Modified radiographic views to prevent the anterosuperior and posterosuperior bony violation during screw fixation of femoral neck fractures.

INTRODUCTION: The standard anteroposterior and lateral fluoroscopic projections used during femoral neck fracture fixation provide a two-dimensional representation of the cephalocaudal and anteroposterior extents of the femoral neck. The radiographic representation differs from the actual extent of the femoral neck. The anterosuperior (AS) and posterosuperior (PS) surfaces of the femoral neck are at risk of bony breach by the fixation screws and that may get easily missed with standard fluoroscopic views. The current study aims at investigating the special fluoroscopy views, based on the orientation of the AS and PS surface of the femoral neck, that can help in the safe placement of screws near these surfaces without bony breach. METHOD: A computed tomography-based analysis of fifty intact proximal femora was performed. The longitudinal axis of the proximal femoral shaft and the center of the femoral head were aligned along a common horizontal plane. The cephalocaudally constricted zone of the femoral neck was identified along its axis. The surface inclinations of the AS surface and the PS surface at the constricted zone of the femoral neck were measured in relation to the horizontal plane. The mean, standard deviation, overall range, interquartile ranges and gender-based variation of each of the two surface inclinations were measured. RESULTS: The mean surface inclinations of the AS surface and the PS surface with reference to the horizontal plane were 55° ± 7.76° and 123.32° ± 7.88°, respectively. There were no significant side to side and male to female differences. CONCLUSIONS: The modified radiographic views based on the surface inclinations of the AS and the PS surfaces can help in the localization of the critical zones of these surfaces which are at risk of bony breach with screw placement close to the surface. A prior fluoroscopic evaluation of these surfaces before guidewire placement can help in preventing the surface violation.

"Turn the tail, not the head": a simple, quick and inexpensive technique for the safe removal of jammed/stripped locking screws.

A jammed screw is a well-known complication of locking plates. Noncompliance to the standard techniques, nonusage of torque limiting screwdrivers and manufacturer-specific instrumentations are the common causes of jammed locking screw heads. Previously, various techniques have been described for the retrieval of jammed locking screws by damaging the screw head, using conical reverse threaded drill bits and often cutting off the plates at jammed screw sites that often generate metal debris and cause bone and soft tissue damage of unknown extent. We present a simple technique and a novel device that does not damage the screw head or the plate, and therefore, no metal debris is generated. The threads on the terminal part of the screw are used to disengage the jammed locking screw head from its locking hole.

Knowledge, Attitude, and Practices Regarding Radiation and its Hazards Among Orthopaedic Surgeons in India: A Questionnaire-Based Study.

Introduction: Orthopaedic surgeons are among the most frequent users of radiation and are often exposed to X-Ray radiation regularly. There is an overall unsatisfactory level of knowledge, attitude, and practices regarding the same among surgeons. This study aimed to assess the practices among orthopaedic surgeons regarding radiation and its hazards in India. Methodology: This questionnaire-based survey was conducted between March and September 2022. The questionnaire broadly assessed the knowledge, awareness, and practices among orthopaedic surgeons regularly exposed to X-ray radiation. The questionnaire consisted of objective and Likert scale questions which were distributed to the respondents electronically using publicly available contact information. A qualitative review of interpretations obtained from the responses and available evidence in the literature was then performed. Results: The response rate for the survey was 36.4%. 65.9% reported using trunk protection all the time during procedures. 57.1% of respondents reported not using thyroid protection during procedures. 92.3% reported not using protective goggles and 100% did not use appropriate gloves. 76.9% were not issued dosimeters, and only 5.5% of those who had been issued one wore it during radiation procedures. 58.2% reported having a dedicated employee to operate the machine. 86.8% of respondents did not have formal training and 81.3% were not aware of institutes offering formal training. Conclusion: There is very high compliance with the use of protection aprons among the respondents however, the use of other apparel like thyroid shields, protection goggles and gloves was poor. The awareness regarding radiation exposure was also poor as most respondents were not issued dosimeters, however, those issued with one were well aware of their exposure. It is imperative to prioritize both surgeons' and patients' safety where radiation exposure is concerned.

Correction: Knowledge, Attitude, and Practices Regarding Radiation and its Hazards Among Orthopaedic Surgeons in India: A Questionnaire-Based Study.

