Abstract. Background. Benign osteolytic lesions of bone represent a diverse group of pathological and clinical entities. The aim of this study is to highlight the importance of intraoperative endoscopic assessment of intramedullary osteolytic lesions in view of the rate of complications during the postoperative follow up period. Methods. 69 patients (median age 27 years) with benign osteolytic lesion had been prospectively followed up from December 2017 to December 2018 in a university hospital in Cairo, Egypt and in a level-1 trauma center in United Kingdom. All patients had been treated by curettage with the aid of endoscopy through a standard incision and 2 portals. Histological analysis was confirmed from intraoperative samples analysis. All patients had received bone allografts from different donor sites (iliac crest, fibula, olecranon, etc). None of them received chemo or radiotherapy. Results. Most of lesions were enchondroma (n=29), followed by Aneurysmal bone cyst (ABC) (n=16), Fibrodysplasia (n=13), Chondromyxoid fibroma (n=3), simple bone cyst (n= 3), non-ossifying fibroma (n= 3), giant cell tumour (n= 1) and chondromyxoid fibroma (n = 1). Site of lesion varied from metacarpals (n = 29), femur (n= 1), lower leg (n= 31), and upper limb (n=18). Complications happened only in 9 cases (pathological fractures (n=2), infection (n= 1), recurrence (n=3, all aneurysmal bone cyst), residual pain (n= 3, all in tibia). None of cases developed malignant transformation. Conclusion. Endoscopy is recommended in management of benign osteolytic bone lesions; as it aids in better visualization of the hidden lesions that are missed even after doing apparently satisfactory blind curettage. From our study the recurrence rate is 2% compared to the known 12–18% recurrence rate in the blind technique from literature

Aim. Restarting elective services presents a challenge to restore and improve many of the planned patient care pathways which have been suspended during the response to the COVID-19 pandemic. A significant backlog of planned elective work has built up representing a considerable volume of patient need. We aimed to investigate the health status, quality of life, and the impact of delay for patients whose referrals and treatment for symptomatic joint arthritis had been delayed as a result of the response to COVID-19. Methods. We interviewed 111 patients referred to our elective outpatient service and whose first appointments had been cancelled as a result of the response to the COVID-19 pandemic. Results. Patients reported significant impacts on their health status and quality of life. Overall, 79 (71.2%) patients reported a further deterioration in their condition while waiting, with seven (6.3%) evaluating their health status as ‘worse than death’. Conclusions. Waiting lists are clearly not benign and how to prioritize patients, their level of need, and access to assessment and treatment must be more sophisticated than simply relying on the length of time a patient has been waiting. This paper supports the contention that patients awaiting elective joint arthroplasty report significant impacts on their quality of life and health status. This should be given appropriate weight when patients are prioritized for surgery as part of the recovery of services following the COVID-19 pandemic. Elective surgery should not be seen as optional surgery—patients do not see it in this way

Non-invasive sampling of tumor-derived genetic material in circulation through liquid biopsy may be very beneficial for an accurate diagnosis and evaluation of response to treatment in patients with malignant and benign soft tissue tumors. We previously showed that tumor-derived genomic aberrations can be detected in plasma of patients with leiomyosarcoma (LMS) and leiomyoma (LM). In LMS patients, we also showed that the levels of circulating tumor DNA (ctDNA) correspond with response to treatment. We developed an approach tailored to genomic profile of LMS (characterized by intermediate levels of point mutations and copy number alterations, CNAs). Based on TCGA data, we designed a panel of 89 most frequently mutated genes in LMS, which we profiled in plasma DNA by deep sequencing. In parallel, plasma samples were analyzed by shallow whole genome sequencing for detection of CNAs. With this approach, we detected ctDNA in 71% (20/28) of samples from 6/7 patients with advanced disease with >98% specificity. The combination approach for orthogonal profiling of point mutations and CNAs proved to increase the sensitivity of ctDNA detection. Currently, we seek to further improve the sensitivity of ctDNA detection by refining our capture panel and tracking LMS-specific DNA methylation markers in circulation, in addition to point mutations and CNAs. The ultimate goals of our ctDNA studies are 1) to develop a highly sensitive assay for evaluation of response to therapy and long-term surveillance for patients with LMS, and 2) to develop a blood-based test for accurate pre-operative distinction between LMS and LM. To identify LMS-specific DNA methylation markers, we analyzed a test cohort of 76 LM, 35 uterine LMS and 31 extra-uterine LMS by Illumina Infinium EPIC arrays. We identified differentially methylated CpGs between LM and uterine LMS, and between LM and all LMS using a newly developed custom pipeline in R. The results of this analysis are currently being validated in a new dataset of 41 LM and 153 LMS generated by our group. Recently published (PMID: 34301934) genomic data from new 53 LMS samples are used to refine the panel of the most frequently mutated genes that we identified previously in the LMS TCGA data. Our preliminary analysis of test cohort revealed >270 differentially methylated CpGs between LM and uterine LMS, and >1000 differentially methylated CpGs between LM and all LMS. The preliminary analysis of genomic data shows that the initial panel of 89 frequently mutated genes could be substantially narrowed down to cover only selected tumor suppressor genes. Once validated, these results will be used to refine the ctDNA assay for LMS and LM. Our results point to multiple epigenetic markers that could be used for ctDNA profiling, in addition to point mutations or CNAs. Further validation will allow us to select the most reliable LMS- and LM-specific DNA methylation markers and the most frequently mutated regions across independent datasets, and these markers will be incorporated into our new ctDNA test for a concurrent detection of point mutations, CNAs and DNA methylation markers in circulation

