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Background Tendinosis at the origin of the direct head of rectus femoris causing anterior hip pain is termed AIISpinitis, but no study has investigated its imaging findings. The aim of the present study was to determine the characteristic imaging findings of AIISpinitis and clarify their pathological significance. Methods We reviewed the preoperative imaging findings of 62 hips in 58 patients who had undergone endoscopy with a diagnosis of AIISpinitis. The origin of the direct head of rectus femoris was evaluated by ultrasound (US) and magnetic resonance imaging (MRI), and the positive rate of abnormal findings and their agreement with endoscopy regarding injury of the direct head of rectus femoris were measured. Signal changes in the fat pad around the anterior inferior iliac spine (AIIS fat pad) in MRI were compared with the pathological findings of that harvested endoscopically. Results Hypoechoic regions in US (53/62, 85%) and signal change in MRI (55/62, 89%) were observed with high frequency and corresponded with injury of the direct head of rectus femoris observed by endoscopy (58/62, 94%) (kappa coefficient, 0.43 [moderate agreement], 0.69 [good agreement] respectively). Hypoechoic regions had high sensitivity (85%) and specificity (86%) for AIISpinitis. Regarding the AIIS fat pad, punctate and completely hypo-intense change relative to normal fat corresponded to fibrosis and scar formation, respectively (weighted kappa coefficient, 0.51 [moderate agreement]). Conclusions Hypoechoic regions on US which had high sensitivity and specificity; and signal change at the origin of the direct head of rectus femoris and hypo-intensity of the AIIS fat pad on MRI were characteristic findings of tendinosis of the direct head of rectus femoris. These findings correspond pathologically to injury of the direct head of rectus femoris and fibrosis or scar formation in the AIIS fat pad, respectively.

AimsThe aims of this study were to analyse the long-term outcome of vascularised fibular graft (VFG) reconstruction after tumour resection and to evaluate the usefulness of the method.Patients and MethodsWe retrospectively reviewed 49 patients who had undergone resection of a sarcoma and reconstruction using a VFG between 1988 and 2015. Their mean follow-up was 98 months (5 to 317). Reconstruction was with an osteochondral graft (n = 13), intercalary graft (n = 12), inlay graft (n = 4), or resection arthrodesis (n = 20). We analysed the oncological and functional outcome, and the rate of bony union and complications.ResultsFive- and ten-year overall survival rates were 89% and 86%, respectively. Local recurrence occurred in two patients. Eight patients developed pulmonary metastases. Bone union was achieved in 44 patients (90%). Fracture occurred in six patients (12%), infection in three (6%), and nonunion in five (10%). The mean Musculoskeletal Tumor Society (MSTS) scores were as follows: osteochondral graft 70%; intercalary graft 73%; inlay graft 89%; and resection arthrodesis 83%.ConclusionAlthough associated with a relatively high rate of complications, each reconstruction method is useful, with a high rate of successful limb salvage and a good long-term functional outcome. Cite this article: Bone Joint J 2017;99-B:1237–43.

Purpose To evaluate the results of carbon ion radiation therapy administered to 188 patients with unresectable primary sacral chordomas. Patients and methods One hundred eighty-eight patients were treated with carbon ion radiation therapy at a single institute between 1996 and 2013 and retrospectively analyzed. The median age was 66 years. The highest proximal invasion reached past S2 level in 137 patients. The median clinical target volume was 345 cm(3). One hundred six patients received 67.2 gray equivalents (GyE)/16 fractions (fr), 74 patients received 70.4 GyE/16 fr, 7 patients received 73.6 GyE/16 fr, and 1 patient received 64.0 GyE/16 fr. Results The median follow-up period was 62 months (range, 6.8-147.5 months). Seventy percent of patients were followed for 5 years or until death. The 5-year local control, overall survival, and disease-free survival rates were 77.2%, 81.1%, and 50.3%, respectively. Forty-one patients had a local recurrence. Sex, tumor volume, level of proximal invasion, and irradiated dose were unrelated to local control. There was grade 3 toxicity of the peripheral nerves in 6 patients and grade 4 toxicity of the skin in 2 patients. Ambulation remained in 97% of patients. Conclusions Carbon ion radiation therapy was safe and effective for unresectable chordoma and provided good local control and survival while preserving ambulation.

Background: Although abduction of the acetabular component is considered to predict factors for polyethylene wear attributable to osteolysis, other radiographic factors have yet to be elucidated. The purpose of the present study was to evaluate whether anteversion or change in implantation angle of the acetabular component influences polyethylene linear wear by using standing and supine radiographs of the hip joint. Methods: Standing and supine plain anteroposterior radiographs of 62 hip joints in which cementless total hip arthroplasty was performed were examined for polyethylene linear wear rate (mm/year), pelvic inclination, and radiological inclination and anatomic anteversion of the acetabular component. Results: All correlation coefficients of measurements of polyethylene linear wear, pelvic inclination angle, anatomical anteversion angle and radiological inclination angle were calculated highly. And by the three-dimensional numerical analysis, anatomic anteversion of the acetabular component had at least some effect on the degree of polyethylene wear. Conclusion: This study suggests that increased anteversion of the acetabular component reduces polyethylene linear wear in metal-on-polyethylene total hiparthroplasty.