[This corrects the article DOI: 10.1007/s43465-023-01068-1.].

Volar dislocation of second, third, and fourth carpometacarpal joints: a rare and easily missed diagnosis.

Volar carpometacarpal dislocation is a rare form of hand injury that can be easily missed without applying a high level of suspicion and performing a meticulous examination. In this case report, we present a rare case of compound volar dislocation of the second, third, and fourth carpometacarpal joints in a 40-year-old male. This was managed by closed reduction and the use of a mini external fixator. The patient regained a good range of motion in 6 weeks with no pain. It is important to diagnose and treat this injury in order to avoid the considerable morbidity associated with this condition.

K Wires or Cannulated Screws for Fixation of Lateral Condyle Fractures in Children: A Systematic Review of Comparative Studies.

Introduction: Lateral condyle fractures in children have been typically been treated operatively using Kirschner wires (K wire) or cannulated screws (CCS); however, a definitive choice of implant remains a matter of debate. This systematic review aims to determine if union and functional outcomes of these fractures are better with screw fixation. Methodology: A search of PubMed, Medline, Cochrane, and Google scholar was performed in March 2021. The results were screened by title and abstract, and relevance and a quality assessment of the data were performed for the articles meeting the inclusion criteria. Articles comparing radiological and functional outcomes of lateral condyle fractures treated with K wires or screws were included for examination. Articles were excluded if they did not compare outcomes of K wires and CCS together, or were in a language other than English, technical notes, case reports, and articles, which describe the use of fixation methods other than K wire or CCS as well as biomechanical studies were also excluded. Risk of bias and quality assessment of included articles were also done. Results: Seven clinical studies were included. 44.4% (n = 4) were retrospective review of records with level III evidence (77.7%, n = 7). Only two included articles had good-quality assessment scores. Union was reported in 85.7% % in K wire group and 99.6% in CCS group. Functional outcomes were not statistically significant between the two groups. Conclusion: Using screws to fix lateral condyle provides better union; however, there is no difference in the functional outcomes and complication rate between the two. Using screws or buried K wires adds the burden of an additional procedure for removal.

K-Wire-Based External Fixator for Management of Salter-Harris Type-II Distal Femur Physeal Injury.

We present a case of a 16-year-old male with a Salter-Harris type II physeal slip of the distal femur managed with closed reduction and K wire and clamp-based external fixator. Knee range of motion exercises were initiated after one week. The union was observed at 10 weeks, and implant removal was done on an outpatient basis. At one year follow-up, the patient had good clinical and radiological outcomes. The K-wire-based external fixator frame is an effective fixation method for distal femur physeal slips in older children, providing favorable radiological and functional outcomes.

Top 50 Cited Papers on Tibial Plateau Fracture Management: A Bibliometric Analysis and Review.

Purpose: The orthopaedic surgeons, especially the young budding surgeons should have a well-balanced knowledge of the past evidence as well the current evidence in the literature for the appropriate as well as optimum management of tibial plateau fractures. Bibliometric analysis of the top-cited papers on tibial plateau fracture management can help know their concurrent interests, deficiencies and conflicting issues regarding their management. This study aimed to identify the 50 most cited research articles in tibial plateau research and analyse their characteristics. Methods: We searched the Thompson Reuters Web of Science database for articles relevant to tibial plateau fracture and prepared a list of top 50 cited articles that included original articles and review articles concerning tibial plateau fractures. The included articles were analysed for contributing journals, corresponding author's country, publication year, cumulative citations, annual citations, citation trends over time, level of evidence and a qualitative review. Results: The search strategy resulted in 2263 articles. The top 50 cited articles were published from 1974 to 2014 and belonged to 12 journal sources. There were 47 original articles and 3 review articles. The average citations per article were 126.2, and the annual citations per article were 6.478 per year. The top-cited articles were relevant to the strategies in the management, classification, fracture reduction, articular restoration, types and number of fixation devices, surgical approaches, associated menisco-ligamentous injuries and applicability of bone grafts/substitutes in tibial plateau fractures. Conclusion: The current bibliometric analysis summarises the top-cited evidence concerning tibial plateau fractures and can be a potential resource for reviewing and locating the same. The analysis shows that most top-cited evidence belongs to the year 2000 onwards. Also, recent articles have a higher annual citation rate. A limited number of journals and mostly, western countries have contributed to the top-cited evidence. Whilst the top-cited evidence has touched several aspects of tibial plateau fractures, it is in the form of level IV case series. It needs better prospective evidence to establish sound recommendations. Supplementary Information: The online version contains supplementary material available at 10.1007/s43465-023-00932-4.

