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   Table of Contents - Current issue
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January-February 2018
Volume 52 | Issue 1
Page Nos. 1-93

Online since Wednesday, January 10, 2018

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GUEST EDITORIAL  

Musculoskeletal oncology: Finding its place in the sun! Highly accessed article p. 1
Ajay Puri
DOI:10.4103/ortho.IJOrtho_674_17  
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SYMPOSIUM - MUSCULOSKELETAL ONCOLOGY Top

Fibulectomy for primary proximal fibular bone tumors: A functional and clinical outcome in 46 patients p. 3
Zile Singh Kundu, Milind Tanwar, Parveen Rana, Rajeev Sen
DOI:10.4103/ortho.IJOrtho_323_16  
Background: Primary benign and malignant tumors of the proximal fibula are not very common. Upper fibula being an expendable bone; the majority of the primary bone tumors at this site are usually treated with en bloc proximal fibulectomy. There is scarce literature on functional results, difficulties faced during dissection when to preserve or sacrifice common peroneal nerve and importance of lateral collateral ligament repair after proximal fibulectomy. The present study attempts at assessing these variables. Materials and Methods: This retrospective study included 46patients; 30males and 16females with age ranging from 12 to 44years(average: 26years) operated between 2003 and 2014. There were 34 benign and 12 malignant tumors. All were treated with proximal en bloc fibulectomy as indicated and decided by the operating surgeon keeping in view its extent on magnetic resonance imaging. Peroneal nerve sacrifice or preservation was decided as per the type(benign/malignant), its involvement by the tumor and the extent of the tumor. In 14(for 12 malignant and two benign giant cell tumors[GCTs]) patients, the peroneal nerve required resection for the margins. Partial upper tibial resection was performed in cases of malignant tumors and three GCTs. The followup ranged between 24 and 120months(median: 48months). Results: Patients with peroneal nerve resection had inferior functional outcome than those without peroneal nerve resection. There was no higher risk of tibia fracture in patients with partial tibial resection. Lateral collateral reconstruction yielded better results and should be performed in all cases. Functional outcome was significantly better in patients with benign tumors than in patients with malignant tumors as these required neither resection of the peroneal nerve nor large amount of muscle excision. The functional results were evaluated using Musculoskeletal Tumor Society(MSTS) score, and clinical outcomes were evaluated using knee and ankle movements and stability. The overall average MSTS score was 26.50. Conclusions: With good reconstruction of lateral ligament we can achieve good results after proximal fibulectomy for benign as well as malignant tumor without much instability. With partial upper tibial resection (i.e., the extra-articular resection of proximal tibiofibular joint) adequate margins are feasible even in malignant tumors.
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Retrospective analysis of giant cell tumor lower end radius treated with En bloc excision and translocation of ulna p. 10
Amit Vyas, Purnima Patni, Narender Saini, Rahul Sharma, Vinit Arora, SP Gupta
DOI:10.4103/ortho.IJOrtho_227_16  
Background: Distal end of radius is third most common site for GCT of long bones and 1% of these metastasize mostly to lungs. Reconstruction methods commonly used are fibula(vascularized and nonvascularized), centralization of ulna, translocation of ulna, and endoprosthetic replacement. We report the outcome of series of twenty cases where we did en bloc excision of tumor with translocation of ulna. Materials and Methods: Twenty cases of giant cell tumor(GCT) of lower end of radius were included in this retrospective study. The mean age of patients was 33.15years(range 21-55years). We had 14 of Campanacci GradeIII and 6 of GradeII. Preoperative radiographs and magnetic resonance imaging of the involved wrist and forearm were done. Results: Of all twenty patients, 14 were males and 6 were females. Mean followup duration was 3.9years(range 1.5–17years). Mean grip strength of involved side as a percentage of normal side was 71%(range 42%–86%) and the actual mean value for operated side was 29kg as compared to 40kg for normal side. The average range of forearm movement was supination 80.25°(60°–90°) and pronation 77.5°(70°–90°). No patient was dissatisfied as far as cosmesis was concerned. Discussion: In our opinion considering the propensity to recur with more aggressiveness after recurrence, en bloc excision with translocation of ulna has become a standard treatment option for GCT of lower end of radius, with advantages of better functional outcomes, retained vascularity, and elimination of risk of donor site morbidity.