Groin pain is a common problem that is known to be a complex issue. The wide variety of possible pathologies in numerous anatomical structures contributes to this complexity. For patients who have anterior hip pain in Patrick's test and tenderness at Scarpa's triangle, we perform periarticular debridement based on the hypothesis that rectus femoris tendinosis, subacute/chronic fibrosis of the anterior inferior iliac spine fat pad, and gluteal muscle adhesion are responsible for such anterior hip pain. This Technical note illustrates the surgical procedure of periarticular debridement for extra-articular pathology-associated anterior hip pain. Repair of the injured labrum and correction of femoroacetabular impingement deformity have never been performed in this cohort. Arthroscopic periarticular debridement is a reliable surgical technique that can relieve anterior hip pain and provide a rapid to return to normal activities.

We present a technique of posterior femoral longitudinal split (FLS) osteotomy. This technique allows the expansion of the metaphyseal–diaphyseal region of the proximal femur facilitating extraction of well-fixed extended porous-coated stems. The extractions were performed using extended transfemoral osteotomy (ETO) and FLS osteotomy between June 2002 and March 2014. The study group, which comprised patients with well-fixed extended porous-coated stems, consisted of two men and ten women with an average age of 63.2 years. The stem was successfully removed using the FLS procedure in 8 of the 10 hips. Reimplantation surgery was performed in 6 of the 12 hips with ARMD, periprosthetic infection, or metallosis. This FLS technique may allow the easy removal of well-fixed extended porous-coated stems and become an alternative method for the removal of all stems.

Background CD109, a TGF-β co-receptor, is reported to be preferentially expressed during the early stages of tumorigenesis in several carcinoma types. Myxofibrosarcoma is one of the most common soft-tissue sarcomas found in elderly patients. This study aimed to elucidate the impact of CD109 expression in myxofibrosarcoma on prognosis and recurrence. Methods Immunohistochemical staining for CD109 was performed on archival specimens from 37 patients. The Fisher exact test was used to evaluate association between CD109 expression and other clinicopathological features. Survival analysis was performed using Kaplan–Meier curves, and the prognostic significance was evaluated using the log-rank test. Multivariate analysis of factors was performed using Cox regression analysis. Results CD109 overexpression was significantly associated with surgical stage and distant metastasis (P = 0.00499, and 0.011, respectively). The frequency of CD109 overexpression was approximately 10% and CD109 overexpression was significantly associated with decreased overall survival (P = 0.004). Five-year overall survival rates 77% and 0% for CD109-negative and CD109-positive patients, respectively. In multivariate analysis, CD109 overexpression was the only independent risk factor for poor outcome (P = 0.02; hazard ratio, 10.64; 95% confidence interval, 1.47–76.91). Conclusions Immunohistochemical CD109 expression in myxofibrosarcoma was associated with poor prognosis. J. Surg. Oncol. 2015 111:975–979. © 2015 Wiley Periodicals, Inc.

Cam impingement is caused by jamming of an abnormal femoral head with an increased radius into the acetabulum during motion. Therefore, the elevation of the contact pressure during the motion is suspected to be an essential pathology of femoroacetabular impingement. However, there is no method to quantify the hip contact pressure during motion. The purpose of this Technical Note is to introduce a technique to measure the hip contact pressure during arthroscopic surgery. The author believes that the current technique will be a useful tool for the detailed investigation of the pathophysiology femoroacetabular impingement and thorough evaluation of its therapeutic significance.

The objective of this study was to investigate the association between ligamentum teres injury and the hip joint cartilage damage pattern in patients with femoroacetabular impingement.We compared articular cartilage damage between ligamentum teres-intact and-ruptured hips. Data were collected for 77 consecutive patients with femoroacetabular impingement who underwent hip arthroscopy. The locations of the chondral lesions were recorded on anatomic articular maps using the geographic zone method. The patients were divided into 2 groups (ligamentum teres-intact and-injured groups), and the incidence and degree of cartilage injury were compared between the 2 groups by use of the Mann-Whitney U test.In patients with ligamentum teres injury, chondral damage extended to the middle-inferior area of the acetabulum (7.6% [grade 1] in ligamentum teres-intact group and 66.6% [grade 1, 12.1%; grade 2, 42.4%; grade 3, 12.1%] in ligamentum teres-injured group, P.01) and the apex of the femoral head (anterior apex: 7.1% [grade 1, 3.8%; grade 2, 3.3%] in intact group and 42.4% [grade 1, 30.3%; grade 2, 12.1%] in injured group, P.01; middle apex: 7.6% [grade 1, 3.8%; grade 2, 3.8%] in intact group and 63.5% [grade 1, 42.4%; grade 2, 18.1%; grade 3, 3.0%] in injured group, P = .04; posterior apex: 7.6% [grade 1, 3.8%; grade 2, 3.8%] in intact group and 42.4% [grade 1, 30.3%; grade 2, 12.1%] in injured group, P.01).This study showed the association between ligamentum teres injury and articular cartilage damage in the inferior middle part of the acetabulum and the apex of the femoral head in patients treated for femoroacetabular impingement.Level IV, case-control study.

