New method of local adjuvant therapy with bicarbonate Ringer's solution for tumoral calcinosis: A case report.

BACKGROUND: Tumoral calcinosis is a condition characterized by deposits of calcium phosphate crystals in extra-articular soft tissues, occurring in hemodialysis patients. Calcium phosphate crystals are mainly composed of hydroxyapatite, which is highly infiltrative to tissues, thus making complete resection difficult. An adjuvant method to remove or resolve the residual crystals during the operation is necessary. CASE SUMMARY: A bicarbonate Ringer's solution with bicarbonate ions (28 mEq/L) was used as the adjuvant. After resecting calcium phosphate deposits of tumoral calcinosis as much as possible, while filling with the solution, residual calcium phosphate deposits at the pseudocyst wall can be gently scraped by fingers or gauze in the operative field. A 49-year-old female undergoing hemodialysis for 15 years had swelling with calcium deposition for 2 years in the shoulders, bilateral hip joints, and the right foot. A shoulder lesion was resected, but the calcification remained and early re-deposition was observed. Considering the difficulty of a complete rection, we devised a bicarbonate dissolution method and excised the foot lesion. After resection of the calcified material, the residual calcified material was washed away with bicarbonate Ringer's solution. CONCLUSION: The bicarbonate dissolution method is a new, simple, and effective treatment for tumoral calcinosis in hemodialysis patients.

Recycled bone grafts treated with extracorporeal irradiation or liquid nitrogen freezing after malignant tumor resection.

INTRODUCTION: Recycled bone autografts prepared using extracorporeal irradiation (ECIR) or liquid nitrogen freezing (LNF) methods have been used for the reconstruction of skeletal elements after wide resection of sarcomas involving bone tissues. Few reports include long-term follow-up data for histological analyses of recycled autografts, particularly in the case of ECIR autografts. MATERIALS: A total of 34 malignant bone and soft tissue tumors were resected and reconstructed using 11 ECIR- and 23 LNF-recycled autografts; the mean postoperative follow-ups were 14 and 8 years, respectively. ECIR was used for either osteosarcomas or Ewing sarcomas, whereas in addition to these tumors LNF was used for chondrosarcomas and soft tissue sarcomas involving bone tissues. Recycled bone was implanted as total bone, osteoarticular, or intercalary grafts, with or without prosthesis or vascularized fibular grafts. RESULTS: The 10-year graft survival rate was similar between groups, 81.8% using ECIR and 70.2% using LNF. There were no autograft-related tumor recurrences in either group. Graft survival was unrelated to type of graft or additional procedures. Complication rates tended to be higher using ECIR (64%) compared with LNF (52%) and the infection rate was significantly higher with ECIR (27%) versus LNF (0%). At the final assessment, plain radiographs revealed original recycled bone was present in 7 of 11 ECIR cases and in zero cases treated with LNF autografts, indicating that recycled bone treated with LNF autografts was remodeled into new bone. Histological examination of ECIR-treated bones revealed a delayed and incomplete endochondral ossification process, necrosis and empty lacunae. Conversely, LNF autografts showed remodeled bones with normal trabecular structures. CONCLUSIONS: ECIR and LNF treatment of autografts provided adequate tumor control with acceptable clinical results as a reconstruction method.

Extending the usefulness of the Stryker Growing Prosthesis in pediatric patients.

Osteosarcoma is a highly invasive primary bone tumor that predominantly occurs in childhood and adolescence. The Stryker Growing Prosthesis provides a means of reconstructing large bone defects resulting from bone resection in skeletally immature patients. This device can be expanded as the patient grows. The possible length of extension depends on the length of the prosthesis. Because further expansion was not possible, by turning the adjustable part of the extension back to zero and adding a new permanent extension allow the prosthesis to be further adjusted as growth ensues. Using this method/device only, a separate endoprosthesis was required to be attached onto the extension. Therefore, the applicable cases are limited, because of the fact that extensive resection usually means total femoral replacement is best indicated. However, this method is still useful for reducing the number of revision surgeries in such cases. This reduces costs and increases savings for insurers/countries.

Golden Ratio Flap Designed Using the Golden Ratio Rectangle.

