Aims:The aim of this study was to achieve consensus for important topics related to periprosthetic infection (PJI) in orthopaedic oncology, and to identify areas for future research. Methods:In January 2024, the Birmingham Orthopaedic Oncology Meeting (BOOM) held in Birmingham, UK, gathered 309 delegates from 53 countries to debate 20 consensus statements on PJI in orthopaedic oncology using a modified Delphi process. Results:Of 20 questions and statements on PJI in orthopaedic oncology, none achieved unanimous consensus, 18 achieved strong consensus, one achieved moderate consensus, and one achieved weak consensus. The statements that reached consensus with notable agreement were on the prophylaxis of infection, management of leaking wounds, and surgical strategies for the treatment of PJI. Short-duration antibiotic prophylaxis was deemed as effective as longer courses for lower-risk reconstructions, and aggressive management was recommended for wounds draining beyond five to seven days to prevent deep infection. Furthermore, single-stage, two-stage, and 1.5-stage revision were recognized as valid strategies, with two-stage revision remaining the most reliable. The statements that did not achieve consensus were on the role of debridement, antibiotics, and implant retention and prolonged antibiotic use post-revision. Conclusion:The BOOM meeting achieved consensus for important topics on periprosthetic infection in orthopaedic oncology, but highlighted the low quality of the underlying evidence. This study has provided recommendations for the treatment of leaky wounds, duration of postoperative antibiotic prophylaxis, and choice of revision strategy.

AIM:To revalidate an MRI protocol for the management of solitary central cartilage tumours (CCTs) of the proximal humerus and around the knee, excluding the proximal fibula. MATERIALS AND METHODS:Data on 387 patients with a solitary CCT assessed in a specialist orthopaedic oncology unit between 2007 and 2016 was updated and combined with a further 393 patients referred from 2017 to 2023. The initial MRI images and any follow-up scans were evaluated for craniocaudal length of the CCT, presence/absence of endosteal scalloping or aggressive/malignant features. The cases were categorised according to the BACTIP. Patient outcome was assessed to ascertain if the application of the protocol led to any delay in the diagnosis of high-grade chondrosarcoma (HGCS). RESULTS:HGCS is rare (7%) in this large series of 780 patients with a solitary CCT. Ascending BACTIP type correlates with malignancy. All Type IA, IB, and IIA lesions were either benign enchondroma or atypical cartilaginous tumour (ACT), whereas 69% of Type III were diagnosed as HGCS. Only 4 cases on follow-up MRI showed a delay in diagnosis with progression to a BACTIP Type III (Type IC x1 and Type IIB x3). All were identified within seven months of presentation and were shown to be HGCS. Therefore, malignant transformation is remarkably rare (0.4%) and tends to occur relatively early (<1year). CONCLUSION:This combined retrospective and prospective study confirms that BACTIP remains a useful tool for the general radiologist in determining which cases of CCT of the proximal humerus and around the knee would benefit from onward referral to a specialist orthopaedic oncology service. It may also have a further role in the future as management preferences for borderline CCTs move away from surgical intervention to a watch-and-scan policy.

AIM To revalidate a MRI protocol for the management of solitary central cartilage tumours (CCTs) of the proximal humerus and around the knee excluding the proximal fibula. MATERIALS AND METHODS Data on 387 patients with a solitary CCT assessed in a specialist orthopaedic oncology unit between 2007 and 2016 was updated and combined with a further 393 patients referred from 2017 to 2023. The initial MRI images and any follow-up scans were evaluated for craniocaudal length of the CCT, presence/absence of endosteal scalloping, or aggressive/malignant features. The cases were categorised according to the XXXXXX. Patient outcome was assessed to ascertain if the application of the protocol led to any delay in the diagnosis of high grade chondrosarcoma (HGCS). RESULTS HGCS is rare (7%) in this large series of 780 patients with a solitary CCT. Ascending XXXXXX type correlates with malignancy. All Type IA, IB and IIA lesions were either benign enchondroma or atypical cartilaginous tumour (ACT) whereas, 69% of Type III were diagnosed as HGCS. Only 4 cases on follow-up MRI showed a delay in diagnosis with progression to a XXXXXX Type III (Type IC x1 and Type IIB x3). All were identified within seven months of presentation and were shown to be HGCS. Therefore, malignant transformation is remarkably rare (0.4%) and tends to occur relatively early (<1year). CONCLUSIONS This combined retrospective and prospective study confirms that XXXXXX remains a useful tool for the general radiologist in determining which cases of CCT of the proximal humerus and around the knee would benefit from onward referral to a specialist orthopaedic oncology service. It may also have a further role in the future as management preferences for borderline CCTs move away from surgical intervention to a watch-and-scan policy.

