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Introduction Acromion is essential for stabilizing the shoulder complex. Tumors of the acromion are rare. We report the largest series of acromion tumor and tumor-like lesion. Materials and Methods A retrospective review of the oncology and radiology database within our tertiary center for orthopaedic oncology was performed to identify all tumors of the acromion over the past 30 years and imaging was reviewed. Results We identified a total of 31 lesions arising in the acromion and chondrosarcoma was the commonest. Conclusion One needs to be aware of tumor and tumor-like lesions of acromion.

Success in the management of bone sarcomas entails being able to achieve wide margins, which helps decrease the risk of local recurrence and provide an improvement in overall survival. The role of computer-assisted surgery has been investigated across various areas of orthopaedics, including joint replacement, cruciate ligament reconstruction, and pedicle screw placements which has led to increased interested in computer assisted tumour surgery (CATS). CATS can be used in a wide array of tumour surgeries, however its role in pelvic and sacral tumours is unparalled. Its importance lies in being able to provide radiological information to guide the surgeon at the time of surgery i.e. the distance from the tumour to the resection margin can be determined precisely based on preoperative planning and intra-operative image guidance. This minimises unnecessary bone resection, aiming to achieve good oncological and functional results which can be challenging in pelvic surgery. Most published articles on CATS have concentrated on the surgical aspects of navigation surgery. Although advanced imaging techniques such as magnetic resonance imaging (MRI) and computed tomography (CT) scans can provide anatomic detail about the primary tumour, the successful transfer of that information from a viewing screen to the intraoperative field can be difficult. The role of the radiologist lies in being able to provide appropriate imaging (CT, MRI) to facilitate surgical planning. This article aims at providing the radiologist a surgical insight on CATS and to facilitate optimal imaging in a patient tentatively being planned for CATS.

OBJECTIVE: Degenerative thoracic stenosis has been shown to most frequently involve the lower thoracic segments (T9-T12) where there is greater mobility and vulnerability due to flexion, extension and rotation of the spine. The thoracolumbar junction is considered anatomically to be T12-L1; the anatomical transition between the relatively immobile thoracic spine and relatively mobile lumbar spine. From anecdotal experience at our institution, we hypothesise that the true thoracolumbar junction is higher, at T10-11; the point of transition from floating to false ribs resulting in increased mobility at T10-11. METHODS AND MATERIALS: A retrospective review was performed of MRI lumbar and whole spine performed on patients aged 10–40 years in our institution over a 5-year period. Patients with previous surgery, chronic spinal disorders and congenital abnormalities were excluded from the study. Intervertebral discs from T8-9 to L1-2 were assessed for evidence of degeneration using the Pfirrmann grading system. Data obtained from a study using computer-based models to assess mean resultant loads in flexion, sitting and standing from T8-9 to L1-2 on patients aged 18–35 years was also analysed. The mean load gradients between two consecutive discs from T8 to L2 were analysed. Statistical analysis was performed with SPSS (p

Objective Cervical spine osteochondromas are rare with approximately 3% of solitary and 7–9% of hereditary osteochondromas occurring in the spine. Almost 50% of spinal osteochondromas occur in the cervical region. Methods A search of osteochondroma of cervical spine was performed of our radiology database. Results In this study, we present 11 cases of adult cervical spine osteochondromas. These predominantly involved the posterior elements. The cartilage cap was more than 2 cm in 2 cases. There was cord compression in 1 case, foraminal narrowing in 2 patients and vertebral artery compression in 1 case. 6 patients underwent excision with majority being osteochondroma. There was only one case of chondrosarcoma. Conclusion Osteochondromas of cervical spine and extremely rare and symptomatology are due to mass effect. One should be aware of this entitly when analysing cervical spine for neck pain or lump.

Objective We describe a novel and safe CT biopsy technique that we have termed the “Birmingham intervention tent technique (BITT).” This technique is ideal for biopsying osseous lesions where a direct approach is not possible due to difficult positioning. Methods The BITT uses a plastic surgical forceps clamp attached at an angle to the biopsy needle, creating a tent shape. The finger rings of the forceps is stabilized on the table. Results In our institution, we have already used the BITT successfully in over 10 cases. Conclusion The BITT is an inexpensive and reproducible technique.