Pathological fractures in children can occur as a result of a variety of conditions, ranging from metabolic diseases and infection to tumours. Fractures through benign and malignant bone tumours should be recognised and managed appropriately by the treating orthopaedic surgeon. The most common benign bone tumours that cause pathological fractures in children are unicameral bone cysts, aneurysmal bone cysts, non-ossifying fibromas and fibrous dysplasia. Although pathological fractures through a primary bone malignancy are rare, these should be recognised quickly in order to achieve better outcomes. A thorough history, physical examination and review of plain radiographs are crucial to determine the cause and guide treatment. In most benign cases the fracture will heal and the lesion can be addressed at the time of the fracture, or after the fracture is healed. A step-wise and multidisciplinary approach is necessary in caring for paediatric patients with malignancies. Pathological fractures do not have to be treated by amputation; these fractures can heal and limb salvage can be performed when indicated

Summary Statement. Treatment of non-union is a highly demanding field with respect to bone healing. BMP 7 is a useful, wide-ranged tool in treating non-union of the foot and benign bone tumors. It represents a low-risk procedure with a high level of reliability. Introduction. Treatment of non-union is a highly demanding field with respect to bone healing. Treatment of tibial fracture non-union with the bone morphogenetic protein 7 (BMP-7) has been successfully reported. BMP 7 is a recombinant human protein produced in ovary cells of the Chinese hamster. It is responsible for the differentiation of mesenchymal stem cells from the periost, muscle and sponious bone and stimulates bone formation. It is the aim of our study to investigate the use of BMP 7 for other locations than the tibia, such as the foot and benign bone tumors. We strive for union or revision in each medical case. Patients & Methods. At our clinic we applied BMP-7 to 13 patients (9 patients with non-union, 4 patients with benign bone cysts). 9 patients with non-union of the foot (4 forefoot, 1 midfoot, 3 hindfoot, 1 tibia) were surgically treated by resection, stabilisation, and application of BMP 7. The study included 5 men and 4 women at an average age of 58,4 years (range 33 – 80), 13 previous surgeries had been carried out. The period of follow up was on average 16.3 months (5 – 40 months). The indication for using BMP-7 instead of autologous bone graft was poor local blood supply, poor local soft tissue because of previous interventions and risk factors like smoking and diabetes. Following an indicated open biopsy, the 4 cases of benign bone tumors (1 juvenile bone cyst of the talus, 1 osteofibrose dysplasia of the proximal tibia and 2 juvenile bone cysts of the proximal humerus) were all treated with resection, followed by an application of BMP-7 and external or internal fixation. In addition two received bone grafting and two received cortisone. The average age of the tumor group was 16,75 years (11–24 years, 2 male, 2 female). Results. At follow-up all patients were satisfied with respect to pain and function, no operative complications had occurred and bone fusion had finished in 7 patients after 3 months. One ankle joint had a fibrous fusion but was free of pain. One arthrodesis of the first metatarsophalangeal joint was turned into a resection arthroplasty, today the patient is free of pain and uses a normal shoe. Both bone cysts have the radiological evidence of rehabilitation. At one humeruscyst we removed the TENS-nails without complications. We had no complications like heterotopic ossification, local erythema or pressure sensitivity. Discussion/Conclusion. These results show that BMP 7 is a useful, wide-ranged tool in treating non-union of the foot and benign bone tumors. It represents a low-risk procedure with a high level of reliability

