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.

Tenosynovial giant cell tumor: a case report

BACKGROUND

This case reports the synchronous diagnosis of two rare unrelated diseases; leiomyosarcoma and tenosynovial giant cell tumor of the knee. It focuses on the challenges of diagnosing tenosynovial giant cell tumor, including cognitive biases in clinical medicine that delay diagnosis. It also demonstrates the pathogenic etiology of tenosynovial giant cell tumor, evidenced by the transient deterioration of the patients' knee symptoms following the administration of prophylactic granulocyte colony-stimulating factor given as part of the chemotherapeutic regime for leiomyosarcoma.

CASE PRESENTATION

A 37-year-old Caucasian man presented with a left groin lump and left knee pain with swelling and locking. Investigations including positron emission tomography-computed tomography and biopsy revealed leiomyosarcoma in a lymph node likely related to the spermatic cord, with high-grade uptake in the left knee that was presumed to be the primary site. His knee symptoms temporarily worsened each time granulocyte colony-stimulating factor was administered with each cycle of chemotherapy for leiomyosarcoma to help combat myelosuppressive toxicity. Subsequent magnetic resonance imaging and biopsy of the knee confirmed a tenosynovial giant cell tumor. His knee symptoms relating to the tenosynovial giant cell tumor improved following the completion of his leiomyosarcoma treatment.

CONCLUSIONS

Tenosynovial giant cell tumor remains a diagnostic challenge. We discuss the key clinical features and investigations that aid prompt diagnosis. The National Comprehensive Cancer Network clinical practice guidelines for soft tissue sarcoma have recently been updated to include the pharmacological management of tenosynovial giant cell tumor. Our case discussion provides an up-to-date review of the evidence for optimal management of patients with tenosynovial giant cell tumor, with a particular focus on novel pharmacological options that exploit underlying pathogenesis.

Injectable Synthetic Beta-Tricalcium Phosphate/Calcium Sulfate (GeneX) for the Management of Contained Defects Following Curettage of Benign Bone Tumours

Benign and low-grade malignant bone tumours are often treated with curettage and filling of the resultant defect using any of a number of materials, including autologous bone grafts, allografts, or synthetic materials. The objective of this study was to report our experience using a synthetic bone graft substitute in these patients. Ten consecutive cases (four males, six females; mean age, 36 years) of benign bone tumours were treated surgically at a tertiary musculoskeletal oncology centre, between 2019 and 2021. Following curettage, the contained defects were managed with injectable beta-tricalcium phosphate/calcium sulfate (GeneX; Biocomposites Ltd., Keele, UK). The desired outcomes were early restoration of function and radiographic evidence of healing. No other graft materials were used in any of the patients. The mean follow-up was 24 months (range, 20–30 months). All patients in this series (100%) demonstrated radiographic evidence of healing and resumed their daily living activities. There were no tumour recurrences and no complications were encountered with the use of GeneX. In patients with contained defects following curettage of benign bone tumours, we found GeneX to be a safe and effective filling agent. These findings contrast with some existing studies that have reported local complications with the use of injectable beta-tricalcium phosphate/calcium sulfate.

“Soar” or “Sore”

The study examines the factors affecting the performances of the Indian banking sector, especially after the global financial crisis. The sample constitutes a total of 33 scheduled commercial banks (SCBs) that were operative in India during the period extending from 2002 to 2016 by employing a panel data model. It also reports that leverage and management efficiency as internal determinants do have a significant impact, while inflation as an external determinant affects the bank's profitability. The Indian banking industry has been less affected by the influence of external factors as compared to profitability.

Barriers to entry of gig workers in the gig platforms: exploring the dark side of the gig economy

Purpose

The alternative arrangements to traditional employment have become a promising area in the gig economy with the technological advancements dominating every work. The purpose of this paper is to explore the barriers to the entry of gig workers in gig platforms pertaining to the food delivery sector. It proposes a framework using interpretive structural modelling (ISM) for which systematic literature review is done to extract the variables. This analysis helps to examine the relationship between the entry barriers to gig platforms. The study further proposes strategies to reduce the entry barriers in gig sector which would help to enhance productivity and generate employment opportunities.

Design/methodology/approach

The study uses interpretive structural model (ISM) to ascertain the relationship between various entry barriers of the gig workers to the gig platforms. It also validates the relationship and understand the reasons of their association along with MICMAC analysis. The model was designed by consulting the gig workers and the experts allied to food delivery gig platforms namely Zomato and Swiggy.

Findings

It was observed that high competition, longer login hours and late-night deliveries are the significant barriers with high driving power and low dependence power. Poor payment structures and strict terms and conditions for receiving the incentives are interdependent on each other and have moderate driving and dependence power. The expenses borne by the gig workers, such as Internet, fuel and vehicle maintenance expenses have high dependence power and low driving power. Hence, they are relatively less significant than other barriers.

Research limitations/implications

The study is confined to food delivery sector of India, without considering other important sectors of gig economy for generalizing the framework. As the study is based on forming an ISM framework through literature review only, it does not consider other research methods for analysing the entry barriers to the gig platforms.

Practical implications

The study attempts to dig out the low entry barriers for gig workers in food delivery platforms as there is a dearth of analysis of these factors. This study would weave them using ISM framework to help the gig platforms overcome these barriers at various levels, thus adding to the body of literature.

Originality/value

The study discusses the need for understanding relationship between the entry barriers in the form of ISM model to identify the dependent and driving factors of the same.

