A new era in the management of spinal metastasis.

Despite the recent advances in cancer treatment, the incidence of patients with spinal metastases continues to grow along with the total number of cancer patients. Spinal metastases can significantly impair activities of daily living (ADL) and quality of life (QOL), compared with other types of bone metastases, as they are characterized with severe pain and paralysis caused by skeletal-related events. Reduced ADL can also lead to treatment limitations as certain anticancer agents and radiation therapy are not compatible treatments; thus, leading to a shorter life expectancy. Consequently, maintaining ADLs in patients with spinal metastases is paramount, and spine surgeons have an integral role to play in this regard. However, neurosurgeon, orthopedic and spinal surgeons in Japan do not have a proactive treatment approach to spinal metastases, which may prevent them from providing appropriate treatment when needed (clinical inertia). To overcome such endemic inertia, it is essential for 1) spine surgeons to understand and be more actively involved with patients with musculoskeletal disorders (cancer locomo) and cancer patients; 2) the adoption of a multidisciplinary approach (coordination and meetings not only with the attending oncologist but also with spine surgeons, radiologists, rehabilitation specialists, and other professionals) to preemptive treatment such as medication, radiotherapy, and surgical treatment; and 3) the integration of the latest findings associated with minimally invasive spinal treatments that have expanded the indications for treatment of spinal metastases and improved treatment outcomes. This heralds a new era in the management of spinal metastases.

Walking ability after resection of soft tissue sarcoma of the thigh and the sciatic nerve.

Walking ability may be fairly well maintained after sciatic nerve resection combined with wide resection of soft tissue sarcoma, therefore, surgeons should not hesitate to perform sciatic nerve resection to achieve an adequate surgical margin.

PRRX1-TOP2A interaction is a malignancy-promoting factor in human malignant peripheral nerve sheath tumours.

BACKGROUND: Paired related-homeobox 1 (PRRX1) is a transcription factor in the regulation of developmental morphogenetic processes. There is growing evidence that PRRX1 is highly expressed in certain cancers and is critically involved in human survival prognosis. However, the molecular mechanism of PRRX1 in cancer malignancy remains to be elucidated. METHODS: PRRX1 expression in human Malignant peripheral nerve sheath tumours (MPNSTs) samples was detected immunohistochemically to evaluate survival prognosis. MPNST models with PRRX1 gene knockdown or overexpression were constructed in vitro and the phenotype of MPNST cells was evaluated. Bioinformatics analysis combined with co-immunoprecipitation, mass spectrometry, RNA-seq and structural prediction were used to identify proteins interacting with PRRX1. RESULTS: High expression of PRRX1 was associated with a poor prognosis for MPNST. PRRX1 knockdown suppressed the tumorigenic potential. PRRX1 overexpressed in MPNSTs directly interacts with topoisomerase 2 A (TOP2A) to cooperatively promote epithelial-mesenchymal transition and increase expression of tumour malignancy-related gene sets including mTORC1, KRAS and SRC signalling pathways. Etoposide, a TOP2A inhibitor used in the treatment of MPNST, may exhibit one of its anticancer effects by inhibiting the PRRX1-TOP2A interaction. CONCLUSION: Targeting the PRRX1-TOP2A interaction in malignant tumours with high PRRX1 expression might provide a novel tumour-selective therapeutic strategy.

Rib stress fracture in a female athlete caused by bouncing the barbell in bench press exercise: A case report.

Rib stress fractures can occur in sports involving repetitive trunk muscle contractions. Few documented cases show rib fractures from repetitive upper-limb training. This report presents a case of a rib stress fracture from micro blunt trauma during bench press exercises. The patient was a 24-year-old elite female sprinter with a history of left navicular stress fracture and secondary amenorrhea treatment a year prior. She modified her bench press technique to involve bouncing the barbell on her rib cage. Within weeks, she experienced anterior chest pain, exacerbated by sneezing. Computed tomography revealed a fifth rib fracture with callus formation. After refraining from bench presses for 4 weeks, her chest pain subsided, allowing her to resume upper-limb training. When athletes performing bench press exercises experience chest pain, rib fractures should be considered, even without acute trauma. Additionally, research on the safety of the bouncing bench pressing technique is required.

