DEATH AND THROMBOEMBOLIC DISEASE AFTER ...

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