Background: Rotation flaps are arcuate repairs that redistribute tension vectors and recruit adjacent and/or distant tissue laxity. The incision curve could be a logarithmic spiral curve to reduce the length of an incision. We propose a rotation flap-the golden ratio flap-designed using a golden rectangle. Methods: The flap incision is an arc though the major square which is beside the minor square of a golden rectangle. The defect is attached to the line of another minor square and diagonal to the major square. The bottom line runs from the incision end to the tangent point of the circle or the oval, and the perpendicular height line runs from the bottom line to the cross point of the flap incision. These parameters were analyzed retrospectively for four superficial sarcomas that were treated using a rotation flap with an incision approximating the logarithmic spiral curve. Results: The ratio of height to bottom of the golden ratio flap design was highly similar to the preoperative flap design in the four cases assessed. With the new design, the ratio of bottom to the defect diameter (minor axis in the oval defect) was 1.3, and for the height, it was 1.4. Conclusions: The golden ratio flap, designed using the golden rectangle, is reproducible. The parameters of height and bottom approximate the flap shape, or the length and width, respectively. For clinical applications, step-by-step guidance for drawing the new flap are also proposed.

System describing surgical field extension associated with flap reconstruction after resection of a superficial malignant soft tissue tumor.

BACKGROUND: Flap reconstruction after resection of a superficial malignant soft tissue tumor extends the surgical field and is an indicator for potential recurrence sites. AIM: To describe a grading system for surgical field extension of soft tissue sarcomas. METHODS: Grading system: CD-grading is a description system consisting of C and D values in the surgical field extension, which are related to the compartmental position of the flap beyond the nearby large joint and deeper extension for the pedicle, respectively. C1/D1 are positive values and C0/D0 are negative. With a known location, 1/0 values can be "p" (proximal), "d" (distal), and "b" (in the tumor bed), and the description method is as follows: flap type, CxDx [x = 0, 1, p, d or b]. RESULTS: Four representative patients with subcutaneous sarcomas who underwent reconstruction using fasciocutaneous flaps are presented. The cases involved a distal upper arm (elbow) synovial sarcoma reconstructed using a pedicled latissimus dorsi (pedicled flap: CpDp); a distal upper arm (elbow) pleomorphic rhabdomyosarcoma reconstructed using a transpositional flap from the forearm (transpositional flap: CdD0); an undifferentiated pleomorphic sarcoma in the buttocks reconstructed using a transpositional flap (transpositional flap: C0D0); and a myxofibrosarcoma in the buttocks reconstructed using a propeller flap from the thigh (pedicled flap: CdDd). CONCLUSION: The reconstruction method is chosen by the surgeon based on size, location, and other tumor characteristics; however, the final surgical field cannot be determined based on preoperative images alone. CD-grading is a description system consisting of C and D values in the surgical field extension that are related to the compartmental position of the flap beyond the nearby large joint and deeper extension for the pedicle, respectively. The CD-grading system gives a new perspective to the flap reconstruction classification. The CD-grading system also provides important information for follow-up imaging of a possible recurrence.

Preoperative Mohs Paste Treatment for a Subcutaneous Sarcoma and a Skin Ulcer to Prevent Intraoperative Bleeding.

Introduction: Mohs paste has a zinc chloride component and the ability to coagulate tissue. Mohs chemosurgery or surgery is a method by which coagulated tissue is removed and can be repeated until the tumor disappears. The palliative purpose of Mohs chemosurgery or surgery is to control bleeding or exudate from a malignancy with a skin ulcer. In the current report, a single application of Mohs paste as a pre-operative treatment for a superficial sarcoma with a skin ulcer prevented intra-operative bleeding. Case Report: Two metastatic sarcomas are described: one in the scalp originating from a rectoperineal dedifferentiated liposarcoma and one in the elbow originating from a humeral telangiectatic osteosarcoma. Mohs paste treatment was performed the day before surgical resection. The Mohs paste procedure successfully prevented intra-operative bleeding from the tumor, leading to easy removal of the tumors with appropriate tumor-free margins. Conclusion: Preoperative Mohs paste treatment is a simple and reliable method. Intra-operative neoplastic bleeding may contaminate the tumor cells within the surgical field; thus the prevention of bleeding with Mohs paste treatment may lead to a decrease in the tumor recurrence rate.

Anatomic variations in retaining ligaments during minimally invasive resection of subcutaneous lipomas.

