Aims. The aims of this study were to identify and evaluate the current literature examining the prognostic factors which are associated with failure of total elbow arthroplasty (TEA). Methods. Electronic literature searches were conducted using MEDLINE, Embase, PubMed, and Cochrane. All studies reporting prognostic estimates for factors associated with the revision of a primary TEA were included. The risk of bias was assessed using the Quality In Prognosis Studies (QUIPS) tool, and the quality of evidence was assessed using the modified Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework. Due to low quality of the evidence and the heterogeneous nature of the studies, a narrative synthesis was used. Results. A total of 19 studies met the inclusion criteria, investigating 28 possible prognostic factors. Most QUIPS domains (84%) were rated as moderate to high risk of bias. The quality of the evidence was low or very low for all prognostic factors. In low-quality evidence, prognostic factors with consistent associations with failure of TEA in more than one study were: the sequelae of trauma leading to TEA, either independently or combined with acute trauma, and male sex. Several other studies investigating sex reported no association. The evidence for other factors was of very low quality and mostly involved exploratory studies. Conclusion. The current evidence investigating the prognostic factors associated with failure of TEA is of low or very low quality, and studies generally have a moderate to high risk of bias. Prognostic factors are subject to uncertainty, should be interpreted with caution, and are of little clinical value. Higher-quality evidence is required to determine robust prognostic factors for failure of TEA. Cite this article: Bone Joint Res 2024;13(5):201–213

Background. Recently, a larger number of elderly individuals with osteoporosis has undergone total knee arthroplasty (TKA). Intuitively, such vulnerable bone condition should deteriorate post-TKA functional recovery compared to a non-osteoporotic condition, but this hypothesis has not been directly examined. Methods. To address this issue, we analysed prognosis of patients who underwent TKA in Toranomon Hospital in Japan between April 2016 and March 2017 (27 of 40 cases, age 75.0±8.2 years old, BMI 24.5±3.1), and evaluated effects of osteoporosis on the changes in functions of the knees three/six/twelve months after the operation. The knee functions were quantified based on Knee Society Score (KSS), and the severity of the pre-operative osteoporosis was evaluated by T-score. We examined the relationships between these scores using multiple regression analyses with age, BMI, and sex as covariates. We excluded patients with rheumatoid arthritis. Results. The multiple regression analyses revealed that the severity of osteoporosis (T-score) before TKA did not have sufficient explanatory powers for either type of KSS (for Knee Score, adjusted R2 ≤ 0.16; for Functional Score, adjusted R2 ≤ 0.15). In addition, Pearson correlation coefficients between the pre-operative osteoporosis severity and KSS were weak (for Knee Score, |r| < 0.07, P > 0.78; for Functional Score, |r| < 0.27, P > 0.21; Fig 1). This tendency was qualitatively preserved even when we repeated these analyses for each sex group. Conclusions. These analyses suggest that counterintuitively, pre-operative osteoporosis does not significantly deteriorate the functional outcome of TKA in the elderly population. Although longer observations of larger samples will be needed, the current findings indicate the possibility that we may not have to hesitate over TKA even for osteoporotic patients. For any figures or tables, please contact the authors directly

Introduction. It is generally held that blood tests are not particularly helpful in establishing the diagnosis of bone tumours but may be useful in prognosis. We reviewed the results of blood tests taken at the time of diagnosis to establish the frequency of abnormalities in common blood tests and whether this was significant in staging or prognosis. Method. Blood test results on all newly diagnosed patients with bone tumours from 2005 – 2010 were exported and abnormalities identified. This was matched to diagnosis, clinical features and prognosis. Results. There were 541 patients included in the analysis of whom 221 had osteosarcoma, 167 chondrosarcoma, 87 Ewing's, and 66 other bone tumours. 340 were adults, 103 children (under 14) and 98 TYA. The most frequently abnormal blood test was a low haemoglobin (⋋13) in 56%, raised alkaline phosphatase in 40%, and raised ESR and CRP in 32%. Patients with metastases at diagnosis tended to have higher levels of ESR (p⋋0.0001) but there was no other significant difference overall. Older patients tended to have a greater number of abnormal results apart from the CRP which was highest in the TYA group. No single blood test was related to prognosis. Conclusion. Abnormal blood tests are common in patients at the time of diagnosis of bone tumours. None are either particularly diagnostic or prognostic

