Pediatric Spinal Giant Cell-rich Osteosarcoma: Case Report and Brief Literature Review.

BACKGROUND: Osteosarcoma, the most common primary malignant bone tumor in childhood, very rarely occurs in the spine. Criteria of complete tumor resection/stable reconstruction of osteosarcoma and the latest protocol of neoadjuvant chemotherapy of the spine have not been reported because of its rarity, technical difficulties, and its continued severe surgical risk. CASE REPORT: A 11-year-old female complained of back pain for several months and walking disability. The workup discovered a large destructive bone lesion in the thoracic 12th (Th12) with vertebral body collapse and subluxation, large amount of associated anteroposterior soft tissue components, and narrowing of the spinal canal. Histology at the 1st decompression and emergent instrumentation surgery revealed giant cell-rich osteosarcoma. Following the 1st surgery, we performed three cycles of neoadjuvant chemotherapy based on the osteosarcoma 95J (NECO95J) protocol and evaluated efficacy of chemotherapy on the Th12 tumor. The tumor was isolated only to Th12 spine following chemotherapy. Therefore, following vascular embolization of the Th12 tumor, we performed surgical resection by single posterior approach that included total en bloc spondylectomy (TES). She recovered well postoperatively, without motor or sensory deficit and no back pain. Six cycles of postoperative neoadjuvant chemotherapy were administered after the 2nd surgery and TES. The patient was disease-free at the 8-months clinical and radiological follow-up and showed no neurological involvement at 8-months. CONCLUSION: We reported a case of pediatric spinal osteosarcoma, the surgical technique of complete tumor resection, and stable reconstruction of spinal osteosarcoma. We also discussed the recent neoadjuvant chemotherapy protocol for osteosarcoma.

Neutrophil-, Monocyte- and Platelet-to-Lymphocyte Ratios, and Absolute Lymphocyte Count for Diagnosis of Malignant Soft-tissue Tumors.

BACKGROUND/AIM: Soft-tissue tumors are difficult to differentiate as benign or malignant. Immune markers, such as the neutrophil-lymphocyte ratio (NLR), monocyte-lymphocyte ratio (MLR), platelet-lymphocyte ratio (PLR), and absolute lymphocyte count (ALC) in serum, have been reported to be useful in the diagnosis and predicting prognosis of several malignancies. We investigated the diagnostic value of these immune markers in differentiating soft-tissue tumors. PATIENTS AND METHODS: A total of 692 patients who underwent biopsy or surgery of soft-tissue tumors were included and divided into benign tumor, low-grade malignancy, or high-grade malignancy groups. Immune markers were calculated from the preoperative blood tests and compared between the groups. A receiver operating curve (ROC) analysis was conducted between the benign disease group and a combination of the groups with malignancy to determine which immune marker had the most diagnostic value. RESULTS: NLR and MLR were significantly different between the three groups with benign disease having the lowest value and high-grade malignancies the highest. Benign disease was also associated with lower PLR and higher ALC. There was no difference between the low- and high-grade malignancies in PLR and ALC. From the ROC analysis, NLR had the highest area under the curve (AUC) value of 0.773 out of the four markers. When limited to small tumors (≤30 mm), NLR had the highest AUC value of 0.729. CONCLUSION: The NLR showed the highest diagnostic value, although the diagnostic ability was not adequately high to differentiate benign and malignant soft-tissue tumors alone. NLR may serve as diagnostic support in combination with clinical history, physical findings, and tumor-imaging results.

Oncological and functional outcomes of planned and unplanned excision of soft tissue sarcoma: A retrospective study.

