Pigmented villonodular synovitis (PVNS) represents an uncommon benign neoplastic process that may involve the synovium of the joint diffusely or focally (PVNS) or that may occur extraarticularly in a bursa (pigmented villonodular bursitis [PVNB]) or tendon sheath (pigmented villonodular tenosynovitis [PVNTS]). Pathologic specimens of the hypertrophic synovium may appear villous, nodular, or villonodular, and hemosiderin deposition, often prominent, is seen in most cases. The knee, followed by the hip, is the most common location for PVNS or PVNB, whereas PVNTS occurs most often in the hand and foot. PVNTS is also referred to as giant cell tumor of the tendon sheath (GCTTS). PVNTS is the most common form of this disease by a ratio of approximately 3:1. Radiographs reveal nonspecific features of a joint effusion in PVNS, a focal soft-tissue mass in PVNB or PVNTS, or a normal appearance. Extrinsic erosion of bone (on both sides of the joint) may also be seen and is most frequent with intraarticular involvement of the hip (>90% of cases). Cross-sectional imaging reveals diffuse involvement of the synovium (PVNS), an intimate relationship to the tendon (PVTNS), or a typical bursal location (PVNB), findings that suggest the diagnosis. However, the magnetic resonance (MR) imaging findings of prominent low signal intensity (seen with T2-weighting) and "blooming" artifact from the hemosiderin (seen with gradient-echo sequences) are nearly pathognomonic of this diagnosis. In addition, MR imaging is optimal for evaluating lesion extent. This information is crucial to guide treatment and to achieve complete surgical resection. Recurrence is more common with diffuse intraarticular disease and is difficult to distinguish, both pathologically and radiologically, from the rare complication of malignant PVNS. Recognizing the appearances of the various types of PVNS, which reflect their pathologic characteristics, improves radiologic assessment and is important for optimal patient management.

Pigmented Villonodular Synovitis: Radiologic-Pathologic Correlation

Current population studies characterize idiopathic scoliosis as a single-gene disorder that follows the patterns of mendelian genetics, including variable penetrance and heterogeneity. The role of melatonin and calmodulin in the development of idiopathic scoliosis is likely secondary, with indirect effects on growth mechanisms. Reported abnormalities of connective tissue, skeletal muscle, platelets, the spinal column, and the rib cage are all thought to be secondary to the deformity itself. Although no consistent neurological abnormalities have been identified in patients with idiopathic scoliosis, it is possible that a defect in processing by the central nervous system affects the growing spine. The true etiology of idiopathic scoliosis remains unknown; however, it appears to be multifactorial.

Etiology of idiopathic scoliosis: current trends in research.

We aimed to assess the impact of timing of surgery in elderly patients with acute hip fracture on morbidity and mortality We systematically searched MEDLINE, the Cochrane Library, Embase, PubMed, and trial registries from 01/1997 to 05/2017, as well as reference lists of relevant reviews, archives of orthopaedic conferences, and contacted experts Eligible studies had to be randomised controlled trials (RCTs) or prospective cohort studies, including patients 60 years or older with acute hip fracture Two authors independently assessed study eligibility, abstracted data, and critically appraised study quality We conducted meta-analyses using the generic inverse variance model We included 28 prospective observational studies reporting data of 31,242 patients Patients operated on within 48 hours had a 20% lower risk of dying within 12 months (risk ratio (RR) 080, 95% confidence interval (CI) 066–097) No statistical significant different mortality risk was observed when comparing patients operated on within or after 24 hours (RR 082, 95% CI 067–101) Adjusted data demonstrated fewer complications (8% vs 17%) in patients who had early surgery, and increasing risk for pressure ulcers with increased time of delay in another study Early hip surgery within 48 hours was associated with lower mortality risk and fewer perioperative complications

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Impact of timing of surgery in elderly hip fracture patients: a systematic review and meta-analysis