Fibrous dysplasia is a genetic not hereditary disease of the skeleton, most frequently located at the femoral bone. The extension and the radiographic morphology of the femoral lesion are variable, and the prognosis is unpredictable. The purpose of this study is to propose a radiographic classification of the femoral lesion, related to the prognosis and the natural history of the disease. The authors reviewed the radiographic examinations of 25 patients affected by fibrous dysplasia of bone with femoral involvement, who were followed-up at least two years after diagnosis. Eleven patients had bilateral localization of the disease, for a total of 36 affected femurs. A radiographic classification of the femoral lesion was proposed based on the localization, the extension and the type of the lesion. The authors classify the femoral lesions as lytic, lytic with surrounding sclerosis, lytic and sclerotic, sclerotic and complex. They observed a prevalence of the lytic lesions and involvement of the proximal part of the femur. Many lesions (40%) expanded with age, and the sclerotic component also increased. The lytic lesions worsened with age, causing severe deformity of the femur. However the mostly sclerotic lesions turned out to be stable at follow-up. The worsening of the lesion was not related to the sex of the subjects; 77% of the worsened lesions were observed in patients younger than 20 years of age, while 66% of the stable lesions were found in patients older than 20 years. In conclusion, this study demonstrated that the prognosis of the femoral lesion in fibrous dysplasia is related to the type of lesion, as per the radiographic classification here in described. Prognosis is also related to the age of the patient and the presence of a sclerotic component, which suggested a greater stability of the lesion

Aims. Machine-learning (ML) prediction models in orthopaedic trauma hold great promise in assisting clinicians in various tasks, such as personalized risk stratification. However, an overview of current applications and critical appraisal to peer-reviewed guidelines is lacking. The objectives of this study are to 1) provide an overview of current ML prediction models in orthopaedic trauma; 2) evaluate the completeness of reporting following the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) statement; and 3) assess the risk of bias following the Prediction model Risk Of Bias Assessment Tool (PROBAST) tool. Methods. A systematic search screening 3,252 studies identified 45 ML-based prediction models in orthopaedic trauma up to January 2023. The TRIPOD statement assessed transparent reporting and the PROBAST tool the risk of bias. Results. A total of 40 studies reported on training and internal validation; four studies performed both development and external validation, and one study performed only external validation. The most commonly reported outcomes were mortality (33%, 15/45) and length of hospital stay (9%, 4/45), and the majority of prediction models were developed in the hip fracture population (60%, 27/45). The overall median completeness for the TRIPOD statement was 62% (interquartile range 30 to 81%). The overall risk of bias in the PROBAST tool was low in 24% (11/45), high in 69% (31/45), and unclear in 7% (3/45) of the studies. High risk of bias was mainly due to analysis domain concerns including small datasets with low number of outcomes, complete-case analysis in case of missing data, and no reporting of performance measures. Conclusion. The results of this study showed that despite a myriad of potential clinically useful applications, a substantial part of ML studies in orthopaedic trauma lack transparent reporting, and are at high risk of bias. These problems must be resolved by following established guidelines to instil confidence in ML models among patients and clinicians. Otherwise, there will remain a sizeable gap between the development of ML prediction models and their clinical application in our day-to-day orthopaedic trauma practice. Cite this article: Bone Jt Open 2024;5(1):9–19

