Search

Toshiyuki Takemori,1 Teruya Kawamoto,1,2 Hitomi Hara,1 Naomasa Fukase,1 Shuichi Fujiwara,1 Kazumichi Kitayama,1 Shunsuke Yahiro,1 Tomohiro Miyamoto,1 Yutaka Mifune,1 Yuichi Hoshino,1 Kenichiro Kakutani,1 Tomoyuki Matsumoto,1 Takehiko Matsushita,1 Takahiro Niikura,1 Ryosuke Kuroda,1 Toshihiro Akisue1,3 1Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan; 2Division of Orthopaedic Surgery, Kobe University Hospital International Clinical Cancer Research Center, Kobe, Japan; 3Department of Rehabilitation Science, Kobe University Graduate School of Health Sciences, Kobe, JapanCorrespondence: Teruya Kawamoto, Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan, Tel +81-783825985, Fax +81-783516944, Email trykwmt@med.kobe-u.ac.jpPurpose: Soft tissue sarcomas (STSs) constitute a group of rare, heterogeneous tumors representing approximately 1% of all cancers. Owing to the rarity and pathological diversity of the disease, unplanned excision (UE) has often been performed for STS, resulting in an unfavorable prognosis. This study aimed to clarify clinical outcomes and prognostic factors in STS patients who underwent UE.Patients and Methods: In a retrospective review of the medical records of patients with STS who underwent surgery at our institution between 1999 and 2015, patients were enrolled to either a UE group or a planned excision (PE) group. An analysis was then conducted to identify factors associated with prognosis after UE.Results: Of 134 patients undergoing surgery for STS, 110 were enrolled to the PE group and 24 to the UE group. The median size of the primary tumor was significantly smaller, and more lesions were located in the superficial layer in the UE group than in the PE group. In addition, plastic reconstruction after additional radical resection was required significantly more often in the UE group than in the PE group. No significant difference in overall survival, local recurrence-free survival, or disease-free survival (DFS) between the UE and PE groups was observed; however, metastasis-free survival was significantly better in the UE group. In the UE group, poorer DFS was associated with older age (≥ 61 years) and a larger primary tumor (≥ 2.9 cm).Conclusion: A prognosis similar to that in patients undergoing PE could be achieved by appropriate additional surgeries in patients initially undergoing UE. However, UE for STS should be avoided, especially in older patients and those with a larger primary tumor.Keywords: unplanned excision, soft tissue sarcoma, survival, prognostic factor

In this study, we observed the germination behaviour of airborne conidia from powdery mildews that settle on thalloid surfaces. We inoculated thalli (flat, sheet-like leaf tissues) and gemmae (small, flat, sheet-like leaf tissues that propagate asexually via bud-like structures) of the common liverwort ( Marchantia polymorpha) with conidia from tomato powdery mildew ( Oidium neolycopersici; KTP-02) and red clover powdery mildew ( Erysiphe trifoliorum; KRCP-4N) and examined their germination and subsequent appressorium formation under a high-fidelity digital microscope. Conidial bodies and germ tubes of the inoculated KRCP-4N conidia were destroyed on both the thalli and gemmae. The destruction of these fungal structures was observed only for KRCP-4N conidia inoculated onto M. polymorpha on both leaf surfaces. No differences in destruction of the KRCP-4N fungal structures between thalli and gemmae were observed. At 4 h post-inoculation, destruction of the germ tube tip was observed when it reached the gemmae leaf surface. At 6 h post-inoculation, the conidial bodies and germ tubes were destroyed. In contrast, KTP-02 conidia were not destroyed and formed normal, well-lobed appressoria on the surface of M. polymorpha gemmae. [ABSTRACT FROM AUTHOR]

Purpose: A procedure using an interspinous process spacer (IPS) was recently developed for the treatment of posture-dependent lumbar spinal-canal stenosis (LSS) patients. We developed a novel IPS which can be inserted with simpler procedures and removed percutaneously. The objectives of this study were: (1) to evaluate the feasibility and safety of this novel technique, and (2) to assess the effectiveness of this spacer in terms of preventing an increase of epidural pressure in lumbar extension using a porcine model.Methods: Eight young pigs were used. Under general anesthesia and image guidance, the spacers were inserted. Three months after operation, MR images were taken and all spacers were removed. Blood samples were obtained before and 1, 3, 7 days after surgery. After killing the animals, the lumbar spines were observed macroscopically. Another six animals were used. Under general anesthesia and image guidance, a flexible pressure transducer was inserted