Epithelioid hemangioendothelioma of the craniocervical junction; case report and review.

Epithelioid hemangioendotheliomas are uncommon vascular neoplasms and their spinal location is even rarer. We report clinical course of a 31-year-old man with an epithelioid hemangioendothelioma at the cranio-cervical junction. A cervical magnetic resonance imaging revealed tumor that caused posterior cervical cord compression. C1,2,3 total laminectomy and surgical excision of the tumor was performed. Postoperative external beam radiation was performed on the surgical field especially around the right vertebral artery. At 2-year follow-up there was no neurological deficit and no tumor recurrence.

Anterior cervical fusion with interbody cage containing beta-tricalcium phosphate: Clinical and radiological results.

AIM: Beta tricalcium phosphate (beta-TCP) is an osteoconductive, resorbable material. Its clinical effectiveness has been proved in many indications. This study was clinical and radiographic study report obtained in patients undergoing anterior cervical discectomy and fusion ACDF in which PEEK cages were filled beta-TCP in an injectable form. MATERIAL AND METHODS: Between January 2010 and June 2011, 16 consecutive patients underwent ACDF using PEEK cages with beta-TCP. The cohort compromised 10 men and 6 women with a mean age of 45.2 years. The surgery was performed when the patient had myelopathy or radiculopathy with progressive neurological deficit, or failure of conservative treatment (a minimum of 3 months). The patients were evaluated by Odom criteria preoperatively and postoperative 3rd, 6th, 12th and 24th months. Preop and postop pain was evaluated with visual analogue scala (VAS). Disc height and fusion success rates were evaluated. RESULTS: Preoperative average VAS score was 7.9 (7-10) for neck pain and 8 (7-10) for arm pain. At the final follow-up, these scores became 1.5 and 1.4 for neck and arm pain, respectively. The average improvement rate was 81% for neck pain and 82.5% for arm pain. Postop ODOM's criteria main rate was 3.4. Bone fusion was achieved in 14 segments (70%) at 3rd month, 19 segments (95%) at 12th month follow-up assessment. CONCLUSION: Clinical and radiological results revealed that B-TCP is a good alternative synthetic fusion material for cervical interbody fusion. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Systematic Evaluation of Drug-Loaded Hydrogels for Application in Osteosarcoma Treatment.

This is a literature review of studies focusing on the preparation of hydrogels for use as oncological drug delivery systems in the treatment of osteosarcoma (OS). The databases of the US National Library of Medicine National Institutes of Health, Embase, OVID, and Cochrane Library, and the references of retrieved studies, were traced from 1843 to December 21, 2015, without language restrictions. The obtained data were evaluated by complementary statistical methods. Potentially relevant studies were found and included in the analysis. OS-specific chemotherapeutic agents can be successfully embedded within the hydrogels and these drug-loaded hydrogels can be applied locally, rather than systemically, without organ tissue toxicity. Further, OS-specific drug-loaded hydrogels significantly increased tumor inhibition and decreased osteolysis and lung metastases. Drug-loaded hydrogels could be useful in the treatment of OS, although their development remains at the experimental phase. Following evaluation of their application in surgery and the completion of drug release kinetics studies, drug-loaded hydrogels could be tested on living mammals in large samples with the aim of applying these in clinical settings. In the future, development of such drug delivery systems and application of targeted approaches against osteosarcoma and other malignancies may render surgery, radiotherapy and chemotherapy unnecessary.

A case report of osteoblastoma on the distal phalanx of the ring finger successfully treated with curettage and polymethylmethacrylate filling.

BACKGROUND: Osteoblastoma is an aggressive benign tumor whose presentation varies with location and size. This rare bone tumor is thus difficult to diagnose particularly when it occurs outside its most common location - the vertebral column and long bones. CASE: We report a case of osteoblastoma of the fourth distal phalanx of the left hand in an 18-year-old male, presented with pain and swelling and treated with curettage and polymethylmethacrylate filling followed by immobilization by a cast, which was opened 10 days later to start physical therapy. Patient was pain-free, recovered full function of his finger, and remained without pain at one month post-surgery. The finger was monitored closely for two years; sequential films showed a radiopaque interface and no evidence of local recurrence. CONCLUSION: This is the first report of osteoblastoma on the distal phalanx. The possibility of osteoblastoma should be considered in cases of pain and swelling of phalanx, and if diagnosed, curettage and polymethylmethacrylate filling may be the treatment of choice.