Reference values of lumbar spine range of motion by sex and age based on the assessment of supine trunk lateral bending-A preliminary study.

[Purpose] The purpose of this study was to clarify the preliminary reference values for the lumbar spine range of motion associated with lateral bending exercises by gender and age group. [Methods] Subjects were 82 volunteers without low back pain, including five males and five females in each age group from 16-19 to 80-89 years. All subjects underwent radiographs of the lumbar spine with lateral flexion; the range of lateral flexion of the vertebrae from T12 to the sacrum (ROLB) was measured twice by three observers. [Results] The ROLB of the entire T12-S1 of all subjects showed a significant negative correlation with age in both sexes (p < 0.01). The ROLB of the lumbar spine tended to be greater in females, with a statistically significant difference between those aged 16-19 and 70-79 (p < 0.05). Lateral flexion angles for each intervertebral segment were largest at L3-L4 and smallest at L5-S1 (0.7°). [Conclusion] Lumbar ROLB reference values were examined by gender and age group; ROLB was greatest in L3-L4, and ROLB tended to be lower in older age groups.

Knee locking caused by osteochondroma of the proximal tibia adjacent to the pes anserinus: A case report.

BACKGROUND: Osteochondroma is one of the most common benign bone tumors, and it may cause bone and joint deformities and limited range of motion of an adjacent joint. The pes anserinus region is one of the most frequent sites of osteochondroma, but knee locking caused by osteochondromas in the pes anserinus region is extremely rare. CASE SUMMARY: We describe a 13-year-old Japanese girl's extra-articular knee locking that occurred when the semitendinosus tendon got caught in osteochondroma that had developed in the pes anserinus region. The osteochondroma was surgically resected. The postoperative outcome has been excellent, with no recurrence of knee locking or tumor one-year post-surgery. CONCLUSION: When a young person develops knee locking, the possibility of extra-articular as well as intra-articular locking should be considered. Osteochondroma, one of the causes of extra-articular locking, can be treated with surgery with good postoperative results.

Radiological and pathological characteristics of synovial hemangioma of the knee.

Synovial hemangioma, a rare benign tumor that occurs most frequently in the knee in children and young adults, has four histological subtypes: Venous, arteriovenous, cavernous and capillary hemangiomas. Since the clinical presentation and radiological findings of synovial hemangioma are non-specific, there is frequently a long period between the onset and the diagnosis. The cases of nine patients, pathologically diagnosed with synovial hemangioma and surgically treated, were retrospectively analyzed. All nine patients had persistent knee pain. In addition, three patients also had a swollen knee with intra-articular hemorrhage. Plain radiography revealed intra-articular phleboliths in two patients. In seven patients, T1-weighted magnetic resonance imaging showed low signal intensity with small signal voids. On T2-weighted imaging, all patients showed high signal intensity containing small signal voids. All patients underwent surgical excision; there was no postoperative recurrence after the final operation, and the knee pain had disappeared at the final follow-up. From the pathological findings, the diagnoses were venous hemangioma, cavernous hemangioma and capillary hemangioma (three patients each).

Dedifferentiation in low-grade osteosarcoma: a Japanese Musculoskeletal Oncology Group (JMOG) study.