Chordomas are rare, low grade, malignant tumours derived from the ectopic remnants of the notochord that line the axial skeleton. They are characterised by their slow growth, long disease course and propensity for local relapse. Furthermore, up to 40% of non-cranial chordomas metastasise. We describe the first reported case of a hand metastasis arising from a conventional sacral chordoma after carbon ion radiotherapy. The common occurrence of distant metastasis with chordomas makes it important to perform a systemic examination, in part because their resection might improve patient prognosis.

Athroscopic treatment of acetabular labral tears is commonly performed for these patients. However, conservative treatment is generally considered to be the first choice of the treatment. We analyzed the clinical and radiological factors contributing to failure of conservative treatment of acetabular labral tears. In this study, 75 patients (82 hips) with positive physical symptoms and radiologic evidence of labral tears were enrolled. All patients underwent conservative treatment for at least 6 weeks. Surgical treatment was carried out if the hip pain was not completely relieved. Clinical and radiological factors contributing to failure of conservative treatment were evaluated using univariate and multivariate analysis. There were 37 patients who improved with nonsurgical treatment, and the remaining patients (47 hips) underwent surgery (6 periarticular osteotomy, 11 partial debridement, and 28 labral refixation). Multivariate analysis indicated that the factor contributing to the response to conservative treatment was a tear of the ligamentum teres (p

Pleomorphic rhabdomyosarcoma is a rare and aggressive variant of rhabdomyosarcoma that usually occurs only in adults aged 45 years or older. Gastric metastasis from a soft-tissue sarcoma of the extremity is likewise very rare, with only a few previously reported cases. Here, we describe the case of a 52-year-old man with gastric metastasis who underwent en bloc excision of the primary tumor and distal gastrectomy but died 6 months after surgery due to lung metastases. This is, to our knowledge, the first reported case of gastric metastasis from pleomorphic rhabdomyosarcoma of the extremity. In cases such as these, patients may have widespread disease, and thus, surgery may only have a limited role in its management.

Background We followed up four patients receiving reconstructive hip arthrodesis with a free-vascularized fibular graft (FVFG) for malignant bone tumor in order to restore lower limb function after wide resection of the periacetabular bone tumor.

Giant cell tumor of the sacrum is extremely difficult to manage. Standard treatments, including surgery and radiation, are associated with significant complications and recurrence rates. In this manuscript, we report an early clinical result of a case of giant cell tumor of the sacrum successfully managed with selective arterial embolization. A 56-year-old woman underwent selective embolization for management of giant cell tumor of the sacrum. Radiologically, massive shrinkage of the extraosseous mass and increased peripheral ossification were obvious. Clinically, rapid pain relief was achieved and gait disability recovered. At final follow-up 28 months after completion of treatment, she retained normal activity in daily life. We stress the effectiveness of selective arterial embolization as a less invasive and less complicated primary treatment of giant cell tumors of the sacrum.

We undertook a prospective study to evaluate the prognostic significance of the serum levels of vascular endothelial growth factor (VEGF) in predicting the survival of patients with osteosarcoma. The levels were measured by an enzyme-linked immunosorbent assay in 15 patients with osteosarcoma before commencing treatment. The patients were divided into two groups, with a high or a low serum VEGF level, and the incidence of metastases and overall survival rate were compared. No significant relationship was observed between the serum VEGF levels and gender, age, the size of the tumour or the response to pre-operative chemotherapy. Patients with a serum VEGF > 1000 pg/ml had significantly worse survival than those with a level < 1000 pg/ml (p = 0.002). The serum VEGF level may be useful in predicting the prognosis for survival in patients with osteosarcoma.

The periosteal chondrosarcoma is an uncommon juxtacortical malignant bone tumor. Most are low-grade (grade 1), and their relatively good prognosis is emphasized even if treatment is local resection. Once periosteal chondrosarcomas recur, however, the grade of malignancy may become higher and it may be diffi cult to excise the tumor completely. Therefore, it is important to demonstrate the extent of the tumor accurately. We report a case of grade 2 periosteal chondrosarcoma of the femur and focus on tumor invasion into the underlying cortex.

