The clinical significance of CD44v6 in malignant and benign primary bone tumors.

BACKGROUND: The objective of this study was to assess the expression profile of CD44v6, a potential cancer stem cell marker, and its diagnostic and predictive significance in three distinct types of primary bone tumors. METHODS: In this study, we utilized real-time qRT-PCR and immunohistochemistry to examine the gene and protein levels of CD44v6 in a total of 138 fresh bone tissues. This included 69 tumor tissues comprising osteosarcoma (N = 23), chondrosarcoma (N = 23), and GCT (N = 23), as well as 69 corresponding non-cancerous tumor margins. Furthermore, we investigated the circulating level of CD44v6 by isolating peripheral blood mononuclear cells from 92 blood samples. Among these, 69 samples were obtained from patients diagnosed with primary bone tumors, while the remaining 23 samples were from healthy donors. The primary objectives of our investigation were to assess the correlation between CD44v6 expression levels and clinic-pathological features of the patients, as well as to evaluate the diagnostic and predictive values of CD44v6 in this context. RESULTS: In patients with osteosarcoma and chondrosarcoma tumors, both the gene and protein expression of CD44v6 were found to be significantly higher compared to the GCT group. Furthermore, the circulating level of CD44v6 was notably elevated in patients diagnosed with osteosarcoma and chondrosarcoma in comparison to the GCT group and patients with malignant tumor characteristics. Additionally, we observed a strong correlation between the gene and protein levels of CD44v6 and important tumor indicators such as tumor grade, metastasis, recurrence, and size at the tumor site. CD44v6 shows potential in differentiating patients with bone tumors from both control groups and tumor groups with severe and invasive characteristics from those with non-severe features. Importantly, the expression level of CD44v6 also demonstrated predictive value for determining tumor grade and the likelihood of recurrence. CONCLUSION: CD44v6 is likely to play a role in the development of primary bone tumors and has the potential to serve as a diagnostic biomarker for bone cancer. However, to obtain more accurate and conclusive findings, further mechanistic investigations involving larger population samples are necessary.

Outcomes of proximal humeral reconstruction with cemented osteoarticular allograft in pediatric patients: a retrospective cohort study.

BACKGROUND: There is no agreement on the best choice of proximal humeral reconstruction following tumor resection in pediatric patients. We reviewed the functional outcomes, oncologic outcomes, and surgical complications in pediatric patients after proximal humeral reconstruction with cemented osteoarticular allograft. METHODS: Eighteen patients aged 8-13 years who underwent proximal humeral osteoarticular allograft reconstruction following resection of primary bone sarcoma were included. The mean follow-up period was 88 ± 31.7 months. At the last follow-up assessment, limb function was evaluated based on shoulder range of motion, Musculoskeletal Tumor Society score, and Toronto Extremity Salvage Score. Tumor recurrence and postoperative complications were extracted from the patients' medical records. RESULTS: Mean active forward flexion of the shoulder was 38° ± 18°. Mean active abduction was 48° ± 18°. Mean active external rotation was 23° ± 9°. The mean Musculoskeletal Tumor Society score was 73.4% ± 11.2%. The mean Toronto Extremity Salvage Score was 75.6% ± 12.9%. Local recurrence occurred in 1 patient. Metastasis developed after the operation in 2 additional patients. We recorded 6 postoperative complications in this series, including 1 superficial infection, 1 late-onset deep infection, 1 allograft fracture, 2 cases of nonunion, and 2 cases of shoulder instability. Two complications required allograft removal. CONCLUSION: In pediatric patients, reconstruction of the proximal humerus with cemented osteoarticular allograft results in acceptable oncologic and functional outcomes while the postoperative complication rate seems to be lower than that of other available techniques.

Establishment of Iran Musculoskeletal Tumor Registry: A Study Protocol and Lessons Learned from Implementation and the Pilot Phase.

