cases (Akerman and Rydholm. 1994). MIII gives the best informa tion for deep-seated soft-tissue tumours which will help pre operative staging (lung and Davis ...
664
CORRESPONDENCE
We agree with Howard et at that patients with subpenosteat collections antibiotics
who do not show dramatic response should have surgical drainage.
to intravenous
side
mobilisation
and
after total hip replacement surgery, but the three contentious issues should be recognised and raised in defence against litiga tion or the imposition of guidelines. D. WARWICK, FRCS G. C. BANNISTER, MD, McI Orth, FRCS, FRCS Ed Southmead Hospital
Kaiser 5, Rosenborg M. Early detection of subperiosteal abscesses by ultrasonography: a means for further successful treatment in pediatric osteomyeitis. Pediatr Radio! 1994:24:336-9.
DEATH AND THROMBOEMBOLIC DISEASE AFTER ifiP REPLACEMENT et al in a retrospective
effects. The use of regional anaesthesia, early graduated compression stockings also helps.
On the balance of probabilities, prophylaxis should be used
E. T. MAH, MD G. W. LEQUESNE, DDR, FRACR, DDU D. C. PATERSON, MD, FRCS, FRACS R. J.GENT, DMU Women's and Children's Hospital North Adelaide South Australia.
Sir@ Warwick
offer a pronounced benefit with no risk of haemorrhagic
study in the January
Bristol, UK. M. H. WILLIAMS, MA, MRCP, MFPHM
University of Bristol Bristol, UK. Imperiale iT, Speroff T. A meta-analysis of methods to prevent venous thromboembolism l994;27l :1780-5.
1995 issue
entitled ‘Deathand thromboembolic disease after total hip replacement' (1995;77-B:6-lO) recorded a thromboembolic mor
bidity of 3.4% and suggested that prophylaxis to reduce this would be justifiable if resulting complications did not produce an alternative morbidity. There are now many studies which show that prophylaxis for thromboembolism is effective in patients undergoing hip replacement and that low-molecular-weight hepar
ULTRASOUND
following
total
hip
OF SOFT-TISSUE
replacement.
JAMA
MASSES
Sir@
Johnstone and Beggs in an editorial in the September 1994 issue entitled ‘Ultrasoundimaging of soft-tissue masses in the extrem ities' (l994;76-B;668-9)
advocate
ultrasound
imaging
as “a wide
ly available, inexpensive and accurate method of assessing suspected soft-tissue lesions of the extremities―. They use high
in offers valuable protection. The authors refer to the complica tions of prophylaxis but those relating to low-dose heparin have
resolution real-time equipment and have found it to be an accurate
not achieved statistical significance and may well relate to surgi cal technique. Properly designed prospective studies with ade quate follow-up are required. Orthopaedic surgeons who do not use prophylaxis against deep
or meniscal cyst by ultrasound is reliable but suggest that clinical examination combined with fine-needle aspiration cytology is
first-line
investigation.
We agree that demonstration
equally cheap and safe. Ultrasound is not diagnostic
of a popliteal
for other soft-tissue
masses
but CT
vein thrombosis expose themselves to the risk of litigation.
or MRI is diagnostic for lipoma, which often mimics soft-tissue
J. H. SCURR, FRCS
addition, haemangioma and neurilemmoma often show specific
sarcoma, especially if it is deep-seated (Gelineck et al 1994). In
Middlesex and University College Hospital
signal
London, UK.
characteristics
on MRI (Greenspan
et at 1992; Söderlund,
Goranson and Bauer 1994). Malignant soft-tissue tumours cannot Warwick D, Bannister GC, Williams MH. Death and thromboembolic disease after total hip replacement.
J Bone Joint Surg (Br]
1995;
77-B:6-10. Authors'
be diagnosed on MRI alone but the findings of necrosis and peritumoural
oedema
strongly
suggest
malignancy
(lung
and
Davis 1993). The authors correctly state that soft-tissue malignant fibrous
reply:
histiocytoma
may present
as a large spontaneous
haematoma
but
we do not advocate early exploration of such a tumour which may Sir,
tead to contamination of normal tissue, complicating later radical
We thank Mr Scurr for his comments on our paper. We agree about the need for proper endpoints, but teleologically, the only
surgery (Mankin, Lange and Spanier 1982). Operation for deep seated masses must be based on preoperative MEl or CT with a
true
endpoint
is the
clinical
expression
of
venous
thrombo
fine-needle or true-cut biopsy; open biopsy can be avoided in most
embolism, namely death, clinical pulmonary embolism and din
cases (Akerman
ical thrombophlebitis;
tion for deep-seated soft-tissue tumours which will help pre
our study tried to quantify
these.
