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Introduction/Objective. Chordomas are rare tumors of a notochordal origin. Wide surgical resection is recommended for treatment. However, it is associated with a high risk of morbidity and mortality. Additionally, these tumors are resistant to chemotherapy. Thus, targeted therapy is needed for the treatment of chordomas. Programmed death ligand 1 (PD-L1) is a promising target for cancer treatment. Here, we investigated PD-L1 expression in patients with chordoma in a single-center study. Methods. Formalin-fixed paraffin-embedded blocks were evaluated for immunohistochemical analysis to evaluate PD-L1 expression. Clinicopathological variables, such as sex, age, and follow-up data (recurrence and outcome), were retrospectively collected from the patients’ medical records. Results. Ten patients diagnosed with sacral chordoma in a single institution between December 2015 and November 2021 were included in this study. The median patient age was 57 years and the median follow-up period was 40 months. The surgical margins were negative in all cases, without any preoperative medical treatment. Four of the ten patients showed PD-L1 positivity on immune cells. These patients showed local recurrence, without metastasis. In these cases, the median time to local recurrence was 15 months. All the patients with the disease were alive. Conclusion. This study demonstrated that PD-L1 positivity in immune cells can be used as a predictive marker for local recurrence at the time of surgical treatment. This can potentially be used to determine the necessity to administer immunotherapy.

Introduction/Objective. This study aims to evaluate changes in surgical strategy and orthopedic epidemiology, and to compare the frequency of surgeries before and during the COVID-19 pandemic. Methods. For periods from April 1 to May 31 in years 2019 and 2020, retrospective data on patient demographics and types of orthopedic surgical procedures were obtained from hospital databases in a tertiary referral hospital. Results. During the COVID-19 pandemic, the most common orthopedic surgical procedures performed were trauma surgery (n = 81), while other procedures were referred to oncology (n = 19), biopsy (n = 11), debridement (n = 10), amputation (n = 6), surgery of dysplastic hip (n = 5), and knee ligament repair (n = 1). The majority of trauma cases were hip fracture surgeries (n = 23). The mean age of the patients was 70.5 years. Sixty-three patients were female and 70 were male. Only one patient had a history of COVID-19 infection. In the same period during the year before the pandemic, 86 patients had trauma surgery, while 49 had oncological surgery and the mean patient’s age was 54.5 years. Sixty-two patients in this group were female, and 73 were male. The number of tumor surgeries before the pandemic was higher compared to the same period during the pandemic (p < 0.05). Conclusion. During the pandemic, although all orthopedic surgeries decreased, the rate of osteoporotic hip fractures surgery was similar to that of the pre-pandemic state. This finding emphasizes the increased need to implement preventive measures regarding hip fractures during lockdown periods. The relation of hip and spine osteoporotic fractures surgery was not different before and during the pandemic.

Introduction/Objectives. Bone and soft tissue infections might mimic bone and soft tissue tumors. Therefore, differential diagnosis is important to prevent errors in treatment. This report aims to present the data of patients with indistinct clinical and radiological findings mimicking benign and malignant bone and soft tissue tumors, which were later diagnosed as inflammatory infections. Methods. A retrospective chart review of the clinical, microbiological, radiologic, and pathologic findings of patients presented with a presumed diagnosis of a possible malignant lesion was performed. Results. The study included 21 patients with a median age (IQR) of 37 (1 month – 72 years) years, and 13 (61%) patients were men. In total, 16 (76%) patients were admitted to the hospital with complaints of pain. The diagnoses were hydatid cyst, tuberculous osteomyelitis, cat-scratch disease, chronic osteomyelitis, subacute osteomyelitis, and soft tissue abscess. All patients were treated depending on the diagnosis of the lesion. Conclusion. There are chances of misdiagnosis due to shared common characteristics of tumoral and infectious lesions which might be mildly increased inflammatory markers with deeply seated non-mobile soft tissue masses and aggressive periosteal reactions and/or bone destruction patterns. So, each pseudotumoral lesion due to possible infectious causes should be histopathologically examined and correlated with other clinical and laboratory data in order to achieve a final diagnosis

