Massage manipulation and progression of osteosarcoma, does it really correlate: a combination of prospective and retrospective cohort study

In Indonesia, the challenge of osteosarcoma progression is further worsened by patients' dependence on traditional massage therapy, low socio-economy, and educational status. This study aims to analyze the differences in the characteristics, laboratory findings, surgery techniques, degree of histopathological necrosis, and metastasis between osteosarcoma patients with and without prior massage manipulation therapy. This research is an analytical observational study with a prospective and retrospective cohort design. Patients were treated and followed for one year to evaluate the occurrence of metastasis. Prospective data was collected through interviews, and secondary data was collected from the patient's medical record. Of 84 subjects analyzed, 69% had a history of massage. There was an increase in LDH and ALP in patients with massage manipulation (p = 0.026). The median time to metastasis from baseline in the massage group (4 months) was statistically significant compared to the non-manipulation group (12 months) (p < 0.0001). This research found that massage therapy significantly increases LDH and ALP levels, making amputations more likely to be performed and a higher risk of metastasis that lowered the survival rate. The onset of metastasis was three times faster in patients with prior massage therapy. Therefore, we strongly recommend against massage manipulation therapy in osteosarcoma patients.

CXCL8, MMP1, MMP2, and FN1 Gene Expression and Tumor Extension in Nasopharyngeal Cancer Patients: A Cross-sectional Study

BACKGROUND

There are correlations between tumor staging, lymph node involvement, and patient survival in Nasopharyngeal cancer (NPC) which is one of the most common types of cancer in Indonesia.  The inflammation process plays a role in tumor progression over the long term and this marked by increased proinflammatory cytokine and gene overexpression. This study aims to identify differentially expressed genes (DEGs) in NPC using T and N staging.

METHODS

This is a cross-sectional study of NPC patients in Cipto Mangunkusumo, Jakarta, between 2018 and 2022. DEGs were identified based on the amount of mRNA detected on paraffin blocks with a 1.5- to -1.5-fold change and an adjusted p-value of <0.05.

RESULTS

We included 48 subjects. The mean age of subjects was 47.75 (10.48) years, and most were male (77.1%). Non-keratinized squamous cell carcinoma was the most common histopathology type. Differences in the tumor size of the T4 and non-T4 in metastatic (33.3%) group when compared to the non-metastatic (37.5%) group were insignificant (p = 0.763). The proportion of N3 subjects in the metastatic vs non-metastatic group was different significantly (83.3% vs. 50%, p = 0.030). Gene expression analysis showed that C-X-C motif ligand 8 (CXCL8), matrix metalloproteinase-1 (MMP1), matrix metalloproteinase-1 (MMP2), and fibronectin-1 (FN1) genes of the T4 and non-T4 group to be different significantly.

CONCLUSION

There was significant finding in the N3 subjects of the metastatic and non-metastatic groups. The DEGs of CXCL8, MMP1, MMP2, and FN1 were statistically significant in the T4 when compared to the non-T4 group.

Intra-articular injection of secretome, derived from umbilical cord mesenchymal stem cell, enhances the regeneration process of cartilage in early-stage osteo-arthritis: an animal study

BACKGROUND AND PURPOSE

Mesenchymal stem cells (MSCs), both endogenous and exogenous, enhance chondrocyte proliferation by stimulating collagen type II. Secretome, an MSC derivate, has shown to also provide this mechanism through a paracrine effect. We aimed to evaluate the use of secretome and MSC in the management of early osteoarthritis (OA).

ANIMALS AND METHODS

19 (1 control) male sheep (Ovies aries), which were operated on with total lateral meniscectomy to induce knee OA, were divided into 3 groups: the secretome group, hyaluronic acid group, and MSC group. Each group was injected with the respective substances and was evaluated macroscopically and microscopically. The Osteoarthritis Research Society International (OARSI) score was calculated for all subjects and a descriptive and comparative statistical analysis was undertaken.

RESULTS

The macroscopic analysis of the treated groups revealed better OARSI score in the secretome group compared with the other 2 groups. The secretome group showed a significantly better microscopic score compared with the hyaluronic acid group (mean difference [MD] 6.0, 95% confidence interval [CI] 0.15-12), but no significant difference compared with the MSC group (MD 1.0, CI -4.8 to 6.8).

CONCLUSION

Intra-articular injection of secretome is effective in managing early-stage osteoarthritis in the animal model compared with hyaluronic acid and has similar efficacy to MSC injection.

Periosteal ganglion cyst of tibia: A rare case report

INTRODUCTION AND IMPORTANCE

Periosteal ganglion cyst is a rare disorder, found only in 55 out of 100,000 people annually. Periosteal ganglion location may cause partial external cortical destruction with irregular saucerization and erosion. This report presents a rare case of periosteal ganglion cyst that occurred of the cruris sinistra.

CASE PRESENTATION

A male patient, 68 years old, came with complaint of a lump in the left cruris since one year ago. Nine months later, the lump has increased in size like a chicken egg and still felt painless. MRI result revealed a well-circumscribed multilocular cystic lesion in the peri-osseous soft tissue of the tibia. We performed directly excisional biopsy within the mass, and the histopathology result was periosteal ganglion cyst.

CLINICAL DISCUSSION

The exact pathogenesis of periosteal ganglion is unclear. Synovial herniation and mucoid degeneration of the connective tissue of the periosteum are two suggested mechanisms. In some cases, ganglion cysts may compress nearby nerves. Surgical treatment is recommended for patients who still experience symptoms after non-surgical management has failed. Complete resection of the cyst and surrounding periosteum is recommended to prevent recurrence. After 6 months post-operative follow up clinical examination, no recurrence symptoms founded on the patient.

CONCLUSION

Periosteal ganglion is a rare lesion and may mimic other bone surface lesions. Resection of the periosteal ganglion cyst with surrounding periosteum is important to prevent recurrence.

The Outcome of Orthopedics Treatment of Lombok Earthquake Victim 2018: A Cohort of One-Year Follow-Up Study-Lesson Learned After Lombok Earthquake

Introduction

There was a magnitude 7 on the Richter scale earthquake on Lombok Island in 2018, causing more than 500 deaths. In the event of earthquakes, there is often an imbalance between overcrowding in hospitals and inadequate resources. The initial management of earthquake victims with musculoskeletal injuries is controversial, arguing over whether to utilize debridement, external or internal fixation, or conservative or operative treatment in an acute onset disaster situation. This study aims to determine the outcome of initial management after the 2018 Lombok earthquake, between immediate open-reduction and internal fixation (ORIF) and Non-ORIF procedures after one year follow-up.

Methods

This is a cohort study to evaluate radiological and clinical outcomes one year after orthopedic treatment in the Lombok earthquake 2018. The subjects were recruited from eight public health center and one hospital in Lombok in September 2019. We evaluate radiological outcomes (non/malunion and union) and clinical outcomes (infection and SF-36 score).

Results

Based on 73 subjects, the ORIF group has a higher union rate than the non-ORIF group (31.1% vs. 68.9%; p = 0.021). Incidence of infection only appeared in the ORIF group (23.5%). Clinical outcome as measured by SF36 showed the ORIF group had a lower mean of general health (p = 0.042) and health change (p = 0.039) clinical outcomes than the non-ORIF group.

Discussion

The most affected public group is the productive age with significant impact on social-economy. ORIF procedure is a major risk factor of infection in initial treatment after earthquake. Therefore, definitive operation with internal fixation is not recommended in the initial phase of a disaster. Damage Control Orthopedic (DCO) surgery protocol is the treatment of choice in acute disaster setting.