Background: The number of available musculoskeletal tumor registries is relatively small. We developed a registry system focused on the clinical aspects of musculoskeletal tumors to improve quality of care indexes through the development of updated national protocols. In this study, we describe our protocol, challenges, and the data collected during the implementation of the registry system in a single-specialty orthopedic center in Iran. Methods: Three main malignant bone tumors, including osteosarcoma, Ewing sarcoma, and chondrosarcoma, were included in the registry. After establishing a steering committee, we defined the minimum data set based on a literature review and suggestions from an expert panel. Accordingly, the data collection forms and the web-based software were developed. The collected information was categorized into 9 classes, including demographics, socioeconomic data, signs and symptoms, past medical history, family history, laboratory tests, tumor characteristics, primary treatment, and follow-up. Data collection was performed both retrospectively and prospectively. Results: Until September 21, 2022, a total of 71 patients were registered (21 patients prospectively and 50 patients retrospectively) and consisted of 36 (50.7%) cases of osteosarcoma, 13 (18.3%) cases of Ewing sarcoma, and 22 (31%) cases of chondrosarcoma. The implementation of the registry demonstrated promising data regarding the tumor characteristics, delay patterns, and socioeconomic status of the patients. Conclusion: The main lessons learned were to develop a monitoring system to make sure that the new staff is adequately trained for the registration process as well as avoid the inclusion of time-consuming useless data in the minimum data set.

Are Fibular Allograft Struts Useful for Unicameral Bone Cysts of the Proximal Humerus in Skeletally Mature Patients?

BACKGROUND: Although most unicameral bone cysts (UBCs) are either successfully treated or have healed by the time of skeletal maturity, a small proportion of patients will have persistent UBCs beyond the age of skeletal maturity. More reliable methods are needed to treat persistent UBCs in the humerus because these cysts are associated with a high risk of fracture due to thinning of the humeral cortex. In this study, we evaluated whether inserting a fibular strut allograft into the humerus would be associated with healing of the cyst and union of associated pathologic fractures in skeletally mature patients with a UBC of the proximal humerus. QUESTIONS/PURPOSES: (1) How effective is inserting a fibular strut allograft in the healing of proximal humerus UBCs in skeletally mature patients with bone cysts and associated fractures? (2) What are the functional results of this procedure? (3) What complications are associated with this procedure? METHODS: Between 2005 and 2018, we surgically treated 23 skeletally mature patients with persistent humeral UBCs and any of the following indications: a progressive cyst that was not responsive to aspiration and 2 to 3 steroid injections, a cyst with a pathologic fracture, and a cyst at high risk of fracture. Of those, patients with a cyst located in the proximal humerus and a defect length more than 6 cm (n = 18) were considered eligible to be treated with insertion of a fibular strut allograft through a hole created in the greater tuberosity. A further two patients were excluded because they were treated by other surgical methods. From the remaining 16 patients, two patients were lost to follow-up before 2 years and could not be analyzed in this study. Another two patients had incomplete datasets, leaving 12 for analyses in this retrospective study. Three patients presented with a pathologic fracture. Complete filling of the cysts with bone within 24 months was regarded as healing, and after 24 months it was classified as delayed healing. Cyst consolidation with small residual areas of osteolysis was considered healed with residual radiographic appearance. Fracture union was determined by the clear observation of at least three of four cortical views bridged by bone in the radiographic follow-up 3 months after the operation. Fractures in which the cortices were not bridged by bone after 3 months were regarded as a delayed union. The functional outcome of the patients was assessed by the Musculoskeletal Tumor Society (MSTS) scoring system, with a total score ranging from 0 to 30. A higher score was indicative of less pain and better function. MSTS scores were obtained through a chart review by an orthopaedist who was not involved in the care administered. RESULTS: At a median (range) follow-up of 57 months (33 to 87), the cyst was completely healed in nine patients and healed with residual cyst in the remaining three. Union was observed within 3 months in all patients who presented with a pathologic fracture. The median MSTS score of the patients was 30 (28 to 30). No postoperative complications such as persistent pain or re-fracture were observed. CONCLUSION: The primary goal of treating a UBC of the proximal humerus is to prevent fracture of the affected bone; insertion of a fibular strut graft in this study met this goal. Therefore, we believe a fibular strut allograft insertion is worth consideration when treating proximal humeral UBCs in skeletally mature patients. Further studies will be needed to determine whether this approach has benefits compared with other treatment options. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Effect of an Endoprosthetic Reconstruction Tube and Medial Gastrocnemius Flap on Extensor Mechanism Function After Oncologic Prosthesis Reconstruction of the Proximal Tibia.

