Controversies in orthopaedic oncology.

Chondrosarcoma is the second most common surgically treated primary bone sarcoma. Despite a large number of scientific papers in the literature, there is still significant controversy about diagnostics, treatment of the primary tumour, subtypes, and complications. Therefore, consensus on its day-to-day treatment decisions is needed. In January 2024, the Birmingham Orthopaedic Oncology Meeting (BOOM) attempted to gain global consensus from 300 delegates from over 50 countries. The meeting focused on these critical areas and aimed to generate consensus statements based on evidence amalgamation and expert opinion from diverse geographical regions. In parallel, periprosthetic joint infection (PJI) in oncological reconstructions poses unique challenges due to factors such as adjuvant treatments, large exposures, and the complexity of surgery. The meeting debated two-stage revisions, antibiotic prophylaxis, managing acute PJI in patients undergoing chemotherapy, and defining the best strategies for wound management and allograft reconstruction. The objectives of the meeting extended beyond resolving immediate controversies. It sought to foster global collaboration among specialists attending the meeting, and to encourage future research projects to address unsolved dilemmas. By highlighting areas of disagreement and promoting collaborative research endeavours, this initiative aims to enhance treatment standards and potentially improve outcomes for patients globally. This paper sets out some of the controversies and questions that were debated in the meeting.

Prognostic Factors Influencing Survival and Oncological Outcome in Patients with Parosteal Osteosarcoma.

This study aimed to evaluate the significance of radiological (magnetic resonance imaging [MRI]) findings, surgical, and previous interventions on prognosis with oncological and functional outcome in patients with parosteal osteosarcoma (POS). Twenty-seven patients (8 male/19 female) who were operated with the diagnosis of primary POS in our institution were retrospectively reviewed. The epidemiological data, biopsy method, misdiagnosis/improper interventions, and delay in diagnosis were noted. The lesions' maximum circumferential extension, maximum longitudinal extension, intramedullary involvement, and neurovascular extensions in MRI sections were evaluated, and the resection type (segmental intraarticular/segmental intercalary/hemicortical), reconstruction type (biologic/non-biologic), and surgical margins were noted. Functional and oncological results at the last follow-up were assessed. The mean age was 31.6 (12-73) years, and mean follow-up was 80.8 (24-270) months. Intramedullary involvement percentage was related with maximum circumferential extension percentage and maximum longitudinal extension. (p = 0.006, p = 0.005) The intramedullary involvement ratio of ≤ 10% suggested no recurrence or metastasis. The neurovascular encasement was related to metastatic disease, deep infections, and complication related surgeries (p = 0.017, p = 0.002, p = 0.005). The most common resection type was segmental intraarticular resection (63%). The maximum circumferential extension percentage, the maximum longitudinal extension of the lesion, intramedullary involvement percentage, and neurovascular encasement had lower MSTS scores (p = 0.003, p = 0.028, p = 0.038, p = 0.022). The mean MSTS score was 81.1% (60-100%). The 5-year overall survival was 96.3%, local recurrence-free survival was 77.2%, and metastasis-free survival was 69.4%. The lesions' extent of intramedullary involvement, neurovascular bundle proximity, and maximum periosteal circumferential extension on MRI should be considered when planning the surgery.

Is higher body mass index associated with secondary osteoarthritis in patients treated with bone cement for benign aggressive bone tumors? Long-term evaluation of 43 patients.

