Search

OBJECTIVE Treatment of chondrosarcomas is grade based; intralesional curettage for grade 1 and resection for grade 2 or more. Currently used methods to determine grades before surgery are not highly accurate and create a dilemma for the surgeon. We have used a PET-CT combined with imaging to answer the following study questions: (1) Does SUVmax value from an 18F-FDG PET/CT correlate with the grade of chondrosarcoma? (2) Can a cutoff SUVmax value be used to differentiate between various grades of chondroid neoplasms with sufficient sensitivity and specificity? (3) Does SUVmax guide the clinician and add value to radiology in offering histologic grade-dependent management? METHODS SUVmax values of patients with suspected chondrosarcoma were retrospectively correlated with the final histology grade for the operated patients. Radiologic parameters and radiology aggressiveness scores (RAS) were reevaluated and tabulated. RESULTS Totally 104 patients with chondroid tumors underwent 18F-FDG PET/CT assessment. In total 73 had tissue diagnosis available as a pretreatment investigation. Spearman correlation indicated that there was a significant positive association between SUVmax and the final histology grading of chondroid tumors (correlation coefficient = 0.743; P

BACKGROUND: Megaprosthetic infections continue to be a leading mode of failure after limb salvage surgery. Though challenging, amputations can be avoided with proper management in majority of the cases. This study aims to describe the spectrum of mega-endoprosthetic infections at our institute and assess the treatment efficacy in these patients. MATERIALS AND METHODS: All patients treated for endoprosthetic infection at our institute between 2010 and 2018 were retrospectively analyzed for overall survival of reconstruction method, site and type of megaprosthesis, adjuvant therapy, microbial isolates, surgical and medical management and outcomes. RESULTS: Thirty-five patients (22 males: 13 females) were analyzed following treatment for endoprosthetic infection. Majority were around the knee joint [most commonly with proximal tibia (n = 14) followed by distal femur (n = 12) megaprosthesis]. Ten patients had undergone primary surgical procedure at our institute, while 25 patients presented with infection after megaprosthesis implantation. In the 28 culture-positive infections, the most common micro-organism was Staphylococcus spp. (18 patients: methicillin-sensitive Staphylococcus aureus = 9, coagulase-negative Staphylococcus = 5, methicillin-resistant Staphylococcus aureus = 1, Staphylococcus epidermidis = 3) and poly-microbial infection was present in three patients. Nine patients underwent successful debridement and wound wash with insertion of antibiotic impregnated cement beads in 5/9 cases. Twenty-one patients required a two-stage revision. Of these 30 patients, all but one has completely resolved infections. One patient with resurfaced late infection after re-implantation is on chronic suppressive antimicrobial therapy and close follow-up. Amputation because of uncontrolled infection was performed in three patients (one death post-operatively due to systemic complications of septicemia), while two patients opted for amputation as opposed to stage revisions. Median antimicrobial therapy duration was 6 weeks (1–12 weeks). Reconstructive surgery for soft tissue cover was required in seven patients. CONCLUSIONS: In patients with early or acute presentation without frank granulation or pus around the implant, debridement and insertion of antibiotic cement beads was adequate. Two-stage revisions with complete removal of the megaprosthesis showed best results in infections that could be controlled with antimicrobial therapy. More than one exchange of cement spacer was required for uncontrolled infections. Multidisciplinary approach in consultation with the infectious disease team is essential to determine choice of antibiotic cement for beads/spacer as well as appropriate adjuvant antimicrobial therapy to solve the challenging problem of endoprosthetic infections following bone tumor surgery. Adequate and healthy soft tissue cover of the implant should be achieved wherever indicated.

Objective This study was aimed to compare comparative efficacy of transsphenoidal endonasal endoscopic and microscopic pituitary surgery at single center of a developing country. Methods This study included 198 patients in which 50 patients were studied prospectively and 148 patients were studied retrospectively, diagnosed with pituitary adenoma who presented to neurosurgery department at Sawai Man Singh hospital in Jaipur, India, and were operated via transsphenoidal route between 2013 and 2018. Patients' records were reviewed and relevant clinical and surgical data were collected. Patients were divided into two groups based on the surgical procedure performed, endoscopic endonasal transsphenoid approach (group 1) and microscopic transsphenoidal approach (group 2). Outcomes, in terms of efficacy and the resulting complications of each procedure were compared and analyzed. Results A total of 198 patients with pituitary adenoma were operated during the study period. Among them, 119 (60.1%) patients were operated by endoscopic and 79 (39.9%) patients were operated by microscopic transsphenoidal approach. In endoscopic group, intraoperative cerebrospinal fluid (CSF) leak was present in 39 patients (32.77%) and 23 (29.11%) in microscopic group. Complete tumor removal was achieved in 69.75% in endoscopic and 48.13% in microscopic group (p = 0.004). Endocrine control was achieved in 78.94% (30 out of 38) in endoscopic and 68.18% (15 out of 22 patients) in microscopic group. Conclusion The transsphenoidal approaches for resection of pituitary adenoma, both endoscopic and microscopic approach, are minimally invasive and effective for disease control. Both the approaches lead to similar endocrine control, visual symptoms, complications, and long-term outcome. Therefore, the selection of the final approach should be individualized, ultimately depending on the surgeons' comfort, experience, and familiarity with the particular technique.

The key to intralesional surgical treatment of giant cell tumor of bone (GCTB) is extended curettage. As GCTB is locally aggressive with a high propensity for local recurrence, a primary factor of surgical treatment is the ability to achieve local tumor clearance. GCTB commonly affects the epimetaphyseal region of the bone, which may compromise the integrity of the articular surface. With the exception of expendable bone that may be considered for resection without the challenge of reconstruction (e.g., the proximal aspect of the fibula or the distal aspect of the ulna), a large majority of cases of GCTB can be treated with joint-preserving techniques. In the present article, we share a video demonstration including the surgeon view of intralesional surgery for GCTB, with emphasis on the 360° visualization of the tumor cavity, dilemmas regarding use of adjuvants for extended curettage, and options in cavity reconstruction. DESCRIPTION: The surgical procedure involves 4 essential components. (1) Surgical exposure and isolation of the soft tissues. The technique begins with a complete exposure that allows visualization of the entire tumor cavity. The initial part of the exposure involves getting to the bone and to the soft-tissue mass outside the bone, when present. The muscles are separated from the bone and retracted away from the soft-tissue component of the tumor. Soft tissue is adequately retracted to allow complete visualization of the tumor cavity. The tissues around the cavity are protected by placing hydrogen peroxide-soaked mops around the tumor cavity. The aim is to isolate the bone opening and avoid any contamination of soft tissue by the tumor, as hydrogen peroxide kills GCTB cells on contact(1). The soft-tissue mass of the tumor is removed en bloc with a cover of normal tissue in order to prevent spillage into uninvolved tissues. Ward and Li advise the use of cautery for this part of the exposure in order to minimize contamination because high-temperature cautery kills the tumor(2). The initial opening into the osseous tumor cavity is made smaller in order to control the tumor spillage, and then enlarged in order to gain complete visualization. (2) Curetting and burring for tumor clearance. The walls are curetted, using the sharp edges of the curet. Good visualization is the key to meticulous and complete curetting. We recommend the use of a surgical loupe and headlight for adequate visualization(1). Tumor cavities often have overhanging osseous ridges with tumor hidden behind them. A curet may not be useful for breaking these hard osseous ridges; a burr is best utilized for this task. In addition to breaking the ridges, a high-speed burr helps to extend the curettage for a few millimeters beyond the grossly visible tumor margin(3,4). (3) Use of adjuvants to achieve extended curettage. Various physical and chemical agents have been utilized to control the microscopic disease remaining in the walls following a thorough curettage. Liquid nitrogen, phenol, hydrogen peroxide, alcohol, electrocautery, bone cement, and argon plasma cautery have been utilized as adjuvants. Balke et al. showed that the rate of recurrence decreases with use of more adjuvants, with high-speed burring having the greatest effect on the rate of recurrence, likely as a result of the larger resection and the thermal effect of the burring(5). We suggest a case-by-case use of specific adjuvants, but in our experience, a high-speed burr is always utilized, hydrogen peroxide is utilized commonly when safe, and argon-plasma cautery is utilized judiciously. (4) Reconstruction of the cavity. The defect may be filled with bone, cement, or a combination of both. We suggest an individual, case-by-case approach to the reconstruction. In cases in which >25% of the articular surface is undermined(2), subchondral bone grafting is recommended prior to cementing (i.e., a sandwich procedure). ALTERNATIVES: GCTB requires tumor clearance for local control. One alternative to intralesional surgical treatment performed around the knee is resection of the tumor-affected segment of bone and reconstruction with an endoprosthesis. This is a joint-sacrificing alternative and, in our experience, should be reserved for patients with joint involvement, multiply recurrent disease, or insufficient remaining wall to curet. RATIONALE: When adequate tumor clearance is possible, joint-salvaging intralesional surgical treatment remains the superior option to achieve physiological joint function(6). Indications for this procedure include maintained or restorable joint congruity and construct stability allowing early mobilization. EXPECTED OUTCOMES: The rate of local recurrence following intralesional surgical treatment ranges from 16% to 25%(1,7). The use of a high-speed burr is an essential part of the curettage(5), and hydrogen peroxide is a safe choice for an adjuvant, if desired and when suitable, to provide greater local control(8). Reconstruction with bone, cement, or both is acceptable, but we recommend building up a few millimeters of subchondral bone with bone graft before cement filling(1,9). IMPORTANT TIPS: Illumination and magnification within the tumor cavity provide better visualization. Isolation of the soft tissue around the tumor with use of hydrogen peroxide-soaked mops can prevent seeding and contamination. Meticulous tumor clearance is more important to minimize recurrence than the use of adjuvants. Use of a C-arm helps to better guide extension of the curettage and avoid inadvertent joint penetration. Maintaining joint congruity is essential.