Telemedicine trends in orthopaedics and trauma during the COVID-19 pandemic: A bibliometric analysis and review.

OBJECTIVES: In the wake of recent widespread interest in telemedicine during the COVID-19 era, many orthopaedic surgeons may be unfamiliar with clinical examination skills, patients' safety, data security, and implementation-related concerns in telemedicine. We present a bibliometric analysis and review of the telemedicine-related publications concerning orthopaedics care during the COVID-19 pandemic. Such analysis can help orthopaedic surgeons become acquainted with the recent developments in telemedicine and its usage in regular orthopaedics practice. METHODS: We systematically searched the database of Thomson Reuters Web of Science for telemedicine-related articles in orthopaedics published during the COVID-19 pandemic. The selected articles were analysed for their source journals, corresponding authors, investigating institutions, countries of the corresponding authors, number of citations, study types, levels of evidence, and a qualitative review. RESULTS: Fifty-nine articles meeting the inclusion criteria were published in 28 journals. Three hundred forty-two authors contributed to these research papers. The United States (US) contributed the most number of articles to the telemedicine-related orthopaedics research during the COVID-19 era. All articles combined had a total of 383 citations and 66.1% were related to the Economic and Decision-making Analyses of telemedicine implementation. By and large, level IV evidence was predominant in our review. CONCLUSION: Telemedicine can satisfactorily cover a major proportion of patients' visits to outpatient departments, thus limiting hospitals' physical workload. Telemedicine has a potential future role in emergency orthopaedics and inpatient care through virtual aids. The issues related to patient privacy, data security, medicolegal, and reimbursement-related aspects need to be addressed through precise national or regional guidelines. Lastly, the orthopaedic physical examination is a weak link in telemedicine and needs to be strengthened.

The Current Consensus on the Management of Post-traumatic Blisters Among Orthopaedic Surgeons.

Introduction: Post-traumatic blister is often encountered in high-energy injuries and following major limb surgeries. Currently, there is very limited evidence concerning blister management resulting in a lack of comprehensive guidelines for their management. The current survey-based study aims to appraise the current consensus in post-traumatic management among the practising orthopaedic surgeons and compare the same with the evidence in the literature. Materials and Methods: We conducted an online questionnaire-based survey of orthopaedic surgeons concerning post-traumatic blister management practices. The questionnaire mainly focused on antibiotic prophylaxis, local invasive procedures, antiseptics dressings and additional treatment options regarding blister management. Results: A high prevalence (~ 78%) of systemic antibiotics administration was noticed for post-traumatic blister management. Similarly, large section of respondents (66.4%) advocated for either de-roofing or aspiration of blisters. Approximately 42% of respondents preferred sending blister fluid for cultures. More than half of the respondents used some form of local dressing to cover the blister bed to provide a healing environment. Additional opinions mostly included anti-inflammatory and swelling reducing measures. Few respondents also advocated for oral steroids for inflammation control. Conclusion: The limited evidence available in literature could be the potential contributing factor for varying clinical practices for post-traumatic blister management. The general measures to reduce soft-tissue oedema have been supported by the literature. However, the use of systemic antibiotics and steroids has not been supported by the literature and should be avoided unless indicated due to other reasons. Further evidence is required to strengthen the recommendations for post-traumatic blister management.

Patient Preferences Regarding Telemedicine to In-person Consultation: A Questionnaire-Based Survey.

Introduction: Telemedicine has been evolving over the last two decades; however, with the advent of the COVID 19 pandemic, its utility and acceptance have drastically increased. Most studies report increasing acceptability and satisfaction rates. This study aimed to assess patient preferences regarding telemedicine to in-person consultations and to attempt to assess the factors driving these preferences. Material and Methods: A questionnaire-based cross-sectional study was conducted for patients who had both teleconsultation and in-person consultation in the orthopedic outpatient. After obtaining consent to participate in the study, the patients were divided into broad clinical categories and responses were recorded regarding the treatment of illness by the doctor and opinions regarding telemedicine. Most questions were in yes/no or a Likert-based questionnaire. Mean, median, percentage and proportions were used for statistical analysis of the data. Results: The study group included 264 patients, with the majority with fractures and dislocations. Most patients (55.7%) were comfortable using the software for teleconsultation, and half the respondents found telemedicine convenient. A large percentage of the study group preferred in-person consultation to teleconsultation (58.7%), and the primary reasons for discontinuing teleconsultation were dissatisfaction during the interaction with the doctor and poor connectivity to telecommunication networks. Conclusion: Telecommunication has high acceptance and satisfaction, but many factors limit its acceptance in developing countries.