BACKGROUND: Extensor mechanism reconstruction after the proximal tibial resection and implantation of a megaprosthesis is challenging. In this study, we evaluated the effectiveness of the Trevira tube and medial gastrocnemius flap in restoring extensor mechanism following the resection of proximal tibial tumor and implantation of megaprosthesis. METHODS: Forty patients who underwent endoprosthetic implantation following the resection of proximal tibial tumor and patellar tendon reconstruction with the Trevira tube and medial gastrocnemius flap were included. The outcome measures were knee range of motion, extensor mechanism function, patellar position, and limb function subjectively evaluated through Toronto Extremity Salvage Score and objectively through Musculoskeletal Tumor Society score. The mean follow-up of the patients was 6.1 years. RESULTS: The patellar position was normal in 28 (70%) patients, patella baja in 3 (7.5%) patients, and patella alta in 9 (22.5%) patients. The mean active knee range of motion was 98.9 ± 17° (range: 85°-125°). Extension lag was present in 7 (17.5%) patients (range: 5°-20°). The mean Toronto Extremity Salvage Score of patients was 92.1 ± 6.9% (range: 85-100). The mean Musculoskeletal Tumor Society score of the patients was 87.7 ± 13 (range: 73.3-100). Postoperative complications included aseptic wound dehiscence (2 patients), aseptic loosening of the tibial component (1 patient), periprosthetic fracture in the femur (2 patients), and wound infection (1 patient). CONCLUSION: Trevira tube combined with gastrocnemius flap augmentation is a suitable procedure for restoring extensor mechanism after proximal tibial resection and megaprosthesis implantation.

How Can We Differentiate Local Recurrence From Heterotopic Ossification After Resection and Implantation of an Oncologic Knee Prosthesis in Patients with a Bone Sarcoma?

BACKGROUND: Heterotopic ossification (HO) is common after total joint arthroplasty and usually does not cause diagnostic problems. However, the occurrence of HO after oncologic prostheses implantation can be troublesome as it may mimic a locally recurrent tumor. Because this distinction could have a profound impact on the surgeon and patient, it is important to distinguish the two entities; to our knowledge, no study has evaluated this after oncologic endoprosthetic reconstruction around the knee after tumor resection. QUESTIONS/PURPOSES: (1) How common is the occurrence of HO compared with local recurrence (LR) after resection of bone sarcoma and the use of an oncologic knee prosthesis? (2) Are there any factors associated with the development of HO after limb salvage procedures with an endoprosthesis? (3) What features allow the surgeon to differentiate HO from a locally recurrent tumor in this setting? METHODS: Between 2002 and 2018, we performed 409 resections of primary bone tumors followed by reconstructions with oncologic endoprostheses. Of these, 17% (71 of 409) died before 2 years and did not have HO at that time, 2% (8 of 409) were lost to follow-up before 2 years, and another 2% (10 of 409) did not have radiographs available at a minimum of 2 years after surgery (and had not developed HO before then), and so could not be analyzed, leaving 320 patients for analysis in this retrospective study. Forty-two patients were excluded; 2% (5 of 320) for a history of failed allograft reconstruction, 3% (8 of 320) for pathologic fracture at presentation, 2% (6 of 320) for inadequate or complicated biopsy, 1% (2 of 320) for stem fractures, 2% (7 of 320) for stem loosening, and 4% (14 of 320) for extracortical bone bridging, leaving 278 patients for final evaluation. Two observers analyzed AP and lateral radiographs for signs of HO at a mean follow-up of 63 ± 33 months after surgery. We defined HO as extraskeletal bone formation in soft tissues. The primary study endpoint was survivorship free from HO, as ascertained by a competing-risks estimator. To identify factors associated with HO appearance, the demographic, radiographic, clinical, pathologic, and surgical characteristics were compared between patients with HO and those who had no lesion. Characteristic features were also compared between patients with HO and those with LR to help their differentiation. Univariate analysis was used for all statistical evaluations. RESULTS: HO developed in 8% (21 of 278) of patients in whom oncologic knee prosthesis was implanted. LR developed in 10% (28 of 278) of the patients. According to survivorship estimates, the HO-free survival rate was not different from the LR-free survival rate at 2 years after oncologic knee reconstruction (76 ± 5% [95% CI 63 to 87] versus 74 ± 5% [95% CI 62 to 88]; p = 0.19). History of infection was more common in patients with HO than in patients with no lesion (19% [4 of 21] versus 5% [12 of 229], Odds ratio [OR] 6 [95% CI 2 to 17]; p < 0.001). The male sex was more common in the HO group as well (76% [16 of 21] versus 55% [128 of 229], OR 2 [95% CI 1 to 5]; p = 0.03). The Modular Universal Tumor and Revision System prosthesis was more frequently used in patients with HO (67% [14 of 21]) compared to those with no lesions (40% [92 of 229]; OR 2 [95% CI 1 to 5]; p = 0.02). The lesion border in radiographs was ill-defined in 19% (4 of 21) of patients with HO and 100% (28 of 28) of patients with LR (OR 8 [95% CI 3 to 20]; p < 0.001). The median time to the appearance of HO was shorter than the time to LR (8 months [3 to 13] versus 16 months [11 to 21], [95% CI 10 to 13]; p < 0.001). Pain at presentation was more frequent in patients with LR than in those with HO (86% [24 of 28] versus 14% [3 of 21], OR 36 [95% CI 7 to 181]; p < 0.001). CONCLUSION: HO may occur after the use of oncologic knee prostheses for reconstruction after tumor resection. In most patients, HO could be differentiated from local recurrence through identifying a well-defined border on radiographs. Otherwise, factors such as an earlier time of presentation and absence of pain could suggest an HO, rather than an LR. LEVEL OF EVIDENCE: Level III, therapeutic study.