Background: This study was conducted to compare the immunogenicity and safety profile of two quadrivalent influenza vaccines (QIVs) in healthy adults (18-60 years) and elderly (>61 years) participants.Method: This phase III study was conducted from March 2018 to April 2018 across 12 sites in India. In this randomized, observer-blind, active-controlled study, 480 participants were randomized to receive a single dose of test vaccine (subunit, inactivated influenza vaccine; Influvac® Tetra, Abbott) (n = 240) or reference vaccine (split virion, inactivated influenza vaccine; VaxiFlu-4, Zydus Cadilla Healthcare) (n = 240). The primary objective was to describe and compare the immunogenicity of each vaccination group based on hemagglutination inhibition (HI) assay seroprotection and seroconversion rates, and geometric mean fold increase (GMFI) against four vaccine strains in two age groups. Safety and reactogenicity were also compared for the vaccines in both the age groups.Results: The pre- and post-vaccination HI titers for both the vaccines were comparable. The GMFI varied from 4.3 - 22.7 in the test and 3.7-21.6 in the reference vaccine group. The seroprotection rates were >90% for the A-strains and ranged between >43% and

Background: Orthopedic oncology has evolved over the past few decades to favor limb salvage over amputations. The noninvasive expandable prosthesis can be lengthened with an externally applied magnetic field eliminating the pain, stiffness, as well as the risk of infection. We present the largest series in Indian experience with this implant over the last 8 years while analyzing its benefit to the surgeons and the patients, but are we able to justify the cost effectiveness? Materials and Methods: Eighteen implants were used in 16 patients with nonmetastatic primary bone sarcoma from May 2006 to June 2015. All implants were manufactured by Stanmore implants worldwide based in London, UK. Lengthening was done in the outpatient department during the followup visits using an external electromagnetic coil. The function was assessed using the musculoskeletal tumor society (MSTS) score. Results: The patients had a mean age of 10.25 years at the time of surgery. The mean followup was 49.56 months. Twelve patients are alive at a followup after surgery. The prostheses were lengthened by a mean of 31.64 mm and average lengthening per session was 4.18 mm. The mean MSTS score was 28.83. Two revisions for jammed mechanism and two patients had a successful two-stage revision for delayed infection. Conclusion: The noninvasive expandable prosthesis is an ideal implant for children undergoing limb salvage surgery for bone sarcoma who are expected to have more than 3 cm of limb length discrepancy at maturity. The initial high cost compared to a minimally invasive expandable implant can be recovered as there is no additional cost of lengthening. The small amounts of lengthening at more frequent intervals is more physiological as compared with the minimally invasive type where more lengthening is done to minimize the number of procedures. While the functional and oncological outcomes are comparable, this implant allows limb lengths to be maintained without pain, functional compromise or risk of infection.

Introduction. Traditionally, centralization of the fibula with fusion across the tibiotalar joint has been used to reconstruct distal tibial defects. Although effective, it requires long periods of protected weight-bearing. The fibula or the fixation often fails before fibular hypertrophy necessitating multiple additional surgeries. A method of using ECRT with the available ipsilateral fibula (nonvascularized) to reconstruct the distal tibia defect with the aim of early return to weight-bearing was evolved. This paper documents our early experience. Patients and Methods. Four patients; with the diagnosis of osteosarcoma in 3 patients and recurrent giant cell tumor of the bone in 1 patient, underwent resection of the distal tibia for tumors between 2017 and 2019. Extracorporeally irradiated (50 Gy) distal tibia along with ipsilateral nonvascularized fibula was used to bridge the defect and fuse the tibiotalar joint. A plate was used to rigidly hold the construct. The final outcome was compared to the historical control group that underwent only pedicled ipsilateral fibula transposition and ankle arthrodesis without recycled autograft or allograft between 2009 and 2017. Oncological reconstruction and functional outcomes were compared for each group. Patient reported outcomes on the acceptability of ankle fusion; cosmesis and function were analyzed and compared between the two groups. Results. The mean resection length in the study group (4 patients) was 7.75 cm (7 to 8.5 cm). As compared to the historical cohort of 7 patients, the study population showed statistically superior results in all reconstruction, functional, and patient-reported outcomes except time to proximal junction union ( p = 0.068 ). There were no reconstruction failures, infection, or nonunions in the study group, whereas the control comparative group had 2 proximal junction nonunions and a mean time to fibular hypertrophy of 143 weeks (82 to 430 weeks) with fibula centralization. Earlier weight-bearing was allowed (mean 26.75 weeks; median 27 weeks) compared to (mean 80.75 weeks; median 80 weeks) in the control group. Conclusion. We think that ECRT with ipsilateral vascularized fibula is a promising method of reconstructing the distal tibia. The recycled autograft tibia added strength to the distal tibia construct in our study and aided the anatomical reconstruction of the distal tibia. The patient-reported outcomes for cosmesis and acceptability add to the benefits of performing this procedure. Consistent early union across the proximal junction and earlier weight-bearing were clear advantages of this method.

Background Joint reconstruction following resection of malignant bone tumors is challenging in itself in spite of several options in hand. Ability to restore joint anatomy, function and mobility while achieving optimal oncological outcomes are the requirement of reconstructions today. While biological reconstructions (allograft or recycled tumor autografts) following tumor bone surgery are popular for intercalary resections not involving the joint, their use for osteo-articular reconstructions are associated with concerns over cartilage and joint health. We have used extracorporeal radiation therapy (ECRT) and re-implantation of the osteoarticular segment as a size matched recycled tumor autograft reconstruction after complex acetabular and proximal ulnar resections; owing to the lack of significantly superior reconstruction alternatives in these locations and also review the current literature on other biological/non-biological reconstruction options. Questions/purposes (1) What are the oncological, reconstruction and functional outcomes with osteo-articular reconstruction using ECRT and re-implantation of recycled tumor autograft for the acetabulum and olecranon? (2) Is there an evidence of cartilage loss, joint damage or avascular necrosis resulting from irradiation of the articular autograft? Methods 19 patients with primary bone tumors underwent limb salvage surgery with en-bloc resection and reconstruction using the resected articular tumor bone after treating it with extra-corporeal irradiation of 50–60Gy. These included 16 acetabular and 3 proximal ulnar. While all patients were included for oncological assessment; minimum follow-up of 24 months was considered for final outcome assessment of function and joint status. Results MSTS scores of the 16 acetabular reconstruction patients with minimum 2 years follow-up was 87% (26/30). Neither delayed union, non-union at osteotomy sites nor was any fractures reported in the irradiated graft. There was no local recurrence within the irradiated graft and only 1 patient required graft excision for uncontrolled infection. All 3 patients of proximal ulna reconstruction achieved healing and full range of movement of the elbow. Scores of MSTS: 100% (30/30), MEPS: 100 and DASH: zero was achieved. Two patients developed osteonecrosis of the femoral head; one requiring a joint replacement and one awaiting replacement. One patient of acetabular reconstruction has joint space narrowing on radiographs with mild clinical symptoms. Conclusions Extracorporeal radiotherapy and re-implantation after osteo-articular resection is an oncologically safe option offering promising outcome in our small series. The availability of size-matched graft, thus avoiding inherent problems of allograft also provides a better economic option over endoprosthesis and its associated complications in select sites. The results can deteriorate over time that may require secondary reconstructive procedures like joint replacement. Level of evidence Level IV, Therapeutic Study.