Effect of pentoxifylline on histopathological changes in steroid-induced osteonecrosis of femoral head: experimental study in chicken.

PURPOSE: Pentoxifylline (PTX) is a derivative of methylxanthine and is used in peripheral vascular and cerebrovascular diseases for its effect on the regulation of blood circulation. We investigated whether PTX could be beneficial for femoral head osteonecrosis associated with steroid through these effects. METHODS: Sixty mature Leghorn type chickens were chosen and divided into three groups. The 25 chickens in group A were given a weekly dose of 3 mg/kg/week methylprednisolone acetate intramuscularly. Four chickens in group B died after the first drug injection and were excluded from the study. Therefore, the remaining 21 chickens in group B were additionally given 25 mg/kg/day pentoxifylline intramuscularly, along with the steroid medication as given in group A. The ten chickens in group C were not given any injections, as they were accepted as the control group. After the sacrifice of the animals at week 14, both femoral heads were taken from each animal. The animals which died along the course of the study also underwent pathological examination but were not a part of the statistical analysis. RESULTS: In this study, steroid induced femoral head osteonecrosis has been experimentally observed in chickens after high doses of corticosteroid therapy. The chickens were given pentoxifylline in order to prevent the effects of steroid on bones and bone marrow. The results showed that chickens are suitable osteonecrosis models, and that steroid causes adipogenesis and necrosis in the bone marrow and the death of the subchondral bone. CONCLUSIONS: The results of this study hint at the assumption that PTX may have a positive benefit on ONFH. PTX seems to minimise the effects of the steroid and reduce the incidence of ONFH.

Diagnosis and planning in the management of musculoskeletal tumors: surgical perspective.

The evaluation of musculoskeletal tumors requires a close interaction between the orthopedic oncologist, radiologist, and the pathologist. Successful outcome can be achieved in a considerable number of patients by following the appropriate diagnostic strategies and staging studies. The aim of this article is to outline the presentation, imaging, and staging of the primary and metastatic bone and soft tissue tumors. Some of the image-guided interventions for these tumors are also presented.

Solitary enchondromas of long bones: pattern of referral and outcome.

OBJECTIVES: Enchondromas are benign cartilaginous tumors, often found incidentally and diagnosed by the radiographic appearance. Active growing enchondromas/low grade chondrosarcomas are diagnosed by clinical symptoms and possibly an aggressive appearance on the radiographs. This study aimed to answer the following questions: Who requests a referral? The radiologist reporting a possibility of sarcoma or the referring physician? What is the outcome of these patients? METHODS: We retrospectively reviewed the medical records of 115 patients with final diagnosis of enchondroma over three consecutive years and recorded the radiological diagnosis on report, patients' symptoms, our initial diagnosis, follow-up, and any decision for a biopsy/surgical management, as well as the histological final diagnosis. RESULTS: Nearly 80% of patients were referred from an orthopedic surgeon. About half of the imaging reports mentioned a malignancy in the differential diagnosis of enchondroma. Very few had the classic signs of an aggressive/growing cartilage tumor. In radiological evaluation, we found scalloping/cortical erosion, lytic areas, cortical breaks, soft tissue extension in only 12 cases of which 8 underwent a biopsy. Of the study patients, 65% were diagnosed with adjacent joint problems. CONCLUSION: Enchondromas are mostly diagnosed incidentally. They are frequently associated with adjacent joint or soft tissue pathologies, which are main source of the symptoms. Even small, well-defined lesions are often confused with a sarcoma or other malignancies, which may be due to the lack of education on bone tumors for both the radiologists and general orthopedists.

Minimally invasive treatment of pathological fractures of the humeral shaft.

