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Juvenile ossifying fibromas (JOFs) are a rare group of fibro-osseous lesions, typically of odontogenic origin. Juvenile psammomatoid ossifying fibroma (JPOF) is one variant, that is, histopathologically distinguished by spherical ossicles resembling psammoma bodies. JPOF tumours are most commonly found in craniofacial skeletal structures and can be locally aggressive. Thus, early management by complete surgical excision is crucial for good outcomes, although recurrence is still possible. Secondary aneurysmal bone cyst (ABC) formation has been reported with JOF lesions, but less commonly with the JPOF variant. We describe an unusual case of JPOF that presented in the calcaneus with secondary ABC formation.

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INTRODUCTION: As life expectancy increases, the incidence of shoulder arthroplasty continues to increase as well. There are few shoulder arthroplasty studies investigating perioperative complication, readmission, and mortality. Furthermore, with bundled payments on the horizon, the cost of shoulder arthroplasty has become a significant issue. Clarifying risk factors for the need for postdischarge acute care will be critical information due to the high cost of such care. The goal of this study was to compare discharge disposition, length of stay (LOS), perioperative complications, readmission, and mortality in elderly and nonelderly cohorts to determine whether age is a risk factor for shoulder arthroplasty. MATERIALS AND METHODS: We retrospectively compared 89 elderly patients (80 years or older) and 86 nonelderly patients (79 years or younger) who underwent hemiarthroplasty, total shoulder arthroplasty, reverse total shoulder arthroplasty, or revision shoulder arthroplasty from 2007 to 2015. Baseline characteristics were compared between the 2 cohorts. We then compared discharge disposition, LOS, 90-day complication rate, readmission, and mortality between the 2 cohorts. RESULTS: Average length of hospitalization and percentage of patients with greater than 2 days of hospitalization were significantly higher in the elderly cohorts. Forty-four percent of the elderly cohorts were discharged to a skilled nursing facility compared to 6% in the nonelderly cohorts (P < .0001). There were no significant differences found in 90-day major complication rate, readmission, or mortality. DISCUSSION: Shoulder arthroplasty is a valuable surgery for various indications in the elderly population. However, the likelihood of a patient to need a prolonged hospitalization or skilled nursing facility care after surgery are important questions that need to be answered. Our study shows that age over 80 years is a risk factor for prolonged hospitalization and need for skilled nursing facility care after shoulder arthroplasty. CONCLUSION: We conclude that elderly patients who undergo shoulder arthroplasty are significantly more likely to have extended hospitalizations and to be discharged to skilled nursing facilities compared to nonelderly patients.

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Temporally consistent individual differences in behavior, also known as animal personality, can have large impacts on individual fitness. Here, we explore the degree to which individual differences in anti-predator response (or boldness) influence survival rates in groups of snails Chlorostoma funebralis when they encounter a predatory sea star Pisaster giganteus. The snail C. funebralis shows consistent individual variation in predator response where some fearful snails actively flee bodies of water occupied by predators whereas bolder snails consistently do not. We show here that bold snails are significantly more likely to survive encounters with a predatory sea star and, somewhat counterintuitively, fearful snails actually suffer higher mortality rates. We also found that smaller snails and those occurring at higher experimental densities experienced higher per capita survival rates. Positive effects of prey boldness on survival are not uncommonly reported in the animal personality literature; however, such results are inconsistent with classic animal personality theory borrowed from the optimal foraging literature. The findings herein add to the growing body of evidence that consistent individual differences in behavior can impact predator-prey interactions and that boldness is potentially under positive predator-driven selection in some systems.

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Group B streptococcal (GBS) infection of a native joint in a nonpregnant adult is uncommon. While many women are colonized with this flora, it rarely becomes pathogenic in its adult host. GBS associated joint infections have been reported, most of which have been related to hematogenous seeding from unknown sources. To our knowledge, there are no published case reports of a GBS joint infection in association with a pelvic exam and Papanicolaou (PAP) smear. In this case report, we present a case of GBS sepsis of a native shoulder, possibly resulting from a routine pelvic exam and PAP smear.

