Recurrent chondroblastoma of the talus: A case report and literature review of recurrent lesions in the foot and ankle.

INTRODUCTION AND IMPORTANCE: Chondroblastoma is a benign cartilaginous tumour that usually presents in the epiphysis of long bones in patients aged 10-20 years old. Only 4 % of primary chondroblastoma occur in the talus. Recurrence is rare, especially in the foot and ankle and there is no consensus regarding how it is best managed. This unique case and literature review add to a limited evidence base. CASE PRESENTATION: A 21-year-old male was referred to our elective orthopaedic clinic with persistent anterior ankle pain exacerbated by weight-bearing. Radiographs and MRI revealed a 2.5 cm non-homogenous mass in the anteromedial talus with expansion of overlying bone consistent with chondroblastoma-ABC. Our patient was initially managed by intralesional curettage and autologous bone grafting but had recurrence 4.5 months postoperatively. Subsequent en bloc resection of the talar neck with talonavicular and calcaneocuboid joint fusion resulted in excellent functional outcomes and disease-free survival at 2 years follow-up. CLINICAL DISCUSSION: There are few reports discussing treatment options for recurrence in the foot and ankle. Successful treatment of primary and recurrent lesions depends on complete local resection. Repeat curettage or en bloc resection are effective options depending on tumour size and location. Type of bone graft or void filler should be considered on a case-by-case basis. Novel therapies (e.g. phenol instillation) may be beneficial. CONCLUSION: This case details successful management of recurrent chondroblastoma with en bloc resection of the talar neck and hindfoot reconstruction. We review the efficacy and outcomes of all previously reported recurrent chondroblastoma in the foot and ankle. We highlight multiple potential treatment options.

Alleged recurrent traumatic shoulder dislocation in a young male patient - Diagnostic and management considerations.

A young male presented to a nearby hospital with a left shoulder dislocation after an alleged kickboxing injury. The patient reported worrying clinical findings including excruciating pain and absent sensation distally. Reduction was successful but his shoulder re-dislocated shortly after. His reported symptoms worsened and he was transferred to our institution. Imaging findings were not immediately concerning and he went to theatre the next day for an examination under anaesthetic. His shoulder was re-located easily and an immobiliser applied. Less than an hour later, the patient managed to re-dislocate his shoulder in recovery. He was subjected to another general anaesthetic and successful reduction. He absconded the following day after being declined multiple and increasing doses of opioid analgesia. He re-presented three weeks later with similar clinical findings but a different mechanism of injury. Further exploration of his collateral history revealed that he had been using a false identity. He had presented to all hospitals in our city within the previous 6 months. Once confronted, he did not return to these hospitals. He was also capable of self-relocating his shoulder. This case bore a striking resemblance to a case described by Warren in 2000 of a young lady with an apparently dislocated shoulder presenting to multiple city hospitals looking for analgesia and general anaesthetics. We wished to highlight the diagnostic and ethical challenges associated with these patients. They are vulnerable and so a high index of clinical suspicion is needed on the part of the surgeon to avoid unnecessary interventions. Effective communication between orthopaedic departments is a key recommendation from this case to mitigate risk of harm to these patients.

Intermediate to Long-Term Follow-up of Distal Femoral Replacements in the Treatment of Neoplastic Disease About the Knee.

BACKGROUND: Limb salvage procedures have become more prevalent in orthopedic oncology. Endoprostheses have been used successfully to reconstruct large skeletal deficits. The aim was to review intermediate to long-term follow-up of distal femoral replacements in the setting of neoplastic disease about the knee. METHODS: This was a single-center retrospective cohort study from 1997 to 2018 in a national referral center for oncology. The secondary objectives were to describe morbidity and mortality in this cohort. We recorded the modes of failure using Henderson classification system, complications, revisions, and all further operations. RESULTS: Seventy-two distal femoral replacements were performed. Osteosarcoma was the most common indication (55 patients). Other indications included chondrosarcoma (7 patients), giant cell tumor (5 patients), Ewing's sarcoma (2 patients), metastatic spread (2 patients), and leiomyosarcoma (1 patient). One-year mortality was 1.38% with an overall mortality of 13.8%, at the end of the study period. The 1-year revision rate was 4.2%, 30.5% for 10 years, and 38.8% for more than 15 years. The overall implant survival rate was 63.8%. The most common reasons for failure included aseptic loosening (16.6%), infection (16.6%), and local recurrence (9.7%) with an amputation rate of 6.9% in the cohort. CONCLUSION: Neoplastic disease of the lower limb is associated with significant morbidity. Aseptic loosening (16.6%) and infection (16.6%) were the most common reasons for failure in this cohort.

Tenosynovial chondromatosis of the flexor pollicis longus tendon: A subtype of primary synovial chondromatosis.

