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Archives of Bone and Joint Surgery  - Volume:8 Issue:1, 2020
  • Volume:8 Issue:1, 2020
  • تاریخ انتشار: 1398/11/23
  • تعداد عناوین: 18
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  • Mohammad Razi, SM Javad Mortazavi * Pages 1-4
  • Ali Parsa *, Hamed Vahedi, Karan Goswami, Arash Aalirezaie Pages 5-10

    Despite widespread research on non-traumatic femoral head osteonecrosis (FHON), there is no consensus about preventative treatment options. Insufficient blood supply and increased intra-osseous pressure are the initiating events in the majority of cases. BMPs are growth factors that belong to the transforming growth factor β (TGFβ) superfamily. Two specific formulations of BMPs have already been approved by the FDA: 1. BMP-2 (Infused, Medtronic) for the treatment of tibial open fractures and spinal fusion; 2. BMP-7 (OP-1, Stryker) in the setting of long bone non-unions. To our knowledge there is no published work reviewing the utility of BMP-2 in the setting of FHON. Online databases (EMBASE, Cochrane, MEDLINE and PubMed) for literature relating to the use of BMP-2 in the treatment of FHON on 2nd June 2017. Animal studies: A total of 169 animal subjects with induced FHON were treated with BMP-2 in all the included in vivo studies. Improved histological parameters, areas of revascularization, areas of new bone formation and osteoid deposition were seen in all studies. The number of osteoclasts decreased post operatively, in the ibandronate and BMP-2 group. Human studies: In combination, 96 human hips were treated in two studies utilizing BMP-2 and mean follow-up was at least five years. Success rate of BMP-2 was above 80 % (based on Harris score and WOMAC score) in both studies. Both are level III studies. The present review of animal and clinical studies could not find well-designed prospective comparable studies with large sample size and preliminary evidence is not sufficient to supports the utilization of BMP-2, and its impact on the midterm outcomes of FHON. Level of evidence: III

    Keywords: BMP-2, femoral head, Osteonecrosis
  • Omid Shahpari, Alireza Mousavian, Nafiseh Elahpour, Michael, Alexander Malahias, Mohammad H. Ebrahimzadeh, Ali Moradi * Pages 11-20

    Two stage total hip arthroplasty revision surgery includes foreign material debridment, insertion of antibiotic impregnatedcement spacer, and finally, reimplantation of the prosthesis. This review has aimed to evaluate the efficacy of antibioticimpregnated cement spacers in infection control and eradication in arthroplasties.A total of 85 articles on total hip arthroplasty were used in this narrative literature review.High concentrations of the antibiotic in targeted drug delivery by means of using antibiotic impregnated cementspacers is effective against infections while reduces the side effects of systemic antibiotic therapy. This results inprevention of bone and muscle atrophy as well as size discrepancy. Also, antibiotic impregnated cement spacersreduce dead space and help stabilize the limb in total hip arthroplasty. Despite all reported drawbacks, antibioticimpregnated cement spacers seem effective in eradicationg infections, although a consensus has not been yetachieved.Level of evidence: I