BACKGROUND: In soft tissue sarcomas, the oncological and functional outcomes between planned excision and unplanned excision with additional wide resection remains controversial. The purpose of this study is to determine the impact of unplanned excision on oncological and functional outcomes. METHODS: A retrospective single-center study was performed. Patients with soft tissue sarcoma surgically treated in 2005-2019 were included in this study. A total of 120 patients consisting of planned excision (PE) group (n = 88), and unplanned excision (UE) group (n = 32) were included. Overall-survival (OS), local recurrence-free survival (LRFS), metastasis-free survival (MFS), disease-free survival (DFS), incidence rate of reconstructive surgery and musculoskeletal tumor society (MSTS) score were assessed. Propensity score matching method was used in statistical analysis. RESULTS: The 5-year survival rate of OS, LRFS, MFS, and DFS did not differ between the PE and UE groups, however, rates of reconstructive surgery were higher in the UE group (PE: 48% vs. UE: 84%, p < 0.001). These results did not differ (PE: 41% vs. UE: 82%, p = 0.012) after propensity score matching was performed to align the backgrounds with difference in tumor size and depth. For MSTS score, the total score and "pain" and "emotional acceptance" scores were higher in the PE group before propensity score matching. The "pain" and "emotional acceptance" scores were higher in the PE group after propensity score matching also. CONCLUSIONS: Unplanned excision did not deteriorate oncological outcomes, however unplanned excision lead to unnecessary reconstructive surgery. Unplanned excision adversely affected patient-reported outcomes without worsening pure functional outcomes.

Refractory satellite ganglion cyst in the hallux and finger.

Painful ganglion cysts that develop in the hallux and finger usually enlarge progressively to the peripheral direction. Simple resection of satellite ganglion cyst alone has been reported to cause a high rate of recurrence and treatment is often very difficult. The purpose of this study is to evaluate the appropriate surgical treatment for painful satellite ganglion cysts in the hallux and finger and discuss the origin of the ganglion cysts in cases treated surgically at our hospital. We reviewed five cases (three males and two females, ages 55-87 years), three of which occurred in the hallux and two in the finger. In all cases, the preoperative magnetic resonance image showed a large fluid of the flexor tendon sheath. And also, joint effusion was found in the metatarsophalangeal joint and the proximal interphalangeal joint. The first case of the hallux ganglion underwent simple excision of the cyst and had recurrences three times. In the other four cases, the additional synovectomy of the metatarsophalangeal joint and the proximal interphalangeal joint was performed along with ganglion cyst excision. These cases had no recurrence up to 1 year after operation. Recently, there have been reports that tendon sheath ganglions are connected to the ankle, wrist, hallux, and phalangeal joints. Although there are a few cases in our department, satellite ganglion cyst of the hallux and finger possibly originates from adjacent joints. Additional synovectomy of the affected joint should be performed for the excision of satellite ganglion cyst to prevent recurrence.

Partial trapeziectomy for Eaton stage III thumb carpometacarpal arthritis: ligament reconstruction with tendon interposition using the entire flexor carpi radialis and interference screw fixation.

BACKGROUND: Trapeziectomy with ligament reconstruction and tendon interposition (LRTI) is currently the most popular technique for treating primary osteoarthritis of the thumb carpometacarpal joint. However, reduced trapezial height has sometimes been reported after LRTI. Longer immobilization and delayed rehabilitation times are also problematic. In this study, we evaluated the clinical and radiological outcomes of patients who underwent our modified LRTI procedure. METHODS: Retrospective study included 26 thumbs in 24 cases with advanced stages. Our modified Burton's procedure was as follows: (1) trapeziectomy was limited to distal-half, (2) the entire flexor carpi radialis (FCR) was harvested from the forearm, and (3) half-slip of the FCR tendon was stabilized by interference screw in the first metacarpal bone tunnel. RESULTS: Pain on the visual analogue scale (VAS), the quick Disabilities of the Arm Shoulder and Hand score, tip pinch strength significantly improved postoperatively. The preoperative height of the trapezial space was well-maintained at final follow-up. Magnetic resonance imaging at the one-year follow-up showed the existence of FCR tendon ball in 15 cases. Eighteen housewives resumed their daily activities after a mean period of 10 days postoperative, while another 6 patients returned to their original jobs after 3 weeks. CONCLUSIONS: Our modified LRTI method involves distal-half trapeziectomy and entire FCR interposition. A sewn FCR tendon ball always provide enough volume to fill the trapeziectomy space, which helps to prevent sinking of the metacarpal bone. Our technique produced sufficient ligamentoplasty and allowed early mobilization after surgery.

