Reconstruction of the elbow with distal humerus endoprosthetic replacement after tumor resection: a systematic review of the literature and institutional case series.

BACKGROUND: Distal humerus replacement (DHR) is a modular endoprosthesis mainly used for bone reconstruction after resection of primary or metastatic bone lesions. Studies on DHR failure rates and postoperative functional outcomes are scarce. We sought to assess implant survival, modes of failure, and functional outcomes in patients undergoing DHR for oncologic indications. METHODS: A systematic review of the PubMed and Embase databases was performed. PRISMA guidelines were followed for this manuscript. Our study was registered on PROSPERO (457,260). Quality appraisal of included studies was conducted using the STROBE checklist. Prosthetic failure was assessed using the Henderson classification for megaprosthetic failures. We additionally performed a retrospective review of patients treated with a DHR for oncologic indications at a large tertiary care academic center. Weighted means were calculated to pool data. RESULTS: Eleven studies with a total of 162 patients met the inclusion criteria. Mean follow-up was 3.7 years (range, 1.66-8 years). Henderson type 2 failures (aseptic loosening) were the most common mode of failure, occurring in 12% of cases (range, 0%-33%). Five-year implant survival was 72% (range, 49%-93.7%). Mean postoperative Musculoskeletal Tumor Society (MSTS) score was 81.1 (range, 74-84.3). In our institutional case series, 2 out of 5 patients had DHR revision for periprosthetic fracture and aseptic loosening at 16 and 27 months after surgery, respectively. CONCLUSIONS: Distal humerus replacement is a successful reconstruction strategy for tumors of the distal humerus, with high implant survival and good to excellent functional outcomes.

Chronic recurrent multifocal osteomyelitis: A multidisciplinary experience of 22 pediatric cases with a mean follow-up of 27 months.

BACKGROUND: Chronic recurrent multifocal osteomyelitis (CRMO) is not a well known disorder among nonpediatricians. The aim of this study is to retrospectively evaluate the clinical outcomes of twenty-two CRMO patients presenting to two referral centres. METHODS: This retrospective study included twenty-two children (12 males, 10 females; mean age 13 years; range 7-17 years). The diagnosis was based on clinical, radiological, and pathological findings. Data were retrieved from hospital charts. RESULTS: The mean delay in diagnosis was 26 months (range, 0-96 months). The mean follow-up after diagnosis was 27.4 months (range, 6-47 months). Symptoms included pain, limping, local swelling, morning stiffness, and fever. 18 patients had multifocal and 4 patients had unifocal disease. Bone lesions were detected with whole-body or local MRI (Magnetic Resonance Imaging). The mean number of bone lesions was 2.5 (range, 1-8). Ten cases underwent biopsy to exclude malignancy and infection. Prior to diagnosis, cast immobilization or curettage was erroneously performed in four patients. One patient suffered from vertebral compression fracture. There is no growth disturbance or deformity in any patient. CONCLUSION: This study demonstrated that early recognition of the disease can be improved by using Bristol criteria which should be evaluated by a multidisciplinary team rather than one single specialist. In this way, the reliability of these criteria is improved and the treatment could be given earlier with decreased delay in diagnosis. This multidisciplinary approach is also important for decision for biopsy, timely aggressive medical treatment, and follow-up of the disease to minimise possible complications.

PD-L1 Status in Tenosynovial Giant Cell Tumors.

Background and Objectives: Tenosynovial giant cell tumors (TSGCTs) are benign soft tissue tumors that are divided into localized- and diffuse-type tumors, according to the World Health Organization classification of soft tissue tumours. The diffuse-type TSGCT sometimes behave aggressively and poses treatment challenges especially in patients with neurovascular involvement. Symptomatic patients who are not good candidates for surgery due to high morbidity risk may benefit from medical therapy. Objectives: Drugs that target programmed death ligand 1 (PD-L1) are among a new generation of medical therapy options, which, recently, have been explored and have displayed promising results in various cancer types; therefore, we aimed to investigate the PD-L1 status of TSGCTs as a possible therapeutic target. Materials and Methods: We assessed the PD-L1 status of 20 patients (15 men and 5 women, median age = 39 years) that had been diagnosed with TSGCTs in a single institution, between 2018 and 2020. The patients had localized- (n = 7) and diffuse-type (n = 13) TSGCTs. Formalin-fixed paraffin-embedded (FFPE) blocks were retrospectively retrieved from the pathology department. An immunohistochemical analysis was performed in sections of 3 micron thickness from these blocks. Results: Seventy-five percent of our patients with TSGCTs were immunopositive to PD-L1 staining. Conclusions: Taking into consideration the high positivity rate of PD-L1 staining in TSGCTs, PD-L1 blockage may be used as a valuable medical treatment for TSGCTs; however, further studies are needed.

