PTH like substance secreting mesenchymal tumor causing oncogenic osteomalacia; unravelling the difficulties in localization - A report of 2 cases.

Background: Oncogenic osteomalacia is a rare paraneoplastic association of Phosphaturic mesenchymal tumor (PMT) secreting excessive levels of a PTH like substance. They usually remain undiagnosed and patients suffer for years. The rarity of this tumor and its non-specific clinical presentations poses great challenge to the treating surgeons. Its management is poorly described in literature. We report two of such rare cases without much diagnostic delay. Case report: We had 2 cases; A 53-year-old south east Asian male with 6 months of debilitating pain over multiple sites, and another 44-year-old male patient with complaints of low back ache, and pain over both lower and upper limbs for 1.5 years. Both had low serum phosphorus and elevated FGF-23 values, but all other parameters were normal. A PMT was suspected and confirmed on a Ga68- DOTATOC scan in both cases, and on complete excision, their symptoms and the altered blood parameters got normalized. Histology was consistent with PMT. Conclusion: Accurate and timely diagnosis of a PMT with non-specific features are extremely challenging, but not without solutions. Even though a tumor of rarity, with the appropriate imaging modalities like Ga68- DOTATOC scan, and estimation of FGF-23 and serum phosphorus levels, they can be diagnosed. Once identified, complete removal is often curative within a few months.

Shoulder injury related to vaccine administration following SARS-CoV-2 inoculation: Case series and review of literature.

Introduction: Shoulder Injuries Related to Vaccine Administration (SIRVA), describes those cases of shoulder severe post-inoculation complications, including pain and prolonged disability. Most of the reported cases have been secondary to influenza vaccination. This study retrospectively describes a series of 18 patients following SARS-CoV-2 inoculation and compares the findings with those previously reported for other vaccines. Materials and methods: Inclusion criteria was onset of symptoms within 48 h after injection, symptoms duration of at least seven days, and restricted range of motion in absence of symptoms prior to vaccination. Average age was 59.4 years old (38-76), and 72.2% were women. Results: In many cases (58%) the initial diagnosis was not clear, which lead to incorrect treatment. The most common pathological finding was subacromial-subdeltoid bursitis (66.6%). All patients who received depot corticosteroids followed by a gentle rehabilitation program showed strong clinical improvement but did not completely resolve the symptoms at 7.2 months average final follow-up. Surgical intervention was necessary in one of the patients due to the persistence of symptoms despite conservative treatment. Conclusions: Shoulder injury related to vaccine administration is rare, but when present, its torpid evolution makes it difficult to treat. We have found in our case series a similar pattern to that already described for other vaccines. A high index of suspicion helps to pick up the condition promptly and early treatment can bring satisfactory outcome.

Arthroscopic capsular release and continuous upper arm brachial block in frozen shoulder - A midterm outcome analysis.

OBJECTIVE: This prospective study aims to evaluate the efficacy of Continuous upper arm brachial block (modified interscalene block) with an arthroscopic capsular release in the outcome of resistant frozen shoulder cases. METHODS: We studied 123 patients who underwent arthroscopic capsular release and subacromial decompression for resistant frozen shoulder cases between June 2016 and July 2019. Postoperative analgesia was provided with Continuous upper arm brachial block and ambulatory patient-controlled analgesia pump for 2-3 weeks. The patients were started on regular physiotherapy on the first postoperative day. All the patients were followed up at 3rd week, 6th week, 3rdmonth, 6th month, 1st year, and 2nd year with VAS and Constant-Murley scores. RESULTS: At a mean follow-up period of 18 months, there was a statistically significant improvement in the range of motion, VAS scores, and Constant-Murley scores postoperatively (p < .01). None of the cases required postoperative opioid administration for pain control. Minor neurological complications like recurrent laryngeal nerve palsy and Horner's syndrome were seen in few cases that resolved with titration of the drug dose. CONCLUSION: Our study verifies the use of continuous upper arm brachial block (CUABB) with a portable infusion pump for 2-3 weeks in arthroscopic capsular release for resistant frozen shoulder cases. It significantly reduced postoperative pain in the initial two weeks that aided with early recovery of the shoulder movements and functions without an increased incidence of acute or chronic neurologic complications.