Effects of sclerostin antibody on bone healing.

Promoting bone healing after a fracture has been a frequent subject of research. Recently, sclerostin antibody (Scl-Ab) has been introduced as a new anabolic agent for the treatment of osteoporosis. Scl-Ab activates the canonical Wnt (cWnt)-ß-catenin pathway, leading to an increase in bone formation and decrease in bone resorption. Because of its rich osteogenic effects, preclinically, Scl-Ab has shown positive effects on bone healing in rodent models; researchers have reported an increase in bone mass, mechanical strength, histological bone formation, total mineralized callus volume, bone mineral density, neovascularization, proliferating cell nuclear antigen score, and bone morphogenic protein expression at the fracture site after Scl-Ab administration. In addition, in a rat critical-size femoral-defect model, the Scl-Ab-treated group demonstrated a higher bone healing rate. On the other hand, two clinical reports have researched Scl-Ab in bone healing and failed to show positive effects in the femur and tibia. This review discusses why Scl-Ab appears to be effective in animal models of fracture healing and not in clinical cases.

Schwannoma in the extremity: clinical features and microscopic intra-capsular enucleation.

Objective: Schwannomas are the most common type of neoplasm of the peripheral nerves. Enucleation is a standard surgical procedure; however, it occasionally results in iatrogenic nerve injury, even with atraumatic procedures. Herein, we present the clinical characteristics of schwannoma arising in the extremities and discuss the clinical outcomes of extra- and intra-capsular enucleation. Patients and Methods: We reviewed 122 schwannomas treated at our institute. Schwannomas arising from the minor nerve (n=30) or intramuscularly (n=15) were operated using the extra-capsular technique. Of the 77 major nerve schwannomas, 62 schwannomas were treated using the intra-capsular technique and 15 schwannomas using the extra-capsular technique. Results: Neurological deficits following enucleation were significantly lower using the intra-capsular technique than with the extra-capsular technique. The patient age, duration of symptoms, maximum tumor diameter, and site of occurrence were not associated with subsequent neurological deficits. With both techniques, no tumor recurrence was observed at the final follow-up. Conclusion: These results support the use of intra-capsular micro-enucleation as a safe and reliable treatment for every type of schwannoma. To minimize the risk of nerve injury, en bloc resection should not be used because the main purpose of schwannoma surgery is the relief of symptoms, not tumor resection.

Combination of Extracorporeally-irradiated Autograft and Vascularized Bone Graft for Reconstruction of Malignant Musculoskeletal Tumor.

BACKGROUND: Reconstruction after wide resection of a malignant musculoskeletal tumor is challenging. We performed biological reconstruction with an extracorporeally-irradiated autograft in combination with a vascularized bone graft. PATIENTS AND METHODS: Fifteen patients who underwent curative resection of malignant musculoskeletal tumor followed by reconstruction with this method were included. Oncological outcomes, survival of the graft, radiological findings and functional outcomes were reviewed. RESULTS: No local recurrences were detected from the irradiated bones, and 93% of the vascularized bone grafts survived. The mean MSTS score was 24.8 in all cases, 22.9 in the osteoarticular cases, and 27 in the intercalary cases. The intercalary tibia cases showed excellent results with a mean MSTS score of 29.3. CONCLUSION: This method has the advantage of combining the mechanical quality of an irradiated autograft and biological quality of a vascularized bone graft. The best indication of this method is for intercalary defects of the tibia.

Unidirectional Porous ß-Tricalcium Phosphate: A New Bone Filling Substitute for Treatment of Distal Radius Fracture in the Elderly Population.