BACKGROUND: This study was designed to investigate the secondary osteoarthritis rate in patients with benign aggressive bone tumors treated with curettage and cementing at long-term follow up. METHODS: Patients diagnosed with benign aggressive bone tumor (giant cell or aneurysmal bone cyst), treated with extended curettage and cementation with polymethylmethacrylate, who had a minimum of 60 months of follow up after surgery were included in this study. After definitive diagnoses were confirmed by a histopathologist, we decided to perform standard surgical management. Osteoarthritis was staged radiologically using the Kellgren-Lawrence scoring system, and the contralateral knees of the patients were used as the control group. Based on the Kellgren-Lawrence classification system, stages 3 and 4 were accepted as the existence of osteoarthritis. Body mass index, the distance to the subchondral joint line, tumor mass volume, the location of the tumor (i.e., femur, tibia, medial condyle, or lateral condyle), age, and sex were also investigated, all of which are factors that can affect the occurrence of osteoarthritis. RESULTS: Forty-three patients, 24 male (56%) and 19 female (44%), were included in the study. The mean age of the patients was 29.5 ± 10 years, and mean follow up duration was 128.7 months. Tumor localization was the distal femur in 20 patients (46.5%) and the proximal tibia in 23 patients (53.5%). The mean tumor mass volume was 77.84 cm3 and the distance to the knee joint subchondral line was 3.2 ± 2 mm. According to this scoring system, 14 patients were at stage 0, 10 patients were at stage 1, 10 patients were at stage 2, four patients were at stage 3, and five patients were at stage 4. When we compared osteoarthritis development, the affected knee had a significantly higher rate of osteoarthritis development than the contralateral knee. A univariate analysis demonstrated that age (P = 0.002) and body mass index (P = 0.045) were associated with secondary osteoarthritis. Moreover, multivariate analysis demonstrated that none of the variables were independently associated with secondary osteoarthritis. CONCLUSION: Patients with contralateral osteoarthritis had bilateral knee osteoarthritis, indicating that primary osteoarthritis progressed in both knees. Seven of the 43 patients (16.2%) showed secondary osteoarthritis. Although age and body mass index were associated with secondary osteoarthritis in univariate analysis, none of the variables were independently associated with secondary osteoarthritis in the multivariate analysis.

Is liquid nitrogen recycled bone and vascular fibula combination the biological reconstruction of choice in lower extremity long bone tumor-related defects?

INTRODUCTION: Combination techniques, which encompass the combined use of vascularized bone grafts with massive allografts or autografts (recycled bone grafts), are especially important in the biological reconstruction of tumor-related lower extremity long bone defects. Liquid nitrogen recycled bone (frozen autograft) and free vascular fibula graft (FVFG) combination, which was coined as the "frozen hotdog (FH)" method by the authors, has not been as widely used nor its outcomes reported for significantly sized patient groups. This study aims to provide an answer to whether FH is a safe and effective reconstructive tool for limb salvage in malignant tumors of the lower extremity regarding radiological, functional, and oncological outcomes. PATIENTS AND METHODS: Sixty-six (male/female: 33/33) patients, who underwent FH reconstruction for tumor-related massive defects of lower extremity long bones between 2006 and 2020, were retrospectively analyzed. The mean age was 15.8 (3.8-46.7) years. The most common tumor localizations were distal femur (42.4%) and proximal tibia (21.2%) while classic osteosarcoma and Ewing's sarcoma were the most common pathologies (60.6% and 22.7%, respectively). Mean resection and FVFG lengths were 160 (90-320) mm and 192 (125-350) mm, respectively. The mean follow-up was 73.9 (24-192) months. RESULTS: The mean MSTS score was 25.4 (15-30) and the mean ISOLS radiographic score was 22.6 (13-24). Mean time to full weight bearing without any assistive devices was 15.4 (6-40) months and the median time was 12 months. MSTS score negatively correlated with resected segment length and vascular fibula length (p < 0.001; p = 0.006). Although full contact apposition of the FH segment correlated with earlier full weight bearing compared to partial apposition (mean 13.7 vs. 17.9 months) (p = 0.042), the quality of reduction did not affect the ISOLS radiographic score at LFU. Overall limb survival rate was 96.3% at 5 and 10 years while FH survival rate was 91.0% and 88.1% at 5 and 10 years. Local recurrence-free survival rates were 88.8% and 85.9%, and overall survival was 89.9% and 86.1% at 5 and 10 years, respectively. Limb length discrepancy was the most common complication with 34 (51.5%) patients while shell nonunion was seen in 21 (31.8%) patients and graft fracture in 6 (9.1%). CONCLUSION: The "FH" method is a safe, effective, and extremely cost-efficient reconstructive tool for tumor-related lower extremity long bone defects. Patient compliance to protracted weight-bearing, ensuring the vitality of the FVFG, and achieving an oncologically safe resection are key factors for a successful outcome.