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We report two children with lymphoma of bone centered in the distal femoral epiphysis who presented with knee pain. Radiographs, magnetic resonance imaging (MRI) and computed tomography (CT) were performed on both patients prior to biopsy. Following biopsy, both patients had fluorodeoxyglucose ((18) F-FDG) positron emission tomography/CT (PET/CT) and whole-body technetium-99m (Tc-99m) scintigraphy performed for staging. One patient met the criteria for primary lymphoma of bone. One patient did not meet the criteria for primary lymphoma of bone because of PET uptake in a popliteal, external iliac and possibly lower abdominal node. Both patients responded well to chemotherapy and are disease free more than 7 years after diagnosis. While an epiphyseal presentation of lymphoma of bone is rare, the efficacy of treatment and the compromised outcome associated with diffuse spread of the disease make early recognition by clinicians important. We present these two cases to increase awareness of the disease and to have clinicians consider it in the differential diagnosis of adolescent epiphyseal lesions.

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CASE: Two patients undergoing constrained endoprosthetic reconstruction following scapulectomy for the treatment of neoplasm sustained atraumatic glenohumeral dissociation. To our knowledge, this complication had not been observed in association with anatomic-orientation constrained designs prior to 2014. CONCLUSION: Despite the improved stability associated with constrained total scapular endoprosthesis designs, every effort should be made to reconstruct the joint capsule and consideration should be given to augmentation with use of a synthetic sleeve. However, even when these measures are taken, dislocations of the constrained glenohumeral articulation may occur. Treatment of dislocations should be based on patient-specific factors, and nonoperative treatment may be appropriate. In the setting of dislocation associated with constrained liner wear, limited revision may be considered. Reassessment of periprosthetic tissue-balancing and potential augmentation should be considered.

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Because of its characteristic morphologic appearance, small cell osteosarcoma (SCO) can be confused with other small round cell malignancies of the bone, most importantly with Ewing sarcoma, making this distinction difficult. A specific tool used in separating SCO from Ewing sarcoma has been the detection of Ewing sarcoma breakpoint region 1 (EWSR1) gene rearrangements in Ewing sarcoma and their absence in SCO. However, there are rare case reports that have documented the existence of EWSR1 gene rearrangement in SCO. In this report, we describe another case of SCO with an EWSR1 gene rearrangement detected by interphase fluorescence in situ hybridization. Our finding adds support to the existing evidence that SCO is a tumor that can be characterized by EWSR1 gene arrangements. Therefore, we caution the pathology community not to rely solely on molecular studies in distinguishing SCO from Ewing sarcoma.

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We report a case of primary extranodal Rosai-Dorfman disease presenting as a painless lesion in the left ilium of a 71-year-old African-American man.

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BACKGROUND: Giant cell tumors of the lumbar spine are uncommon lesions. Aggressive management of such lesions via spondylectomy to obtain local control and prevent recurrence is often necessary. Spinal reconstruction after total spondylectomy can be challenging. Traditional reconstructions typically require multisegment fixation with an association loss of segmental motion and limited 3-column reconstruction. METHODS: The authors report a case of a GCT of the lumbar spine occurring in a 49-year-old woman. The authors describe the surgical management of such a lesion via a 1-stage posterior-anterior-posterior procedure that entails a lumbar spondylectomy and short-segment posterior fixation with 3-column reconstruction using a stackable carbon-fiber-reinforced cage device with direct posterior rod connection for pedicle reconstruction. RESULTS: At 33 months postoperative follow-up, neither tumor recurrence nor instrumentation-related complications were noted, bone fusion was prevalent, and sagittal alignment was well maintained. The patient reported no loss of functions, was neurologically intact, and remained active. CONCLUSIONS: Aggressive operative management via spondylectomy of a lumbar GCT provides local tumor control. In select patients, spinal reconstruction after a spondylectomy via a 1-stage posterior-anterior-posterior approach to establish short-segment, 3-column reconstruction with recreation of the pedicles is a promising procedure that provides immediate spinal stabilization without evidence of early instrumentation-related complications, maintains spinal alignment, promotes a quick return to daily activities, and avoids sacrificing excessive motion segments and biomechanical function associated with more traditional procedures.