Schwannoma occurring in the psoas muscle is rare. We report a 49-year-old male who presented to the orthopaedic oncosurgery team with persistent lower back pain radiating to the right lower limb following a fall on the back a few months ago. Magnetic resonance imaging revealed a well-defined lesion in the right psoas muscle at the level of third lumbar vertebra (L3). He underwent a laparoscopic excision of this mass using one 10 mm and two 5 mm ports. Intraoperative frozen section after a complete excision showed this to be a benign schwannoma. He was discharged the day after surgery. His symptoms gradually reduced over a period of time and he remains well 3 years after surgery. This case highlights the feasibility and safety of minimally invasive treatment of this rare tumour.

AIM: Mega-prostheses required for reconstructing large gaps in bone after limb-saving surgeries for osteo-sarcoma patients have a long development cycle. This includes design of prosthesis components and surgical armamentarium, followed by pilot batch production, lab testing, human clinical trials and regulatory approvals. Most manufacturers stay away due to small market size coupled with the difficulties and high costs involved. Prostheses developed in the West are often unsuitable and unaffordable for the majority of Indian patients. There is a need for high-quality yet low-cost prostheses that are compatible with the anatomy and functionality of local population. METHOD: An inter-disciplinary group comprising orthopedic oncologists, mechanical engineers and materials scientists from three different organizations in India took up the above challenge. They developed a novel modular tumour knee prosthesis with rotating hinge, as well as surgical armamentarium with femoral and tibial cutting jigs and other instruments. Knee simulator and testing machines were developed to test the prosthesis. A dedicated pilot production facility along with inspection and quality management system was set up. RESULT: The new prosthesis provides flexion-extension up to 120 degrees and axial rotation of ±5 degrees. It successfully completed ten million cycles of fatigue and wear testing. The regulatory body of the government and institutional ethical committees of hospitals approved the human clinical trials, which are currently in progress. CONCLUSION: The design, manufacturing and testing of the prosthesis components and armamentarium took more than a decade and presented many challenges. These were overcome by several technological innovations by the engineering team and continuous feedback from the surgeons. The experience is expected to be useful to all others interested in this field.

BACKGROUND Pelvic resections are challenging, and reconstruction of the resected acetabulum to restore mobility and stability is even more difficult. Extracorporeal radiation therapy (ECRT or extracorporeal irradiation) of autograft bone and reimplantation allows for a perfect size match and has been used with some success in the extremities. Although the risk of wound complications in pelvic surgery has discouraged surgeons from using ECRT of autografts in that anatomic site, we believe it may be a reasonable option. QUESTIONS/PURPOSES In a small series, we asked: (1) What was the median surgical time and blood loss for these procedures, and what early complications were observed? (2) Is there evidence of osteonecrosis or cartilage loss at a minimum of 2 years after ECRT of acetabular autografts, and what functional scores were achieved? (3) What were the oncologic outcomes after ECRT? METHODS Between March 2007 and September 2016, one surgeon performed 12 ECRT acetabular autografts and reimplantations after resections of pelvic or acetabular tumors. Of those, 10 with minimum 2-year followup are reported on here with respect to oncologic, functional, and radiographic assessment; all 12 are reported on for purposes of surgical parameters and early complications. During that period, we generally performed this approach when we judged it possible to achieve a tumor-free margin, adequate bone stock, and sufficient remaining hip musculature to allow use of the bone as an autograft with restoration of hip mobility. We generally did not use this approach when we anticipated a difficult resection with uncertain margins or where remaining bone was judged of poor strength for use as a graft or if both iliopsoas and abductors were sacrificed. Since 2010, this series represents seven of the 21 pelvic resections with reconstruction that we performed (five patients in this series had the procedure performed before 2010). Followup was at a median of 65 months (range, 33-114 months) for nine patients whose functional outcomes were evaluated. The median patient age was 30 years (range, 10-64 years). Clinical parameters were recorded from chart review; radiographic analysis for assessment of cartilage was performed by looking for any obvious loss of joint space when compared with the opposite side. Functional scoring was done using the Musculoskeletal Tumor Society score, which was obtained from chart review. Oncologic assessment was determined for local recurrence as well as metastases. RESULTS Median surgical time was 8.6 hours and median blood loss was 2250 mL. There were no perioperative wound-related complications. Two patients underwent a second surgical procedure during the postoperative period, one for a femoral artery thrombus and another for a complete sciatic nerve deficit. No patients developed avascular necrosis of the femoral head. None of the patients who underwent osteoarticular grafting showed radiographic evidence of joint space narrowing. The median Musculoskeletal Tumor Society score was 28 (range, 17-30). No fractures in the radiated segment of reimplanted bone were seen in this small series. CONCLUSIONS Results from this small series suggest that ECRT is a potential option in selected patients who have good bone stock and adequate soft tissue coverage. Although technically challenging, ECRT is a low-cost alternative to prostheses in providing a mobile and stable hip. Although we did not observe cartilage wear on plain radiographs, followup here was short term; it may appear as we continue to follow these patients. Future studies from retrieval specimens may shed light on the actual status of cartilage on the acetabulum. LEVEL OF EVIDENCE Level IV, therapeutic study.

BACKGROUND: Although giant cell tumors (GCTs) are benign, their aggressiveness and tendency to recur locally challenge the orthopaedic surgeon’s ability to perform joint-preserving intralesional surgery with an acceptably low risk of local recurrence. Denosumab has emerged as a possible medical treatment of GCT because it seems to halt the progression of GCT, alleviate pain, and increase perilesional bone formation, but its exact role has been questioned, and specifically its efficacy and associated complications are not well characterized. QUESTIONS/PURPOSES: (1) Does denosumab reduce the risk of recurrence after resection or intralesional surgery? (2) What are the complications associated with the use of denosumab? METHODS: Fifty-four patients with 30 primary and 25 recurrent tumors between November 2013 and July 2016 were treated with denosumab after a confirmed histopathologic diagnosis of GCT. Another 17 patients in the same period were treated without denosumab. During the study period, we encouraged the use of denosumab in all patients except those who refused, could not afford it, or where it was contraindicated (eg, in pregnancy). In all patients undergoing intralesional surgery, we arbitrarily planned six doses before surgery. Variations in total doses before surgery were dependent on patient-related factors; in some, we gave less doses because patients expressed the inability to afford any more doses, whereas in some patients, extra doses were added when the patient wished to delay surgery as well as the because of surgeon judgment wherein in some patients, we stopped before six doses when we thought adequate bone had formed for intralesional curettage. The mean number of doses was 6.8 per patient (median, 6; range, 3-17) preoperatively. The minimum followup was 12 months (median, 27 months; range, 12-42 months). Every patient showed improvement clinically in terms of pain and halting of tumor progression within three to four doses. This was seen radiologically as a sharply defined soft tissue mass as well as hazy ossification within the tumor. For a case-matched comparison study, we identified controls as 34 patients undergoing curettage from the retrospective analysis of 68 patients curetted without denosumab between February 2010 and July 2016 matched to 25 denosumab-treated patients in terms of site, size, Campanacci grade, and recurrent versus primary status, and with a minimum 2 years followup for the control group. Fisher’s exact test was used for statistical study. Patients undergoing resection were planned for surgery after three doses of denosumab to allow the tumor to solidify and potentially decrease tumor spillage at the time of surgery. The resections could not be case-matched for comparison owing to the smaller numbers. RESULTS: We observed 14 recurrences out of the 37 curetted tumors (38%). In the case-matched analysis, 11 of 25 patients in the denosumab-treated curettage group had recurrences (44%) compared with seven of 34 (21%) in the nondenosumab-treated control group. The risk of denosumab-treated patients experiencing local recurrence as compared with the nondenosumab-treated patients was nonsignificant with a two-tailed p value of 0.085 (significance at p < 0.05) as derived from Fisher’s exact test (odds ratio, 3.03; 95% confidence interval, 0.96–9.54). There was no recurrence in the resection group. Because we do not have a control group for resection, we are unable to comment on the importance of this finding. One major complication that we observed was a recurrence with malignant transformation in a patient with a proximal humeral GCT. We did not observe any other complications related to the denosumab therapy. CONCLUSIONS: Although we could not demonstrate a higher risk of local recurrence with preoperative denosumab for intralesional surgery in the dose and frequency we administered, we advise caution in its routine use for intralesional procedures because it may be important to curette up to margins on pretreatment imaging owing to the potential residual tumor within the denosumab-mediated thick bony shell, which may result in local recurrence. We believe that denosumab treatment before resection of a large tumor aids resection without tumor spillage, particularly where important structures like the neurovascular bundle are dissected away from the tumor margin, although we cannot confirm that it helps lower the incidence of recurrence. We are concerned regarding the malignancy-causing potential from our observation in one patient as well as reports of this by others and recommend judicious use of this drug in patients with GCT. LEVEL OF EVIDENCE: Level III, therapeutic study.