Closed incision negative pressure wound therapy versus conventional dressings following soft-tissue sarcoma excision: a prospective, randomized controlled trial

Aims

The primary objective of this study was to compare the postoperative infection rate between negative pressure wound therapy (NPWT) and conventional dressings for closed incisions following soft-tissue sarcoma (STS) surgery. Secondary objectives were to compare rates of adverse wound events and functional scores.

Methods

In this prospective, single-centre, randomized controlled trial (RCT), patients were randomized to either NPWT or conventional sterile occlusive dressings. A total of 17 patients, with a mean age of 54 years (21 to 81), were successfully recruited and none were lost to follow-up. Wound reviews were undertaken to identify any surgical site infection (SSI) or adverse wound events within 30 days. The Toronto Extremity Salvage Score (TESS) and Musculoskeletal Tumor Society (MSTS) score were recorded as patient-reported outcome measures (PROMs).

Results

There were two out of seven patients in the control group (28.6%), and two out of ten patients in the intervention group (20%) who were diagnosed with a SSI (p > 0.999), while one additional adverse wound event was identified in the control group (p = 0.593). No significant differences in PROMs were identified between the groups at either 30 days (TESS, p = 0.987; MSTS, p = 0.951) or six-month (TESS, p = 0.400) follow-up. However, neoadjuvant radiotherapy was significantly associated with a SSI within 30 days of surgery, across all patients (p = 0.029). The mean preoperative modified Glasgow Prognostic Score (mGPS) was also significantly higher among patients who developed a postoperative adverse wound event (p = 0.028), including a SSI (p = 0.008), across both groups.

Conclusion

This is the first RCT comparing NPWT with conventional dressings following musculoskeletal tumour surgery. Postoperative wound complications are common in this group of patients and we observed an overall SSI rate of 23.5%. We propose proceeding to a multicentre trial, which will help more clearly define the role of closed incision NPWT in STS surgery.

Cite this article: Bone Jt Open 2021;2(12):1049–1056.

Extra-thoracic, extra-meningeal solitary fibrous tumours - A case series and service review

BACKGROUND

Solitary fibrous tumours (SFT) are a type of mesenchymal tumour. Whilst the majority of cases follow an indolent course a significant proportion of patients suffer metastases or disease recurrence post-surgical excision. Due to the unpredictable clinical course follow up duration and intensity remains contentious.

AIMS

We aimed to determine current outcomes of management of this tumour, apply and assess current risk recurrence models to determine if our standard of care could be improved upon.

METHODS AND PATIENTS

A prospective database of patients treated at a regional musculoskeletal oncology service was assessed. Only extra-pleural, extra-meningeal SFTs were included in the study. Surgical outcome and post-operative investigations were scrutinised and the Pasquali and Demicco recurrence risk models were applied and assessed.

RESULTS

From 2009 to 2019 12 patients were identified, 8 female and 4 males. Their age at diagnosis ranged from 21 to 76 years. 11 patients underwent surgery with curative intent and no patient suffered disease progression or recurrence, with a mean follow up time of 41 months. One patient presented with metastatic disease and was managed palliatively.

CONCLUSIONS

Following this review of our case series and utilising risk recurrence models published in the literature we have changed our follow up protocol. In new cases of SFT the Pasquali prognostic model, with the addition of the presence or absence of necrosis, will be utilised. If a patient has benign features on initial biopsy we propose to not perform staging. Furthermore, if biopsy and final pathology results remain concordant, with no concerning features, and the patient has undergone complete excision reduced intensity follow up could be considered.Level of evidence Level IV, retrospective case series.

Blended Learning: Strategi Pembelajaran Alternatif di Era New Normal SD Tunas Harapan

The program to help students learn is a community service carried out at SD Tunas Harapan Tanjung Anom, which is located at Jl.  Griya Permata II housing, Durian Jangak, Pancur Batu District, Deli Serdang Regency, North Sumatra,   for 1 month starting from August 16, 2021 until August 22, 2021. The activities carried out in this service are teaching and learning activities in schools and assisting students in doing school assignments which are carried out for 1 month.  Teachers or students can combine face-to-face learning and online learning which is called blended learning.  Blended learning can bemake it easier for students and teachers to share and receive materials online.  In addition to students can using advanced technology when learning online, students can still learn face to face directly.  The material comes from thematic books and guide books from schools.  In the implementation of this service, there are several obstacles such as: inadequate facilities, lack of attention from students in studying at home, lack of awareness of students about their responsibilities in doing assignments, lack of communication and parental attention to their children.

Inflammatory prognostic scoring systems are risk factors for surgical site infection following wide local excision of soft tissue sarcoma

Introduction

Limb-sparing surgery with negative margins is possible in most soft tissue sarcoma (STS) resections and focuses on maximising function and minimising morbidity. Various risk factors for surgical site infections (SSIs) have been reported in the literature specific to sarcoma surgery. The aim of this study is to determine whether systemic inflammatory response prognostic scoring systems can predict post-operative SSI in patients undergoing potentially curative resection of STS.

Methods

Patients who had a planned curative resection of a primary STS at a single centre between January 2010 and December 2019 with a minimum follow-up of 6 months were included. Data were extracted on patient and tumour characteristics, and pre-operative blood results were used to calculate inflammatory prognostic scores based on published thresholds and correlated with risk of developing SSI or debridement procedures.

Results

A total of 187 cases were included. There were 60 SSIs. On univariate analysis, there was a statistically significant increased risk of SSI in patients who are diabetic, increasing specimen diameter, American Society of Anaesthesiology (ASA) grade 3, use of endoprosthetic replacement, blood loss greater than 1 L, and junctional tumour location. Modified Glasgow prognostic score, C-reactive protein/albumin ratio and neutrophil–platelet score (NPS) were statistically associated with the risk of SSI. On multivariate analysis, ASA grade 3, junctional tumour location and NPS were independently associated with the risk of developing a SSI.