into the epidural space and epidural pressure was measured in neutral and at maximum extension with and without spacer insertion.Results: Percutaneous insertion and removal of the spacer was successful for all animals through small skin incisions. MR images showed minimal damage to the muscle. No significant up-regulation of Interleukin-6 (IL-6) and CRP was detected. Macroscopic observation of the lumbar spine 3 months after the operation revealed that the area of the interspinous process contacting with the inserted spacer showed some bone erosion/remodeling. Insertion of the spacer did not affect the epidural pressure in neutral but significantly prevented an increase of epidural pressure in lumber extension.Conclusions: This study demonstrated that the percutaneous insertion and removal of a novel IPS was feasible and safe using a simple technique. Furthermore, this procedure can be recognized as minimally invasive surgery from the viewpoint of skin incision, short insertion track, inflammatory mediators, and muscle damage. Improvements should be attempted in future studies using softer or more elastic materials for the spacer to lessen bone erosion/remodeling at contacting area of the inserted spacer. [ABSTRACT FROM AUTHOR]

RNA interference (RNAi) technology has recently emerged as an important biological strategy for gene silencing. Previously, the efficacies of RNAi in cultured nucleus pulposus cells in vitro have been reported. However, RNAi in the disc in vivo has never been reported. Therefore, the aims of the present study were to establish a method for RNAi in the disc in vivo and to evaluate the applicability of this technique for endogenous genes in the intervertebral discs using Fas Ligand (FasL) as a representative endogenous gene. To evaluate the efficacy of RNAi in vivo, two reporter luciferase plasmids (Firefly and Renilla) were used. These plasmids and unmodified short interference RNA (siRNA) duplex for targeting Firefly luciferase were co-transfected into coccygeal intervertebral disc of Sprague-Dawley rats in vivo using the ultrasound gene transfer technique. To evaluate the RNAi of the endogenous gene in vivo, siRNAs targeting rat FasL were transfected with the same technique. Non-specific siRNA was used as the negative control. The discs receiving no siRNAs were used as the control. The inhibitory effect of Firefly luciferase against Renilla luciferase was obtained using the results of dual-luciferase assay. Down-regulation of endogenous FasL was calculated by the data from real-time PCR. Our results showed that siRNA for Firefly luciferase can dramatically down-regulate the Firefly luciferase gene expression in vivo compared with Renilla luciferase. The inhibitory effects were maintained for at least 24 weeks and at 24 weeks post transfection, the inhibitory rate was 80% compared with the control group. Furthermore, the siRNA co-transfection group inhibited endogenous FasL expression by 53% compared with the control group. The present study demonstrates long-term down-regulation mediated by unmodified siRNA is possible not only for the exogenous reporter gene, but also for endogenous FasL expression in rat discs in vivo. This application of RNAi might be promising as a local therapy for disc degeneration and associated disorders by down-regulating some of the genes that are harmful for the normal physiology of the disc and may cause disc degeneration. [ABSTRACT FROM AUTHOR]

Disc degeneration is deeply associated with many spinal disorders and thus has a significant clinical impact on society. The currently available surgical treatment often necessitates removing a pathological disc and spinal fusion. However, it is also well known that these surgical treatments have many potential problems including invasion and cost. Therefore, biological approaches for regenerating these pathological discs have received much attention. Gene therapy is one of these biological approaches. Gene therapy involves the transfer of genes to cells so the recipient cells express these genes and thereby synthesize the RNA and protein they encode in a continuous fashion. One of the significant advantages of gene therapy is that we can expect a lasting duration of biological effect which is potentially beneficial for most disc degeneration associated disorders, as they are, by nature, chronic conditions. Originally, gene therapy was mediated by viral vectors, but recent technological progress has enabled us to opt for non-virus-mediated gene therapy for the disc. Furthermore, the development of the RNA interference technique has enabled us to down-regulate a specific gene expression in the disc opening the door for a new generation of intradiscal gene therapy. [ABSTRACT FROM AUTHOR]