Radial head fractures are common and mainly require a functional conservative treatment. About 20% of patients will present an unsatisfactory final functional result. There is, however, little data allowing us to predict which patients are at risk of bad evolve. This makes it difficult to optimize our therapeutic strategies in these patients. The aim of this study is to determine the personal and environmental factors that influence the functional prognosis of patients with a radial head fracture. We realized over a 1-year period a prospective observational longitudinal cohort study including 125 consecutive patients referred for a fracture of the radial head in a tertiary trauma center. We originally collected the factors believed to be prognostic indicators: age, sex, socioeconomic status, factors related to trauma or fracture, alcohol, tobacco, detection of depression scale, and financial compensation. A clinical and radiological follow-up took place at 6 weeks, 3 months, 6 months, and 1 year. The main functional measurement tool is the Mayo Elbow Performance Score (MEPS) and the Disabilities of the Arm, Shoulder and Hand (DASH). 123 patients were included in the study. 114 patients required nonsurgical management. 102 patients completed the 1-year follow-up for the main outcome (89 for the DASH score). Two patients required an unplanned surgery and were excluded from analyses. At 1 year, the average MEPS was 96.5 (range, 65–100) and 81% of subjects had an excellent result (MEPS ≥90). The most constant factor to predict an unsatisfactory functional outcome (MEPS <90 or DASH >17) is the presence of depressive symptoms at the initial time of the study (P = 0.03 and P = 0.0009, respectively). This factor is present throughout the follow-up. Other observed factors include a higher socioeconomic status (P = 0.009), the presence of financial compensation (P = 0.027), and a high-velocity trauma (P = 0.04). The severity of the fracture, advanced age, female sex, and the nature of the treatment does not influence the result at 1 year. No factor has been associated with a reduction in range of motion. Most of the radial head fractures heal successfully. We identified for the first time, with a valid tool, the presence of depressive symptoms at the time of the fracture as a significant factor for an unsatisfactory functional result. Early detection is simple and fast and would allow patients at risk to adopt complementary strategies to optimize the result

Aims: to present a new classification of haematogenous chronic osteomyelitis based on the clinical and radiographic presentation so that a reliable post-surgery prognosis can be done. Methods: between January 2002 and December 2008, 864 children underwent 1632 surgeries for haematogenous osteomyelitis. The clinical and surgical notes were reviewed. Three groups were identified based on clinical and radiographic findings: the first consisting of 565 patients with “ordinary” osteomyelitis requiring treatment of the infection through a sequestrectomy. The second group, classified as “difficult” osteomyelitis, included 134 patients who needed more than one surgery to cure the bone infection. The third group consisted of 165 patients with “complex” osteomyelitis in need of treatment of the infection and its complications, such as pathological fractures, bone loss, and septic arthritis. In the latter group techniques of bone transport, bone graft and radio-ulna/fibula-tibia fusion were used. Results: all the cases of haematogenous osteomyelitis in our series could be classified in one of the following categories and the prognosis and the length of treatment needed to cure this condition appear to be closely related to these. The first group in the CoRSU classification is “Ordinary Osteomyelitis”. The sequestrum is clearly defined and there is a good involucrum on X-ray film. Surgery under tourniquet is possible. In most cases the surgical treatment achieves the healing of the bone and recurrence is uncommon. The second group is classified as “Difficul osteomyelitis”. The bone involved presents with multiple erosions-cavities and there is no clear sequestrum on X-ray film. This category also includes those cases where surgery under tourniquet is impossible. Blood for transfusion must be available. Despite treatment, this type of osteomyelitis often recurs and further surgeries are often needed. All the cases of multiple osteomyelitis are included in this group as well. The third category covers “Complex Osteomyelitis”, whereby chronic osteomyelitis is associated with a pathological fracture or septic arthritis. There is axial deformity, bone loss and non-union. Some sort of reconstruction is always required. Conclusions: Haematogenous chronic osteomyelitis in African children accounts for about 30% of the total number of orthopaedic surgeries performed in our Unit. The classification that is presented here facilitates the planning of the surgery, predicting the prognosis and the length of treatment needed to cure this condition