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Distal medullary canal decompression in long stem hip replacement in long bone metastasis: Does it reduce cardiopulmonary complications? p. 15
Vivek Ajit Singh, Siamak Sarrafan, Ramesh Singh Veriah
DOI:10.4103/ortho.IJOrtho_101_17  
Background: The femur is the most common long bone affected by metastatic bone disease, with 25% involving the proximal third of the femur. Long stem cemented hip replacement(LHR) is an important option for cases of impending fracture. Pulmonary embolism is a critical complication that can occur. This study evaluates the effectiveness of distal femoral canal decompression in reducing the risk of cardiopulmonary events. Materials and Methods: Thirty two patients with metastatic bone disease of the proximal femur undergoing LHR were recruited and randomized. Conventional technique was used in 16cases and distal decompression of the medullary canal was carried out for the other 16patients. The decompression was carried out through a trocar inserted into the distal medullary canal, connected to a vacuum suction. Quantity of emboli was detected through A4 chambers transesophageal echocardiography; the blood pressure and oxygen saturation readings were also recorded. Results: The decompression group experienced significantly lower Grade2 and Grade3 embolic events compared to the conventional group(11vs. 26), and the duration of the embolic phenomena was shorter. Insertion of the stem and relocating the hip gave the highest amount embolic events. There was a significant drop in systolic blood pressure(SBP) in 12 out of 16patients(75.0%) in the conventional group and 5 out of 16patients in the decompression group(31.3%). This is statically significant(P=0.0124). The average drop in SBP for the conventional group is 45.8mmHg and the decompression group was 32.9mmHg. Oxygen saturation remained at above 96% in the decompression group. However, in the conventional group, 25% of the patients had their oxygen saturation drop to below 96% during the insertion of stem and relocation of hip joint. Conclusion: Distal femoral canal decompression is an effective method in reducing the risk of cardiopulmonary embolic events associated with LHR.
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Navigation in musculoskeletal oncology: An overview p. 22
Guy Vernon Morris, Jonathan D Stevenson, Scott Evans, Michael C Parry, Lee Jeys
DOI:10.4103/ortho.IJOrtho_205_17  
Navigation in surgery has increasingly become more commonplace. The use of this technological advancement has enabled ever more complex and detailed surgery to be performed to the benefit of surgeons and patients alike. This is particularly so when applying the use of navigation within the field of orthopedic oncology. The developments in computer processing power coupled with the improvements in scanning technologies have permitted the incorporation of navigational procedures into day-to-day practice. Acomprehensive search of PubMed using the search terms “navigation”, “orthopaedic” and “oncology” yielded 97 results. After filtering for English language papers, excluding spinal surgery and review articles, this resulted in 38 clinical studies and case reports. These were analyzed in detail by the authors(GM and JS) and the most relevant papers reviewed. We have sought to provide an overview of the main types of navigation systems currently available within orthopedic oncology and to assess some of the evidence behind its use.