Introduction. Limb salvage surgery following proximal ulna resection poses a challenge in reconstruction of the complex elbow anatomy. Various reconstruction methods described offer inadequate restoration of function and stability. Following resection of proximal ulna tumors, we aimed to restore the joint using the resected osteochondral segment of proximal ulna treated with extracorporeal irradiation and reimplantation. Questions/Purposes. (1) Does irradiated osteoarticular autograft reconstruction for proximal ulna allow anatomical joint restoration and what are the oncological and functional outcomes? (2) Is there evidence of graft-related complications or osteoarthritis at a minimum of 2 years follow-up with irradiated osteoarticular autografts for the proximal ulna? (3) How does our method of reconstruction fare as compared to reported reconstruction options in the literature? Materials and Methods. 3 patients with primary bone tumors involving the proximal ulna underwent limb salvage surgery with en bloc resection and reconstruction using the resected bone after treating it with extracorporeal irradiation of 50 Gy. Minimum follow-up of 2 years was considered for assessment of final outcomes. Radiographs were assessed for bony recurrence, union across osteotomy junction, and signs of joint arthritis. Functional outcome measures included range of movement, muscle power testing, and functional and disability scores. Results. 2 complete and 1 partial olecranon involving proximal ulnar resections were performed for three cases of Ewing’s sarcoma in 2 males and 1 female. Follow-up ranged from 28 to 42 months, and all patients continue to remain disease free. All 3 patients have achieved full range of flexion-extension and pronosupination movement in comparison to the contralateral side. Muscle power for flexion and extension was 5/5. MSTS score: 100% (30/30); MEPS score: 100; and DASH score: zero were achieved for all patients. Union across osteotomy junctions at median follow-up of 8 months without need for intervention/bone grafting was achieved. No complications related to joint laxity/subluxation, infection, graft fracture, or implant failure was noted. None of the patients have clinical or radiological signs of joint arthritis across the irradiated articulation. Conclusion. Biological restoration of elbow anatomy using osteoarticular irradiated graft for proximal ulna reconstruction offers great joint stability and functional outcomes. Although the potential risks of infection and graft failure need to be considered, reconstruction with the size-matched radiated autograft eliminates donor site morbidity, offers a low-cost alternative to endoprosthesis, and provides outcomes superior to any other methods of reconstruction as analyzed from the literature.

Bone sarcomas are rare tumors, approximating 0.2% of all cancers, with osteosarcoma (OGS), chondrosarcoma, and Ewing sarcoma being the most common cancers in this subset. The formation of disease management groups/clinics focused on sarcomas has resulted in better understanding and management of these uncommon tumors. Multiple large-scale retrospective data from Tata Memorial Hospital (TMH) and All India Institute of Medical Sciences have reported outcomes comparable to Western data in the field of OGS and Ewing sarcoma, with interesting prognostic factors identified for further evaluation. Soft tissue sarcomas are a rare heterogeneous group of tumors, more than 50 different tumor entities. The common subtypes identified in India include Ewing sarcoma and synovial sarcoma. Valuable work regarding brachytherapy has been done by radiation oncologists from the TMH, especially in pediatric patients.

BackgroundThiazide and thiazide-like diuretic agents are being increasingly used at lower doses. Hydrochlorothiazide (HCTZ) in the 12.5-mg dose remains the most commonly prescribed antihypertensive agent in the United States.ObjectivesThis study compared chlorthalidone, 6.25 mg daily, with HCTZ, 12.5 mg daily, by 24-h ambulatory blood pressure (ABP) monitoring and evaluated efficacy. Because HCTZ has been perceived as a short-acting drug, a third comparison with an extended-release formulation (HCTZ-controlled release [CR]) was added.MethodsThis 12-week comparative, double-blind, outpatient study randomized 54 patients with stage 1 hypertension to receive either chlorthalidone, 6.25 mg, (n = 16); HCTZ 12.5 mg (n = 18); or HCTZ-CR 12.5 mg (n = 20). ABP monitoring was performed at baseline and after 4 and 12 weeks of therapy.ResultsAll 3 treatments significantly (p < 0.01) lowered office BP at weeks 4 and 12 from baseline. At weeks 4 and 12, significant reductions in systolic and diastolic 24-h ambulatory and nighttime BP (p

Objective: The aim of this study was to investigate the root and canal morphology of maxillary third molars in Central India population using cone-beam computed tomography (CBCT) analysis. Materials and Methods: CBCT images of 116 maxillary third molars were observed, and data regarding the number of roots, the number of canals, and Vertucci's Classification in each root was statistically evaluated. Results: Majority of Maxillary third molars had three roots (55.2%) and three canals (37.9%). Most MB root (43.8%), DB root (87.5%), and palatal root (100%) of maxillary third molars had Vertucci Type I. Mesiobuccal root of three-rooted maxillary third molars had Vertucci Type I (43.8%) and Type IV (40.6%) configuration. Overall prevalence of C-shaped canals in maxillary third molars was 3.4%. Conclusion: There was a high prevalence of three-rooted maxillary molars with three canals.

Background: Because nearly 23,000 more neurosurgeons are needed globally to address 5 million essential neurosurgical cases that go untreated each year, there is an increasing interest in task-shifting and task-sharing (TS/S), delegating neurosurgical tasks to nonspecialists, particularly in low- and middle-income countries (LMICs). This global survey aimed to provide a cross-sectional understanding of the prevalence and structure of current neurosurgical TS/S practices in LMICs. Methods: The survey was distributed to a convenience sample of individuals providing neurosurgical care in LMICs with a Web-based survey link via electronic mailing lists of continental societies and various neurosurgical groups, conference announcements, e-mailing lists, and social media platforms. Country-level data were analyzed by descriptive statistics. Results: The survey yielded 127 responses from 47 LMICs; 20 countries (42.6%) reported ongoing TS/S. Most TS/S procedures involved emergency interventions, the top 3 being burr holes, craniotomy for hematoma evacuation, and external ventricular drain. Most (65.0%) believed that their Ministry of Health does not endorse TS/S (24.0% unsure), and only 11% believed that TS/S training was structured. There were few opportunities for TS/S providers to continue medical education (11.6%) or maintenance of certification (9.4%, or receive remuneration (4.2%). Conclusions: TS/S is ongoing in many LMICs without substantial structure or oversight, which is concerning for patient safety. These data invite future clinical outcomes studies to assess effectiveness and discussions on policy recommendations such as standardized curricula, certification protocols, specialist oversight, and referral networks to increase the level of TS/S care and to continue to increase the specialist workforce. Key words: Capacity, Global health, Global neurosurgery, LMIC, Task-sharing, Task-shifting, Workforce

Aim: To highlight radiological features and emphasize the need for tissue diagnoses to confirm bone pathology. Tuberculosis is known to present without constitutional symptoms and with unconventional imaging features mimicking sarcomas as shown in our series of 25 patients; where the imaging and biopsy protocols at our institute helped to solve these diagnostic dilemmas. Material and methods: We retrospectively analyzed clinical and radiological features and tissue diagnoses in 25 patients referred to the department of orthopedic oncology with radiological suspicion of tumor. Results: Only 7 patients had cultures positive for Mycobacterium Tuberculosis T.B. Radiological features suggestive of infection were Metaphyseal and joint involvement, permeative lesions, absence of Codman’s triangle, and soft tissue mass suggestive of a cold abscess. The predictive accuracy of the orthopedic oncologist was 60% and musculoskeletal radiologist was 72% (based on radiology). Final diagnosis is 100% confirmed on histopathology. Conclusion: Diagnosis based primarily upon imaging is a wrong approach. A multimodal approach to differentiating tuberculous bone infections from sarcomas is essential.

