We reviewed and discussed the results of thirteen distal femoral allografts in conjunction with revision total knee arthroplasty for the treatment of periprosthetic femoral supracondylar fractures associated with poor bone stock. The mean follow up time was six years. We looked at graft survivorship, functional outcome, radiographic assessment, and complications. We concluded that this is a viable salvage procedure for this type of injury.

The incidence of periprosthetic supracondylar fractures of the femur is rising due to the aging population, and the increased number of total knee arthroplasties (TKA) being performed. One option for the treatment of severe fractures, associated with poor bone stock, is the use of a distal femoral allograft (DFA) in conjunction with revision TKA. The purpose of this study was to review and discuss the results of thirteen consecutive patients who were treated at our center between 1990 and 2001.

Data was obtained from a prospective database. Ten of the thirteen patients were available for follow up. The average age was sixty-five years (range twenty-four to ninety-three) and the mean length of follow up was six years (range one to twelve). A chart review was performed to identify complications and graft survivorship. Functional assessment was made on the basis of the modified Hospital for Special Surgery knee score (HSS) and the MOS 36-ITEM Short Form Health Survey (SF-36). Patients were evaluated radiographically by two independent observers (kappa = 0.75, P = 0.02) in an attempt to determine union between the graft and host bone, graft resorption, and component loosening. The average postoperative HSS score and SF-36 were seventy-five and eighty-eight respectively. Mean flexion was 100°. One had an amputation due to the recurrence of infection. X-rays showed no migration, no loosening, good interface union in nine cases and mild to moderate resorption in three cases. We concluded that this is a viable salvage procedure for this type of injury.

Purpose: Prevalence of supracondylar fractures above a total knee arthroplasty (TKA) is increasing due to the increasing age of treated patients and the larger number of implants. We report the functional results in a series of thirteen patients treated with a distal femoral graft (DFG) associated with revision TKA.

Material and methods: Between 1990 and 2001, thirteen patients (twelve women and one man), mean age 65 years (24–93) were treated with DFG associated with revision TKA. All fractures were type III using the Lewis classification and involved severe osteoporotic bone associated with loosening of the femoral piece. Before fracture, the patients had had two operations on average (1–4). The fracture occurred as a result of a fall in nine patients, low-energy trauma in three, and during mobilisation under general anaesthesia in one. The functional results were noted prospectively using the modified HSS score and the SF-36 quality-of-life questionnaire. Radiographic assessment of bone healing and implant stability was performed by two independent observers (kappa=0.75, p=0.02).

Results: At mean follow-up of 60 months (12–144), the mean HSS score was 75 (64–86). Mean knee flexion was 100° (50–115°). One patient required subsequent amputation due to infection. Using our classification, functional outcome was good or excellent in seven patients, fair in four and poor in two. For nine patients, x-rays showed no sign of loosening. In three patients, there was minimal to moderate periprosthetic bone resorption.

Discussion: Treatment of periprosthetic fractures of the knee is a therapeutic challenge. Osteoporosis and comminution is a complex association making stable osteo-synthesis difficult with conventional methods. Massive knee prosthesis using a DFG and a standard TKA is an attractive alternative. This technique allows restoration of the bone stock by bone healing and constitutes a less aggressive therapeutic solution.

Conclusion: Despite the risk of infection, we believe that composite prostheses can be an attractive option for the treatment of periprosthetic supracondylar fractures of the knee.

Purpose: Fusion of subtalar arthrodesis is achieved in 94% of cases. There is a significant superficial cutaneous and neurological risk. Since 1985, we have performed partial arthrodesis using curettage-filling of the tarsal sinus via a minimally invasive approach. We wanted to know whether this technique decreases morbidity while preserving maximal rate of fusion.

Material and methods: We reviewed 52 patients (55 arthrodeses) operated on by the same surgeon. Immediate weight-bearing was allowed in all patients with a walking boot cast worn for ten weeks. We studied speed of fusion, the hindfoot axis, the development of complications, and the functional outcome (Kitaoka score).

Results: Fusion was not achieved in one case at ten weeks. Cutaneous necrosis occurred on one patient who had required a wide approach for other procedures. There was one superficial infection and one reflex dystrophy. Defective residual alignment was observed in six feet where the deformation could not be reduced preoperatively. The mean function score was 39/100 preoperatively and 86/94 postoperatively.

Conclusion: This technique provides excellent results with minimal morbidity but can only be proposed if the misalignment can be reduced preoperatively.

