammatory cytokine mediators. Specific bone complications of radiation include osteopenia, growth arrest, fracture and malignancy. Some of these complications, such as osteopenia, are reversible and severity is dose dependent. Insufficiency fractures are a common complication after radiation therapy and generally affect those bones under most physiologic stress and with the highest ratio of trabecular to cortical bone. Familiarity with the radiographic appearance of irradiated bone, including computed tomography (CT) and magnetic resonance imaging (MRI), will improve image interpretation and facilitate accurate diagnosis.

Lateral patellar dislocation: mechanism of disease, radiographic presentation, and management.

Lateral patellar dislocation is a common injury occurring in young active adults. The mechanism is that of twisting injury to the knee on a planted foot with valgus stress. Several predisposing factors, including femoral trochlear dysplasia, patella alta, and lateralization of the tibial tuberosity, contribute to patellar instability and lateral patellar dislocation. Magnetic resonance (MR) imaging of the knee is the modality of choice to evaluate underlying bone contusion patterns, associated soft-tissue injuries, and additional complex ligamentous and osteochondral injuries, many of which are not apparent on conventional radiographs.

Sonography of supraspinatus tendon abnormalities in the neutral versus Crass and modified Crass positions: a prospective study.

OBJECTIVES: The purpose of this study was to investigate how well the neutral arm position correlates with the Crass and modified Crass positions in sonographic evaluation of supraspinatus tendon abnormalities. METHODS: A prospective study was performed on 32 shoulders in 31 patients with shoulder pain. Images were acquired in the long axis of the supraspinatus tendon in the neutral, Crass, and modified Crass positions and were reviewed independently of each other by 2 radiologists in consensus. The images were evaluated for visualized tendon length, tendinosis, partial- or full-thickness tears, calcific tendinosis, subdeltoid bursitis, and enthesopathic changes. Kappa values of agreement between neutral and Crass and neutral and modified Crass positions were determined. RESULTS: The mean visualized tendon lengths were 1.78, 2.83, and 2.77 cm in the neutral, Crass, and modified Crass positions, respectively. Kappa agreements between neutral and Crass and neutral and modified Crass positions were as follows: perfect agreement for calcific tendinosis (neutral versus Crass, κ =1.00; neutral versus modified Crass, κ = 1.00), almost perfect agreement for full-thickness tears (neutral versus Crass, κ = 0.85; neutral versus modified Crass: κ= 0.92) and tendinosis (neutral versus Crass, κ = 0.93; neutral versus modified Crass, κ = 0.86), substantial agreement for enthesopathic changes (neutral versus Crass, κ= 0.80; neutral versus modified Crass, κ= 0.61) and subdeltoid bursitis (neutral versus Crass, κ = 0.63; neutral versus modified Crass, κ = 0.75), and moderate agreement for partial tears (neutral versus Crass, κ = 0.44; neutral versus modified Crass, κ = 0.47). CONCLUSIONS: For patients who cannot tolerate the Crass or modified Crass position, the neutral position can show full-thickness tears, tendinosis, calcific tendinosis, enthesopathic changes, and bursitis.

Leiomyoma of the foot: sonographic features with pathologic correlation.

Leiomyomas arising outside of the uterus and gastrointestinal tract are uncommon, though these benign soft tissue neoplasms have been reported in the lower extremity and foot. To our knowledge, the sonographic appearance of a lower extremity leiomyoma has not been described in the literature. This report involves a case of leiomyoma of the foot and its sonographic imaging features. MR correlative imaging and histopathology are also provided.

Osteoporosis: a disease in men.

Osteoporosis, a metabolic bone disease characterized by low bone mass, microarchitectural deterioration of bone tissue, and increased susceptibility to fracture, now is recognized to be a disease of men and women. Based on bone mineral density measurements established by the World Health Organization, approximately 2 million men in the United States currently are affected. Information about the pathogenesis, diagnosis, and treatment of osteoporosis in men is accumulating. Estrogen now is known to be necessary for normal skeletal maturation and for maintenance of adult bone mass in men. As we will discuss, the age-related decline in bone mineral density in men seems to result from an age-related decline in the levels of bioavailable estrogen. Osteoporosis candidate genes have been discovered, and their polymorphisms may predispose men to a weakened, osteoporotic phenotype. Determining a bone mineral density standard to diagnose men with osteoporosis has proven challenging, often leaving diagnosis until a fragility fracture has occurred. General prevention strategies for osteoporosis in men are targeted at men most likely to sustain a fragility fracture. Specific medical therapies for osteoporosis in men, including bisphosphonates and intermittent parathyroid hormone, are proving promising.