Faculty Bibliography

A case of metastatic lobular carcinoma of the breast in conjunction with osteopoikilosis is described. Widespread diffuse sclerotic bone lesions were identified on radiographs in a patient with breast carcinoma. In addition computed tomography demonstrated discrete spherical areas of increased density throughout the skeleton manifest typically by osteopoikilosis. No systemic symptoms were evident, blood parameters were normal and the lesions did not demonstrate any increased uptake of technetium on bone scan. An iliac crest bone biopsy, however, revealed metastatic disease in addition to osteopoikilosis. Conventional radiological investigations may not delineate metastasis on a background of bone dysplasia.

The purpose of this study was to assess functional outcome of patients with a Lisfranc fracture dislocation of the foot by applying validated patient- and physician-based scoring systems and to compare these outcome tools. Of 25 injuries sustained by 24 patients treated in our institution between January 1995 and June 2001, 16 were available for review with a mean follow-up period of 36 (10-74) months. Injuries were classified according to Myerson. Outcome instruments used were: (a) Medical Outcomes Study 36-Item Short Form Health Survey (SF-36), (b) Baltimore Painful Foot score (PFS) and (c) American Orthopedic Foot and Ankle Society (AOFAS) mid-foot scoring scale. Four patients had an excellent outcome on the PFS scale, seven were classified as good, three fair and two poor. There was a statistically significant correlation between the PFS and Role Physical (RP) element of the SF-36.

We performed a retrospective analysis of 212 patients (299 hips) with slipped capital femoral epiphysis (SCFE) over a 9-year period to assess the incidence of osteonecrosis of the femoral head. Risk factors for the occurrence of osteonecrosis and the influence of treatment on the development of osteonecrosis were determined. Osteonecrosis occurred in 4 hips with unstable SCFE (4/27) and did not occur in hips with stable SCFE (0/272). The proportion of hips in which osteonecrosis developed was significantly higher among the unstable hips (4/27 vs. 0/272, p < 0.0001). Among those with an unstable hip, younger age at presentation was a predictor of a poorer outcome. Magnitude of the slip, magnitude of reduction, and chronicity of the slip were not predictive of a poorer outcome in the unstable group. In situ fixation of the minimally or moderately displaced "unstable" SCFE demonstrated a favorable outcome. We have identified the hip at risk as an unstable SCFE. The classification of hips as unstable if the epiphysis is displaced from the metaphysis or if the patient is unable to walk is most useful in predicting a hip at risk for osteonecrosis.

STUDY DESIGN/METHODS:Case report. OBJECTIVES/OBJECTIVE:To report on the diagnosis and current treatment of a rare tumor about the cervical spine. SUMMARY OF BACKGROUND DATA/BACKGROUND:Extraskeletal Ewing's sarcoma (EES) is rare and has not been previously described about the cervical spine. We present a case of a 24-year-old man with a large mass in the posterior triangle of the neck extending through the vertebral foramens of the cervical vertebrae. This was identified as an extraskeletal Ewing's sarcoma. Traditional treatment paradigms have been associated with a poor prognosis. Since the recommendations of the Intergroup Rhabdomyosarcoma Study II study of multimodal chemotherapy and radiotherapy, this tumor has a significantly better prognosis. METHOD/METHODS:Surgical debulking of the tumor was necessary to relieve cord compression. Histologic analysis was used to confirm both magnetic resonance imaging and computed tomography diagnosis. A chemoradiation therapy program was commenced in accordance with Intergroup Rhabdomyosarcoma Study II recommendations. RESULTS:Computed tomography and magnetic resonance imaging demonstrated a large lobulated mass extending through the exit foramens of C2/C3 and C3/C4. The mass was entirely extraskeletal and extradural. Histologic examination of the excised mass showed microscopy consistent with extraskeletal Ewing's sarcoma. After surgical debulking and chemoradiation, the patient made a complete recovery. CONCLUSION/CONCLUSIONS:A review of the literature confirms that extraskeletal Ewing's sarcoma is a rare tumor and particularly so in the region of the cervical spine. Early diagnosis and surgical debulking combined with current multimodality chemoradiation programs can produce a favorable outcome.

OBJECTIVE:To determine the functional and radiographic outcome of low Weber C ankle fractures and to evaluate the contribution of the syndesmotic screw in their outcome. DESIGN/METHODS:Prospective evaluation of a consecutive series. SETTING/METHODS:Level I trauma center. PATIENTS/METHODS:Forty-five patients divided into two groups matched for age, sex, and severity of injury. Twenty-six patients were treated with open reduction, internal fixation, and a supplemental syndesmotic screw, and nineteen patients were treated without a syndesmotic screw. Minimum time to follow-up was three years. METHODS:A subjective, objective, and radiographic ankle scoring system was used. Logistical regression analysis was performed to determine whether the presence or absence of a syndesmotic screw was a predictor of a poor outcome. The likelihood ratio test was used to evaluate the significance of each variable in both univariate and multivariate analyses. RESULTS:There was no statistically significant difference between either group, either using subjective outcome criteria (p = 0.86) or in ankle range of motion (p = 0.94). Logistical regression analysis indicated that fracture dislocation could be used as a predictor of a poor outcome for either group. Inadequate reduction and advancing age were also found to be significant predictors of a poorer outcome regardless of the use of a syndesmotic screw (p = 0.003, p = 0.004). CONCLUSIONS:Judicious fixation of Weber C type injuries within five centimeters of the ankle joint, with or without a syndesmotic screw, gives similar results. Obligatory fixation of these fractures with syndesmotic screws appears to have no benefit and creates the need for an additional procedure.