Does computerized tomography change the treatment decision in pediatric medial epicondyle fractures?

The amount of displacement in medial epicondylar fracture is one of the most important criteria for treatment decision. The displacement of medial epicondyle fractures of the humerus may be underestimated by standard AP and lateral views of elbow. The aim of the current study is to show the clinical relavance of computerized tomography (CT) for medial epicondyle fractures. A retrospective analysis on patients with medial epicondyle fracture was performed. Measurements were performed by 9 reviewer, there were 12 cases available for review with both radiographs and CT. The difference between measurement of AP Xray versus frontal and axial CT scans was found to be statistically significant for 1st and 2nd assessments (p=0.001). The decision for operative treatment was higher after evaluation with CT for both first and second assessment and this was statistically significant (p=0,0001). CT is found to be superior to determine the real amount of the fracture displacement and was relavant for treatment decision of pediatric medial epicondylar fractures. We also found a better interobserver agreement for axial CT scans relative to treatment decision. Level of evidence : IV.

A treatment strategy for proximal femoral benign bone lesions in children and recommended surgical procedures: retrospective analysis of 62 patients.

PURPOSE: We aimed to develop a surgical treatment strategy for benign bone lesions of the proximal femur based upon retrospective review of our data in 62 children. METHODS: Sixty-two children [38 male, 24 female; median age 9 years (range 5-18 years)] with proximal femoral benign bone lesions were surgically treated between 2005 and 2013. Histopathological diagnoses were simple (31) or aneurysmal (27) bone cysts, and nonossifying fibromas (4). The pathological fracture rate was 77.4 %. Surgical treatment was determined due to four criteria, including patient's skeletal maturity, localization and initial diagnosis of lesion, and amount of bone loss in the femoral neck and lateral proximal femur. Surgical procedure consisted of biopsy, curettage, bone grafting, and internal fixation when required. The median follow-up was 45 months (range 25-89 months). RESULTS: Complete clinical recovery was achieved in 56 (90.3 %) patients between 4 and 8 months postoperatively; full weight-bearing and mobilization, without pain and limping, was possible. The median preoperative and postoperative last follow-up Musculoskeletal Tumor Society (MSTS) scores were 13.3 % (range 10-23.3 %) and 96.6 % (range 90-100 %), respectively (p < 0.0001). The pathological fractures were healed in 10 weeks on average (range 8-12 weeks). Fifty-seven (92 %) patients demonstrated complete or significant partial radiographic healing between 5 and 7 months that maintained throughout follow-up. Local recurrence was not observed, and only 1 (1.6 %) patient required reoperation for partial cyst healing. There were 5 (8 %) complications, 1 (1.6 %) of which required reoperation. CONCLUSIONS: This treatment strategy can provide good local control and excellent functional and radiological results in the management of benign bone lesions of the proximal femur in children.

Oncological approach with antihelminthic chemotherapy and wide resection in the treatment of musculoskeletal hydatidosis. A review of 10 cases with mean follow-up of 64 months.

The objective of this retrospective study was to evaluate clinical outcomes, local recurrence and complication rates of antihelminthic chemotherapy and wide resection in patients with muscle or bone hydatidosis. The authors treated 10 patients (6 females, 4 males) between 2004 and 2012: 8 with muscle and 2 with bone hydatidosis. The mean age at surgery was 42.5 years (range, 11-66 years). All patients were treated with wide resection and pre- and postoperative chemotherapy with albendazole. The mean follow-up was 64 months (range, 28-120 months). All patients achieved satisfactory clinical outcomes. There were no local recurrences. Surgical complications were seen in 3 patients (30%) : one superficial infection, one deep infection, and one hematoma. Two (20%) required additional surgery. An aggressive oncological approach, consisting of antihelminthic chemotherapy and wide resection, can provide favorable clinical outcomes and prevent local recurrence in patients with musculoskeletal hydatidosis. Potential complications of aggressive surgery should be preferred to potential morbidity of local and systemic dissemination.