Introduction The posterior compartment of the thigh is composed of three major muscles collectively known as the hamstring muscles. These consist of the biceps femoris short and long head, semimembranosus and semitendinosus. Excluding the short head of biceps femoris, the hamstrings contribute to the movement of the hip and the knee joints as they span across both joints. Our hypothesis is that the nature of the conjoint tendon -ischial angle predisposes to an increased risk of tearing in this hamstring component. We therefore aim to look at the anatomy of the hamstring origin at the ischial tuberosity and spatial relationship between the long head of biceps, semitendinosus and semimembranosus in the form of vector angles. Material and methods 100 consecutive pelvic MRIs in patients under the age of 40 years were reviewed by musculoskeletal radiology fellow and a consultant musculoskeletal radiologist with more than 10 years’ experience in musculoskeletal radiology and measured the angle of origin of conjoined tendon and semimembranosus at its ischial origin. P value using a paired t-test was less than 0.0001 confirming that the difference in the vector angle of the different hamstring components was statistically significant. Results The median angle of origin of conjoined tendon was 12° and for semimembranosus was 6°. Applying the concept of Newton’s second law to the angles calculated we demonstrated that an increase of 9% force applied to the conjoint tendon origin when compared to the semimembranosus tendon. Conclusion We hypothesis that the difference in the angle of origin of the components of hamstrings might be one of the reasons for the difference in the incidence and patterns of the injuries of the various muscles of the hamstrings.

Purpose To evaluate the correlation between trochlear dysplasia and acetabular coverage. Materials and methods 109 retrospective CT studies referred from the young adult knee clinic were independently reviewed by two observers. Anterior acetabular (AASA) and posterior acetabular (PASA) sector angles were calculated bilaterally on axial CT. Trochlear dysplasia was graded using the Dejour classification (A-D). ANOVA test was used. Results Dejour types A, B and D trochlear dysplasia were associated with a significantly increased AASA (P value = 0.0011). Conclusion Our results demonstrate a significant relationship between trochlear dysplasia and anterior acetabular coverage, as measured by AASA.

Numerous corticosteroid preparations are available, but the type and dose administered is frequently at the discretion of the clinician. This is often based on anecdotal evidence and experience rather than formal clinical guidelines. In order to better understand current practice, we anonymously surveyed 100 members of the British Society of Skeletal Radiologists. The results of the survey demonstrated the arbitrary use of all types of steroid preparation at different anatomical locations. In this article, we review the commonly used corticosteroids and propose a guideline to help practitioners decide on the type and dose of steroid depending on the treatment location.

Facet joints are the only synovial joints in the spine and can be involved in a large number of pathological processes including arthropathy, infection, inflammation, trauma and tumour. In this review article, we present a spectrum of pathologies that arise from or involve facet joints that we have encountered in our tertiary orthopaedic and spinal centre. The objective of this review is to create an aide memoire for the general radiologist who may encounter facet joint pathology, which they may not be familiar with.

Soft tissue sarcomas are rare tumours which can be clinically difficult to differentiate from more common benign lesions. Imaging plays a fundamental role in diagnosis, but in some cases it can be difficult to differentiate benign from malignant conditions. This article reviews potential pitfalls in soft tissue sarcoma imaging.

Aim To present the imaging features of post-traumatic heterotopic ossification (HO) of the distal tibiofibular syndesmosis initially suspected to be a surface osteosarcoma. Materials and methods A retrospective review was conducted of the presenting complaint and imaging features of patients with a final diagnosis of HO referred over an 8 year period to a specialist orthopaedic oncology centre. Results Five patients with HO were identified. All were adult males with an age range of 19–41 years. There was a history of prior ankle trauma in all cases but the significance was not recognized at the time of referral to the specialist centre. There was radiographic evidence of HO arising from the inner aspects of the distal tibia and fibula approximately 3 cm proximal to the ankle joint. The HO was “kissing” in two cases and partially fused (synostosis) in two. The HO in the fifth case was arising on the inner fibular cortex alone. Magnetic resonance imaging (MRI), available in four cases, showed predominantly low signal intensity due to the dense bone formation. Conclusion The history of prior ankle trauma with ossification arising from the inner aspects of both the distal tibia and fibula is typical of post-traumatic HO and distinguish this benign condition from the rare surface osteosarcoma at this site.