Most patients with pathological fractures due to cancer metastasis have a limited life expectancy. Orthopaedic procedures, therefore, should be minimally invasive in order to avoid additional surgical morbidity. The purpose of this study was to analyse the results of minimally invasive approaches, including locked intramedullary nailing, followed by early postoperative radiation for pathological humeral shaft fractures. Twenty-four pathological fractures of the humerus diaphysis in 23 patients were treated with the prospective protocol, including antegrade unreamed intramedullary nailing and postoperative radiotherapy (20 Gy and five fractions). The patients and results of the surgery were evaluated by the Musculoskeletal Tumor Society upper extremity scoring system. All patients had a stable extremity, and the average function of 20 patients was 64% of the normal upper extremity function. Only one patient required revision surgery. The minimally invasive treatment of patients with pathological fractures of the humeral shaft with closed unreamed intramedullary nailing combined with adjuvant radiotherapy is an effective and safe procedure, even in seriously ill patients.

Metastatic behaviour of giant cell tumour of the spine.

Lung metastases from giant cell tumours (GCT) of the spine have not been specifically addressed in the literature. We reviewed our cases and compared the incidence, treatment, and outcomes with those from the extremities. Between 1970 and 2006, we identified seven cases (three females and four males) of lung metastases from a total of 51 cases of GCT of the spine (13.7%). Four of the seven patients had presented to our institution with a spine recurrence after previous treatments and the rest developed recurrences later. The treatments for the lung nodules consisted of metastectomy in two and chemotherapy in six patients. At the latest follow-up (ranging from 18 to 126 months), two had died of the disease, two had no evidence of the disease, and three were alive with disease. Our series shows a higher metastatic rate from spine GCT as compared to those from the extremities, but the overall behaviour and treatment outcomes of the lung metastases are similar. When there is a recurrence of GCT, with or without metastases, the local and possibly the metastases should be biopsied to confirm the original diagnosis. Progression of benign GCT into an aggressive sarcoma has been documented, and the method of management should be altered.

Minimally invasive management of spinal metastases.

In most patients who have spinal metastases, treatment is mainly palliative. The conventional surgical methods carry higher risks of complications and postoperative morbidity. Minimally invasive spinal interventions seem to be reasonable alternatives to treat spinal metastatic disease. These procedures can result in less soft tissue trauma, lower blood loss, shorter hospitalization time and are better tolerated by the patients. In this review, the techniques and results of minimally invasive management in spinal metastasis, including percutaneous image-guided interventions (vertebroplasty, kyphoplasty, and radiofrequency ablation) and minimally invasive surgical techniques (endoscopic and minimal access operations), are presented.

Spine oncology: Daedalus, Theseus, and the Minotaur.

Over the past three decades, progress has been dramatic in the management of spine tumors. For example, advanced imaging technologies made available at manageable costs have lowered the threshold for scanning. CT, MRI, and PET imaging modalities have greatly enhanced the ability of the surgeon to accurately delineate the extension of the lesion within the bone, the soft tissue, and the spinal canal. Such enhancements have led to great leaps forward in preoperative planning and postoperative evaluation, including improved reconstruction options are resulting in improved outcomes. This article introduces the theme of this volume.

Prophylactic bypass grafting and long-term bracing in the management of anterolateral bowing of the tibia and neurofibromatosis-1.