Most randomised clinical trials address the venographic pro valence of deep-vein thrombosis (DVT). The unproven extrapola tion is then made that a reduction in venographic DVT is reflected in a reduced clinical expression of venous thromboembolism. studies
have shown that mortality
from pulmonary
embolism
No
1994). MIII gives the best informa
operative staging (lung and Davis 1993).
The authors state that their experience with fine-needle aspira tion cytology is disappointing, but there are a number of studies which confirm the value of this diagnostic tool (Akerman, Ryd
after
holm and Persson 1985; Layfieldet al 1986; Oland et al 1988;
that, when prophylaxis was not used rou was considerably lower than is often
Young 1993). We agree that solid masses always require further investigation but feel that patients with such masses in the extremities, espe
hip replacement can be reduced by prophylaxis. Our study showed tinely, the mortality
and Rydholm
assumed, although the clinical expression of venous thrombo
cially
embolism
further investigation and management.
was fairly substantial.
Routine
prophylaxis
should
therefore be considered, bearing in mind three contentious issues: the scientific validity of the studies supporting the prophylaxis, the potential
side-effects
of the prophylaxis,
and the extrapolation
if deep-seated,
should
be referred
to a tumour
centre
for
M. A@i@w@r H. BAUER A. RYDHOLM
between venographic DVT and clinical thromboembolism.
V. SODERLUND
On this basis, low-molecular-weight heparin is the most effec tive chemical agent, reducing venographic DVT to about 17% with a low risk of side-effects (Imperiale and Speroff 1994). The
Akerman M, Rydhoim A, Persson BM. Aspiration cytology of soft tissue tumours: the 10-year experience at an orthopaedic oncology
AV Impulse Foot Pump has fewer published studies but appears to
center. Acta Orthop ScaM l985;56:407-l2.
ThE JOURNAL OF BONE AND JOINT SURGERY
CORRESPONDENCE Akerman
M, Rydholm A. Surgery based on fine-needle aspiration cytol
ogy. Acta Orthop Scand l994;65 Suppl 256:69-70. Gelineck J, Keller J, Myhre-Jensen 0, Nielsen OS, Christensen T. Evaluation
of lipomatous
soft tissue tumors by MR imaging. Acta
Radio! 1994;35:367-70.
665
Ball ABS, Fisher C, Pittam M, Watkins RM, Westbury G. Diagnosis of soft tissue tumours by Tru-Cut biopsy. Br J Surg 1990:77:756-8.
Van HolsbeeckM, Introcaso JH. Musculoskeletalultrasound.St Louis: Mosby Year Book, 1991:48-51. Kissin MW, Fisher C, Carter RL, Horton LWL, Westbury G. Value of Tru-cut biopsy in the diagnosis of soft tissue tumours. Br J Surg 1986:73:742-4.
Greenspan A, McGalhan JP, Vogelsang P, Szabo RM. Imaging strate gies in the evaluation of soft-tissue hemangiomas of the extremities: correlation of the findings of plain radiography, angiography, CT, MRI and ultrasonography in 12 histologically proven cases. Skeletal Radio! l992;21:l 1-8.
Shives TC. Biopsy of soft-tissue tumors. C/in Orthop 1993:289:32-5. Simon MA, Biermann JS. Biopsy of bone and soft tissue lesions. J Bone
Johnstone AJ, Beggs I. Editorial. Ultrasound imaging of soft-tissue masses in the extremities. J Bone Joint Surg [Br] l994;76-B:688-9.
Thomas EA, Cassar-Pufficino
Layfield 14, Anders MI, Glasgow BJ, Mirra JM. Fme-needleaspirationof primary soft-tissuelesions.Arch Patho! Lab Med 1986;llO:420-4. Mankin LU, Lange TA, Spanier SA. The hazards of biopsy in patients with malignant primary bone and soft-tissue tumors. J Bone Joint Surg [Am] 1982;64-A:1 12 1-7. Oland J, Rosen A, Reif R, Sayfan J, Orda R. Cytodiagnosis of soft tissue tumours. J Surg Onco! l988;37:l68-70. Söderlund V, Goranson H, Bauer HC. MR imaging of benign peripheral nerve sheath tumors. Acta Radio! 1994;35:282-6. ‘flingGA, Davis LM. The role of magnetic resonance imaging in the evaluation of the soft tissue mass. Crit Rev Diagn Imaging l993;34:239-308. Young JA. Fine needle aspiration cytopathology. London: Blackwell Scientific Publications, 1993:251-7.