Comparison of characteristic features and local recurrence in syndromic versus non-syndromic multifocal non-ossifying fibroma.

BACKGROUND: Multiple non-ossifying fibromas (MNOF) could be presented with other extraskeletal anomalies (syndromic) or not (non-syndromic). In this study, we aimed to compare characteristic features and local recurrence between symptomatic syndromic and non-syndromic MNOFs. METHODS: Thirty-five patients with symptomatic MNOF were included in this study, comprised of 30 patients without the café-au-lait spot (non-syndromic) and five with café-au-lait spots plus other signs of neurofibromatosis type 1 (syndromic). Characteristic features of the patients and lesions were compared between syndromic and non-syndromic MNOFs. The lesions were treated with curettage and bone graft. The rate of local recurrences was also compared between the two groups of syndromic and non-syndromic MNOF. RESULTS: Study population included 19 (54.3%) males and 16 (45.7%) females with the mean age of 7.63 ± 3.1 years (range 4-11). The mean follow-up of the patients was 65.6 ± 38.2 months (range 24-96). The lesion was bilateral in 13.3% of non-syndromic MNOFs and 80% of syndromic MNOFs. This difference was statistically significant (p = 0.01). After curettage and bone grafting, the lesion recurred in 6.7%of non-syndromic MNOFs and 60% of the syndromic MNOF. This difference was statistically significant, as well (p = 0.01). No other significant difference was found between syndromic and non-syndromic MNOFs. CONCLUSIONS: The syndromic form of MNOF is much less prevalent and is associated with a higher rate of recurrence after surgical removal. Therefore, a more rigorous removal of the MNOF lesions might be necessary when presented in a syndromic context.

Extended curettage versus en bloc resection for the treatment of grade 3 giant cell tumour of the knee with pathologic fracture: a retrospective study.

PURPOSE: For the treatment of giant cell tumour of the bone (GCTB) around the knee, preserving the native joint confers advantages over scarifying it. But, there is a controversy about the efficacy of intralesional curettage versus en bloc resection for treatment of such lesions. In this study, we compared local recurrence, functional outcomes, and complications of extended curettage and en bloc resection in these lesions. METHODS: Patients with grade 3 GCTB of the distal femur or proximal tibia who were presented with a pathologic fracture and treated with either en bloc resection (n = 22) or extended curettage (n = 20) were included. The mean follow-up of the patients was 6.4 ± 1.9 years in the resection group and 5.5 ± 2.4 years in the extended curettage group. The primary outcome was a local recurrence. Secondary outcomes were limb function evaluated by the Musculoskeletal Tumor Society (MSTS) score and rate of complications. RESULTS: Local recurrence was seen in four (20%) patients of the curettage group and three (13.7%) patients of the resection group (P = 0.69). The mean MSTS score was 24 ± 1.9 in the resection group and 26.5 ± 1.3 in the curettage group (P < 0.001). The number of complications was not significantly different between the two study groups (P = 0.49). However, the number of complications that required revision surgery was significantly more in the resection group (P = 0.049). CONCLUSION: In grade 3 GCTB around the knee with pathologic fracture, extended curettage results in comparable oncologic outcomes to en bloc resection, while providing better function and a lower rate of revision.

