Osteoporosis Prediction Using Machine-Learned Optical Bone Densitometry Data.

Optical bone densitometry (OBD) has been developed for the early detection of osteoporosis. In recent years, machine learning (ML) techniques have been actively implemented for the areas of medical diagnosis and screening with the goal of improving diagnostic accuracy. The purpose of this study was to verify the feasibility of using the combination of OBD and ML techniques as a screening tool for osteoporosis. Dual energy X-ray absorptiometry (DXA) and OBD measurements were performed on 203 Thai subjects. From the OBD measurements and readily available demographic data, machine learning techniques were used to predict the T-score measured by the DXA. The T-score predicted using the Ridge regressor had a correlation of r = 0.512 with respect to the reference value. The predicted T-score also showed an AUC of 0.853 for discriminating individuals with osteoporosis. The results obtained suggest that the developed model is reliable enough to be used for screening for osteoporosis.

Non­surgical outcomes and risk factors for pulmonary metastasis from giant cell tumor of bone.

The present study detailed four factors associated with an increased risk of pulmonary metastasis, age, pathological fracture, local recurrence and mode of treatment. Local recurrence and pathological fracture were independent risk factors for developing metastasis. From January 2016 to December 2021, data from 50 patients diagnosed with giant cell tumor of bone (GCTB) treated in Khon Kaen Hospital, Thailand, were retrospectively analyzed. The risk factors, including age at diagnosis, location of GCTB, clinical presentation, Campanacci stage and no. of local recurrences, for GCTB-induced pulmonary metastasis were evaluated using univariate and multivariable logistic regression analyses. Of the 50 patients analyzed, 9 patients (18%), with a mean age of 46.3 years (range, 18-68 years), developed pulmonary metastasis. No patients died from pulmonary metastasis in the present study. Statistically significant associations were observed between the development of metastasis and both clinical fracture [odds ratio (OR), 6.107; 95% confidence interval (CI), 1.08-34.70] and local recurrence (OR, 6.48; 95% CI, 1.03-40.87). Patients presenting with both a clinical fracture and local tumor recurrence require more rigorous clinical observation due to the significantly elevated risk of disease progression.

Reconstruction After En Bloc Resection of a Distal Radius Tumor. An Updated and Concise Review.

The distal radius is rarely affected by either primary or metastatic bone cancers. The most frequent tumors of the distal radius are giant cell tumors, which are benign tumors with the propensity to invade. En bloc excision of giant cell tumors of the distal radius achieves a low recurrence rate but compromises the wrist joint, necessitates a significant reconstruction, and has functional consequences. Reconstruction after en bloc resection of a distal radius bone tumor is challenging. Furthermore, orthopedic oncologists disagree on treating such long bone anomalies most effectively. The present article summarizes the various biological and non-biological reconstruction techniques performed after en bloc resection of a distal radius tumor, discusses the advantages and disadvantages of each reconstruction strategy, and summarizes several case studies and case reports.

Innovative method with two-stage surgery for Ewing sarcoma with personalized distal clavicle reconstruction: A case report and diagnosis review.

A 13-year-old boy presented with a growing lump on his left clavicle for 5 months. The plain radiograph revealed an osteolytic mass with aggressive periosteal reaction, suggesting a malignant lesion. The results of advanced imaging and histopathological examinations revealed that the patient had Ewing sarcoma without metastasis. The two-stage surgery was as follows: resection-observation-reconstruction. The underlying rationale was that Ewing sarcoma has a high recurrence. After 2 years of resection, the patient had remission, and he currently has a personal 3D-printed titanium implant with intact shoulder function.

Extended Neoadjuvant Chemotherapy in Delayed Primary Resection of Ewing Sarcoma During the COVID-19 Era: A Case Report.