Aims:Following resection of a primary bone tumour, reconstruction is commonly performed using either a megaprosthesis or biological reconstruction. Periprosthetic joint infection (PJI) remains one of the most frequent complications. Various treatment strategies exist for PJI, including debridement, antibiotics, and implant retention (DAIR), and single- and two-stage revision, although consensus on optimal management remains elusive. This study aimed to investigate the global practices regarding DAIR in tumour cases through an electronic survey among orthopaedic oncology surgeons. Methods:A global cross-sectional observational survey study was distributed to 272 orthopaedic oncology surgeons who attended the BOOM Consensus Meeting in January 2024. The survey contained 19 multiple choice questions focusing on DAIR practices. Responses were collected anonymously and analyzed using descriptive statistics. Results:The survey was completed by 173/272 surgeons (64%) from 44 countries. While 62% (169/272) routinely performed radical soft-tissue debridement in DAIR, only 39% exchanged all modular components, indicating variability in surgical approaches. DAIR was more commonly performed in acute rather than chronic infections, with 55% finding it very useful in acute cases. The use of local antibiotic delivery was supported by 56%, although only 49% found antibiotic cement coatings beneficial. Systemic antibiotic duration post-DAIR varied, with 39% favouring six weeks and 35% preferring three months. Conclusion:The study highlights global inconsistencies in DAIR practices for PJI in orthopaedic oncology, with financial disparities impacting modular component exchange. Standardized definitions are lacking, and we propose that if only polyethylene is changed, then the procedure is referred to as 'poly exchange'; we recommend defining the procedure as DAIR when extensive debridement, lavage, and removal, wash, and reimplanting of all modular components is done while retaining stable stems, followed by suppressive antibiotic therapy; and finally, we recommend that if all the modular components are changed for new ones, the procedure is referred to as 'DAIR plus'.

Background and Aims: Spondylolysis refers to a stress fracture of the pars interarticularis. We investigated if there is a correlation between a novel measurement, the sagittal pars inclination angle and the incidence of spondylolysis (pars defect) in adolescent and young adult patients. Methods: A retrospective cohort study was conducted at the Royal Orthopaedic Hospital, UK (a tertiary referral orthopaedic centre) over two years identifying 37 Adult patients under the age of 30 years who had a computed tomography (CT) scan of the lumbar spine. In total 255 pars interarticularis, from levels L2 to L5, were analysed in 37 patients (19 male, 18 female). The pars interarticularis were divided into two groups: (1) pars intact ( N = 217) and (2) pars defect ( N = 38). Statistical analysis of each group and vertebral level was performed including load measurements. Results: In the pars intact group ( N = 217), the sagittal mean ± standard deviation (SD) pars inclination angle for the pars intact group was 17.91 ± 5.62°. In the pars defect group ( N = 38), the mean ± SD sagittal pars inclination angle was 35.95 ± 6.42°. A two-tailed P value was less than .0001. There was an increase in the normal sagittal pars angle from L2 to L5. Conclusion: In this study, an increased sagittal pars inclination angle demonstrated a significant association with spondylolysis. Its implications in the management of athletic individuals, surgical planning and indeed a true causative relationship are yet to be evaluated in future studies.

Introduction and Objective:Thoracic disc calcification is a radiological finding which may be incidental or diagnosed in patients presenting with myelopathy due to spinal cord compression. We performed a study to analyze the imaging patterns of calcified thoracic discs (CTDs). Patients and Methods:A retrospective review of the spinal and radiology database of a tertiary referral orthopedic hospital was conducted for the incidence of CTDs between 2007 and 2020. Patients' demographics and radiological findings were recorded. The relationship between disc size, morphology, spinal cord compression, and management was assessed. Results:Fifty-one cases of CTDs were identified. The mean size of CTD was 806.2 mm3 (range: 144-2340). The most common level of disc calcification was T9-T10 (24%) in 12 patients. Thoracic disc calcifications in our series commonly involved disc "protrusion" in 67% (34 patients), followed by "mushroom" type in 31% (16 patients) and "extrusion" in 2% (1 patient). 37% (19 patients) had spinal cord compression with 12% (6 patients) undergoing surgical interventions. There was no statistically significant difference in the mean sizes of CTD between the groups with and without spinal cord compression (P = 0.566, independent sample t-test). Patients with "mushroom" type calcification were more likely to have surgical intervention (P = 0.01, Fisher's exact test). Conclusion:Thoracic disc calcifications, while common, can still be underdiagnosed till late myelopathic deterioration. Care of the elderly physicians, spinal surgeons, and radiologists need to be aware of them to guide diagnosis and management. Our study demonstrates that disc morphology plays a vital role in myelopathic presentation and therefore determines the need for surgical intervention instead of the absolute size of disc calcification.