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STUDY DESIGN: Surgical technique with case example. OBJECTIVE: To report on a novel technique that allows for the placement of 4 separate longitudinal rods across the lumbo-pelvic junction. SUMMARY OF BACKGROUND DATA: Despite advances in surgical techniques and instrumentation, lumbo-pelvic fixation remains a significant challenge. Fusions to the pelvis create long lever arms and generate high forces across the lumbosacral junction, resulting in high rates of screw pullout and implant fracture. In the attempt to achieve better bony fixation, techniques described include the use of bone cement, hydroxyapatite, and expandable screws. Although this process has decreased the incidence of screw pullout, it has not addressed the problem of rod fracture at the lumbo-pelvic junction. METHOD: There are 4 separate longitudinal rods placed across the lumbo-pelvic junction that couples proximal lumbar screw anchors to 4 separate pelvic fixation points. Proximal lumbar fixation anchors are based on alternating Roy-Camille "straight ahead" screws and Magerl "lateral to medial converging" pedicle screws. There are 4 distal pelvic fixation anchors used based on 1 pair of Galveston-like screws and 1 pair of proximal iliac wing screws. RESULTS: Early results of both ex vivo and in vivo reconstruction show that careful insertion of the lumbar and pelvic screws allows for divergent placement of the pedicle screw heads in a manner that 2 longitudinal rods can be placed per side, resulting in a total of 4 longitudinal rods across the lumbo-pelvic junction. Selection of cross-links in various combinations allows for additional axial and torsional stability, depending on the desired reconstruction. CONCLUSION: Longer follow-up is necessary, and biomechanical and finite element studies are needed to show long-term efficacy of this technique, however, early results indicate that such a construct is feasible. Furthermore, depending on the general medical condition of the patient, immediate postoperative weight bearing is possible and reasonable.

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This case report discusses two cases in which patients present with the uncommon triad of extremity pain, focal periosteal reaction on imaging studies, and intramuscular hemangioma on pathologic examination. Both patients presented in this article were older than those previously reported in the literature. Neither patient reported complete resolution of pain following excision, although there was marked improvement.

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BACKGROUND: Lipedema is a condition characterized by diffuse, bilaterally symmetrical, painful swelling of the legs and buttocks. Microscopically, there are dermal and septal edema, adipocyte degeneration, and numerous mast cells, features held in common with lipedematous alopecia. CASE REPORT: We present the case of a 60-year-old woman with a long history of bilateral leg masses with microscopic features of lipedema. In addition, elastic-fiber changes typical of pseudoxanthoma elasticum (PXE) were discovered within the subcutaneous septa in three separate specimens obtained from an affected extremity. The patient did not have other clinical findings of PXE, although there was a history of both hypertension and congestive heart failure. CONCLUSION: This tumefactive presentation of lipedema has not been previously described. Regarding the elastic-tissue abnormalities, the patient could have either a subclinical form of PXE, perhaps predisposing to lipedema, or secondary elastic-tissue changes resulting from the massive edema. If the latter is the case, then this could represent an unusual manifestation of localized acquired cutaneous PXE (calcific elastosis).

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OBJECTIVE: To determine whether resistive indices obtained from spectral Doppler waveforms can be used to distinguish benign from malignant musculoskeletal soft tissue masses. METHODS: A retrospective review of Doppler sonograms was performed for 52 patients with 53 soft tissue masses. All masses showed internal flow on color or power Doppler sonography, and spectral Doppler sonography yielded waveforms from which resistive indices were calculated. This information was analyzed along with the histologic diagnosis of each lesion with significance set at P > .05. RESULTS: There were 19 benign lesions and 34 malignancies. The resistive indices of the benign masses ranged from 0.44 to 1.0 (mean +/- SD, 0.72 +/- 0.42), whereas the malignant masses had resistive indices ranging from 0.28 to 1.0 (mean, 0.62 +/- 0.36). There was no statistically significant (P > .05) difference between the resistive indices of benign and malignant lesions. CONCLUSIONS: Resistive indices cannot be used to distinguish benign from malignant musculoskeletal soft tissue masses.