Wound-Healing Effects of Common Antineoplastic Agents and Perioperative Considerations for the Orthopaedic Surgeon.

In oncologic patients, optimal postoperative wound healing is crucial for the maintenance of systemic therapies and improved survival. Although several risk factors for postoperative wound complications have been identified, the clinical effect of new antineoplastic agents on wound healing remains uncertain. The available literature on the effect of antineoplastic agents in wound healing is complex to analyze because of other confounding risk factors such as radiation therapy and certain patient-specific variables. Available perioperative drug recommendations are based on database opinion and case reports from adverse event alerts. This review highlights the characteristics of old and new antineoplastic agents commonly used in the treatment of sarcoma, carcinoma, and other cancers and their potential effects on the wound-healing process. It also aims to provide perioperative treatment cessation recommendations to guide orthopaedic surgeons and prevent drug-related wound complications to the fullest extent possible.

What is the diagnostic accuracy of fluorescence-guided surgery for margin assessment in appendicular bone and soft tissue tumors? - A systematic review of clinical studies.

BACKGROUND: Fluorescence-guided surgery (FGS) is a novel technique to successfully assess surgical margins intraoperatively. Investigation and adoption of this technique in orthopaedic oncology remains limited. METHODS: The PRISMA guidelines were followed for this manuscript. Our study was registered on PROSPERO (380520). Studies describing the use of FGS for resection of bone and soft tissue sarcomas (STS) on humans were included. Diagnostic performance metrics (sensitivity, specificity, positive predictive value [PPV], negative predictive value [NPV] and accuracy) and margin positivity rate were the outcomes assessed. RESULTS: Critical appraisal using the Joanna Brigs Institute checklists showed significant concerns for study quality. Sensitivity of FGS ranged from 22.2 % to 100 % in three of the four studies assessing his metrics; one study in appendicular tumors in the pediatric population reported 0 % sensitivity in the three cases included. Specificity ranged from 9.38 % to 100 %. PPV ranged from 14.6 % to 70 % while NPV was between 53.3 % and 100 %. The diagnostic accuracy ranged from 21.62 % to 92.31 %. Margin positivity rate ranged from 2 % to 50 %, with six of the seven studies reporting values between 20 % and 50 %. CONCLUSIONS: FSG is a feasible technique to assess tumor margins in bone and STS. Reported performance metrics and margin positivity rates vary widely between studies due to low study quality and high heterogeneity in dying protocols. LEVEL OF EVIDENCE: Level III, diagnostic study.

The Biocompatibility of a New Type of 45S5 Bioactive Graft in a Sheep Model: A Pilot Study.

Background Bone is a dramatically regenerating tissue with the ability to heal after trauma, although intensive surgical management is required to treat considerable damage. In this study, 45S5 bioactive grafts were prepared through the melt-quenched method in compliance with the guidelines on medical product requirements (MDD regulations; 93/42/EEC Annex-II section 3&4 and ISO standardizations; ISO 13485:2016) for bone repair and regeneration. Methodology After preparing the graft/scaffold, it was evaluated for biocompatibility according to the principles of "lSO 10993-6 2015 Biological evaluation of medical devices: Tests for local effects after implantation, Annex D 'Test method for implantation in bone,'" "lSO 10993-2:2005 Biological evaluation of medical devices: Animal welfare requirements," and "lSO 10993-12 2012 Biological evaluation of medical devices sample preparation rules and standards." Defects were created on the tibia of the right hind leg. The defects were filled with 3-mm bioactive granules, and a cylindrical polypropylene biocompatible material was used as a negative control. After 120 days, the sheep were sacrificed, and the tibia were analyzed. Results The results demonstrated the safety of 45S5 bioactive grafts. Histological evaluation showed no signs of pathological changes around the implant area. Hematoxylin and eosin sections demonstrated the presence of a few multinucleated giant cells, macrophages, and non-irritant mild fibrotic changes on the surface of the biomaterial. Conclusions 45S5 bioactive glass was found to be biocompatible in a sheep model, demonstrating its capacity to promote bone consolidation while also justifying its further preclinical application as a bone-bonded material owing to the layer formation of the growing bone mineral.