Conclusion

This study supports the routine use of simple inflammation-based prognostic scores in identifying patients at increased risk of developing infectious complications in patients undergoing potentially curative resection of STS.

What Matters to Us: Impact of Telemedicine During the Pandemic in the Care of Patients With Sarcoma Across Scotland

In Scotland, approximately 350 sarcoma cases are diagnosed per year and treated in one of the five specialist centers. Many patients are required to travel long distances to access specialist care. The COVID-19 pandemic brought a number of rapid changes into the care for patients with cancer, with increasing utilization of telemedicine. We aimed to evaluate how the utilization of telemedicine affects professionals and patients across Scotland and care delivery, at the Beatson West of Scotland Cancer Centre Sarcoma Unit.

PKM Bimbingan Belajar Siswa SD Negeri 057239 Sekoci Langkat Sumatera Utara di Masa Pandemi Covid-19

The program to help students learn is a community service carried out at SD Negeri 057239 Sekoci, Besitang District, which is located at Sukaramai Hamlet, Sekoci Village, Langkat Regency, North Sumatra. for 1 month starting from March 31, 2021 to May 6, 2021. The activities carried out in this service are teaching and learning activities at home and helping students in doing school assignments which are carried out for 1 month. The material comes from thematic books and guidebooks from schools. In the implementation of this Community Service there are several obstacles such as: The distance to teaching at home between classes 3,4 and 5 is very far in insufficient time, Lack of attention from students in learning at home, students' awareness of their responsibility in doing assignments is still lacking, lack of communication and parental attention to their children.

A virtual multi-disciplinary meeting is a cost-effective method of triaging referrals to a regional musculoskeletal oncology service

BACKGROUND AND AIMS

In 2010, a virtual sarcoma referral model was implemented, which aims to provide a centralised multidisciplinary team (MDT) to provide rapid advice, avoiding unnecessary appointments and providing a streamlined service. The aim of this study is to examine the feasibility of this screening tool in reducing the service burden and expediting patient journey.

METHODS AND RESULTS

All referrals made to a single tertiary referral sarcoma unit from January 2010 to December 2018 were extracted from a prospective database. Only 26.0% events discussed required review directly. 30.3% were discharged back to referrer. 16.5% required further investigations. 22.5% required a biopsy prior to review. There was a reduction in the rate of patients reviewed at the sarcoma clinic, and a higher discharge rate from the MDT in 2018 versus 2010 (p < 0.001). This gives a potential cost saving of 670,700 GBP over the 9 year period.

CONCLUSION

An MDT meeting which triages referrals is cost-effective at reducing unnecessary referrals. This can limit unnecessary exposure of patients who may have an underlying diagnosis of cancer to a high-risk environment, and reduces burden on services as it copes with increasing demands during the COVID-19 pandemic.

Stabilisation of pathological humerus fractures using cement augmented plating: A case series

The humerus is the second most common long bone for metastatic tumours. These lesions result in weakened bone architecture and increased fracture risk with patients suffering pain, loss of function and diminished quality of life, often when life expectancy is short. Fractures or impending fractures require surgical stabilisation to relieve pain and restore function for the remainder of the patient's life without the need for further surgery. Conventional management of these lesions in the humerus is intramedullary nailing, however there are issues with this technique, particularly regarding rigidity of fixation. Advances in contoured locking plates have led to the development of different stabilisation techniques. The preferred technique in our regional oncology unit is curettage of the tumour and plating, augmented with cement to fill the defect and restore the structural morphology. In this case series we evaluate the survivorship of the construct and the clinical outcomes in patients who had an established or prospective pathological humeral fracture treated with curettage and cement augmented plating, since 2010. We identified 19 patients; 17 had metastasis and 2 myeloma of whom 15 had established fractures and four impending. The mean age at surgery was 69 years (51-86), and mean time since surgery 3.2 years. Overall mean follow up time was 20 months with 14 patients deceased and 5 surviving. There was 100% survivorship of the construct with no mechanical failures and no re-operations. There were no post-operative wound complications. Excellent early pain control was achieved in 18 patients with one experiencing pain controlled by analgesia. Function was assessed using Toronto Extremity Salvage Score (TESS) and was satisfactory; mean 79/100 (range 72-85). Cement augmented plating for pathological humerus fractures is a suitable alternative to intramedullary nailing and addresses several of the concerns with that technique. It provides immediate rigidity and allows early unrestricted function.

Multiple widespread fixed drug eruption caused by rabeprazole

Fixed drug eruption is one of the most common forms of cutaneous adverse drug reactions. Analgesics and antibiotics are the most common drugs causing fixed drug eruption. Here, we report a case of multiple widespread fixed drug eruption caused by rabeprazole.