Background: A new beta-tricalcium phosphate with unidirectional pore structure (UDPTCP), Affinos® (Kurray, Okayama, Japan), has been in clinical use since 2015. To date, there have been only a few clinical studies using this material. We report here the first clinical study for distal radial fracture in the elderly population treated with UDPTCP. Methods: Consecutive patients aged 65 years or older with dorsally displaced unstable fracture of the distal radius (n = 36) were treated operatively in our department. Following reduction of the fracture site, a 7 mm size cube of UDPTCP was placed in the gap of the bony defect and the fracture stabilized with mono-axial or poly-axial type locking plates and screws. Remodeling of the UDPTCP was evaluated by plain radiograph and clinical outcomes were also assessed. Results: UDPTCP was significantly resorbed at 2 months after surgery, both at the center and periphery of the material. Complications were only observed in the post-operative period. Significant correction loss of radial alignment was seen in patients stabilized with poly-axial locking plate. The clinical outcome in all cases was excellent. Conclusions: Block UDPTCP is a safe and convenient material for the treatment of distal radius fracture and is replaced within a suitable time period after grafting into the fracture site. UDPTCP and stable internal fixation is therefore a reliable strategy for restoring and preserving anatomical position, especially in the elderly population.

Synovial hemangioma of the knee joint in pediatrics: our case series and review of literature.

BACKGROUND: Synovial hemangioma is a benign intra-articular tumor. This condition is rare and unfamiliar soft tissue tumor to most orthopedic surgeons. Delayed diagnosis causes osteoarthritic damage and the destruction of joint structures due to infiltrating tumor growth. We discuss the patterns of tumor location and the appropriate surgical procedure for this condition. METHODS: Ten patients were treated surgically in our department. These comprised five males and five females ranging in age from 0 to 17 years (average age 12.4 years). Preoperative diagnosis was made using clinical findings, plain radiographs and magnetic resonance imaging. The follow-up time after surgery was at least 3 years. RESULTS: The main symptom was pain. Three cases revealed hemarthrosis. The range of motion of the affected knee joint was limited in five cases. The average time between onset of pain and diagnosis was 3 years. Tumor location was classified into three patterns: (1) anterior patellofemoral joint type in five, (2) posterior popliteal type in two and (3) diffuse proliferation type in two. Open arthrotomy with synovectomy was performed in all cases. No tumor recurrences were experienced after a minimum follow-up of 3 years. CONCLUSION: Clinical symptom and magnetic resonance imaging are helpful to obtain the diagnosis and determine the extent of the lesion. Depending on the tumor location, synovial hemangioma in the knee joint can be classified into patellofemoral, popliteal and diffuse types. Open arthrotomy with sufficient tumor and synovectomy is important to prevent tumor recurrence.

Diffuse Pigmented Villonodular Synovitis Around the Ankle.

BACKGROUND: Pigmented villonodular synovitis (PVNS) is a rare disorder around the ankle joint. The optimal treatment for diffuse-type PVNS is still controversial because of the high incidence of recurrence. We present the clinical features of our patients and review the current diagnostic and treatment modalities. METHODS: Five patients with PVNS located around the ankle were surgically treated. In three patients, diffuse PVNS arose from the ankle joint, and in the other two it arose from the calcaneocuboid and intercuneiform joints. The average follow-up time after surgery was 2.9 years (range, 2-4.6 years). RESULTS: The average time between onset of pain and diagnosis of PVNS was 6.4 years (range, 4-10 years). Arthrotomic tumor resection was performed in all of the patients. In the three patients with ankle joint PVNS, both medial and lateral approaches were used. One patient experienced mild infection at the surgical site, but this healed conservatively. No tumor recurrences had occurred after minimum follow-up of 2 years, although mild pain persisted in the three patients with ankle PVNS. CONCLUSIONS: Diagnosis of diffuse PVNS is frequently delayed due to vague symptoms and variable growth patterns. Orthopedic clinicians should be aware of the existence of this lesion, and it should be suspected in patients with persistent ankle swelling. To prevent tumor recurrence, accurate evaluation of tumor location and careful operative planning are mandatory. A combined surgical approach involving medial and lateral incision is necessary to expose the entire joint cavity.

