Clinical and radiological aspects of idiopathic diabetic muscle infarction. Rational approach to diagnosis and treatment.

The systemic effects of diabetes mellitus are well recognised. The heart, kidney, central and peripheral nervous systems, and the distal parts of the limbs are often the site of end-organ damage resulting from ischaemia. Infarction of large muscle groups in the limb, not associated with gangrene, is uncommon. There have been few reported cases other than radiological descriptions of diabetic muscle infarcts. While previous reports have illustrated some of the clinical and radiological characteristics of this condition, the paucity of published cases makes it difficult to determine the most appropriate methods of diagnosis and treatment. During a five-year period we treated 14 patients with diabetes mellitus, aged from 32 to 59 years, who were referred to a musculoskeletal oncology service for suspected soft-tissue sarcoma, but were subsequently found to have a diabetic muscle infarct. Closed needle biopsy was performed in 13 without complications. In 12 patients, the symptoms resolved without surgical treatment.

Neuropathy secondary to pigmented villonodular synovitis of the hip.

Pigmented villonodular synovitis is a benign proliferative process of unknown origin that may cause extensive bone and joint destruction. Patients with this condition typically present with symptoms of mild discomfort and associated stiffness of the involved joint; however, the spectrum of presentations is broad. Although pigmented villonodular synovitis begins in, and usually is confined within, a synovium-lined joint, it may extend beyond the joint capsule and present as a soft tissue mass. Three cases of a previously unrecognized presentation of pigmented villonodular synovitis of the hip joint are presented. The authors believe these to be the first reported cases in the English language literature of pigmented villonodular synovitis of the hip seen with femoral or sciatic neuropathy.

Triple-phase bone scan findings in aggressive fibromatosis. Before and after radiation therapy.

The authors present comparative triple-phase bone scan findings in three cases of histologically proven aggressive fibromatosis both before (initial evaluation) and after radiation therapy. The purpose of the study was to compare triple-phase bone scan findings in aggressive fibromatosis both before and after radiation therapy and to determine whether any additional physiological information could be obtained. Before radiation therapy, the triple-phase bone scintigraphy demonstrated increased flow and radiotracer pooling in the areas of tumors on dynamic flow and immediate blood pool images, respectively. However, the delayed static images demonstrated variable radiotracer uptake. When compared to preradiation therapy triple-phase bone scan, decreased vascularity was well demonstrated in all three patients after radiation therapy. In addition, it also provided information regarding the changes in the size and extent of tumor, noninvaded underlying bone, and remainder of the skeleton. This additional information can be particularly useful in patients with equivocal or questionable histologic diagnosis especially from small, unrepresentative biopsies.

Fibrous lesions of bone.

Fibrous lesions of bone include entities with a wide range of radiographic appearance and clinical behavior. Many benign fibrous lesions, such as medial supracondylar defects, fibrous cortical defects, and nonossifying fibromas have typical radiographic appearances and usually are self-limited. Desmoplastic fibromas and benign fibrous histiocytomas are less common, behave more aggressively, and usually require biopsy and surgical management. Fibrous dysplasia varies from solitary clinically unimportant lesions to wide-spread, deforming skeletal involvement that can lead to severe functional impairment and, rarely, even to death. Malignant fibrous lesions, including malignant fibrous histiocytomas and fibrosarcoma, produce aggressive lytic lesions, which require careful anatomic staging, accurate biopsy, and aggressive and appropriate treatment.

Evaluation of patients for high tibial osteotomy.

Fifty-one osteoarthritic knees evaluated by arthroscopic, roentgenographic, and clinical examinations prior to high tibial valgus osteotomy were reevaluated roentgenographically and clinically after a minimum follow-up period of five years (average, 6.2 years; range, 5-8.3 years). The number of good and excellent results decreased over time but was unrelated to the preosteotomy condition of the lateral and patellofemoral compartments as documented by arthroscopy. Knees with 7 degrees to 13 degrees of valgus angulation at the follow-up evaluation had significantly better results than knees with less than 7 degrees of valgus, regardless of the arthroscopic findings. Preosteotomy arthroscopic findings had no predictive value in evaluating patients for this procedure.

Lesser digital arthrodesis.

Arthrodesis at the proximal interphalangeal joint is a surgical procedure useful when dealing with semireducible or nonreducible contractures of the lesser digits. When arthrodesis of the proximal interphalangeal joint is performed, there is conversion of the retrograde dorsal buckling force of the long extensor tendon to a plantargrade straightening force of the flexor tendon. This occurs as a result of the rigid strut created at the arthrodesis site. If metatarsal equinus is present, arthrodesis can help reduce this deformity and eliminate plantar pressure contributing to submetatarsal tyloma. An arthroplasty procedure does not resist deforming forces and is more useful in correcting painful deformities where flexibility is desired postoperatively. It is therefore important, even in "simple" digital surgery, to understand the etiology of the pathology and identify and structure the goals of the surgery. The end-to-end arthrodesis offers the advantage of being easy to perform, relatively free of complication, and able to maintain the length of the digit. A fixation device, such as a Kirschner wire or monofilament wire, may be needed to maintain the correction. Its inherent complications have been described. It can be relatively unstable. The peg in hole arthrodesis offers the advantage of better stability which does not necessarily require internal fixation. There is also rapid bone healing due to the side-to-side configuration of the arthrodesis site. The procedure is more complicated and time consuming to perform than an end-to-end procedure. There is more shortening in the peg in hole. Taking these factors into account, the surgeon should choose the procedure which best meets the preoperative criteria and expected postoperative results.