Objective: Lipomas are common, benign tumors usually located in the subcutaneous tissue. The "one-inch method" is a minimally invasive technique for resecting large subcutaneous lipomas through a one-inch incision after blunt dissection of the lipoma from its peripheral retaining ligaments. The limitations of this method are currently unclear. Materials and methods: We assessed twenty-five patients with large lipomas, defined as a tumor diameter greater than 5 cm. The location of the lipoma was at the shoulder in fifteen patients, the extremity in six patients, and the torso in four patients. Results: The mean operative time for all lesions was 28.3 minutes, with a mean time of 25.9 minutes for lipomas at the shoulder, 21.8 minutes for the extremities, and 47.0 minutes for the torso. We classified patients into three groups according to operative time: the short group (10-29 min), middle group (30-49 min), and long group (50-70 min). For lipomas of the shoulder, there were eleven patients (73%) in the short group, three patients (20%) in the middle group, and one patient (7%) in the long group. For lipomas of the extremity, the groups contained five patients (83%), one patient (17%), and no patients (0%), respectively. For lipomas of the torso, the groups contained one patient (25%), no patients (0%), and three patients (75%), respectively. Conclusions: Lipomas of the torso require a longer operative time than those of the shoulder or extremity; this difference could be due to the number of retaining ligaments present, which is reportedly higher in the back than in the anterior or side body. Lipomas of the back are less amenable to the one-inch method, and posterior shoulder lipomas may take more time than those at other parts of the shoulder or at the extremities.

T2-star (T2*)-weighted magnetic resonance imaging of tenosynovial giant cell tumors.

Purpose: Tenosynovial giant cell tumors (TSGCTs) are benign but aggressive lesions, and the treatment is resection. A low to intermediate signal intensity on both T1- and T2-weighted images of magnetic resonance imaging (MRI) is characteristic, which is similar to the signal intensity of muscle, and therefore can be challenging for lesion detection. T2-star (T2*)-weighted MR images reflect paramagnetic deoxyhemoglobin, methemoglobin, or hemosiderin. Methods: In 23 TSGCT patients (6 male and 17 females), the T2*MRI findings were analyzed. The tumor locations involved 10 large joints including nine knees and one ankle, 10 small joints including six fingers and four toes, as well as three wrists/hands. Results: Ten diffuse and 13 localized tumors were predominantly located in the large joints and small joints, respectively. The T2*-weighted images indicated three signal patterns of low, iso and high signal intensity compared to muscle. Low-, iso- and high-signal intensities were seen in 22 (96 %), 23 (100 %) and 12 (52 %) of the locations, respectively. To distinguish TSGCTs from the surrounding tissue, the low intensity T2*-weighted images and low to intermediate intensity T1-weighted images when compared to muscle and fluid, respectively were useful for the large joints. Low to intermediate intensity on T1- or T2-weighted images was useful to distinguish TSGCTs from subcutaneous tissue in the small joints. Conclusions: MRI using T2*-, as well as T1- and T2-weighted images, may be useful to detect lesions and assess the extent of TSGCTs in a tissue-specific manner, which is important for surgical planning.

Radiographic Evaluation after Arthroscopic Partial Trapeziectomy with Suture-button Suspensionplasty for Thumb Carpometacarpal Arthritis.

Arthroscopic partial trapeziectomy with suture-button suspensionplasty was developed for the surgical treatment of thumb carpometacarpal arthritis. However, the relationship between clinical results and radiographic evidence is unclear. Methods: The authors retrospectively reviewed 33 consecutive patients who underwent arthroscopic partial trapeziectomy with suture-button suspensionplasty for thumb carpometacarpal arthritis between 2016 and 2021. Clinical and radiographic outcomes were recorded, and the correlations between them were evaluated. Results: The average patient age at surgery was 69 years. Patient radiologic evidence was Eaton stage Ⅱ in three thumbs, Ⅲ in 25 thumbs, and Ⅳ in five thumbs. The average trapezial space ratio (TSR) was 0.36 immediately after the operation but declined to 0.32 after 6 months. In contrast, the average joint subluxation was reduced to 0.005 immediately after the operation compared with 0.28 before, and was maintained at 0.04 at final follow-up. A statically significant correlation was detected between grip strength and TSR (P = 0.03), and between pinch strength and TSR (P = 0.02). A significant correlation was detected between TSR and trapezium height (P = 0.0215), which remained after partial trapeziectomy. No correlation was detected between rope position and other clinical or radiographic scores. Conclusions: Suture-button can have an effect on the medialization of the first metacarpal base. Excessive trapeziectomy can result in functional deficiency of the thumb through metacarpal subsidence, which potentially causes loss of grip and pinch strength.