Aims: To evaluate the outcome of surgical treatment of benign and aggressive chondroblastoma in the Prague bone tumours register. Methods: Between 1969–2001 57 patients (38 men and 19 women) with chondroblastoma have been registered. The age ranged from 7 to 52 years – in average 19 years. The most frequent localizations were epiphyses of long bones (13 proximal humerus, 10 proximal femur, distal femur and proximal tibia each 11). We also observed atypical localizations (3 patella, 2 pelvis and 1 each in, fibula, talus, 5th metatarsal). All patients had available x-rays for evaluation and some arteriography or CT. All had histological verification. The treatment of choice was intralesional curetting and filling with auto or allografts. The femoral head lesions were treated through an original femoral neck approach to prevent hip luxation. We registered 5 aggressive variants with a different clinical course. They recur after intralesional surgery, are purely osteolytic and richly vascularized. One patient even developed lung metastasis. Results: In the usual type of benign chondroblastoma all patients were healed after intralesional surgery and graft filling with well-preserved function. In the aggressive form we performed a limb saving reconstructive surgery (knee arthrodesis, total knee or hip endoprosthesis). Conclusions: For benign chondroblastoma intra-lesional surgery brings excellent results. The aggressive form should be differentiated and resected at least marginally without delay to prevent larger skeletal defects

Aim. To report late development of sarcomas on sites of previously curetted and grafted benign tumours. Rare cases of development of sarcomas in sites of previous benign lesions are documented, and the development is generally considered secondary to progression of benign lesions, even without radiotherapy. Methods and Results. In our files, 12 cases curetted and grafted, without radiotherapy addition developed sarcomas from 6 to 28 years from curettage (median 18). Age at first diagnosis (9 GCT, 1 benign fibrous histiocytoma, ABC and solitary bone cyst) ranged from 13 to 55 (median 30). For all cases radiographic and clinic documentation was available. Histology was available for 7 of the benign lesions and for all malignant lesions. The type of bone used to fill cavities was autoplastic in 4 cases, homoplastic in 2 cases, homoplastic and tricalciumphosphate/hydrossiapatite in 1 case, autoplastic and homoplastic in 1 cases, heteroplastic in 1 case. In 3 cases the origin was not reported. Secondary sarcomas, all high grade, were 8 OS, 3 MFH, and 1 fibrosarcoma. Conclusions. It is impossible to calculate the exact incidence of this transformation, but from a comparison with 137 secondary sarcomas treated in the same years (1975-2005) at the Rizzoli Institute, it is similar to the risk of a sarcoma on fibrous dysplasia or lower than a sarcoma on bone infarcts or on Paget's disease. Recurrence with progression from benign tumours can occur, but the very long intervals reported in the present series suggest a possible different pathogenesis. Recent preclinical papers report development of sarcoma in mice after transplantation of mesenchymal stem cells, independently from the type of scaffold used. The fact that reparative proliferative changes occuring in the area of dead bone, with stimulation of mesenchymal stem cells, could cause malignant transformation, is a new hypothesis

A case of malignant transformation of a benign chondroblastoma of the tibia in a fifteen-year-old boy is reported. The tumour was not irradiated at any time during the course of the disease. The tumour showed a typical appearance of benign chondroblastoma at the first operation. It recurred repeatedly after curettage, and finally emerged as a highly malignant undifferentiated sarcoma. In spite of amputation the patient died nine years after the onset of the disease with an enlarged liver and inguinal lymph nodes