    Keywords: Antibiotic, cement spacer, Infection, Total joint replacement
  • Matthew Tarabochia, Stein Janssen *, Paul T. Ogink, David Ring, Neal C. Chen Pages 21-26
    Background
    Enthesopathy of the extensor carpi radialis brevis origin [eECRB] is a common idiopathic, noninflammatorydisease of middle age that is characterized by excess glycosaminoglycan production and frequentlyassociated with radiographic calcification of its origin. The purpose of our study was to assess the relationship ofcalcification of the ECRB and advancing age.
    Methods
    We included 28,563 patients who received an elbow radiograph and assessed the relationship of calcificationsof the ECRB identified on radiograph reports with patient age, sex, race, affected side, and ordering indication usingmultivariable logistic regression.
    Results
    Calcifications of the ECRB were independently associated with age (OR:1.04; P<0.001); radiographsordered for atraumatic pain (OR2.6; P<0.001) or lateral epicondylitis (OR5.5; P<0.001); and Hispanic ethnicity (OR1.5;P<0.001) and less likely to be found at the left side (OR0.68; P<0.001). Similarly, incidental calcifications of the ECRB,those on radiographs not ordered for atraumatic pain or lateral epicondylitis, were independently associated withage (OR1.03; P<0.001) and Hispanic ethnicity (OR1.5; P<0.024) and less likely to be found on the left side (OR0.71;P<0.001).
    Conclusion
    We observed that about nine percent of people have ECRB calcification by the time they are in their sixthdecade of life and calcifications persist in the absence of symptoms which supports the idea that eECRB is a common,self-limited diagnosis of middle age.Level of evidence: II
    Keywords: Calcification, Enthesopathy, extensor carpi radialis brevis, lateral epicondyle, Lateral epicondylitis, Radiograph, Prevalence, Tennis elbow
  • Femke M.A.P. Claessen *, Bexkens, Rens, I. F. Kodde, Job N. Doornberg, Michel P. J. V. Bekerom, Denise Eygendaal Pages 27-32
    Background
    Evaluation of the accurate position after radial head arthroplasty remains a challenge for surgeons.Standard radiographs are used to evaluate the position of the implant, however, results regarding radiographicdeficiencies on clinical outcome are not consistent. In this retrospective study our main aim was to determine if subtleradiographic deficiencies after radial head arthroplasty can predict functional outcomes measured with the Mayo ElbowPerformance Score (MEPS).
    Methods
    A total of 24 patients, that had a press-fit bipolar radial head arthroplasty because of persistent symptomsafter treatment of a radial head fracture, were included. The mean follow-up time was 27 months and the MEPS wasassessed at the final follow-up. Three upper extremity orthopaedic surgeons evaluated 12 potential deficiencies onanteroposterior and lateral radiographs in consensus agreement.
    Results
    The median MEPS was 97.5 (Interquartile Range 82.5-100). No association was found between the presenceof subtle radiographic deficiencies and MEPS.
    Conclusion
    Functional outcome of the elbow after uncemented press-fit bipolar radial head arthroplasty is notassociated with subtle radiographic deficiencies. Therefore, surgeons might accept small imperfections on postoperativeradiographs.Level of evidence: IV
    Keywords: Arthroplasty, Fracture, Outcome, Radial head, radiographs
  • Layla Haidar, Joost Kortlever, David Ring * Pages 33-37
    Background
    The general population’s understanding of musculoskeletal health is likely influenced by media reports of the ailments of prominent athletes. We assessed factors independently associated with debatable or potentially misleading medical statements in mainstream sports media coverage of the ailments of professional and college athletes.
    Methods
    We identified and assessed 200 Internet media reports of musculoskeletal ailments of prominent athletes between February 19th and March 26th, 2018. We recorded medical statements about mechanism, diagnosis, treatment, and prognosis. We then classified those statements as accurate, debatable, or possibly misleading. We created a multivariable logistic regression model to identify factors independently associated with debatable or possibly misleading statements.
    Results
    Forty-five percent of statements were debatable or possibly misleading. Statements about diagnosis (Odds Ratio [OR]=0.17; P< 0.001), treatment (OR=0.33; P=0.007), or prognosis (OR=0.27; P=0.003) and statements about shoulder and elbow ailments were more likely to be inaccurate compared to statements about mechanism and statements about knee ailments (OR=3.3; P=0.04) respectively.
    Conclusion
    Coverage of sports ailments in the mainstream media are a common source of misinformation. Ailments of prominent athletes may represent a useful opportunity to teach people about musculoskeletal health.Level of evidence: Not applicable.
    Keywords: Ailments, media, Misinformation, musculoskeletal, Sports
  • Daniel Davis E. *, Benjamin Zmistowski, Joseph Abboud, Surena Namdari Pages 38-43
    Background
    Laminar flow ventilation systems were developed to reduce surgical contamination in joint arthroplastyto avoid periprosthetic joint infection (PJI). The goals of this study are to evaluate the cost-effectiveness and economicviability of installing and maintaining a laminar flow system in an operating room.
    Methods
    A Monte Carlo simulation was used to evaluate the cost effectiveness of laminar flow. The variables includedwere cost to treat PJI, incidence of PJI, cost of laminar flow, years of operating room use, and arthroplasty volume asthe dependent variable.