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The values of receptor activator nuclear Kappa-B ligand expression in stage III giant cell tumor of the bone p. 31
Sabrina Abdul Ghani, Wan Faisham Wan Ismail, Md Salzihan Md. Salleh, Sahran Yahaya, Zawawi Muhamad Syahrul Fitri
DOI:10.4103/ortho.IJOrtho_153_17  
Background: Giant cell tumor(GCT) of bone is a benign locally aggressive primary bone tumor which is risky for local recurrences and pulmonary metastasis. Till date, there are still many uncertainties in predicting the aggressiveness of GCT. We aim to investigate whether receptor activator nuclear kappa-B ligand(RANKL) expression may determine the prognosis of the lesion. Materials and Methods: We examined RANKL expression in 39patients(21males, 18females) by immunohistochemistry. Four patients(10%) were presented with tumor recurrence, eight patients(20%) were complicated with lung metastasis, and two patients(5%) were presented with both recurrence and lung metastasis. Positive RANKL expression was assessed according to a scoring system evaluating the percentage of the immunostained epithelial area and the staining intensity. The cumulative score was calculated to determine the final score value. Data were analyzed using PASW version18.0 and independent t-test between nonrecurrence/recurrence groups, and nonlung metastasis/lung metastasis groups. Significance was set at P <0.05. Results: Thirty-two patients(82%) scored 3 in RANKL-staining percentage from whole stromal cell population(>75%), 6patients scored 2, and 1patient scored 1. Nine patients(23%) scored 3 in RANKL-staining intensity(most intense), 19patients(48%) scored 2, and 11patients(29%) scored 1. Twenty six patients(67%) had strong RANKL expression(total score of 5–6), 12patients(31%) showed moderate score(3–4) whereas only 1patient(2%) showed weak RANKL expression. Together, the mean value of RANKL-staining percentage was 2.79, intensity 1.95 and the total score 4.77. The mean RANKL-staining percentage between recurrence and nonrecurrence groups was statistically significant(P=0.009). There was no significant difference in the mean staining intensity and total score between nonrecurrence and recurrence groups, and staining percentage staining intensity and a total cumulative score of RANKL expression between lung metastasis and nonlung metastasis groups. Conclusion: RANKL expression is generally high in Stage III GCT and is a reliable prognostic marker in predicting the risk of local recurrence however not in lung metastasis.
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Soft-tissue sarcomas p. 35
Domagoj Ante Vodanovich, Peter F M Choong
DOI:10.4103/ortho.IJOrtho_220_17  
This article discusses the epidemiology, diagnosis, and management of primary soft-tissue sarcomas (STS). These musculoskeletal tumors are a rare and heterogeneous group of malignancies, which are best managed by multidisciplinary teams in specialist sarcoma referral centers. Historically, the standard for local control of these tumors has been amputation. Evolutions in multimodality treatment have seen a shift toward preservation of the limb. Advances in limb-sparing surgery have seen the quality of life in sarcoma patients to improve drastically; however, unplanned surgical excision of STS remains a major treatment dilemma in the control of local disease.
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Effect of intravenous zoledronic acid on histopathology and recurrence after extended curettage in giant cell tumors of bone: Acomparative prospective study p. 45
Zile Singh Kundu, Rajeev Sen, Ankur Dhiman, Pankaj Sharma, Ramchander Siwach, Parveen Rana
DOI:10.4103/ortho.IJOrtho_216_17  
Background: Giant cell tumor(GCT) of the bone is known for its locally aggressive behavior and tendency to recur. It is an admixture of rounded or spindle-shaped mononuclear neoplastic stromal cells and multinucleated osteoclast-like giant cells with their proportionate dispersion among the former. Zoledronic acid(a bisphosphonate) is being used in various cancers such as myelomas and metastasis, for osteoporosis with an aim to reduce the resorption of bone, and as an adjuvant treatment for the management of GCT of bone for reduction of local recurrence. We have carried out a prospective comparative study to assess the effect of intravenous infusion of zoledronic acid on histopathology and recurrence of GCT of bone. Materials and Methods: The study was carried out in the biopsy proven GCTs in 37patients; 15males and 22females, in the age range from 17 to 55years. They were treated with extended curettage. Of these 37patients, 18 were given three doses of 4mg zoledronic acid infusion at 3-week intervals and extended curettage was performed 2weeks after the last infusion whereas the other 19 were treated with extended curettage without zoledronic infusion. The post infusion histopathology of the curetted material was compared with the histopathology of initial biopsy. All the patients were evaluated at 3-month intervals for the first 2years and then six monthly thereafter, for local recurrence and functional outcome of limb using the Musculoskeletal Tumor Society(MSTS) score. Results: In postzoledronic infusion cases, the histopathology of samples showed abnormal stromal cells secreting matrix leading to fibrosis and calcification. The type of fibrosis and calcification was different from pathological calcification and fibrosis what is usually observed. There was a good marginalization and solidification of tumors which made surgical curettage easier in six cases in the study group. There was noticeable reduction in the number of giant cells and alteration in morphology of stromal cells to the fibroblastic-fibrocytic series type in comparison to preinfusion histopathology. Recurrence occurred in one case out of 18patients in infusion group whereas in four cases among 19patients in control group. The functional results were assessed, and the overall average MSTS score was 27.50(range 24–30) and 27.00(range 23.50–30) in the study and control groups, respectively. Conclusions: We observed that bisphosphonates reduce osteoclast activity and affects stromal cells in GCT, resulting in the reduction of their numbers and noticeable apoptosis. This results in better marginalization of the lesions and reduced recurrence. Extended curettage of friable GCT became easier and adequate which otherwise might not have been possible.