We reviewed 234 benign solitary schwannomas treated between 1984 and 2004. The mean age of the patients was 45.2 years (11 to 82). There were 170 tumours (73%) in the upper limb, of which 94 (40%) arose from the brachial plexus or other nerves within the posterior triangle of the neck. Six (2.6%) were located within muscle or bone. Four patients (1.7%) presented with tetraparesis due to an intraspinal extension. There were 198 primary referrals (19 of whom had a needle biopsy in the referring unit) and in these patients the tumour was excised. After having surgery or an open biopsy at another hospital, a further 36 patients were seen because of increased neurological deficit, pain or incomplete excision. In these, a nerve repair was performed in 18 and treatment for pain or paralysis was offered to another 14. A tender mass was found in 194 (98%) of the primary referrals. A Tinel-like sign was recorded in 155 (81%). Persistent spontaneous pain occurred in 60 (31%) of the 194 with tender mass, impairment of cutaneous sensibility in 39 (20%), and muscle weakness in 24 (12%). After apparently adequate excision, two tumours recurred. No case of malignant transformation was seen

We report our experience of treating 17 patients with benign lesions of the proximal femur with non-vascularised, autologous fibular strut grafts, without osteosynthesis. The mean age of the patients at presentation was 16.5 years (5 to 33) and they were followed up for a mean of 2.9 years (0.4 to 19.5). Histological diagnoses included simple bone cyst, fibrous dysplasia, aneurysmal bone cysts and giant cell tumour. Local recurrence occurred in two patients (11.7%) and superficial wound infection, chronic hip pain and deep venous thrombosis occurred in three. Pathological fracture did not occur in any patient following the procedure. We conclude that non-vascularised fibular strut grafts are a safe and satisfactory method of treating benign lesions of the proximal femur

The purpose of this study was to elaborate “sparing” surgical treatment of benign tumors and tumorlike lesions of bones in children. Ninety-six experiments on human defrosted tibias and twenty-four operations on chinchilla rabbits showed the effect of co2-laser radiation on osteal structures.the clonation of human bone marrow (one hundred ad nineteen cultures) and seventy-two experiments on chinchilla rabbits revealed the effect of uv-radiation on osteogenesis. The clinical study included five hundred and fifty-seven children with benign tumors and tumorlike lesions of bones. Experimental and clinical investigation showed that co2-laser scanning of residual bone cavity after economic resections prevented relapses of pathological process in 98% cases.osteoplasty with uv-radiated autologus bone marrow in combination with allo-bone material stimulated osteogenesis and provided restoration of bone structure in nine to twelve months. c02-laser operations with simultaneous osteoplasty by uv-radiated autogenous bone-marrow is an effective “sparing” method of surgical treatment of benign tumors and tumorlike lesions of bones in children

Giant cell tumour of tendon sheath is usually benign in nature but their tendency to recur is well known, this cause problems for surgeons and there is always a puzzle in determining the appropriate therapy. This study was done to highlight characteristics, differential diagnosis and current options of treatment for giant cell tumour of tendon sheath. We report two cases treated at our hospital. Both are females, one of 24 years while other was 65 years at the time of diagnosis. First patient had incidental associated benign teratoma of ovary as well. One tumour was of thumb in non dominant hand while in older patient it was at distal interphalangeal joint of ring finger in dominant hand. Both presented with history of slowly growing painful swelling, they were treated with local excision but in both patients there was an aggressive local recurrence. Revision surgery was performed with wider local excision. There was no recurrence this time. Giant cell tumour of tendon sheath is mostly benign condition but need to be differentiated from serious conditions like clear cell sarcoma. Therapy of choice is local excision. Wider excision after surgery should be reconsidered where microscopic examination reveals a lesion with characteristics suggestive of potential aggressive behaviour. A literature review and discussion of salient diagnostic and treatment issues is included