Aim To investigate the association of a fatigue-type stress fracture and a fibrous cortical defect/non-ossifying fibroma (FCD/NOF) of the lower limb long bones in skeletally immature patients. Materials and methods The patient database of a specialist orthopaedic oncology centre was searched to determine the number of skeletally immature patients (≤16 years of age) over an 18 year period with a lower limb long bone lesion ultimately shown to be a fatigue-type stress fracture. The diagnosis was established by a combination of typical imaging findings of a fatigue-type stress fracture, the absence of aggressive features suggestive of a sarcoma (e.g., interrupted periosteal reaction, cortical breach, and a soft-tissue mass) together with evidence of consolidation or healing on follow-up radiographs and resolution of symptoms over the subsequent weeks. The database was also used to determine the number of skeletally immature cases (≤16 years of age) referred in the same period in which the principal lesion was shown to be a fibrous cortical defect (FCD) or non-ossifying fibroma (NOF) of the lower limb long bones. The clinical and imaging features of those cases common to both groups (i.e., with both a fatigue-type stress fracture and a FCD or NOF) were reviewed. Results Six percent of patients (five cases) referred to an orthopaedic oncology unit, who were subsequently shown to have a stress fracture of the lower limb long bones, were found to have a related FCD/NOF. All had been referred with a suggested diagnosis of a bone sarcoma and/or osteomyelitis. The possibility of a stress fracture had been raised in only one case. Four cases involved the proximal tibia and one the distal femur. Radiographs revealed that both lesions arose in the posteromedial cortex in all but one of the cases. The radiographs and magnetic resonance imaging (MRI) features were considered typical of the overlapping pathological features of the lesions. Conclusions A sarcoma could be effectively excluded in the absence of true cortical destruction and soft-tissue extension. Both fatigue-type stress fractures and FCD/NOFs occur at similar sites in the long bones. It is postulated that the existence of the latter may cause localized weakening of the bone thereby predisposing to the development of a stress fracture. The co-existence of these two conditions in the skeletally immature should be recognized as the dual pathological processes may contribute to radiological misdiagnosis.

Erdheim–Chester disease presenting with destruction of a metacarpal A.M. Davies , S.P. Colley , S.L.J. James *, V.P. Sumathi , R.J. Grimer c Department of Radiology, Royal Orthopaedic Hospital, Birmingham B31 2AP, United Kingdom Department of Histopathology, Royal Orthopaedic Hospital, Birmingham B31 2AP, United Kingdom Department of Orthopaedic Oncology, Royal Orthopaedic Hospital, Birmingham B31 2AP, United Kingdom

Sacral insufficiency fractures are a relatively common cause of low back pain in the elderly. Osteoporosis is the leading cause, most commonly affecting elderly women. Other causes include chronic steroid use, radiation exposure, and arthritis. Patients typically present with severe low back pain, which in some cases results in immobility with its associated complications. However, sacral insufficiency fractures are commonly underdiagnosed due to difficulty in visualizing the fracture line on radiographs. However, other imaging methods, such as computed tomography (CT), magnetic resonance imaging (MRI), and bone scintigraphy, can accurately diagnose this condition. Denis and co-workers reported a classification system for sacral fracture patterns, which describes three zones: zone I (alar zone) fractures extend through the ala without any extension into the foramina or the central sacral canal; zone II (foraminal zone) fractures involve one or several foramina; and zone III (central zone) fractures primarily involve the central sacral canal. Although most sacral insufficiency fractures affect the sacral ala, the fracture line may extend to involve the sacral foramina. A potential complication of sacroplasty is the extrusion of cement into the sacral foramina that could lead to injury of the sacral nerves or cement migration into the spinal canal. Therefore, a fracture line extending into the sacral foramen must be treated with caution and it has been suggested that only zone I fractures should be treated with