BACKGROUND: Low-grade osteosarcomas, namely parosteal osteosarcoma (POS) and low-grade central osteosarcoma (LGCOS), occasionally dedifferentiate into high-grade malignancy, referred to as dedifferentiation in low-grade osteosarcoma (DLOS). This study aimed to elucidate the clinicopathologic features of DLOS, which are poorly described to date due to the extreme rarity of the disease. METHODS: A total of 33 patients with DLOS were included. Clinical characteristics, including the diagnostic accuracy of tumor biopsy, multimodal treatments, and clinical course, were retrospectively reviewed. Univariate analysis was performed to identify prognostic factors associated with overall survival (OS) and metastasis-free survival (MFS). RESULTS: The tumor subtypes comprised 10 cases (30.3%) of LGCOS and 23 cases (69.7%) of POS. The timing of dedifferentiation was synchronous in 25 (75.8%) and metachronous in 8 (24.2%) patients. The rates of preoperative diagnosis of DLOS were 40.0% and 65.4% for core needle biopsy and incisional biopsy, respectively. All patients underwent surgery and 25 patients received perioperative chemotherapy. Of the 13 patients who received neoadjuvant chemotherapy, 11 exhibited a poor histological response. The 5-year OS and MFS rates were 88.1% and 77.7%, respectively. Univariate analysis revealed that local recurrence was associated with poor OS (P < 0.01) and MFS (P < 0.01). Perioperative chemotherapy did not affect OS or MFS. CONCLUSIONS: The diagnostic accuracy of tumor biopsy for DLOS was lower than that for bone sarcomas, as reported previously. In contrast to conventional osteosarcomas with high chemosensitivity, both histological responses and survival analysis revealed low efficacy of chemotherapy for DLOS.

Fibulo-Scapho-Lunate Arthrodesis With Free Vascularized Fibular Graft for a Japanese Kyudo Archer With Osteosarcoma of the Left Distal Radius: A Case Report.

BACKGROUND: Recent progress in the chemotherapy and surgical procedures for osteosarcoma have enabled the preservation of limb function even when cancer occurs in the distal radius, a rare primary site of osteosarcoma. CASE REPORT: We describe a case of osteosarcoma that occurred in an 18-year-old, male Kyudo (Japanese archery) archer's left distal radius. Since the patient desired to resume Kyudo and the left hand was quite important for gripping a bow, we chose partial wrist arthrodesis (fibulo-scapho-lunate arthrodesis) with free vascularized fibular grafting (FVFG) as the reconstruction procedure following wide resection. After the wide resection, the major axis of bone defect was 8 cm. We harvested a free vascularized fibular graft with fascio-cutaneous flap with wide fascia to reconstruct the gliding surface of the extensor tendon. Fibula-proximal radius and fibulo-scapho-lunate fixation was performed by locking plates individually. Vascular anastomosis was performed between the radial artery and peroneal artery in a flow-through manner. Two peroneal veins were anastomosed with the radial vein and cephalic vein. CONCLUSION: Fibulo-scapho-lunate arthrodesis with FVFG may provide satisfied stability and function even in a Kyudo archer. The patient obtained sufficient wrist stability and grip strength, and could resume Kyudo.

Surgical treatment for a combined anterior cruciate ligament and posterior cruciate ligament avulsion fracture: A case report.

BACKGROUND: Independent avulsion fractures with anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL) attachment are relatively common among tibial intercondylar eminence fractures, and their postoperative outcomes are generally favorable. Conversely, huge avulsion fractures of the intercondylar eminence containing the attachment site of both the ACL and the PCL are extremely rare, and the reported clinical outcomes are poor. CASE SUMMARY: We describe a 30-year-old Japanese male's huge avulsion fracture of the intercondylar eminence of a tibia containing the attachment site of both the ACL and PCL, together with a complete tear of the medial collateral ligament and a partial tear of both the medial and lateral menisci caused by a fall from a high place. All of these injuries were treated surgically, with anatomical reduction and stable fixation. The limb function at 1 year post-surgery was excellent (Lysholm score: 100 points). CONCLUSION: Although this patient's complete surgical repair was complex, it should be performed in similar cases for an excellent final clinical outcome.

Pregnancy and Lactation-Associated Osteoporosis Successfully Treated with Romosozumab: A Case Report.