PurposeHaglund’s deformity, an abnormality at the postero-superior corner of the calcaneus is a common cause of posterior heel pain. To date numerous measurements of radiological angles related to the calcaneus have been proposed to differentiate between symptomatic and asymptomatic patients with the deformity. Traditionally, these measurements have been assessed on plain radiographs. The aim of this study was to identify measurements which can be applied to Magnetic Resonance Imaging (MRI) studies of the ankle.MethodsA retrospective cohort analysis of 30 MRI ankle studies from patients with symptomatic Haglund’s deformity and 32 normal studies as controls was undertaken. The angle of BRINK, the Achilles angle, Calcaneal pitch, Achilles-plantar fascia angle and soleus calcaneal distance were measured on optimal T2 fat-saturated sagittal slices.ResultsThere was a statistically significant difference (p<0.0001) in the angle of BRINK between the Haglund’s and control group. The Area-Under-the-Curve (AUC) was 0.7783 in keeping with good discrimination between the two groups. The angle of BRINK measurement is reproducible, with an intra-observer ICC of 0.837 and an inter-observer ICC of 0.824. There was no statistically significant difference between the two groups for the other measurements. In the Haglund’s group the Achilles tendon was more likely to attach to the mid 1/3 of the posterior calcaneus as opposed to the superior 1/3 (p=0.02), calcaneal oedema was more likely to be present (p<0.001) and non-insertional tendinopathy was more likely to be present (p<0.001). The presence of a retrocalcaneal bursa is non-specific (p=0.602).ConclusionThe angle of BRINK demonstrates good discrimination between normal and Haglund’s cases on MRI studies and may improve patient management by supporting surgical decision-making. Future work should correlate the angle of BRINK to long-term outcomes.

Background A widely accepted set of imaging criteria or classification has not yet been adopted to evaluate response to treatment by percutaneous sclerotherapy for aneurysmal bone cyst (ABC). In this article, we described and illustrated the Royal Orthopaedic Hospital (ROH) scoring system which is a new, reproducible, and objective tool to evaluate the radiological response. We also reported our institutional experience in the efficacy of computed tomography (CT)-guided sclerotherapy for treating such lesions. Patients and Methods A retrospective analysis was conducted for 19 patients who underwent CT-guided sclerotherapy with doxycycline and albumin to treat ABC. Follow-up magnetic resonance imaging, at a minimum of 12 months, was assessed according to the four ROH scoring system parameters: cystic component, fluid-fluid level, presence of consolidation, and cortical integrity. The cumulative score was used to grade response as either: excellent, good, equivocal, or poor. Results Out of 19 patients with a mean age of 17.8 years, 11 cases occurred in the long bones, 5 cases in the pelvis, and 1 in each of the C3 vertebral body, scapula, and talus. The mean parameter of response score for cystic component was 2, fluid-fluid level was 1.3, consolidation was 2, and cortical integrity was 2.1. Four cases showed excellent response, 12 cases showed good response, 2 cases showed equivocal response, and 1 case showed poor response. Interrater reliability was excellent (kappa = 0.9). Conclusion The ROH scoring system provides the radiologist and surgeon with an objective method to score imaging parameters of response independently and achieve a grade based on the cumulative score.

The spinous processes act as a lever for attachments of muscles and ligaments. Spinal imaging is commonly performed as a diagnostic test for pain and radiculopathy. A myriad of incidental or unexpected findings, both potentially asymptomatic and symptomatic, may be encountered during the interpretation of these images, which commonly comprise radiographs, Computed Tomography (CT) and Magnetic Resonance Imaging (MRI). Isolated lesions of the spinous process, although less common, are some of the lesions that may be encountered and can present a diagnostic dilemma. These can range from congenital abnormalities, traumatic lesions, neoplasms and lesions of inflammatory, infective and metabolic aetiology. The literature specifically reviewing these lesions is sparse. The article reviews a range of pathologies affecting the spinous process, along with their pertinent imaging features, based on isolated pathologies of spinous process lesions identified on imaging by the authors at a tertiary orthopaedic centre over a 10-year period. A search on the hospital Picture Archive and Communication System (PACS) and Radiology Information System (RIS) was performed using the keyword “spinous process” and a list of the isolated pathologies of the spinous process based on the imaging reports was compiled for the purpose of this narrative review. It is important that radiologists consider these lesions when they are identified on routine imaging of the spine.