It is time for a more cautious approach to surgical diathermy, especially in COVID-19 outbreak: A schematic review.

BACKGROUND: Many surgeons are unaware of the risks posed by the surgical diathermy. Apart from the numerous chemicals, surgical smoke had been shown to harbour intact bacterial and virus particles especially COVID-19 in the current time. OBJECTIVE: To identify the inhalational, infectious, chemical, and mutagenic risks of surgical smoke and suggest evidence-based hazard reduction strategies. Also to cogitate on the very high risk of viral spread by the use of surgical diathermy in COVID-19 outbreak. METHODS: A review of articles indexed for MEDLINE on PubMed using the keywords surgical smoke, diathermy, electrocautery, surgical smoke hazards, smoke evacuator, and guidelines for surgical smoke safety was performed. The review included evidences from 50 articles from the dermatology, surgery, infectious disease, obstetrics, and cancer biology literature. RESULTS: There are risks associated with surgical smoke. Although some surgeons were aware, majority were not keen in the hazard reduction strategies. CONCLUSION: Many chemical and biological particles have been found in surgical smoke. It is highly recommended to follow the standardised guidelines for surgical smoke safety. Surgical smoke carries full virus particle(such as COVID-19 virus), it is strongly recommended to minimise or avoid electrocautery during the COVID-19 outbreak.

Acute isolated dorsal midtarsal (Chopart's) dislocation: a case report.

UNLABELLED: Isolated midtarsal (Chopart's) joint dislocations are rare, although cases involving medial, lateral, plantar, and dorsal displacement have been reported. These dislocations are often associated with osteochondral fractures. To the best of our knowledge, isolated dorsal midtarsal dislocation owing to plantarflexion of the forefoot on the hindfoot with the ankle in a neutral or dorsiflexed position is rare. In this article, we describe a case of isolated Chopart's dorsal dislocation and discuss the mechanism of injury, management, and outcome. The patient was treated with open reduction and repair of ligamentous structures, and Kirschner wire transfixation. At approximately 96 weeks following treatment, the patient was walking without aid, despite the development of posttraumatic degenerative changes at the calcaneocuboid joint. In retrospect, primary arthrodesis of the calcaneocuboid joint may have been more beneficial for the patient. We also describe the unusual mechanism whereby a plantarflexory force applied to the forefoot, without ankle plantarflexion, results in dorsal dislocation of the midtarsal joint. LEVEL OF CLINICAL EVIDENCE: 4.

Butterfly vertebra: an uncommon congenital spinal anomaly.

STUDY DESIGN: This is a report of a patient with T6 butterfly vertebra, which is an uncommon congenital spinal anomaly. OBJECTIVE: To illustrate the significance of identifying butterfly vertebra that may be confused with other pathologic conditions like fractures, infections, and metastases. SUMMARY OF BACKGROUND DATA: We report a 46-year-old woman with butterfly vertebra of T6 spine. The patient presented with complaints of low back pain and examination showed an abnormal bony prominence at midthoracic level. Radiologic and hematologic investigations confirmed the presence of butterfly vertebrae at T6 level, which proved to be a coincidental finding along with nonspecific low back pain. Knowledge about this condition is very important, since the condition can be easily confused with a pathologic fracture. METHODS: The patient presented with a history of low back pain of 2 months. The patient was evaluated clinically and with hematological investigations. The diagnosis was confirmed with computerized tomography (CT) and magnetic resonance imaging (MRI) scans. RESULTS: Routine examination of the motor and sensory system was found to be normal. Roentgenogram of the thoracic and lumbosacral spine showed anterior wedging of T6 vertebrae in the lateral view and features suggestive of the presence of a butterfly vertebra at T6 level in the anteroposterior (AP) view. Hematologic evaluation was done to rule out pathologic causes of anterior wedging of the vertebra like infections and metastases in the spine. MRI and CT scans of the spine confirmed the presence of T6 butterfly vertebra. Patient was treated for her low back pain and assured that the abnormal midthoracic bony prominence was a benign condition that needs no treatment. CONCLUSION: A high index of suspicion is needed to identify this benign spinal anomaly that may be confused with many pathologic conditions. Knowledge of this condition helps in making rational use of extensive noninvasive and invasive diagnostic procedures.