    Results
    Laminar flow would be financially-justified when 1,217 (SD: 319) TSA cases are performed annually withassumed 10% reduction in PJI from laminar flow and 487 (SD: 127) with assumed 25% reduction. In a high volume OR,laminar flow costs $25.24 per case (assuming 10% reduction) and $8.24 per case (assuming 25% reduction). Laminarflow would need to reduce the incidence of PJI by 35.1% (SD: 9.1) to be a cost-effective strategy.
    Conclusion
    This analysis demonstrates the substantial arthroplasty volume and large reduction in PJI rates required tojustify the installation and maintenance costs of this technology. This high cost of implementation should be consideredprior to installing laminar flow systems.Level of evidence: II
    Keywords: Cost effectiveness, Laminar flow, Laminar flow cost effectiveness, Laminar flow efficacy, Sensitivity analysis, Total Shoulder Arthroplasty
  • Carlo Ross *, Mohamad Alqubaisi, Anand Pillai Pages 44-49
    Background
    Anxiety following casting is an unrecognised complication that results in frequent visits to fracture clinic in the UK. There is a paucity of research regarding this complication. Failure to recognise Cast Anxiety (CA) leads to increased visits, frequent cast changes and possible failure of treatment despite no objective problems with the cast. Prior research has suggested a possible link between CA and claustrophobia but lacks statistical evidence. The Diagnostic and Statistical Manual of Psychiatric Disorders (DSM-V) categorizes claustrophobia as a Specific Phobia (SP) and questionnaires for both claustrophobia and SP exist. As such, the main purpose of this study is to examine the statistical correlation between the SP Questionnaire and the Claustrophobia Questionnaire to identify if a link exists between CA and claustrophobia. The secondary goal is to develop a screening questionnaire to identify those at high risk of CA, the significance of which lies in possible prevention of failure of surgical treatment and frequent visits to fracture clinic.
    Methods
    Self-report questionnaires were distributed to patients attending fracture clinic and accident emergency for review/ cast application/ problems with the cast over a one month period, no preference between upper or lower limb casts. This group completed both self-report questionnaires (N=157). From this group, patients were identified as having CA if they required frequent cast changes and frequent visits to fracture clinic despite no objective problems with the cast, or had themselves described feelings of anxiety/ claustrophobia. Follow up interviews with patients identifiedas having CA were undertaken. On the basis of the data gathered, a screening questionnaire was developed and distributed to a second group of patients with the same inclusion and exclusion criteria (N=50).
    Results
    A correlation between the two questionnaires was found: N= 157, r= 0.522, Pidentified as encompassing CA: Anxiety, Cognition and Physiological responses and Behaviour, evidencing an anxiety based disorder. The screening questionnaire identified over 80% of patients suffering from CA when scoring > 20/26. *Any patient scoring = 20/26 should be considered high risk of CA.
    Conclusion
    Based on this data, CA fits the criteria of an anxiety based condition. The modified screening tool permits early identification of individuals at high risk of CA. Usage of the screening tool is encouraged prior to casting and for future research modifications. Early identification will allow consideration of an alternative treatment option, anticipatory conversation and could prevent the failure of treatment.Level of evidence: II
    Keywords: Anxiety, Cast, Trauma
  • Tyler J. Broiln *, Ryan M. Cox, John G. Horneff, Surena Namdari, Joseph A. Abboud, Kristen Nicholson, Matthew L. Ramsey Pages 50-57
    Background
    We sought to characterize humeral-sided radiographic changes at a minimum of 2 years after reverseshoulder arthroplasty (RSA) to determine their association with specific implantation techniques.
    Methods
    The immediate and most recent postoperative anteroposterior radiographs of 120 shoulders with primary RSAand a minimum of 2-years of radiographic follow-up were analyzed (mean follow-up 35.2 months). Stress shielding wasevaluated by measuring cortical thickness at 4 different locations. Three independent examiners evaluated radiographsfor humeral osteolysis, radiolucent lines, stress shielding, stem loosening, and scapular notching.
    Results
    The cortical diameter, marker of external stress shielding, significantly decreased from initial to mostrecent measurement (P<0.001), but did not differ between cemented and uncemented groups. Cemented stems hadsignificantly more osteolysis and radiolucent lines; uncemented stems had significantly more internal stress shielding(P<001). The presence of scapular notching was significantly correlated with the presence of humeral osteolysis(P<0.001). Three (2.5%) stems were deemed “at risk” for loosening and 2 (1.7%) were loose.
    Conclusion
    Cemented humeral stems were associated with an increased rate of radiolucent lines and osteolysis,whereas uncemented stems were associated with more internal stress shielding. Humeral cortical thickness significantlydecreased over time regardless of fixation. There was an association between scapular notching and increasedhumeral osteolysis.Level of evidence: III
    Keywords: humeral stem loosening, osteolysis, radiographic changes, Radiolucent line, Reverse shoulder arthroplasty, scapular notching, stress shielding
  • Mohamad Fares, Jawad Fares *, Youssef Fares, Joseph Abboud Pages 58-69
    Background

