Bone & Joint

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Bone & Joint: Click on section headings below (in blue) to expand or collapse the section content

Diagnostic Headings (i.e. specimen & procedure)

Diagnostic Headings		CPT Code
	Bone, left ____ , core biopsy:
	Bone, right ____ , excisional biopsy:
	Left / Right forearm, amputation:
	Left / Right foot/hand, amputation:
	Left / Right leg, below/above-the-knee amputation:

Dx. Menu -- Wording of Common Abnormalities

Bone Lesions

Cartilage Lesions

Extremities (Gangrene and Other Benign Lesions)

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Clinical scenario: .

Right lower limb, below-the-knee amputation:

-- Gangrene with skin ulcers and extensive soft tissue necrosis (heel).

-- Severe stenotic to occlusive (greater than 95%) arteriopathy of the posterior tibial artery.

-- Severe fibrocalcific arteriopathy with stenosis (up to 75%), peroneal artery and anterior tibial artery.

-- Focal mild to moderate acute osteomyelitis of the heel bone.

-- The proximal resection margins are free of inflammation and ischemic necrosis.

Slides examined: H&E x 3

CPT code: 88304 x 1, 88330 x 1

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.

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Clinical scenario: 66-year old man with hip pain.

Left femoral head, resection:

-- Moderate degenerative joint disease (DJD) / osteoarthritis.

-- Normal cellular bone marrow with trilineage differentiation.

Slides examined: H&E x 3

CPT code: 88304 x 1, 88330 x 1

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.

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Clinical scenario: .

Femoral head and soft tissue, left hip, excision:

-- Moderate degenerative joint disease (DJD) with a subchondral cyst.

-- Benign prominent villous synovial hyperplasia (see note).

-- Normal cellular bone marrow with trilineage hematopiesis.

-- No active inflammation, granuloma, pigmented cells or neoplasia.

Slides examined: H&E x 3

CPT code: 88304 x 1, 88330 x 1

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.

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Clinical scenario: 72-year old woman with femoral fracture.

Left femoral head, resection:

-- Fragments of non-viable bone, old hemorrhage and fibrosis consistent with recent fracture

-- Significant hypoplasia and atrophy of trabecular bone

-- No osteomyelitis or malignancy identified.

Slides examined: H&E x 3

CPT code: 88304 x 1, 88330 x 1

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.

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Clinical scenario: 63-year old man h/o severe peripheral vascular disease.

Right lower extremity, above-the-knee amputation:

-- Gangrene with multiple open skin ulcers on the foot (see Gross Description)

-- Focal moderate acute and chronic osteomyelitis of bone underlying ulcers

-- Severe occlusive atherosclerotic vasculopathy with dystrophic calcification (posterior tibial artery)

-- Severe stenotic atherosclerotic vasculopathy of popliteal artery (75% stenosis) with dystrophic calcification

-- The proximal soft tissue resection margin is viable and free of inflammation or ischemic changes

-- The proximal marrow resection margin is unremarkable.

Slides examined: H&E x 3

CPT code: 88304 x 1, 88330 x 1

Editor's comment:

For resection margin of large tubular bone, bone marrow (without thick cortex) should be sufficient for evaluation. In fact, osteomyelitis in adults does not extend across a joint and it almost never involves the margin beyond a joint.

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Clinical scenario: 63-year old man h/o severe peripheral vascular disease.

Leftt lower leg, above-the-knee revision amputation:

-- Severe occlusive atherosclerotic arteriopathy with extensive dystrophic calcification, both anterior and posterior tibial arteries

-- Extensive coagulative necrosis and mild chronic inflammation of subcutaneous soft tissue, previous amputation site

-- Soft tissue margin at the new resection/amputation site is viable and free of inflammation

-- No osteomyelitis identified

Slides examined: H&E x 3

CPT code: 88304 x 1, 88330 x 1

Editor's comment:

To sample resection margin of large tubular bone, bone marrow (without thick cortex) should be sufficient. In fact, osteomyelitis in adults does not extend across a joint and it almost never involves the margin beyond a joint.

