Search

Chronic low back is one of the most common reasons that patients seek medical attention. There is little agreement on how to treat pain that persists despite an adequate trial of conservative care. When the pain generator can be determined, a logical and targeted treatment plan can be implemented. Diskography can be used to identify an abnormal, painful disk, although the value and safety of this diagnostic tool have been debated. Lumbar fusion for chronic low back pain remains a contentious issue that has been widely debated; however, many studies have inherent flaws that weaken their conclusions. Procedures that do not include interbody fusion ignore the role of the painful disk and might be associated with poorer results. With proper attention to selecting the correct patient, identifying the correct diagnosis, and choosing the correct procedure, good outcomes can be achieved with lumbar fusion for discogenic low back pain.

Femoral neuropathy secondary to iliopsoas hematoma has been documented in a variety of case reports and studies 1-3. Iliopsoas hemorrhage and femoral neuropathy can develop without any evidence of trauma in individuals who have hemophilia, particularly in those who have the acquired form of the disease and a factor inhibitor. Patients experience pain deep in the groin, and some present with contracture of the hip in acute flexion. Prolonged insult may result in permanent paresthesias, weakness, and atrophy of the quadriceps muscle. Prompt diagnosis is important because the risk of permanent injury is decreased when therapy is initiated rapidly 2. We will review a case of femoral neuropathy secondary to an iliopsoas hematoma in a woman with an acquired postpartum factor-VIII inhibitor syndrome. We present this case to heighten awareness about this unusual variant of hemophilia and the musculoskeletal sequelae that may result. Our patient was informed that data concerning the case would be submitted for publication. A twenty-nine-year-old woman presented with a three-day history of severe pain in the anterior aspect of the left hip and the proximal aspect of the left thigh. There was no history of trauma. The patient also had numbness in the lateral and the anterior aspect of the thigh, and she was having difficulty walking because she could not extend the hip without severe pain. The patient was four months postpartum and recently had been diagnosed with postpartum factor-VIII inhibitor syndrome after she had presented with spontaneous bruising of the extremities. Three days before the current presentation, she had been discharged from the hospital after being treated for a spontaneous hemorrhage in the left calf and tarsal tunnel. The medical history of this patient was otherwise unremarkable. Physical examination revealed an otherwise healthy-appearing, thin woman. The patient held the left …

Whether a preoperative long leg radiograph taken with the patient standing helps the surgeon reproduce a normal mechanical axis after total knee arthroplasty is unknown. The purpose of the current study was to evaluate whether a preoperative long leg radiograph helps to restore normal limb alignment after total knee arthroplasty. Ninety-four patients (124 primary total knee arthroplasties) were randomized to either receive or not receive a preoperative long leg standing radiograph. Patients with previous hip or ankle surgery, femoral or tibial fracture, deformity of 15 degrees or greater, or those who were obese (body weight index40 kg/m2) were excluded. All arthroplasties were done by one surgeon. The angle of distal femoral resection varied between 5 degrees and 8 degrees (mean, 6.2 degrees) among patients with long leg radiographs. In patients without long leg radiographs, the distal femur was cut at 5 degrees. Long leg radiographs were obtained postoperatively in all patients and the mechanical axis was assessed, first by whether the mechanical axis fell within the central third of the knee, and second by the distance in millimeters that the mechanical axis fell from the knee center. No significant difference in the postoperative mechanical axis was detected between the two groups. Eighty-six percent of the patients with long leg preoperative radiographs and 92% of the patients without long leg preoperative radiographs had the mechanical axis pass through the central (1/3) of the knee. Preoperative hip to ankle long leg radiographs taken with the patient standing did not significantly help to obtain a neutral mechanical axis during routine total knee arthroplasty.