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PURPOSE: To review the reliability of computed tomographic (CT) and magnetic resonance (MR) imaging features in distinguishing lipoma and well-differentiated liposarcoma. MATERIALS AND METHODS: CT (n= 29) and MR (n = 40) images and radiographs (n = 28) of 60 patients with histologically verified fatty tumors (35 lipomas and 25 well-differentiated liposarcomas) were retrospectively reviewed in 31 females and 29 males (mean age, 56 years; age range, 1-88 years). Images were assessed for adipose tissue content, and non-fatty component was classified (thin and/or thick septa and nodular and/or globular components) as absent, mild, moderate, or pronounced. Also assessed were signal intensity and tissue attenuation of the fatty components and non-adipose elements. RESULTS: Statistically significant imaging features favoring a diagnosis of liposarcoma included lesion larger than 10 cm (P <.001), presence of thick septa (P =.001), presence of globular and/or nodular non-adipose areas (P =.003) or masses (P =.001), and lesion less than 75% fat (P <.001). The most statistically significant radiologic predictors of malignancy were male sex, presence of thick septa, and associated non-adipose masses, which increased the likelihood of malignancy by 13-, nine-, and 32-fold, respectively. Both lipoma and liposarcoma demonstrated thin septa and regions of increased signal intensity on fluid-sensitive MR images. CONCLUSION: A significant number of lipomas will have prominent non-adipose areas and will demonstrate an imaging appearance traditionally ascribed to well-differentiated liposarcoma. Features that suggest malignancy include increased patient age, large lesion size, presence of thick septa, presence of nodular and/or globular or non-adipose mass-like areas, and decreased percentage of fat composition.

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OBJECTIVE: The purpose of our study was to identify the characteristic MR imaging features of intramuscular myxoma. MATERIALS AND MATERIALS: We retrospectively reviewed the MR imaging features of 20 patients with intramuscular myxoma. Clinical assessment included the age and sex of the patient and location of the tumor. Radiologic evaluation included the lesion size and shape, border definition, signal on T1- and T2-weighted or fluid-sensitive MR sequences, enhancement pattern, presence or absence of a fat rind, and presence or absence of increased signal in the adjacent muscle on T2-weighted or fluid-sensitive MR sequences. RESULTS: The mean age of patients presenting with intramuscular myxoma was 61 years (range, 15-85 years; median, 64 years). The mean lesion size was 6.9 cm (range, 3-17 cm; median, 6.3 cm). A peritumoral fat rind was present in 13 of the patients (65%) with myxoma, and an increased signal in the adjacent muscle on fluid-sensitive sequences was present in 11 patients (55%). Intramuscular myxomas were homogeneously low in signal intensity on T1-weighted MR sequences in 19 patients (95%), with all lesions showing a high signal intensity on T2-weighted or fluid-sensitive MR sequences. Twelve of the myxomas had well-defined borders, and eight had borders that were partially ill defined. Of the 11 lesions imaged after gadolinium administration, six (55%) showed intense heterogeneous enhancement. CONCLUSION: Findings of a mass that on MR images shows a perilesional fat rind, the signal intensity of fluid, and an increased signal in the adjacent muscle on T2-weighted or fluid-sensitive MR sequences are strongly suggestive of intramuscular myxoma. The degree of lesion enhancement varies but is most frequently intense and heterogeneous. Although the recognition of these features likely will not obviate biopsy of any individual lesion, it will allow more accurate prebiopsy diagnosis and preoperative planning.

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