Introduction The major neoplastic and proliferative component of GCTB is the stromal tumor cells; that they have shown no evidence of bone destruction, instead the massive tissue destruction appears to be a result of tumor induced osteoclastogenesis. The discovery of receptor activator of nuclear factor kB (RANK) and RANK binding ligand (RANKL) uncovered the bone homeostasis and molecular mechanism by which multiple compounds (including vitamin D) regulated osteoclast differentiation; a function mediated by osteoblastic cells and osteoclast-precursor cells. Hypothesis In a country burdened by vitamin D deficiency, causal relation between hypovitaminosis D and GCTB was hypothesized based on the vitamin D mediated RANKL expression and osteoclastogenesis, as India is also a population with higher incidence of GCTB as compared to Western populations described in the literature. The possibility of vitamin D regulated osteoclastogenesis in GCTB is postulated on the evidence from molecular research linking it to the RANK/RANKL/OPG pathway. The aim of this study was to analyse the prevalence of Vitamin D deficiency in patients with primary GCTB and to elucidate any difference in serum Vitamin 25(OD)D3 levels amongst the matched control population data. Materials and results 130 patients of primary GCTBs were matched to 310 controls from the general health check population and serum levels of 25(OH)D3 were analyzed. Statistical analysis performed on the non-parametric data and Mann Whitney U Test used to derive inference with significance set at p 56 females and 76 males with median Vitamin D level in the GCTB group was 15.9 ng/ml (Mean 19.41; Range 1.03 to 92) as compared to the control population with median level of 22.2 ng/ml (Mean 25.1; Range 2.6 to 87.9). The results were significant (p value Discussion The differential expression of RANKL and OPG in response to levels of vitamin D has been established. The stromal cells of osteolytic GCTB express high levels of RANKL, which is a key signal regulator in development of this disease and bone destruction typical of GCTBs. This has resulted in research targeting this pathway for therapeutic approach in GCTBs. As vitamin D supplementation is simple and safe, increased awareness to assess and if necessary correct vitamin D status of patients is warranted, however the question as to whether patients with low vitamin D levels are more prone to develop GCTB and thus would profit from vitamin D supplementation remains unanswered. To conclude, it is essential to assess vitamin D levels in patients with GCTB as deficiency is pronounced. Future research on this hypothesis might lead to an association between Vitamin D deficiency and the onset/natural history of GCTB that may in the future help us cure or prevent GCTBs.

To evaluate the efficacy and safety of atorvastatin + hydroxychloroquine fixed-dose combination tablets in comparison with atorvastatin alone in treatment of dyslipidemia.This double-blind, randomized, out-patient study was conducted in 328 patients with primary dyslipidemia having low-density lipoprotein cholesterol (LDL-C) ≥ 130 mg/dL (3.37 mmol/L) to ≤ 250 mg/dL (6.48 mmol/L) and triglycerides ≤ 400 mg/dL (4.52 mmol/L). Eligible patients were randomized to receive either atorvastatin 10 mg (n = 167) or atorvastatin 10 mg + hydroxychloroquine 200 mg (n = 161) for 24 weeks.CTRI/2010/091/006138.To compare percentage change in LDL-C, total cholesterol (TC), triglycerides, high-density lipoprotein cholesterol (HDL-C) and non-high-density lipoprotein cholesterol (non-HDL-C) from baseline to Week 12 and Week 24 between groups. To compare mean change in glycated hemoglobin (HbA1c), fasting blood glucose (FBG), high-sensitivity C-reactive protein (Hs-CRP), and percentage of patients achieving lipid goals at Week 12 and Week 24.At Week 24, percentage reduction in LDL-C (-32.52 [-36.13 to -28.91] vs -39.54 [-43.25 to -35.83]; p = 0.008), TC (-24.41 [-27.10 to -21.72] vs -29.30 [-32.07 to -26.54]; p = 0.013), and non-HDL-C (-30.37 [-33.71 to -27.04] vs -36.76 [-40.18 to -33.33]; p = 0.009) was significantly greater in combination treated patients. Both the treatments showed a significant reduction in triglycerides at Week 24 from baseline, however, this reduction was not statistically significantly different between treatment groups. No significant change in HDL-C was observed in patients from both the treatment groups. At Week 24, change in HbA1c (0.22 [0.07 to 0.37] vs -0.13 [-0.28 to 0.03]; p = 0.002) and FBG was also statistically significant in favor of combination therapy (0.37 [0.07 to 0.67] vs -0.29 [-0.59 to 0.03]; p = 0.003), whereas no statistically significant difference was observed in change in Hs-CRP (p = 0.310). Significantly more patients from the combination group achieved LDL-C and TC goals. Exploratory analysis in patients with pre-diabetes showed development of diabetes in 8 patients (15.09%) from the monotherapy group and 1 patient (1.96%) from the combination group (p = 0.034). Study medications were generally safe and well tolerated.Based on study results and widely reported pleiotropic benefits, hydroxychloroquine could emerge as a potential drug for combination with statins for treatment of dyslipidemia. Long duration studies with larger sample sizes are required to further explore the role of hydroxychloroquine as adjunct to statins in reducing risk of cardiovascular events and prevention of statin-induced diabetes.

Skeletal metastasis is a common cause of severe morbidity, reduction in quality of life (QOL) and often early mortality. Its prevalence is rising due to a higher rate of diagnosis, better systemic treatment, longer lives with the disease and higher disease burden rate. As people with cancer live longer and with rising sensitivity of body imaging and surveillance, the incidence of pathological fracture, metastatic epidural cord compression is rising and constitutes a challenge for the orthopedic surgeon to maintain their QOL. Metastatic disease is no longer a death sentence condemning patients to "terminal care." In the era of multidisciplinary care and effective systemic targeted and nontargeted therapy, patient expectations of QOL, even during palliative end of care period is high. We lay emphasis on proving the diagnosis of metastasis by biopsy and histopathology and discuss imaging modalities to help estimate fracture risk and map disease extent. This article discusses at length the evidence and decision-making process of various modalities to treat skeletal metastasis. The modalities range from radiation including image-guided, stereotactic and whole body radiation, systemic targeted or hormonal therapy, spinal decompression with or without stabilization, extended curettage with stabilization, resection in select cases with megaprosthetic or biological reconstruction, percutaneous procedures using radio frequency ablation, cementoplasties and discusses the role of emerging modalities like high frequency ultrasound-guided ablation, cryotherapy and whole body radionuclide therapy. The focus lies on the role of multidisciplinary care, which considers complex decisions on patient centric prognosis, comorbidities, cost, feasibility and expectations in order to maximize outcomes on QOL issues.

Background: Mastalgia is one of the most common presenting symptoms of benign breast diseases, which may be cyclical or continuous. Mastalgia is the commonest breast symptom presenting in surgical clinics. FNAC has been employed in diagnosis of benign breast disease (BBD) doubts still exist upon its accuracy and reliability. However its accuracy has been compared to clinical examination and mammography in diagnosing BBD. To study cytomorphological findings in women aged 15-35 years suffering from cyclic mastalgia presenting to our OPD is the main objective of the present study. Methods: Women 94 in number age between 15 years-35 years of attending the outpatient department with complain of pain in breast were initially included in the study. Out of this 72 cases were deemed fit for study as they fulfilled the criteria mentioned in material and method. Results: We found that fibroadenosis alone constitutes 58.3% of all cases of cyclical mastalgia and is the most common cause of cyclical mastalgia in women presenting to OPD. Conclusions: Fibroadenosis is most common cause of cyclical mastalgia in women aged 15-35 years which is due to Hormonal disturbances unlike non-cyclical mastalgia.