Virulent bacteriophage PK-101 was isolated from soil infested with strain K-101 of Pseudomonas solanacearum and nucleic acid was prepared from the phages. Some chemical properties of phage nucleic acid and its infectivities to various strains of P. solanacearum were examined in the present study. By digestion with restriction endonucleases, phage nucleic acid was shown to be linear duplex DNA approximately 35 kb long. Restriction fragment length polymorphism was observed when electrophoresis patterns of enzyme-digested PK-101 DNA were compared with those of DNA prepared from different phage isolates. Transfection of host strains by PK-101 DNA was carried out, and it was infectious not only to host strain K-101, but also to other strains which were resistant to phage particles. Transfection efficiency was considerably enhanced by directly introducing phage DNA into bacterial cells by means of an electroporation. The electroporation technique was also effective to transform P. solanacearum with large-size plasmid DNA. [ABSTRACT FROM AUTHOR]

Melanoma is an interesting tumor, showing the appearance of metastasis without any trace of its primary lesion. To report a very rare case of malignant melanoma in the sacrum with unknown primary origin. The authors present a case of a 52-year-old man who was admitted with increasing lower back, left buttock, and left lower extremity pain, and dysuria. Plain radiograph, computed tomography scan, and magnetic resonance imaging revealed a destructive lesion in the sacrum and left ilium, which infiltrated the spinal canal and sacroiliac joint. The tumor cells were immunoreactive for HMB-45. The pathological diagnosis was malignant melanoma. No obvious primary malignant melanoma was detected on the skin surface, on the oral or anal mucosa, or in the fundus oculi. Following radiotherapy and chemotherapy, the severe buttock pain disappeared and the patient was able to walk without impediment. However the patient died nine months after initial diagnosis. Malignant melanoma in the sacrum with an unknown primary site, showing S1 radiculopathy is reported for the first time. The melanoma could have been a metastatic tumor of the sacrum, although the primary site was not detected. The incidence of primary melanoma is increasing faster than any other cancer. Thus treatment of patients with spinal metastasis of melanoma is an important challenge for orthopedic surgeons. [ABSTRACT FROM AUTHOR]

Study Design: Multicenter, prospective registry study., Objective: To clarify minimal clinically important differences (MCIDs) for surgical interventions for spinal metastases, thereby enhancing patient care by integrating quality of life assessments with clinical outcomes., Background: Despite its proven usefulness in degenerative spinal diseases and deformities, the MCID remains unexplored regarding surgery for spinal metastases., Patients and Methods: This study included 171 (out of 413) patients from the multicenter "Prospective Registration Study on Surgery for Metastatic Spinal Tumors" by the Japan Association of Spine Surgeons. These were evaluated preoperatively and at 6 months postoperatively using the Face Scale, EuroQol-5 Dimensions-5 Levels (EQ-5D-5L), including the Visual Analog Scale, and performance status. The MCIDs were calculated using an anchor-based method, classifying participants into the improved, unchanged, and deteriorated groups based on the Face Scale scores. Focusing on the improved and unchanged groups, the change in the EQ-5D-5L values from before to after treatment was analyzed, and the cutoff value with the highest sensitivity and specificity was determined as the MCID through receiver operating characteristic curve analysis. The validity of the MCIDs was evaluated using a distribution-based calculation method for patient-reported outcomes., Results: The improved, unchanged, and deteriorated groups comprised 121, 28, and 22 participants, respectively. The anchor-based MCIDs for the EQ-5D-5L index, EQ-Visual Analog Scale, and domains of mobility, self-care, usual activities, pain/discomfort, and anxiety/depression were 0.21, 15.50, 1.50, 0.50, 0.50, 0.50, and 0.50, respectively; the corresponding distribution-based MCIDs were 0.17, 15,99, 0.77, 0.80, 0.78, 0.60, and 0.70, respectively., Conclusion: We identified MCIDs for surgical treatment of spinal metastases, providing benchmarks for future clinical research. By retrospectively examining whether the MCIDs are achieved, factors favoring their achievement and risks affecting them can be explored. This could aid in decisions on surgical candidacy and patient counseling., Level of Evidence: II., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Prospective multicenter study., Objectives: Palliative surgery is crucial for maintaining the