Background We retrospectively reviewed 137 consecutive total hip arthroplasties performed with AML-A stems and Tri-Lock cups to see whether design modifications made to these components would achieve durable biological fixation in the Japanese population in whom developmental dysplasia of the hip (DDH) is relatively common. Patients from our initial clinical series using these components are available for more than 10 years’ follow-up. Methods Between April 1988 and June 1994, we performed 137 total hip arthroplasties using the AML-A prosthesis for the patients with osteoarthritis of the hip joint. We excluded 26 hips with less than 10 years’ follow-up and five hips from patients who died before the 10-year follow-up. The mean follow-up for the 105 remaining THAs is 155.2 months (range 120–237 months). The average age of these patients at the time of surgery was 53.1 years (range 22–81 years). Results In total, 17 THAs required component revisions. In seven cases, the first revision was limited to a liner exchange for polyethylene wear or osteolysis. Another seven hips underwent revision surgery for recurrent dislocation. Three cups have been revised owing to aseptic loosening. Because of the high incidence of wear-related revisions, Kaplan-Meier survivorship at the 15-year follow-up, using acetabular component revision for any reason as an endpoint, was 75.0% (95% CI 69.4%–83.8%). In contrast, no revision of the femoral stem was performed. Severe stress shielding occurred in 12 hips. Thigh pain was mild, however, and all of the femoral stems remained stable. Conclusions Despite revisions for wear-related complications, the fixation achieved with these porous-coated components remained durable throughout the 15-year follow-up. Acetabular osteolysis has been associated with cup reoperation, but femoral stress shielding has never resulted in stem loosening.

We evaluated triple-phase bone scintigraphy in the differential diagnosis of peri-prosthetic infection in 46 patients with a total hip replacement or bipolar hemiarthroplasty who were due for revision surgery. There were 18 men and 28 women, with a mean age at operation of 64.6 years (28 to 81). We defined peri-prosthetic infection as an increased uptake of radioisotope in all the phases of triple-phase bone scintigraphy and validated these results against the histological and/or microbiology results in every case. The positive and negative predictive values for the presence of infection were 83% and 93%, respectively. The diagnostic sensitivity was 88% and the specificity was 90%. This study indicates that triple-phase bone scintigraphy is a useful tool in the detection of peri-prosthetic infection and offers a cost-effective method of screening.

Background We have previously offered data suggesting a positive linkage of postoperative up-regulation of systemic angiogenic activity and postoperative progression of pulmonary metastasis in osteosarcoma. The finding that the significant down-regulation of endostatin was critical in angio-genic elevation after primary tumor removal suggests that endostatin is a candidate for antiangiogenic therapy for osteosarcoma. Methods In the current study, we evaluated the effect of anti-angiogenic therapy using endostatin on postoperative progression of pulmonary metastasis from osteosarcoma. Mouse osteosarcoma cell line LM 8 cells were inoculated in subcutaneous layer of nude mice. Two weeks after tumor inoculation, the primary tumor was removed surgically, and antiangiogenic therapy using adenovirus encoding endostatin expression vector (Ad5CMV-mEnd) was performed. Two weeks after the antiangiogenic treatment, pulmonary metastasis was evaluated by counting the number of metastatic nodules. The evaluation of systemic angiogenic activity was performed using Matrigel plug assay. Results Two weeks after the viral injection, mice were sacrificed, and the macroscopic pulmonary metastases were counted. Notably, the number of pulmonary metastases was smaller in the mice injected with Ad5CMV-mEnd than in controls, accompanied by significant suppression of systemic angiogenic activity. In addition, the sizes of the pulmonary metastases of the mice injected with Ad5CMV-mEnd were smaller than in the control group. Conclusions Our results indicate that antiangiogenic therapy using endostatin has the potential to prevent postoperative progression of pulmonary metastasis from osteosarcoma. Although this therapeutic strategy cannot provide a cure for osteosarcoma, it should enable osteosarcoma patients to coexist with dormant pulmonary metastasis and lead to improvement of their prognosis.

Acetabular chondral carpet delamination is a frequent finding at hip arthroscopy. The cartilage is macroscopically normal but deboned from the subchondral bone, without a disruption at the chondrolabral junction. Arthroscopic anatomic repair of delaminated cartilage is challenging. We propose that a combination of microfracture and use of stitches to press the delaminated cartilage against the subchondral bone using a suture limb offers an effective method to provide an environment for cartilage repair. This article describes the technique of bridging suture repair for carpet delamination in detail; the technique enables the surgeon to stabilize the delaminated acetabular cartilage. Intra-articular soft anchors and an acetabular rim knotless anchor footprint provide a stable repair for delaminated cartilage. This technique is especially helpful in cases with acetabular cartilage carpet delamination.