Introduction: One of the aims of root canal treatment is to prevent or eliminate pain. Postoperative endodontic pain control continues to be a significant challenge. Aim: To compare and evaluate the effect of single oral dose of 100 mg of tapentadol, 400 mg of etodolac, or 10 mg of ketorolac as a pretreatment analgesic for the prevention and control of postoperative endodontic pain in patients with symptomatic irreversible pulpitis. The incidence of side effects was recorded as secondary outcome. Materials and Methods: Sixty emergency patients with moderate to severe pain, diagnosed with symptomatic irreversible pulpitis were randomly allocated (1:1:1) to any of the three groups; tapentadol, etodolac, or ketorolac. Medications were administered 30 min before beginning of the endodontic treatment. Patients recorded pain intensity on 10 cm visual analog scale (VAS) after treatment, for upto 24 h. Results: At 24 h, mean ±standard deviation (SD) of VAS scores (in cm) for tapentadol, etodolac, and ketorolac were 0.89 ± 0.83, 2.68 ± 2.29, and 0.42 ± 0.69, respectively. Kruskal-Wallis (K-W) test showed significant difference among the three groups (P = 0.001). Mann-Whitney test showed significantly lower VAS scores in tapentadol and ketorolac than etodolac group (P = 0.013 and 0.001, respectively). Conclusions: Single oral dose of 10 mg of ketorolac and 100mg of tapentadol as a pretreatment analgesic significantly reduced postoperative endodontic pain in patients with symptomatic irreversible pulpitis when compared to 400 mg of etodolac.

Primary tumors of the sacrum are difficult to manage, as they often require morbid resections and complex reconstructions. In the case of tumors such as chordoma or chondrosarcoma, aggressive resections are often required to achieve appropriate margins (extending disease-free survival), followed by complex reconstructions. These reconstructions are aimed at restoring the pelvic ring and have traditionally resulted in a lumbosacral construct that utilizes structural allograft/autograft bone (fibula most commonly used) and more recently, reconstruction with 3D-printed custom sacral prostheses. While there are no reports of anatomical reconstruction using sacral allografts, extracorporeal radiation therapy (ECRT) and reimplantation provides a size and shape-matched irradiated autograft which avoids the cultural stigma, structural strength and graft-host concerns associated with allografts, as well as the high costs and time to production associated with custom 3D-printed implants. Here we present an illustrative case with technical notes, outlining the steps used at our center for ECRT. While early results with ECRT in the sacrum are promising, future larger studies should be carried out to help detect differences that may exist in long-term complications.

Tumour knee prostheses reconstruct bone gaps, left after resecting the tumour affected tissues, in limb salvage surgeries of bone cancer patients. They typically comprise of 6-12 different components chosen from a family of components that are manufactured in discrete variations (intended to cater to a wide range of patient conditions including gender, tumour position, leg (left/right), and resection length). These variations generate numerous combinations and selecting a correct set of components from a family of 100 or more total components has made the process difficult for a given patient. This article describes an adaptive probabilistic approach developed for selection of tumour knee prosthesis components, driven by geometric details. These details were extracted from the 3D virtual anatomical model, reconstructed from set of CT scan images of patients. The selection was performed in two steps. First, the grossly undersized and oversized components were eliminated. Then the geometric details of components were mapped, with the measured anatomical parameters of the patient, to form a fuzzy-logic based decision tree. This was based on pre-defined rules compiled from surgeons' experience. A set of measures (geometric difference, bone curvature, knee centre shift, and reconstruction length) were used to evaluate the selected prosthesis components. Evaluation was based on their suitability with respect to the patient's anatomy, and classified with a qualitative tag: ‘most suitable’, ‘probably suitable’, or ‘not suitable’. A case study of distal femur replacement is presented to explain the proposed methodology. This approach eliminates the risk of over and under sizing of the prosthesis components and reduces the average inventory to be maintained for each patient.

Low-cost indigenous megaprostheses used in the developing world are prone to mechanical failure but the frequency and causes are not well established.We retrospectively analyzed the causes of failure, particularly design, and suggest changes to reduce the breakage. We also report our experience with revision surgery.We identified 28 breakages in 266 megaprosthetic knee arthroplasties performed between January 2000 and December 2006. Twenty-six breakages were revised to another prosthesis. The complications were studied and the function was evaluated. Prostheses were studied for failure by the computer-aided design program SolidWorks(®) and Hyperworks(®) for finite element analysis (FEA). Design improvements were performed based on these results.In 21 cases, the failure occurred at the stem-collar junction, the point of maximum stress predicted by FEA. Stainless steel implants were prone to failure. There was one early and one late infection. Three patients died of metastatic disease. The most difficult surgical step involved the removal of the well-cemented broken stem from the intramedullary canal. Musculoskeletal Tumor Society scores varied from 27 to 29 after revision. FEA revealed stress could be reduced by filleting the stem-collar junction and by two-piece stems.Revisions of broken total knee megaprostheses, though technically difficult, have allowed patients reasonable function. We recommend design analysis for custom prostheses to point to areas of weakness. Breakages can be reduced by using titanium stems and filleting the junction or by having two-piece inserted stems. Incorporating these changes has reduced the failures in our experience.

Background: Limb salvage in extremity tumors is now established as an oncologically safe option without compromising long-term survival. En bloc resection followed by extracorporeal radiation and reimplantation is a biological reconstruction option in diaphyseal Ewing's sarcomas. We analyzed the results of 12 cases of diaphyseal Ewing's sarcomas treated using this modality. Materials and Methods: Between March 2006 and March 2008, 12 patients with Ewing's sarcoma underwent enbloc resection and reconstruction, with reimplantation of the sterilized tumor bone, after extracorporeal irradiation. There were eight males and four females, with a mean age of 14 years (range 2 to 22 years). The femur was the most common bone involved (n=8) followed by the tibia and the humerus (two cases each). All these patients were non-metastatic at presentation and received chemotherapy as per the existing hospital protocol. The mean length of the bone resected was 20 cm (range 11 to 25 cm). The specimen was irradiated with 50 Gy prior to reimplantation and stabilized with the host bone, using suitable internal fixation. Standard biplanar radiographs were assessed for evidence of union on the follow-up visits. The functional status was assessed using the Musculoskeletal Tumor Society Scoring system at the time of the last follow up. The mean follow up duration was 29 months (range 12 to 57 months). Results: Two patients (17%) had early infection with graft removal, hence are excluded from any analysis of union, however they are included when analysing complications such as infection. Rest 10 cases were analyzed for bony union at the osteotomy sites. Sixteen (84%) of the 19 osteotomy sites united primarily, without any intervention. Implant failure and non-union was seen at three diaphyseal osteotomy sites. The average time for union of all osteotomy sites was 7.2 months (range 3 to 13 months).The average time for union of the metaphyseal osteotomy sites was 5.9 months (range 3 to 12 months) and of diaphyseal osteotomy sites was 8.3 months (range 4 to 13 months). The mean Musculoskeletal Tumor Society Score was 27 (range 19 to 30) with a mean of 27. Nine of the ten patients with lower limb involvement were independent ambulators without additional aids. At the time of the last review, six patients were free of disease and six patients had died from the disease. There were two recurrences around the operative site. Both were associated with disseminated disease and in both the recurrences were in the soft tissue, away from the irradiated graft. Conclusion: Extracorporeal irradiation is a useful, convenient technique for limb salvage in diaphyseal Ewing's sarcomas when there is reasonable residual bone stock. It is oncologically safe and has good functional results. A radiation dose of 50 Gy for sterilizing the bone ensures adequate tumor kill, while minimizing the deleterious effects on the biomechanical and biological properties of the bone. The use of appropriate implants for adequate internal fixation and supplementary bone grafting at the index surgery may help reduce the need for subsequent additional interventions to achieve union. The limitations of this procedure are that it is not applicable in tumor bones that are structurally weak and in bones with pathological fractures.

Skeletal metastasis from a cardiac myxoma is rare. We describe an extremely unusual case of a cardiac myxoma metastasing to the femur in a 46-year-old female presenting with pain in the right hip. Radiographs showed an expansile lytic lesion with pathological fracture involving the neck and proximal shaft of the right femur. Histology revealed features of cardiac myxoma with heterologous glandular elements, which was initially mistaken for a metastatic mucin-secreting adenocarcinoma.