    Gorham-Stout disease (GSD) is a rare skeletal disorder characterized by massive osteolysis of a bony area in the body. When it hits the shoulder, the patient is faced with a debilitating limitation in terms of motion, stability and quality of life. GSD etiology and pathology are unknown and, as a result, therapeutic modalities remain unclear. The aim of this paper is to explore and offer medical insight into the possible etiologies, pathologies and therapeutic modalities of Gorham-Stout Disease in the shoulder.

    Methods

    We explored PubMed/Medline for GSD cases in the shoulder. The search involved all articles published from database inception until February 1, 2019. Only articles published in English were included. Demographics and clinical information extrapolated from the reported cases were analyzed to deduce patterns and infer conclusions.

    Results

    Only 32 studies met our criteria, with a total of 37 cases (n=37). Males predominated in 21 cases (57%). Twelve cases (32%) were younger than 18 years, and 18 cases (49%) were aged between 18 and 65 years. Shoulder pain was the predominant reporting symptom. The humerus was the most common shoulder site affected (54%), followed by the scapula (35%) and the clavicle (30%). Almost half of the cases affected the right shoulder (51%), the left shoulder was affected in 16 cases (43%). Conservative treatment was opted in 17 cases (46%), while surgery was performed in 13 cases (35%). Good outcomes were reported in 28 cases (76%), while death occurred twice (5%).

    Conclusion

    Understanding the demographics and clinical characteristics of GSD in the shoulder region will help in formulating better therapeutic interventions and preventive health policies.