Conclusion

The ORIF group had better radiological outcomes than the non-ORIF group. However the ORIF group had higher cases of infection and lower SF-36 than the non-ORIF group. Definitive treatment in acute onset disaster setting should be prevented.

Double-bundle ACL reconstruction versus anatomic single-bundle ACL reconstruction combined with anterolateral ligament reconstruction: a comparative study of clinical outcome

INTRODUCTION

Recent studies showed increasing evidences of anterolateral ligament (ALL) reconstruction in conjunction with anterior cruciate ligament (ACL) reconstruction that proves to be more superior to the previous double-bundle (DB) ACLR technique especially in improving knee stability in biomechanic studies. However to date, there have been no studies evaluating the functional outcome of DB-ACLR vs single-bundle (SB) with ALL in ACLR.

METHODS

A total of 138 patients with ACL deficient knee were enrolled to the study. Double-bundle ACL reconstruction (DB-ACLR) was performed in 75 patients and single-bundle ACL reconstruction with anterolateral ligament reconstruction (SB + ALL) ACLR was performed in 63 patients. Surgical outcomes were compared with The International Knee Documentation Committee Subjective Knee Form (IKDC) and the Kujala score at the 3rd, 6th and 9th month post-operative.

RESULTS

The IKDC score in the 3rd and 6th month was superior in the SB + ALL group compared to the DB group. However, this difference was not statistically significant. In the meantime, there were no statistically significant difference between the Kujala Score at the 3rd, 6th, and 9th months consecutively. There were no statistically significant differences in the functional outcomes of DB-ACLR and SB + ALL groups at the 3rd, 6th, and 9th months post-operative period.

CONCLUSION

The functional outcome comparison showed non-superiority of SB + ALL group compared to the DB-ACLR group. The patellar pain was less found in DB-ACLR group at 6- and 9-months post-operative period.

Clinical Outcomes of Delayed Osteoarticular Tuberculosis: A Review of 30 Cases

Purpose

The lack of knowledge regarding osteoarticular tuberculosis (TB) cases in Indonesia leads to delayed and chronic conditions. This study aims to evaluate clinical outcomes of patients with osteoarticular TB.

Materials and Methods

Thirty osteoarticular cases were retrospectively analyzed, with a focus on non-immunocompromised patients without spine involvement. Chemotherapy length, operative treatment method, and infection recurrence were evaluated.

Results

The majority (60%) of patients were aged between 19 to 49 years. The most common complaint was painful swelling, particularly during physical activity. Weight-bearing joints, such as the hips, knees, and ankles, were the most affected. Laboratory results showed over half of the patients had anemia, 96% had elevated erythrocyte sedimentation rate (ESR), and 76% had elevated C-reactive protein (CRP) levels. Radiological findings varied, with lytic lesions, abscesses, and joint destruction observed. All patients presented with pathognomonic histological tubercle appearances, with caseous necrosis, lymphocytes, and Langhans giant cells present. Twenty-nine cases were treated with anti-TB drugs for 12 months, while one recurrent case received the drugs for 24 months. All patients underwent surgery to gain local infection control.

Conclusion

Osteoarticular TB is a common manifestation of extrapulmonary TB and must not be overlooked. Early detection of osteoarticular TB may prevent limb morbidity. Although anti-TB drugs are the primary treatment for osteoarticular TB, in some cases, surgery is required to establish a diagnosis and gain local infection control.

Giant cell tumor with secondary aneurysmal bone cyst of the left calcaneus

Introduction and importance

Giant cell tumors (GCT) of the feet bones are rare, comprising of <1 % of cases. The lack of well-documented cases and similarity with other tumors under radiologic and histological evaluation makes diagnosis difficult. Current treatment modalities for GCT still result in a relatively high recurrence rate, making the overall management of the case a challenge. We reported a 27-year-old male diagnosed with GCT of the left calcaneus with secondary aneurysmal bone cyst (ABC) treated with curettage and femoral head allograft combined with bone cement application.

Case presentation

A 27-year-old male presented with lump on the left heel since seven months before admission. Physical examination demonstrated solid, palpable mass on the left heel region and limited ankle motion. Magnetic resonance imaging examination demonstrated expansile bone tumor at the left calcaneus with cystic components building fluid levels and hemorrhagic components, suggestive of giant cell tumors with secondary ABC. The patient is diagnosed with giant cell tumor with secondary ABC of the left calcaneus Campanacci grade 2. The patient was managed limb salvage surgery by curettage and subsequent mix of femoral head allograft and bone cement application to fill the defect.

Discussion

Conservative surgery via careful curettage is typically preferred for lower Campanacci grade lesions followed by bone reconstruction. In terms of filling bone defects, it is known that both bone cement and allografts have advantages and disadvantages. We hence decided to perform limb salvage surgery via curettage due to the size of the tumor and bone reconstruction using a mix of femoral head allograft and bone cement to fill the defect.

Conclusion

Curettage and bone allograft with bone cement reconstruction is an option for surgical management of lower Campanacci grade 2 GCT of the calcaneus.

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A 27-year-old male diagnosed with GCT of the left calcaneus with secondary aneurysmal bone cyst (ABC)

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GCT of the left calcaneus with secondary aneurysmal bone cyst (ABC) treated with curettage and femoral head allograft combined with bone cement application.

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Conservative curettage, followed by bone allograft application is effective and safe to manage lower Campanacci grades of giant cell tumors of the calcaneus

Particular precautions and the role of intraoperative neuromonitoring in cervical cord injury in elder recreational cyclist: A case report

INTRODUCTION AND IMPORTANCE

The trend in cycling nowadays affects all age groups. However, special precautions must be considered in the elderly group. Minor trauma to the cervical region can cause severe neurological deterioration, leading to fatality because of the pre-existing degenerative process.

CASE PRESENTATION

We present a case of a 61-year-old male recreational cyclist with acute onset of tetraplegia following a minor fall. The radiological result revealed a long-standing degenerative process. Unfortunately, the patient deceased due to the sequelae of the paralysis and cardiac event despite our prompt surgical decompression and the improvement shown on intraoperative neuromonitoring.

CLINICAL DISCUSSION

The degenerative process can aggravate cervical cord injury even in its mildest form of injury. In this study, immediate improvement was detected by the intraoperative neuromonitoring (IONM) - although the clinical improvement had not improved yet as the general condition is poor.

CONCLUSION

The elder cycling population is increasing. Safety measures and injury avoidance are advisable along with expert consultation before the exercise. In a pre-existing degenerative condition of the cervical, a special precaution is also needed during the exercise. If the surgery has been indicated, the use of intraoperative neuromonitoring is found to be useful to guide the decompression and potentially beneficial as a predictive value for the clinal outcome.

A challenging diagnosis: Lesson from case series of sacral Ewing sarcoma

Background

Ewing's sarcoma is an aggressive bone and the surrounding soft tissue cancer primarily found in children and young adults. It is mostly observed in the trunk and long bones while unusually seen in the sacrum. Sacral Ewing sarcoma has a unique anatomic limitation due to neurological structures, vertebral column, and pelvic involvement. Hence, identifying sacral Ewing's sarcoma remains a challenge.

Method

This is a case series including three patients diagnosed with Sacral Ewing's sarcoma. These three cases have been diagnosed based on clinical and radiographic examination, MRI, histopathology, and immunohistochemistry examination.

