EXTENDED SUBTOTAL MANDIBULECTOMY IN A CAT WITH ALVEOLAR OSTEOMYELITIS CHARACTERIZED BY A SPICULATED PERIOSTEAL REACTION

Orthopaedic Case of the Month: Painful Lower-leg Mass in a 76-year-old Man

The objective of this study is to evaluate the relationship between the radiological features of periosteal reactions (PR) and histopathological features of the lesions. A total of 4605 CBCT images were evaluated and they were classified according to their radiological differential diagnosis. Images with pathologies were listed according to their histopathological examinations as cystic lesions, benign tumours, malignant tumours, fibro-osseous lesions and osteonecrosis, while images without pathologies were listed as traumas and others. All groups were reclassified as with or without the presence of detected PR. Pathologies and traumas were detected in 1801 of 4605 patients. There were 3 PR in 1140 cystic lesions, 4 PR in 102 benign tumours, 16 PR in 43 malignant tumours, 67 PR in 156 osteonecrosis/osteomyelitis cases and 3 PR in 262 trauma cases. As a result of the chi-square test between groups, there was a significant relationship between histopathologic diagnoses and periosteal reaction patterns (p = 0.000). Although there is a significant overlap between the patterns of PRs, PRs can be used to narrow the possibilities in the differential diagnosis. However, PRs alone are not sufficient variables for differential diagnosis in the absence of cortical bone destruction, localization, clinical and systemic findings.

Limping in a 12-year-old boy.

To investigate the diagnostic significance of a periosteal reaction (PR) in diseases of the jaws. The frequency of PR was investigated in 1142 patients who had undergone CT of the maxilla or mandible. The pattern of PR was categorized as either parallel, irregular, spicule or Codman's triangle. We examined the relationship of the pattern of PR to the specific disease categories of osteomyelitis, trauma, cysts, benign tumours and malignant tumors. Seventy patients were found to have PR. It was found in 40% of cases with osteomyelitis and 15% of malignant tumors. The only benign lesion was an eosinophilic granuloma. There were no cysts. The frequency of PR was higher in younger patient and in those with sarcomas or bone metastases compared with those with carcinomas. Ninety-one percent of the patients with osteomyelitis showed single or multi-layered PR parallel to the cortical bone, while 61% of those with malignant tumors had a spicule pattern. With the exception of Codman's triangle, none of the PR patterns were specifically associated with any one disease category. When the PR pattern was combined with the pattern of cortical bone destruction, 90% of the patients with PR could be correctly assigned to one or other of the four disease categories of osteomyelitis, trauma, benign lesion or malignant tumor. The pattern of PR on CT in combination with the pattern of the cortical destruction of the cortex is useful in differentiating osteomyelitis from malignant tumors.

A 1-year-old captive female bearded dragon (Pogona Vitticeps) was presented with swelling of all four limbs and arthrosclerosis that had been present for one week. On physical examination, all the limbs presented with pain on palpation, especially the left forelimb. Under X-ray examination, expanded articular spaces without erosive lesions or periosteal reaction were noted in the elbow and stifle joint, together with swelling of the surrounding soft tissue. Lesions were most severe in the left elbow joint. Arthrocentesis was performed for analysis of synovial fluid and cytology. Under microscopic examination, ＞10 cells/high power field (HPF) were found, in which inflammatory cells predominated. The cells comprised 10.7% synovial cells, 43.7% monocytes, 30.0% lymphocytes and 15.6% heterophils; the monocytes showed a prominent toxic reaction, and phagocytosis was also recorded. No microorganisms or crystals were observed. All synovial fluid cultures were negative. Based on the results of hematology and cytology, immune-mediated polyarthritis was diagnosed. The total white blood cells count (TNCC) and the percentage of polymorphonuclear neutrophil leukocytes (%PMN) were obtained in an attempt to obtain a diagnosis, and the results suggest a diagnostic value for this evaluation method in reptiles. The patient was treated with prednisolone at 1.5 mg/kg orally once per day (s.i.d.) with a tapering program, which resulted in a good response.