Effectiveness of Needle Tenotomy for Correction of Equinus in Clubfoot.

INTRODUCTION: During the COVID-19 surge, due to a lack of operating room availability, we performed Achilles tendon tenotomy in clubfoot patients using a 16/18 gauge needle to avoid delay in their management. The procedures were performed on an outpatient basis. The current retrospective study aims to investigate the effectiveness of needle tenotomy for the correction of equinus in clubfoot at a minimum of one year of follow-up. METHODS: Clinical records of all clubfoot patients that underwent needle tenotomy of Achilles tendon from March 2020 onwards with at least one year of follow-up were reviewed. We recorded Pirani scores and the equinus deformity at the initial presentation, after Achilles tendon tenotomy, and at the final follow-up. We also recorded any procedure-related complications following the Achilles tendon tenotomy. We compared dorsiflexion after final cast removal and after one year of follow-up. RESULTS: A total of 26 clubfeet in 14 patients underwent needle tenotomy of the Achilles tendon and completed one year of follow-up. Ankle dorsiflexion was achievable in all patients and the mean dorsiflexion of 27.4 degrees. The average Pirani score after tenotomy at final cast removal was 0.16, while the mean dorsiflexion at final cast removal was 24.2 degrees (p = .00084). No tenotomy procedure-related complications were noted. CONCLUSION: Percutaneous needle tenotomy of the Achilles tendon is a simple, safe, and effective technique for equinus correction in clubfoot. Considering the less invasive nature of the procedure, it can be done as a short procedure on an outpatient basis and has a limited risk of hemorrhage and other wound-related complications.

Conventional fluoroscopic views are inadequate to predict the Tip Apex Distance and articular clearance of sliding screw devices: A computed tomography-based analysis.

INTRODUCTION: Tip-apex-distance (TAD) has been widely advocated as the index to predict the risk of screw cut out in hip fractures treated with sliding hip screw devices. The fluoroscopic extents of the femoral head can change with the slightest change in the limb position which includes internal and external rotations, adduction and abduction. These changes can affect the visible TAD and articular-clearance of the screw-tip. The purpose of this Computed-tomography(CT) based analysis is to analyze the variations of the radiographically visible articular-clearance and TAD measurements with limb positioning and to determine the appropriate fluoroscopic projections for different screw-positions within the femoral head. MATERIAL AND METHODS: We retrospectively analysed CT studies of twenty healthy proximal femora. Spatial markers simulating screw tips were placed in the different combinations of anteroposterior(AP) and cephalocaudal(CC) positions. Software-based AP and lateral radiographs were developed for each screw position. Additional AP radiographs with femur in internal and external rotation, and lateral radiographs with the femur in adduction and abduction were developed. The variation of TAD and articular-clearance of the screw was measured among these radiographs for individual screw tip positions. RESULTS: Screw tip placed centrally in AP and CC planes position didn't show any significant variation in TAD and articular-clearance with modified AP and lateral radiographs. Significant differences were observed in TAD and articular-clearance values for other screw tip positions. Anteriorly placed screw tips had higher TAD and articular-clearance values with external rotation and similar changes were observed with posteriorly placed tips in internal rotation. Inferiorly placed tips had higher articular-clearance and TAD with limb abduction and similar changes were observed for superiorly placed tips with limb adduction. CONCLUSIONS: For the sliding screws placed in non-central locations, the clearance of the screw tip from the articular margins can not be appropriately estimated with conventional AP and lateral views. Additional views with the limb in internal rotation and external rotation in AP view, and adduction-abduction in lateral view are required to safely place the sliding screw in the femoral head. The limb should be brought to a neutral alignment for the accurate estimation of TAD.

Effectiveness of Calcium Sulfate and Hydroxyapatite Composite in Collapse Prevention in Osteonecrosis of Femoral Head.

