Uncemented Customized Hollow Stems in Tumor Endoprosthetic Replacement-A Good Opportunity to Protect the Adjacent Joint in Children?

This study aimed to retrospectively analyze the follow-up results of cases in which the adjacent joint was preserved using a custom-made uncemented short-stem design (hollow stem) with optional external flanches in tumor endoprosthetic replacement due to bone sarcomas in 13 patients (with an average age of 9.6 years) between 2017 and 2023. Reconstructions were proximal femur (n = 6), intercalary femur (n = 4), intercalary tibia (n = 2), and proximal humerus (n = 1) tumor prostheses. The hollow body was used distally in 10 of the megaprotheses, proximally in 1, and both proximally and distally in 2 of them. The average distance from the joints was 6 cm in stems with flanches and 11.8 cm in stems without flanches. No aseptic loosening or deep infection was observed during an average follow-up of 34 months. Except for one case with a tibial intercalary prosthesis that needed a revision, all cases were well osteointegrated and all lower extremity cases could bear full weight without pain. In cases where the remaining bone stock after bone resection is insufficient for a standard stem implantation, reconstruction with a patient-specific short hollow-stem design appears to be a good alternative to protect healthy joints with high prosthesis survival and low revision rates in the short-term follow-up.

Undifferentiated High-Grade Pleomorphic Bone Sarcoma: A Case Report.

Undifferentiated pleomorphic bone sarcoma (UPS-B) is a rare high-grade sarcoma of bone that is usually seen in advanced age. There is no specific line or pattern of differentiation, and the diagnosis is often made by exclusion. It is especially important to differentiate it from osteosarcoma and dedifferentiated chondrosarcoma. It tends to be located most frequently in the lower extremity, particularly the femur. It is treated with the osteosarcoma protocol. In this study, a case of undifferentiated high-grade pleomorphic bone sarcoma located in the distal femur was reported. It aimed to discuss the patient's clinical presentation, diagnostic approach, treatment, and follow-up process in light of the literature. In this case, the tumor was resected with wide margins after neoadjuvant chemotherapy. He died of diffuse lung metastases during the adjuvant chemotherapy process. Unlike the literature, the patient was only 29 years old. The patient died 8 months after the first diagnosis.

Painless Growing Swelling on the Palm of a 4-year-old Boy: Malignant Peripheral Nerve Sheath Tumor.

In this study, we present a 4-year-old male patient with a slowly growing painless mass in the palm of his left hand for 2 years. Although musculoskeletal tumors are rare, hand localized tumors are even rarer in pediatric patients. The fact that very few (less than one in ten) tumors are malignant and there are dozens of subtypes, each with different treatment management, shows the importance of the management of these lesions. Appropriate diagnosis and management of soft tissue masses, especially insidious malignant tumors, is vital. Due to the rarity of soft tissue tumors, adequate guidelines for their management are limited. The purpose of this report is to present an example of the approach to one of the soft tissue tumors.

A challenging case of an adamantinoma of fibula with soft tissue mass harboring distinct histopathology.

We present a case of adamantinoma that originated from the fibula and had a large soft tissue component measuring approximately 6 cm. Clinical, radiological, and pathological investigations initially suggested that the tumor might be a bone-invading synovial sarcoma. To the best of our knowledge, no other case of fibular adamantinoma with such a large soft tissue component has been reported in the literature.

Slipped capital femoral epiphysis after tumor prosthesis implantation in a patient receiving chemotherapy.

While the usual etiology of slipped capital femoral epiphysis (SCFE) is idiopathic, there are many other factors that increase the predisposition to slippage. Chemotherapy can be one of them. In this article, we report a rare case of acute SCFE after tumor prosthesis implantation in a patient who received chemotherapy. A 10-year-old girl with osteosarcoma of the right distal femur underwent (neo-) adjuvant chemotherapy, wide tumor resection, and reconstruction using a growing tumor prosthesis and a short non-cemented femoral stem. Half a year after implantation, she developed aseptic loosening. Revision surgery was performed using a hydroxyapatite (HA)-coated cementless femoral stem. Postoperative plain radiographs revealed SCFE that was treated by closed reduction and screw fixation. The patient recovered without complications, and unaffected hip showed no radiographic signs of slippage on follow-up. The forces of implanting a tumor prosthesis, particularly with a non-cemented stem, can increase the risk of an acute SCFE. The controversy over prophylactic pinning of the uninvolved hip in chemotherapy-associated SCFE is unresolved. Pinning can be considered only in the presence of abnormal prodromal radiological findings.