Vitamin D and gastrointestinal cancer

Vitamin D serves as a precursor to the potent steroid hormone calcitriol, which has widespread actions throughout the body. Calcitriol regulates numerous cellular pathways that could have a role in determining cancer risk and prognosis. Low Vitamin D levels have been implicated in numerous disease processes including fracture risk, falls, cardiovascular disease, hypertension, diabetes mellitus, and cancers. Metabolite of 1, 25-dihydroxyvitamin D3 (1,25[OH]2D3) regulates numerous genes that control gut physiology and homeostasis. 1,25(OH)2D3 serves various functions such as maintaining the integrity of epithelial barrier and absorption of calcium and phosphate, and the host's defense against pathogens, and the inflammatory response by several types of secretory and immune cells. Although epidemiological data remain inconsistent, and randomized control trials in humans do not yet exist to conclusively support a beneficial role for Vitamin D, results from some correlating studies strongly suggest that Vitamin D deficiency increases the risk of developing cancer and that avoiding deficiency and adding Vitamin D supplements might be an economical and safe way to reduce cancer incidence and improve cancer prognosis and outcome. The present review highlights the role of Vitamin D in cancer of the gastrointestinal tract including esophagus, gastric (stomach), liver, pancreas, and colon.

Radiofrequency ablation for osteoid osteoma - Recurrence rates and predictive factors

BACKGROUND AND PURPOSE

Osteoid osteoma is an infrequent but debilitating benign bone lesion which can be successfully managed by percutaneous radiofrequency ablation (RFA). There are few studies investigating the efficacy and follow-up of this treatment. An arbitrary upper limit of 15 mm has been used to differentiate between osteoid osteoma and osteoblastoma with surgery used for lesions above this limit. We aimed to analyse the cases identified from our prospectively maintained database over a ten year period since adoption of this technique in our unit. The primary objectives were to investigate factors which influenced recurrence and the time period at which patients are at risk of this.

BASIC PROCEDURES

Consecutive patients with confirmed osteoid osteoma were included. Patient demographics, complications, and recurrence were recorded and multiple regression analysis was performed to investigate causation.

MAIN FINDINGS

Within a minimum follow up of 21 months (mean 72), a recurrence rate of 16.3% was noted, higher than the published literature. Cox regression analysis to predict chance of recurrence revealed a relationship between larger lucent diameter and recurrence (p = 0.049, CI 95%, hazard ratio 1.33).

CONCLUSIONS

The traditional cut off between osteoid osteoma and osteoblastoma appears less rigidly defined than previously thought and probably represents a progressive scale with larger lesions responding less well to RFA. This study indicates that each millimetre increase represents a ×1.33 chance of recurrence. Clinicians should counsel patients accordingly with lesions approaching the larger limits of this diagnosis.

Computer assisted navigation in total knee and hip arthroplasty

Introduction: Computer assisted surgery was pioneered in early 1990s. The first computer assisted surgery (CAS) total knee replacement with an imageless system was carried out in 1997. In the past 25 years, CAS has progressed from experimental in vitro studies to established in vivo surgical procedures.

Methods: A comprehensive body of evidence establishing the advantages of computer assisted surgery in knee and hip arthroplasty is available. Established benefits have been demonstrated including its role as an excellent research tool. Its advantages include dynamic pre-operative and per-operative assessment, increased accuracy in correction of deformities, kinematics and mechanical axis, a better alignment of components, better survival rates of prostheses and a better functional outcome. Adoption of computer navigation in the hip arthroplasty is still at an early stage compared to knee arthroplasty, though the results are well documented. Evidence suggests improved accuracy in acetabular orientation, positioning, hip offset and leg length correction.

Results: Among the orthopaedic surgeons, navigated knee arthroplasty is gaining popularity though slowly. The uptake rates vary from country to country. The Australian joint registry data shows increased navigated knee arthroplasty from 2.4% in 2003 to 28.6% in 2015 and decreased revision rates with navigated knee arthroplasty in comparison with traditional instrumented knee arthroplasty in patient cohort under the age of 55 years.

Conclusion: Any new technology has a learning curve and with practice the navigation assisted knee and hip arthroplasty becomes easy. We have actively followed the evidence of CAS in orthopaedics and have successfully adopted it in our routine practice over the last decades. Despite the cautious inertia of orthopaedic surgeons to embrace CAS more readily; we are certain that computer technology has a pivotal role in lower limb arthroplasty. It will evolve to become a standard practice in the future in various forms like navigation or robotics.

Negative Pressure Wound Therapy for Closed Surgical Wounds in Musculoskeletal Oncology Patients - A Case-Control Trial

Following excision of musculoskeletal tumours, patients are at high risk of wound issues such as infection, dehiscence and delayed healing. This is due to a multitude of factors including the invasive nature of the disease, extensive soft tissue dissection, disruption to blood and lymphatic drainage, residual cavity and adjuvant therapies. The use of negative pressure wound therapy (NPWT) has a growing body of evidence on its beneficial effect of wound healing such as promoting cell differentiation, minimising oedema and thermoregulation. Traditionally, these dressings have been used for open or dehisced wounds; however recent research has investigated its role in closed wounds.

Aim:

To evaluate the effect of NPWT in patients with closed wounds, either primarily or with flap coverage, in our high risk group. Consecutive patients who had a NPWT dressing applied were selected, and a control group was established by a blinded researcher with matching for tissue diagnosis, surgical site, gender and age. The primary outcome measured was documented for wound complications, with secondary data collected on radiotherapy and wound drainage.

Results:

Patients were well matched between the intervention (n=9) and control (n=9) groups for gender, age and tissue diagnosis. Both groups had 1 patient who underwent preoperative radiotherapy. A total of 3 wound infections occurred in the control group and none in the NPWT group. Overall there was a trend towards lower drain output and statistically significantly reduced infection rate in the NPWT group.

Conclusion:

In this short series, despite the NPWT patients having more additional risk factors for wound issues, they resulted in fewer infections. The sample size is not sufficient to have statistically significant reduction. Further evaluation on the value of NPWT in this patient group should be prospectively evaluated.