Introduction Calcium-sulfate-hydroxyapatite bioceramics have been widely used as void fillers in bone. However, their effectiveness as void fillers in core decompression for osteonecrosis of the femoral head (ONFH) in preventing femoral head collapse prevention has limited evidence. The current study investigates the effectiveness of calcium-sulfate-hydroxyapatite bioceramics as a void filler in the core decompression procedure for ONFH. Methods We retrospectively reviewed the clinical and radiological records of ONFH patients that underwent core-decompression using either autologous iliac crest cancellous bone graft or calcium-sulfate-hydroxyapatite bioceramic paste as void fillers with at least one-year follow-up. The primary outcome of this study was the radiological progression of collapse in the last available standard anteroposterior (AP) radiographs of the hip. The collapse progression was compared between the two groups based on void fillers. Results This study included patient records with 44 hip joints that underwent core decompression. There were five female and 33 male patients. The mean age was 29.1±6.3 years. The mean follow-up duration was 21.4±3.4 months. No significant differences in collapse progression were observed between the two groups based on void fillers. Conclusion The use of calcium-sulfate-hydroxyapatite as a void filler in core decompress for ONFH is not superior to the autologous cancellous bone in terms of collapse prevention and mechanical support. Further modifications in the core decompression techniques and well-planned prospective studies would help establish sound recommendations.

Comparison of Functional and Radiological Outcomes of Transverse Patellar Fractures Fixed with Tension Band Fixation Using Cannulated Screws and Kirschner Wires: A Prospective Randomized Study.

PURPOSE: To compare functional and radiological outcomes of transverse patella fractures treated with tension band wiring using either two 4.5 mm cannulated screws or Kirshner wire. METHODS: This is a non-blinded prospective randomized study comprising of two groups (n = 30 each) with closed transverse patella fractures treated with tension band wiring using Kirschner wire (K wire group) and two 4.5 mm cannulated screws (CCS group). Outcomes measured were radiological union, Knee Society score, range of motion and post-operative complications. RESULTS: The CCS group showed a statistically significant higher range of motion than K wire group for each follow up (p < 0.001 in flexion and p < 0.005 in extension). A statistically significant higher percentage of patients in the CCS group showed signs of union at 6th and 12th post-operative week (p = 0.001 and 0.011 respectively) but no difference at 24th post-operative week (p = 0.313). The rate of hardware complications was significantly higher in K wire group (p = 0.001). No significant difference was noted in in the Knee society score and post-operative complications between the groups. CONCLUSION: This study concludes that the fixation of closed transverse patella fractures using two 4.5 mm cannulated screws is allows a faster rate of union, a better knee range of motion and lesser hardware complications as compared to Kirschner wires. However more studies with larger sample sizes and longer follow up are required.

Ulnar dimelia variant: a case report.

We report a case of ulnar dimelia, commonly called mirror hand, in a 2-month-old female child who had restriction of elbow flexion and forearm rotation. There was no facial or other internal organ malformation. Radiographs revealed seven triphalangeal digits with double ulnae (one following the other) and absent radius. To the best of the authors' knowledge, this is the first report of this mirror hand deformity in which fingers are symmetrical while duplicated ulnae are not.

Concentric Circle Technique for Assessment of Femoral Head Deficiency in Osteonecrosis of Femoral Head.

Introduction There is a lack of standardized objective tools to assess collapse for osteonecrosis of the femoral head (ONFH) patients' follow-up. We describe a quantitative technique of collapse assessment using a superimposed concentric circular ring matching the intact part of the femoral head in anteroposterior (AP) radiographs. Methods We retrospectively analyzed 30 normal femoral heads and 30 ONFH (15 pre-collapse,15 post-collapse) in anteroposterior hip radiographs. A best-fitting circle was superimposed on articular margins of the femoral head and the maximum width of the deficient zone of the femoral head (not matching the circle) was measured. The width (pW) was measured as percentage-width in proportion to the circle's diameter. The findings were compared among normal and ONFH radiographs. Intraclass correlation coefficients were calculated for intraobserver and interobserver reliability of the measurements. Results The mean femoral head deficiencies predicted by pW were 0.2±0.5% for normal hip, 2.8±1.1% for pre-collapse, and 8.9±3.8% for post-collapse radiographs. We observed significant differences in the measurements of pW among the control group, pre-collapse and post-collapse groups. Interobserver and intraobserver reliabilities for the measurements were high. Conclusion The described concentric circle technique is a simple and reliable method for objective assessment of subtle alterations in the sphericity of the femoral head and can be helpful for the radiographic follow-up of ONFH patients.