We retrospectively reviewed 11 hip arthroplasties in 7 patients receiving long-term (15 years) hemodialysis for chronic renal failure. Osteonecrosis of the femoral head, osteoarthritis, and amyloid arthropathies were treated by total hip arthroplasty (THA) or bipolar hemiarthroplasty (BHA) using cementless anatomic medullary locking stem. The average follow-up period was 8 years and 3 months (range, 3-13 years). The D'Aubigne and Postel hip score was restored to 14.5 postoperatively from 7.7 preoperatively. All femoral cementless components achieved bone-ingrown fixation. Although 1 BHA resulted in central migration, there was no loosening of the cementless acetabular component. We are encouraged by the predictable long-term stability of the bone-implant interface achieved by cementless fixation with an extensively coated implant. Cementless THA remains a useful treatment option for patients on long-term hemodialysis.

Concomitant tumour resistance (CTR) is a unique phenomenon in which animals harbouring large primary tumours are resistant to the growth of smaller metastatic tumours by systemic angiogenic suppression. To examine this clinically, in ten patients with osteosarcoma, we investigated the effects of removal of the primary tumour on the development of pulmonary metastases, the systemic angiogenesis-inducing ability and the serum levels of several angiogenesis modulators. We found that removal of the primary tumour significantly elevated systemic angiogenesis-inducing ability in five patients who had post-operative recurrence of the tumour. Post-operative elevation of the angiogenesis-induced ability was suppressed by the addition of an angiogenic inhibitor, endostatin. Also, primary removal of the tumour decreased the serum levels of vascular endothelial growth factor and endostatin. These findings suggest, for the first time, the presence of CTR in patients with osteosarcoma for whom postoperative antiangiogenic therapy may be used to prevent the post-operative progression of micrometastases.

A retrospective review was conducted of giant cell tumors treated between 1984 and 1998 using the technique of aggressive curettage through a large bone window followed by acrylic cement reconstruction. Fifteen patients with a mean follow-up time of 46 months (range, 24–188 months) were identified. One patient had a local recurrence 24 months postoperatively. All the patients showed a radiolucent zone at the bone–cement interface up to 2.5 mm in width during the first 6 months after operation. However, the radiolucent zones were nonprogressive and did not affect the stability of the bone cement. Osteoarthritis of the knee joint occurred 14 years postoperatively in one patient with an intraarticular fracture at presentation. A stress fracture occurred in one patient who had the largest tumor in the distal femur. Acrylic cement reconstruction is a safe and effective procedure that provides local adjuvant therapy. Giant cell tumors with an associated intraarticular fracture remain a challenging problem to treat.

Differential diagnosis of small round cell sarcomas (SRCSs) grouped under the Ewing sarcoma family of tumors (ESFT) can be a challenging situation for pathologists. Recent studies have revealed that some groups of Ewing-like sarcoma show typical ESFT morphology but lack any EWSR1-ETS gene fusions. Here we identified a novel gene fusion, CIC-FOXO4, in a case of Ewing-like sarcoma with a t(X;19)(q13;q13.3) translocation. The patient was a 63-year-old man who had an asymptomatic, 30-mm, well-demarcated, intramuscular mass in his right posterior neck, and imaging findings suggested a diagnosis of high-grade sarcoma. He was treated with complete resection and subsequent radiotherapy and chemotherapy. He was alive without local recurrence or distant metastasis 6 months after the operation. Histologic examination revealed SRCS with abundant desmoplastic fibrous stroma suggesting a desmoplastic small round cell tumor. Immunohistochemical analysis showed weak to moderate and partial staining for MIC2 (CD99) and WT1, respectively. High-throughput transcriptome sequencing revealed a gene fusion, and the genomic rearrangement between the CIC and FOXO4 genes was identified by fluorescence in situ hybridization. Aside from the desmoplastic stroma, the CIC-FOXO4 fusion sarcoma showed morphologic and immunohistochemical similarity to ESFT and Ewing-like sarcomas, including the recently described CIC-DUX4 fusion sarcoma. Although clinicopathologic analysis with additional cases is necessary, we conclude that CIC-FOXO4 fusion sarcoma is a new type of Ewing-like sarcoma that has a specific genetic signature. These findings have important implications for the differential diagnosis of SRCS.