A Novel Antibiotic Spacer for Significant Proximal Femoral Loss - Surgical Technique

Background:

Infections of proximal femora with prosthetic implants in situ have long been a major concern in orthopedic surgery. The gold standard in the management of infected proximal femurs in the presence of prosthetic implants has traditionally been a two-stage revision. However, this is challenging in the setting of extensive bone loss.

Methods:

A 3 case series of such infections leading to extensive loss of the proximal femur is presented. We specifically describe our technique of debriding the infected segments as well as utilization of a trochanteric slide osteotomy to resect the femur.We also demonstrate preparation of the “pseudoacetabulum” and femoral component with an antibiotic spacer.

Conclusion:

The high cost of such a procedure is offset by reduction in time spent in hospital. The spacer also helps to allow mobilization by partial weight bearing on a stable femoral component and provide pain control which improves quality of life as compared to prolonged intravenous antimicrobial therapy.

The modified Glasgow prognostic score in patients undergoing surgery for bone and soft tissue sarcoma

BACKGROUND

The prognostic significance of markers of the systemic inflammatory response in patients with soft tissue and bone sarcomas remains unclear. Therefore, the present study aimed to compare the prognostic value of markers of the systemic inflammatory response in patients undergoing surgery for primary soft tissue and bone sarcoma.

METHOD

Patients who underwent resection of primary soft tissue/bone sarcoma between 2008 and 2012 and had pre-operative measurements of the systemic inflammatory response [C-reactive protein, albumin, white cell, neutrophil, lymphocyte and platelet counts, and the combination of C-reactive protein and albumin (mGPS)] were included in the study (n = 111).

RESULTS

The majority of the patients were ≤50 years old (84%), were female (63%), had soft tissue sarcoma (62%), and had tumours >10 cm (52%), mostly of high grade (85%). The median follow-up of survivors was 50 months (range 34-78); 24 (21%) developed local recurrence, 35 (31%) developed distant metastases and 30 (30%) died of their cancer. On univariate analysis, tumour size (P < 0.001), tumour grade (P < 0.001), C-reactive protein level (P < 0.001), albumin level (P < 0.001) and mGPS (P < 0.001) were significantly associated with distant recurrence-free survival. On a multivariate analysis, only tumour size [hazard ratios (HR) 2.57, 95% confidence intervals (CI) 1.14-5.32, P < 0.05], tumour grade (HR 7.01, 95% CI 0.94-52.17, P < 0.10) and mGPS (HR 1.92, 95% CI 1.31-2.83, P < 0.01) were independently associated with distant recurrence-free survival. On a multivariate analysis, only tumour size (HR 2.85, 95% CI 1.10-7.39, P < 0.05) and the mGPS (HR 2.03, 95% CI 1.31-3.16, P < 0.01) were independently associated with cancer-specific survival.

CONCLUSION

The systemic inflammatory response, as evidenced by the mGPS, was an important independent predictor of recurrence-free survival and cancer-specific survival in patients undergoing surgery for bone and soft tissue sarcoma.

Status report, The Public Health and Planning 101 project: strengthening collaborations between the public health and planning professions

INTRODUCTION

Land use planning is a complex field comprised of legislation, policies, processes and tools. A growing body of evidence supports the relationship between land use planning decisions, community design and health. The built environment has been shown to be associated with physical inactivity, obesity, cardiovascular disease, respiratory disease and mental illness. Consequently, there is a growing interest within public health to work with planners on land use planning initiatives such as official plans and transportation master plans.

METHODS

Two surveys were developed: one for public health professionals and the other for planning professionals (survey questions available upon request to the corresponding author). The surveys were pilot tested in two separate focus group sessions with public health and planning professionals. Focus group volunteers helped to validate the surveys by verifying survey questions, design and overall flow.

RESULTS

In early 2012, 304 public health professionals and 301 planning professionals completed the two separate surveys, comprising the total survey respondents for each respective profession used to calculate proportions. The survey results represent a convenience sample and are not generalizable to the entire population of public health and planning professionals in Ontario. Results compare survey responses from both groups where appropriate. Most respondents worked either as public health staff (78%) or planners/senior planners (58%). A smaller percentage of public health and planning professionals worked either as managers (15% and 11%, respectively) or directors (5% and 9%, respectively).

CONCLUSION

Health is associated with how communities are planned and built, and the services and resources provided within them. Inspired by the results of our survey and based on user feedback from the pilot tests, a free online training program entitled "Public Health and Planning 101: An Online Course for Public Health and Planning Professionals to Create Healthier Built Environments" was launched in 2016 by OPHA as a collaborative project with OPPI and PHAC. This course is designed to bridge the gaps between the two professions, as well as provide greater opportunities for developing collaborative partnerships to help create and foster healthy built environments.

Primary osseous tumours of the elbow: 60 years of registry experience

BACKGROUND

We present the largest series of surgically treated primary bone tumours of the elbow in the English literature (75 cases). We sought to identify characteristics specific to these lesions and recommend an investigatory protocol.

METHODS

The national registry and case notes were reviewed between 1954-2014. Tumours were classified according to Enneking's spectrum.

RESULTS

There were no benign latent cases in this series as these were managed locally. All patients presented with persistent rest pain, with or without swelling. The distal humerus, in contrast to the proximal radius and ulna, was responsible for the majority and the more aggressive cases. Misdiagnosis was evident in 13% of cases; most of which were attributed to simple bone cysts. All patients that were referred required surgical intervention to either establish the diagnosis or for treatment. Benign tumours had a 19% recurrence rate, with giant cell tumour the most aggressive. Malignant tumours carried 39% local recurrence rate and a 5-year mortality of 61%.