Background Magnetic resonance imaging (MRI) is key in evaluating central cartilage tumors. The BACTIP (Birmingham Atypical Cartilaginous Tumour Imaging Protocol) protocol assesses central cartilage tumor risk based on the tumor size and degree of endosteal scalloping on MRI. It provides a management protocol for assessment, follow-up, or referral of central cartilage tumors. Objective Our study compared four MRI sequences: T1-weighted (T1-w), fluid sensitive (Short Tau Inversion Recovery (STIR)- weighted, STIR-w), and grayscale inversions (T1-w GSI and short tau inversion recovery [STIR] GSI) to see how reliably endosteal scalloping was detected. Materials and Methods Two senior consultant musculoskeletal radiologists with experience reviewed randomly selected 60 representative central cartilage tumor cases with varying degree of endosteal scalloping to reflect a spectrum of BACTIP pathologies. The endosteal scalloping was graded as per the definition of BACTIP A, B, and C. They agreed on a consensus BACTIP grade for each of the 240 key images (60 cases x 4 sequences), which was considered the final "consensus" BACTIP grade. These 240 images were then randomized into a test set and given to two fellowship-trained consultant musculoskeletal radiologists for analysis. They assigned a BACTIP grade to each of the 240 selected images while being blinded to the final "consensus" BACTIP grade. The training set was further subdivided into three groups based on the MR image quality (good quality, average quality, and poor quality) to ascertain if the quality of the acquired images influenced intraobserver and interobserver agreements on the BACTIP grading. The two observers were blinded to the grade assigned to the image quality. Results Linearly weighted kappa analysis was performed to measure the agreement between the BACTIP grading answers by two observers and the "consensus" BACTIP grading answers, as well as the BACTIP grading agreement between the two observers themselves. The analysis revealed that T1-w and STIR-w sequences demonstrated more consistent and higher agreement across different image qualities. However, the T1-w GSI and STIR-w GSI sequences exhibited lower agreement, particularly for poor-quality images. T1-w imaging demonstrated substantial agreement between BACTIP gradings for poor-quality images, suggesting potential resilience of T1-w sequence in challenging imaging conditions. Conclusion T1-w imaging is the best sequence for BACTIP grading of endosteal scalloping, followed by fluid-sensitive STIR sequences.

A 35-year-old young adult male presented with a painless mass in the left knee, progressively enlarging over a period of approximately 12 months.No prior history of trauma or injury.No past medical or surgical history otherwise.On examination, the patient had difficulty in flexing the knee (Figs. 1, 2, and 3).

Meralgia Paresthetica (MP) causes outer thigh discomfort, numbness, and tingling. Compression or injury to the Lateral Femoral Cutaneous Nerve (LFCN), which gives sensory innervation to outer aspect of the thigh. It frequently gets impinged beneath the inguinal ligament resulting in in sensory impairment in the distribution of LFCN. Compression of the LFCN is a frequent cause of MP, whereas LFCN neuromas is a rare cause. This case report describes a unique case of Meralgia Paresthetica produced by a LFCN neuroma and enhances our knowledge of Meralgia Paresthetica.

Pathologies of the scapulothoracic articulation may lead to painful symptoms such as crepitus and bursitis. While conservative treatments are preferred, persistent symptoms may require image-guided injections. This study aims to determine the optimal hand positioning during ultrasound to maximize the distance between the scapula and thoracic wall, and improve its accessibility during injections. This cross-sectional observational study included ten healthy adult volunteers without scapulothoracic issues or history of trauma/surgery. Two musculoskeletal radiologists independently measured the scapulothoracic distance on Ultrasound in three hand positions: 1. Hands under the head; 2. Hands by the side of the trunk; and 3. Hands hanging by the side of the couch. Data was analyzed using SPSS 24.0. Continuous variables were described using mean and standard deviation (SD), with significance set at p < 0.05. Measurements on 20 scapulothoracic articulations (10 volunteers) showed the following findings: Position 1: Baseline value of 1. Position 2: Distance increased by 1.515 mm ± 3.617 (95