The aim of this study was to obtain data on chondral damage and compare the damage patterns of various hip disorders. Data were collected at 100 consecutive arthroscopies, and chondral lesions were recorded on anatomic articular maps divided into different anatomical zones. This geographic zone method made it possible to analyze the ICRS grade and location in relation to the hip morphology. The distribution and degree of the chondral defects showed a hip morphology-specific pattern. On the acetabular side, there were high incidences of full-thickness defects in the anterior–superior zone and the middle superior zone in patients with femoroacetabular impingement (FAI) (zone 2: 25.4 % grade 3, 35.5 % grade 4; zone 3: 20.3 % grade 3, 37.2 % grade 4) and borderline dysplasia (zone 2: 31.2 % grade 3, 12.5 % grade 4; zone 3: 18.7 % grade 3, 25 % grade 4). However, in patients with joint laxity, partial-thickness defects were dominant (zone 2: 50 % grade 1, 15 % grade 2; zone 3: 40 % grade 1). In patients with acetabular dysplasia, full-thickness defects extended even to the posterior superior zone (zone 4: 80 % grade 4). On the femoral head side, the incidence of full-thickness cartilage injuries was high in patients with FAI and borderline dysplasia compared to those with joint laxity and acetabular dysplasia. Evaluation of chondral damage using the geographic zone method showed that the pattern of cartilage damage was influenced by hip morphology. Understanding of hip disorder-specific chondral damage patterns may be useful for the development of arthroscopic classification of hip disorders and may lead to the establishment of treatment guidelines. Diagnostic study, Level III.

Myxofibrosarcoma is one of the most common sarcomas in the extremities of elderly people. It is characterized by a high frequency of local recurrence due to an infiltrative growth property. In contrast, the overall risk of distant metastases is generally low. This makes the prognosis for the patients with myxofibrosarcoma definitely good. In this paper, we will report the case of a 79-year-old female with very aggressive metastatic low-grade myxofibrosarcoma. The disease progression was really unexpected and misled every possible medical interpretation, leading to rapid worsening of the patient's clinical conditions and no chance for therapy. The tumor developed diffuse infiltration in lung, spine, skeletal bone, abdomen, paravertebral muscles, and liver. The patient died 8 months after the diagnosis of remote metastases due to rapid tumor progression.

Myxofibrosarcoma is characterized by a high local recurrence rate despite optimal surgical treatment. The definition of prognostic factors for recurrence offers high-risk patients a closer follow-up and a multidisciplinary therapeutic approach. A cohort of 23 patients treated for primary myxofibrosarcoma was retrospectively analyzed. The patients (sex and age), tumors (size, stage, tumor location, bone and/or joint attachment), radiological findings (abnormal signal extension in MRI), histological findings (FNCLCC grade and microscopic extension along the muscle fascia), and treatment (surgical margin) characteristics were included in univariate prognostic factor analysis. After a median follow-up of 63.3 months (range 15–191), the overall recurrence rate was 34.7%. Median time between initial surgery and recurrence was 24.8 months (range 8–52). Inadequate surgical margins (p = 0.026) and bone and/or joint attachment (p = 0.001) were associated with an increased recurrence rate. For the further improvement of local recurrence-free survival of patients with myxofibrosarcoma, accurate diagnosis of the tumor extension and adequate planning for the surgical margin should be focused on in cases with bone and/or joint attachment.

Total hip replacement for high dislocation of the hip joint remains technically difficult in terms of preparation of the true acetabulum and restoration of leg length. We describe our experience of cementless total hip replacement combined with a subtrochanteric femoral shortening osteotomy in 20 hips with Crowe grade IV dislocation with a mean follow-up of 8.1 years (4 to 11.5). There was one man and 17 women with a mean age of 55 years (44 to 69) at the time of the operation. After placment of the acetabular component at the site of the natural acetabulum, a cementless porous-coated cylindrical femoral component was implanted following a subtrochanteric femoral shortening osteotomy. The mean Japanese Orthopedic Association hip score improved from a mean of 38 (22 to 62) to a mean of 83 points (55 to 98) at the final follow-up. The mean lengthening of the leg was 14.8 mm (−9 to 34) in patients with iliofemoral osteoarthritis and 35.3 mm (15 to 51) in patients with no arthritic changes. No nerve palsy was observed. Total hip replacement combined with subtrochanteric shortening femoral osteotomy in this situation is beneficial in avoiding nerve injury and still permits valuable improvement in inequality of leg length.

The metal-on-metal bearing total hip prosthesis is expected to reduce the risk of debris-related osteolysis. However, several reports demonstrated that the socket-stem impingement in the metal-on-metal prosthesis due to the implant malposition results in titanium wear debris and secondary metallosis. In this article, we presented a case of massive metallosis due to metal-on-metal impingement. A 60-year woman had severe hip pain due to fracture of the greater trochanter. We planned a revision of the metal-on-metal inlay. Intraoperatively, the trochanteric bursa and joint space were found to be stained black. Black stained granulation tissue was observed between the femoral stem and the great trochanter. Intraoperatively, notching was noticed on both the posteroinferior aspect of the neck of the femoral component and the anterior aspect of the metal liner and polyethylene core. The notch corresponded to the position of impingement between the socket and the femoral neck during the maximum extension of the hip. To clarify the mechanism of cup-neck impingement, the alignment of the prosthesis and pelvic tilt were evaluated. The cup was placed in too much anteverted position. In addition, increased posterior tilt of pelvis in the standing position made the anteversion of the acetabular cup more significant, which enhanced the cup-neck impingement during the gait. Careful attention is necessary for implant alignment and pelvic tilt especially in metal-on-metal-bearing total hip arthroplasty.