CONCLUSIONS

The suspicion of a tumour should be raised in the patient with unremitting, unexplained, non-mechanical bony elbow pain. These echo the NICE recommendations and we recommend prompt specialist referral. With high rates of local recurrence, we recommend close postoperative monitoring.

The mechanical effects of extracorporeal irradiation on bone

Extracorporeal irradiation of an excised tumour-bearing segment of bone followed by its re-implantation is a technique used in bone sarcoma surgery for limb salvage when the bone is of reasonable quality. There is no agreement among previous studies about the dose of irradiation to be given: up to 300 Gy have been used. We investigated the influence of extracorporeal irradiation on the elastic and viscoelastic properties of bone. Bone was harvested from mature cattle and subdivided into 13 groups: 12 were exposed to increasing levels of irradiation: one was not and was used as a control. The specimens, once irradiated, underwent mechanical testing in saline at 37°C. The mechanical properties of each group, including Young's modulus, storage modulus and loss modulus, were determined experimentally and compared with the control group. There were insignificant changes in all of these mechanical properties with an increasing level of irradiation. We conclude that the overall mechanical effect of high levels of extracorporeal irradiation (300 Gy) on bone is negligible. Consequently the dose can be maximised to reduce the risk of local tumour recurrence.

Bilateral tarsometatarsal joint injuries: An unusual mechanism producing unusual variants

Tarsometatarsal (Lisfranc) joint injuries are rare but potentially devastating conditions requiring anatomical reduction and internal fixation or arthrodesis. We describe an unusual mechanism involving forced eversion and dorsiflexion on both fully supinated feet resulting in bilateral tarsometatarsal joint injury. The injury pattern involved incongruity between the medial and middle columns extending between the cuneiform bones with associated fracture of the cuboid on the right and the cuboid, os calcis and talus on the left. Operative fixation is discussed and the clinical outcome was good at 4 years post-operatively. We believe this introduces an additional and potentially serious mechanism of injury and pattern of ligamentous and osseous disruption into the pantheon of injuries classed as Lisfranc, which surgeons should be aware of. Furthermore, we recommend attention to the mechanism of injury in consideration with classification to aid in operative reduction and fixation.

Basal cell ameloblastoma: a rare histological variant of an uncommon tumor

Ameloblastomas are an inscrutable group of oral tumors. Basal cell ameloblastoma is a rare variant of ameloblastoma with very few cases reported until date. The tumor is composed of more primitive cells and has less conspicuous peripheral palisading. It shows remarkable similarity to basal cell carcinoma, basal cell adenoma and intra-osseous adenoid cystic carcinoma. This report describes the case of a 27-year-old male with an ameloblastoma in the right posterior mandible. Orthopantomography computed tomography and finally histopathological examination directed us toward the confirmatory diagnosis of basal cell variant of ameloblastoma. Considering the rarity of the lesion and histological paradox regarding its diagnosis, we report here an interesting and rare case of basal cell ameloblastoma of the mandible with emphasis on differential diagnosis from other entities with basaloid differentiation having varying prognosis. After surgery, long-term follow-up at regular intervals is recommended as no sufficient statistical information regarding the behavior of this tumor is available.

Case report: fibrous dysplasia of the navicular bone treated with excision of navicular and talo-cuneiform arthrodesis

Fibrous dysplasia is an uncommon beningn disorder of bone. It usually affects the long bones, and is uncommon in the navicular. We describe a case of fibrous dysplasia of the navicular successfully treated with navicular excision and talo-cuneiform arthrodesis.

The evolving role of computer-assisted navigation in musculoskeletal oncology

We report our experience of using a computer navigation system to aid resection of malignant musculoskeletal tumours of the pelvis and limbs and, where appropriate, their subsequent reconstruction. We also highlight circumstances in which navigation should be used with caution.

We resected a musculoskeletal tumour from 18 patients (15 male, three female, mean age of 30 years (13 to 75) using commercially available computer navigation software (Orthomap 3D) and assessed its impact on the accuracy of our surgery. Of nine pelvic tumours, three had a biological reconstruction with extracorporeal irradiation, four underwent endoprosthetic replacement (EPR) and two required no bony reconstruction. There were eight tumours of the bones of the limbs. Four diaphyseal tumours underwent biological reconstruction. Two patients with a sarcoma of the proximal femur and two with a sarcoma of the proximal humerus underwent extra-articular resection and, where appropriate, EPR. One soft-tissue sarcoma of the adductor compartment which involved the femur was resected and reconstructed using an EPR. Computer navigation was used to aid reconstruction in eight patients.

Histological examination of the resected specimens revealed tumour-free margins in all patients. Post-operative radiographs and CT showed that the resection and reconstruction had been carried out as planned in all patients where navigation was used. In two patients, computer navigation had to be abandoned and the operation was completed under CT and radiological control.

The use of computer navigation in musculoskeletal oncology allows accurate identification of the local anatomy and can define the extent of the tumour and proposed resection margins. Furthermore, it helps in reconstruction of limb length, rotation and overall alignment after resection of an appendicular tumour.

Cite this article: Bone Joint J 2015;97-B:258–64.

A novel approach for retreatment of multirooted tooth by partial radisection

Modern advances in all phases of dentistry have provided the opportunity for patients to maintain a functional dentition for lifetime. Therapeutic measures performed to ensure retention of teeth vary in complexity. The treatment may involve combining restorative dentistry, endodontics, and periodontics so that the teeth are retained in whole or in part. Thus, tooth resection procedures are used to preserve as much tooth structure as possible rather than sacrificing the whole tooth. This treatment can produce predictable results as long as proper diagnostic, endodontic, surgical, prosthetic, and maintenance procedures are performed. The keys to long-term success appear to be thorough diagnosis, selection of patients with good oral hygiene and careful surgical and restorative management.