Discussion

Sacral Ewing's sarcoma remains a challenge to diagnose due to its unique anatomy site. MRI examination is sensitive to detect lesions but nonspecific. Thus, require histopathological confirmation.

Conclusion

Early diagnosis of Ewing's sarcoma is essential and we need to perform further examinations, such as immunohistochemistry examination, to confirm the diagnosis of Ewing's sarcoma.

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Sacral Ewing's sarcoma remains a challenge to diagnose due to its unique anatomy site.

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MRI examination is sensitive to detect lesions but nonspecific.

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We recommended to perform further examinations, such as immunohistochemistry examination, to confirm the diagnosis of Ewing’s sarcoma.

A rare case of oxidized zirconium - All polyethylene tibia unicompartmental arthroplasty failure: A case report

Oxidized zirconium (Oxinium) implants has been claimed as the best material in terms of wear reduction. However, longevity of an all polyethylene uni knee arthroplasty (UKA) has been a long debate. We reported a rare case of 74 year old female who was performed all polyethylene UKA 6 years prior and fell 3 months prior. After the incident, patient was wheel-chair ridden afterwards. There was no evidence of fracture upon conventional radiography examination. Conversion of UKA to total knee replacement (TKA) was performed and patient was able to walk with aid after the surgery. The failed Oxinium all polyethylene UKA failure in this case is suspected due osteoarthritis progression.

Fabrication of Magnesium-Carbonate Apatite by Conventional Sintering and Spark Plasma Sintering for Orthopedic Implant Applications

Magnesium-Carbonate Apatite (Mg-xCA) is one of the potential magnesium composites to be developed as an alternative biodegradable implant material. Several attempts were made to optimize its characteristics. In this study, Mg-xCA (x = 0, 5, 10, and 15% wt) was prepared by powder metallurgy through warm compaction (WC) and further densified by 2 sintering process methods, namely conventional sintering (CS) and spark plasma sintering (SPS). The characterization included density test, XRD test, microstructure test (OM and SEM-EDS-Mapping), microhardness test, and electrochemical test. The SPS process improves the characteristics of Mg-xCA better than the CS process. The SPS process can increase the relative density by about 0.7-2.4%, increase the hardness by about 2-13%, and reduce the corrosion rate by about 32-49% compared to the initial condition before sintering (WC). The SPS structure has a lower oxygen elemental content than the CS structure. The sintered process with SPS is considered effective for the fabrication of Mg-xCA powder-based composites compared to the CS process.

Cement arthrodesis of the knee using combined intramedullary nail, plate and screws after wide excision in huge chondromyxoid fibroma of proximal tibia, a case report

Introduction and importance

Chondromyxoid fibroma is a rare benign cartilaginous neoplasm, a mixture of benign cartilage and fibrous and myxoid tissue. It usually affects young people, commonly in the second and third decades of life with male being predominant. Differential diagnosess in chondromyxoid fibroma, are giant cell tumor, bone cyst, enchondroma, osteoblastoma, and low-grade chondrosarcoma.

Case presentation

We present a case of an 18-years-old male, with chief complaint of pain on the right knee since 3 year ago with an increasing size reaching diameter of 55 cm within three years. The radiograph and MRI revealed lytic blastic expansile multiloculated lesion, with wide transitional zone, and periosteal reaction on the epymetadiaphyseal part of right proximal tibia. The surgical procedure was performed consist of wide excision, reconstruction by cement knee arthrodesis using Kuntscher-nail, dynamic compression plate, bone cement and gastrocnemius flap.

Clinical discussion

After 3 months of surgery follow-up, there was no sign of recurrence, the patient walked partially weight bearing with a crutch. In 1 years post operative follow up, the Muscukoskeletal Tumor Society Scoring (MSTS) was 80%. There was no sign of recurrence.

Conclusion

In cases with large tumor size, wide excision with bone and soft tissue reconstructive surgery is required as mechanical and biological reconstruction. The cement arthrodesis provides a faster duration of surgery, lower risk of infection, and good functional outcome.

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Chondromyxoid fibroma is a rare benign cartilaginous neoplasm, mixture of benign cartilage and fibrous and myxoid tissue

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There are no specific recommendation in management of chondromyxoid fibroma due to limited published article with chondromyxoid fibroma.

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The mechanical and biological reconstruction are very important during reconstructive surgery.

Clinical Outcome Following Prolonged Neoadjuvant Chemotherapy and Delayed Surgery in Osteosarcoma Patients: An Evidence-based Clinical Review

BACKGROUND

The incidence of osteosarcoma reached 16.8 cases annually at dr. Cipto Mangunkusumo Hospital in 1995-2008. Previous studies suggested that prolonged neoadjuvant chemotherapy followed by delayed surgery improves the clinical outcome. Prolonged neoadjuvant chemotherapy followed by delayed surgery commonly occurs in Indonesia, as diagnostic imaging and surgery waiting list will delay the surgery. The aim of this study is to observe the survival rate and the event-free survival rate of osteosarcoma patients with prolonged neoadjuvant chemotherapy and delayed surgery.

METHODS

This review included randomized controlled trials (RCTs), cohort studies, retrospective cohort studies, clinical trials, and reviews. Literature search was conducted through MEDLINE (PubMed search engine), Cochrane Central Register of Controlled Trial, and Scopus. The studies were screened and selected according to inclusion criteria by author and contributors independently.

RESULTS

Six studies were included in the qualitative synthesis of this study. Overall survival rate, event-free survival rate, histological response and recurrence as well as neoadjuvant chemotherapy duration, cycle and regiment were assessed in this study.

CONCLUSION

Prolonged neoadjuvant chemotherapy and delayed surgery results in 5-years survival rate of 43.2% to 96.6% and 5-years event-free survival rate of 35.7% to 86.4%.

Effectiveness of Kyphosis Reduction Using Cantilever Method in Thoracolumbar Spondylitis Tuberculosis: A Short-Term Follow-Up

Background

Kyphosis in spondylitis tuberculosis (STb) is more than just a cosmetic issue. It has a potentially detrimental effect on both spine-associated structures and cardiopulmonary function. It can be corrected in any stage of STb; however, the corrective surgery is challenging, especially in the late case, in which the additional stiffness of the spine can come into consideration. To date, the cantilever technique is still a gold standard for sagittal plane deformity correction. However, no study to date has explored its effectiveness for thoracolumbar kyphotic deformity, especially that caused by spondylitis tuberculosis.

Methods

This is a retrospective study of 16 consecutive cases of spondylitis tuberculosis with thoracolumbar kyphosis that underwent corrective surgery in our center in the period of 2020–2021. We aim to evaluate the effectiveness of the cantilever technique that we use for kyphotic correction in thoracolumbar STb patients.

Results

At the 3-months follow-up, the mean Cobb angle was 14.6°±10.27°, with the mean gain of 20.90°±12.00° and positively correlate with the thoracolumbar kyphosis (TLK) correction (68.69%, r = 0.654, p = 0.001). The mean thoracic kyphosis, lumbar lordosis, and sagittal vertebral axis were 30.6°±13.08°, 39.4°±16.02°, and 1.4±4.09 cm, respectively, with sagittal Cobb difference of 12.70±9.85.

Conclusion

The kyphotic Cobb angle reduction by cantilever technique in the thoracolumbar area significantly improved the thoracolumbar kyphosis and realign the spinal sagittal axis. Thus, the cantilever technique remains the gold standard for sagittal plane deformity correction which can be applied for kyphotic deformity correction in thoracolumbar STb cases.