CASE: A 13-year-old adolescent boy visited our hospital with a growing mass on his left leg. Investigations and examinations were performed to obtain a final diagnosis of Ewing sarcoma in the head of the left fibula with lung metastasis. Neoadjuvant chemotherapy was extended to 11 courses with radiation before wide tumor resection could be performed. The final 3 adjuvant chemotherapy courses were administered to complete the original protocol while surgical resection complications were also treated. The pathological report revealed free margin resection with nonviable tumor cells. CONCLUSION: An extended neoadjuvant chemotherapy regimen with additional radiation therapy for Ewing sarcoma provided extra local control and allowed limb salvage.

Recurrence Leiomyosarcoma of the Popliteal Vein: A Rare Soft Tissue Sarcoma.

Background: Leiomyosarcoma (LMS) is a soft tissue sarcoma that originates from smooth muscle cells and constitutes approximately 5-10% of all soft tissue sarcomas. Vascular LMS is the least common subtype of LMS. About one-third of vascular LMS is located in the extremities, most commonly in the saphenous vein (25%). Vascular LMS originating from the popliteal vein is very rare, and to the best of our knowledge, only nine cases have been reported to date. Case presentation. We herein report a case of a 49-year-old woman who presented with recurrence of a mass that was located at the posterior aspect of the right proximal leg and extended to the popliteal fossa. She had mild pain and intermittent claudication without a history of an edematous leg. The tissue diagnosis was LMS. Wide en bloc resection of the tumor, including the segment of the involved popliteal vein, was performed without venous reconstruction. The patient received no other adjuvant treatments. At the 16-month follow-up, she had good oncologic and functional outcomes. Conclusion: Vascular LMS at the popliteal vein is uncommon but should be considered as a differential diagnosis in a patient who presents with a mass at the popliteal fossa. The magnetic resonance imaging (MRI) and core needle biopsy were needed for a definite diagnosis. The mainstay of treatment is wide en bloc resection of the tumor, including the involved segment of the vein. Venous reconstruction after resection is unnecessary in chronic cases without a history of an edematous leg. Radiotherapy is an important adjuvant for local control when the surgical margins are close or positive. The role of chemotherapy in systemic management remains unclear.

Comparing clinical outcomes between extended curettage and wide resection in Enneking stage 3 giant cell tumor of bone.

PURPOSE: Our objectives were (1) to compare the recurrence, metastases, and complication rates of patients with Enneking stage 3 GCTB who underwent extended curettage vs wide resection and (2) examine the factors which might influence surgical options for each patient. METHODS: We retrospectively reviewed the records of patients with Enneking stage 3 GCTB from January 2006-December 2015. Extended curettage was performed in patients in whom there was a moderate expansile lesion, minimal/no articular cartilage damage, and less than 50% of cortical deformation compared to its circumference from a CT scan/MRI. The percentages of cortical deformation were collected. Surgical complications, recurrence, and metastatic rates were analyzed. RESULTS: There were 28 extended curettage and 41 wide resections. The mean percentages of cortical deformation compared to circumference were 52.6% (range, 23.9-81.9%) and 91.6% (range, 52.1-100%)(P < 0.01) for the curettage and wide resection groups, respectively. There were three recurrences, 2/28 (7.1%) from the curettage group and 1/41 (2.4%) from the resection group (P = 0.56). There were no cases of pulmonary metastasis. There were two complications in the curettage group and five complications in the resection group. CONCLUSION: Both extended curettage and wide resection are useful methods to treat Enneking stage 3 GCTB. Extended curettage with proper technique is a viable option showing no difference in local recurrence rate and potentially fewer complications. Preference to do extended curettage in patients in whom when the articular cartilage has minimal or no destruction, a moderate expansile lesion and the cortical deformation is less than 50% of the circumference.

Efficacy of Cabbage Leaf versus Cooling Gel Pad or Diclofenac Gel for Patients with Knee Osteoarthritis: A Randomized Open-Labeled Controlled Clinical Trial.