Lower Leg Pain in a 17-Year-Old BoyOrthopaedic-Radiology-Pathology Conference

Objective To analyze the radiological imagines and SPECT imaging features of primary leiomyosarcoma of bone and to improve the diagnostic level. Methods The imaging data of 16 patients in our hospital from January 2009 to May 2018 were retrospectively analyzed by two senior musculoskeletal radiologists, and they were all proved by surgery and pathology. The location of the lesions, type of bone destruction, size, soft tissue mass, mineralization, pathological fracture and periosteal reaction were detected by radiography and CT. The types of bone destruction are osteolytic, cystic and mixed. Periosteal reaction was divided into codman triangle, layered periosteal reaction and spiculate periosteal reaction. The signal intensity of lesions, size, distruction of the bony cortex, soft tissue mass and peritumoral edema were detected by MRI.Signal intensity was divided into low signal,iso-signal and high signal by taking surrounding normal muscles as reference. Enhancement scan was used to detect the form of enhancement. SPECT bone scan: compared with normal bone, SPECT bone scan signals were higher than normal bone, which was called concentrated radioactivity. Results Among the 16 cases, located in tibia(5 cases), femur (4 cases), sacrum(1 case), pubis(1 case), ilium(1 case), thoracic vertebra (2 cases) and humerus(2 cases). Radiography showed osteolytic, cystic and mixed bone destruction, among which 8 cases were osteolytic, 2 cases were cystic, 4 cases were mixed, and 1 case was normal. On CT images, 9 cases were osteolytic, 6 cases with soft tissue masses, among which 3 cases with partial sclerosis rim (2 cases with pathological fractare and obviously enhanced), 1 case with mild bone expansion and soft tissue, 2 cases with partial sclerosis rim. Four cases were mixed, all with cortical bone destruction, penetration, 1 case with soft tissue mass and periosteal reaction, 1 case which in the long bone of the extremity was central in location with periosteal reaction. Two cases were obviously and heterogeneously enhanced atter the enhanced CT scanning (1 case with bone expansion). Two cases were cystic,all with cortical destruction and penetration,1 case with soft tissue mass,1 case with partial sclerotic rim;after the enhanced CT scanning,2 case were obviously and heterogeneously enhanced. The most of the MR imagines showed the iso-intensity signal (10cases) and/or lightly lower signal (3cases), lightly higher sign (2cases) on T1WI, inhomogeneous hyperintensity on T2WI (15cases),after injected contrast medium,the tumor was inhomogeneous enhancement (14cases) with the cysts, necrosis and hemorrhage in it,11 cases with soft tissue masses,12 cases accompanied by peritumoral edema. On SPECT bone scan, 10 Cases showed significant concentrated radioactivity(1 case was circumferential) and 1 case was mild concentrated radioactivity. Conclusion PLB usually occurs in the lower extremities,more frequently at the distal end of the femur, the proximal end of the tibia. The mainly appearance are central situated and osteolytic destruction with mass of the soft tissue. Although PLB has some imaging features, it is difficult to differentiate it from malignant bone tumors. Multi-imaging modalities such as radiography, CT, MRI and SPECT may suggest the diagnosis. Key words: Leimyosarcoma; Bone; Magnetic resonance imaging; Tomography, X-Ray computed

An improved understanding of the computed tomographic (CT) features for malignant versus benign oral tumors would be helpful for guiding prognosis and treatment planning decisions in dogs. This retrospective, multi-center, observational study compared the CT features of malignant and benign tumors in 28 dogs with 31 oral masses. Malignant tumors were present in 20 dogs, including malignant melanoma (n = 14), squamous cell carcinoma (SCC, n = 4), adenocarcinoma (n = 1), and fibrosarcoma (n = 1). Eight dogs had benign tumors, including giant cell granuloma (n = 2), peripheral odontogenic fibroma (n = 2), acanthomatous ameloblastoma (n = 2), plasmacytoma (n = 1), and oncocytoma (n = 1). Common CT features of malignant tumors included heterogeneous enhancement, tumor invasion into the adjacent bone, tooth loss, and ipsilateral mandibular lymphadenopathy. Malignant tumors were significantly larger than benign tumors. Bone lysis was found in benign tumors (n = 4) such as acanthomatous ameloblastoma, giant cell granuloma, and plasmacytoma. The bone lysis was a well-defined geographic area regardless of malignancy and tumor type. In periosteal reactions, amorphous patterns were seen in both malignant (n = 2) and benign tumors (n = 2); the latter subgroup also showed solid patterns. Bone expansion (n = 2) was identified in malignant melanoma and acanthomatous ameloblastoma. Findings supported a diagnosis of possible malignancy for dogs with oral tumors having the following CT characteristics: large size, heterogeneous contrast enhancement pattern, bone lysis, tooth loss, and ipsilateral lymphadenopathy. However, there was a considerable overlap of CT findings among the different types of oral tumors and between benign and malignant tumors. Histological evaluation therefore remains necessary for definitive diagnosis.