Treatment of neuropathic unstable knee osteoarthritis by a condylar, rotating-hinge prosthesis with cementless pentagonal stem: a case series.

INTRODUCTION AND IMPORTANCE: Total knee arthroplasty (TKA) in the neuropathic unstable knee (NUK) setting is classically a challenging orthopedic problem due to intraoperative technical difficulties and a higher frequency of periprosthetic complications. More recently, satisfactory results have been reported using improved constraints, stems and revision-type TKA components. The study aims to present long-term results of a small case series with NUK osteoarthritis reconstructed by a condylar, semi-constrained prosthesis with a polygonal, hydroxyapatite-coated (HA-coated) press-fit stem. CASE PRESENTATION: From 2009 through 2010, three knees in three patients with advanced NUK arthropathy underwent TKAs in our institution using the PENTA® prosthesis. The average age at surgery was 44 years (32-58). The patients were followed up for a mean period of 124 months (120-128). The etiology of NUK was determined to be poliomyelitis sequela in 2 cases and spinal cord injury in one case. Functional outcomes were assessed with Knee Society (KS) Knee and Function Scores, and radiological outcomes were evaluated with ISOLS radiographic implant scores. Patients were monitored for complications clinically and radiologically. CLINICAL DISCUSSION: KS knee scores improved from a mean of 12,3 (0-37) preoperatively to 71,3 (65-77) and KS function scores improved from a mean of 1,7 (0-5) preoperatively to 68,3 (55-80) at the latest follow-up. Radiological outcomes were excellent according to ISOLS scores, and no complications were observed. CONCLUSION: Although this is a small case series, the significant improvement in functional scores, excellent radiological outcome, and implant survival at the end of a long follow-up period warrants TKA with a semi-constrained hinged implant in the setting of NUK. PENTA® prosthesis offers a good choice of implant with its hydroxyapatite-coated, press-fit, pentagonal stem and precisely designed rotating hinge.

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 Role of Whole-Body Magnetic Resonance Imaging in Assessing Extrapulmonary Metastases in Osteosarcoma Staging and Restaging: A Pilot Study.

OBJECTIVE: The aim of the study is to investigate the role of whole-body magnetic resonance imaging (MRI) in assessing extrapulmonary metastases in primary osteosarcoma staging. METHODS: We retrospectively reviewed medical data to identify primary osteosarcoma patients with available preoperative whole-body MRI obtained in the staging or restaging. Histopathology was the reference test for assessing the diagnostic performance, if available. Otherwise, oncology board decisions were used as the reference. In addition, the benefits of whole-body MRI to F-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET-CT) and bone scintigraphy were investigated. RESULTS: In all, 36 patients with osteosarcoma (24 staging, 12 restaging) with a mean age of 16.36 ± 5.63 years (range, 9-29 years) were included in the study. The median follow-up duration was 26.61 months (interquartile range, 33.3 months). Of 36 patients, 8 had skeletal, 1 had a lymph node, and 1 had a subcutaneous metastasis. Whole-body MRI correctly identified all patients with metastatic disease but incorrectly classified a bone infarct in one patient as a skeletal metastasis, equating a scan-level sensitivity, specificity, accuracy, negative predictive value, and positive predictive value of 100%, 96.3%, 97.3%, 100%, and 90.91%. Whole-body MRI contributed to bone scintigraphy by identifying a skeletal metastasis in one patient and positron emission tomography-computed tomography by ruling out a skeletal metastasis in another. CONCLUSIONS: Whole-body MRI could accurately identify extrapulmonary metastases in primary osteosarcoma patients for staging or restaging. In addition, it might contribute to the standard whole-body imaging methods.

Femoral Discrepancy After Childhood Bone Sarcoma Surgery Can Be Treated With Magnetic Intramedullary Nails.