Introduction/Objective. Sciatica is a disabling pathology with variable etiologies. The most common pathologies arise from discogenic or non-discogenic causes. Mass lesions are a rare cause of extraspinal sciatica, which have been commonly overlooked, leading to unnecessary spinal surgeries, delay in diagnosis or inadequate treatment. There is no standard surgical approach and functional outcomes after surgical treatment of these lesions are not well-known. The aim of this study is to evaluate clinical outcomes after surgical treatment of mass lesions causing sciatica in different locations. Methods. Data were obtained by a retrospective review from 2015 to 2020. The mean duration of symptoms at the time of surgery was 10.3 months (3–48 months). The mean age of patients at the time of surgery was 43.8 years (14–73 years). The mean follow-up was 19.5 months (4–50 months). In total, 14 cases had an extrapelvic localization distal to sciatic notch. The other three cases had lesions in the intrapelvic area, including left sciatic notch (1), right acetabulum (1), sacroiliac and lumbosacral region (1). None of the patients had palpable masses. Transgluteal, infragluteal, lateral, and posteromedial approach were used depending on location and size of the lesion. Results. At the final follow-up, all patients recovered with pain relief. The median musculoskeletal tumor society score was 90% (70–100). There was no recurrence at the latest follow-up. Conclusion. Our study demonstrated that early detection by neurological examination and radiological work-up can avoid unnecessary surgeries, enable early surgical treatment of tumoral mass with satisfactory clinical outcomes. The surgical approach should be individualized according to location and size of the lesion.

Introduction/Objective. Pathologic fractures are devastating complications in metastatic bone disease. Treatment of these condition varies, and includes systemic therapies and surgical interventions. Lack of evidence still exists for standardized care. The aim of this study is to analyze radiological healing response and clinical outcomes after intramedullary nailing (IMN) and adjuvant radiotherapy in complete pathologic fractures of femur or humerus Methods. A total of 19 patients who presented with pathological fracture were retrospectively reviewed. Data regarding demographic characteristics, clinical outcomes and radiologic images were obtained from hospital records. All patients in this cohort were treated with closed, unreamed IMN and adjuvant radiation treatment. Results. Pain relief and full range of motion was obtained in all patients. The mean postoperative Musculoskeletal Tumor Society scores at last follow-up were 69% (range 50–85). All patients demonstrated complete radiographic healing between 2 and 6 months. Only one patient required reoperation for refracture at the tip of the nail which was revised with a longer nail. Conclusion. Our study demonstrated that pathologic fractures managed with closed unreamed IMN and adjuvant multifractional 20 Gy dose radiotherapy yielded good clinical outcomes with complete radiologic response regardless of patient’s life expectancy, adjuvant treatments and overall condition. Closed unreamed IMN was also associated with decreased surgical time in these high-risk patients.

Author(s): Korhan Ozkan [1]; Burak Ozturan [1]; Zilan Karadag [1]; Bulent Erol [2]; Bugra Alpan [3]; Harzem Ozger [4]; Volkan Gurkan [5]; Omer Sofulu [2]; Merter Yalcinkaya [6]; Erhan Okay [...], Objective: Accurate determination of life expectancy becomes very important when determining the treatment of patients with pathologic fractures. We aimed to investigate the predictive role of the PATHFx model in Turkish patients by estimating the area under curve (AUC) of the receiver operator characteristic (ROC) and externally validating the results of PATHFx on the Turkish population. Methods: The data of 122 patients who presented to one of four orthopaedic oncology referral centres in Istanbul (2010-2017) and underwent surgical management of pathologic fractures were retrospectively collected. Patients were evaluated according to age, sex, type of pathologic fracture, presence of organ metastasis, presence of lymph node metastasis, haemoglobin concentration at presentation, primary oncologic diagnosis, number of bone metastases, and Eastern Cooperative Oncology Group (ECOG) status. Estimations of the PATHFx program by months were statistically evaluated using ROC analysis. Results: In our study population (122 patients), all survived the first month, 102 survived the third month, 89 were alive at 6 months, and 58 patients survived at 12 months. At 18 and 24 months, 39 and 27 patients were alive, respectively. The AUC value was 0.677 at 3 months, 0.695 at 6 months, 0.69 at 12 months, 0.674 at 18 months, and 0.693 at 24 months. The 3-, 6-, 12-, 18-, and 24-month survival rates were statistically significant (P < 0.01 and P < 0.05). ECOG performance status was 0-2 points in 33 patients (Memorial Sloan-Kettering Cancer Center (MSKCC) data set: 93 cases, our data set: 33 cases). ECOG performance status was 3-4 points in 89 patients (MSKCC data set: 96 cases, our data set: 89 cases). Conclusions: The objective data used by PATHFx for prediction provided statistically accurate estimates on Turkish patients, who are presumed to have mixed genomes through history from both Europe and Asia, and demonstrates its applicability to the Turkish population. Keywords: Expected survival, metastatic bone disease, PATHFx, pathologic fracture