Nodular fasciitis is a benign soft tissue pseudotumour typically occurring in the upper extremities, head and neck, thigh and trunk. It is most commonly seen in subcutaneous locations but also can be present in intramuscular and intermuscular (fascial) locations. Its occurrence in the hand is rare, and while it can occur in close proximity to tendons, its presentation as an intra-tendinous mass has not been previously described. We present a unique and rare case of nodular fasciitis arising within the flexor digitorum profundus (FDP) tendon of the hand in a 16-year-old female. The patient presented with a painful swelling in the volar aspect of the base of her left middle finger, with progressive flexion deformity of the finger. Ultrasound and magnetic resonance imaging revealed a mass within the FDP tendon of the middle finger. An ultrasound-guided biopsy revealed a diagnosis of nodular fasciitis. Given the self-limiting nature of the condition, she was managed conservatively with close clinical and imaging follow-up. This case highlights the importance of considering nodular fasciitis in the differential diagnosis of an intra-tendinous lesion in the hand, even though it is a rare occurrence in this location. The clinical presentation, diagnostic workup, and management of this unique case are discussed, emphasising the potential for its misdiagnosis as a malignancy which can have important implications in management.

Objective To report the incidence of indeterminate pulmonary nodules (IPN) and the rate of progression of IPNs to metastasis in patients with primary bone cancers. We also aimed to evaluate clinical or radiological parameters that may identify IPNs more likely to progress to metastatic disease and their effect on overall or event-free survival in patients with primary bone sarcoma. Methods A systematic search of the electronic databases Medline, Embase, and Cochrane Library was undertaken for eligible articles on IPNs in patients with primary bone sarcomas, published in the English language from inception of the databases to 2023. The Newcastle-Ottawa Quality Assessment Form for Cohort Studies was utilized to evaluate risk of bias in included studies. Results Six studies, involving 1667 patients, were included in this systematic review. Pooled quantitative analysis found the rate of incidence of IPN to be 18.1% (302 out of 1667) and the rate of progression to metastasis to be 45.0% (136 out of 302). Nodule size (more than 5 mm diameter), number (more than or equal to 4), distribution (bilaterally distributed), incomplete calcification, and lobulated margins were associated with an increased likelihood of IPNs progressing to metastasis, however, their impact on overall or event-free survival remains unclear. Conclusion The risk of IPNs progressing to metastasis in patients with primary bone sarcoma is non-negligible. Large IPNs have a high risk to be an actual metastasis. We suggest that IPNs in these patients be followed up for a minimum of 2 years with CT imaging at 3, 6, and 12 month intervals, particularly for nodules measuring >5 mm in average diameter. Advances in knowledge This is the first systematic review on IPNs in patients with primary bone sarcomas only and proposes viable management strategies for such patients.

Background Vertebral insufficiency fractures in the elderly are associated with increased morbidity and mortality. Early diagnosis is essential to direct patient-specific rehabilitation. Aims We hypothesize that in patients with vertebral insufficiency fractures, there is atrophy of the psoas and paraspinal muscles with alteration in the cross-sectional area (CSA) of the muscles. Materials and Methods Magnetic resonance imaging (MRI) studies for 100 consecutive patients, older than 60 years presenting with lower back pain, were included in the study. For each MRI study, the CSA of the psoas and paraspinal muscles (multifidus) at the level of L4/5-disc space was measured to calculate the cross-sectional area ratio (CSAR) by two readers. One reader repeated the measurements after an interval of 2 weeks. We divided the patients (n = 100) into various groups based on the number of vertebral fractures. Results In total, 77 patients with vertebral body fractures (48 with one, 16 with two and 13 with more than two fractures) were identified with a mean age of 73 (range 60–92) years. The ratio of multifidus CSA to psoas CSA was calculated with mean values of each group (1–4) as 2.56, 1.89, 2.09 and 2.16, respectively. There was statistically significance difference of the CSAR between the cohorts (p-value = 0.0115). Conclusion Vertebral insufficiency fractures in the elderly are associated not only with atrophy of psoas and the multifidus group of muscles as evident by the CSA values, but they also affect the CSAR depending on the number of fractures. This finding may help to direct targeted patient-specific physiotherapy rehabilitation and interventions to prevent further such fractures.

Purpose or Learning Objective: Spondylolysis is a defect in the pars interarticularis of the vertebrae, most commonly the lumbar vertebrae. It is seen in 3 to 10% of adults and can be diagnosed on radiographs, magnetic resonance imaging (T1 volumetric interpolated breath-hold examination), computed tomography (CT), or single-photon emission computed tomography. These defects are common in athletes, particularly in gymnasts, cricketers, footballers, and weight lifters. A pars defect is a sequela of repetitive stress. The maximum stress occurs at the L5–S1 level. We hypothesize that the orientation of the pars interarticularis in relation to the vertebral body is a key factor contributing to the development of a pars defect.