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Benign aggressive lesions of femoral head and neck: Is salvage possible? p. 51
Yogesh Panchwagh, Sujit K Joshi, Parag K Sancheti
DOI:10.4103/ortho.IJOrtho_209_17  
Background: Benign aggressive bone lesions of the femoral head and neck are mostly seen in young adults and warrant treatment for pain, impending fracture or established fracture, and disease clearance. It becomes challenging to treat them effectively while attempting salvage of the femoral head and yet achieving long term disease control with minimum complications. We describe our technique and experience in dealing with these lesions which can achieve the above-mentioned goals and can be easily replicated. Materials and Methods: We analyzed 15cases of surgically treated, biopsy-proven benign, locally aggressive lesions affecting the femoral head and neck in skeletally mature individuals. All cases were treated with extended curettage through anterolateral modified Smith–Petersen approach along with tricortical iliac crest bone graft(combined with fibular graft in some cases) reconstruction with or without suitable internal fixation. Results: All, except one, patients were available for follow up. The age ranged from 18 to 43years and the follow up ranged between 24 and 124months(average 78months). These included aneurysmal bone cysts(9), giant cell tumors(4), and fibrous dysplasia(2). The indication was pain(8), with impending(2) or established pathological neck femur fracture(5). In all cases, there was satisfactory healing of lesion and timely rehabilitation. Nonunion, avascular necrosis or local recurrences were not seen. The MSTS functional score was good or excellent in all(range 26–29, average 28). Conclusion: Benign aggressive lesions affecting femoral head and neck in young and middle-aged adults pose a treatment challenge. Asturdy, lasting reconstruct with acceptable functional outcome and minimal recurrence rate can be achieved by salvaging the femoral head and neck using curettage and reconstruction, obviating the need for replacement at such an early age.
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Methotrexate free chemotherapy and limb salvage surgery for paediatric osteosarcoma in India p. 58
Reghu Kesavapillai Sukumaran, Binitha Rajeshwari, Subin Sugath, S Guruprasad Chellappan, Priyakumari Thankamony, Kusumakumary Parukuttyamma
DOI:10.4103/ortho.IJOrtho_195_17  
Background: Osteosarcoma (OS) is the most common primary malignant tumor of bone. The survival of OS patients has steadily improved from<20% in the early 20th century to around 70% with current treatment. There are very few studies in pediatric OS from India analyzing various aspects of the disease. This study focuses on the clinical profile, treatment options, and their complications and survival outcomes in pediatric osteosarcoma(OS) patients. Materials and Methods: This was a retrospective observational study which included pediatric patients<14years of age, with newly diagnosed OS confirmed by histological diagnosis. Medical records of all patients were reviewed for clinical profile, treatment data, surgical management, and treatment complications. Patients alive at the end of treatment were followed up and overall(OAS) and disease-free survival(DFS) were analyzed. Results: Sixty-two patients were diagnosed with OS during the study of whom 55 opted for treatment. Cisplatin, adriamycin, and ifosfamide(PAI) was offered as chemotherapy and was completed as planned in the majority of patients. Limb salvage surgery was performed in most patients(87%, n=40). The local recurrence occurred in 7patients. The 3years overall survival for the cohort was 54.6% ± 7.8% and DFS was 43.4% ± 7.9%, with females and those with the localized disease having a significantly better DFS. Conclusions: High dose methotrexate free chemotherapy can give good OAS in localized disease and LSS is feasible in most of the pediatric OS patients. However the modest DFS even for localized disease with PAI chemotherapy and extremely poor outcomes in the metastatic OS, demand further research and innovations in systemic therapy to improve outcomes.