Inhibition of RANKL Expression in Osteocyte-like Differentiated Tumor Cells in Giant Cell Tumor of Bone After Denosumab Treatment.

Giant cell tumors of bone (GCTBs) are locally aggressive tumors with the histological features of giant cells and stromal cells. Denosumab is a human monoclonal antibody that binds to the cytokine receptor activator of nuclear factor-kappa B ligand (RANKL). RANKL inhibition blocks tumor-induced osteoclastogenesis, and survival, and is used to treat unresectable GCTBs. Denosumab treatment induces osteogenic differentiation of GCTB cells. In this study, the expression of RANKL, special AT-rich sequence-binding protein 2 (SATB2, a marker of osteoblast differentiation), and sclerostin/SOST (a marker of mature osteocytes) was analyzed before and after treatment with denosumab in six cases of GCTB. Denosumab therapy was administered a mean of five times over a mean 93.5-day period. Before denosumab treatment, RANKL expression was observed in one of six cases. After denosumab therapy, spindle-like cells devoid of giant cell aggregation were RANKL-positive in four of six cases. Bone matrix-embedded osteocyte markers were observed, although RANKL was not expressed. Osteocyte-like cells were confirmed to have mutations, as identified using mutation-specific antibodies. Our study results suggest that treatment of GCTBs with denosumab results in osteoblast-osteocyte differentiation. Denosumab played a role in the suppression of tumor activity via inhibition of the RANK-RANKL pathway, which triggers osteoclast precursors to differentiate into osteoclasts.

Combined latissimus dorsi and scapular flaps for reconstruction of a large defect after a shoulder sarcoma resection.

Reconstruction with a pedicled latissimus dorsi flap is used for a large defect after resection of soft tissue sarcoma of the shoulder. Primary donor site closure is sometimes difficult and a skin graft is necessary, possibly delaying postoperative chemotherapy. Combined latissimus dorsi and scapular flaps are used for free flaps in head and neck reconstruction. Myxofibrosarcoma resection in the shoulder of a 76-year-old man resulted in a 16 cm diameter skin resection. The defect was reconstructed with a scapular flap (width = 5 cm) for the distal defect and a pedicled latissimus dorsi muscle flap (flap size, 10 × 7 cm) for the proximal defect. Primary closure of the donor site in the latissimus dorsi flap was easy. By adding a scapular flap to the latissimus dorsi flap, the latissimus dorsi flap area can be reduced, making it easy for primary suture and contributing to less invasive surgery.

Clinical Results of Arthroscopic Partial Trapeziectomy With Suture-Button Suspensionplasty for Thumb Carpometacarpal Arthritis.

BACKGROUND: This study represents the clinical results, especially range of motion (ROM) improvement, of arthroscopic partial trapeziectomy with suture-button suspensionplasty for symptomatic grade II and III thumb carpometacarpal arthritis with a minimum 1-year follow-up. METHODS: Thirty-two patients (mean: 67.5 years) with grade II and III thumb carpometacarpal arthritis treated with arthroscopic partial trapeziectomy with suture-button suspensionplasty were retrospectively followed up for at least 1 year. The physical assessments included ROM, pain visual analogue scale (VAS), strength, and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. The physical variables were retrospectively compared before surgery and at the final follow-up. RESULTS: Preoperative radial abduction and palmar abduction (45.4 ± 16.4° and 54.3 ± 13.9°, respectively) were significantly increased at the final follow-up (59.7 ± 16.9° and 65.5 ± 14.2°, respectively). Preoperative VAS score, pinch strength, and DASH score (70.5 ± 14.0, 57.2 ± 24.8% and 36.8 ± 14.8, respectively) were also significantly improved at the final follow-up (7.9 ± 9.1, 91.0 ± 39.6%, and 11.7 ± 10.5, respectively). Complications involved 1 case of irritation of the superficial branch of the radial nerve and 1 case of dystonia. Two suture-buttons were removed due to patient discomfort. CONCLUSIONS: A significant increase in ROM and pain relief was obtained after suture-button suspensionplasty with arthroscopic partial trapeziectomy.