This study aims to determine whether femoral lengthening with a magnetic motorized intramedullary nail (PRECICE; NuVasive) is safe and effective in patients with discrepancy due to limb salvage performed for bone sarcomas before skeletal maturity. Six patients (male, 4; female, 2) with a mean age of 9.3 years (range, 4.8-12.8 years) at the time of index limb salvage surgery were retrospectively analyzed. Four patients had undergone biological reconstruction with liquid-nitrogen recycled frozen autograft shell and inlaid vascular fibula combination and 2 had undergone nonbiological reconstruction with distal femur modular tumor endoprosthesis. The mean age at PRECICE operation was 16.1 years (range, 13.4-20.1 years). The mean prelengthening femoral discrepancy was measured as 60 mm (range, 39-80 mm). Lengthening was achieved in 5 of these 6 patients. Although the PRECICE nail was successfully implanted in the sixth patient, lengthening could never be performed owing to failure to overcome the chronic diaphyseal nonunion first, as intended with compressive use of the nail. For the other 5 patients, in whom lengthening was performed, the mean lengthening was 45 mm (range, 35-52 mm), the mean ratio of achieved to planned lengthening was 93% (range, 74%-100%), and the mean bone-healing index was 41 days per cm (range, 24-69 days per cm). Mean Musculoskeletal Tumor Society score improved from 25.6 to 27.2 after lengthening. No major complications occurred. The outcomes of this study demonstrate that the PRECICE implant can safely and effectively correct femoral length discrepancy caused by limb salvage performed for osteosarcoma before skeletal maturity. [Orthopedics. 2023;46(1):27-34.].

Long-term results of different surgical options in the management of solitary enchondroma.

BACKGROUNDS: We aimed to compare the average 10-year results of patients treated with three different surgical methods, that is, extended curettage, extended curettage with grafting and extended curettage with cementation for the management of solitary enchondromas. METHODS: Two hundreds and three patients with a solitary enchondroma who underwent surgery at our department between 1990 and 2015 were evaluated retrospectively. Only extended curettage was performed in Group A (n: 75), extended curettage with grafting with autologous bone graft from the iliac crest in Group B (n: 58), and extended curettage with bone cement in Group C (n: 70). Surgical complications and recurrence were analysed and compared between these groups. RESULTS: No significant differences were noted among the groups in terms of gender (P = 0.654), age (P = 0.264) and follow-up duration (P = 0.919). The mean follow-up period in all groups was 122.9 ± 39 (range: 60-271) months. In addition to curettage and cementation, three patients received mechanical support with plate screws because of fracture risk. One patient in the extended curettage with grafting group had surgical site infection that was treated with simple debridement and antibiotherapy. One patient in the extended curettage group had lost motions of the proximal interphalangeal joint, which was treated with aggressive physiotherapy. CONCLUSION: We compared the average 10-year results of patients treated with three surgical options, namely, extended curettage, extended curettage with grafting, and extended curettage with cementation and no difference was found among the groups in local control of solitary enchondromas.

Mid-term implant survival, functional and radiological results and mechanical complications of mega-prosthetic reconstruction around the knee with the PENTA® system.

AIM: Mega-prosthetic reconstruction is the most common treatment method for massive osteoarticular defects caused by tumor resection around the knee. The new implant is a highly modular rotational-hinged megaprosthesis system with a distinct pentagonal stem geometry and variable implantation options. The aim of this study is to present the mid-term implant survival characteristics, functional and radiological results and mechanical complication profile of the new megaprosthesis. METHODS: One hundred and one mega-prosthetic knee reconstruction procedures in 90 patients (M/F: 51/39) utilizing the new implant system were retrospectively analyzed. In 68 patients, the megaprosthesis was used for primary reconstruction following tumor resection while it was used for revision of other implants in 22. The mean age was 28.5 (7-66) years and the mean follow-up was 59.2 (24-124) months. The most common primary pathology was osteosarcoma with 63-70% patients, the most common anatomical site of involvement was the distal femur with 56-62% patients. RESULTS: Henderson Type 2 failure (aseptic loosening) was seen in only 2-2.2% patients while Type 3 (structural failure) was seen in 29-32.2% Although the 5-year anchorage survival rate was 94.3%, overall mechanical implant survival was 76.1% at 5 years due to a relatively high failure rate in the first-generation hinge mechanism of the implant. The 5-year hinge survival rate demonstrated a significant improvement rate from 61.7% to 87.2% between the first and second generations of the implant (p = 0.027). The mean MSTS score was 24 out of 30 (14-29). The mean cumulative ISOLS radiographic score for index megaprosthesis operations was 19.7 (12-24), which corresponded to excellent outcome. CONCLUSION: The new megaprosthesis system is a reliable choice for the reconstruction of tumor-related massive osteoarticular defects around the knee. Although long-term follow-up is necessary for a definitive evaluation of the implant's survival characteristics, midterm follow-up yields exceptional anchorage properties related to pentagonal stem geometry with very good functional outcomes.

