Aims

The primary aim of this study was to determine the morbidity of a tibial strut autograft and characterize the rate of bony union following its use.

Purpose of the study: Secondary chondrosarcoma is rare (1% of malignant bone tumours). Most cases develop from solitary exostosis or concern an exostosis disease. Localisations predominate in the girdles. Management is difficult and no consensus has been reached. The purpose of this study was to present a series of 25 secondary chondrosarcomas in order to improve diagnostic and therapeutic management.

Material and methods: This was a retrospective analysis of 25 cases of secondary chondrosarcoma (10 on solitary exostosis and 15 on exostosis disease) treated by one surgical team from 1970 to 2008. The epidemiological features, clinical signs, radiographic findings, type of treatment and outcome at last follow-up were analysed for the two groups.

Results: Patients with secondary chondrosarcoma were 10 to 20 years young than those with primary chondrosarcoma. There were an equivalent number of men and women and the predominant sites involved flat bones in both groups. The radiographic signs of sarcomatous degeneration most widely observed included heterogeneous calcifications, irregular contours, and soft tissue invasion. Tumours were generally well differentiated. The rate of local recurrence after surgery was 15% at five years and 20% at ten years. Mortality was 2% at five years and 5% at ten years. Most of the deaths occurred after local recurrence. Metastases were identified in four patients after the initial resection. The rate of local recurrence was lower after wide surgical resection.

Discussion: The real objective with secondary chondrosarcoma is to ensure a regular effective follow-up of these patients with a known risk of recurrence (exostosis disease) in order to recognise early signs of sarcomatous degeneration. One of the most reliable signs is recent development of unusual pain on a known exostosis. Education of at-risk patients is crucial and should enable early screening and detection.

Conclusion: Secondary chondrosarcoma occurs 10 to 20 years earlier than primary sarcoma and generally involves the girdles. Outcome and management practices are similar to primary chondrosarcoma. The most important issue is to ensure good patient follow-up in order to enable early diagnosis in patients at risk.

The purpose of this study was to define immediate post-operative ‘quality’ in total hip replacements and to study prospectively the occurrence of failure based on these definitions of quality. The evaluation and assessment of failure were based on ten radiological and clinical criteria. The cumulative summation (CUSUM) test was used to study 200 procedures over a one-year period. Technical criteria defined failure in 17 cases (8.5%), those related to the femoral component in nine (4.5%), the acetabular component in 32 (16%) and those relating to discharge from hospital in five (2.5%). Overall, the procedure was considered to have failed in 57 of the 200 total hip replacements (28.5%). The use of a new design of acetabular component was associated with more failures. For the CUSUM test, the level of adequate performance was set at a rate of failure of 20% and the level of inadequate performance set at a failure rate of 40%; no alarm was raised by the test, indicating that there was no evidence of inadequate performance.

The use of a continuous monitoring statistical method is useful to ensure that the quality of total hip replacement is maintained, especially as newer implants are introduced.

Purpose of the study: Primary bone tumors of the sacroiliac joint are difficult to diagnose. We present the procedure used to resect these tumors and reconstruct the pelvic ring, and the carcinological and functional outcome.

Materials and Methods: This was a retrospective analysis of a consecutive series of patients treated for a tumor of the iliac bone or of the sacrum which involved the sacroiliac joint. Tumor grading was based on the Enneking classification and the functional outcome on the MSTS score.

Results: From 1986 to 2003, 24 patients were treated for a a tumor involving the sacroiliac joint. Six with invasion of the sacral body. The histology was osteosarcoma (n=8), chondrosarcoma (n=8), malignant hystiocytofibroma (n=3), Ewing’s sarcoma (n=2), schwannoma (n=1), leiomysarcoma (n=1) and haemangiopericytoma (n=1). Seventeen patients were given neoadjuvant chemotherapy. A wide crest approach was used to access both aspects of the pelvic ring. Neurological sacrifice was required in six patients. Operative time was 5.27 hours on average. Reconstruction was achieved with an autograft and instrumentation. The resection was wide in 11 cases, marginal in 12, and contaminated in one. The mean follow-up was 4.77 years. Ten patients died from their disease. Survival was correlated with the quality of the resection and with the initial tumor stage. Hemisacrectomy did not affect survival. Bone healing was achieved in 13 patient, ten who survived. The mean MSTS score was 48% at last follow-up in 14 survivors. For the nine patients who did not require neurological sacrifice, the mean score was 58%. For the five other patients, the mean score was 38% This score was 65% in patients with bone healing and 8% in those with nonunion.

Discussion: The survival of patients with a tumor of the sacroiliac joint is basically related to the histological diagnosis and the quality of the resection. If the disease can be controlled, the method of the reconstruction proposed here enables bone healing with a satisfactory functional result when neurological sacrifice can be avoided.

Purpose of the study: The rate of failure can be high for massive reconstruction prostheses after tumor resection. We studied the causes and possible factors of failure.