Authors'
Joint Surg [Am] l993;75-A:6l6-2l. YN, McCall 1W. The role of ultrasound in
the early diagnosis and management of heterotopic bone formation. C/in Radio! l99l;43:190-6.
SEMICONSTRAINED ELBOW REPLACEMENT FOR DISTAL HUMERAL NONUNION Sir@ We read with interest the article by Money and Adams in the January
1995 issue regarding
semiconstrained
elbow
replacement
for distal humerat nonunion (l995;77-B:67-72). The use of this elbow prosthesis has made a great improvement in the care of such injuries in the older patient or in patients in whom bone stock is insufficient
for reconstruction.
The results
which they report are
most encouraging and support the continued use of this prosthesis in that role.
reply:
In younger patients, however, there is another reasonable We thank Akerman and his colleagues for their comments but fear that they have not appreciated our central point. A normal ultra sound examination excludes a mass lesion and obviates the need
option. While Money and Adams refer to the “ . . . very low incidence of satisfactory results―after secondary osteosynthesis for this condition reported in two earlier papers, no mention is made of a more recent study which describes a more optimistic
for further examination or referral to a tumour centre. Their
outlook.
advocacy
patients who had internal fixation of malunion and nonunion of
Sir@
of fine-needle
aspiration
of popliteat
and meniscat
cysts
is difficult to reconcile with their wish to see tumours referred ‘untouched' to tumour centres.
They are wrong to say that ultrasound can charactense only cystic lesions since both muscle hernias (Van Holsbeeck Introcaso
1991)
and
myositis
ossificans
(Thomas,
and
Cassar-Pull
icino and McCall 1991), which may simulate soft-tissue sarcoma clinically, have characteristic appearances. Malignant fibrous his tiocytoma
may present
with a spontaneous
haematoma
and have
microscopic tumour in the wall of the haematoma undetected by imaging and only found at surgery, hence our suggestion of early intervention. The debate over the form of biopsy is by no means seuled (Shives 1993). We acknowtedge the excellent results achieved by Akerman,
Rydhoim
and Persson
(1985).
We continue
to use fine
We have published
(McKee
increase in function, obtaining an average postoperatively (average 43°preoperatively)
available to the orthopaedic challenging problem.
surgeon
cut) needle or open biopsy provides specimens with the original architecture
preserved
and a high
diagnostic
accuracy
and we
continue to rely on such techniques. Specific tumour type and histological grade can also be established (Kissin et at 1986; Ball et al 1990; Simon and Biermann 1993).
who chooses
to deal with this
M. D. McKEE, MD, FRCS C J. B. JUPITER, MD
and have been
with a cutting (e.g. Iru
arc of motion of 97° and an average Mor
rey elbow score of 83. Although elbow replacement remains an excellent option for the older patient, our results support the use of open reduction and internal fixation in the younger patient when bone stock permits. The two techniques complement each other and both should be
and 10% false-positive results are disappointing Biopsy
of 13
graft, elbow release, ulnar neurolysis and early motion. The patients in this series showed a gratifying decrease in pain and
55 Queen Street East, Toronto, Canada.
1993).
a series
intra-articular fractures of the distal humerus, using a compre hensive approach which included rigid fixation, iliac-crest bone
needle aspiration cytology but our findings of 20% false-negative found by others (Shives
et al t994)
WACC 527, Massachusetts
General Hospital, Boston
McKee MD, Jupiter J, Toh CL, et al. Reconstruction after malunion and nonunion of intra-articular fractures of the distal humerus: methods and results in 13 adults. J Bone Joint Surg (Br] 1994;76-B:614-21. Morrey BF, Adams RA. Semiconstrained elbow replacement for distal humeral nonunion. J Bone Joint Surg [Br] l995;77-B:67-72.
Akerman and his colleagues write from the perspective of a tumour centre, but our experience is as clinicians faced patients who may (or may not) have soft-tissue masses.
with
A. J. JOHNSTONE, FRCS University of Aberdeen Aberdeen, UK. I.BEGGS, FRCR Princess Margaret Rose Orthopaedic Hospital Edinburgh, UK. Akerman M, Rydholm A, Persson BM. Aspiration cytology of soft tissue tumors: the 10-year experience at an orthopedic oncology center.
Acta Orthop Scand 1985;56:407-l2. VOL. 77-B, No. 4, JULY 1995
Author's reply: Sir@
I agree completely with the comments of Dr McKee and Dr Jupiter. It is important to emphasise that total elbow replacement is not an appropriate
option
for younger
individuals
with
non
union of the distal humerus. My surgical approach and technique for this problem in the younger age group are precisely those described
in their
article;
the latter
was not cited
because
our
paper was submitted before it appeared in March 1994. I am sure