Abstract Introduction We present the case of a patient with extensor carpi ulnaris tendon subluxation who was first treated for distal radioulnar joint sprain. Case presentation A 25-year-old Caucasian man was seen at our policlinic one month after he had fallen on his outstretched hand. A diagnosis of extensor carpi ulnaris subluxation was made clinically but we also had the magnetic resonance imaging scan of the patient’s wrist which displayed an increased signal on T2-weighted images consistent with inflammation around the extensor carpi ulnaris tendon. The extensor carpi ulnaris tendon was found to be dislocating during supination and relocating during pronation. The sheath was reconstructed using extensor retinaculum due to attenuation of subsheath. Conclusion There was no recurrent dislocation of the extensor carpi ulnaris tendon of the patient at his last follow up 12 months after the operation.

Abstract Introduction We present a case of a patient with juxtaarticular hemangiohamartoma with a synovial extension associated with hemorrhagic synovitis and recurrent spontaneous hemarthrosis. Case presentation A 21-year-old Caucasian woman was admitted to our hospital complaining of pain and swelling at her knee for 6 months. In the magnetic resonance imaging, T2-weighted and fat-suppressed scans revealed a mass with high signal intensity just posterior to the patellar tendon. We performed an excisional biopsy of the mass through an anterior longitudinal incision. Excised material included arterial and venous vascular structures, which were found to be spread among the fat, connective and peripheral nerve tissues microscopically. Conclusion Although hemangiohamartomas are not true neoplasms, they may cause knee pain, swelling and hemarthrosis that warrant surgical resection. This lesion, although rare, should be considered in the differential diagnosis, especially in teenagers and young adults.

Abstract The meniscofibular ligament is an anatomically defined ligament of the knee in humans. However, there are no data regarding the prognosis following injury to this ligament. Our case was a 42-year-old man who presented at our clinic with pain of the lateral side of his left knee. MRI of his left knee revealed the rupture of the meniscofibular ligament. The mechanism of injury was consistent with anatomical and mechanical studies of the meniscofibular ligament. The patient was treated conservatively for 1 year, but his pain did not resolve completely. A case series of patients with the same injury is required to establish an effective treatment for this rare injury.

Abstract Introduction Pyomyositis is a disease in which an abscess is formed deep within large striated muscles. Case presentation We report the case of a 10-year-old boy who presented with fever and a painful hip and was subsequently diagnosed with pyomyositis of the tensor fascia lata. In children with clinical and laboratory findings of inflammation in the vicinity of the hip joint, the differential diagnosis includes transient synovitis, an early stage of Legg-Calvé-Perthes disease, infectious arthritis of the hip, rheumatologic diseases and extracapsular infection such as osteomyelitis. Conclusion To the best of the authors' knowledge, this is the first report of pyomyositis of the tensor fascia lata. Although pyomyositis is a rare disease and the differential diagnosis includes a variety of other commonly observed diseases, pyomyositis should be considered in cases where children present with fever, leukocytosis and localized pain.

Abstract Introduction Clay-shoveler's fracture is a rare cervicodorsal spinous process fracture and there is little information regarding the prognosis of patients with this condition in conjunction with osteoporosis and corticosteroid use. Case presentation A 39-year-old man was admitted to our institution with a 6-month history of cervicodorsal pain prior to admission. The patient had previously undergone renal transplantation and was on corticosteroids, and had developed osteoporosis. We treated him with a cervical collar, non-steroidal anti-inflammatory agents and alendronate. The patient was advised against performing weight-bearing activities for 6 months. Conclusion Clay-shoveler's fracture with osteoporosis and corticosteroid use presented by fracture of the cervicodorsal aspect of the spinous processes may be successfully treated with a collar, alendronate and long-term rest.

Abstract Introduction Bilateral fractures of the distal radius and scaphoid are extremely rare injuries. Case presentation A patient with bilateral comminuted, displaced distal fractures of the radius and bilateral fractures of the scaphoid was treated via internal fixation of the scaphoid fractures with Herbert screws and internal fixation of the distal radius fractures with locked volar plating. Conclusion Rigid internal fixation of distal radius and scaphoid fractures is mandatory to start early active rehabilitation of the wrist without the need for wrist immobilization with a plaster or external skeletal fixation.