Cortical hypertrophy in intramuscular hemangioma mimicking bone tumor.

Although hemangiomas are the most common soft tissue tumors, intramuscular hemangiomas account for only 0.8% of all vascular tumors. These lesions are rarely located adjacent to the bone and cause changes in the adjacent bone. They are often mistakenly diagnosed as bone tumors. In this study, a case of a 19-year-old male patient with intramuscular hemangioma causing cortical thickening was reported.

Cyclops syndrome following anterior cruciate ligament reconstruction: Can relapse occur after surgery?

Symptomatic cyclops lesions are complications that can be seen at rates of up to approximately 10% after anterior cruciate ligament reconstruction. However, recurrent cyclops lesions have rarely been documented. There are case rare series in the literature regarding the treatment of recurrent cyclops lesion. Future large studies are needed to investigate factors contributing to the development of cyclops lesions and syndrome and treatment options.

Indication and surgical approach for reconstruction with endoprosthesis in bone-associated soft tissue sarcomas: Appropriate case management is vital.

It is important for surgeons performing sarcoma surgery to know that bone resection and tumor prosthesis applications in soft tissue sarcomas (STS) have unique features in terms of indication, surgical approach and follow-up, in terms of the management of these cases. Some STS are associated with bone and major neurovascular structures. Bone-associated STS are generally relatively large and relatively deep-seated. Additionally, the tendency for metastasis is high. In some cases, the decision about which structures to resect is difficult. These cases are often accompanied by poor oncological and surgical outcomes. Management of cases should be done by a multidisciplinary team in advanced centers specialized in this field. The surgical team must have sufficient knowledge and experience in the field of limb-sparing surgery. Preoperative evaluation and especially good planning of bone and soft tissue reconstruction are vital.

Expandable endoprostheses in skeletally immature patients: Where we are.

Approximately 45 percent of malignant bone tumors are seen under the age of 16 and one of the important results of growth plate sacrification in patients with immature skeletons is limb inequality. Until the early 1990s, the treatment options for these patients were rotationplasty or amputation. Multimodal approaches that combine imaging, chemotherapy, and surgical techniques have enabled the development of limb-preserving methods with satisfactory results. In order to overcome inequality problems, expandable prostheses have been developed in the 1980s. Extendable endoprosthesis replacements have been improved over the years and are now an established and safe alternative. Noninvasive prostheses appear to be advantageous compared to minimally invasive expandable prostheses that require multiple surgical procedures, but the complication rate remains high. Therefore, although expandable prostheses are not the definitive answer to the treatment of bone sarcomas in skeletally immature children, they are still a suitable interim choice until full adulthood is achieved. Due to reported high complication rates, the procedures require significant experience and are recommended for use only in specialized cancer centers.

Management of Giant Cell Tumors in Hand and Foot.

The aim of this study is to determine the treatment modalities and clinical characteristics of 12 patients diagnosed with giant cell tumor (GCT) of the hand and foot. The clinical findings, treatment modalities, and treatment failures of 12 patients with giant cell tumors of the hand and foot bones between 2007 and 2018 years were evaluated retrospectively. The average age at diagnosis was 29.2 ± 14.9 std. (between 16 and 62 years old), 8 males (66.6%) and 4 females (33.3%). Tumor was more frequently located in the talus, metacarpal, and metatarsal bones. The mean tumor size was 3.1 ± 1.1 cm (between 2.2 and 5.3 cm). The mean post-operative follow-up period was 76.3 ± 42.5 (between 12 and 139 months). The most of patients' (58.3%) common complaints were pain. The most commonly used surgical method was curettage + autografting (91.7%). Infection was seen in one patient after relapse surgery. Recurrence occurred in 33.3% of the patients in the first year. Only one patient was detected to have knee and lung metastases. Swelling and pain in the hand and foot should be examined for tumor lesions. When a bone lesion is detected, the giant cell tumor of the bone should be included in the differential diagnosis. Patients with giant cell tumors should be followed closely for recurrence and metastasis after treatment.