Material and methods: The series included 91 patients who underwent surgery from 1972 to 1994 for resection of a bone tumor involving the knee joint. A GUEPAR prosthesis was implanted in all cases for reconstruction (megaprosthesis in 58 cases and composite prosthesis in 33). The extensor system had to be reconstructed in 37 patients. A GUEPAR II implant was used in 73 patients; 48 of these implants had an antirotation system. The analysis was retrospective. Outcome was studied in terms of survival and independent factors predictive of failure unrelated to the tumor.

Results: Mean follow-up was 72 months. At last follow-up, 68 patients were living disease free. There were nine cases of rupture of the extensor system. Preservation of a continuous extensor system at the time of bone resection reduced the risk of rupture (p=0.036). Seven allografts fractured, two loosened, and six became infected. Use of an allograft did not reduce the risk of loosening (p=0.17). Intraxial laxity was observed in 17 patients. Use of an antirotation system was a factor of risk of intraxial laxity (p=0.0023) but not of aseptic loosening. Aseptic loosening was observed in 18 patients: 10 femur reconstruction and 8 tibia reconstruction. The difference was not significant (p=0.6). In all, 104 revisions were required in 53 patients; 36 revisions of the prosthesis, 23 of them for mechanical causes. Overall median survival, excepting tumor-related causes, was 130 months. It was 130 months for femur reconstructions and 117 for tibia reconstructions (p=0.57). Age, length of resection, tumor location, use of an allograft, and use of an antirotation system were not found to be significant prognostic factors for implant survival.

Discussion: As reported by many others, we found that the rate of failure of massive prostheses for infectious and mechanical causes remained high in patients treated for bone tumors involving the knee joint. Survival of massive implants is much lower than that of gliding prostheses.

Conclusion: Technical progress is required to improve the survival of massive implants used for the treatment of bone tumors involving the knee joint.

Purpose of the study: Diagnosis and treatment of primary malignant tumors of the pelvis raise difficult problems. The purpose of this retrospective study was to analyze the functional and cancerological results observed after surgical treatment in a single center.

Material and methods: Between 1973 and 2002, 24 patients (16 men and 8 women) underwent surgery in our unit for histological proven malignant tumors. A posterior approach was used for curettages and sacrectomies of the apex. A combined anterior and posterior approach was used for total sacrectomy and hemisacrectomy. Oncological results were assessed in terms of local recurrence, presence of metastasis and patient status at last follow-up. Overall survival and disease-free survival were calculated with the Kaplan-Meier method.

Results: Mean age was 53.38 years. Mean follow-up in our series was 54 months. Mean time to diagnosis was 16 months. Pain was the predominant symptom. Sixteen patients presented neurological manifestations and the digital rectal examination was positive in all. Chondroma was the most frequent histological type (18/24). None of the patients had metastatic disease at diagnosis. A posterior approach was used for 15 patients and a combined approach for the others. There was a clear correlation between type of resection and volume of blood loss (p=0.0002). Wide dissection was wide in five patients, marginal in five and oncologically insufficient in 14. Mean operative time was 1.34 hours for posterior approaches and 9 hours for combined approaches. The postoperative period was uneventful for ten patients. Infection was the most frequent complication. Adjuvant radiotherapy, delivered in 16 patients, effectively retarded the occurrence of local recurrence. Functional disorders were correlated with the level of the neurological sacrifice. At least one S3 root had to be preserved to limit the urological and digestive incapacity. At last follow-up, local recurrence was present in 12 patients. Mean time to first recurrence was 32 months. There was a strong correlation between quality of the resection and time to local recurrence. There was a significant difference between patients with a wide resection and those with an oncologically insufficient resection (p=0.0312). Five patients had metastases. Five-year actuarial survival was 73±12%. At ten years it was 32±14%. Local recurrence-free survival was 55±11% at five years and zero at 10 years.

Discussion and conclusion: In light of these results, factors of poor prognosis were: late diagnosis, soft tissue invasion, proximal extension, marginal or insufficient resection.

Purpose of the study: Composite knee prostheses using a massive implant and an allograft is one option for joint reconstruction after extensive resection of the knee joint for bone tumor. Implant survival after resection of the proximal tibia is not well documented. We analyzed survival and complications in 26 composite knee prostheses.

Material and methods: A composite prosthesis was implanted in 26 patients after resection of a tumor of the proximal tibia. Median length of resection was 14 cm (range 9–20 cm). A GUEPAR massive implant was used in all cases. Allografts were sterilized with gamma radiation. Median length of the tibial stem was 30 cm (range 20–38 cm). The stem was cemented in the allograft and in the tibia.