Bilateral keratocystic odontogenic tumor: A report of two cases

The designation “keratocyst” was used to describe any jaw cyst in which keratin was formed to a large extent. A rare incidence of bilateral mandibular cysts (odontogenic keratocysts) was related to third molar teeth. Herein, we report two cases of bilateral keratocystic odontogenic tumor in a 22-year-old male and 15-year-old female, which was diagnosed by a series of investigations and treated appropriately.

Association between use of tobacco and age on graying of hair

Aims and Objectives:

To determine the association between smoking, chewing tobacco (gutka), and age of individual on graying of hair.

Materials and Methods:

The present study was conducted on 120 patients attending the Outpatient Department of the DJ College of Dental Sciences and Research, Modinagar, UP. The individuals were classified into four groups (group I, II, III, IV) on the basis of the form of tobacco use (smoking or chewing). The Pearson correlation coefficient was utilized to find the correlation between the mean percentage of individuals with gray hair, risk multiplication factor (RMF), and age of the individual.

Results:

Mean percentage of individual with gray hair and RMF (r = 0.6487) are found to be positively associated. A significant and positive correlation was observed between the age of the individual and the frequency of individuals with gray hair.

Conclusion:

This study suggests that there is a significant association between tobacco use and aging on graying of hair.

Genetically altered fields in head and neck cancer and second field tumor

The concept of field cancerization has been ever changing since its first description by Slaughter et al in 1953. Field cancerization explains the mechanisms by which second primary tumors (SPTs) develop. SPTs are the tumors, which develop in the oral cavity in succession to the primary malignant tumors, which might vary in duration ranging from few months to years. Conceivably, a population of daughter cells with early genetic changes (without histopathology) remains in the organ, demonstrating the concept of field cancerization. This review explains the concept of field cancerization and various field theories along with molecular basis of field formation.

A comprehensive analysis of articles retracted between 2004 and 2013 from biomedical literature - a call for reforms

Science is a dynamic subject and it was never free of misconduct or bad research. Indeed, the scientific method itself is intended to overcome mistakes and misdeeds. So, we aimed to assess various factors associated with retraction of scientific articles from 2004 to 2013. Data were retrieved from PubMed and Medline using the keywords retraction of articles, retraction notice, and withdrawal of article in April 2014 to detect articles retracted from 2004 to 2013. Statistical analysis was carried out using t-test and Karl Pearson's correlation coefficient. Results showed that a total of 2343 articles were retracted between 2004 and 2013, and original articles followed by case reports constituted major part of it. Time interval between submission and retraction of article has reduced in recent times. Impact factor and retraction do not have any significant correlation. We conclude that although retraction of articles is a rare event, its constant rise in scientific literature is quite worrisome. It is still unclear whether misconduct/mistakes in articles are increasing hastily or the articles are retracted at a rapid rate in recent times. So, it should be considered as an urgent issue and it is the responsibility of journal editors to track misconduct by following Committee on Publication Ethics (COPE) guidelines and making an effective strategy.

Guarding the precious smile: incidence and prevention of injury in sports: a review

The paper provides a review about the orofacial injuries sustained during sports and the options available to the athletes for their prevention. It was done with a purpose to determine three different aspects incidence of dental injury during sporting activities, role of mouthguards in preventing sports injury, types of mouthguards and their properties. From this review, it is clear that sports carry a considerable risk of injury, this is not only true for the contact sports such as rugby or kickboxing, but also for seemingly less dangerous sports such as football. Amongst the different types of mouthguards, the most acceptable and safe ones are the custom-fabricated mouthguards, in particular the pressure-laminated ones. In general, mouthguard usage is less than the dental profession would recommend. As much of progress has been made in this area, need for the use of mouthguard needs to be emphasized and promoted by the dental profession.

Radiofrequency ablation of osteoid osteoma: outcomes from the West of Scotland

Background

Osteoid osteoma is a classically described benign bone tumour. Traditionally, the surgical treatment of choice was excision, but this can have significant morbidity. Percutaneous radiofrequency ablation (RFA) has grown in popularity as an alternative treatment. This study reports the outcomes using this technique in our regional bone tumour unit.

Methods

Between May 2003 and October 2007, 14 patients underwent CT-guided RFA. All patients were subsequently offered follow-up in the out-patient clinic. Outcomes were taken from the Scottish Bone Tumour Registry database.

Results

Eleven patients (78.6%) had complete resolution of symptoms after one RFA. Three (21.4%) cases were unsuccessful but one of these was due to technical failure. All three of the above patients had complete relief of symptoms after one further RFA. One (7.1%) patient initially had complete relief of symptoms, but suffered recurrence after 9 months. This patient also had a second curative treatment.

Conclusion

Percutaneous RFA for osteoid osteoma is an attractive treatment due to its efficacy and low morbidity. Our results showed a primary success rate of 78.6%, a secondary success rate of 100% (after one additional procedure). Our results add to the growing literature supporting RFA as the preferred treatment for osteoid osteoma.

Herpes Zoster with disseminated lesions. What is it?

Herpes Zoster (HZ) is a Cutaneous Viral infection caused by Varicella zoster virus (VZV). Lesions of HZ are usually limited to one dermatome only but sometimes, there can be dissemination of lesions. The present case describes the role of proper examination of HZ case, which presents with disseminated lesions.