Background. Treatment of aggressive benign bone lesions with curettage, burring, cementation and plate augmentation is a widely accepted treatment. We have used the above method using a locked plate (rather than conventional), facilitating stability and early mobilisation. We hypothesise that this is an alternative to megaprosthetic joint replacement, and provides acceptable functional outcomes at follow-up. Methods. Patients with peri-articular aggressive benign bone lesions of the lower limb were treated with marginal excision, intra-lesional curettage, burring and cementation. This was augmented with a locked plate of varying designs. Where feasible, liquid nitrogen was used as an adjunctive treatment. Functional outcome was evaluated at follow-up using the Musculoskeletal Tumour Society Score (MSTS). Routine X-rays were performed at follow up to determine if there was any radiographic evidence of recurrence or any complications. Results. 13 patients with aggressive benign tumours of the lower limb were treated between 2005 and 2009. All tumours were aggressive benign peri-articular tumours with extension to the articular surface. Several of the tumours had fractured the articular cartilage and extended into the joint. Several pathological fractures were noted. The patients were treated in the manner described. The average MSTS score was 89%. Average follow-up time is 35 months. Patients were discharged 2 weeks post-operatively, a prerequisite being the ability to achieve 90° of knee flexion. To date there have been no complications or evidence of radiological recurrence. Conclusion. Our early results in a small series make us cautiously optimistic that this may be an alternative to immediate megaprosthetic reconstruction in patients with relative joint preservation and form an intermediate step in the treatment of aggressive benign peri-articular bone tumours. These may be amenable to arthroplastic reconstruction at a later stage, if necessary

Aim: In the present study we examine the role of bone scan with 99mTc-MIBI, following a positive 99mTc-MDP scan, in the work up to differentiate between malignant and benign bone lesions. Material and methods: Fifty-nine patients, with a positive 99mTc-MDP bone scan had further investigation of the affected area with the oncophilic radiopharmaceutical 99mTc-MIBI (15 mCi). The agent was administered IV and images were obtained (planar/SPECT) 20 min and 3 hours later. All patients had biopsy and CT/MRI imaging. The 99m Tc-MIBI images were estimated by 3 independent observers and every abnormal uptake, ranging from faint to intense, was considered positive. Results: 32 patients had benign bone lesions according to histology pathology; 28 of them (87.5%) had a negative 99mTc-MIBI scan (trauma, benign bone tumors). Four patients with benign bone lesions had positive 99mTc-MIBI (chronic osteomyelitis,osteochondroma, osteochondroblastoma, chondroblastoma). 27 patients had malignant bone tumors proven by biopsy; 25 of them (92.6%) had possitive 99mTc-MIBI scans (sarcomas and metastases) and 2 negative (chondrosarcoma, MFH). Conclusions: The 99mTc-MIBI scan in patients with positive 99mTc-MDP scan and a high index of suspicion for malignancy (either primary or metastatic) was found to have a high negative pedictive value (NPV=0.875) in excluding the presence of malignancy and a high positive pedictive value (PPV=0.926) in identifying patients with malignancy. The 99mTc-MIBI was positive in all patients with metastatic disease (PPV=1.00). We suggest the use of 99mTc-MIBI as a useful method in decision-making in cases with bone pathology

Purpose: We report a retrospecitve series of 88 benign osteolytic tumours of the knee treated by curettage-filling between 1973 and 2000. The purpose of this analysis was to evaluate the role of curettage-filling in the treatment of this type of tumour. Material and methods: Mean patient age was 31 years. The sex ratio was 1. Pain was the main sign and 9% of patients had a pathologic fracture. An equivalent number of tumours were found in the lower extremity of the femur and the upper extremity of the tibia. We analysed clinical features, imaging findings, treatments and complications, recurrence, and treatment of recurrence. Results: Giant-cell tumours predominated (n=63), followed by aneurysmal cysts (n=7) and chondroblastomas (n=6). Tumours were treated by curettage associated with filling (n=83) and osteosynthesis (n=51). There were six cases of mechanical complications, but only two required total knee arthroplasty. No re-operations for arthrolysis were required. The recurrence rate after curettage was 23%; a second curettage-filling was performed after 90% of the recurrences. Discussion: This study confirms that curettage-filling is the standard surgical treatment for benign osteolytic tumours of the knee, independently of histological type. This simple procedure with a low complication rate enables preservation of the joint in young subjects. We prefer this approach to resection-arthroplasty. We were unable to identify any factor predictive of local recurrence (histologic type of osteolytic tumour). Repeated curettage-filling is an appropriate treatment for recurrence

1. Three cases of a benign osteoblastic lesion of bone are described. An outstanding feature of each was the hyperostosis of adjacent bones or synovitis in an adjacent joint. 2. The clinical, radiological and histological features resembled osteoid osteomata more than benign osteoblastoma in each case. 3. The significance of this observation is questioned in relation to the pathogenesis of osteoid osteoma