Pulmonary Lymphangioma

The radiographic appearance of a solitary metastatic focus in bone is frequently mistaken for a primary malignant bone tumor. As Lodwick pointed out, “the solitary metastatic lesion of bone is the one which usually offers the real challenge in differential diagnosis” (3). Often, the distinguishing feature of a primary sarcoma is the presence of an associated periosteal reaction which authors have stated to be absent or scant in metastatic bone lesions. This investigation was initiated to determine if periosteal new-bone formation is in fact rare in metastasis and, therefore, a roentgenographic finding of value in differentiating primary from secondary bone tumors. Clinical Material A. Metastatic Tumors: In a period of six years, 35 patients with solitary metastatic lesions in bone were studied. This study was a selective review as only patients with isolated metastatic foci in bone were included. These included primarily lesions involving the appendicular skeleton, those most difficult to differentiate from primary bone sarcomas. Histologic documentation of the lesion was available in most cases. The presence and type of periosteal reactions were recorded from the roentgenograms. The types of periosteal responses were classified into one of four categories: (a) the lamellated reaction (onion peel), (b) a perpendicular or spiculated sunburst appearance, (c) a dense periosteal reaction which is difficult to differentiate from thickened cortical bone and often associated with osteoblastic metastases, and (d) the Codman or reactive triangle at the margin of the lesion. Patients with callus formation at the site of pathologic fracture were excluded from the clinical study because it was difficult to decide from the radiographs what represented normal fracturehealing and what represented periosteal response to tumor. There were a variety of primary sites in the metastatic series; 13 in all. When periosteal reaction was present, however, the most frequent primary tumors noted were in the gastrointestinal tract, prostate, kidney, lung, and adrenal gland. In fact, the finding of a solitary metastasis to the femur from a latent primary focus in the lung masquerading as a reticulum-cell sarcoma stimulated this study (Fig. 1). Only after biopsy was the true nature of the lesion disclosed. Thirteen of 35 patients in this group showed radiographic evidence of one or more types of periosteal reaction. In most instances the new-bone responses were varied, but in patients with osteoblastic metastasis a dense periosteal reaction was frequently noted (Fig. 2). The most pronounced periosteal responses were in metastases from the colon, prostate, and adrenal glands (neuroblastoma) (7). The incidence of reaction was 37 per cent, and the distribution of cases is illustrated in Figure 3. B. Primary Bone Tumors: A comparative study of 41 patients with primary bone a periosteal reaction. Because osteosarcomas can produce tumor bone in the soft tissues, however, it is difficult to be certain if one is dealing with periosteal non-tumor bone or tumor bone o

Regarding treatment strategies for medication-related osteonecrosis of the jaw (MRONJ), surgical therapy has recently been reported to be more effective than conservative therapy. However, some patients did not achieve complete healing, even when extensive surgery was performed. Periosteal reaction in MRONJ patients is often observed by the CT examination. Tssshe purpose of this study was to investigate the relationship between periosteal reaction and treatment outcome of MRONJ. A total of 164 surgeries in 136 patients with MRONJ at two hospitals were included in the study. Correlations between various clinical and radiographic factors and treatment outcome were examined with Cox regression analysis. The results showed that the presence of periosteal reaction, as well as primary disease involving malignant tumor, were independent risk factors related to poor outcome. Furthermore, we examined factors related to the occurrence of the periosteal reaction and found that 4 variables were significantly correlated with periosteal reaction by multivariate analysis: gender (female), site (lower jaw), primary disease (malignant tumor), and osteosclerosis (severe). The present study clarified that the cure rate after surgical treatment decreased in cases with periosteal reaction, suggesting that it is necessary to review the treatment method.

The present study aimed to investigate the imaging characteristics of primary malignant bone tumors in children. The imaging results of 34 children with primary malignant bone tumors confirmed by histopathological diagnosis between March 2008 and January 2014 were retrospectively analyzed. In total, 25 patients had osteosarcoma, with radiography and computed tomography (CT) showing osteolytic bone destruction or/and osteoblastic bone sclerosis, an aggressive periosteal reaction, a soft-tissue mass and cancerous bone. The tumors appeared as mixed magnetic resonance imaging (MRI) signals that were inhomogeneously enhanced. A total of 5 patients presented with Ewing sarcoma, with radiography and CT showing invasive bone destruction and a soft-tissue mass. Of the 5 cases, 2 showed a laminar periosteal reaction. The tumors were shown to have mixed low signal on T1-weighted images (T1WI) and high signal on T2-weighted images (T2WI); 1 case showed marked inhomogeneous enhancement. Another 3 patients exhibited chondrosarcoma. Of these cases, 1 was adjacent to the cortex of the proximal tibia, and presented with local cortical bone destruction and a soft-tissue mass containing scattered punctate and amorphous calcifications. MRI revealed mixed low T1 signal and high T2 signals. Another case was located in the medullary cavity of the distal femur, with radiography revealing a localized periosteal reaction. The tumor appeared with mixed MRI signals, and with involvement of the epiphysis and epiphyseal plates. Radiography and CT of the third case showed bone destruction in the right pubic ramus, with patchy punctate, cambered calcifications in the soft-tissue mass. MRI of the soft-tissue mass revealed isointensity on T1WI and heterogeneous hyperintensity on T2WI. Ossifications and the septum appeared as low T1WI and T2WI. Of the 34 patients, 1 patient presented with lymphoma involving the T12, L1 and L2 vertebrae. CT showed vertebral bone destruction, a soft-tissue mass and a compression fracture of L1. MRI showed a soft-tissue mass with low T1 signal and high T2 signal and marked inhomogeneous enhancement. Overall, osteosarcoma was the most common primary malignant bone tumor, followed by Ewing sarcoma, chondrosarcoma and lymphoma. Osteoblastic or osteolytic bone destruction, an invasive periosteal reaction, soft-tissue masses, a tumor matrix and inhomogeneous enhancement were important imaging features of malignant bone tumors.