Tailored treatment of aneurysmal bone cyst of the scapula: en bloc resection for the body and extended curettage for the neck and acromion.

BACKGROUND: The acromion and neck of the scapula are essential components of shoulder function, but the body section is less critical. We treated aneurysmal bone cysts (ABCs) of the neck and acromion with extended curettage and ABCs of the body with en bloc resection. This article reports on local recurrence and the functional outcomes of this approach. MATERIALS AND METHODS: Seventeen patients with primary ABCs of the scapula were included in this retrospective study. We treated 10 patients with extended curettage and bone grafting and 5 patients with en bloc resection. In 2 cases, both the body and neck were involved. We treated these patients with a combination of curettage and resection. We used the Musculoskeletal Tumor Society score for functional assessment of outcomes. RESULTS: The mean age of the patients was 20.5 ± 7.4 years. One local recurrence occurred in patients who underwent extended curettage and bone grafting (1 of 12 cases, 8.3%). No recurrence was observed in patients who underwent en bloc resection alone. The mean Musculoskeletal Tumor Society score was 27.9 ± 1 in patients who underwent curettage alone and 24.86 ± 0.7 in patients who underwent en bloc resection alone or in combination with curettage (P < .001). CONCLUSION: Despite the higher risk of local recurrence after curettage, this method can be selected for the treatment of ABCs of the acromion and neck of the scapula to minimize shoulder disability. For the body of the scapula, en bloc resection is a more reasonable treatment, despite a higher rate of functional impairment.

Favorable outcome of extended curettage for the treatment of unifocal chronic sclerosing osteomyelitis of clavicle: a case series.

BACKGROUND: Chronic sclerosing osteomyelitis (CSO) of the clavicle, especially its unifocal subset, is scarcely reported, and little is known about its characteristic features and treatment. We aim to describe the characteristic features and outcome of treatment in a series of patients with unifocal CSO of the clavicle. MATERIALS AND METHODS: In a retrospective study, we identified 6 patients with a diagnosis of unifocal CSO of the clavicle. All patients underwent a core needle biopsy, and histologic examination confirmed the diagnosis. Laboratory investigations included the white blood cell count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, and bacteriologic culture. We used plain radiographs, computed tomography scanning, and magnetic resonance imaging for the radiologic evaluation. RESULTS: The median age of the patients was 16.5 years (range, 10-29 years). The ESR and CRP level were elevated in 5 cases. The bacterial culture results were negative in all cases. Sclerosis was the main radiologic symptom. Other radiologic features such as bone expansion, cystic change, periosteal reaction, cortex destruction, and soft-tissue edema could accompany sclerosis. Anti-inflammatory medications temporarily and slightly reduced the symptoms. Four patients underwent extended curettage, in whom the clinical, radiologic, and laboratory symptoms considerably subsided. In the 2 patients who did not agree to undergo surgical intervention, the clinical and radiologic symptoms fluctuated at the follow-up visits. CONCLUSION: Unifocal CSO of the clavicle is associated with negative bacterial culture results, but the ESR and CRP level are frequently elevated. The symptoms fluctuate if not adequately treated. Extended curettage could be regarded as the treatment of choice.

Aneurysmal bone cysts of the clavicle: a comparison of extended curettage and segmental resection with bone reconstruction.

BACKGROUND: Although curettage of an aneurysmal bone cyst (ABC) of the clavicle has a high rate of local recurrence, segmental resection is often avoided for treatment as it causes functional impairment and shoulder deformity. We evaluated the rate of local recurrence and functional outcomes of extended curettage vs. segmental resection with bone reconstruction for the treatment of clavicular ABC. METHODS: A total of 14 patients with clavicular ABC were studied. Extended curettage and segmental resection with bone reconstruction were done for 6 and 8 patients, respectively. The number of local recurrences and postoperative complications was recorded for each group. The function of the shoulder was assessed using the Constant-Murley score. RESULTS: The mean age of the patients was 26.2 ± 14.7 years (range, 4-56 years). At a mean follow-up of 60 ± 37.6 months, 2 recurrences developed, both in the curettage group. Two postoperative complications (1 infection and 1 nonunion) were also recorded, both in the segmental resection group. The mean Constant-Murley score was 88.2 ± 3.4 in the extended curettage group and 87.3 ± 2.4 in the segmental resection group (P = .85). CONCLUSIONS: Considering the comparable function of the shoulder in curettage and segmental resection with bone reconstruction in clavicular ABC, we recommend the latter approach because of the lower recurrence rate, albeit with a higher rate of potential complications.