We performed transtrochanteric rotational osteotomy to treat severe slipped capital femoral epiphysis in four young patients. All four male patients, with an age range of 12–22 years, were followed for an average of 2 years and 10 months. The JOA score of 37 points preoperatively improved to an average of 90 points postoperatively. The posterior tilt angle (PTA) of 82° preoperatively improved to an average of 24° postoperatively. The flexion angle of the affected hip joint in neutral improved from 10°–25° to 70°–90°. Although one patient with acute on chronic type of SCFE developed osteonecrosis of the femoral head after the operation, the function of the hip joint was restored. Our results suggest that transtrochanteric rotational osteotomy is a valuable option for the treatment of severe slipped capital femoral epiphysis in young patients.

Slipped capital femoral epiphysis is a well-known disorder of the hip in adolescents. In general, the direction of slip of the capital femoral epiphysis on the femoral neck is posterior and inferior, although superior slips have been reported1,2. We report a case of slipped capital femoral epiphysis in which the epiphysis was displaced anteriorly in relation to the neck. The patient and her family were informed that data concerning the case would be submitted for publication. An eleven-year-old girl presented with a two-month history of pain in the right knee. There was no history of trauma to the right hip or knee. Physical examination revealed a well-developed, well-nourished girl. She was 143 cm tall and weighed 39 kg. The body mass index was 19.1. The physical examination was normal, except with regard to the right lower extremity. She walked with a right antalgic gait. The right leg was 2.0 cm shorter than the left. Hip motion was not painful, and there was neither tenderness nor swelling about the right hip. Range of motion of the right hip included 15° of external rotation, 80° of internal rotation, 115° of flexion, and a 30° flexion contracture. As the right hip was flexed, adduction and internal rotation occurred spontaneously. Radiographs and computed tomography revealed an anterior-inferior slip of the capital femoral …

Despite the availability of effective treatment and well-publicized treatment guidelines for preventing osteoporotic fractures, there are significant gaps in implementing the recommendations, and it is unknown how many patients are treated for prevention of secondary osteoporotic fractures. In this study, we investigate what percentage of osteoporosis patients were treated with antiosteoporotic drugs after osteoporotic fractures of the hip, wrist, and proximal humerus, and we discuss here the need for improvement in the treatment of osteoporosis following fracture.We studied 422 patients with osteoporotic fractures, 91 men and 331 women, with an average age of 77.1 years (range, 52-102 years). The 422 cases consisted of 299 hip fractures, 97 distal radius fractures, and 26 proximal humerus fractures. All patients underwent surgical intervention. The variables were examined to ascertain whether osteoporosis patients were medicated with antiosteoporotic drugs at postfracture.Fifty-five (13%) of the 422 patients received antiosteoporotic medication at postfracture. Pharmaceutical treatment was given in 44 cases (14.7%) of hip fractures, 8 cases (8.2%) of distal radius fractures, and 3 cases (11.5%) of proximal humerus fractures. Thirty-one (7.3% of total) of the 55 patients were taking the same medication pre- and postfracture. Seven (1.7%) of the 55 were administered a different drug compared to before the fracture, and 17 (4%) started to take an antiosteoporotic drug for the first time subsequent to the fracture.The present rate of treatment is insufficient given the high risk of secondary fractures and the availability of appropriate drugs that would reduce that risk.

We performed rotational acetabular osteotomy in order to treat dysplasia of the hip in five ambulatory adults with cerebral palsy. There was one man and four women, with a mean age of 21 years (16 to 27) who were followed up for a mean of 12 years and two months. The mean Sharp angle improved from 52° to 43°, the mean acetabular index from 30.2° to 2.8°, the mean centre-edge angle from −5.6° to 29.2°, and the mean acetabular head index from 49.2 to 88.2. There was no progression of joint degeneration and relief from pain was maintained. Our results suggest that rotational acetabular osteotomy is a valuable option for the treatment of acetabular dysplasia in adults with cerebral palsy who have incapacitating pain in the hip.