During routine follow-up of patients treated with a three-piece stainless-steel modular femoral nail, osteolysis and periosteal reaction around the modular junctions of some of the nails were noted on radiographs. The purpose of this study was to evaluate the prevalence, etiology, and clinical relevance of these radiographic findings. Forty-four femoral fractures or nonunions in forty-two patients were treated with a modular stainless-steel femoral intramedullary nail. Seventeen nails were excluded, leaving twenty-seven intramedullary nails in twenty-seven patients for this study. All patients had had a femoral diaphyseal fracture; nineteen had had an acute fracture and eight, a nonunion. These twenty-seven patients returned for radiographs, a physical examination, assessment of functional outcomes, assessment of thigh pain with a visual analog scale, determination of serum chromium levels, and nail removal if desired. A control group of sixteen patients treated with a one-piece stainless-steel femoral intramedullary nail was evaluated with use of the same outcome measures and was compared with the group treated with the modular femoral nail with regard to prevalence of thigh pain and serum chromium levels. Twelve modular femoral nails were removed according to the study protocol. The modular nail junctions were analyzed for corrosion products, and histopathologic analysis of tissue specimens from the femoral canal was performed. The twenty-seven patients were seen at a mean of twenty-one months after fracture fixation; twenty-six of the twenty-seven fractures healed. Twenty-three femora had at least one of three types of abnormalities-osteolysis, periosteal reaction, or cortical thickening--localized to one or both modular junctions. Eighteen patients had severe reactions, defined as osteolysis of > or =2 mm, cortical thickening of > or =5 mm, and/or a periosteal reaction (group 1). Nine patients had mild or no reactions (group 2). Serum chromium levels in group 1 (mean, 1.27 ng/ mL; range, 0.34 to 3.12 ng/mL) were twice as high as those in group 2 (mean, 0.53 ng/mL; range, 0.12 to 1.26 ng/mL). However, this difference did not reach significance with the numbers available. The differences in serum chromium levels between group 1 and the control group with a one-piece nail (mean, 0.26 ng/mL; range, 0.015 to 1.25 ng/mL) (p<0.01) and a control group without an implant (mean, 0.05 ng/mL; range, 0.015 to 0.25 ng/ mL) (p<0.01) were significant. The level of thigh pain recorded on the visual analog scale was also significantly different between group 1 and the control group with a one-piece implant (p = 0.03). Retrieved modular nails had signs of fretting corrosion as well as stainless-steel corrosion products adherent to the junction where the osteolysis occurred. Histologic and spectrographic analysis revealed two types of corrosion products that were consistent with stainless-steel within the peri-implant tissue and were associated with a foreign-body granulomatous response. The presence of corrosion products at the taper junctions suggests that particulate debris was a major factor in the etiology of the radiographic findings of osteolysis, periosteal reaction, and cortical thickening. Serum chromium levels were substantially elevated in the patients with a modular femoral nail, and such levels may serve as a marker of fretting corrosion of these devices.

Osteosarcoma/Ewing Sarcoma

Objective To summarize the clinical characteristics,treatment methods and prognosis of periosteal surface hemangioma in the palm.Methods A retrospective review was conducted of 3 cases of periosteal surface hemangioma in the palm who were treated from 2008 to 2012.Results All 3 cases were cured after resection of the mass.The pathological diagnosis was intramuscular hemangioma.There was no recurrence in the follow-up.Pain in the palm was completely alleviated.Function of the hand was normal.Conclusion Periosteal surface hemangioma in the palm is rare.Continuous pain in the palm with no known etiology usually is the only symptom.A good prognosis depends on early diagnosis and surgical resection. Key words: Pain; Metacarpus; Periosteal surface hemangioma; Periosteal reaction