This preliminary report demonstrates the effective use of Apapore in the management of benign cystic bone lesions. The use and development of bone graft substitutes over the past ten years has increased dramatically to improve their osseo-integration to a level similar to autografting techniques without the drawbacks of comorbidity from the graft site. Apapore is a synthetic bone graft substitute which consists of a scaffold of synthetic phase-pure hydroxy apatite with micro- and macroporosity and inter-connectivity to favour bone repair. Nineteen patients (12M:7F) with a mean age of 18.6years (8–33 years) having had procedures for the management of benign cystic lesions of bone with grafting using Apapore were followed up retrospectively for a mean period of 8 months (1–16months). In each case the diagnosis of a benign cystic lesion was made histologically prior to surgery. The subsequent definitive procedure was performed by a consultant on the Bone Tumour Unit at the Royal National Orthopaedic Hospital (Stanmore) in each case involving curettage and impaction of Apapore into the cavity in a standard fashion as a general anaesthetic procedure in the operating theatre. There have been no complications to date. All patients have made uneventful recoveries. Short-term radiological follow-up demonstrates excellent incorporation of the bone graft substitute and osseo-integration

We present a retrospective study of patients suffering from a variety of benign tumours in whom external fixators were used to treat deformity and limb-length discrepancy, and for the reconstruction of bone defects. A total of 43 limbs in 31 patients (12 male and 19 female) with a mean age of 14 years (2 to 54) were treated. The diagnosis was Ollier’s disease in 12 limbs, fibrous dysplasia in 11, osteochondroma in eight, giant cell tumour in five, osteofibrous dysplasia in five and non-ossifying fibroma in two. The lesions were treated in the tibia in 19 limbs, in the femur in 16, and in the forearm in eight. The Ilizarov frame was used in 25 limbs, the Taylor Spatial Frame in seven, the Orthofix fixator in six, the Monotube in four and the Heidelberg fixator in one. The mean follow-up was 72 months (22 to 221). The mean external fixation period was 168 days (71 to 352). The mean external fixation index was 42 days/cm (22.2 to 102.0) in the 22 patients who required limb lengthening. The mean correction angle for those with angular deformity was 23° (7° to 45°). At final follow-up all patients had returned to normal activities. Four patients required a second operation for recurrent deformity of further limb lengthening. Local recurrence occurred in one patient, requiring further surgery

Introduction: Benign bone-forming tumours are common in children and adolescents. Careful radiographical and histological study is necessary to distinguish slow growing from more aggressive bone forming tumours. We reviewed 25 cases of primary benign bone forming tumours of the spine to investigate whether there were any obvious differences in their biological behaviour in adults compared to children. Materials and Methods: Twenty five cases of primary benign bone forming tumours of the spine were identified from the Scottish Bone Tumour Registry: this data is collected prospectively. A retrospective review of this data was performed. There were 9 osteoid osteomas, 15 osteoblastomas and 1 aggressive osteoblastoma. These cases were divided into group A (children) and group B (adults). Results: There were 16 patients in group A (6-osteoid osteoma, 9-osteoblastoma, 1-aggressive osteoblastoma), 10 boys and 6 girls. The mean age was 12.1 years (range, 6–16 years). There were 2 cervical, 4 thoracic, 8 lumbar and 2 sacral tumours. There were 9 patients in Group B (3-osteoid osteoma, 6-osteoblastoma), 7 boys and 2 girls. The mean age was 26.6 years (range, 18–53 years). There were 1 cervical, 6 thoracic, 2 lumbar and none sacral tumours. Twenty two tumours were excised and 3 had curettage performed (1 child and 2 adults). There were 2 recurrences (one osteoid osteoma, one osteoblastoma), one from the excision group and one who had curettage, both in adults. These were successfully treated with re-excision. Mean follow-up was 8 years and all were alive at the time of final follow-up. Conclusions: Benign bone forming tumours of the spine are extremely uncommon. In children they occur more commonly in lumbar spine, while thoracic involvement predominates in adult patients. Good outcomes are obtained with surgical treatment. Recurrence occurred only in the adult group: both of these patients had successful outcomes following further treatment

1. Benign chondroblastoma is a rare primary neoplasm of bone with excellent prognosis. It is believed that instances of it are still being missed. 2. Six cases are described with special emphasis on diagnostic pitfalls. 3. A critical survey of the literature and a discussion on nomenclature and histogenesis are included