Study design Intervertebral disc tissue was analyzed during or removed at routine surgery for correction of scoliosis. Tissue was analyzed for glucose, lactate, oxygen, glycosaminoglycan, collagen concentrations, and cell viability. Objectives To investigate the cell viability of the scoliotic disc on the concave and convex sides and in relation to curve apex, and to relate cell viability to concentrations of nutrients, metabolites, and extracellular matrix components. Summary of background data Compositional differences have been measured in relation to the deformation of scoliotic discs. However, the causes of these in relation to cellular activity or viability are unknown. Methods Oxygen concentration was measured at surgery using a microelectrode. A segment of disc then was removed and sections at defined locations measured for cell viability and glucose, lactate, glycosaminoglycan, and collagen concentrations. RESULTS Cell viability was lower toward the convex side of the curve, with the greatest difference between the sides in the apical disc. The apical disc had the lowest oxygen and highest lactate concentrations, and lowest total number of cells. Glucose concentration correlated with the number of live cells. Concentrations of glycosaminoglycans and collagen per dry weight of tissue were similar on both sides of the disc. Conclusions Differences in cell viability correlated with changes in nutrient and metabolite levels, and also with disc deformity (convex concave and distance from curve apex). Thus asymmetrical loads, tissue deformation, and nutrient supply may work separately or in combination to cause cell death. A loss of matrix macromolecules was not seen, possibly because the period between cell death and surgery was too short, as compared with long matrix turnover times. Cell death is expected eventually to have a deleterious effect on cell matrix and disc function.

Cell viability in scoliotic discs in relation to disc deformity and nutrient levels.

Background: Delirium in hip fractured patients is a frequent complication. Dementia is an important risk factor for delirium and is common in frail elderly. This study aimed to extend the previous knowledge on risk factors for delirium and the consequences. Special attention was given to patients with dementia and delirium. Methods: This is a retrospective cohort study performed in the Amphia Hospital, Breda, the Netherlands. A full electronic patient file system (Hyperspace Version IU4: Epic, Inc., Verona, WI, USA) was used to assess data between January 2014 and September 2015. All patients presented were aged ≥70 years with a hip fracture, who underwent surgery with osteosynthesis or arthroplasty. Patients were excluded in case of a pathological or a periprosthetic hip fracture, multiple traumatic injuries, and high-energy trauma. Patient and surgical characteristics were documented. Postoperative outcomes were noted. Delirium was screened using Delirium Observation Screening Scale and dementia was assessed from medical notes. Results: Of a total of 566 included patients, 75% were females. The median age was 84 years (interquartile range: 9). Delirium was observed in 35%. Significant risk factors for delirium were a high American Society of Anesthesiology score, delirium in medical history, functional dependency, preoperative institutionalization, low hemoglobin level, and high amount of blood transfusion. Delirium was correlated with a longer hospital stay (P=0.001), increased association with complications (P<0.001), institutionalization (P<0.001), and 6-month mortality (P<0.001). Patients with dementia (N=168) had a higher delirium rate (57.7%, P<0.001) but a shorter hospital stay (P<0.001). There was no significant difference in the 6-month mortality between delirious patients with (34.0%) and without dementia (26.3%). Conclusion: Elderly patients with a hip fracture are vulnerable for delirium, especially when the patient has dementia. Patients who underwent an episode of delirium were at increased risk for adverse outcomes.

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Dementia and delirium, the outcomes in elderly hip fracture patients

Nowadays, fracture surgery represents a big part of the orthopedic surgeon workload, and usually has associated major clinical and social cost implications. These fractures have several complications. Some of these are medical, and other related to the surgical treatment itself. Medical complications may affect around 20% of patients with hip fracture. Cognitive and neurological alterations, cardiopulmonary affections (alone or combined), venous thromboembolism, gastrointestinal tract bleeding, urinary tract complications, perioperative anemia, electrolytic and metabolic disorders, and pressure scars are the most important medical complications after hip surgery in terms of frequency, increase of length of stay and perioperative mortality. Complications arising from hip fracture surgery are fairly common, and vary depending on whether the fracture is intracapsular or extracapsular. The main problems in intracapsular fractures are biological: vascularization of the femoral head, and lack of periosteum -a major contributor to fracture healing- in the femoral neck. In extracapsular fractures, by contrast, the problem is mechanical, and relates to load-bearing. Early surgical fixation, the role of anti-thromboembolic and anti-infective prophylaxis, good pain control at the perioperative, detection and management of delirium, correct urinary tract management, avoidance of malnutrition, vitamin D supplementation, osteoporosis treatment and advancement of early mobilization to improve functional recovery and falls prevention are basic recommendations for an optimal maintenance of hip fractured patients.