Clinical Outcomes of Patients With Osteosarcoma Experiencing Relapse or Progression: A Single-institute Experience.

BACKGROUND: Patients with osteosarcoma who experience relapse or progression [R/P] have a poor prognosis. METHODS: Data from 30 patients who experienced R/P among 59 with a diagnosis of high-grade osteosarcoma, who were younger than 40 years old between 2000 and 2019, were retrospectively analyzed to identify prognostic and therapeutic factors influencing their outcomes. RESULTS: The 5-year overall survival [OS] rates after the last R/P of patients experiencing first [n=30], second [n=14], and third [n=9] R/P were 50.3%, 51.3%, and 46.7%, respectively. Multivariate analysis did not identify any independent risk factors affecting OS. The 5-year PFS rate of the 30 patients after first R/P was 22.4%, and multivariate analysis identified histologic subtype and curative local surgery as independent risk factors influencing PFS. Long [>6 mo] partial response was observed in three patients treated using temozolomide+etoposide, irinotecan+carboplatin, or regorafenib. CONCLUSIONS: OS rate in the patients with osteosarcoma experiencing R/P included in this study was markedly higher than that reported previously, mainly due to the surgical total removal of tumors, even after subsequent R/P. The recent establishment of salvage chemotherapy or molecular targeted therapy may also increase survival rates in a subgroup of patients.

Reconstruction using low-porosity ß-tricalcium phosphate for a chondroblastoma in the proximal humeral epiphysis.

Chondroblastoma is a locally aggressive tumor, commonly occurring in the epiphysis of long bones. Damage after curettage at the joint surface can occur. Low porosity ß-tricalcium phosphate (ß-TCP) blocks are characterized by their high compression resistance. Reconstruction in which low-porosity ß-TCP blocks are used as a strut have been reported for bone tumors around the knee. In the current report, a 13-year-old female with a chondroblastoma that extended to the subchondral bone of the proximal humeral epiphysis was treated with curettage and strut reconstruction using low-porosity ß-TCP blocks. The implanted ß-TCP blocks were incorporated without damage or shoulder dysfunction. Application of the strut reconstruction method using low-porosity ß-TCP blocks is suitable for a chondroblastoma of the epiphysis in the humerus.

The Association Between the Volar Aspect of the Distal Radial Diaphysis and the Lunate Rotation Center on Lateral View X-ray of the Wrist.

Purpose: For the treatment of severe distal radius fracture dislocations or malunions, especially those accompanied by intra-articular fractures, radiographic indexes based on the relationship between the carpus and radius are occasionally needed to achieve the ideal radiocarpal reconstruction. This study defined a reference point on the lunate and examined whether this point was located on a line extending along the volar aspect of the distal radial diaphysis on lateral radiographs of the wrist. Methods: Two hundred one lateral wrist radiographs of adults were obtained, and the center of a circle passing through 3 selected points on the proximal articular surface of the lunate was defined as the lunate rotation center. Thereafter, the distance between the rotation center and a line extending along the volar aspect of the distal radial diaphysis was measured. Additionally, the distance between the rotation center and the midpoint of the distal articular surface of the lunate was measured. Results: The mean distance between the lunate rotation center and the line extending along the volar aspect of the distal radial diaphysis was -0.01 ± 0.09 mm. The difference in this distance between both wrists in the same patient was 0.3 ± 0.12 mm. The distance between the rotation center and the midpoint of the distal articular surface of the lunate was 0.3 ± 0.05 mm. Conclusions: This study demonstrated that the lunate rotation center was located on a line extending along the volar aspect of the distal radial diaphysis and at the midpoint of the distal articular surface of the lunate. Clinical relevance: This study demonstrates that this association could become an important index for preoperative planning of corrective osteotomy for complicated intra-articular distal radial fracture malunions. Additionally, it may aid in confirming the reduced position during or after surgery for wrist fracture dislocations.

Anterolateral thigh flap for upper extremity reconstruction in older patients.