Revision hip arthroplasty can sometimes be very challenging due to poor proximal bonestock following multiple revisions, bone resorption, infection or peri-prosthetic fracture. The challenge for the surgeon is to achieve fixation of the implant distally in healthy bone, yet allow bone in-growth proximally to encourage regeneration of the deficient femur. We present our early experiences with a fully hydroxyapatite coated modular long stems with distal screw locking (REEF, Depuy) in difficult revision scenarios. A total of 21 patients with a mean age of 68 (range 37–86) were followed up for a mean period of 19 months (9–36 months). Revision was performed for aseptic loosening with severe proximal bone loss in 14 cases (67%), peri-prosthetic fractures in 6 cases (28%) and 1 case with infection (5%). Oxford hip score was determined for each patient. Radiographs were assessed for the formation of spot welds, cortical hypertrophy, radiolucent lines, subsidence of implants, calcar resorption and heterotopic ossification. One patient underwent re-revision due to initial undersizing of the stem. Radiological review of all the femoral components, including the one re-revision showed stable bony in-growth and no radiolucent lines in any zone. The incidence of spot weld formation and cortical hypertrophy was highest in zone 6. One patient had persistent thigh pain and subsidence of 2 cm occurred in one case (5%). There were no dislocations, infections or calcar resorption. Three patients developed Grade 1 and three patients developed Grade 2 heterotopic ossification. Improvement in stem design, surface coating, distal locking and modularity allow independent fitting of the diaphysis and metaphysis, adjustment of length, offset and version to facilitate more biological reconstruction of proximal femur. Early results with this stem in salvage revisions appear promising.

To study the role of PET-CT in evaluating sarcomatous transformation in osteochondromas.This was a retrospective analysis of a prospective data base of 12 patients from 2005 to 2007 with a clinical diagnosis of an osteocartilaginous lesion who were referred for a FDG PET-CT study to evaluate for possible malignant transformation. Imaging was performed on a GE Discovery ST PET-CT system after intravenous injection of 370 MBq (10 mCi) of F-18 FDG.Seven patients with histopathological evidence of a sarcomatous transformation to grade II chondrosarcoma showed moderate to high FDG uptake (SUV 3.3-6.9), whereas 1 patient with a dedifferentiated chondrosarcoma showed a focus of very intense uptake (SUV 11.4). Four patients with histopathological and/or clinical or follow-up diagnosis of a benign osteocartilaginous lesion showed low grade FDG uptake (SUV 0.8-1.3). FDG uptake was also noted in an asymptomatic osteochondroma which on histopathology revealed a grade II chondrosarcoma.Whole body FDG PET-CT is an important adjunct to conventional morphologic imaging in evaluating suspected malignant transformation in osteochondromas. Increased glucose metabolism can help diagnose sarcomatous transformation at the suspected sites as well as detect early malignant change at clinically unsuspected sites. Moreover, its ability to detect a focus of dedifferentiation can be useful for prognostication and to plan adjuvant treatment. A small cohort limits statistically sound conclusions to be drawn from this study, however further prospective trials based on these findings can help explore the potential application of FDG PET-CT in this clinical condition.

The Manchester-Modified Disability of Arm, Shoulder and Hand questionnaire (M2 DASH) was developed by the authors as a modification to the original DASH questionnaire. In this study, we assessed the validity, reliability, responsiveness, and bias of the M2 DASH questionnaire for hand injuries using completed M2 DASH, Patient Evaluation Measure, and Michigan Hand Outcome questionnaires from 40 patients. The M2 DASH scores showed significant positive correlations with the Patient Evaluation Measure and Michigan Hand Outcome scores suggesting validity. There was also no evidence of a statistical difference in the M2 DASH scores when the condition had stabilized suggesting good test–retest reproducibility and reliability. The effect size and the standardized response mean for the M2 DASH score were greater than those for the Patient Evaluation Measure and Michigan Hand Outcome scores establishing that the M2 DASH is highly responsive. There was no gender, hand dominance, or dominant side injured bias for the M2 DASH score. There was, however, a relatively weak association between age and the M2 DASH score at presentation. We conclude that the M2 DASH questionnaire is a robust region-specific outcome measure. It is a valid and responsive questionnaire with test–retest reliability proven for hand injuries in this study. Gender, handedness, and side injured did not cause bias in the responses.

We evaluated the results of fibular centralisation as a stand alone technique to reconstruct defects that occurred after resection of tumours involving the tibial diaphysis and distal metaphysis. Between January 2003 and December 2006, 15 patients underwent excision of tumours of the tibial diaphysis or distal metaphysis and reconstruction by fibular centralisation. Their mean age was 17 years (7 to 40). Two patients were excluded; one died from the complications of chemotherapy and a second needed a below-knee amputation for a recurrent giant-cell tumour. A total of 13 patients were reviewed after a mean follow-up of 29 months (16 to 48). Only 16 of 26 host graft junctions united primarily. Ten junctions in ten patients needed one or more further procedure before union was achieved. At final follow-up 12 of the 13 patients had fully united grafts; 11 walked without aids. The mean time to union at the junctions that united was 12 months (3 to 36). The mean Musculoskeletal Tumor Society Score was 24.7 (16 to 30). Fibular centralisation is a durable reconstruction for defects of the tibial diaphysis and distal metaphysis with an acceptable functional outcome. Stable osteosynthesis is the key to successful union. Additional bone grafting is recommended for patients who need postoperative radiotherapy.

Aims and Objectives: We studied 45 patients with chondrosarcoma, without metastasis at diagnosis, who were surgically treated between January 2000 and December 2004 to evaluate the risk factors associated with local recurrence and metastasis. Materials and Methods: Fourteen (31%) patients had had some major prior intervention, either in the form of an open biopsy or a curettage / unplanned excision, before presenting to us. Eight patients had pathologic fractures at presentation. None of the patients received adjuvant chemotherapy or radiotherapy. The follow-up duration ranged from 8-75 months. All survivors had a minimum follow-up of 36 months (range 36-75 months). Results: There were 11 grade 1 (24.5%), 23 grade 2 (51%), and 11 grade 3 (24.5%) chondrosarcomas. Thirty-two (71%) patients had tumors that were larger than 8 cm in the greatest dimension. Margins were adequate in 31 patients. Twenty-five patients had disease relapse; there were four local failures, nine distant failures, and 12 combined failures. At the time of the last review, 12 patients had died, 11 were alive with disease, and 22 were free of disease. The cumulative event-free survival was 44% and the overall survival was 73%. Conclusion: Grade of tumor, size of tumor, and adequacy of resection might be important predictors of outcome. Local recurrence is a prelude to distant metastasis and portends poor ultimate survival. The presence of a pathological fracture could indicate biologically aggressive disease, and limb salvage in these cases should be advised with caution. Even in cases where there has been a prior unplanned intervention, local control can be achieved by subsequent adequate resection.

Posterior dislocation or fracture-dislocation of the shoulder is a rare entity, and is often missed in the Emergency Department. The causes include a tonic-clonic seizure, electrocution, and major trauma. The clinical presentations are often misleading and thus the correct diagnosis may be delayed. Proper imaging of the shoulder in suspected cases is important in making the correct diagnosis. We report a rare case of bilateral posterior fracture-dislocation of the shoulders, which presented in the Emergency Department with clinical features suggestive of a dissecting aneurysm of the thoracic aorta. A review of the relevant literature is also presented.

Metallosis after shoulder replacement has not previously been described in the literature. We report a patient who developed extensive metallosis after implantation of an uncemented Nottingham shoulder replacement. He underwent a revision procedure. Examination of the retrieved prosthesis showed that the titanium porous coating was separating from the humeral stem and becoming embedded in the ultra-high-molecular-weight polyethylene glenoid component, resulting in abrasive wear of the humeral component. There was metallosis despite exchange of the modular humeral head. Both components had to be exchanged to resolve the problem.

Successful management of osteosarcoma with limb salvage surgery is a challenging problem in the developing world. We report our early results with low-cost chemotherapy (without methotrexate) and low-cost limb salvage surgery. We prospectively collected data for 135 patients with histologically proven high-grade osteosarcoma of the extremities given neoadjuvant chemotherapy and treated with limb salvage surgery between January 2000 and February 2004. A locally designed and fabricated stainless steel customized megaprosthesis was used in 78 patients. Disease status and function was evaluated at followup ranging from 24 to 72 months. Followup data were available for 120 of the 135 patients. There were eight infections, four prosthesis breakages and three loosenings. Eighteen patients had local recurrence; 17 of these patients also developed lung metastases. Seventy-three patients (61%) were disease-free at followup. The group of 34 patients with 100% necrosis had better disease-free survival (79%). According to a modified Enneking system, the average functional score was 25.5 of 30 (85%) for the lower extremity and 20 of 30 (66%) for the shoulder. Our preliminary results suggest osteosarcoma can be managed well in a developing country in a cost-effective way. Limb salvage surgery has now become the standard of care.

