Role of dynamic MRI and clinical assessment in predicting histologic response to neoadjuvant chemotherapy in bone sarcomas.

BACKGROUND: Neoadjuvant chemotherapy has become the first-line therapy in management of malignant bone tumors. Response to it is best assessed with evaluation of tumor necrosis postoperatively. This study was carried out to evaluate the role of clinical parameters and dynamic magnetic resonance imaging (MRI) to predict the histologic response before surgery. MATERIALS AND METHODS: Our study included 14 patients (12 osteosarcoma and 2 malignant fibrous histiocytoma) with mean age of 21.8 years, treated with neoadjuvant chemotherapy followed by surgery, who were evaluated clinically and with dynamic MRI twice, before starting chemotherapy and before surgery. Clinical parameters (pain, tumor girth, maximum tumor diameter, surface temperature, and consistency) and dynamic MRI parameter (slope of signal intensity-time curve) were correlated with histologic response (percentage of necrosis) using Pearson and Spearman correlation test. RESULTS: Significant correlation with histologic necrosis was seen in change in pain, tumor girth, maximum tumor diameter, surface temperature, and dynamic MRI slope (P<0.01). Change in consistency did not show significant correlation (P>0.05). Complete relieve of pain with reduction of >4 grades, ≥5% reduction in tumor girth, ≥8% reduction in tumor diameter, attainment of normal body temperature or decrease of ≥2°F temperature, and ≥60% reduction in slope proved to be an indicator of good histologic response. CONCLUSIONS: Both dynamic MRI and clinical evaluation are reliable methods of assessment of response of the bone tumors to neoadjuvant chemotherapy.

Unusual inferior dislocation of shoulder: reduction by two-step maneuver: a case report.

Dislocation of the shoulder is the commonest of all large joint dislocations. Inferior dislocation constitutes 0.5% of all shoulder dislocations. It characteristically presents with overhead abduction of the arm, the humerus being parallel to the spine of scapula. We present an unusual case of recurrent luxatio erecta in which the arm transformed later into an adducted position resembling the more common anterior shoulder dislocation. Such a case has not been described before in English literature. Closed reduction by the two-step maneuver was successful with a single attempt. MRI revealed posterior labral tear and a Hill-Sachs variant lesion on the superolateral aspect of humeral head. Immobilisation in a chest-arm bandage followed by physiotherapy yielded excellent results. The case is first of its kind; the unusual mechanism, unique radiological findings and alternate method of treatment are discussed.

Undergraduate orthopedic education: Is it adequate?

BACKGROUND: Basic musculoskeletal knowledge is essential to the practice of medicine. The purpose of this study was to assess the adequacy of musculoskeletal knowledge of medical students. MATERIALS AND METHODS: The validated basic competency examination in musculoskeletal medicine devised by Freidman and Bernstein was administered to final year medical students just prior to their final professional examination. Participants were also required to assess their confidence at making a musculoskeletal physical examination and diagnosis as well as comment on the adequacy of time in the curriculum devoted to Orthopedics. RESULTS: The response rate was 83% (40/48). The average cognitive examination score was 48.3%. Two participants (5%) obtained a score of >/= 73.1%, the recommended mean passing score. Seventeen students (42.5%) felt orthopedic clinical cases were the most difficult to perform a physical examination and diagnose. Thirteen students (32.5%) felt that the time devoted to orthopedics in the medical curriculum was inadequate. CONCLUSIONS: Ninety-five percent of the students failed to show basic musculoskeletal competency. A change in medical curriculum and teaching methods is required to address this problem.

Bone allografting: an Indian experience.

Freeze-drying is considered to be the best technique for allograft preparation and storage. This method is, however, unsuitable for use in developing countries due to high costs. Ethylene oxide sterilization is still controversial because of its effect on osteoinductive capacity. This study involved setting up a bone bank for the first time. Cancellous bone collected from 40 patients was cleaned thoroughly, chemically processed, and sterilized with ethylene oxide gas and stored doubly packed. The grafts were implanted in 11 patients with 14 nonunions. Patients were followed up clinically and radiologically. Thirteen sites were united at the end of 12 months, taking an average of 44.8 weeks to unite. Allograft was also used in 8 benign bone lesions, which showed incorporation of the graft by 29 weeks. This study shows cancellous allograft is suitable for packing cavities in the treatment of benign bone lesions and in treatment of nonunion. There was one deep infection. The low infection rate confirms the efficacy of ethylene oxide as a reliable option for sterilization of bone allograft, and it is also cost effective.