Benign bone tumours of tibial tuberosity clinically mimicking Osgood-Schlatter disease: a case series.

INTRODUCTION: Osgood-Schlatter disease (OSD) is a traction apophysitis of the tibial tubercle and a common cause of anterior knee pain in growing adolescents. A variety of benign neoplasms can also cause bony prominence over the tibial tubercle in adolescents that might clinically imitate OSD. Therefore, the differential diagnosis of tumours mimicking OSD is critical and considered the primary goal of this study. METHODS: Eleven patients who were referred to our orthopaedic oncology department with clinical suspicions of OSD and obscure radiographic presentation were identified. The final diagnosis was OSD in three cases. The demographic, clinical, and radiologic characteristics of the remaining eight patients in whom a tumour mimicked OSD were evaluated. The diagnosis was confirmed by pathologic examination. RESULTS: The final diagnosis was periosteal chondroma in four cases, osteochondroma in three cases, and dysplasia epiphysealis hemimelica (DEH) in one case. The average age of the patients was 10.5 ± 3.1 years. In the majority of patients (62.5%), the lesion was painless. The mean size of the bump was 6.5 ± 1.2 cm2. In patients with a painful knee, the pain was constant and activity-independent. At history taking, the pain and bump size were progressive. CONCLUSION: Lack of pain, progressive pain and bump, activity-independent pain, a bump size larger than 5 cm2 at presentation, and age fewer than ten years could be considered in favour of tumours and against OSD.

Curettage, phenolization, and cementation in paediatric Ewing's sarcoma with a complete radiological response to neoadjuvant chemotherapy.

PURPOSE: Although wide resection is the standard treatment for Ewing's sarcoma (ES), it has complications especially in children. In this study, we compared the oncologic and functional outcomes of wide resection with extended curettage and local adjuvant therapy (phenolization and cementation), as a less extensive surgery for paediatric ES with a complete radiologic response to neoadjuvant chemotherapy. METHODS: Children aged ≤ ten years, with ES of non-expendable long-bones and complete radiologic response to neoadjuvant chemotherapy, were included in this case-control study. Twenty-six patients were treated with extended curettage and local adjuvant therapy (case group) and 17 were managed with wide resection (control group). The average follow-up period was 60.1 ± 28.7 months (range 30-168 months). Functional outcome was assessed with the Musculoskeletal Tumor Society (MSTS) scoring system. RESULTS: Three local recurrences (11.5%) and three distant metastases (11.5%) were observed in the case group. Two local recurrences (11.7%) and two metastases (11.7%) were recorded in the control group. The rate of local recurrence was not statistically different between the two study groups (p = 0.668). The rate of metastasis was not statistically different between the two study groups as well (p = 0.668). The complication rates were 15% in the case group and 53% in the control group (p = 0.005). The mean MSTS score was 98.3% and 74% in the case and control group, respectively (p < 0.001). CONCLUSION: The oncologic outcome of extended curettage and local adjuvant therapy in paediatric ES with complete radiological response to neoadjuvant chemotherapy is comparable to wide resection, yet it offers considerably better functional results.

Locking plate and fibular strut-graft augmentation in the reconstruction of unicameral bone cyst of proximal femur in the paediatric population.

