Limb-salvage surgery offers better five-year survival rate than amputation in patients with limb osteosarcoma treated with neoadjuvant chemotherapy. A systematic review and meta-analysis.

BACKGROUND: Osteosarcoma is the most common primary bone sarcoma. Currently, the main treatment option for high-grade osteosarcomas is neoadjuvant chemotherapy, followed by surgical resection of the lesion and adjuvant chemotherapy. Limb salvage surgery (LSS) and amputation are the main surgical techniques; however, controversy still exists concerning the best surgical method. Our meta-analysis compared the effectiveness of LSS and amputation combined with neoadjuvant chemotherapy in patients with limb osteosarcoma, in terms of 5-year overall survival (OS), 5-year disease-free survival (DFS) and local recurrence rate. METHODS: Following the established methodology of PRISMA guidelines, a literature search was conducted in PubMed, Cochrane, Google Scholar from 1975 until January 2020. Two independent reviewers evaluated the study quality based on the Newcastle-Ottawa scale. Odds ratio and 95% confidence interval of the OS, DFS and local recurrence rate were calculated. RESULTS: Thirteen studies were finally included with a total of 2884 patients; 1986 patients undergone LSS and 898 amputations. Five-year overall survival was almost 2-fold in patients treated with LSS than those treated with amputation (OR: 1.99; 95% CI: 1.35-2.93; I2 = 74%, p < 0.001). No difference was found in 5-year DFS between LSS patients and amputees (OR: 1.24; 95% CI: 0.55-2.79; I2 = 67%, p = 0.01). The odds of local recurrence was numerically higher in LSS compared to amputation but not statistically significant (OR: 2.29; 95% CI: 0.95-5.53; I2 = 47%, p = 0.05). However, the included studies did not clearly define differences in the stages of patients of the two groups. CONCLUSION: Our study demonstrated that in patients with limb osteosarcoma treated with neoadjuvant chemotherapy, LSS is associated with a higher 5-year overall survival and the odds of local recurrence may be increased but these results should be interpreted with caution due to high heterogeneity.

The Role of Anxiety in Simulation-Based Dexterity and Overall Performance: Does It Really Matter?

BACKGROUND: Essential Skills in the Management of Surgical Cases (ESMSC) is an international undergraduate surgical masterclass which combines ex vivo, dry lab and high fidelity in vivo simulation-based learning (SBL). It consists of 32 stations of skills-based learning, including open reduction internal fixation (ORIF) of fractures. Current literature suggests early involvement in skills-based learning at the undergraduate level is vital. AIMS: To compare students' dexterity and skills-based performance with demographic and educational background parameters. METHODS: 112 medical students from European Union countries including the United Kingdom, Germany, Greece, Cyprus, Germany, and Bulgaria were selected from a competitive pool of candidates to attend the course. Students undertook ORIF in an ex vivo swine model, and in a simulated fracture on a bamboo rod. Skills-based performance was assessed by two consultant surgeons with validated direct observation of procedural skills (DOPS) forms. Anxiety was self-assessed using the Westside Anxiety Scale prior to the ORIF stations. Dexterity was measured with the O'Connor tweezer dexterity test. RESULTS: Female students had significantly higher dexterity scores (median difference 7, p =.003). Right-handed students achieved higher dexterity than left-handed students (median difference 7, p =.043). There was no difference in students' performance across different medical schools, and across year groups (p <.05 for any correlation). Self-reported anxiety was not correlated with high fidelity skills-based performance (r = 0.032, p =.74). CONCLUSION: Anxiety does not seem to play a significant role in Simulation Skills-Based learning. Undergraduate surgical curricula should incorporate SBL-based modules to enhance practical skills learning and motivate future orthopedic surgeons.

The role of sternum in the etiopathogenesis of Scheuermann disease of the thoracic spine.

STUDY DESIGN: A clinical cohort study of sternum clinical measurements was performed in 10,057 students, during a school screening program for Scheuermann disease. OBJECTIVE: To determine whether the length of sternum is correlated with Scheuermann disease pathogenesis. SUMMARY OF BACKGROUND DATA: Many theories have been proposed for the etiology of Scheuermann disease, but the true cause remains unclear. Probably mechanical factors play a role in the development of the deformity. The reported success of brace treatment leads to the support to this theory. METHODS: There were 5048 boys and 5009 girls. The mean age of children was 13,07 years (SD = +/-0.82). Scheuermann disease was detected clinically and was documented with lateral radiograph of spinal column. All children were measured for their sternum's length from the jugular notch until the top of xiphoid process. This measure was repeated 3 times for each child. The height of all students and the arm span were measured, as well. RESULTS: In total 10,057 students screened, children with Scheuermann disease (study group) were 175 (147 men and 28 women). The length of sternum was greater in the healthy (control) group. There was a statistically significant difference between the 2 groups with regard to the sternum's length (Mann-Whitney U test, P = 0000). This is of particular importance, because in 2 groups that were comparable according to age (Mann-Whitney U test, P = 0605), the children with Scheuermann disease were taller in relation with the control group (Mann-Whitney U test, P = 0000). CONCLUSION: The smaller length of sternum than the normal has a possible correlation with the appearance of Scheuermann disease. Probably the smaller length of sternum increases the compressive forces on the vertebral endplates anteriorly, allowing uneven growth of the vertebral bodies with wedging. More studies are required for the documentation of this theory of pathogenesis.