BACKGROUND: Congenital anterolateral bowing of the tibia is a pre-pseudarthrosis stage of congenital pseudarthrosis of the tibia and is associated with a substantial risk of fracture and pseudarthrosis. We evaluated the results of prophylactic bypass grafting performed in combination with bracing to prevent fracture and pseudarthrosis. METHODS: This retrospective series included ten patients with pre-pseudarthrosis of the tibia treated, between 1991 and 2002, with prophylactic bypass grafting with an allograft fibula placed posteromedially in a stress-bearing fashion. The average patient age was 2.3 years at the time of diagnosis, 3.6 years at the time of surgery, and ten years at the time of final follow-up. The mean duration of follow-up was seventy-eight months. Brace protection was recommended at the time of diagnosis and was continued after the operation until maturity. Despite the bracing, a low-energy fracture developed and partially healed prior to the bypass grafting in one patient. The remaining nine patients had no fractures prior to the bypass grafting. At the time of final follow-up, the patients were examined clinically and radiographically for the presence of a fracture or pseudarthrosis and for residual deformity, including malalignment, ankle and knee joint abnormalities, and leg length discrepancy. RESULTS: No patient had either a fracture or a pseudarthrosis of the tibia at the time of follow-up. All grafts united to the tibia at both ends. Complications included an allograft fracture in three patients, which healed in all; allograft resorption in one patient; and pseudarthrosis of the ipsilateral host fibula in one patient. At the time of final follow-up, a mean of 9 mm (range, 0 to 37 mm) of leg length discrepancy was found. A corrective osteotomy was done for four patients (three because of ankle valgus and one because of diaphyseal deformity). CONCLUSIONS: In this small series of ten patients with congenital anterolateral bowing of the tibia treated with bypass strut grafting and long-term bracing, there were no cases of pseudarthrosis of the tibia. Distal tibial deformity may persist throughout the growth period and require operative correction in patients treated with this procedure. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

A case report: pregnancy-induced severe osteoporosis with eight vertebral fractures.

Osteoporosis associated with pregnancy and lactation is a rare condition. The prevalence, etiology and its pathogenesis is unknown. It causes one or more vertebral fractures with severe, prolonged back pain and height loss in affected women. Majority of the cases are seen in the third trimester or just after delivery in primagravid women. In this case report, a 30-year-old woman who had severe pregnancy-induced osteoporosis with 8 vertebral fractures was presented. During last month of her first pregnancy she had moderate back pain. After delivery, the back pain has gotten worse. The radiological examinations have shown that there was 50% in T6, T8 and T10; 30% in L2; 20% in L1 height loss and biconcave vertebral images in L3-5. In the bone mineral density, L2-4 T score was -4.7 and total femoral T score was -3.1. There was no abnormality in the laboratory findings except mild elevation in alkaline phosphates. Although pregnancy-associated osteoporosis is a rare condition, when pain occurs in the last trimester or early postpartum period, it should be considered in differential diagnosis.

Aggressive treatment of giant cell tumour with multiple local adjuvants.

The results of aggressive management of giant cell tumour including high speed burr, argon plasma cauterisation and phenolisation were reviewed. Twenty four patients with primary or recurrent tumours were treated with a standardised protocol. There were 14 women (56%) and 10 men (44%) with a mean age of 34 years (14 to 62). The defects created after curettage and local adjuvants were reconstructed with PMMA. Additionally, internal fixation was used in weight-bearing bones. Local recurrence occurred in only one patient. Two patients (8%) developed pulmonary metastases. Reconstruction failed only in one patient. These findings support that the combined use of local adjuvants in the treatment of giant cell tumour is a safe and effective way to reduce the rate of local recurrence.

Iatrogenic seeding of a giant cell tumor of the patella to the proximal tibia.

Iatrogenic transplantation of tumor is a rare but avoidable complication, often resulting in additional morbidity or even mortality. We present a case of a 22-year-old woman with a giant cell tumor of the patella initially treated by curettage and bone grafting from the ipsilateral proximal tibia. Local recurrence and tumor growth in the proximal tibia required extensive surgeries. We will discuss the risk of iatrogenic metastasis by direct implantation, often attributable to inadequate surgical planning or poor surgical techniques. The cause and prevention of implantation metastasis are discussed and the basic principles of musculoskeletal tumor management emphasized.

Implant-related infection model in rat spine.