PURPOSE: Several therapeutic strategies have been used for managing unicameral bone cyst (UBC) of the proximal femur. However, there is insufficient evidence to support one treatment over another, and the optimal treatment is controversial. This study aims at describing our experience with surgical reconstruction of paediatric UBCs of the proximal femur using a proximal locking plate and fibular strut allograft. METHODS: In total, 14 consecutive paediatric patients with Dormans types IB (four cases) and IIB (10 cases) UBC were assessed. Mean patient age was 8.6 ± 2.3 years, and mean follow-up period was 41.7 ± 29.8 months. Six patients (42.8%) were referred with a pathologic fracture. Clinical/radiological outcome and complication rates were evaluated at the final follow-up session. RESULTS: No cysts were Capanna's class III (recurrence) or IV (no response). Complete healing (Capanna's class I) was seen in ten cysts, while four other cysts healed with residual radiolucent areas (Capanna's class II). Mean healing period was 14.1 ± 5.1 (9-24 months). One patient had superficial infection, one heterotopic ossification, and one mild coxa vara, and mean Musculoskeletal Tumor Society (MSTS) score was 99.5%. CONCLUSION: According to our results, locking plate and fibular strut graft in Dormans classification types IB and IIB results in a favorable outcome in managing UBC of the proximal femur in the paediatric population.

Surgical treatment outcome of giant cell tumor of distal ulna: En bloc resection vs. curettage and bone graft.

Background: Giant cell tumor (GCT) of the bone is a benign neoplasm with local aggressive behavior. Distal ulna is a very rare place for GCT. Published studies have mainly focused on case reports, and thus there is no consistent treatment strategy for this tumor at this location. This retrospective study was conducted to evaluate the oncological and functional results of 2 different surgical treatment methods for GCT in distal ulna. Methods: In this study, 9 patients with GCT of distal ulna were followed after surgical treatment of GCT of distal ulna. Of the patients, 2 had local recurrence after surgery in other hospitals and 7 had primarily been admitted to our hospital. Four patients, all with grade 2 Enneking and Campanacci's classification, were treated by extended curettage and bone grafting, while 5 patients with grade 3 were managed by distal ulnar resection. Minimum follow-up time was 24 months. Results: Patients with grade 3 GCT of distal ulna, who had extended curettage, had a local recurrence up to one year after surgery. Local recurrence was never seen in those with grade 3 disease with resection or in those with grade 2 disease with extended curettage as the treatment of GCT in this location. Conclusion: Based on our study, which is the largest cohort of GCT of distal ulna, extended curettage, and en bloc resection can be suggested as valuable methods of treatment for grades 2 and 3 tumors, respectively.

Florid reactive periostitis of the long bone: A case series of seven patients.

BACKGROUND: Florid reactive periostitis (FRP) is a rare benign periosteal lesion, which mostly involves the tubular bones of the extremities. FRP of the long bone is especially rare. We here report a case series of long bone FRP and also discuss the differential diagnosis and clinical outcome of our series. PATIENTS AND METHODS: In total, four female and three male patients with long bone FRP and a mean age of 25.1 years were evaluated for this study, from which four upper extremity and three lower extremity FRP lesions were identified. Patients were classified according to the clinical, radiological and pathological manifestations of the lesion. RESULTS: Periosteal reaction and edema around the lesions were observed in all cases. Calcified mass, bone marrow edema and cortical erosion were observed in six out of seven patients. Moreover, two lesions with peripheral mineralization and zoning appearances were observed. Limb rest and anti-inflammatory therapy proved to be sufficient treatment in all cases. The lesions were spontaneously resolved in all cases, leaving a residual exostosis. CONCLUSION: Our report indicates that short bone and long bone FRP could reveal different characteristics in some aspects, including the choice of the therapeutic approach. In spite of the favorable clinical outcome of long bone FRP, its differentiation from more aggressive lesions, especially osteosarcoma and osteomyelitis, should still be taken into consideration. In addition, according to our evidence, the implication of the zonal pattern in differential diagnosis of FRP and myositis ossificans (MO) could be re-evaluated.

The effect of cement augmentation and anteromedial plating on proximal humerus allograft reconstruction.