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Clinical scenario: Women at 70's

Right femoral head, excision:

-- Focal chondral plate collapse and reactive subchondral bone changes, most compatible with focal subchondral bone loss, probably secondary to old avascular necrosis or osteoporotic microfracture

-- Osteoarthritis (degenerative joint disease)

-- Bone marrow with trilineage maturation

-- No osteomyelitis or active bone necrosis identified .

Note: Use this template first. Convert is later into table formats

Slides examined: H&E x 3

CPT code: 88304 x 1, 88330 x 1

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.

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Clinical scenario: 30-year old man; history of "enchodroma" of the left hand.

Synovium and soft tissue, left knee, arthroplasty:

-- Diffuse prominent reactive synovial hyperplasia.

-- Multiple polarizable exogenous materials and associated foreign body giant cell reactions.

-- No granuloma or significant acute inflammation (PMNs <1/HPF).

Slides examined: H&E x 3

CPT code: 88304 x 1, 88330 x 1

Editor's comment:

One common error in PMN counting is to include intra-vascular PMNs.

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Clinical scenario:

Great toe, right foot, debridement:

-- Multiple lobular deposits of monosodium urate (gout) with peripheral multinucleated giant cell reaction (see note)

-- Extensive acute and chronic inflammation with bone destruction.

-- Prominent reactive hyperplastic synovitis

-- Severe degeneration of fibrotendinous tissue

Note: The specimens were received in formalin. Thus, the birefringent polarizing crystals characteristic of monosodium urate can no longer be identified microscopically. Correlation with follow-up lab results to confirm the above interpretation is recommended.

Slides examined: H&E x 3

CPT code: 88304 x 1, 88330 x 1

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.

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Clinical scenario:

Soft tissue, left wrist, debridement:

-- Nodular deposit of calcium pyrophosphate dihydrate (pseudogout) and associated acute inflammation.

-- No polarizable monosodium urate crystals identified.

Slides examined: H&E x 3

CPT code: 88304 x 1, 88330 x 1

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.

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Clinical scenario:

Soft tissue, right wrist, excision:

-- Chondrocalcinosis (calcium pyrophosphate dihydrate disease/pseudogout) and associated multinucleated giant cell reaction.

Slides examined: H&E x 3

CPT code: 88304 x 1, 88330 x 1

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.

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Clinical scenario:

Right hip, acetabulum, bone fragment and soft tissue, total hip orthroplasty:

-- Marked reactive synovial hyperplasia with focal foreign body giant cell reaction and calcification

-- No significant neutrophilic inflammation (PMN < 2/hpf).

Slides examined: H&E x 3

CPT code: 88304 x 1, 88330 x 1

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.

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Clinical scenario:

Synovium, right shoulder, excision:

-- Reactive synovial hyperplasia with fibrin deposition

-- No significant neutrophilic inflammation (PMN < 2 /HPF).

Slides examined: H&E x 3

CPT code: 88304 x 1, 88330 x 1

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.

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Clinical scenario:

Soft tissue, left knee, excisional biopsy:

--- Consistent with synovial osteochondromatosis (chondrometaplasia)

--- Focal reactive synovitis.

--- No trabecular bone or marrow component

--- No malignancy identified..

Note: Use this template first. Convert is later into table formats

Slides examined: H&E x 3

CPT code: 88304 x 1, 88330 x 1

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.

Synovial & Periarticular Lesions

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Clinical scenario: .

Soft tissue and bone, left elbow, debridement:

-- Prominent reactive synovial hyperplasia.

-- Fibrosis and degenerative changes.

-- No active inflammation (PMN <1 per high power field), granuloma or polarizable exogenous material.

Slides examined: H&E x 3

CPT code: 88304 x 1, 88330 x 1

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.

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Clinical scenario: .

Left knee, posterior mass, excision:

-- Consistent with synovial cyst (Baker's cyst).

-- No active inflammation, granuloma or neoplasia.

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Clinical scenario: .

Left ankle, soft tissue, excisional biopsy:

-- Most compatible with a tenosynovial giant cell tumor (TSGCT with exuberant xanthomatous inflammation (see note).

-- No granuloma, geographic necrosis, exogenous polarizable material identified.