Functional neuro-vascularized muscle transfer for oncological reconstruction of extremity sarcoma.

The strategy of limb salvage following surgical resection of skeletal tumor has led to an increased demand for more complex reconstructive options in order to achieve better functional outcomes. Functional neuro-vascularized muscle transfer (FMT) is a beneficial tool for restoring joint movement involving the reconstruction of "movement" in the affected extremity. Until now, however, the clinical application of FMT was mainly limited to trauma cases and to date, very few studies have focused on musculoskeletal oncology. In this study, we reviewed patients who underwent wide resection for extremity sarcoma and functional reconstruction using FMT and discussed the advantages, indications and complications of the procedure.

Stimulation of neo-angiogenesis by combined use of irradiated and vascularized living bone graft for oncological reconstruction.

Reconstruction for large bone and osteochondral defects following musculoskeletal tumor excision remains challenging. Mega-prosthesis is clearly a useful reconstructive tool. Because the survival time of tumor patients has been increasing due to better treatment options, the aim of our group is to achieve complete biological reconstruction without using any artificial materials. With this approach, durability would not be a limitation. In the present study, we reviewed the biological reconstructive procedures currently available for large bone defects after tumor excision. Devitalized bone autograft is particularly well suited in the region where allografts are not readily available. However, the complication rate, such as infection and spontaneous bone resorption, was unexpectedly high due to non-viable graft. In an attempt to reduce these complications, we have used irradiated bone autograft in combination with free vascularized viable bone graft. In an experimental study, we demonstrated a neo-vascularization effect of vascularized bone graft with devitalized bone autograft, i.e. to convert dead bone into living bone. Clinically, this technique is best indicated for reconstruction of intercalary bone defect, especially tibial shaft. Some degree of articular change occurs after irradiation and cannot be prevented, even with the combined use of vascularized bone graft. In our experience, secondary procedures such as surface replacement prosthesis are necessary to treat the osteoarthritis in such cases, even if the radiological finding is severe. The rationale for a combined vascularized and irradiated bone autograft is the cumulative advantage provided by the biological properties of the former with the mechanical endurance of the latter.

Reconstruction of the proximal humerus by combined use of extracorporeally-irradiated osteochondral graft and free vascularized fibula following resection of Ewing sarcoma.

Reconstruction of the proximal humerus following limb-saving resection of malignant bone tumor is extremely challenging. We describe here a novel anatomical reconstruction technique in a young patient. A 6-year-old girl with Ewing sarcoma of the proximal humerus was treated by wide excision of the tumor followed by reconstruction with extracorporeally-irradiated osteoarticular autograft combined with an intramedullary inserted free vascularized fibula graft. Proper alignment of the shoulder joint was maintained with no osteoarthritic changes after 16 months. The resulting limb function was satisfactory. This biological reconstruction method was safe and without serious complication. It is indicated for the reconstruction of non-weight-bearing joints and is ideal for the proximal humerus.

Reconstruction of periacetabular bone tumor by vascularized fibula graft and irradiated autograft.

BACKGROUND: Periacetabular reconstruction following malignant bone tumor resection for limb saving is extremely challenging. We attempted a new reconstruction method in two patients by combining a free vascularized fibula graft with an extracorporeally irradiated autograft. PATIENTS: A 14-year-old boy with osteosarcoma and a 44-year-old man with chondrosarcoma were treated with wide excision of the tumor, followed by periacetabular reconstruction with an autogenous, extracorporeally irradiated osteoarticular graft combined with a free vascularized fibula graft. RESULTS: Incorporation of the irradiated pelvic bone was achieved without any complications and the resulting limb function was good. Osteoarthritic changes were seen in one patient. CONCLUSION: This reconstruction method was safe and reliable for primary, limb-sparing surgery. It is best indicated when the femoral head can be preserved and the mechanical strength of the affected acetabulum is maintained.