Primary osseous tumors of the hindfoot: why the delay in diagnosis and should we be concerned?

BACKGROUND

Bony tumors of the foot account for approximately 3% of all osseous tumors. Diagnosis is frequently delayed as a result of lack of clinician familiarity and as a result of their rarity. The reasons for the delays, however, are unclear.

QUESTIONS/PURPOSES

We therefore determined (1) how hindfoot tumors present and the specific reasons for delay in diagnosis; (2) whether the spectrum of disease varies between the talus and calcaneus; and (3) how these patients were treated.

METHODS

We retrospectively reviewed the medical notes and imaging for all patients with 34 calcaneal and 23 talar tumors recorded in the Scottish Bone Tumour Registry. Demographics, presentation, investigation, histology, management, recurrence, and mortality were recorded.

RESULTS

Hindfoot tumors present with pain and often swelling around the heel (calcaneus) or ankle (talus), most often misdiagnosed as soft tissue injury. Calcaneal lesions were more likely to be malignant than talar lesions: 13 of 34 versus three of 23.

CONCLUSIONS

Clinicians should be aware that hindfoot tumors can be initially misdiagnosed as soft tissue injuries and suspicion of a tumor should be raised in the absence of trauma or persistent symptoms. Lesions affecting the calcaneus are more likely to be malignant. Early diagnosis and adjuvant therapy are important.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Primary bone tumours of the talus: the Scottish Bone Tumour Registry experience

BACKGROUND

Primary bone tumours of the talus are rare and the existing literature is limited. The aim of this study was to investigate the epidemiology of primary bone tumours affecting this uncommon site and suggest a management protocol for these tumours.

METHODS

We retrospectively reviewed the Scottish Bone Tumour Register from January 1954 to May 2010 and included all primary bone tumours of the talus.

RESULTS

We identified only twenty three bone tumours over fifty six years highlighting the rarity of these tumours. There were twenty benign and three malignant tumours with a mean age of twenty eight years. A delay in presentation was common with a mean time from onset of symptoms to diagnosis of ten months.

CONCLUSIONS

Tumour types identified were consistent with previous literature. We identified cases of desmoplastic fibroma and intraosseous lipodystrophy described for the first time. We suggest an investigatory and treatment protocol for patients with a suspected primary bone tumour of the talus.

Gene therapy with growth factors for periodontal tissue engineering--a review

The treatment of oral and periodontal diseases and associated anomalies accounts for a significant proportion of the healthcare burden, with the manifestations of these conditions being functionally and psychologically debilitating. A challenge faced by periodontal therapy is the predictable regeneration of periodontal tissues lost as a consequence of disease. Growth factors are critical to the development, maturation, maintenance and repair of oral tissues as they establish an extra-cellular environment that is conducive to cell and tissue growth. Tissue engineering principles aim to exploit these properties in the development of biomimetic materials that can provide an appropriate microenvironment for tissue development. The aim of this paper is to review emerging periodontal therapies in the areas of materials science, growth factor biology and cell/gene therapy. Various such materials have been formulated into devices that can be used as vehicles for delivery of cells, growth factors and DNA. Different mechanisms of drug delivery are addressed in the context of novel approaches to reconstruct and engineer oral and tooth supporting structure.

Key words: Periodontal disease, gene therapy, regeneration, tissue repair, growth factors, tissue engineering.

Management of vascular involvement in extremity soft tissue sarcoma

Advances in adjuvant treatment protocols and improvements in imaging techniques have helped improve the limb-salvage rate for extremity soft tissue sarcomas to approximately 95%. Moreover, improvements in operative techniques have enabled successful limb-salvage surgery to be performed even in the face of vascular invasion or encasement by tumor. En bloc resection of major vascular structures with the tumor and reconstruction with reversed saphenous vein grafts, femoral venous grafts, or synthetic grafts has proved to be a feasible option in limb-salvage surgery. However, the surgical oncologist and patient should be aware that although overall function is only slightly worse after these procedures, individual functional results are less predictable. In addition, procedures requiring vascular resection and reconstruction are associated with an increased risk of complications, including amputation.

Outcome of 17 pigmented villonodular synovitis (PVNS) of the knee at 6 years mean follow-up

Between January 1950 and December 2000, 16 patients were identified from Scottish Bone Tumour Registry with 17 histologically proven pigmented villonodular synovitis (PVNS) of the knee. The mean follow-up was 6 years (range, 1-14 years). A knee swelling of chronic duration with dull ache was the common presenting symptom. The mean duration of symptoms prior to presentation was 25 months (1-108 months), however it was much less (mean, 7 months) in four patients with a history of trauma. The mean age was 33 years (range, 16-58 years) with a slight male predominance. The lesion was predominantly anterior in nine patients, posterior in four, anterolateral in two, and medial and lateral in one each. Three patients (four knees) had localised disease and 13 diffuse. Anteroposterior and lateral radiographs of the knee revealed normal findings in 11 patients, features of gonarthrosis in four and a large suprapatellar loose body in one patient (both knees). Open (incisional-eight, excisional-eight) biopsy was carried out in all and all were histologically confirmed as PVNS. Removal of a localised synovial mass or loose body with surrounding partial synovectomy (four) was carried out for the localised variety, whilst open partial (three) or total (radical) synovectomy (10) was performed in all cases of diffuse PVNS. Three of seventeen knees had a recurrence, noted at 4, 6 and 8 years postoperatively (0% - localised, 23% - diffuse variety). A total (radical) synovectomy should be considered in diffuse PVNS in order to obtain optimal outcome.