A simple management of massive bone defect after en-bloc resection of osteofibrous dysplasia of tibial shaft: A case report

INTRODUCTION

Osteofibrous dysplasia is a relatively rare disease, exclusively found in children, affecting the tibial diaphysis. Various management approaches are already available, but an internationally approved management guideline is not yet established. There is a major concern in the current management of wide excision technique as it frequently results in massive bone defect.

CASE PRESENTATION

Here we present a case of osteofibrous dysplasia on a 10-year-old girl in Cipto Mangunkusumo Hospital with chief complaint of mild persistent pain of her lower leg since two years before with slight bowing deformity. The radiograph and histopathological examination support the diagnosis of osteofibrous dysplasia. She was managed with en-bloc resection (wide excision) of the tumor, followed with reconstruction using biomaterials substitute; combination between demineralized bone matrix (BonegenerR) and bone substitute "hydroxyapatite and calcium sulphate" and internal fixation using plate and screw.

RESULTS

Clinical and radiological evaluation showed successful improvement and outcome. The patient showed progressive functional outcomes and achieved functional score of 100% LEFS at 3 years follow-up. The plate and screw was removed at 48 weeks after adequate callus formation andradiological union was achieved.

CONCLUSION

Simple reconstruction using biomaterial bone substitute not only created new bone formation with good stability, but also enabled patient to have an improved quality of life. This method is recommended to overcome the massive bone defect after tumor resection in osteofibrous dysplasia patient.

Alkaline phosphatase, lactic dehidrogenase, inflammatory variables and apparent diffusion coefficients from MRI for prediction of chemotherapy response in osteosarcoma. A cross sectional study

BACKGROUND

This present study aimed to assess if clinical, laboratory and MRI were an accurate benchmark in assessing the effectiveness of neoadjuvant chemotherapy in osteosarcoma patients.

METHODS

This was an observational analytic study with a cross-sectional design. We correlated among clinical, laboratory and magnetic resonance imaging (MRI) data before and after neoadjuvant chemotherapy; and percentage of tumor necroses from osteosarcoma patients during the period between January 2017-July 2019.

RESULTS

Of the 58 patients included in this study, 38 were male and 20 were female aged 5 - 67 years (mean: 16-year-old. 37(63.8%) patients underwent neoadjuvant chemotherapy with CAI regimens and 13 (36.2%) with CA regiments. The tumors were classified as stage IIB in 43 (74.1%) patients and stage III in 15 (25.9%) patients. Wilcoxon test showed significant differences between alkaline phosphatase (ALP), erythrocyte sedimentation rate (ESR), and neutrophil to lymphocyte ratio (NLR) before and after neoadjuvant chemotherapy in the poor-response group. We found no significant difference between lactic dehydrogenase (LDH) and lymphocyte-to-monocyte ratio (LMR) before and after neoadjuvant chemotherapy in the good-response group. MRI revealed decreased tumor volume in patients in the good-response to chemotherapy.

CONCLUSION

We demonstrated that ALP level was statistically significant in the poor-response group. We also found that LDH value before neoadjuvant chemotherapy had a strong correlation with degree of necrosis and could be used as a predictive indicator. MRI plays an important role in evaluating tumor volumes and preoperative radiological changes to predict histological necrosis.

Osteofibrous dysplasia-like adamantinoma versus osteofibrous dysplasia in children: A case report of challenging diagnosis

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Challenging diagnostic regarding diagnosis of Osteofibrous dysplasia and Osteofibrous dysplasia-like adamantinoma.

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There is controversy spectrum disease between adamantinoma and OFD-like adamantinoma and OFD in children.

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Histopathology and immunohistochemical staining for diagnostic OFD, OFD-like adamantinoma and adamantinoma.

Introduction

Osteofibrous dysplasia (OFD) and Osteofibrous dysplasia-like Adamantinoma have a similar appearance both in clinical and radiography, but different in its histopathology. Despite this similarity, the treatment and prognosis are different, therefore the diagnosis should be established precisely.

Case illustration

A three-year-old boy was admitted to hospital after falling on his lower leg. A bead size lump appeared on his tibia with pain and swelling, which later became enlarged. Diagnosis of osteofibrous dysplasia and adamantinoma was considered. We performed limb-salvage procedure by curretage, bone grafting, and internal fixation application. The histology section showed woven bone rimmed by polygonal osteoblast cell with intervening fibrous stroma and small nests of tumour cells raised the possibility of epithelial differentiation. The positivity for cytokeratin immunostaining confirmed the diagnosis as osteofibrous dysplasia-like adamantinoma. In this case it is a very rare spectrum of malignancy in children.

Discussion

These two tumor entities have identical radiographic characteristics, histopathology features the distinction between classic adamantinoma and OFD-like adamantinoma based on the predominant epithelial component. The relationship of osteofibrous dysplasia with adamantinoma is unclear. Several authors considered possible calling relationship osteofibrous dysplasia as “juvenile adamantinoma”. However, does not rule out the possible existence of de novo osteofibrous dysplasia not related to adamantinoma.

Conclusions

OFD-like adamantinoma and Osteofibrous Dysplasia had similar histopathology pattern, a pathologist must be aware of this feature and perform immunohistochemical staining for keratin particularly when the histopathological feature of osteofibrous dysplasia showed small nests of tumor cells within the fibrous stroma. diagnostic challenging and require multidisciplinary approach.

Emergency orthopaedic surgery in the pandemic era: A case series at Cipto Mangunkusumo national tertiary hospital in Jakarta, Indonesia

INTRODUCTION

Every emergency surgery performed is aimed at saving lives; however, during COVID-19 pandemic, surgeries are often postponed. Many existing recommendations take into account postponing surgery during a pandemic. How these surgeries can lead to increasing infection rates has not been widely published. This study aims to investigate the relationship of emergency orthopaedic surgery and the incidence rate of COVID-19.

PRESENTATION OF CASE

This was a case series of 14 patients. The study was performed at the emergency department unit at a national tertiary hospital in Jakarta, Indonesia. A total of 14 patients underwent orthopaedic surgery in the emergency room of our institution. The mean age of the subjects was 40.07 ± 20.5 years. Twelve (85.7%) were male patients and 2 (14.3%) were female patients. The average duration of surgery was 125 minutes. The most used type of anaesthesia was general anaesthesia for 6 operations (50%). Patients were hospitalized for an average length of 4 days. Three patients had infiltrates found on plain x-ray examination, which required further examination to determine whether the cause was COVID-19 infection or not. There was no ground glass appearance (GGO) in the three patients in further follow-up examination.

CONCLUSIONS

We found that emergency orthopaedic surgery was not associated with increasing number of COVID-19 cases. Factors including duration of surgery, length of stay, types of anaesthesia and comorbidities were also not associated with COVID-19 cases in this study.

Hallux valgus among sales promotion women wearing high heels in a department store

BACKGROUND

Wearing high heels for an extended period of time can cause several pathological conditions in women's feet, one of such is the hallux valgus (HV), as shown by a number of cross-sectional studies. This study aims to evaluate the incidence of HV among sales promotion women and to know the association of the high heel shoes with the severity of HV in that population.

METHOD

This study used comparative cross-sectional design between two groups, wearing high heel and flat shoes; sales promotion women who work for at least 1 year were recruited as subjects by means of purposive sampling and were given questionnaires, and then physical and radiological examination of the foot were performed to detect any HV and its severity.