    Keywords: Gorham-Stout Disease, shoulder, osteolysis, Bone loss
  • Ludovico Lucenti, Kevin F. Lutsky, Lauren Banner, Zachary Lazev, Pedro K. Beredjiklian * Pages 70-74
    Background
    The hemi-hamate arthroplasty (HHA) can restore joint congruity and stability in chronic fracturedislocationsof the proximal interphalangeal joint (PIPJ). Purpose of this study was to compare the width of the distalhamate articular surface (DHAS) to the width of the base of the middle phalanges (P2) of the fingers. We hypothesizedthe dimensions of the width of the DHAS would be similar to those of P2, leaving a small amount of residual DHASwidth after autograft harvest.
    Methods
    Fifty-nine CT scans of the hand without any bony pathology were evaluated. Three observers measured thefollowing parameters and compared: (a) Width of the DHAS in the axial and coronal planes; (b) Width of the P2 articularbases of all four fingers; (c) Maximum capitate length (MaxCap) in the coronal plane.
    Results
    The residual DHAS on the coronal plane after graft harvest (bone remaining on the radial and ulnar aspectseach, not accounting for saw blade or osteotomy width thickness) among all patients was 1.3, 0.9, 1.4, and 2.4 mm forthe index, long, ring and small fingers respectively. There was a strong correlation between DHAS and MaxCap r=0.76.
    Conclusion
    There is likely to be a very small amount of residual hamate articular surface width left after the graft isharvested if the entire base of P2 is reconstructed.Level of evidence: III
    Keywords: Hemi-hamate arthroplasty, HHA, PIPJ fracture-dislocations, Proximal interphalangeal joint
  • Jonathan D. Barlow, Grant Jamgochian, Zachary Wells, Dexter Kenneth Bateman, Amber A. Schmerfeld, Joseph A. Abboud *, Gerald R. Williams Pages 75-82
    Background
    It is unclear whether hemiarthroplasty (HA) or reverse shoulder arthroplasty (RS) are superior for patientswith cuff tear arthropathy (CTA) and preserved preoperative motion (elevation >90˚).
    Methods
    This was a retrospective, single institution study. Patients who underwent RSA or HA for CTA were included ifthey had preserved preoperative motion with a minimum of 2 years of follow-up, or until complication/revision. ShoulderROM and functional outcomes scores were obtained.
    Results
    Twenty-six HAs and 21 RSAs were evaluated at mean of 38.6 months (HA) and 36.3 months (RSA). Patientsin the RSA group were significantly older at surgery (73.9 versus 65.1 years; P=0.003). Postoperatively, the meanchange in active elevation was -15° for HA versus 26° for RSA, with RSA having significantly greater active elevation(153° versus 123°; P=0.01). There were no significant differences in final internal or external rotation between groups.Superior outcomes were seen for RSA versus HA for ASES score (84 vs. 66, P=0.003), Simple Shoulder Test (8.8 vs.7.3, P=0.3), Single Assessment Numeric Evaluation (85 vs. 70, P=0.017), and 100mm VAS pain (7 vs. 33, P<0.001).
    Conclusion
    In patients with CTA and preserved preoperative forward elevation, RSA provided greater pain relief,superior functional outcomes, and better ROM compared with HA.Level of evidence: IV
    Keywords: Hemiarthroplasty, Reverse shoulder arthroplasty, rotator cuff tear arthropathy
  • Alireza Manafi Rasi, Reza Zandi, Mohamad Qoreishi *, Ali Habibollahzadeh Pages 83-88
    Background
    Surgical techniques and rehabilitations after total hip arthroplasty (THA) play a significant role in theimprovement of pain and limping. This study aimed to assess hip abductor muscle’s diameter and its strength after 6months postoperative THA performed by Hardinge approach.
    Methods
    After obtaining the patients’ demographic characteristics, the preoperative values of patients’ hip abductormuscle diameter were measured using magnetic resonance imaging, and were compared with postoperative values 6months later. Moreover, the hip abductor muscle’s strength was assessed using the Trendelenburg test.
    Results
    A total of 88 patients participated in this study with a mean age of 47.3±1.574 years. It should be noted that55.7% of the participants were male. Muscle diameter decreased from a mean value of 27.07±7.485 preoperative tomean value of 25.64±7.353 mm postoperative (P<0.001). Moreover, the degrees of Trendelenburg test (i.e., mild orsevere) decreased after surgery (P<0.001). There was no significant difference between the frequencies of differentgrades of limping according to the studied variables.
    Conclusion
    A decrease was observed in gluteus medius muscle diameter, and the Trendelenburg test results wereimproved in this study. Moreover, the difference between pre- and postoperative gluteus medius muscle diameters weremeasured using MRI. It can be concluded that MRI is not an appropriate diagnostic tool for the assessment of abductorstrength after THA in the 6-month postoperative visit. Accordingly, it is suggested to evaluate muscle strength beforeand after each surgery to schedule the following treatment protocol required for each patient.Level of evidence: IV
    Keywords: Hardinge, Hip Abductor Diameter, magnetic resonance imaging, Trendelenburg test
  • Seyed Mohammad Tahami, Amir Aminian *, Negar Azarpira Pages 89-93
    Background
    Surgical drainage and antibiotic therapy are the cornerstones of treatment protocols in septic arthritis; however, in some circumstances, the diagnosis and initiation of treatment may be retarded by slow disease progression or the time when the patient’s condition precludes early surgery. Therefore, it is beneficial to find ways to reduce the amount of articular injury. This study aimed to evaluate the effects of nonsteroidal anti-inflammatory drugs (NSAIDs) on the prevention of articular cartilage damage in an animal model of staphylococcal septic arthritis.
    Methods
    Knee joints of 40 rabbits were infected by the intra-articular injection of 105 colony-forming units of Staphylococcus aureus. Subsequently, they were categorized into four groups. The first (i.e., control group) and second groups were treated with a placebo and intramuscular injection of Ceftriaxone, respectively. Moreover, the third and fourth groups were treated with Naproxen alone and a combination of Ceftriaxone and Naproxen, respectively. All medications were started 24 h after the inoculation of microorganisms into the knee joint and continued for 3 days. Following that, the cartilage was evaluated using the International Cartilage Repair Society (ICRS) Visual Histological Assessment Scale.
    Results
    The group treated with the combination of Ceftriaxone and Naproxen obtained better results in terms of cell viability in tibial side cartilage and surface in both tibial and femoral cartilages (P<0.0125), compared to the group treated with antibiotics alone.
    Conclusion
    According to the results, in case of septic arthritis, the early administration of NSAID in conjunction with an appropriate systemic antibiotic may decrease further articular cartilage damage that is evoked by an infection.Level of evidence: III
    Keywords: Articular cartilage, International cartilage repair society, Joint, Nonsteroidal anti-inflammatory drugs, Septic arthritis
  • Femke M.A.P. Claessen, Ilse Schol, Gregory P. Kolovich, David Ring * Pages 94-98