Results: Median patient survival was 68 months. At last follow-up, 19 patients were living disease free. Among the 26 allografts, seven had fractured and five were partially resorbed. Seven allografts exhibited signs of fusion at the junction with the recipient bone. Seven reconstructions of the extensor system failed (rupture). Conversely, there were no ruptures in patients whose extensor system could be preserved (continuity) at tumor resection. Six composite prosthesis were infected, four early (< 2 months) and two late. There were four cases of local recurrence. Globally, 48 secondary procedures were required in 21 patients: 26 for mechanical defects, 13 for infection, 7 for local recurrence and 2 for postoperative complications (necrosis of the tibialis anterior in both). There were 14 revisions: 9 composite prostheses were replaced, fusion was performed in 2 patients, and 3 patients required amputation. Median survival of the reconstructions, considering all failures together, was 102 months (95%IC 64.3-Inf). Median survival, including all failures for local recurrence, was 105 months (95%IC 101-Inf).

Discussion: The rate of failure and of complications is high for massive knee prosthesis combined with a radiated allograft for reconstruction of the proximal tibia. There is no series reported in the literature. When possible, the extensor system should be preserved.

Conclusion: We currently use massive knee prostheses without allografts, reconstructing the extensor system with a vastus medialis flap.

Purpose: We report three cases of extensive resection of the ulna without reconstruction.

Material and methods: For the first two patients, resection was performed for ulnar tumour, on low-grade osteosarcoma and one adamantinoma. In the third patient with a voluminous giant-cell tumour, the distal part of the ulna was resected and used as a graft for arthrodesis after resection of the distal third of the homolateral radius. Resection involved the distal half, three-quarters, and one-third of the ulna in these three patients.

Results: At follow-up of 4, 23 and 1 year respectively, wrist motion is normal in the two patients and elbow motion is normal in two out of three. None of the patients experienced wrist pain or ulnar stump pain. Grip force decreased in the two patients who underwent isolated ulnar resection.

Discussion: Our observations corroborate reports in the literature leading to the conclusion that reconstruction of the ulna is not justified when one-quarter of the bone can be preserved. The ulna offers an exceptional graft material for reconstruction of the homolateral radius.

Aims: The purpose of this retrospective study was to report on the treatment of migrated ununited greater trochanter following total hip arthroplasty. Methods: Between January 1986 and December 1999, 72 non-unions of the greater trochanter in 71 patients were treated using a trochanteric claw plate. The mean age of the patients was 66 ± 11 years. The average time to re-operation was 8 months. Fixation of the non-united greater trochanter was performed using a claw plate only in 47 hips, and the association of frontal wires with a claw plate in the remaining 25 hips. The main criterion for evaluation was the consolidation of the greater trochanter judged as follows: bony consolidation (no pain, no Trendelenboug gait, radiologic fusion); fibrous consolidation (moderate pain, no Trendelenboug gait, radiologic fusion difficult to assess); and non-union (Trendelenboug gait and/or absence of radiologic fusion). Results: The average follow-up of the series was 4 years (1 to 14 years). The mean d’Aubigné score significantly increased from 13.5 preoperatively to 15.9 at last follow-up (paired signs test, p < 0.0001). Bony consolidation was obtained in 51 hips, fibrous in 9, whereas repeat non-union occurred in 12. The only predictive factor for union was the use frontal wires in association with a claw plate that provided 87.5% of unions and no failure (Chi square test, p = 0.006). Conclusions: This study indicated that non-union of the greater trochanter following total hip arthroplasty can be successfully treated with frontal wires in conjunction with a trochanteric claw plate.

Purpose: The hand-to-forehead test is a new subjective and objective test for anterior shoulder instability. This test is performed preoperatively under general anaesthesia and involves a quantifiable patient-controlled apprehension test and an objective quantitative test of anterior stability.

Material and methods: Between January 1998 and April 2000, 135 patients (97 men and 38 women), mean age 25 years, age range 16–40 years, candidates for surgery for anterior instability of the shoulder (115 Latarget, 14 Bankart, 6 capsular shift) were tested. A control group of 300 candidates free of any shoulder disorder for other surgery were also tested.

Results: the Apprehension test was positive in 95 of the operated patients and negative in 40. Mean angle was 160° (90–180°). The test was always negative in patients with an underlying hyperlaxity (18 patients). The test was positive in 20 controls and negative in 270. Test sensitivity was 72%, specificity 92.5%, positive predictive value 42%, (prevalence 1.5%) and negative predictive value 86%. Reproducibility was 80%. The objective test was positive in 125 of the operated patients and negative in 10. The value was 2++ in 55% of the cases. In the control group, the objective test was positive in 28 and negative in 272. The sensitivity of the objective test was 95%, specificity 90%, positive predictive value 55% and negative predictive value 95%. Reproducibility was 92%.

Discussion: The purpose of the hand-to-forehead test is to express the instability as perceived by the patient and to exteriorise anterior laxity without reproducing true anterior displacement. Excepting cases with underlying hyperlaxity, this test does not appear to be inflenced by different injuries subsequent to recurrent anterior dislocation. (no significant difference between glenoid bone lesions, Broca lesions or Malgaigne notches).

Conclusion: This new test provides a reliable objective assessment of anterior instability of the shoulder using a quantifiable combination of classical apprehension and laxity tests. It is a supplementary diagnostic tool for difficult cases and a useful aid for pre- and postoperative evaluation of these patients.