Early relapse with distant metastasis often is observed in patients with cancer after resection of the primary tumor. It is considered that resection of the primary tumor induces activation of systemic angiogenesis and enhances progression of remote metastasis. The authors show that resection of the primary osteosarcoma tumor enhances progression of pulmonary metastasis in animal osteosarcoma models. Matrigel plug neovascularization assay revealed that systemic angiogenic activity was elevated after primary tumor removal (tumor intact group, 1.61 +/- 0.21 g/dL; tumor removed group, 4.92 +/- 0.35 g/dL). In addition, serum concentration of the angiogenesis inhibitor, endostatin, decreased significantly after primary tumor removal. Treatment with the antiangiogenic reagent TNP-470 suppressed postoperative progression of pulmonary metastasis. These results indicate the possibility that activation of angiogenic activity after resection of osteosarcoma tumors enhances progression of pulmonary metastasis. The current data also suggest that administration of antiangiogenic reagents can prevent progression of pulmonary metastasis in osteosarcoma postoperatively.

Because of the difficulty of developing pairs of osteosarcoma cell lines and cytotoxic T lymphocytes (CTLs), no osteosarcoma tumor antigens that are useful for antiosteosarcoma immunotherapy have yet been identified. In parallel with continuous attempts to develop such pairs from osteosarcoma, we employed serological identification using a recombinant expression cloning (SEREX) method to identify B cell-defined antigens. Consequently, a human osteosarcoma cell line, OS2000, was established from a primary osteosarcoma of a patient cured of hereditary retinoblastoma. Repetitious in vitro stimulations by OS2000 cells to the autologous peripheral T cells induced cytotoxic activity in the autologous osteosarcoma cells but not in the nontumor cells. The cytotoxicity was inhibited by anti-HLA class I monoclonal antibody. SEREX analysis revealed that autologous humoral immunity reacted to two proteins expressed in OS2000. One was the self HLA-Cw*0102 molecule, and the other was wild-type smooth muscle myosin light chain (SMMLC). However, no antigenicity of these proteins was seen versus the sera of the other patients. In conclusion, our results demonstrated the presence of host cellular and humoral immune responses to autologous osteosarcoma cells. This offered the opportunity to identify osteosarcoma antigens recognized by autologous immunity.

We report a case of peri-prosthetic tuberculous infection nine years after total hip arthroplasty in a patient with no history of tuberculosis before the procedure. Further investigation revealed active pulmonary tuberculosis which was thought to have spread haematogeneously to the arthroplasty. The infection did not respond to standard antituberculous drugs. Removal of the prosthesis and insertion of an antibiotic spacer were required.

We report a case with hypersensitivity to CoCr in total hip arthroplasty coupled with conventional polyethylene and CoCr femoral head. The patient complained of left hip pain and systemic fever, and computed tomography imaging revealed a periprosthetic cystic lesion, so we performed revision total hip arthroplasty using a titanium stem and ceramic head and highly crosslinked polyethylene. Hip pain and cystic lesion disappeared 3 years after revision surgery.

Background: Bone and soft tissue sarcomas (BSTS) are rare malignant tumors. Recently, the combination of gemcitabine and docetaxel (GD) was shown to have activity as second-line setting in BSTS. However, the efficacy as first-line and adjuvant settings and precise profiles of adverse events in Japanese patients are not known yet. In the present study, the feasibility and efficacy of GD in patients with BSTS were investigated. Methods: Patients with BSTS treated with GD in our institutions were retrospectively analyzed. Information regarding clinical features, adverse events, and outcome was collected and statistically studied. Factors related to survival were analyzed using log-rank test and Cox proportional hazard regression method. Results: A total of 134 patients were analyzed. GD was carried out as adjuvant setting in 9, first-line in 23, second-line in 56, and third-or-greater line in 46 patients. The response rate (RR) for all patients was 9.7%. RR for the patients treated as adjuvant or first-line setting was 18.8%, whereas that as second-or-greater line was 6.9%. The median progression-free survival (PFS) and overall survival (OS) of all patients were 4.8 (95% CI 3.5–6.1) and 16.4 (95% CI 9.8–22.9) months, respectively. Survival tended to be better in the patients treated as first-line than in those treated as second-or-greater line. Multivariate analysis demonstrated that history of prior chemotherapy (p = 0.046) and response to GD (p = 0.009) was significantly associated with PFS and OS, respectively. The leucopenia and neutropenia were the most frequent adverse events, and grade 3 or 4 leucopenia and neutropenia were observed in 69.4 and 72.4% of the patients. Grade 2 or 3 pneumonitis was observed in one (0.7%) and four (3.0%) patients, respectively. All the patients with pneumonitis had experienced prior chemotherapy and/or radiotherapy. Conclusions: GD used as both first- and second/later line is effective chemotherapy for a proportion of patients with advanced BSTS. Higher response rate and better outcome was achieved in chemotherapy-naïve patients. This regimen is associated with high incidence of severe hematological toxicity, as well as the risk of severe pneumonitis, especially in pre-treated patients. GD is promising for further analysis by phase III study for the patients with BSTS.