Complete posterior dislocation of fractured lateral condyle of tibia with disruption of proximal tibiofibular joint: Technical note.

Tibial plateau fracture-dislocations are relatively uncommon injuries. They represent instability patterns due to injured collateral ligaments or extensive condylar depression. Medial and lateral subluxations of the fractured fragments represent the majority of these injuries. Posterior dislocations with the tibial plateau fractures are extremely rare injuries. Moreover, isolated posterior dislocations of the tibial condyles with a normally maintained position of the remaining tibia have not been reported in literature. We describe a difficult case scenario in which whole of the articular segment of the lateral condyle of the tibia was separated from its anterolateral rim and completely dislocated posteriorly, with no contact with the lateral condyle of the femur. Besides this, there was a complete disruption of the proximal tibiofibular joint as well. To further add to the problem, the distal pulses in the affected limb had a reduced volume. Stepwise management of all aspects of this injury has been described in this technical note along with a six-month follow-up.

Salvaging Chronic Nonunion of Femoral Neck and Infected Nonunion of Ipsilateral Femoral Shaft Fracture Using Intramedullary Antibiotic Cement Spacer and External Fixator Alone.

Concomitant ipsilateral fractures of femoral neck and shaft are rare injuries and pose challenging management. Infected non-unions of such fractures can further complicate the management options and have not been discussed in the literature. We present a case of an eight-month-old atrophic non-union of ipsilateral femoral shaft and femoral neck with evidence of intramedullary infection that was managed using a cost-effective, low strain rail fixator assembly and an intramedullary antibiotic cement spacer. Both fracture non-unions were salvaged without the need for any additional procedure. The patient returned to his regular activities within a year follow-up period. There was no clinical evidence of infection during the last follow-up at 16 months, and inflammatory markers were within normal limits. The current case study suggests that while aggressive debridement and intramedullary antibiotic cement spacer can control the intramedullary infection, and simultaneous union of even atrophic nonunion of femoral shaft and femoral neck, both, can be obtained using a tensioned Schanz pin-based external fixator without the need for any secondary procedure. Such a fixator and cement spacer assembly can thus address the dual purpose of fracture stabilization during infection control as well as the union of the non-union sites.

Role of Zoledronic Acid Supplementation in Reducing Post-Surgical Recurrence of Giant Cell Tumor of Bone: A Meta-Analysis of Comparative Studies.

Zoledronic acid is a bisphosphonate that has recently gained interest in adjuvant therapy for giant cell tumor of bone (GCTB). It has an apoptotic effect on osteoclasts that are precursors of GCTB. However, the evidence suggesting the role of zoledronic acid in preventing GCTB recurrence is mixed, and therefore, a consensus is yet to be established. The purpose of the current meta-analysis was to analyze the impact of zoledronic acid supplementation on tumor recurrence in surgical treated GCTB. A systematic search was conducted on PubMed, Embase, and Web of Science databases to identify studies that analyzed the impact of local or systemic zoledronic acid supplementation on clinical outcomes in surgically treated GCTB. The data from the comparative studies were pooled and analyzed to investigate the association of zoledronic acid supplementation with tumor recurrence. Additionally, other factors such as age, gender, soft tissue extension, polymethyl methacrylate (PMMA) cement application, recurrent presentation, and extended curettage were also investigated for any association with tumor recurrence. Of the 271 results, 13 unique studies reported the clinical outcomes in GCTB. Seven studies compared the outcomes of zoledronic acid supplementation with control groups. Six studies presented the tumor recurrence-related data among the comparison groups. The zoledronic acid supplementation was associated with significantly lower tumor recurrence rates (p = 0.007). Additionally, a significant association of soft tissue extension and non-usage of PMMA cement with tumor recurrence were observed. The current meta-analysis suggests that zoledronic acid supplementation reduces tumor recurrence rates in surgically treated GCTB. We, therefore, recommend the use of zoledronic acid following aggressive extended curettage of the tumor. Further, well-planned randomized controlled trials will help strengthen this evidence.