BACKGROUND: Limb salvage following the resection of tumor from the proximal part of the humerus, poses many challenges, and there is no consensus regarding the best reconstructive technique after proximal humerus resection. The aim of this study was to evaluate the effect of anteromedial placing of the plate in the absence of deltoid muscle and cement augmentation on the functional outcome, complication rate and survival of proximal humerus allograft reconstruction. PATIENTS AND METHODS: A number of 36 osteoarticular allograft reconstructions of proximal humerus were included in final study. In 26 cases, medullary canal of the allograft was filled by cement and the complication rate and survival was compared to non-cemented allografts. In addition, anteromedial placement of plate was applied for all resection type IB (18 cases), in which the deltoid muscle was resected. The mean follow-up of patients was 46 months. RESULTS: In total, 12 complications including 3 fractures, 4 resorptions, 3 infections and 2 nonunions were reported. Complication rates were significantly lower in cemented allografts (p = 0.001). Five year survival rates of cemented and non-cemented allografts were found to be 82% and 70%, respectively. The mean MSTS score was 84.9%, ranging 76-90. CONCLUSION: According to our results, cement augmentation improves survival and reduces the complication rate of allografts. Moreover, our results showed that anteromedial placing of the plate in resection type IB could improve the functional outcome of allografts. However, the detailed effect of anteromedial plating should be further investigated in future studies.

Surgical outcomes of 26 patients with pigmented villonodular synovitis (PVNS) of the knee at a mean follow-up of 4 years: introducing a novel technique.

BACKGROUND: Pigmented villonodular synovitis (PVNS) is characterized by the presence of inflammation and hemosiderin deposition in the synovium. Two forms of PVNS distinguished in the literature are diffused and localized involvements. There are controversies in the literature about the surgical management of PVNS. We report our experience in the management of knee PVNS at a mean follow-up of 4 years. We also introduce our preferred method of treatment for these patients. METHODS: A number of 26 patients (26 knees) with histologically proven PVNS of the knee in the pathology department at Shafa Yahyaeyan hospital were identified between January 1996 and February 2012. Annual clinical follow-up was conducted in all patients and a follow-up MRI scans was ordered for symptomatic cases. All patients were examined according to the Knee Society Score (KSS) in which the knees were graded from excellent to poor. RESULTS: Mean age of the patients was 28.08±12.5. A number of 15 patients (58%) had diffused involvement of the knee joint and 11 (42%) had a localized form of involvement. Mean follow up was 4 years. The mean duration of symptoms prior to presentation was 44.40±38.69 months. In five cases (23%) subtotal synovectomy and in 21 cases (77%) total synovectomy was performed. Two cases (7.7%) had recurrence. In a comparison between new methods vs. routine methods, after adjusting the pre-operation KSS scores, there was a significant difference between both methods in their post-op results. There were no complications in the form of knee instability, infection or neurovascular injury. CONCLUSION: The PVNS of knee joint; especially the diffused form should be carefully observed and managed using appropriate investigations. Staged open total synovectomy with a posterior and then an anterior approach seems to be a superior method for surgical treatment of diffused forms.

Outcomes of ilium and iliosacral Ewing's sarcoma resection reconstructed with tibial strut allograft.

Aims: Ilium is the most common site of pelvic Ewing's sarcoma (ES). Resection of the ilium and iliosacral joint causes pelvic disruption. However, the outcomes of resection and reconstruction are not well described. In this study, we report patients' outcomes after resection of the ilium and iliosacral ES and reconstruction with a tibial strut allograft. Methods: Medical files of 43 patients with ilium and iliosacral ES who underwent surgical resection and reconstruction with a tibial strut allograft between January 2010 and October 2021 were reviewed. The lesions were classified into four resection zones: I1, I2, I3, and I4, based on the extent of resection. Functional outcomes, oncological outcomes, and surgical complications for each resection zone were of interest. Functional outcomes were assessed using a Musculoskeletal Tumor Society (MSTS) score and Toronto Extremity Salvage Score (TESS). Results: The mean age of the patients was 17 years (SD 9.1). At a mean follow-up of 70.8 months (SD 50), the mean functional outcomes were 24.2 points (SD 6.3) for MSTS and 81 points (SD 11) for TESS. The mean MSTS and TESS scores were associated with the iliac resection zone (< 0.001). Nine patients (20.9%) had local recurrence. The recurrence was not associated with the zone of iliac resection (p = 0.324). The two-year disease-free survival of the patients was 69.4%. The mean time to graft union was longer in patients with the I4 resection zone (p < 0.001). The complication rate was 34.9%, and nerve palsy (11.6%) was the most common. The rate of surgical complications was not associated with the resection zone. Conclusion: Reconstruction using tibial strut allograft is an efficient procedure after the resection of the ilium and iliosacral ES. Functional outcomes and complications of iliac ES depend on the resection zone, and inferior outcomes could be generally expected when more segments of the pelvic ring are resected, even if it is reconstructed.