RESULT

Incidence of HV is 25.25% (25 of 99) among subjects who were wearing high heel shoes and 10.87% (10 of 92) for those who were wearing flat shoes. Subjects wearing high heel shoes are 2.77 times (95% confidence interval (CI): 1.25-6.15; p = 0.01) more at risk for developing HV than those who wore flat shoes. The incidence of HV increases with age ( p < 0.05). Those who have been working for >4 years are 5.2 times (95% CI: 1.95-14.31) at more risk for developing HV than those who have been working for ≤4 years ( p < 0.001). The duration of wearing shoes per day, the type of toe box, and body mass index are not statistically significant with HV ( p > 0.05). The incidence of HV increased among overweight and obese subjects ( p > 0.05). The severity of HV in subjects was mostly mild to moderate.

CONCLUSION

The incidence of HV is higher among sales promotion women who wear high heel shoes than flat shoes. Age and working experience are also related to the development of HV. Factors that affect the severity of HV cannot be shown in this study.

Outcomes of En bloc resection followed by reconstruction of giant cell tumor around knee and distal radius. A case series

INTRODUCTION

This study is to evaluate the outcomes of En bloc resection and reconstruction in patients with GCT of the bone around the knee and in the distal radius.

MATERIALS AND METHODS

We reviewed 41 cases of GCT of the bone that was treated by En bloc resection around the knee joint and in the distal radius from 2011 to 2018. The local recurrence, metastases, complications and functional score were evaluated for each operation technique.

RESULTS

The average of MSTS score for all group was 78% (excellent). In the knee joint, the megaprostheses group had an excellent MSTS score of78.9% and good 21.1%. The MAMC group had an excellent MSTS score of40.0%, good 50.0% and fair 10.0%. One patient in the megaprostheses group had metastasis to the lung and 1 patient in the knee arthrodesis group has a recurrence. Infection occurred in 2 cases of megaprostheses while only 1 case in MAMC. Both of the groups in knee joint GCT had 1 patient with implant loosening. In the distal radius, FVFG group had an excellent MSTS score 100% and NVFG group had an excellent score 77.7%, good 11.1% and fair 11.1%. One patient in the NVFG group had an infection, 1 patient has implant loosening and another one patient had graft failure. Two patients in the NVFG group had a recurrence. No metastasis was found in both of the group types of surgery in distal radius GCT.

CONCLUSION

Functional outcome of a patient with GCT of the bone after En bloc resection and reconstruction with the above techniques had comparable results with previous studies.

Early stage fibrodysplasia ossificans progressiva: A case report

Fibrodysplasia ossificans progressiva is a very rare autosomal dominant genetic connective tissue disease with a progressive ectopic ossification of muscle (intramuscular) or perimuscular connective tissue such as tendons or joint capsules. The osseous masses produced will form bridges that abnormally connect sections of the skeleton, causing disfiguration and normal motor function inhibition. We reported a 5-year-old girl with multiple hard nodules on the back region which initially present as a painful soft mass on the posterior neck region. As the pain subsided, the mass hardened and also appeared in other parts of her back. We decided not to do a biopsy or excisional surgery to prevent flaring up of the disease. Early diagnosis prevents catastrophic diagnostic and treatment procedures. The progressive nature of this disease is difficult to stop but we should delay it as much as possible by preventing muscle trauma, giving disease modifying agent and long-term physiotherapy to counter further disabilities which will eventually develop.

Various Surgical Treatment of Hemophilic Pseudotumor : A Case Series

BACKGROUND

Bleeding episodes in severe hemophilia may occur more frequently and spontaneously after mild trauma or daily activities. An inadequate treatment of that bleeding in hemophilia may result in pseudotumor, usually in the muscle adjacent to the bone. We reported haemophilic pseudotumor treated with various surgical interventions.

METHODS

This study was conducted inthe Department of Orthopaedic and Traumatology at a government hospital over a period of 7 years(2010 -2017). Patients Perioperative management was done in accordance with the Integrated Hemophilia Team of our institution protocol.Diagnosis and management planning of hemophilic pseudotumor was confirmed via Integrated HemophiliaTeam meeting. After the surgery, all patients were asked to come for routine follow up.

RESULTS

We reported six Haemophilia-A patients with pseudotumor in the pelvis, proximal femur and lower leg. One case in pelvic bone underwent hematoma evacuation, acetabular reconstruction using the Harrington procedure, and total hip arthroplasty.Two cases, a case in the proximal femur and another case in the distal fibula, were treated with amputation, other two cases, one was soft tissue psedotumor in the pelvic region and was treated by hematoma evacuation, and the remaining casewas managed with wide excision and followed by defect closure.

CONCLUSION

Surgery is a preferable treatment for pseudotumors that have been present for years.It's associated with the best outcomes especially when selected as the primary line ofwith preventable and manageable bleeding complication. As previously published by many authors, this paper confirms that surgical excision is the treatment of choice but should only be carried out in major hemophilia centers by a multidisciplinary surgical team.

Various Dosages of BMP-2 for Management of Massive Bone Defect in Sprague Dawley Rat

BACKGROUND

BMP-2 has a crucial role in the treatment of extensive bone defect. However, data about the optimal dosage of BMP-2 in the massive bone defect casesis rare.

METHODS

Twenty-five SD rats were randomly allocated into a control group of hydroxyapatite (HA) alone (Group I), HA+BMP-2 1µg/mL (Group II), HA+BMP-2 5 ug/mL (Group III), HA+BMP-2 10 µg/mL (Group IV), and HA+BMP-2 20 ug/mL (Group V). Osteotomies were performed in each group with 10 mm bone defect in the right femur, followed by fixation and filling the defect. The fracture healing was evaluated by histomorphometry, and radiographs using RUST score.

RESULTS

We found there were significant differences in the mean total area of callus between the treatment groups (P<0.001); there were significant differences in the mean area of woven bone between group II, III, IV, and V with the control group (respectively P=0.009, P=0.016, P=0.009 and P=0.016), the area of the cartilage between the treatment groups and control group (respectively P=0.009, P=0.009, P=0.009 and P=0.028). A statistically significant difference was found in the average area of fibrosis between group II and control group, group IV and control group (respectively P=0.047 and P=0.009). RUST scores showed significant differences between the control group and group II, III, IV, V (respectively P=0.005, P=0.006, P=0.005 and P=0.006).

CONCLUSION

The administration of BMP-2 stimulates the formation of bone bridging in a massive bone defect. The bone bridging filling massive bone defect depends on the dose or concentration of BMP-2. Administration of an optimal dose (10 µg/mL) of BMP-2 demonstrates better result than lower or higher dose for massive bone defect healing in SD rate.

Diagnosis and treatment of Langerhans Cell Histiocytosis with bone lesion in pediatric patient: A case report

BACKGROUND

Langerhans cell histiocytosis (LCH) is a rare group of disorders without a well understood etiology. Known formerly as histiocytosis X, the disease has a wide spectrum of clinical presentations, including eosinophilic granuloma (solitary bone lesion), diabetes insipidus, and exophthalmos. Many of these patients initially present to orthopaedic surgeons, and misdiagnosis is frequent.

METHODS

We deliver a case of a 10-month-old boy who consulted to our department. Previously misdiagnosed as a Kawasaki syndrome, TORCH, and osteomyelitis. He had undergone several examinations and had been discussed in clinocipathological conference (CPC) to narrow down the diagnosis.