Complications of hip fractures: A review.

Study design An experimental study of the influence of intrinsic muscle imbalance on the spinal column of a growing rabbit. Objectives To create an in vivo experimental model of scoliosis for comparison with human scoliosis. Summary of background data There is evidence that asymmetric lordosis may produce scoliosis and that there is muscle imbalance in scoliotic patients. Methods Surgical tethering of the spinous apophysis and transverse apophysis of rabbits was performed at three upper levels on the same side of the spine to simulate dominance of one side of the paravertebral musculature over the other. Results All animals exhibited scoliosis that was convex toward the side opposite that receiving surgery. Radiography showed the curve to increase with time. Postmortem examination of vertebrae revealed structural alterations similar to those produced in human scoliosis. Conclusions Intrinsic muscle imbalance in the spinal column of the experimental growing animal may produce scoliosis with characteristics similar to those of human idiopathic scoliosis.

Scoliosis induced by asymmetric lordosis and rotation: an experimental study.

STUDY DESIGN The incidence of pes cavus and scoliosis was studied in three groups of patients. Group A contained 130 patients with idiopathic scoliosis, Group C contained 210 patients with idiopathic pes cavus, and Group B (control) contained 200 patients of similar age. OBJECTIVES To investigate the joint presentation of pes cavus and idiopathic scoliosis, because both deformities may share a common etiology linked to muscle imbalance. SUMMARY OF BACKGROUND DATA Sixty five percent of Group A patients (85 of 130) had an abnormally high plantar arch, compared to only 9.5% (19 of 200) of Group B control subjects. Nine percent (20 of 210) of the patients in Group C had scoliosis curves, compared to only four patients in Group B. METHODS Radiographs were taken to determine the type of scoliosis curve, its location, and its magnitude, and to identify the incidence of spina bifida occulta in the three groups. The incidence and degree of pes cavus were established by means of foot prints. Statistical analyses were performed on all results. RESULTS A statistically significant relationship (P < 0.01) was found for the incidence of pes cavus between Group A (scoliosis) and Group B (control), and for the incidence of scoliosis between Group C (pes cavus) and Group B (control). No statistical significance was observed for the other relationships investigated (sex, curve location, magnitude, spina bifida). CONCLUSIONS There was a significant correlation between scoliosis and pes cavus--spina bifida was not an etiologic factor. Therefore, in certain patients where scoliosis and pes cavus present jointly, deformity may be secondary to altered balance or to disorders of the central nervous system.

The relationship between pes cavus and idiopathic scoliosis.

Pigmented villonodular synovitis, a rare proliferative disease of unknown etiology, is rare in the foot (2% of these lesions). A retrospective review was undertaken of the case histories, radiographs, and imaging results of eight patients treated for pigmented villonodular synovitis of the foot. Pigmented villonodular synovitis was located in the rearfoot in five patients and in the forefoot in the other three. Radiographs in six patients showed bone involvement. Affected bones included the talus, first cuneiform, first and fifth metatarsals, and second phalanx. Treatment was surgical, and only one recurrence was recorded after 24 months. Pigmented villonodular synovitis should be considered in the differential diagnosis of foot tumors. (J Am Podiatr Med Assoc 97(5): 415–419, 2007)

Clinical and Radiologic Features of Pigmented Villonodular Synovitis of the Foot Report of Eight Cases

(1996). Methadone-induced fibrous and calcified myopathy-a report of 2 cases. Acta Orthopaedica Scandinavica: Vol. 67, No. 4, pp. 404-406.

Manuel Mesa

Papers

Complications of hip fractures: A review.

Scoliosis induced by asymmetric lordosis and rotation: an experimental study.

The relationship between pes cavus and idiopathic scoliosis.

Clinical and Radiologic Features of Pigmented Villonodular Synovitis of the Foot Report of Eight Cases

Methadone-induced fibrous and calcified myopathy--a report of 2 cases.