Pregnancy- and lactation-associated osteoporosis (PLO) is a rare type of premenopausal osteoporosis that occurs mainly in the third trimester or immediately after delivery; one of its most common symptoms is back pain caused by a vertebral fracture. The pathogenesis of PLO is unclear, and there is no accepted consensus regarding the treatment of PLO. Although treatments with drugs such as bisphosphonate, strontium ranelate, denosumab, and teriparatide were reported, there is no report of a patient with PLO treated with romosozumab. We present the first case of a patient with PLO treated with romosozumab following 4-month teriparatide treatment. A 34-year-old primiparous and breastfeeding Japanese woman experienced severe low back pain 1 month postdelivery. She was diagnosed with PLO on the basis of low bone marrow density (BMD) and multiple vertebral fractures with no identified cause of secondary osteoporosis. She was treated with teriparatide injection for 4 months, but the treatment was discontinued because of the patient feeling severe nausea after every teriparatide injection and the appearance of new vertebral fractures. Thereafter, we used romosozumab for 12 months. After the romosozumab treatment, her BMD was increased from the baseline by 23.6% at L1-L4, 6.2% at the femoral neck, and 11.2% at the total hip. Treating PLO with 12-month romosozumab after 4 months of teriparatide injection remarkably increased the BMD of the lumbar spine, femoral neck, and total hip without subsequent fracture. Romosozumab has potential as a therapeutic option to improve the BMD and reduce the subsequent fracture risk of patients with PLO.

Progressive enlargement of thoracic ossification of the ligamentum flavum in professional baseball pitchers: a report of two cases.

Both systemic and local factors might influence the development of ossification of the ligamentum flavum (OLF); however, whether specific physical activities play a role in the development of OLF remains unclear. This report presents two cases of thoracic radiculopathy owing to progressive enlargement of thoracic OLF within a few years in Japanese professional baseball pitchers. Two left-handed, Japanese, professional baseball pitchers in their 20s experienced thoracic radiating pain. Mild hypesthesia of the lower thoracic vertebral levels was observed, and an increase in the size of the OLF within a few years was identified in the lower thoracic spine using computed tomography and magnetic resonance imaging. Neither patient exhibited myelopathy and were, therefore, treated conservatively. Both patients were able to return to playing in top condition within 4 months after onset. The findings in these cases suggest that thoracic OLF might increase in size and become exacerbated in certain individuals, such as professional pitchers, who experience repeated, localized, mechanical stress on the thoracic spine, irrespective of age.

Familial development of lumbar spondylolysis: a familial case report of 7- and 4-year-old brothers and their father.

The incidence of lumbar spondylolysis is affected by sex, race, and congenital abnormalities. These differences suggest a genetic component to the etiology of spondylolysis. However, no definitive evidence has been presented regarding the inheritance of lumbar spondylolysis. We report familial cases of lumbar spondylolysis in 7- and 4-year-old brothers and their father, each of whom visited our clinic complaining of low back pain. Spondylolysis in the fifth lumbar vertebra (L5) was identified in both boys and their father from clinical, radiographic, computed tomographic, and magnetic resonance imaging examinations. Conservative treatment was provided for both boys. No bony union of any spondylolytic lesions was obtained, but they returned to sports activity without low back pain. Frequent development of spondylolysis, even at younger ages, in all male family members might indicate an underlying genetic etiology in lumbar spondylolysis, primarily in the form of autosomal dominant inheritance. However, information on patients and their parents should be considered carefully, as bony union with conservative therapy is not expected in such patients.

Periprosthetic Fracture Resembling Atypical Femoral Fracture After Fixation With Retrograde Intramedullary Nail in Elderly Women: A Report of Two Cases.