quality of life (QOL) in patients with spinal metastases. This study aimed to compare the short-term outcomes of QOL after palliative surgery between patients with metastatic spinal tumors at different segments., Methods: We prospectively compared the data of 203 patients with spinal metastases at 2-3 consecutive segments who were divided into the following three groups: cervical, patients with cervical spine lesions; thoracic, patients with upper-middle thoracic spine lesions; and TL/L/S, patients with lesions at the thoracolumbar junction and lumbar and sacral regions. Preoperative and postoperative EuroQol 5-dimension (EQ5D) 5-level were compared., Results: All groups exhibited improvement in the Frankel grade, performance status, pain, Barthel index, EQ5D health state utility value (HSUV), and EQ5D visual analog scale (VAS) postoperatively. Although preoperative EQ5D HSUVs did not significantly differ between the groups (cervical, 0.461 ± 0.291; thoracic, 0.321 ± 0.292; and TL/L/S, 0.376 ± 0.272), the thoracic group exhibited significantly lower postoperative EQ5D HSUVs than the other two groups (cervical, 0.653 ± 0.233; thoracic, 0.513 ± 0.252; and TL/L/S, 0.624 ± 0.232). However, postoperative EQ5D VAS was not significantly different between the groups (cervical, 63.4 ± 25.8; thoracic, 54.7 ± 24.5; and TL/L/S, 61.7 ± 21.9)., Conclusions: Palliative surgery for metastatic spinal tumors provided comparable QOL improvement, irrespective of the spinal segment involved. Patients with upper and middle thoracic spinal metastases had poorer QOL outcomes than those with metastases in other segments; however, sufficient QOL improvement was achieved., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Study Design: Multicenter case-control study., Objective: To identify imaging characteristics of the cervical spine in patients with retro-odontoid pseudotumor (ROP) without rheumatoid arthritis (RA) and determine the pathogenesis of ROP., Background: ROP results from proliferative changes in the soft tissue of the atlantoaxial junction surrounding the region of the transverse ligament, and is commonly seen in RA patients. However, the pathogenesis of ROP caused by mechanical instability of the upper cervical spine in patients without RA is yet to be explained., Materials and Methods: We collected imaging data [preoperative radiographs, magnetic resonance imaging (MRI), and computed tomography (CT)] of patients who underwent surgery between April 2011 and March 2022 at the three university hospitals for ROP (cases) and cervical spondylotic myelopathy (as age, sex, and institution matched controls). The two groups were compared for different parameters on cervical dynamic radiographs, MRI, and CT., Results: The ROP group consisted of 42 patients, and the control group comprised 168 patients. C2-C7 range of motion was significantly smaller in the ROP group (25.8 ± 2.6°) compared with the control group (33.0 ± 1.0°). C2-C7 sagittal vertical axis was significantly larger in the ROP group than the control group (39.3 ± 3.6 vs. 32.2 ± 1.3 mm). MRI and CT assessment showed progressive degeneration at all intervertebral levels in the ROP group. A significant positive correlation was observed between the thickness of the soft tissue posterior to the dental process and the atlantodental interval in the flexion position ( r = 0.501)., Conclusions: The development of ROP was associated with degeneration of facet joints and intervertebral disks in the middle and lower cervical spine. Our findings suggest that decreased mobility of the middle and lower cervical spine may cause instability in the upper cervical spine, leading to the formation of ROP., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Pediatric lumbar spondylolysis, a stress fracture of the lumbar spine, frequently affects young athletes, and nonoperative treatment is often the first choice of management. Because the union rate in lumbar spondylolysis is lower than that in general fatigue fractures, identifying risk factors for nonunion is essential for optimizing treatment., Purpose: To determine the risk factors for nonunion after nonoperative treatment of acute pediatric lumbar spondylolysis through multivariate analysis., Study Design: Case-control study; Level of evidence, 3., Methods: We analyzed 574 pediatric patients (mean age, 14.3 ± 1.9 years) with lumbar spondylolysis who underwent nonoperative treatment between 2015 and 2022. Nonoperative treatment included the elimination of sports activities, bracing, and weekly athletic rehabilitation, with follow-up computed tomography. Patient data, lesion characteristics, sports history, presence of spina bifida occulta at the lamina with a lesion or at the lumbosacral spine excluding the lesion level, and