Background: Osteoarthritis (OA) is one of the most common joint degeneration ailments adversely affecting the elderly population by impairing their physical movements and quality of life. This study aimed to establish the efficacy of cabbage leaf application in alleviating pain-related distress and positively improving OA conditions. Materials and Methods: Patients with moderate to severe (grades 3-4) OA by the Kellgren and Lawrence grading system with a poor to good Oxford Knee Score were selected for enrollment in this clinical trial. The participants were divided into three intervention groups: the cooling gel pad group for 20 minutes duration once a day (n = 20), the diclofenac gel group for 4 times a day (n = 20) as the control group (total n = 40), and the cabbage leaf group for 1-hour duration once a day (n = 20) as the experimental group (total n = 20). All trial participants were trained to record their Numerical Rating Scale (NRS) pain score and Oxford Knee Score and were advised to undergo weekly follow-ups and assessment of the outcome at 4 weeks. Data were analyzed by the paired t-test and analysis of variance (ANOVA). Results: The cabbage leaf group and cooling gel pad group showed a significant difference in both the Oxford Knee Score (p < 0.001 in both groups) and NRS score (p < 0.001 in both groups) before and after the intervention, by using the paired t-test. The three study procedures were found to be significantly different with respect to both the Oxford Knee Score (p=0.012) and NRS score (p < 0.001), by using ANOVA. Conclusion: This study clinically demonstrated that cabbage leaf application and cooling gel pad application showed similar improvements in reducing OA symptoms in terms of the overall NRS score and Oxford Knee Score. Their therapeutic effectiveness was better than that of diclofenac gel.

Pleomorphic Liposarcoma of Femur: A Rare Soft Tissue Sarcoma Metastasized to the Bone-Case Report and Review of Literature.

Background: Pleomorphic liposarcoma (PLPS) accounts for less than 5% of liposarcoma, and its metastasis to bone is rare. As a high-grade tumor, PLPS is reported to be more invasive with high local recurrence and distant metastasis. Here, we report a case of PLPS of the femur and undertake a review of the literature. Case Presentation. A 58-year-old man presented with a big mass at posterior aspect of his left thigh. The computed tomography of the chest for staging revealed two nodules at the left upper lung field. Wide resection of the soft tissue mass at the left thigh was performed by a general surgeon. Thoracotomy and wedge resection of the lung nodules was carried out by a cardiothoracic surgeon. Pathologic diagnosis suggested PLPS. Three years later, he was presented with sudden right hip pain after he slipped. The plain radiograph revealed an osteolytic lesion at the right proximal femur with minimally displaced pathological fracture. The MRI showed the presence of a tumor at the proximal part of the right femur and its soft tissue invasion. The patient underwent en bloc proximal femur wide resection followed by cemented long-stem bipolar hemiarthroplasty. The final histopathology report from definite surgery specimen revealed pleomorphic spindle, round, and polygonal cells arranged in sheets, short fascicles, and storiform arrays. There were no complications, adverse outcomes, or recurrence reported at six months after surgery. The patient could walk without gait aid and had good functional outcomes according to the TESS questionnaire. Conclusion: PLPS is a highly aggressive tumor with a high distant metastatic rate. The definite diagnosis of PLPS is made on the basis of histopathology. Surgical treatment involving wide resection that aims to achieve a negative margin is the best option currently available, and we recommend treating bone metastasis from PLPS as the primary site of the tumor. The effect of chemotherapy and radiotherapy in preventing postoperative recurrence is still unclear and requires further studies.

En bloc resection and vascularized ulnar pedicle graft reconstruction with plate fixation for giant cell tumour of the distal radius.

We retrospectively reviewed the medical records of ten patients (five men and five women) who were treated in our unit for Campanacci Grade III giant cell tumour of the distal radius between July 2017 and December 2019. Following en bloc resection of a giant cell tumour of the distal radius, the wrist was reconstructed by transposing a vascularized pedicle graft from the ipsilateral ulnar shaft. The graft was fixed to the radial shaft and proximal carpal row with plates. At a mean follow-up of 23.5 months (range 18 to 31), bony union was achieved in all cases and there were no tumour recurrences. All patients had a good range of pronation and supination, but flexion and extension of the wrist was limited. DASH scores ranged from 5 to 11. This reconstruction method is a safe and effective procedure that provides good aesthetic outcomes, removes the need for microvascular techniques and reduces donor site morbidity.Level of evidence: IV.