Is surgical indication in multiple myeloma a poor prognosis sign? SEER database analysis.

AIM: This study aims to investigate demographic data, survival rates, and the relationship of these rates with surgery in a large case series including multiple myeloma (MM) patients. METHOD: MM cases were analyzed retrospectively using the latest version of the SEER database published in April 2020. This version covers January 1975 to December 2017. Patients were classified according to gender, age, and race/ethnicity. Tumors were classified according to their localization, grade, year of diagnosis, and follow-up results. RESULTS: There were 60,239 patients diagnosed with Plasma Cell Myeloma. While 670 patients (1.2%) were operated on, 43,976 patients (76.7%) did not indicate operation, and 12,670 patients (22.1%) could not be operated on despite the recommendation. The mean survival was 62 months in those without an indication for surgery, and 42 months in patients with an indication but could not be operated on, and the difference was significant (p = 0.001). The mean survival was 58 months in the operated patients, and 42 months in the patients who could not be operated on despite the indication, and the difference was significant (p = 0.001). There was no difference between those who did not indicate surgery and those who were operated on with an indication (p = 0.243). CONCLUSION: In multiple myeloma, the best prognosis is in the group of patients who received medical treatments without any indication for operation, while an indication for operation indicates a worse prognosis. A worse prognosis should be expected in patients who do not accept the operation or who cannot be operated on compared to the operated patients.

Do metastatic volumes measured in breast cancer patients with bone metastases correlate with the numbers of skeletal and extraskeletal events?

OBJECTIVES: The study aimed to investigate the relationship between metastatic volume measurement, skeletal-related events, and survival in women diagnosed with breast cancer and bone metastases. PATIENTS AND METHODS: This retrospective study was conducted with 82 female breast cancer patients (mean age: 53±14.3 years; range, 23 to 87 years) diagnosed, treated, and followed up between January 2005 and December 2019. The collected data included information on metastasis sites and the presence of skeletal-related events. Metastatic volume was measured in two ways: the number of metastases (high to low) and their localization (the first, second, and third groups). The first group consisted of vertebrae, ribs, sternum, and calvarial bones; the second group included scapula, clavicle, proximal humerus, and proximal femur regions; the third group consisted of femur and humerus diaphyseal and distal regions, as well as metastasis regions in other long bones. RESULTS: Sixty-three (76.8%) patients were diagnosed with ductal carcinoma. Half of the patients had bone metastases at the time of initial diagnosis, while 62 (75.6%) experienced skeletal-related events, with at least three events occurring in 30 (36.6%) patients. Bone pain was the most common skeletal-related event. No correlation was found between metastatic volume measurement based on the localization of bone metastases and the number of bones and the occurrence of skeletal-related events (p>0.05 for each). Patients' survival time spanned from one to 231 months (median: 56.8 months) from their first diagnosis. Patients with high metastatic volume, those in the third group, those whose pelvis and lung were involved, and elderly patients had a shorter survival time (p<0.05 for each). CONCLUSION: The study indicates that measuring metastatic volume may be a critical factor in evaluating the survival of breast cancer patients with bone metastases. Future prospective and randomized controlled studies can explore the potential of this measurement to create practical clinical tools.

Painless Growing Swelling on the Palm of a 4-year-old Boy: Malignant Peripheral Nerve Sheath Tumor / Inchaço crescente indolor na palma da mão de um menino de 4 anos: Tumor maligno da bainha do nervo periférico

Abstract In this study, we present a 4-year-old male patient with a slowly growing painless mass in the palm of his left hand for 2 years. Although musculoskeletal tumors are rare, hand localized tumors are even rarer in pediatric patients. The fact that very few (less than one in ten) tumors are malignant and there are dozens of subtypes, each with different treatment management, shows the importance of the management of these lesions. Appropriate diagnosis and management of soft tissue masses, especially insidious malignant tumors, is vital. Due to the rarity of soft tissue tumors, adequate guidelines for their management are limited. The purpose of this report is to present an example of the approach to one of the soft tissue tumors.