lumbosacral parameters were examined. Differences between the union and nonunion groups were investigated using multivariate analysis to determine the risk factors for nonunion., Results: Of the 574 patients, 81.7% achieved bone union. Multivariate analysis revealed that an L5 lesion and the progression of the main and contralateral lesion stages were significant independent risk factors for nonunion. An L5 lesion had a lower union rate than non-L5 lesions. As the main lesion progressed, the likelihood of nonunion increased significantly, and the progression of the contralateral lesion also showed a similar trend. Spina bifida occulta and lumbosacral parameters were not significant predictors of nonunion in this study., Conclusion: We identified the L5 lesion level and the progression of the main and contralateral lesion stages as independent risk factors for nonunion in pediatric lumbar spondylolysis after nonoperative treatment. These findings aid in treatment decision-making. When bone union cannot be expected with nonoperative treatment, symptomatic treatment is required without prolonged external fixation and rest, and without aiming for bone union. Individualized treatment plans are crucial based on identified risk factors., Competing Interests: The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Objective: This study aimed to elucidate postoperative outcomes in patients with spinal metastases of prostate cancer, with a focus on patient-oriented assessments., Methods: This was a prospective multicenter registry study involving 35 centers. A total of 413 patients enrolled in the Japanese Association for Spine Surgery and Oncology Multicenter Prospective Study of Surgery for Metastatic Spinal Tumors were evaluated for inclusion. The eligible patients were followed for at least 1 year after surgery. The Frankel Classification, Eastern Cooperative Oncology Group Performance Status, visual analog scale for pain, face scale, Barthel Index, vitality index, indications for oral pain medication, and the EQ-5D-5L questionnaire were used for evaluating functional status, activities of daily living, and patient motivation., Results: Of the 413 eligible patients, 41 with primary prostate cancer were included in the study. The patient-oriented assessments indicated that the patients experienced postoperative improvements in quality of life and motivation in most items, with the improvements extending for up to 6 months. More than half of the patients with Frankel classifications B or C showed improved neurological function at 1 month after surgery, and most patients presented maintained or improved their classification at 6 months., Conclusion: Surgical intervention for spinal metastases of prostate cancer significantly improved neurological function, quality of life, and motivation of the patients. Consequently, our results support the validity of surgical intervention for improving the neurological function and overall well-being of patients with spinal metastases of prostate cancer., Competing Interests: Declaration of competing interest The Authors declare that there is no conflict of interest., (Copyright © 2024 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Study Design: Retrospective case series., Objective: To report the detailed bone fusion rates and duration of treatment in unilateral and bilateral cases of pediatric lumbar spondylolysis (LS)., Summary of Background Data: Early diagnosis and optimal conservative management for LS are crucial for achieving bony healing without surgery. However, existing research on the conservative treatment of pediatric LS, particularly regarding bone union rates and treatment duration for each stage of bilateral spondylolysis, is limited., Methods: We retrospectively analyzed 590 pediatric patients (522 boys and 68 girls) under 18 years of age diagnosed with LS and treated conservatively from 2015 to 2021. The diagnosis was based on computed tomography scans and magnetic resonance imaging findings, with stages classified as very early, early, progressive, or terminal. Patient background, sports history, level and stage of spondylolysis, presence of spina bifida occulta, bone union rate, duration of conservative treatment, and recurrence rate were retrospectively analyzed., Results: The overall bone union rate was 81.9%, with a mean conservative treatment duration of 53.7 days. Unilateral LS cases showed decreased bone union rates with stage advancement (very early; 98.2%, early; 96.0%, progressive; 64.3%). Bilateral LS cases with progressive or terminal stage demonstrated low bone union rates (very early/very early; 100%, early/very early; 94.1%, progressive/very early; 66.7%, early/early; 82.9%, progressive/early; 32.3%, progressive/progressive; 23.7%, very