Functional and radiologic results of extensor mechanism reconstruction methods following proximal tibial modular endoprosthetic reconstructions: Direct versus medical textile augmented reattachment.

BACKGROUND: Following proximal tibial resection and modular endoprosthetic reconstruction, extensor mechanism can be reconstructed with different techniques. This study compares direct reattachment (DR) with medical textile augmented reattachment (MTAR) methods in terms of functional results and radiological results. MATERIALS AND METHODS: Fifty-five patients (34 male, 21 female) operated between 1990 and 2015 with a minimum follow up of 24 months in a single center were evaluated retrospectively. The median age was 18 years (range: 9-64). The reconstruction was performed via MTAR (polypropylene mesh, Trevira) in 23 patients and DR in 32 patients. Incidence and degree of extension lag, degree of flexion and development of postoperative patella alta were evaluated at 3, 6 and 24 months. RESULTS: The mean follow up was 78.5 months. Extension lag incidence at 24 months was 71.9% in the DR group compared with 43.5% in the MTAR group (P < 0.05).Theextensionlagratiosat 24 months in DR was 0-5° in 8.7% (n = 2), 6-10° in 21.7% (n = 5), 11-15° in 17.4% (n = 4) and > 15° in 52.2% (n = 12), respectively. Extension lag ratios at 24 months in MTAR were 0-5° in 12.5% (n = 4), 6-10° in 6.3% (n = 2), 11-15° in 6.3% (n = 2) and > 15° in 6.3% (n = 2). The mean MSTS score in DR group was 20.7 compared with 23.2 in the MTAR group (P = 0.008). CONCLUSION: MTAR is associated with a lower incidence as well as a lower degree of extension lag. The flexion range and the incidence of patella alta are not statistically different between the groups. MSTS scores of MTAR group are significantly higher than DR group at 2-year follow up.

Management of primary malignant bone and soft tissue tumors of foot and ankle: Is it worth salvaging?

BACKGROUND AND OBJECTIVE: Performing limb salvage with safe margins and preserving meaningful function is very difficult in the setting of primary malignant bone and soft tissue tumors due to the complex and constrained anatomy of the foot and ankle. The study aims to evaluate the efficacy of limb salvage procedures in terms of functional and oncological outcomes. METHODS: Clinical data of 48 patients, who underwent surgical treatment between 1992 and 2015 in our institution, were retrospectively analyzed. Twenty-one (43.7%) patients had unplanned resections elsewhere previously. Limb salvage surgery (LSS) was the index surgery in 43 (89.6%) patients. In the LSS group, 28 (65.1%) received preoperative radiotherapy and 13 (30.2%) underwent complex reconstruction. The functional outcomes were assessed with Musculoskeletal Tumor Society (MSTS) scores. Limb survival and oncological outcomes were evaluated according to Kaplan-Meier curves. RESULTS: The mean follow-up time was 32.7 (3-115) months. Mild deformities and wound healing problems were the most common problems. While the functional scores were significantly higher in the LSS group, no significant difference was detected between amputation and LSS patients in terms of survival rates. CONCLUSION: LSS performed in specialized centers is an effective treatment method for malignant tumors of the foot and ankle.

Neoadjuvant radiotherapy for myxoid liposarcomas: Oncologic outcomes and histopathologic correlations.