BACKGROUND: The anterolateral thigh (ALT) flap has been used in upper extremity reconstruction. However, there is no consensus about the age at which the flap can be used safely, which is a concern when applying ALT flaps for upper extremity reconstruction in older patients. We present the results of the use of ALT flap for upper extremity reconstruction in a series of older patients. PATIENTS AND METHODS: Seventeen patients who underwent ALT flaps for soft tissue defects in the upper extremities from 2010 to 2020 were included. The patients' mean age was 63.5 (range, 26-83) years. Ten of seventeen patients were smokers. Defect locations were the dorsum of the hand in seven patients, palm in two patients, dorsum and palm in two patients, and forearm in six patients. Etiologies of the defect were traumatic in 14 patients and malignant tumor in three patients. The defect size was 8 to 25 × 5 to 11 cm. When dissecting the perforators, we preserved the surrounding small muscular and fatty tissue with the perforators and to harvest them together to prevent intima damage. Flap thinning was performed for 16 flaps to adjust the flap thickness to match defect site requirements. We used an end-to-side or interposition arterial anastomosis to regulate the blood flow. RESULTS: The flap size was 9 to 28 × 5 to 13 cm. One patient had venous congestion and vein re-anastomosis was needed. All flaps survived. One patient had a methicillin-resistant Staphylococcus aureus infection and debridement and irrigation was needed. The mean follow-up period was 20 (range, 13-37) months. Fifteen patients returned their previous activities. The mean DASH score was 30.6 (range, 3-70). CONCLUSIONS: Regardless of patient age or smoking status, the ALT flap was a safe and reliable surgical option for soft tissue defect reconstruction of the upper extremity.

Experimental Exploration for Genes Related to Susceptibility and Resistance to Irinotecan.

BACKGROUND/AIM: Anticancer drug resistance is an important issue in cancer treatment. Multiple genes are thought to be involved in resistance to anticancer drugs; however, this is still not fully understood. This study aimed to identify the genes involved in irinotecan resistance and their functional characteristics. MATERIALS AND METHODS: Gene trap insertion mutant Chinese hamster ovary (CHO) cells were used in the experiments, and next-generation sequencing, gene-ontology enrichment, and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses were used to evaluate the biological functions of differentially expressed genes (DEGs). RESULTS: In total, 2,134 DEGs were identified, including 1,216 up-regulated and 918 down-regulated genes. In KEGG pathways, microRNAs in cancer were significantly associated with up-regulated DEGs, while spliceosome and p53 signaling pathways were significantly associated with down-regulated DEGs. The pathway analysis identified several genes that might be involved in irinotecan resistance. CONCLUSION: Using CHO cells, the genes involved in irinotecan resistance and functional characteristics were predicted. These results provide new clues for predicting irinotecan resistance.

Enthesopathy of the bicipital tuberosity of the radius treated under intraoperative computed tomography.

BACKGROUND: There is no report of the application of intraoperative computed tomography to the extremities, and its usefulness is not mentioned. CASE PRESENTATION: We present a case of a patient with the elbow pain and loss of the forearm rotation due to the prominent bicipital tuberosity of the radius, which was diagnosed as enthesopathy. Surgical treatment to excise the prominent part of the bicipital tuberosity of the radius was recommended. However, it is difficult to perform the appropriate excision of the abnormal prominent part because of complications such as bicipital tendon rupture. The patient was successfully treated by surgical resection under the control of intraoperative computed tomography. CONCLUSIONS: Intraoperative computed tomography scan is a useful tool to assess the remaining volume of the abnormal bones.

Intractable Fractures of the Bilateral Proximal Ulnae After 8 Years of Zoledronate Treatment for Breast Cancer Bone Metastasis.

Long-term administration of bisphosphonates strongly suppresses osteoclastic bone resorption and rarely causes atypical fractures. This report presents a case of bilateral atypical ulnar fractures, following an 8-year course of zoledronate to treat breast cancer bone metastasis. Nonsurgical treatment for the left ulnar fracture failed, in spite of minimal displacement with callus formation at initial presentation. After failure of plate fixation with a pedicled vascularized bone graft, removal of osteosclerotic lesions and plate fixation with corticocancellous iliac bone graft resulted in bone healing, although the healing process took 1.5 years. Plate fixation for the contralateral fractured ulna was unsuccessful.