early/terminal; 0%, early/terminal; 50.0%, progressive/terminal; 11.1%). The duration of conservative treatment extended as the stage of the main and contralateral lesions progressed, ranging from 39.1 days (very early/none) to 105 days (progressive/terminal). The recurrence rate after bone fusion was 16.6%, with no differences based on lesion stage., Conclusions: In this series of 590 patients, conservative treatment yielded high bone union rates for pediatric LS. However, union rates decreased with stage advancement, especially in bilateral cases. These findings provide valuable insights for prognosticating natural history and outcome regarding LS treatment, bone union, and return to activity., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Despite the increasing prevalence of cervical odontoid fractures in older adults, the treatment strategy is controversial. The objectives of the current study are to investigate the prognosis and complications of cervical odontoid fractures in elderly patients and to identify factors associated with worsening of ambulation after 6 months., Methods: This multicenter, retrospective study included 167 patients aged 65 years or older with odontoid fractures. Patient demographic and treatment data were investigated and compared according to the treatment strategy. To determine associations with worsening ambulation after 6 months, we focused on the treatment strategies (nonsurgical treatment [collar immobilization or halo vest], conversion to surgery, or initial surgery) and patients' background., Results: Patients who received nonsurgical treatment were significantly older, and patients who underwent surgery had more Anderson-D'Alonzo type 2 fractures. Of the patients initially treated nonsurgically, 26% later underwent surgery. Numbers of complications, including death, and degrees of ambulation after 6 months did not differ significantly among treatment strategies. Patients who had worsened ambulation after 6 months were significantly more likely to be older than 80 years, to have needed assistance with walking before injury, and to have cerebrovascular disease. Multivariable analysis showed that a score of ≥2 on the 5-item modified frailty index (mFI-5) was significantly associated with worsening ambulation., Conclusions: Preinjury mFI-5 scores of ≥2 were significantly associated with worsening ambulation 6 months after treatment of cervical odontoid fractures in older adults., (Copyright © 2023 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Background: Sacral fatigue fractures are a rare injury but should be considered as a differential diagnosis for low back and buttock pain in young adults. Collective reports are limited, most of which have focused on long-distance runners., Purpose: To investigate the characteristics of sacral fatigue fractures in adolescents., Study Design: Case series; Level of evidence, 4., Methods: We analyzed patient background characteristics, physical examination and imaging findings, and treatment courses of those diagnosed with sacral fatigue fractures using magnetic resonance imaging., Results: Among 34 patients with sacral fatigue fractures, 15 and 19 were male and female patients, respectively, with an age range of 11 to 19 years (mean age, 15.0 years). Almost all patients were athletes, and 29 patients performed their sport ≥5 times a week. Long-distance runners were the most commonly affected, comprising 7 patients, and participants in other common sports such as baseball (6 patients), basketball (4 patients), and soccer (3 patients) were also affected. Physical examination revealed tension sign (Lasègue test) on the affected side in 6 patients and tight hamstrings in 24 patients. Imaging findings included 18 patients with right-side involvement, 12 with left-side involvement, and 4 with involvement on both sides. In 11 patients, spina bifida occulta was observed at S1 and 8 patients had a history of lumbar spondylolysis with 4 patients having concurrent sacral fatigue fractures. Physical therapy was performed concurrently with the cessation of exercise, and return to exercise was permitted if the pain had been relieved after 1 month. All patients returned to sports at a median of 48 days (range, 20-226 days) after symptom onset. However, 2 patients experienced recurrence (1 patient on the ipsilateral side and 1 patient on the contralateral side)., Conclusion: Sacral stress fractures are not limited to long-distance runners in this population and can manifest as lower back pain or buttock pain in athletes participating in a variety of sports. Although the course of treatment was generally good, the possibility of recurrence must always be considered., Competing Interests: The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.