Multicentric epithelioid angiosarcoma of the spine: a case report of a rare bone tumor.

BACKGROUND CONTEXT: Epithelioid angiosarcoma (EA) is a high-grade sarcoma of vascular origin. EA is a rare variant of angiosarcoma. It is characterized by large cells with an epethelioid morphology. EA has been reported in sites like skin thyroid, adrenal gland, soft tissue, and rarely in bone. PURPOSE: The current article describes a case of multicentric EA of the spine that presented simultaneously at T4 spine and the posterior one third of the left fourth rib. STUDY DESIGN/SETTINGS: This study included a patient with a rare spinal tumor, which presented insidiously. Radiologically, the lesions were osteolytic with erosion of cortices. The tumor was composed of nests and cords of malignant cells with epithelioid morphology with areas of vascular differentiation, necrosis, and hemorrhage. Anastomosing vascular spaces lined by epithelioid endothelial cells suggested focal endotheliod differentiation. METHODS: Histopathological evaluation of the tumor obtained from en bloc resection of the fourth rib and specimen from decompression of the fourth thoracic vertebra was done. Immunohistochemistry showed positivity for endothelioid cell markers like CD31 and factor VIII related antigen. The authors point out the need for immunohistochemical evaluation after careful histological analysis for vascular differentiation for an accurate diagnosis of vascular bone tumors with epithelioid features so that an erroneous diagnosis of metastatic carcinoma can be avoided. EA occurs rarely in bone. EA is marked by the presence of large polygonal epithelioid malignant cells with marked cellular atypia and pleomorphism. The arrangement of the cells may mimic epithelial neoplasm. These types of lesions are a definite diagnostic challenge in bone biopsy. The tumor was treated with en bloc resection of the rib and decompression of the body of T4 spine, followed by megavoltage radiotherapy. Follow-up X-rays showed regression of the tumor at 2 years. CD31 is the most sensitive marker for EA. Even in the absence of obvious vascular differentiation, abundant intratumoral hemorrhage and intratumoral neutrophils are definite morphologic changes that should suggest a vascular origin. RESULTS: The patient was followed up for 2 years. A conservative surgical approach with a radical course of megavoltage radiotherapy could yield a good result in EA of bone. At the time of writing this report, there is no evidence of tumor recurrence. CONCLUSION: It is important to differentiate EA from other tumors because the clinical course and treatment are specific for these conditions. Careful histologic and immunohistochemical analysis will clinch the diagnosis. Even though rare, we stress the importance to be aware of the existence of this tumor, which is essential for correct diagnosis.

Role of tumor necrosis factor-alpha, interleukin-8, and dexamethasone in the focal adhesion kinase expression by human nucleus pulposus cells.

STUDY DESIGN: Human nucleus pulposus cells from intervertebral disc specimens were cultured to study the effects of tumor necrosis factor (TNF)-alpha and interleukin (IL)-8 on the focal adhesion kinase (FAK) expression by these cells. The effect of co-stimulation with dexamethasone on the FAK expression by nucleus pulposus cells was also studied. OBJECTIVES: To evaluate the possible role of activated FAK expressed by the human nucleus pulposus cells and its correlation with inflammatory cytokines (TNF-alpha, IL-8) and dexamethasone. SUMMARY OF BACKGROUND DATA: There have been no reported studies showing the correlation between the activated FAK expression by human nucleus pulposus cells with inflammatory cytokines and dexamethasone. METHODS: The FAK expression in cultured human nucleus pulposus cells was studied, and Western blot and immunofluorescence analysis were performed to assess its relation to TNF-alpha, IL-8, and dexamethasone. RESULTS: Treatments of TNF-alpha and IL-8 up-regulated the activated FAK expression. Dexamethasone attenuated the cytokine-induced FAK expression. The effects of inflammatory cytokines on the FAK expression were found to be concentration dependent, with greater correlation shown by IL-8 than TNF-alpha. CONCLUSION: TNF-alpha and IL-8 stimulation up-regulated the FAK expression of human nucleus pulposus cells, and the coadministration of dexamethasone attenuated it.