Aims: The authors report oncological and functional results after 15 acetabular reconstructions, followed tumor resection, with an original technique using homo-lateral proximal femoral autograft and total hip prosthesis. Material and method: The modiþed Musculoskeletal Tumor Society Score (MSTS) and the Toronto Extremity Salvage Score (TESS) were used for functional analysis. Functional results were available for only 10 patients who presented with a minimal of 2 years follow-up. Results: Fifteen consecutive patients, 9 men and 6 women with a median age of 50 years, were managed in our department for acetabular bone malignant tumor. The tumors involved the zones II in 5 patients, the zones II and III in 5 patients. The tumors included 10 chon-drosarcomas, 1 malignant þbrous histiocytoma, 1 radio-induced sarcoma, 1 myeloma and 2 metastasis. The mean follow-up was 31 months (Range, 12 to 50 months). Local recurrence occurred in 1 case and metastases in 3 cases. Three patients died of tumoral disease and one of intercurrent disease. Eight complications were observed: aseptic failure (n=1), obturator nerve damage (n=1), deep infection (n=4), skin necrosis (n=2), pros-thesis dislocations (n=1) and deep venous thrombosis (n=1). Five revision were performed. The mean MTS was 72% (range, 40 to 96%) and the mean TESS was 82.5% (range, 56 to 86%). Fusion occurred in all reconstructions and all patients recovered an active hip abduction and ßexion. Discussion: This original technique, using an autograft and a standard total hip prosthesis, is available for zone II and III acetabular reconstructions.

Purpose: We report oncological and functional outcome after ten pelvis reconstructions using the Puget technique.

Material and methods: Ten patients (six men and four women), mean age 50 years (37–71) with malignant bone tumours, generally a chondrosarcoma, were included in this series. The tumour involved zone II in five patients, zones II and III in the other five. Resection was followed by reconstruction using the superior portion of the homolateral femur and a cemented total hip arthroplasty. Mean resection was 13 cm (7–23). Mean operative time was 386 min and mean blood loss was 5490 ml. The resection was wide in seven patients, marginal in two and resection margins were contaminated in one. The patients were reviewed at three, six and twelve months then each year. The function score (Enneking) was recorded for all patients. Living patients also filled out a TESS quality of life questionnaire.

Results: At mean follow-up of 22 months (7–42), four patients were living and disease free and two patients were living with recurrent disease. Three patients had died from their disease and one from pulmonary embolism. Postoperative complications were: one dislocation, one phlebitis, one reflex dystrophy, one injury to the internal genital nerve, two infections and one necrosis of the scar tissue. Bone healing was obtained at a mean five months. The mean Enneking function score was 68% and the mean TESS score was 75%.

Discussion: The high proportion of deaths is related to the severe prognosis of these pelvic tumours. This reconstruction technique described by Puget, provides an interesting alternative to other reconstruction methods for the acetabular region. The autogenous graft combined with a standard total hip arthroplasty makes this a rather easy to perform and low-cost procedure.

Conclusion: Functional outcome has been, in our experience, better than with arthrodesis, acetabular prosthesis, or saddle prosthesis and massive allograft of the pelvis.

Purpose: Nonunion of the tibia is a therapeutic challenge requiring a good understanding of bone healing, bone substance loss and skin trophicity disorders. The fibula pro tibia Huntington procedure consists in transposing the homolateral fibula onto the injured tibia. This allows bridging the bone defect, realignement and stabilisation of the nonunion segment.

Material and methods: This retrospective series included eleven patients (ten men and one woman), mean age 32 years (16–62). The cause of the injury was a traffic accident in six cases, defenestration in one, adamatinoma in one and osteomyelitis in one. The skin was broken in nine patients with septic nonunion in seven. Mean follow-up was 13 years (1–21).

Results: Mean delay to healing was 10.5 months (8.5 for post-traumatic nonunions) and was achieved in eight cases. A higher tibial nonunion persisted after resection of an adamantinoma measuring 22 cm and two patients had to be amputated in a context of acute suppuration. Walking without crutches was possible for eight patients whose tibia had healed and the mean pain score was 2 / 10.

Discussion: Several solutions can be proposed for patients with a tibial nonunion. The inter-tibiofibular graft requires a large bone graft in patients who have already had several operations. Th Papineau method only provides cancellous bone which is mechanically weak. The Ilizarov method can allow bone transfer and dynamisation of the nonunion with compression distraction. Microanastomosis transfers using a free fibula require a trained team with the risk of potential infection of the anastomoses in these infected patients. The Huntington method has the advantage of providing osteosynthesis without the inconvenients of inert material. The fibular acts like a biological plate with good vascularisation and stability to realign and lengthen the tibial segment.

Conclusion: This surgical technique is a supplementary therapeutic means for treating (septic) nonunion of the tibia. It is easy to perform and may be the last salvage method. The advantages are: a solid compact graft fixed in the mechanical axis of the tibia, possibility of bridging bone loss of more than 28 cm, short operative time without risk of complications related to graft harvesting, shorter hospital stay.