Outcomes of 2-octyl cyanoacrylate skin adhesives following musculoskeletal oncology surgery: A STROBE-compliant observational study.

ABSTRACT: 2-octyl cyanoacrylate (2OCA) is a high-viscosity medical-grade tissue adhesive that is routinely used. However, no studies have evaluated its use in musculoskeletal surgery.We enrolled 99 patients who underwent musculoskeletal surgery. 2OCA was chosen for wound closure and was performed by a specific surgeon for all patients. The drying times for the adhesive were recorded, and photographs were obtained intra-operatively. Posttreatment follow-up consisted of queries regarding pain level and recording incisional dehiscence, wound infection, hematoma, and incisional bleeding. Data collection was performed postoperatively at 48 hours, 5 to 10 days, 14 days, and 30 days. Other adverse events were documented.2OCA was applied to 110 incisions in 99 patients, comprising 62 female and 37 male patients. The mean age of patients was 50.41 (±16.83) years; mean incision length was 10.24 (±5.7) cm, and the mean pain score using a visual analogue scale was 2.37 on a postoperative day 7. The mean drying time was 1.81 (±0.59) minutes; 91 (91%) patients reported excellent and superior satisfaction, and the remaining patients reported "good" (6%) and "fair" (2%) satisfaction. The percentages of dehiscence, hematoma and keloid formation were considerably low.In this study, 2OCA was safe for musculoskeletal oncology surgical incisions. The incidence of postoperative adverse events was low. However, some patients develop hematomas. Postoperative pain was low, and patient satisfaction was high. 2OCA can be a practical alternative to traditional suture closure for skin incisions after musculoskeletal surgery.

Ketorolac plus Lidocaine vs Lidocaine for pain relief following core needle soft tissue biopsy: A CONSORT-compliant double-blind randomized controlled study.

BACKGROUNDS: The main objective of this study was to compare the pain control efficacy of local administration of Lidocaine with or without the nonsteroidal anti-inflammatory drug, Ketorolac, and local conventional Lidocaine injection in core needle biopsy of the musculoskeletal tumor. METHODS: The current study was a randomized, double-blind controlled clinical trial that included 128 patients with suspected musculoskeletal tumors. Patients were randomly assigned to either the Ketorolac plus Lidocaine (n = 64) or Lidocaine group (n = 64). The Ketorolac - Lidocaine combination syringe contained 30 mg Ketorolac and 2% Lidocaine - adrenaline dosage, and the Lidocaine syringe contained 2% Lidocaine - adrenaline dosage. The level of pain after core needle biopsy was evaluated for each patient at 1, 6, 12, 24, 48, and >48 hours by a Visual Analog Scale (VAS). The mean VAS changes over time were compared between the Ketorolac plus Lidocaine and Lidocaine groups using a linear mixed model. RESULTS: baseline information including mean age of patients in Lidocaine group (51.5 ±â€Š19.4 years) and in Lidocaine - Ketorolac combination group (50.1 ±â€Š18 years), diagnosis (malignant, benign, metastatic, infection), tumor location (upper and lower extremities, back), VAS score 1-hour post-operation (mild and moderate pain) were noted. The VAS score ratings were significantly lower in Lidocaine - Ketorolac combination group when compared to the Lidocaine group during the 1 to 24 hours post-operation time period. CONCLUSION: Patients receiving Lidocaine - Ketorolac combination dosage had significantly lower VAS scores, and these results confirm that local injection of Lidocaine - Ketorolac combination had a superior pain-controlling effect during the first 24 hours after the biopsy procedure in comparison to Lidocaine injection alone, as measured by VAS score scale.

The reconstruction after en-bloc resection of giant cell tumors at the distal radius: A systematic review and meta-analysis of the ulnar transposition reconstruction technique.