OBJECTIVE: The rate of postoperative infections is approximately 1% in spine surgery. However, when metal implants are used, postoperative infection rates significantly increase and were reported between 2.1 and 8.5%. This study aim to set up an infection model in the rat spine with a metal implant. MATERIALS AND METHODS: Forty white male Sprague Dawley rats were randomly divided in four groups. In all rats, under operation microscope, a 3 mm titanium microscrew was implanted in the thoracolumbar area (T10-L1) after laminar decortication. In Group I (control group), sterile isotonic solution and in other three groups, different concentrations of Staphylococcus aureus [Group II: (10(2)), Group III: (10(3)), Group IV: (10(6))] were squirted on the decorticated lamina site. All animals were sacrificed after 2 weeks, and then blood cultures and cultures from fascia, muscle and bone were obtained. Bacterial number in each tissue was measured as colony-forming unit per gram tissue. Titanium microscrews were placed in 0.5 ml tryptic soy broth and vortexed than plated on trypticase soy agar to determine bacterial growth. Two animals from each group were subjected to histological examination. RESULTS: Blood cultures obtained by intra-atrial puncture after 2 weeks were negative in all groups indicating no systemical infection developed. Bacterial cultures were negative in all specimens of Group I (control group). A significant osseous infection was confirmed in Groups II, III and IV. Comparison of bacterial counts in bone cultures showed no significant difference between Group III (10(3) CFU/10 microl) and Group IV (10(6) CFU/10 microl) (P > 0.05), while both groups had significantly higher counts than Group II (10(2) CFU/10 microl) (P > 0.05). Microscopic findings of supurrative inflammation were present only in Group IV (10(6) CFU/10 microl). CONCLUSIONS: This study shows that inoculation of S. aureus in 10(6) CFU/10 microl concentration at the decorticated lamina after implantation of a titanium screw in rat spine is a reproducible model for spinal infection and can be used for the animal model of prophylaxis and treatment and of postoperative infection.

[Image-guided minimal invasive surgical resection of osteoid osteomas of the long bones]. / Uzun kemik yerlesimli osteoid osteomada görüntüleme yardimli minimal invaziv cerrahi.

OBJECTIVES: In this prospective study, we evaluated the efficiency of image-guided minimal invasive surgical resection of osteoid osteomas of the long bones. METHODS: Fourteen patients (11 males, 3 females; mean age 13 years; range 4 to 22 years) with osteoid osteoma of the long bones underwent image-guided minimal invasive intralesional extended curettage. Preoperatively, all the patients were evaluated by plain radiographs, computed tomography (CT), bone scintigraphy, and magnetic resonance imaging (MRI). Localization of the nidus was determined by measurements on thin-section (1-1.5 mm) CT scans and MR images and complete excision of the nidus was performed by image-guided minimal invasive technique. All the patients were evaluated by visual analog scale or faces pain scale to determine pain levels before and after surgery. The mean follow-up period was 17 months (range 13 to 31 months). RESULTS: The mean visual analog scale scores were 7.9+/-1.2 (severe pain) and 0.3+/-0.6 (no pain) before and after surgery, respectively (p<0.05). Bone grafting or internal fixation were not required during operations. No perioperative or postoperative complications or recurrences were encountered. Early mobilization was possible in all the patients. At the final follow-ups, all the patients were asymptomatic and had full functional use of their operated extremities. CONCLUSION: Image-guided minimal invasive surgery is effective in the local control of osteoid osteomas affecting the long bones and causes less morbidity. This technique also provides a good identification of the nidus intraoperatively.

Bilateral tibial stress fracture in a young man due to hypercalciuric osteoporosis: a case report.

Osteoporosis is commonly thought of as a disease of postmenopausal women, and older men have a lower risk of fracture than women. A stress fracture is an overuse injury and an important cause of disability in the athletic population. Presented here is a 30-year-old healthy man with pain on the anterior surface of the bilateral tibia. He did not communicate any trauma or overuse activity. The neurologic and locomotor system examinations were normal. Radiological examinations revealed tibial stress fractures in both left and right tibia and he had low bone mineral density. Routine hematological tests, bone resorption and formation markers were normal, except for hypercalciuria. After analyzing the results of these tests, the patient was diagnosed with bilateral tibial stress fractures due to hypercalciuric secondary osteoporosis. Osteoporosis should be considered in the differential diagnosis of atraumatic insufficiency fractures, especially in young healthy adults.