RESULT

After serial examinations, the diagnosis of Langerhans Cell Histiocytosis was confirmed and chemotherapy was initiated. And after 6 cycles of chemotherapy, with 1-week interval of each therapy, the clinical appearance of this patient significantly improved.

CONCLUSION

Despite major advances in our understanding and management of LCH, it remains one of the most challenging diagnoses for the orthopedic surgeon. By doing a comprehensive examination, it is possible to narrowing down the diagnosis and planning the accurate treatment.

Clinical outcome of various limb salvage surgeries in osteosarcoma around knee: Megaprosthesis, extracorporeal irradiation and resection arthrodesis

Background

We evaluated the outcome and the survival rate of Limb salvage surgeries (LSSs) in osteosarcoma around knee by using megaprosthesis, ECI autograft, and modified arthrodesis of the knee with metallic plus bone cement (MAMC).

Methods

We reviewed 35 cases of osteosarcoma around the knee that was treated by megaprosthesis, ECI autograft and MAMC from 2012 to 2017. The survival, local recurrence, metastases, complications and functional MSTS score were evaluated for each operation technique. Kaplan-Meier was used to describe the survival rate for each technique.

Result

Megaprostheses group had an excellent MSTS score (78.7%), the ECI group (72.3%) and MAMC group (68.4%). Local recurrence occurred in the megaprothesis group (0%), the ECI group (9.1%) and MAMC group (20%). Infection occurred in 3 cases of ECI (13.6%) while only 2 (40%) cases in MAMC group and 1 case (12.5%) in the megaprostheses group. Aseptic loosening occurred in the megaprostheses group 1 case (12.5%) and MAMC 1 case (20%). Metastases occurred in 18.2% of the ECI group compared to 25% of the megaprostheses group and 40% of the MAMC group. The megaprosthesis group had an overall survival rate of 90.9 months, whilst the ECI group is on 94.6 months and the MAMC group was 47.2 months.

Conclusion

Megaprosthesis showed good-excellent functional outcome and survival rate. ECI that is an option in LSS has good functional outcome as well. Knee arthrodesis with MAMC it is still an option to perform LSS even in the advanced local stage of the disease.

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Various reconstruction options are available for the reconstruction of the distal femur and proximal tibia osteosarcoma.

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Megaprosthesis showed good-excellent functional outcome and survival rate.

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ECI that is an option in LSS has good functional outcome as well.

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Knee arthrodesis with MAMC it is still an option to perform LSS even in the advanced local stage of the disease.

Joint reconstruction using sternocleidomastoid tendon autograft as a treatment for traumatic posterior dislocation of sternoclavicular joint: A case report

Introduction

Posterior sternoclavicular joint dislocations are extremely rare and emergent injuries.

Presentation of case

We presented a case of a seventeen-year-old male patient who was diagnosed with traumatic posterior dislocation. He underwent joint reconstruction using sternocleidomastoid tendon autograft, and the operation went well.

Discussion

At four-week and fourteen-week follow-up post-operatively revealed a surgical wound that healed well, regained stable sternoclavicular joint that was marked by a normal left sternoclavicular notch, full range of movement of the left shoulder and the pain subsided.

Conclusion

These findings provide evidence that the method of joint reconstruction and augmentation may produce good outcome for posterior dislocation of the sternoclavicular joint.

Low-grade intramedullary osteosarcoma presenting with multiple sclerotic bone lesions

Low-grade intramedullary osteosarcoma is a less-aggressive type of osteosarcoma for which delays in diagnosis are common. We present the case of a 42-year-old woman with complaints of low back pain. Multiple imaging evaluations and biopsy procedures were necessary to make the final diagnosis. The key radiologic feature was multiple sclerotic lesions throughout the skeleton, best seen on the bone scan. The difficulties in diagnosing this condition are evident in this case.

Osteosarcoma of the talus treated with extraarticular resection " total talectomy" and reconstruction using fibular bone graft: A case report

Introduction

In most cases, osteosarcoma occurs in the metaphysis of long bones such as femur, tibia, or humerus. Meanwhile, osteosarcoma of the talus is extremely rare.

Presentation of case

We presented a case of a thirty-eight-year-old male patient with osteosarcoma of the talus treatedwith limb salvage surgery. That procedure consists of wide excision as extra-articular resection“ totaltalectomy” followed by challenging reconstruction of the defect using fibular graft and followed by internal fixation and arthrodesis. We did an extraarticular resection of the talus, which consists of total talectomy and excision of the distal tibia and fibula. An ipsilateralnon vascularized fibular graft as harvested and placed in a horizontal plane to bridge the distal tibia and fibula to the navicular. The graft was fixated using 7.5mm cannulated headless screw and was followed by arthrodesis across the distal tibia and fibula to the calcaneus.

Discussion

Options for surgical treatment for osteosarcoma of the talus islimb salvage surgery. Extraarticular resection “total talectomy” and reconstruction using fibular bone grafttechnique creates a good functional outcome and no signs of local recurrence were found during one-yearfollow-up

Conclusion

Extraarticular resection and reconstruction using fibular bone graftis a good technique for management of osteosarcoma of the talus.

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Osteosarcoma of the talus is extremely rare.The accurate diagnosis can be complicated by subtle clinical features.

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Patients with osteosarcoma of the talus could be considered for limb salvage surgery.

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The limb salvage surgery consists of extra-articular resection total talectomy and reconstruction with fibular graft.

Vascularized fibular graft as a surgical option for osteosarcoma of distal humerus: A case report

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This is an unsual case of osteosarcoma of distal humerus.

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It is not only a rare case but also an interesting surgical management.

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Limb salvage surgery which consists of wide excision, followed by reconstruction with vascularized fibular graft and interpositional elbow arthroplasty is a good option.

Introduction

Distal humerus is a very rare predilection site of osteosarcoma. Limb salvage surgery has widely replaced amputation for surgical treatment of most types of malignant bone sarcomas.

Presentation of case

We presented a 42 years old male with rapidly growing osteosarcoma on his right distal humerus. After induction chemotherapy, wide excision and reconstruction using free vascularized fibular graft followed with interpositional elbow arthroplasty technique was done.

Discussion

One of the option for surgical treatment for distal humerus osteosarcoma is limb salvage sugery with free vascularized fibular graft technique. Good functional outcome and no signs of local recurrence were found during 2,5 years follow up.

Conclusion

Free vascularized fibular graft with interpositional elbow arthroplasty is a good option for management of bone sarcoma of distal humerus.

Management of aggressive giant cell tumor of calcaneal bone: A case report

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This is an advanced case of aggressive GCT of calcaneus.

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It is not only a rare case but also an interesting diagnosis and surgical management.

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Limb salvage surgery which consists of wide excision-total calcaneoctomy, followed by reconstruction with femoral head allograft and soft tissue coverage with sural flap is a good option.

Introduction

Prevalence of giant cell tumor (GCT) at atypical locations like bones of the feet are rare, seen in <1% of cases. GCT may have aggressive features, including cortical expansion or destruction with a soft-tissue component. Difficult diagnosis most often followed with complicated management and high recurrence rate remains a challenge that is rarely reported.

Presentation of case

We presented a case of forty-six-year-old male patient with giant cell tumor of the right calcaneus Campanacci 3 with secondary aneurysmal bone cyst (ABC). Wide excision total calcaneoctomy, followed by reconstruction bone defect using femoral head allograft and soft tissue coverage with sural flap had been done.