Twenty-three cases of extraskeletal myxoid chondrosarcoma, evaluated at the Mayo Clinic between 1968 and 1996, were studied for clinicopathologic features, immunohistochemical profile, Ki-67 activity, and ploidy status to identify adverse prognostic factors. Females and males were equally affected, and the median age at diagnosis was 50 years. The tumors were located mainly in the lower extremities (83%), and the median tumor size was 9.5 cm. Sixteen tumors showed low cellularity (70%), and eight tumors had high mitotic activity (more than two per 10 high-power fields). The tumors were immunoreactive for vimentin (89%), synaptophysin (72%), epithelial membrane antigen (28%), and S-100 protein (17%). Nine tumors were diploid, three aneuploid, and one tetraploid. Mean Ki-67 activity was 11% (range, 1 to 45%). The 10-year overall survival rate was 78%. On univariate analysis, tumor size > or = 10 cm, high cellularity, presence of anaplasia or rhabdoid features, mitotic activity more than two per 10 high-power fields, Ki-67 > or = 10%, and Ki-67 "hot spot" > or = 25% were associated with decreased metastasis-free or overall survival. Ploidy status was not associated with any adverse outcome. The presence of any of these adverse prognostic factors can indicate the possibility of a more aggressive behavior in extraskeletal myxoid chondrosarcoma, and a closer follow-up is suggested.

Eighty-six children to 18 years of age were treated for nonrhabdomyosarcoma soft tissue sarcomas of the trunk and extremities. Synovial sarcoma (31), fibrosarcoma (13), malignant fibrous histiocytoma (11), epithelioid sarcoma (10), and clear cell sarcoma (7) were the most common diagnoses. Four patients presented with metastatic disease. A high percentage of patients presented after biopsy by the referring physician, although this could not be shown to affect outcome. Patients were treated with wide removal of the tumor when possible, with judicious use of adjuvant radiation, or with chemotherapy in selected cases. Mean followup was 11 years. Five- and 10-year survival was 92% and 84%, respectively. Tumors larger than 5 cm were associated with a worse prognosis. When compared with published data in adults, the prognosis of primary, localized nonrhabdomyosarcoma soft tissue sarcomas in children appears to be more favorable.

Ruptures of the extensor mechanism of the knee are rare, when compared with other knee injuries, and are frequently misdiagnosed. The outcome after surgical repair may be compromised if surgery is delayed. A case of quadriceps tendon rupture that was misdiagnosed for 2 months and a review of the literature are presented. Including extensor mechanism disruption in the differential diagnosis, and careful attention to key physical findings in the examination of all acutely injured knees, will ensure that this important injury is not overlooked.

The medical records and histologic material of 16 patients with extraskeletal myxoid chondrosarcoma were reviewed. The mean age of the patients was 52 years. Thirteen tumors arose in the lower extremity. Thirteen patients presented with primary, localized disease, whereas three presented with pulmonary metastases. Treatment of the primary site included wide excision or amputation in 13 patients and marginal or intralesional resections with radiation in three patients. The mean followup was 7.4 years. Five patients were continuously disease free (5- and 10-year event free survival 43% and 14%, respectively). Local recurrence developed in four, and metastases developed in six of 13 patients presenting with localized disease. Of six patients who received chemotherapy for systemic disease, four had disease progression and died, and two had a response to chemotherapy (one partial, one complete). The mean survival after onset of metastases was 45 months. Overall 5- and 10-year survival was 87% and 63%, respectively. The current series suggests that extraskeletal myxoid chondrosarcoma is an intermediate-grade neoplasm with a tendency toward recurrence and metastasis. Survival after relapse may be prolonged. More effective therapy for systemic disease is needed.

Neoplasia occurring in a sinus tract is a well known complication of chronic osteomyelitis. Previous series have been too small to permit survival analysis. Fifty-three consecutive patients (44 men and 9 women) from the authors' institution were reviewed, including 24 who previously were reported. There were 50 patients with squamous cell carcinomas, one with fibrosarcoma, one with myeloma, and one with lymphoma. Mean age was 59 years. One patient sought treatment elsewhere and was lost to followup. Forty-four patients underwent amputation, and eight underwent limb salvage. Followup averaged 9 years. Of 50 patients with squamous cell carcinoma, five died of disease. Overall survival in this group was not statistically different from that expected for age matched controls. Despite the low grade nature of most of these lesions, amputation often is chosen as the most reliable means of treating the tumor and the chronic infection.