Primary synovial chondromatosis is a rare benign neoplastic process, in which cartilaginous nodules are produced in the subsynovial tissue. It has 3 main subtypes (intra-articular, tenosynovial and bursal). We present the case of a 61-year-old female, with a mass involving her right thumb for at least 5 years, which had recently increased in size. X-ray showed a soft tissue mass, without calcification or any underlying bony abnormality. Ultrasound and MRI showed a 6-cm mass surrounding the right flexor pollicis longus tendon of the right thumb. The patient went on to have surgical resection and was given a diagnosis of tenosynovial chondromatosis.

Atraumatic groin pain secondary to an aneurysmal bone cyst: A case report and literature review.

BACKGROUND: Bone lesions can present the multi-displinary team with a challenge by way of diagnosis as some lesions share many radiological and histological characteristics. Giant cell tumours of the bone (GCTB) are relatively common, benign bone tumours. Aneurysmal bone cysts (ABC) are less common benign osteolytic lesions that are histologically similar to GCTBs but produce blood filled cavities. Both GCTBs and ABCs are locally aggressive and are typically found on meta-epiphyseal regions of long bones with pelvic tumours being less common. CASE SUMMARY: A 17-year old female presented with atraumatic right groin pain and was initially diagnosed with a GCTB on the right superior pubic ramus of the pelvis. The patient was treated successfully with a wide excision, curettage and bone graft and underwent open reduction and internal fixation of the right hemi-pelvis. Following further intra-operative histological investigations, the lesion was diagnosed as an ABC. CONCLUSION: This patient has had an uncomplicated post-operative course, has returned to comfortable weight bearing and will be reviewed for minimum 5 yr in the out-patient setting to monitor for reoccurrence.

Orthopaedic perspective on bone metastasis.

The incidence of cancer is increasing worldwide, with the advent of a myriad of new treatment options, so is the overall survival of these patients. However, from an orthopaedic perspective, there comes the challenge of treating more patients with a variety of metastatic bone lesions. The consequences of such lesions can be significant to the patient, from pain and abnormal blood results, including hypercalcemia, to pathological fracture. Given the multiple options available, the treatment of bone metastasis should be based on a patient-by patient manner, as is the case with primary bone lesions. It is imperative, given the various lesion types and locations, treatment of bone metastasis should be performed in an individualised manner. We should consider the nature of the lesion, the effect of treatment on the patient and the overall outcome of our decisions. The dissemination of primary lesions to distant sites is a complex pathway involving numerous cytokines within the tumour itself and the surrounding microenvironment. To date, it is not fully understood and we still base a large section of our knowledge on Pagets historic "seed and soil" theory. As we gain further understanding of this pathway it will allow us develop more medical based treatments. The treatment of primary cancers has long been provided in a multi-disciplinary setting to achieve the best patient outcomes. This should also be true for the treatment of bone metastases. Orthopaedic surgeons should be involved in the multidisciplinary treatment of such patients given that there are a variety of both surgical fixation methods and non-operative methods at our disposal.

Small is challenging; distal femur fracture management in an elderly lady with achondroplastic dwarfism.

Achondroplasia is an autosomal dominant dwarfing condition that represents the most common form of skeletal dysplasia. The disease is caused by a mutation in the gene encoding fibroblast growth factor receptor 3 (FGFR3) found at the p16.3 locus on chromosome 4 which results in severe inhibition of subchondral bone growth. Anatomic variations, including articular and periarticular deformities classically seen with this condition, amplify the complexity of fracture fixation. Blood volume loss, age-related bone fragility, component selection and positioning pose serious orthopaedic challenges. Concomitant cardiovascular, respiratory and neurological comorbidities pose additional high-risk perioperative considerations. Despite an estimated prevalence of 1:25 000 in the general population, there is little literature concerning the operative and postoperative treatment challenges faced by orthopaedic surgeons dealing with fracture management on a patient with this condition. We present a case of an intercondylar femoral fracture in an elderly achondroplastic lady successfully treated with percutaneous screw fixation.

Osteomyelitis of the tibia following anterior cruciate ligament reconstruction.

INTRODUCTION: Osteomyelitis following anterior cruciate ligament (ACL) reconstruction is extremely rare. PRESENTATION OF CASE: We present a thirty year old man who presented with pain in his proximal tibia six years after ACL reconstruction. Haematological investigations were normal. He was diagnosed with osteomyelitis of his proximal tibia. He was successfully treated with washout and debridement of his tibial tunnel. DISCUSSION: This case highlights the need to exclude osteomyelitis as a late complication of ACL reconstruction in patients with proximal tibial pain. We also report on an unusual pathogen as casue of osteomyelitis. CONCLUSION: Osteomyelitis in a tibial tunnel can present as a late complication of ACL reconstruction, even in the presence of normal haematological investigations.

Conservative management of paediatric clavicle fractures.

Paediatric clavicle fractures have traditionally been treated nonoperatively. Recent studies have recommended operative management for displaced midshaft fractures. We conducted a retrospective review of all clavicle fractures in children aged one to sixteen over a two-year period. We classified fractures and evaluated followup and clinical outcome. We identified 190 fractures. There were 135 boys and 55 girls. 65% of fractures were displaced and 35% undisplaced. Mean radiographic and clinical followup was 35 days and 44 days, respectively. Clavicle fractures in children heal with nonoperative management. Radiographs of clavicle fractures in children are unnecessary in the absence of clinical symptoms.