Discussion

Conservative surgery with careful curettage and placement of bone cement should be considered the treatment of choice when feasible. However, aggressive GCTs may require wide excision and reconstruction or may be amputation. We decided to do salvage surgery since: traditionally curettage is not possible, adequately wide resection of local tumor could be achieved, neurovascular bundle was not involved, and also bone and soft tissue reconstructions could be done. In addition, he refused for amputation.

Conclusion

Wide excision total calcaneoctomy, bone allograft reconstruction and soft tissue coverage with sural flap is a good option for surgical management in aggressive GCT of calcaneus instead of amputation.

Wide resection versus curettage with adjuvant therapy for giant cell tumour of bone

PURPOSE

To determine the association between type of surgery (wide resection versus curettage with adjuvant therapy) and outcome in patients with giant cell tumour (GCT) of bone.

METHODS

Records of 30 male and 52 female consecutive patients aged 10 to 62 years who underwent wide resection (n=57) or curettage with adjuvant therapy (n=25) for primary GCT of bone were reviewed. The surgical decision was based on patient age, tumour location, functional demand, and patient preference. The median tumour size was 8.5 cm. Tumours were classified as stage 1 (n=4), stage 2 (n=60), and stage 3 (n=18), and 25%, 68.3%, and 83.3% of them were treated with wide resection, respectively. Functional outcome was assessed using the Musculoskeletal Tumor Society (MSTS) score; the maximum score was 30.

RESULTS

The wide resection and curettage with adjuvant therapy groups were comparable in terms of patient age, gender, tumour size, location, symptoms, tumour stage, type of biopsy, and MSTS score. The MSTS score was excellent in 50.2% of patients, good in 38.7% of patients, and fair and poor in the remaining patients. The MSTS score was not associated with tumour stage or type of surgery. Four patients in the wide resection group had metastasis to the lung. They also had lower haemoglobin level (10.6 vs. 12.7 g/dl, p=0.020) and higher percentage of stage-3 tumour (100% vs. 17.9%, p=0.001) but had no recurrence (0% vs. 6.4%, p=0.774), compared with those without metastatsis. All died from massive haemoptysis and respiratory failure. Eight patients died; their haemoglobin level was lower than that of patients who were still living (11.2 vs. 12.7 g/dl, p=0.032). Mortality was associated with metastasis (100% vs 5.2%, p<0.001) but not recurrence or complication. Two patients in each group had recurrence; recurrence was not associated with type of surgery.

CONCLUSION

There was no association between type of surgery and tumour recurrence, metastasis, or outcome. Curettage with adjuvant therapy was more commonly performed for stage 1 and 2 tumours, whereas wide resection was more for stage 3 tumours. Metastasis was associated with stage 3 tumour and mortality but not recurrence.

Effect of povidone iodine and hydrogen peroxide on fracture healing: a histomorphometric study on rats

PURPOSE

To evaluate the effect of povidone iodine and hydrogen peroxide on fracture healing in a rat model.

METHODS

The middle section of the right femur of 36 male Sprague Dawley rats was osteotomised with a saw. In the control group (n=9), the wound was irrigated with 100 ml 0.9% saline. In the 10% povidone iodine (n=9), 1% povidone iodine (n=9), and 3% hydrogen peroxide (n=9) groups, the wound was completely soaked with the respective solution for 2 minutes, and then irrigated with 100 ml saline. The osteotomy was fixed with an intramedullary Kirschner wire. Rats were euthanised at week 1, 2, and 5. In each femur, the percentage area of osseous, cartilaginous, and fibrous tissue in the callus was evaluated in 3 slides (one median and 2 paramedian).

RESULTS

The control group differed significantly to the other 3 groups (p=0.023 to p<0.001) in weeks 1, 2, and 5, except for the 1% povidone iodine group in terms of percentage of osseous (p=0.349) and fibrous (p=0.999) tissue. The healing process was similar in the 1% povidone iodine group and the control group, whereas healing was impaired in the 10% povidone iodine group and 3% hydrogen peroxide group, as indicated by the lower percentage of osseous tissue, higher percentage of fibrous tissue, and increased percentage of cartilaginous tissue between weeks 2 and 5 (delayed bone healing).

CONCLUSION

The 1% povidone iodine solution is recommended as the irrigation adjuvant in fracture surgery.

Clinical Outcome and Survival of Osteosarcoma Patients in Cipto Mangunkusumo Hospital: Limb Salvage Surgery versus Amputation

AIM

to analyze the outcome and survival rate of osteosarcoma patients in our hospital as well as the factors affecting prognosis and functional outcome.

METHODS

this is a retrospective cohort study of osteosarcoma patients in Cipto Mangunkusumo Hospital underwent limb salvage surgery (LSS), amputation, LSS + amputation, and refused surgery from year 1995 to 2014. The surgical decision was based on patient's age, staging, location, neurovascular involvement, Huvos type, functional demand, patient preference, and general condition. Functional outcome was assessed using the Musculoskeletal Tumor Society (MSTS) score with the maximum score of 30.

RESULTS

subjects consisted of 80 male and 52 female aged 4 to 61 year-old. They underwent limb salvage surgery (LSS) (n=37), amputation (n=42), LSS + amputation (n=2), and refused surgery (n=51). Overall 5-year cumulative survival rate was 14.6%. The 5-year survival rate for each group; LSS, amputation, combined LSS and amputation, and refused surgery was 34.8%; 15.9%; 0%; and 0%, respectively. Patients with tumor size <8 cm tend to underwent LSS compared to amputations (60.7% vs 39.3%, p=0.046). Local recurrence-free survival for LSS and amputation was 96.2% and 86.5% respectively (p=0.586). MSTS score was higher in LSS than amputation group (25.0 vs 18.5, p=0.011).

CONCLUSION

LSS had higher survival rate than amputation in osteosarcoma patients who were treated in Cipto Mangunkusumo Hospital. MSTS functional score in the LSS group was higher than amputation group.

Fibrodysplasia Ossificans Progressiva: Difficulty in Diagnosis and Management A case report and literature review

Introduction:

Fibrodysplasia ossificans progressiva (FOP) is a rare autosomal dominant genetic disorder and characterized by postnatal progressive heterotopic ossification of the connective tissue. There are difficulties in diagnosing FOP, thus delayed or misdiagnosis and mismanagement is common.

3D printers have now become widely available and inexpensive, and can be used to rapidly produce life-size models based on CT scans of an individual patient. The availability of patient specific, accurate and detailed models of complex acetabular fractures can aid planning of surgical management on a patient specific basis.

Case Report:

We present the diagnosis and surgical management of a 9-year old Indonesian girl with FOP. She presented with extensive involvement of cervical spine and both shoulders. Total excision of occipito-cervico-lumbar and paravertebral ossification and also exostoses at bilateral shoulder was done. At three years follow up, she had local recurrence with similar range of movement of the shoulder and cervical spine.

Conclusion:

FOP is an extremely rare case. It is difficult to diagnose and manage FOP, therefore delayed or misdiagnosis and also inappropriate management is common.

Correlation between survival and tumour characteristics in patients with chondrosarcoma

PURPOSE

To evaluate the correlation between survival and tumour characteristics in 23 patients with chondrosarcoma.