External validation of the PATHFx decision-support tool on Turkish patients with skeletal metastasis.

Objective: Accurate determination of life expectancy becomes very important when determining the treatment of patients with pathologic fractures. We aimed to investigate the predictive role of the PATHFx model in Turkish patients by estimating the area under curve (AUC) of the receiver operator characteristic (ROC) and externally validating the results of PATHFx on the Turkish population. Methods: The data of 122 patients who presented to one of four orthopaedic oncology referral centres in Istanbul (2010-2017) and underwent surgical management of pathologic fractures were retrospectively collected. Patients were evaluated according to age, sex, type of pathologic fracture, presence of organ metastasis, presence of lymph node metastasis, haemoglobin concentration at presentation, primary oncologic diagnosis, number of bone metastases, and Eastern Cooperative Oncology Group (ECOG) status. Estimations of the PATHFx program by months were statistically evaluated using ROC analysis. Results: In our study population (122 patients), all survived the first month, 102 survived the third month, 89 were alive at 6 months, and 58 patients survived at 12 months. At 18 and 24 months, 39 and 27 patients were alive, respectively. The AUC value was 0.677 at 3 months, 0.695 at 6 months, 0.69 at 12 months, 0.674 at 18 months, and 0.693 at 24 months. The 3-, 6-, 12-, 18-, and 24-month survival rates were statistically significant (P < 0.01 and P < 0.05). ECOG performance status was 0-2 points in 33 patients (Memorial Sloan-Kettering Cancer Center (MSKCC) data set: 93 cases, our data set: 33 cases). ECOG performance status was 3-4 points in 89 patients (MSKCC data set: 96 cases, our data set: 89 cases). Conclusions: The objective data used by PATHFx for prediction provided statistically accurate estimates on Turkish patients, who are presumed to have mixed genomes through history from both Europe and Asia, and demonstrates its applicability to the Turkish population.

The Impact of COVID-19 Pandemic Restrictions on Musculoskeletal Pathology Services.

BACKGROUND AND OBJECTIVES:  The COVID-19 pandemic has had a negative impact on healthcare in musculoskeletal pathology. There is no standard protocol for pathology services during a pandemic. The study aimed to assess the impact of COVID-19 restrictions on the workload of the musculoskeletal pathology service and the hurdles faced in collaboration with the orthopedic oncology unit in a tertiary reference center in a developing country. MATERIALS AND METHODS:  The pathology reports from mid-March to mid-June 2019, 2020, and 2021 were retrospectively reviewed. RESULTS:  Significant differences were found between the pandemic period (2020) and the non-pandemic periods (2019-2021) in benign bone and soft tissue lesions, resection surgeries, and soft tissue tumors, which were more prevalent in the non-pandemic periods. However, there was no significant decrease in biopsy procedures. Conclusion: During the pandemic period, the biopsy procedure appears to be feasible for bone and soft tissue lesions without the need for anesthesia.

Effect of fracture location on rate of conversion to open reduction and clinical outcomes in pediatric Gartland type III supracondylar humerus fractures.