To identify the relationship between depth and size of soft-tissue mass lesions relative to histological diagnosis in a range of malignant neoplastic, benign neoplastic, and non-neoplastic conditions on magnetic resonance imaging (MRI).The MRI findings of 571 consecutive patients referred to a supra-regional orthopaedic oncology unit with a suspected soft-tissue neoplasm were reviewed and included in the study. The patient age, histological diagnosis, lesion size, anatomical location, and lesion depth (superficial or deep to fascia) were recorded.There were 288 males and 283 females (mean age 48 years, age range 2-92 years). The mean age was 54.1 years for malignant neoplastic lesions compared with 40.1 years for benign neoplastic and 45.4 years for non-neoplastic conditions. There was a significant age difference when malignant lesions were compared with benign neoplastic and non-neoplastic lesions (p0.001). No significant relationship was present between lesion depth (480 deep, 91 superficial) and diagnosis (288 malignant neoplastic, 197 benign neoplastic and 86 non-neoplastic lesions). However, a significant relationship was identified between lesion size and diagnosis (p0.001). Furthermore, a significant relationship was identified when lesion size greater than 5 cm, lesion depth, and diagnosis were analysed.Current guidelines suggest the most important variables for assessing risk of malignancy in a soft-tissue lesion include size, depth in relation to the fascia, increasing size, and pain. The current study suggests that relationship to fascia is less important as a predictor of malignant potential in a patient cohort treated at a supra-regional centre. Significant risk factors include increasing patient age and lesion size greater than or equal to 5 cm.

Soft tissue sarcomas are uncommon malignancies that have a high risk of local recurrence despite adequate initial surgery. The aim of follow-up imaging with any malignancy is to detect recurrence promptly so that treatment can be instigated at the earliest possible opportunity. In this review article, we discuss the imaging modalities that can be employed to detect local recurrence following surgery for an extremity soft tissue sarcoma. The role of radiographs, computed tomography, magnetic resonance imaging and positron emission tomography is reviewed followed by a discussion on the imaging modalities useful in the detection of metastatic disease. Finally, we present a robust pathway that is suggested for the follow-up of patients with an extremity soft tissue sarcoma.

A hibernoma is a rare lipomatous tumour sharing morphological features with brown fat [1–3]. Brown fat is involved in thermoregulation and can be focally found in the head and neck region in neonates, children and young adults [4]. Hibernoma is a well-demarcated, slow-growing benign tumour, which rarely recurs after surgical excision. Sixty-one percent of hibernomas occur in the third and fourth decades with a predilection for the upper trunk and thigh. These normally arise in the subcutis or within skeletal muscle [5]. An intraosseous location appears to be very rare in hibernomas. An intraosseous hibernoma of the sacrum has been described by Kumar and colleagues [1]. Thorns and colleagues describe hibernoma-like histological changes in a bone marrow trephine without an apparent mass lesion [2]. Reyes and colleagues describe a case of bilateral femoral hibernomas; however, histological and radiological documentation on this case is not available [3]. We report a case of intraosseous hibernoma within the ilium in a 40-year-old woman and describe its imaging and pathological features.

Osteoid osteomas are relatively common accounting for approximately 10% of all biopsied benign bone tumours. They typically present with pain and arise predominantly in the cortex of long bones in children and young adults.1 Traditional treatments include surgical resection and curettage; however, localization of the central nidus intraoperatively can be problematic. This may lead to incomplete removal and subsequent increased risk of recurrence. Furthermore, removal of a section of the cortex to access the nidus canweaken the bone potentially resulting in fracture. A number of percutaneous treatments have been described including radiofrequency ablation, drilling, trepanation, laser photocoagulation, and chemical destruction of the nidus.2 The most widely used of these techniques is radiofrequency ablation and it has become the method of choice in the treatment of osteoid osteoma.3 Complications are rare and include infection, thermal injury to skin, soft tissues, and articular cartilage, and equipment malfunction. Needle fracture is a recognized

Surface aneurysmal bone cysts are uncommon benign primary bone tumours. Involvement of the bones of the hand has only rarely been described. We report the clinical presentation, imaging and histological findings of a case of subperiosteal aneurysmal bone cyst of the index finger metacarpal.

We present details of a case of giant cell tumour of bone (GCTOB) involving the triquetrum. GCTOB arising within the carpus is exceedingly rare and, to our knowledge, this is only the second case of monostotic GCTOB of the triquetrum that has been reported.