Background. There is a paucity of prognosis research in patients with neuropathic low back-related leg pain (LBLP) in primary care. Purpose. To investigate the clinical course and prognostic factors in primary care LBLP patients consulting with neuropathic pain (NP). Methods. LBLP patients in a primary-care cohort study (n=606) completed the self-report version of Leeds Assessment for Neurological Symptoms and Signs (s-LANSS, score of ≥12 indicates possible NP) at baseline and 4-months. Mixed effects models compared pain-intensity (highest of mean leg or mean back pain - 0–10 NRS at baseline, 4-months, 12-months and 3-years) between those with persistent NP (s-LANSS ≥12 at baseline and 4-months) and those without (s-LANSS ≥12 at baseline and <12 at 4-months). Univariable and multivariable binary logistic regression examined association between potential prognostic factors (chosen from baseline self-report questionnaires, clinical examination, MRI scan findings) and persistent NP. Multiple imputation was used to account for missing data. Results. 44% (72/164) of patients with NP at baseline had persistent NP at 4-months. Mean pain intensity of patients with persistent NP was higher at 4-months, 12-months and 3-years compared to those without. In univariable analysis, only pain self-efficacy was significantly associated with persistent NP (OR 0.98, 95% CI 0.96 to 0.998). In multivariable analysis, none of the 7 investigated factors were significantly associated with persistent NP. Conclusion. Patients with persistent NP were consistently worse-off up to 3-years follow-up compared to those without. It was difficult to identify those patients with NP at baseline who would have persistent NP at 4-months. No conflicts of interest. Sources of funding: Sarah Harrisson is a Clinical Doctoral Fellow funded through a National Institute for Health Research (NIHR) Research Professorship for Nadine Foster (NIHR-RP-011-015). Nadine Foster is a NIHR Senior Investigator. Kika Konstantinou is supported by a Higher Education Funding Council for England/ National Institute for Health Research Senior Clinical Lectureship. The views expressed in this publication are those of the author(s), not necessarily those of the NHS, NIHR or the Department of Health and Social Care. This work relates to an Education and Continued Professional Development (level 2) award by the Musculoskeletal Association of Chartered Physiotherapists to Sarah Harrisson (June 2016)

The purpose of this study was to validate the usefulness of SPECT/CT as an evaluation method for determining treatment and prognosis for patellofemoral cartilage lesions, based on MRI and arthroscopic findings. From August 2009 to February 2010, SPECT/CT was performed on 80 patients (24 male and 56 female, average 53.3 years old) with chronic anterior knee pain who had no degenerative changes or patellar malalignment on plain radiographs. Radioisotope uptake findings on patellofemoral joint from SPECT/CT were classified into three grades by one nuclear medicine specialist. In the patients who demonstrated poor improvements after conservative treatments, MRI and arthroscopy were performed. Patellofemoral cartilage conditions under arthroscopic finding (ICRS grades) were compared with SPECT/CT grading. In all cases, there were increased uptakes on patellofemoral joints. Eighteen cases showed low uptake (Group 1), 22 cases showed medium uptake (Group 2) and 40 cases high uptake (Group 3). At the follow-up examination after mean 1.7 months, 16 cases of Group 1 (89%), 14 cases of Group 2 (64%) and 28 cases of Groups3 (70%) responded positively to the conservative treatments. For those 22 cases showing poor improvement, MRI and arthroscopy were done. Damage or thinning of patellofemoral cartilage, subchondral cyst, edema and fissuring were observed in every case that underwent MRI. Every arthroscopic case was found that there was patellofemoral cartilage damage. Each of ICRS grade I and grade II was found in 2 cases from Group 1. Two cases of grade II, 4 cases of grade III, and 2 cases of grade IV were found in Group 2. Two cases of grade II, 4 cases of grade III, and 6 cases of grade IV were found in Group 3. There was significant difference in the success rate of conservative treatment between SPECT/CT grade 1 and 2 or 3. And there was significant association between SPECT/CT grade and ICRS grade (P=0.034). SPECT/CT could be a useful modality in determining the treatment and prognosis for patellofemoral cartilage lesions compared with MRI and arthroscopic findings