BACKGROUND: Supracondylar humerus fractures are the most common form of elbow fracture in children and adolescents. At present, treatment planning is based on the Gartland classification. Reduction and percutaneous pinning are done for Gartland type III fractures. In cases where closed reduction is unsuccessful, the procedure is converted to open reduction. However, there is no consensus on which patients are more likely to require conversion to open reduction. The aim of this study was to investigate the effect of fracture location on the rate of conversion to open reduction and clinical outcomes. METHODS: A total of 112 patients who underwent early surgery for Gartland type III supracondylar humerus fracture between August 2011 and August 2017 were evaluated. The patients' age, sex, facture location, post-operative loss of reduction, and complications were noted. The fractures were classified according to fracture level relative to isthmus (high level) or at/below the isthmus (low level). Closed reduction was initially preferred. Open reduction with percutaneous pinning was performed, when necessary. Flynn's criteria were used to evaluate elbow motion after treatment. RESULTS: Mean follow-up time was 39 months (16-62 months). The mean age of the patients was 6.4±2 years (1.4-12 years). Thirty-nine of the patients were female, 73 were male; 32 fractures were in the dominant arm, 80 were in the non-dominant arm. Ninety of the fractures were classified as high level (proximal) and 22 as low level (distal). Patients with low-level fractures were significantly younger (p<0.01). Patients with low-level fractures also showed a significantly higher rate of conversion to open reduction compared to those with high-level fractures (p<0.01). Clinical outcomes evaluated with Flynn's criteria were statistically equivalent between the high and low fracture groups (p>0.05). CONCLUSION: The Gartland classification provides important guidance for the treatment of supracondylar humerus fractures, but may have limitations. Our results suggest that revising the classification by incorporating fracture location may be more beneficial for pre-operative planning.

Quadriceps reconstruction with suture anchor and Achilles allograft combination in quadriceps tendon re-rupture after primary surgical repair: A novel technique.

Quadriceps ruptures are one of the pathological conditions of the knee extensor mechanism, accounting for 3% of all tendon injuries. These injuries cause substantial disability of the extensor mechanism. Primary repair is the treatment of choice in acute presentation. In the setting of chronic conditions, the treatment becomes more challenging. Available surgical options include lengthening procedures, and reconstruction with auto graft or allografts. The traditional Scuderi and Codivilla techniques are challenging to perform in degenerative or traumatic retracted ruptures. There is no standard effective treatment in these patients, which yields the best clinical and biomechanical outcomes. An 18-year-old male patient with quadriceps re-rupture after a primary repair was managed with allograft reconstruction using suture anchors. At six years of follow-up, the patient gained a full range of motion with excellent clinical outcomes. He returned to his previous work. In conclusion, quadriceps reconstruction using suture anchor and Achilles allograft combination is a feasible technique in neglected cases who present with quadriceps tendon re-rupture after primary surgical repair.

Rosai-Dorfman Disease of the Talus in a Child: A Case Report.

BACKGROUND: Primary Rosai-Dorfman disease of bone is a rare disorder. Radiologic and clinical evaluation is insufficient in differentiating malignancy from these lesions. METHODS: We present a talar lesion in a 17-month-old boy who presented with deterioration in gait pattern, limping, pain, and swelling of the left ankle of 4-months' duration. Curettage and demineralized bone matrix grafting were performed. RESULTS: At 1 year after surgery, complete clinical and radiological healing was obtained. CONCLUSIONS: Primary RDD of bone may present a diagnostic challenge. The condition must be included in the differential diagnosis of lytic or lucent lesions of the skeleton. Curettage and grafting provide satisfactory outcomes in talar RDD lesion in the pediatric age group.

Do Magnetically Controlled Growing Rods Stimulate Longitudinal Vertebral Growth in Early-Onset Scoliosis Patients?

OBJECTIVE: Distraction-based systems are the most common systems used in the treatment of early-onset scoliosis. In addition to its corrective and deformity progression preventive properties, its vertebral growth stimulation effect has been proved. Recently popularized magnetically controlled growing rods (MCGRs) showed superior results in terms of outcomes and decreased complication rate. Its vertebral growth stimulation effect has not been studied. The aim of the study is to evaluate the vertebral growth stimulation effect in patients treated with MCGR. METHODS: Patients with progressive scoliosis treated by dual MCGR, who had no obvious lumbar vertebral deformity and had a regular 3-month interval spinal lengthening for at least 30 months, were subdivided into 2 groups according to the inclusion of L3 vertebra within instrumentation segments. The L3 vertebral vertical and horizontal lengths were measured postoperatively and at the last follow-up, and their differences were analyzed statistically in both groups. RESULTS: Twenty-four patients were included; 18 of them had an L3 vertebra outside instrumentation segments, while the other 6 had spanned by MCGR. Uninstrumented L3 were followed up for an average of 36 months. The height difference between initial postoperative examination and the last follow-up was 3.55 mm ± 0.63 mm, and the width difference was 3.85 mm ± 0.75 mm. Conversely, patients with instrumented L3 were followed up for a mean of 38.9 months. Their initial postoperative examination and last follow-up differences in height and width were 6.91 mm ± 1.11 mm and 3.66 mm ± 0.92 mm, respectively. CONCLUSIONS: Frequent distractions stimulate longitudinal vertebral growth in vertebrae spanned by MCGR.