BACKGROUND/AIM: The number of individuals diagnosed with and requiring medical treatment for osteoporosis continues to increase due to global population aging and the high awareness of osteoporosis. Bone-modifying agents (BMAs) including bisphosphonate and denosumab are widely used for osteoporosis, and atypical femoral fracture (AFF) is also gaining attention as a severe potential side effect of long-term BMA treatment. The definition of AFF excludes periprosthetic femoral fracture; here, we describe two cases of a periprosthetic femoral fracture that resembled AFF. CASE REPORT: The fractures occurred at the proximal tip of the retrograde femoral nail after an internal fixation for a distal femoral shaft fracture in elderly Japanese women. Each woman had been treated with bisphosphonate therapy for >2 years and had continued the bisphosphonate after undergoing surgery for a distal femoral shaft fracture. Each patient had noticed thigh pain before falling down, and plain radiographs showed a short oblique or transverse fracture with medial spike and localized periosteal reaction of the lateral cortex in each case. The fractures were re-fixed with an antegrade intramedullary nail, and bone union was achieved at >1 year after the second operation. Although these two cases were classified as periprosthetic fractures, they fulfilled the characteristics of AFF. CONCLUSION: Physicians should conduct a thorough interview of patients with a history of BMA treatment in order to correctly diagnose periprosthetic fractures that resemble AFFs, and they should be aware that symptomatic fractures can be prevented by prophylactic fixation. The discontinuance of BMA therapy and the introduction of another drug such as teriparatide may lead to faster healing of surgically treated AFFs.

'Acute Masquelet technique' for reconstructing bone defects of an open lower limb fracture.

INTRODUCTION: The reconstruction of bone defects of open lower leg fractures is challenging, and there is no established treatment strategy to date, especially in the acute phase. We report herein an 'acute Masquelet technique' for reconstructing bone defects of open lower limb fractures as the primary treatment in the acute phase. PATIENTS AND METHODS: We retrospectively analyzed the outcomes of seven lower limbs of the seven Japanese patients (five males, two females, aged 24-76 years [mean 53 years]) who underwent the acute Masquelet technique for open fractures with bone defects. We evaluated postsurgical complications including deep infection, absorption of grafted bone, and the final result of the bone union. RESULTS: Deep infection occurred in one of the seven limbs (14%). There was no case with absorption of grafted bone in our series. We have treated two patients who needed additional surgery for delayed bone union. Bone union was eventually obtained in all seven limbs. All of the patients became pain-free and could walk without a cane. CONCLUSION: The 'acute Masquelet technique' was quite useful for reconstructing bone defects of open lower limb fractures as the primary treatment in the acute phase. We believe that this is one of the options that might be successful in the treatment of open lower limb fractures.

Salvage Reconstruction With the Masquelet Technique Following Wide Resection for Chondrosarcoma of the Proximal Femoral Metaphysis: A Case Report.

BACKGROUND: Bone reconstruction following a wide resection for a malignant musculoskeletal tumor remains challenging, especially for an intercalary defect following the resection of a metaphyseal lesion. CASE REPORT: Here, we describe a surgical procedure using the Masquelet technique for the biological reconstruction of a huge subtrochanteric bone defect following failed pasteurized autologous bone grafting for a conventional chondrosarcoma of the proximal femoral metaphysis with a subtrochanteric pathological fracture. The patient, a 43-year-old Japanese male, was able to walk without a cane or a brace at 15 months after the final operation (International Society of Limb Salvage score, 86.7%). CONCLUSION: This procedure should be considered as one of the reconstruction options following the wide resection of malignant bone tumors located in the metaphysis.

Talipes Equinus Deformity Caused by Fibrous Gastrocnemius Muscle Contracture After Direct Contusion in Football Players: Report of Two Cases.

Two main causes of gastrocnemius contracture have been considered: 1) congenital deformities in pediatric patients, such as limb-length discrepancy, cerebral palsy, flatfoot, and clubfoot; and 2) secondary conditions such as immobilization for trauma or a nonfunctional limb. Talipes equinus deformity caused by fibrous gastrocnemius contracture after a direct muscle contusion is extremely rare. We describe 2 cases of talipes equinus deformity caused by fibrous gastrocnemius muscle contracture after a direct contusion in football players. Both of the players had a talipes equinus deformity with a severe restriction of ankle dorsiflexion, and a cord-like structure was observed at the proximal part of the lateral gastrocnemius head. Both patients' histological examinations revealed fibrous tendon-like tissue within the structure. After discission of the cord-like structures, the restriction of ankle dorsiflexion was completely resolved, and the patients were able to fully return to playing football without any discomfort in their calves.