OBJECTIVE: The aim of this study was to evaluate the histopathological features of primary extremity myxoid liposarcoma before and after neoadjuvant radiation therapy, and to evaluate the oncological outcomes of the patients. METHODS: The study included 23 patients (16 men and 7 women with a mean age of 43 (24-69) years) with primary myxoid liposarcoma of the extremities, who were treated between January 1998 and December 2015. Inclusion criteria were histopathological confirmation of the diagnosis with both the initial biopsy and the resection specimen, and having undergone neoadjuvant radiotherapy. Demographic, clinical and histopathological data were evaluated. RESULTS: Over a mean follow-up time of 55.2 (8-139) months, 5 patients (21.7%) died secondary to disease progression, leaving 18 patients (78.3%) still alive at the time of last follow-up. Only one patient (4%) experienced local recurrence and six (26%) patients developed distant metastases. Disease-free survival at 5 and 10 years were 66%; whereas, overall patient survival at 5 and 10 years were 78.1% and 71.0%, respectively. Tumor size (>15 cm) and presence of metastasis were significantly associated with increased overall mortality. On histopathology, necrosis was present in 12/23 resection specimens. Hyalinization/fibrosis and residual viable tumor was present in all specimens. Adipocytic maturation/cytodifferentiation was seen in 8/23 patients. CONCLUSION: Neoadjuvant radiotherapy was effective for myxoid liposarcomas histopathologically, although these histopathological features did not affect the patients' oncological outcomes. Favorable oncological outcomes were obtained with neoadjuvant radiotherapy, surgical resection and chemotherapy. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Clinical management of a challenging malignancy, osteoblastoma-like osteosarcoma: a report of four cases and a review of the literature.

Osteoblastoma-like osteosarcoma, a rare form of osteosarcoma, is a malignant lesion associated with risks of both local recurrence and distant metastasis. The differential diagnosis of osteoblastoma-like osteosarcoma from osteoblastoma and aggressive osteoblastoma remains controversial and challenging. Previous studies suggest that these three types of tumor are distinct entities. However, working out a precise diagnosis may not always be possible immediately on the basis of initial clinical, radiological, and histopathological features. On the other hand, the importance of a correct diagnosis cannot be overemphasized since the treatment strategies change dramatically according to the nature of the lesion. In all of our cases, initial Tru-Cut biopsies revealed osteoblastic features with minimal atypia, but further biopsies confirmed malignancy. A high index of suspicion and considerable experience are prerequisites for accurate diagnosis in case of clinicopathological and radiological discordance.

Lung Metastasis Mimicking Fingertip Infection.

Metastasis fingers (acral metastasis) are finding a poor prognosis. Past medical history should be questioned and metastasis from primary tumor should be kept in mind in patients with pain, swelling, and hyperemia in fingers. Successful surgical treatment on acral metastasis does not extend the life expectancy; however, it reduces the patient's pain during his terminal period, saves the functions of the limb, and increases life comfort.

Avulsion fractures involving the straight and reflected heads of the rectus femoris.

Tumours and sport injuries can both affect active, young patients, and the symptoms of the two often overlap. Neglected avulsion injuries sometimes cause a mass to develop which can mimic a tumour. We discuss the diagnosis, treatment, and results following nine anterior inferior iliac spine (AISS) avulsion fractures.

Osteoid osteoma of the great toe mimicking osteomyelitis: a case report and review of the literature.

Osteoid osteomas are well-known benign tumors, seen generally in long bones. When seen in phalanxes or toes, they can cause a diagnostic dilemma. A young male presented to us with complaints of enlargement of the great toe and severe pain. He had had an ingrown toe-nail operation before, and this situation caused a diagnostic dilemma. In this case report, we emphasize that osteoid osteomas can cause diagnostic dilemmas and it should be kept in mind as a differential diagnosis.

Bilateral simultaneous traumatic hip dislocation in opposite directions: a case report.

Bilateral traumatic hip dislocation is rarely seen. A patient who presented with simultaneous dislocation of both hips in opposite directions is presented in this case report. A 42-year-old female patient who was injured in a motor vehicle accident as a passenger was brought to the emergency department and was diagnosed with posterior fracture dislocation of the right hip and anterior dislocation of the left hip. Both hips were reduced under general anaesthesia by closed manipulation, and reduction was confirmed with computerized tomography. No skeletal or skin traction was applied. Hip range of motion exercises were begun immediately. The patient was mobilized at the end of the sixth week and returned to daily activities without any complaint at the end of 16th week.