BACKGROUND: En-bloc resection of giant cell tumors (GCTs) of the distal radius remains the mainstay treatment for those with high-graded lesions. Several techniques have been described for reconstruction of the resected segment, of which transposition of the ipsilateral ulna is scarcely reported. OBJECTIVES: To investigate the efficacy and safety of the different techniques of ulnar translocation following GCTs total resection. METHODS: A systematic review and meta-analysis was conducted concerning the reported functional outcomes, including grip strength, range of forearm motion, functional scores, and new bone formation, as well as postoperative complications, such as delayed union, local recurrence and metastasis. The ranges of functional outcomes were reviewed and the pooled prevalence rates of complication and their respective 95% confidence intervals (95% CIs) were computed. RESULTS: In a total of 12 studies, 90 patients (51.1% males, 84.8% had Campanacci grade III tumors) underwent five different reconstruction techniques. As compared to the normal side, the mean grip strength in the affected side ranged between 59 and 71%. The average union time was 1-8 months, while delayed union was reported in 50% (95% CI, 15.35 to 84.65) of patients whom their grafts were fixed with Steinmann pins. The shortest union time, the highest forearm supination and pronation degrees, new bone formation at the ulnar stump, and the highest functional scores were reported following a modified distal radius plate technique. Using a dynamic compression plate and a clover leaf plate provided lower, but considerable, functional outcomes. CONCLUSION: Ulnar translocation following GCT en-bloc resection warrants additional investigation in large cohorts and well-designed studies to corroborate the promising outcomes presented in this review.

Glomus tumor of uncertain malignant potential of the brachial plexus: A case report.

BACKGROUND: Glomus tumor is an uncommon benign tumor usually presenting with a small mass occurring in the dermis or soft tissue of an extremity, especially subungual region. However, intraneural glomus tumor is sporadic. While most of the glomus tumors are benign, atypical glomus tumors with unusual features can be occasionally found, leading to distinctive malignant potential required different therapeutic approaches. Glomus tumor of uncertain malignant potential is one type of atypical glomus tumor with limited criteria for malignancy and without metastasis. CASE SUMMARY: Herein, we report a case of a 48-year-old Thai male with a large painful mass in his axilla for one year without apparent neurological deficit. Magnetic resonance imaging showed a large heterogeneous mass encasing entire posterior cord of left brachial plexus and axillary artery. The tumor tissue from core needle biopsy histologically demonstrated the sheets and cords of relatively uniform tumor cells with foamy cytoplasm and round to oval hyperchromatic nuclei without atypia. The mitotic count was 0 per 50 high power field. A final diagnosis of glomus tumor of uncertain malignant potential was rendered. Complete surgical resection was performed, followed by adjuvant radiation due to positive margin. Neither local recurrence nor distant metastasis was observed at 2-year follow up. Unfortunately, postoperative incomplete brachial plexopathy without signs of re-innervation by electromyography was persisted. Later nerve grafting reconstruction was performed, followed by ongoing neurological rehabilitation. CONCLUSION: Glomus tumor of uncertain malignant potential is exceedingly rare, especially around brachial plexus. Although the prognosis is good, careful histological diagnosis and treatment are needed to achieve an optimal outcome with lower morbidity.

Surgical Technique for Open Reduction-Internal Fixation of an Unstable Displaced 3-Part Proximal Humeral Fracture Using a Proximal Humeral Locking Plate.

The proximal humeral locking plate (PHLP) is a recently developed fixed-angle implant that is an option for open reduction-internal fixation of an unstable displaced proximal humeral fracture. Various articles have reported successful outcomes using the PHLP when compared with other implant designs. However, many complications still occur with use of the PHLP, such as avascular necrosis of the humeral articular fragment, malreduction (particularly varus malalignment), and screw penetration. These complications are related to the difficulty in fixation of this particular type of fracture, as well as ineffective surgical technique. We have therefore proposed a step-by-step surgical technique for open reduction-internal fixation of an unstable displaced 3-part proximal humeral fracture using a PHLP. This technique focuses on the precise placement of the PHLP according to the plate design, as well as an effective intraoperative assessment, to improve surgical outcomes and prevent the various complications of proximal humeral fractures.