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Gait analysis in patients with wide resection and endoprosthesis replacement around the knee p. 65
Vivek Ajit Singh, Chan Wei Heng, Nor Faissal Yasin
DOI:10.4103/ortho.IJOrtho_188_17  
Background: Limb salvage surgery with endoprosthesis for bone tumor around the knee is reported to have good functional and oncological outcomes. However, the functional assessment using musculoskeletal tumor society(MSTS) and Toronto extremity scoring system remains subjective. We performed gait analysis as an objective assessment of their functional outcome. Materials and Methods: Gait analysis was performed in 20patients with endoprosthesis replacement around the knee. The temporal parameters assessed during gait analysis were walking velocity, stride length, duration of stance, and goniometry of the knee. These parameters were compared with the functional outcome score of the MSTS. Results: The mean free-paced walking velocity was 0.91m/s(normal is 1.33m/s), which was 68% lower than normal gait. The stride length and stance phase were shorter for the affected limb compared to normal(P<0.05). However, the gait was symmetrical with no difference in stride length(P=0.148), velocity(P=0.918), knee flexion(P=0.465), and knee extension(P=0.321) between the affected and unaffected limbs. Sixteen patients demonstrated stiff knee gait, two had a flexed knee gait, and only two patients had normal gait during the stance phase. The mean MSTS score was 21. There was significant correlation between overall MSTS scores(P=0.023), function(P=0.039), and walking scores(P=0.007). Conclusion: Limb salvage surgery with endoprosthesis reconstruction around the knee gives good functional outcome, both objectively and subjectively, as evidenced by the symmetrical gait pattern and significant correlation with MSTS score. Despite decreased walking velocity, stride length, and stance phase of the operated limb, the patient still has a symmetrical gait.
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Does radiotherapy after surgery affect outcomes in Ewing's sarcoma of the pelvis? p. 73
Ajay Puri, Ashish Gulia, Saniya Crasto, Tushar Vora, Nehal Khanna, Siddharth Laskar
DOI:10.4103/ortho.IJOrtho_388_17  
Background: The impact of postoperative radiotherapy(PORT) on outcomes has been a matter of debate after adequate resection in Ewing's sarcoma of the pelvis. We evaluated our cases after surgical excision in pelvic Ewing's sarcoma and assessed local control and overall survival(OS) with respect to PORT and chemotherapy-induced percentage necrosis. Materials and Methods: Forty four surgically operated patients(June 2002–November 2014) of localized Ewing's sarcoma were retrospectively reviewed. There were 31males and 13females. Age ranged from 2 to 53years. All patients received institutional chemotherapy protocol. No patient received preoperative radiotherapy. Specimen was analyzed for margins and chemotherapy-induced percentage necrosis. PORT was offered to patients on case-by-case basis. Presence of a large preoperative soft-tissue component, margin evaluation, and percentage necrosis were factors considered. At time of the last followup, 29patients were alive, 11 died, and 4 were lost to followup. Survivors had a minimum followup of 2years(range: 31–118months, mean=69months). Results: One of twenty(5%) patients with PORT had a local recurrence as against 2 of 24(8%) without PORT. OS of all patients was 76% at 5years. Twelve patients with<90% necrosis had OS of 56% and 32 with>90% necrosis had OS of 83%(P=0.040). OS of patients with PORT was 74%, without PORT was 78%(P=0.629). Conclusions: The decision to offer PORT after surgical excision in pelvic Ewing's sarcoma is multifactorial; the absence of PORT in selected cases is not detrimental to local control. Poor responders to chemotherapy had poorer survival while PORT did not impact on outcomes.