    No consensus regarding optimal treatment or etiology of Preiser disease exists. We described the epidemiology,classification and treatment characteristics of 18 patients with Preiser disease. Patients with changes related to previoustrauma, and without radiographs were excluded. Based on the radiographs at diagnosis, we classified 13 scaphoids asHerbert Lanzetta stage II, four as stage III, and one as stage IV. In 12 patients nonspecific treatment was offered andonly two patients received surgical treatment. We found that chosen treatment is not associated with the severity ofHerbert Lanzetta stage and the outcome is not influenced by chosen treatment.Level of evidence: I

    Keywords: Avascular necrosis, osteonecrosis scaphoid, preiser disease, retrospective study, Treatment
  • Patrick K. Cronin *, Ian T. Watkins, Matthew Riedel, Philip B. Kaiser, John Y. Kwon Pages 99-111

    Orthopedic implant removal is a commonly performed procedure. While implant removal can be associated withimproved symptoms, risks of the surgery are notable. Stripped screws, broken and retained hardware, and morbidityassociated with soft tissue compromise during difficult removal are all common. Familiarity with the instruments iscritical to procedure success. The purpose of this study is to assist removal of unfamiliar screws in upper extremitysurgery by offering a reference for screw and driver compatibility across manufacturers.Inclusion of device manufacturers was determined by market share. Screw size, drive configuration, and screw removalsystem compatibility data was collected and recorded. Screw, guide-wire, and screwdriver compatibility was assessedand compared to two commonly utilized universal implant-removal sets.Eight upper extremity implant vendors were included. The data was compiled in table format according to manufacturerand sub-categorized to facilitate screw identification according to radiographically identifiable characteristics.The diversity of orthopaedic implants in upper extremity surgery requires careful preoperative planning to identify theappropriate equipment for implant removal.The goal of this work is to provide a centralized reference of commonly implanted screws, guide-wires, and drivers forthe upper extremity to facilitate removal.Level of evidence: V

    Keywords: hardware complication, Hardware Removal, implant removal, screw removal
  • Mohammad Razi *, Hamed Mazoochy, Elaheh Ziaei Ziabari, Haleh Dadgostar, Alireza Askari, Peyman Arasteh Pages 112-116

    A 24 year old otherwise healthy male was presented with a chief complaint of giving way in the left knee. MRI reportedcomplete anterior cruciate ligament (ACL) tearing. Arthroscopy showed ACL agenesis, ring-shaped lateral meniscus,and an anomalous thick band extending from the anterior horn of the lateral meniscus to the intercondylar notch of thelateral femoral condyle, which is known as the anterolateral meniscofemoral ligament (MFL). The MFL was attachedto the anatomic site of anteromedial bundle of ACL. ACL reconstruction surgery was performed using central 1/3 bonetendon bone graft.Practitioners should be aware that ACL reconstruction in lateral meniscofemoral ligament with associated ACL agenesisis a treatment option in which the preservation of MFL, as the stabilizer of anterior horn of lateral meniscus, should beconsidered during ACL reconstruction as a good treatment choice.Level of evidence: V

    Keywords: Anterior lateral meniscofemoral ligament
  • Keivan Rahbari, Mahmoud Farzan, Hana Saffar, Amir R. Farhoud * Pages 117-120

    Malignant transformation of glomus tumor is exceedingly rare and most common reported in lower extremity and abdominal viscera. We could find only 6 previous case report of malignant glomus tumor in the hand. Although large and deeply located glomus tumors are considered to be malignant, evidence has shown that most of these cases were clinically benign. These lesions are better considered as glomus tumor of uncertain malignant potential. Due to rarity of malignant glomus tumor, decision for operative treatment must be based on few case reports. In this article we review the literature for malignant glomus tumor of hand and their management, also we report a 49 year-old man with glomus tumor of uncertain malignant potential in thumb who was treated by wide amputationLevel of evidence: IV

    Keywords: Bone involvement, Glomus Tumor, Malignancy