Resumo Neste estudo, apresentamos um paciente do sexo masculino de 4 anos com uma massa indolor de crescimento lento na palma da mão esquerda há 2 anos. Embora os tumores musculoesqueléticos sejam raros, os tumores localizados nas mãos são ainda mais raros em pacientes pediátricos. O fato de pouquíssimos (menos de um em cada dez) tumores serem malignos e existirem dezenas de subtipos, cada um com tratamento diferente, mostra a importância do manejo dessas lesões. O diagnóstico e manejo apropriados de massas de tecidos moles, especialmente tumores malignos insidiosos, são vitais. Devido à raridade dos tumores de tecidos moles, as diretrizes adequadas para seu manejo são limitadas. O objetivo deste relato é apresentar um exemplo de abordagem de um dos tumores de partes moles.

The Role of Preoperative Embolization in the Management of Aneurysmal Bone Cyst: A Comparative Analysis.

Introduction: The aim of this study was to evaluate the role of preoperative embolization in the management of aneurysmal bone cysts. Methods: In this study, the data of a total of 19 patients, 11 females and 8 males, with a mean age of 19.6 (range 5-46 years), who were operated on in our hospital with the diagnosis of ABC between January 2015 and January 2021 were retrospectively analyzed. In the specified date range, there were 10 patients with a diagnosis of ABC who were operated on within 48 h after preoperative embolization. For statistical comparison, 9 patients who were operated on without embolization in the same date range were included as the control group. Results: The mean age of the study group was 16.7 (between 5 and 27 years), while the mean age of the control group was 22.6 (between 16 and 46 years). In the embolization group (group I), the mean intraoperative blood loss was 550 mL (100-1200 mL), the mean intraoperative blood transfusion was 270 mL (0-900 mL), and the mean surgical time was 85 min. In the non-embolization group (group II), the mean intraoperative blood loss was 1250 mL (600-2200 mL), the mean intraoperative blood transfusion was 450 mL (450-1800 mL), and the mean surgical time was 90 min. In comparison, a statistically significant difference was found between the embolization group and the non-embolization group in terms of blood loss and blood transfusion requirement (p = 0.011 and p = 0.017, respectively). The mean surgery time was slightly shorter in the embolized group, and there was no significant difference in surgical time between the two groups (p = 0.821). Conclusion: Evidence suggests that preoperative embolization of an aneurysmal bone cyst, performed 0-48 h before surgery, can result in a reduction in intraoperative blood loss and intraoperative blood transfusion volume.

Knowledge and attitudes of orthopedic surgeons regarding prosthesis joint infection.

BACKGROUND: Periprosthetic joint infection (PJI) is a critical complication after joint arthroplasty and is accompanied by increasing rates of morbidity and mortality. Several studies have aimed at preventing PJI. AIM: To research the knowledge level and attitudes of orthopedic surgeons, who play a key role in both preventing and managing PJI. METHODS: We conducted a web-based survey to evaluate orthopedic surgeons' knowledge level and attitudes regarding PJI. The Likert scale survey utilized consisted of 30 questions which were prepared based on the "Proceedings of the International Consensus on Periprosthetic Joint Infection". RESULTS: A total of 264 surgeons participated in the survey. Their average age was 44.8, and 173 participants (65.5%) had more than 10 years of experience. No statistically significant relationship was found between the PJI knowledge of the surgeons and their years of experience. However, participants who worked in training and research hospitals demonstrated higher levels of knowledge than the ones in the state hospitals. It was also noticed that surgeons' knowledge concerning the duration of antibiotic therapy and urinary infections was not consistent with their attitudes. CONCLUSION: Even though orthopedic surgeons have adequate knowledge about preventing and managing PJI, their attitudes might contradict their knowledge. Future studies are required to examine the causes and solutions of the contradictions between orthopedic surgeons' knowledge and attitudes.

Wide Resection, Extracorporeal Radiotherapy, Ipsilateral Vascularized Fibula Transposition, and Internal Fixation in a Case of Tibia Diaphyseal Ewing's Sarcoma.

A 24-year-old female patient was referred to our hospital with the diagnosis of Ewing's sarcoma localized in the left distal tibia. Neoadjuvant chemotherapy was completed for the patient who had localized disease. En-bloc resection of the tumor segment in the diaphyseal tibia, intraoperative extracorporeal radiotherapy, and then re-implantation of the segment after clearing the tumor were performed. Transfer of the ipsilateral pedicled fibula to the medulla of the irradiated segment was performed. As far as we know, the simultaneous application of extracorporeal radiotherapy and the re-implantation method after resection of the tibial tumoral segment and the transfer of the ipsilateral fibula with its pedicle has not been previously reported in the literature. In this case, this new technique was accompanied by a satisfactory result.