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Considerations for the long term treatment of pediatric sarcoma survivors p. 77
Kurt R Weiss, Melissa N Zimel
DOI:10.4103/ortho.IJOrtho_248_17  
Sarcomas are primary malignancies of the connective tissues. They are exceedingly rare in adults, but much more common in children. The historically recent advent of cytotoxic chemotherapy for pediatric sarcomas has revolutionized the treatment of these diseases and dramatically improved their prognoses. There is thus a population of pediatric sarcoma survivors that are “coming of age” as adults. However, this progress is not without consequences. Due to aggressive treatment protocols that include various combinations of surgery, chemotherapy, and radiation therapy, pediatric sarcoma survivors are at risk of myriad physical, medical, and psychological difficulties as they enter adulthood. These include but are not limited to physical disabilities, chemotherapy-induced cardiac issues, second malignancies, and anxiety. These patients pose unique challenges to their adult primary care physicians. One possible solution to these challenges is multidisciplinary sarcoma survivorship clinics. By paying greater attention to the unique issues of pediatric sarcoma survivors, involved physicians can maximize the physical and emotional health of pediatric sarcoma survivors.
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Could routine magnetic resonance imaging detect local recurrence of musculoskeletal sarcomas earlier? A cost-effectiveness study p. 81
Andrew George, Robert J Grimer, Steven L J James
DOI:10.4103/ortho.IJOrtho_234_17  
Background: Current practice in our unit is to perform clinical assessment and plain film radiographs at regular intervals following treatment of a bone or soft tissue sarcoma(STS). Cross-sectional imaging is used in cases with a clinical suspicion of recurrence. We aimed to investigate the effectiveness of this protocol to determine if earlier detection may have been possible had more intensive imaging been undertaken, and whether this may have affected outcome. Materials and Methods: We reviewed clinical records and imaging of all patients with diagnosed local recurrence(LR) in the previous 5years to investigate: how it was diagnosed, the site and size of recurrence, and management. Avalue judgment was then made as to whether earlier diagnosis may have altered treatment and/or outcome. Results: 161patients with LR were identified: 87 with a STS and 74 with bone sarcoma. Median time from diagnosis to LR was 17.8months for STS and 20.1months for bone sarcoma. One hundred and fifteen cases(71%) were identified by the patient, 28 by routine imaging(17%), 13 by a doctor(8%), and five diagnosed by other methods. Median size of LR was 5.5cm for STS and 5cm for bone sarcomas. Seventy nine of the patients(49%) could have had their LR diagnosed earlier with routine imaging. Of these, 53 would have received the same treatment, but 26(33%) could have had different treatment. Conclusion: Earlier diagnosis could have led to altered management in one-third of those patients with the potential to have their LR diagnosed earlier. If all patients had regular magnetic resonance imaging, it would cost£6987 per recurrence where management was altered in imaging costs alone. We suggest a stratified approach whereby patients at highest risk of LR and those in whom early detection of LR may be easily treatable are prioritised for more intensive followup.
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CASE REPORT Top

Spontaneous conventional osteosarcoma transformation of a chondroblastoma: A case report and literature review p. 87
Prashant Narhari, Amber Haseeb, Serene Lee, Vivek Ajit Singh
DOI:10.4103/ortho.IJOrtho_495_17  
Chondroblastomas are a primary benign cartilaginous tumor that accounts for approximately 1% of all benign bone tumors. Primarily they are treated by curettage. The patient presented 4years after a successfully treated chondroblastoma (curettage and Bone cement). Wide resection of the proximal tibia with endoprosthesis replacement was done. Lung CT showed multiple lung metastasis and despite starting chemotherapy, he succumbed to the disease. We discuss regarding the possibilities of “aggressive” chondroblastoma and more recently termed chondroblastoma-like osteosarcoma which is a separate entity from chondroblastoma. Aggressiveness in chondroblastoma can be 1 of 3 types as follows: 1. benign chondroblastoma with lung metastasis. 2. malignant chondroblastoma. 3. subsequent malignant transformation of benign chondroblastoma. We have attempted to review the literature and describe the “aggressive” chondroblastoma and chondroblastoma-like osteosarcoma in this report.
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BOOK REVIEW Top

Complex primary total knee arthroplasty p. 91
Shekhar Agarwal, Rakesh John
DOI:10.4103/ortho.IJOrtho_623_17  
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PROFILE Top

Legends of Indian Orthopedics: Puliyur Krishnaswamy Duraiswami p. 92
Bhavuk Garg, SM Tuli
DOI:10.4103/ortho.IJOrtho_709_17  
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