Short Segment Spinal Instrumentation in Early-onset Scoliosis Patients Treated With Magnetically Controlled Growing Rods: Surgical Technique and Mid - Short-term Outcomes.

STUDY DESIGN: A prospective, a single-institution, nonrandomized study. OBJECTIVE: The aim of this study was to evaluate the safety and effectivity of short-segment instrumentation in early-onset scoliosis (EOS) patients treated by magnetic-controlled growing rods (MCGRs). SUMMARY OF BACKGROUND DATA: Despite the common use of conventional growing rods and the recent popularity of MCGR in the treatment of progressive EOS, distal instrumented vertebra and number of the spanned levels are not standardized. METHODS: Patients with progressive EOS, characterized by the major thoracic curve and nonstructural compensatory curve, were a candidate to be treated by dual MCGR short segment spinal instrumentation spanning the major thoracic curve; such patients are followed up for a minimum period of 30 months. Radiological data were collected and analyzed in terms of Cobb angle of both primary and secondary curve, kyphosis angle, T1-T12, and T1-S1 distances, and T1-T12/T1-S1 ratio in preoperative, postoperative, and last follow-up. RESULTS: Sixteen patients with different diagnoses of EOS, mean age at the operation was 7 years and 10 months (5 years and 6 months-9 years and 10 months), and mean period of follow-up was 37 (30-54) months. The Cobb angle of both major and compensatory curve are corrected by the mean value of 62° (44-85), 35° (22-45) preoperatively to 29° (12-49), 14° (9-24) postoperatively, and maintained at 28° (10-47), 10° (2-20) in the last follow-up, respectively. The T1-T12/T1-S1 ratio was 0.58 preoperatively, 0.6 postoperatively, and 0.62 at the last follow-up. The average yearly T1-T12 and T1-S1 length increase were calculated as 7 and 9 mm/year, respectively. CONCLUSION: Selective fusion principals are applicable to EOS, in that short segment instrumentation with MGCR in thoracic curve EOS patients is an effective technique in correction of both structural and compensatory curve, and in maintaining the correction during subsequent nonsurgical spinal distraction. LEVEL OF EVIDENCE: 4.

The influence of acetabular morphology on prediction of proximal femur fractures types in an elderly population.

INTRODUCTION: The role of proximal femur morphology to the development of certain proximal femur fracture types both femoral neck and trochanteric fractures has been observed. However, the relavance of acetabular morphology to the development of proximal femur fractures is not extensively questioned. Therefore the aim of the study was to determine whether there is a correlation between acetabular morphology and pathogenesis of 2 different hip fracture types after low energy trauma. METHODS: This retrospective study includes 60 cases (41 women, 19 men) with a proximal femoral fracture after a low energy trauma between July 2012 and December 2014. Acetabular depth and acetabular index were measured on pelvic radiographs. Neck shaft angle, hip axis length and cortical index were measured on pelvic computed tomography scans. All measurements were performed on the contralateral hip. RESULTS: Mean age was 77.56 ± 8.99 years (range 61-92 years). No statistically significant difference was found with regard to neck shaft angle, acetabular depth or cortical index measurements between patients with femoral neck fracture and patients with trochanteric femoral fractures (p>0.05). Acetabular index measurement was higher (p = 0.001) and hip axis length measurement was lower (p = 0.001) in trochanteric fracture group as compared to femoral neck fracture. CONCLUSIONS: The rate of trochanteric femur fractures is higher in patients with high acetabular index, whereas the rate of femoral neck fractures is higher in patients with increased hip axis length.

Minimal invasive intralesional excision of extremity-located osteoid osteomas in children.