In malignant surface tumors, hemicortical excision in select cases may allow adequate margins with better function. We treated 10 of 22 malignant surface tumors with hemicortical excision and reconstruction from January 2000 to June 2003. There were eight conventional parosteal osteosarcomas, one high-grade surface osteosarcoma, and one surface chondrosarcoma. Six tumors occurred in the femur, two in the tibia and one each in the humerus and radius. Defects were reconstructed with allograft (five), fibula autograft (three), or autogenous iliac crest (two). Internal fixation as suitable was used. Margins were reported uninvolved in all cases. At followup ranging from 40 months to 61 months we observed no local recurrence. Using the MSTS scoring system, six patients had a maximum possible score of 30; the other four had a score of 29. None developed distant metastasis. Though a longer followup is ideal, in selected cases hemicortical excision appears a reasonable procedure that obviates joint replacement. Biological reconstruction with bone could help reduce the incidence of subsequent revision surgery that would likely occur in cases treated initially with conventional excision and replacement with megaprostheses or circumferential intercalary allografts.

Gossypiboma, an iatrogenic mass lesion caused by a retained surgical sponge is an extremely rare event following musculoskeletal procedures. This entity is therefore a very unusual experience and can create considerable confusion. Unsuspecting surgeons may thus be caught out by this unlikely presentation. We present our experience with a recurrent gossypiboma in the thigh occurring several years after surgical evacuation of a similar gossypiboma from the same anatomic location with interval resolution of symptoms. The purpose of this case report is to highlight the possibility of a "recurrent" soft tissue mass occurring for reasons other than a neoplasm. In the absence of a definitive biopsy diagnosis of tumor in patients who have undergone prior surgical procedures in that area, it may be more prudent to adopt a conservative surgical resection rather than a conventional radical resection as warranted by the dramatic clinical presentation mimicking a soft tissue sarcoma.

Aims: The aim of this study was to evaluate the number of intracanal bacteria extruded apically during root canal preparation using rotary ProTaper, K3XF, twisted, and hand K-file system. Subjects and Methods: Seventy extracted single-rooted human mandibular premolar teeth were used. Access cavities were prepared and the teeth were mounted in glass vials. Root canals were then contaminated with a pure culture of Enterococcus faecalis (ATCC 29212) and incubated at 37°C for 24 h. The contaminated roots were divided into four experimental groups of 15 teeth each and one control group of 10 teeth. Group 1: ProTaper; Group 2: K3XF; Group 3: Twisted file; Group 4: Hand K-file; Group 5: Control group. Bacteria extruded from the apical foramen during instrumentation were collected into vials. The microbiological samples were incubated in culture media for 24 h. Colonies of bacteria were counted and the results were given as number of colony-forming units (CFU)/ml. Statistical Analysis Used: The obtained data were analyzed using the Kruskal–Wallis one-way analysis of variance and Mann–Whitney U-tests. Results: There was a significant difference between the rotary and hand instrumentation system related to the apically extruded intracanal bacteria. Conclusions: Both the rotary and hand instrumentation systems extruded intracanal bacteria through the apical foramen. K3XF file system showed least bacterial extrusion amongst all instrumentation groups.

Purpose It is very difficult to cement intramedullary canals smaller than 10 mm with standard commercially available cement syringes due to mismatch in canal and syringe diameters. This is often encountered in children and in the upper limb. We describe a simple method of cementing, using cement gun with size-matched plastic endotracheal tube (ET). Methods The medullary canal is prepared and the size determined. ET with outer diameter 0.5–1 mm smaller than the canal diameter is chosen. The standard cementing syringe nozzle is cut at the middle and fitted to Portex® tube with the adaptor connector, which comes with the ET. The plastic ET is cut to an appropriate length depending on canal length to be cemented. The nozzle is fitted to the syringe and cementing done in the usual way. We applied this new modification in the method to cement narrow canals of ulna, humerus, tibia and femur. Results The method has proven to be consistently reliable and useful in cases of cementing stems into bones with narrow intramedullary diameters. Apart from femur and tibia in children, humerus and ulna in adults were also cemented. The cement mantle by this technique is uniform and uninterrupted. Special care should be taken to fit the connector properly to the syringe nozzle and to hold it firmly while cementing. Conclusions In our experience, this new technique has proven to be very useful, easy to use, reproducible and effective in cementing narrow canals.

The goal of this study was to evaluate the efficacy of temporary interstitial brachytherapy (BRT) for patients undergoing combined modality management of soft tissue sarcomas (STS).From January 1990 to December 2003, 155 adults 18-88 years of age (median = 42 years) with STS who had received BRT as part of locoregional treatment were included in this review. Sixty-four percent were males. Sixty-nine percent had primary lesions. Sixty percent had lesions involving the lower extremities. Spindle cell sarcoma (28%) and synovial sarcoma (16%) were the most common histologic types and 51% had grade III lesions. Treatment included wide local excision of primary tumor with BRT with or without external beam radiotherapy (EBRT).After a median followup of 45 months, the local control (LC), disease-free survival (DFS), and overall survival (OS) for the entire cohort was 71%, 57%, and 73%, respectively. DFS was superior for superficial tumors compared with that for deep tumors (96% vs. 54%, P =.02). Patients with a tumor less than 5 cm had superior OS (88% vs. 63%, P =.05). Cumulative radiotherapy dose greater than 60 Gy had a significant positive impact on LC (P = .003), DFS (P =.003), and OS (P =.048). Subcutaneous fibrosis (21%) was the major complication.Temporary perioperative iridium-192 interstitial BRT with or without EBRT after function-preserving surgery results in satisfactory outcome in patients with STS. Both low dose rate and high dose rate BRT are equivalent in terms of disease control and complications when used alone or in combination with EBRT. BRT results in fewer complications compared with the combination of BRT and EBRT.

The purpose of this study was to evaluate and assess the sporting and physical activities of patients who had undergone an Oxford medial unicompartmental knee arthroplasty (UKA). Seventy-six patients who underwent a UKA between 2000 and 2003 were reviewed. Demographic data such as age, sex and comorbidities were recorded. University of California Los Angeles (UCLA) activity level ratings and Oxford knee scores were determined for each patient. The sporting and physical activities of all patients' pre- and post-operatively were recorded. The mean age of patients was 64 years (range 49-81) at surgery and 66 years (range 53-82) at review. The mean follow up time was 18 months (range 4-46). Following surgery there was a significant improvement in UCLA activity level scores from 4.2 to 6.5 (Wilcoxon Matched-pairs Signed-rank Test, p

A 26-year-old female with a tibial lesion diagnosed as an adamantinoma was treated with intra-lesional curettage, bone grafting and intra-medullary nailing. Six years post-surgery, she presented with an asymptomatic primary site but with a metastatic lesion in the mid-shaft of the ipsilateral femur and lung metastases. The femoral lesion was treated with wide excision and reconstructed with an allograft and plate fixation. Pulmonary metastatectomy was carried out for the lung lesions. A follow-up CT scan of the chest at 1 year after the surgery for the metastatic lesions revealed fresh unresectable bilateral metastases. Although cases of local recurrences and pulmonary metastases in adamantinoma are reported, this case is unusual in presenting without a local recurrence but with simultaneous skeletal and pulmonary metastases.

Background Adamantinoma is a rare tumor of long bones that can be mistaken for a carcinoma, and numerous other lesions such as myoepithelial tumor, malignant mixed tumor of bone, fibrous dysplasia/osteofibrous dysplasia, and vascular tumors. Methods The histology and clinical features of 12 cases accrued from the surgical pathology files over a period of 23 years were analyzed. Results Of the 12 cases, 4 were men and 8 women, with a mean age of 30 years. Radiologically the tumor presented as a lytic, eccentric, intracortical lesion in the tibia. The histology revealed epithelial islands with basaloid, spindle, and squamous features on a background of fibrotic stroma. Three patients came back with local recurrences, and one of them developed pulmonary metastasis. Discussion In this article, an attempt is made to study the morphology, biology, and the differential diagnoses of adamantinoma of long bones. J. Surg. Oncol. 2006;93:429–433. © 2006 Wiley-Liss, Inc.