Note: Sections show exuberant villous / papillary synovial hyperplastic growth pattern. The hypercellularity of this tumor, focally nuclear hyperchromasia and the presence of mitotic figures may raise the concern of malignancy. However, the orderly villous architecture, presence of scattered multinucleated giant cells, histiocytes and hemosiderin-laden microphages, and absence of geographic necrosis, granulomatoid or epitheloidl component support the above interpretation. TSGCT may erode contiguous bone by pressure. If incompletely removed, they may recur locally.

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Clinical scenario: .

Organ, site, surgical procedure:

-- Dx Heading above font = 04Heading; Style = 04DxHeadings.

Note: 02958203.

Slides examined: H&E x 2

CPT code: 88305 x 1

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.

Spine Lesions

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Clinical scenario:

Lumbar spine, L3-L5, laminectomy:

-- Degenerated fibrocartilage .

-- No inflammation or neoplasm.

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.

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Clinical scenario:

Lumbar spine, L1-L2, laminectomy:

-- Focal elastic fibrosis, consistent with intraspinal fibroelastoma (see note)

-- Multiple fragments of degenerated fibrocartilage

-- Unremarkable bone fragments

-- No inflammation, granuloma or vascular neoplasia.

Note: The presence of conspicuous amount of elastic material as thick and irregular fibers, globules and grained nodules that are admixed with ample hyalinized collagenous matrix is typical of elastofibroma. Correlation with radiographic findings is required to confirm the histological diagnosis.

Reference:

O. Daum et al.: Elastofibromatous Changes in Tissues From Spinal Biopsies. A Degenerative Process Afflicting a Small but Important Subset Of Patients Operated for Spinal Canal Compression: Report of 18 Cases. NT J SURG PATHOL (2010) 18 (6): 508-515.

Slides examined: H&E x 2

CPT code: 88305 x 1

Editor's comment:

Spinal elastofibroma seems to be much more common than reported and expected. Morphological criteria have not be well established. Key histological features are described in the Note section above. But the main diagnostic challenge appears to come from fragmentation of tissue sample and its "histologic overlap" with normal ligmentum flavum to unfamiliar viewers.

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Clinical scenario:

Lumbar spine, l1-l2, laminectomy:

-- Focal elastic fibrous changes, suggestive of incipient elastofibromaouse degenerative process (see Note).

-- Severely degenerated fibrocartilage.

-- Unremarkable bone fragments.

-- No inflammation, granuloma, vascular neoplasia or malignancy.

-- No neural component is present in this biopsy.

Note: A portion of ligmentum flavum is present with disarray, fragmentation of elastic fiber, focal grained globules and increased interstitial collagenous matrix. These changes are often associated with spinal elastofibroma (ref). However, these changes involve a very small portion of the specimen and are insufficient for a definite diagnosis of elastofibroma. Correlation with clinical findings (esp. imaging studies) is recommended.

Reference:

Editor's comment:

Spinal elastofibroma seems to be much more common than reported and expected. Morphological criteria have not be well established. But the main diagnostic challenge appears to come from fragmentation of tissue sample and its "histologic overlap" with normal ligmentum flavum to unfamiliar viewers.

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Clinical scenario:

Spine, C7-T3, excisional biopsy:

-- Synovial cyst and degenerative changes

-- No active inflammation, granuloma or neoplasm.

Note: Use this template first. Convert is later into table formats

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.

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Clinical scenario: 76-year old woman, multiple lung nodules and bone lesions; r/o metastasis .

Vertibral column, L4-L5, core biopsy:

-- Metastatic adenocarcinoma (to the marrow space), at least ___ cm, suggestive of lung origin (see Note).

Note: The immunohistological findings of this tumor are not uniquely typical of adenocarcinoma of the lung. However, decalcification is known to alter immunohistological detection. Given the imaging finding of a __ -cm mass and "multiple small nodules in the ___ lung" on CT with IV contrast (per EMR dated ___), the histological findings are consistent with a metastatic adenocarcinoma, likely of lung origin although other source (e.g., upper GI tract and pancreatobiliary tree) cannot be entirely excluded.

Slides examined: H&E x 3

CPT code: 88305 x 1, 8830X