First case of medullary osteogenic sarcoma of the pelvis: 12-year follow-up of reconstruction with hemipelvis allograft after resection.

A 45-year-old male patient with low-grade central osteosarcoma (LGCO) in the periacetabular region underwent wide resection, fresh frozen hemipelvis allograft reconstruction, and total hip prosthesis. To the best of our knowledge, this case is the first example of low-grade osteogenic sarcoma in flat bones. Aseptic loosening of the acetabular cup was observed 44 months after the operation, and it was revised with a constrained acetabular cup. Recurrent subluxation due to constraint ring failure and cup malposition was observed at 89 months after the revision surgery. Revision operation was performed with cage + non-constrained cup. Twelve years after the first operation, he is in exceptionally functional and disease-free condition. He can walk unlimited distances without pain. Radiographs show complete union at the junction of the allograft and disease-free bone.

Outcomes of Planned Marginal and Wide Resection of Sarcomas Associated with Major Vascular Structures in Extremities.

Bone and soft tissue sarcomas of lower and upper extremities may sometimes be in close contact with neurovascular structures. In such cases, it is controversial that whether en bloc resection and vascular reconstruction to reach wider surgical margins or planned marginal resection with the help of adjuvant therapies should be preferred. This study aimed to determine surgical and oncological outcomes of planned marginal and wide resection of extremity sarcomas that are associated with major vascular structures in the extremities. The collected database of 54 patients treated by the same orthopedic and vascular surgeon for primary or locally recurrent soft and bone tissue sarcoma of extremities was retrospectively reviewed. Eligible subjects for this study were patients diagnosed with upper and lower extremity soft and bone tissue sarcomas that encased a maximum of 50% of the circumference of the major vascular structures, requiring limb-sparing resection. When microscopic positive (19 patients, 33.9%) and negative cases' (35 patients, 66.1%) surgical margins were compared, local recurrence, metastasis, amputation, and tumor type (soft/bone) parameters showed no statistically significant difference. When metastatic and non-metastatic patients were compared, it was shown that bone tumors metastasized more than soft tissue tumors (p = 0.001). However, there was no difference between metastasis and amputation, histopathology, grade, nerve involvement, surgical margins, or local recurrences. The mean survival was 1460.6 ± 137.4 days, and the 6-year mortality was 87.5%. Anesthetic and surgical complication rates may be higher since en bloc resection surgeries of large tumors with vascular reconstructions take a very long time. Therefore, we suggest marginal resection with sub-adventitial dissection in those locations and wide resection at other areas according to the surgeon's experiences about safe margin with the contribution of radiotherapy.

Epidemiology of Nosocomial Candidemia, Mortality, and Antifungal Resistance: 7-Year Experience in Turkey.

Candidemia is an important clinical condition that prolongs hospital stays and increases morbidity, mortality, and hospital costs. The aim of this retrospective study was to evaluate the epidemiological and microbiological characteristics of patients with candidemia between January 2013 and December 2019. Two hundred forty-one episodes of candidemia were observed in 230 patients, 45% of whom were female. The median age was 63 years, and 53.9% of the episodes were in the intensive care unit (ICU). Commonly observed predisposing factors for candidemia included antibiotic use (71.3%), urinary catheterization (56.3%), central venous catheter placement (50.3%), total parenteral nutrition (47.9%), solid-organ malignancy (46%), surgery (48.6%), chemotherapy (37%), and steroid treatment (25.5%). The crude mortality rate was 52.7%. A significant difference was found between survivors and non-survivors (P = 0.007) according to the Charlson Comorbidity Index. However, no statistically significant association was found between mortality and age, sex, surgical procedure, catheter-related candidemia, or Candida spp. infection. The most frequently isolated Candida sp. was C. albicans (51%). Overall resistance rates to fluconazole, voriconazole, caspofungin, micafungin, and flucytosine were 3.7%, 0%, 2.5%, 1.8%, and 1.8%, respectively. Consequently, there is a need for tests that provide higher success rates, rapid diagnosis of candidemia, and local epidemiological data on antifungal resistance.