The complications of septic arthritis in the elderly.

BACKGROUND AND AIMS: An epidemiological analysis of cases of spontaneous community acquired septic arthritis in an elderly population at a university teaching hospital. METHODS: Confirmed cases of spontaneous septic arthritis in the over-65 population were studied. Patients with prosthetic joint infections were excluded from the study. Analysed data included initial presenting complaint and clinical examination, hematological and microbiological tests together with ultimate patient outcome. RESULTS: There were 7 confirmed cases of spontaneous septic arthritis in the over 65 population in the past 6 months (2 hips, 5 knees). The mean age was 72.14 (range 65-82) with a mean length of stay of 49 days. Those with septic arthritis of the knee presented with swelling, pain and immobility. Hip cases presented with pain and immobility. All patients were systemically well at the time of presentation, with no other foci of infection detected after septic screening. All patients had confirmed aspirate and arthroscopic/arthrotomy infection. Staphylococcus aureus was isolated from 6 joint aspirations and Pseudomonas Aeruginosa from one patient. Complications of treatment included acute renal failure, cardio/respiratory failure, disseminated infection, and death (1 case). CONCLUSION: Septic arthritis must be considered as a differential diagnosis in all patients with joint pain, swelling and immobility. This diagnosis is not confined to the pediatric population. A background of degenerative disease and occult presentation in the elderly may delay diagnosis. Sepsis must be considered in the elderly with joint pathology, and treatment must be initiated in a prompt and aggressive manner, to prevent sequelae.

Mesenchymal stem cell secretion of chemokines during differentiation into osteoblasts, and their potential role in mediating interactions with breast cancer cells.

Over 70% of patients with advanced breast cancer will develop bone metastases for which there is no cure. Mesenchymal Stem Cells (MSCs) and their derivative osteoblasts are subpopulations of cells within the bone marrow environment, postulated as potential interacting targets for disseminating cancer cells because of their ability to secrete a range of chemokines. This study aimed to investigate chemokine secretion throughout MSC differentiation into osteoblasts and their effect on the breast cancer cells. Primary MSCs and osteoblast progenitors were cultured in appropriate conditions to induce differentiation into mature osteoblasts. Chemokines secreted throughout differentiation were detected using ChemiArray and ELISA. Migration of breast cancer cells in response to the bone-derived cells was quantified using Transwell inserts. Breast cancer cells were cocultured with MSCs, retrieved using magnetic beads, and changes in CCL2 expression were analyzed. MSCs secreted a range of factors including IL-6, TIMP-1 and CCL2, the range and level of which changed throughout differentiation. CCL2 secretion by MSCs increased significantly above control cells as they differentiated into mature osteoblasts (p<0.05). The bone-derived cells stimulated migration of breast cancer cells, and this was inhibited (21-50%) in the presence of a CCL2 antibody. CCL2 gene expression in breast cancer cells was upregulated following direct coculture with MSCs. The varying levels of chemokines secreted throughout MSC differentiation may play an important role in supporting tumor cell homing and progression. These results further highlight the distinct effect MSCs have on breast cancer cells and their potential importance in supporting development of metastases.

The effect of menopause and hysterectomy on systemic vascular endothelial growth factor in women undergoing surgery for breast cancer.

BACKGROUND: Vascular endothelial growth factor (VEGF) is a potent angiogenic cytokine produced physiologically by the uterus. Pathological secretion by tumours promotes growth and metastasis. High circulating VEGF levels potentially have a deleterious effect on breast cancer by promoting disease progression. The aims of this study were to investigate circulating VEGF levels in breast cancer patients and assess the effect of menopause or hysterectomy on systemic VEGF. METHODS: Patients undergoing primary surgery for breast cancer and controls matched for age, menopausal and hysterectomy status were prospectively recruited. Serum VEGF, FSH, LH, estrogen, progesterone and platelet levels were measured. Serum VEGF was corrected for platelet load (sVEGFp) to provide a biologically relevant measurement of circulating VEGF. SVEGFp levels were analyzed with respect to tumor characteristics, menopausal status and hysterectomy status. RESULTS: Two hundred women were included in the study; 89 breast cancer patients and 111 controls. SVEGFp levels were significantly higher in breast cancer patients compared to controls (p = 0.0001), but were not associated with clinico-pathological tumor characteristics. Systemic VEGF levels reduced significantly in the breast cancer patients following tumor excision (p = 0.018). The highest systemic VEGF levels were observed in postmenopausal breast cancer patients. Postmenopausal women who had had a previous hysterectomy had significantly higher VEGF levels than those with an intact postmenopausal uterus (p = 0.001). CONCLUSION: This study identifies an intact postmenopausal uterus as a potential means of reducing circulating levels of VEGF which could confer a protective effect against breast cancer metastatic potential.