In this retrospective study, we evaluated the efficiency of minimal invasive intralesional extended curettage in the treatment of osteoid osteomas of the extremities in children. Forty-seven children (29 males, 18 females; mean age 10.5 years; range 4-19 years) with osteoid osteoma of the extremities underwent minimal invasive intralesional extended curettage. The exact localization of the nidus was determined preoperatively by thin-section (1-1.5 mm) computed tomography scans, and complete excision of the nidus was performed using a modified burr-down technique. None of the procedures required bone grafting or internal fixation. The median follow-up duration was 59 months (range, 12-136 months). Histopathological confirmation of osteoid osteoma was achieved in all procedures. All patients experienced immediate and complete relief of lesional pain after surgery. Preoperative (a day before surgery) and postoperative (at the time of discharge) mean visual analogue scale scores, questioning the pain derived from osteoid osteoma, were 7.7±1.2 and 0.3±0.6, respectively, confirming complete removal of the nidus. Early motion of the involved extremities and mobilization of the patients were achieved within 2 days. The children resumed normal function within 3 weeks. Postoperative complication or recurrence was not encountered in any of the patients. Even though percutaneous radiofrequency thermoablation is accepted as the treatment of choice for extraspinal osteoid osteomas, this technique requires a regional reference institution. Minimal invasive intralesional extended curettage can be performed in conventional institutions, even those not specialized in bone tumor surgery, by orthopedic surgeons with high success and low morbidity rates, in addition to rapid functional recovery.

A comparative study for the treatment of simple bone cysts of the humerus: open curettage and bone grafting either without instrumentation or with intramedullary nailing.

Functional and radiographic outcomes, in addition to complication and reoperation rates of open curettage and grafting without instrumentation or with intramedullary nailing, in the treatment of simple bone cysts (SBCs) of the humerus were compared. Thirty-seven children [25 males, 12 females; median age=9.5 years (range, 3-17 years)] with humeral SBC were treated with curettage and grafting without instrumentation (group 1, 21 patients) or with intramedullary nailing (group 2, 16 patients). The pathological fracture rate was 85.7% in group 1 and 87.5 in group 2. The follow-up duration ranged from 26 to 85 months. The average last follow-up Musculoskeletal Tumor Society functional scores for groups 1 and 2 were 28.9 and 29.5 (P>0.05). Higher, but statistically insignificant (P>0.05), complete or significant partial radiographic healing rates were achieved in group 2 (100%) compared with group 1 (76.2%). The overall complication rate of the entire study population was 21.6% (19%; 4/21 in group 1; 25%; 4/16 in group 2). The reoperation rates for groups 1 and 2 were 9.5% (2/21; one for partial cyst healing, one for recurrence) and 56.25% (9/16; one for surgical complication, eight for implant removal). Surgical intervention is indicated for selected patients with SBCs. Even though perfect functional results were possible with open curettage and grafting, continuous intramedullary decompression with elastic nails led to a higher radiographic healing rate in the treatment of humeral SBCs. Open curettage and grafting with or without intramedullary nailing was associated with a high number of complications, but the rate of reoperation for complications was very low.

Solitary cystic tuberculosis of the distal femur and proximal tibia in children.

Pediatric skeletal (extraspinal) tuberculosis may mimic pyogenic infections and bone tumors. The aim of this study was to show a multimodality approach to the correct diagnosis and to evaluate the long-term clinical and radiological results of curettage and antituberculosis treatment. Between 2004 and 2012, we treated eight children (five boys, three girls) with histologically proven solitary cystic tuberculosis of the proximal tibia and distal femur. The average age at presentation was 4 years (range, 2-6 years). Except for one case with metadiaphyseal involvement, all lesions were located in the metaphysis and crossed the physis in three. The patients were managed by curettage without bone grafting, followed by antituberculosis therapy. The average follow-up was 4 years (range, 2-7 years). All children achieved complete clinical and radiological healing without any residual lesion or recurrence. In three cases with epiphyseal involvement, the growth plate maintained its function and gradually remodeled within 24 months, without any deformity. No surgical complication was observed. The diagnosis of pediatric skeletal tuberculosis can be made with a good correlation of clinical, radiological, and histological findings. High healing rates can be achieved with surgical debridement and chemotherapy.