METHODS

Records of 15 men and 8 women aged 14 to 66 (mean, 37) years who were diagnosed with primary (n=19) or secondary (n=4) chondrosarcoma of the axial skeleton (n=8), proximal extremity (n=9), or distal extremity (n=6) were reviewed. The tumour diameter was <10 cm in 4 patients, 10-19 cm in 12, and 20-30 cm in 7. The tumour involved the intramedullary in 17 and the periosteum in 6 patients; tumour extension was intracompartmental in 5 and extracompartmental in 18 patients. The Evans histological grade for the tumours was grade 1 in 6 patients, grade 2 in 10, and grade 3 in 7. The mean tumour size was 12.3 cm for grade 1 tumours, 18.2 cm for grade 2 tumours, and 18.3 cm for grade 3 tumours. 13 patients had no metastasis and 3 of 10 patients with grade 2 tumours and all 7 patients with grade 3 tumours had metastasis to the lung at presentation. 17 patients underwent surgery, one underwent adjuvant treatment only, and 5 declined treatment.

RESULTS

The mean follow-up period for the 23 patients was 3.1 years (range, 3 weeks to 9 years). The 5-year survival rate was 43% overall, 83.3% for grade 1 tumours, 50% for grade 2 tumours, and 0% for grade 3 tumours. The median survival duration was 20 (95% confidence interval, 11-29) months. Two patients had local recurrence and 16 did not, and the 5 patients who declined treatment died. Survival correlated with Evans histological grading (p=0.004), the presence of metastasis at presentation (p=0.026) and local recurrence (p=0.004).

CONCLUSION

The survival rate was lower in patients with higher Evan grading, metastasis, or local recurrence.

Autologous mesenchymal stem cell (MSCs) transplantation for critical-sized bone defect following a wide excision of osteofibrous dysplasia

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No recurrence of osteofibrous dysplasia at 84 week following a wide extraperiosteal excision.

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The combination of autologous BM-MSCs, HA granules and BMP-2 successfully created new bone tissue.

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The newly formed bone tissue filled in the gap of critical-sized bone defect and was able to improve the patient’s quality of life significantly.

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No neoplastic, immunologic or other side-effects were noted at 84 weeks after autologous MSC transplantation.

Introduction

Osteofibrous dysplasia is a rare non-neoplastic disease that is almost exclusive to pediatric tibial diaphysis. Wide excision of the lesion is recommended to avoid recurrence. However, such radical surgery will results in large segmental bone defects that will require further extensive reconstructive surgery. We report a novel approach of treating bone defect by implementing the diamond concept of bone healing using autologous bone marrow derived mesenchymal stem cells (BM-MSCs).

Presentation of case

An eight-year-old Indonesian male presented with severe bowing deformity of the left lower leg. Radiographic and histological analysis confirmed the diagnosis of osteofibrous dysplasia. A wide excision of the defect was made leaving a critical-sized bone defect. A combination of autologous transplantation of 50 million BM-MSCs, hydroxyapatite (HA) granules, bone morphogenic protein 2 (BMP-2) and Djoko-Zarov hybrid circular external fixator was used to treat the defect. The outcomes measured were subjective complaints, functionality based on LEFS and radiological assessments.

Discussion

Radiographic assessments showed successful new bone tissue formation and integration of implanted HA granules. The external fixator was removed at 42 weeks after adequate callus formation and clinical stability was achieved. The patient underwent progressive functional improvements and reached a near normal functionality of 90% LEFS at 84 week. No therapy side effect or complication was reported.

Conclusion

Osteofibrous dysplasia was successfully excised without signs of recurrence after 84-week follow-up. Autologous transplantation of augmented BM-MSCs has successfully created new normal bone tissue without causing any side effect and had significantly improved the patient’s quality of life.

Bilateral iliopsoas haemophilic "soft tissue pseudotumours": A case report

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Haemophilic pseudotumour was caused by repetitive bleeding.

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This is a bilateral iliopsoas pseudotumour with neurologic deficit and contracture.

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After excision, there was improvement in muscle power from score 2/5 to 4/5.

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Recurrent bleeding will cause joint contractures chronic pain and nerve compression.

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Surgery should be performed in major center by an integrated surgical team.

Haemophilic soft tissue pseudotumour is one of the rarest complications of haemophilia that caused by repetitive bleeding resulting in an encapsulated mass of clotted blood and necrotic tissue. Soft tissue pseudotumour may not only cause flexion contracture but also chronic pain and femoral nerve compression that cause severe disability. Thus, surgical excision is the treatment of choice. It should only be carried out in a major haemophilic center by an integrated multidisciplinary surgical team.

Transplantation of mesenchymal stem cells, recombinant human BMP-2,and their combination in accelerating the union after osteotomy and increasing, the mechanical strength of extracorporeally irradiated femoral autograft in rat models

BACKGROUND

Delayed union, nonunion, and mechanical failure is still problems encountered in limb salvage surgery (LSS) using extracorporeal irradiation (ECI). This study aimed to determine whether bone marrow mesenchymal stem cells (MSC) and recombinant human bone morphogenetic protein-2 (rhBMP-2) improve hostgraft union after osteotomy and also increase its mechanical strength.

METHODS

Thirty Sprague Dawley rats were randomly divided into five groups. Group I (control) underwent LSS using ECI method with 150 Gy single doses. Similar procedures were applied to other groups. Group II received hydroxyapatite (HA) scaffold. Group III received HA scaffold and MSC. Group IV received HA scaffold and rhBMP-2. Group V received HA scaffolds, MSC, and rhBMP-2. Radiograph were taken at week-2, 4, 6, and 8; serum alkaline phosphatase and osteocalcin were measured at week-2 and 4. Histopathological evaluation and biomechanical study was done at week-8.

RESULTS

The highest radiological score was found in group IV and V Similar result was obtained in histological score and ultimate bending force. These results were found to be statistically significant. There was no significant difference among groups in serum alkaline phosphatase and osteocalcin level.

CONCLUSION

Combination of MSC and rhBMP-2 was proven to accelerate union and improve mechanical strength of ECI autograft.

Pelvic haemophilic pseudotumour: a case report

We report on a 30-year-old haemophilic man with a pelvic pseudotumour compressing adjacent structures causing pain and swelling and destruction of surrounding soft tissues and bones. He underwent evacuation of the pseudotumour, acetabular reconstruction using the Harrington procedure, and total hip arthroplasty.

Noncontingent positive and negative feedback during maximal exercise

A closed skill, maximal effort on a bicycle ergometer was used to study the effects of noncontingent external feedback on performance, perceived effort, and the subject's assessment of the quality and accuracy of the feedback. The 47 subjects included elite athletes as well as physical education majors. They were asked to perform a series of 5 60-sec. trials of maximal effort, trials which included positive, negative, positive and negative, and no-feedback conditions. Although there were no significant effects on performance for the various feedback conditions, subjects judged the positive feedback favourably and as accurate, but negative feedback was judged unfavourably and considered to be inaccurate. This result is seen as supportive of the 1982 McCarrey, et al. supposition that successful athletes may have less need to internalize attributions of effect.

Informational feedback and self-esteem among male and female athletes

The self-esteem of male and female competitive athletes was compared after each was provided either positive or negative (verbal) informational feedback on a nonathletic task, a series of single-solution anagrams. Subjects were 50 men and 50 women, aged 18 to 25 years, who were tested on the semantic differential to estimate athletes' self-esteem before and after receiving the informational feedback. Over-all, female athletes responded more strongly to both feedback conditions, with both groups being more influenced by negative rather than by positive feedback.