Aims. The number of convolutional neural networks (CNN) available for fracture detection and classification is rapidly increasing. External validation of a CNN on a temporally separate (separated by time) or geographically separate (separated by location) dataset is crucial to assess generalizability of the CNN before application to clinical practice in other institutions. We aimed to answer the following questions: are current CNNs for fracture recognition externally valid?; which methods are applied for external validation (EV)?; and, what are reported performances of the EV sets compared to the internal validation (IV) sets of these CNNs?. Methods. The PubMed and Embase databases were systematically searched from January 2010 to October 2020 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The type of EV, characteristics of the external dataset, and diagnostic performance characteristics on the IV and EV datasets were collected and compared. Quality assessment was conducted using a seven-item checklist based on a modified Methodologic Index for NOn-Randomized Studies instrument (MINORS). Results. Out of 1,349 studies, 36 reported development of a CNN for fracture detection and/or classification. Of these, only four (11%) reported a form of EV. One study used temporal EV, one conducted both temporal and geographical EV, and two used geographical EV. When comparing the CNN’s performance on the IV set versus the EV set, the following were found: AUCs of 0.967 (IV) versus 0.975 (EV), 0.976 (IV) versus 0.985 to 0.992 (EV), 0.93 to 0.96 (IV) versus 0.80 to 0.89 (EV), and F1-scores of 0.856 to 0.863 (IV) versus 0.757 to 0.840 (EV). Conclusion. The number of externally validated CNNs in orthopaedic trauma for fracture recognition is still scarce. This greatly limits the potential for transfer of these CNNs from the developing institute to another hospital to achieve similar diagnostic performance. We recommend the use of geographical EV and statements such as the Consolidated Standards of Reporting Trials–Artificial Intelligence (CONSORT-AI), the Standard Protocol Items: Recommendations for Interventional Trials–Artificial Intelligence (SPIRIT-AI) and the Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis–Machine Learning (TRIPOD-ML) to critically appraise performance of CNNs and improve methodological rigor, quality of future models, and facilitate eventual implementation in clinical practice. Cite this article: Bone Jt Open 2021;2(10):879–885

With modern polychemotherapy Ewing’s sarcoma exhibit remarkable chemosensitivity leading to 5-year survival rates approaching 60–70%. However, in the last decade, no significant progress has been achieved in terms of improved cure rates and quality of life. In addition, prognosis is poor either in relapsed patients and in patients with metastasis at diagnosis. Thus, it is imperative to develop novel therapeutic strategies and to identify markers for risk-adapted therapies. The PROTHETS European Consortium through collaborative studies defined prognostic markers and new therapeutic targets in the Ewing’s sarcoma family of tumours (ESFT), to provide rigorous scientific justifications for the development of clinical trials for this rare disease. Genetic studies have been performed for the screening of high-risk patients and patients responding differently to chemotherapy. Between others, these studies identified in gluthation metabolism a major pathway regulating Ewing’s sarcoma chemoresistance. The prognostic relevance of glutathione metabolism pathway was validated by RT-PCR and the expression of MGST1, the microsomal glutathione transferase (GST), was found to clearly predict EWS prognosis. MGST1 expression was associated with doxorubicin chemo sensitivity. This prompted to assess the in vitro effectiveness a new anticancer agent (NBDHEX) that efficiently inhibits GST enzymes. The consortium have collected more than 600 cases in specific tissue arrays for validation studies. Their use allowed the identification of some markers of prognosis, either conventional or new (ki-67, adhesion proteins, GAL3BP). Overall, theses studies started to define possible forthcoming risk-adapted strategies. Another goal of the project was the creation of new tools and drugs as well as the optimization of molecular approaches against three therapeutic targets, EWS-FLI1, CD99 and IGF-IR that have great potential in terms of clinical application. The studies on IGF-IR have provide the rationale for the currently on-going clinical studies in Ewing’s sarcoma

Purpose. To compare information on heredity among patients with idiopathic scoliosis. Methods. 1440 patients with idiopathic scoliosis were recruited. Information on prevalence of scoliosis among relatives was obtained by questionnaire. Results. 1256 (87%) were women and 184 (13%) were men. 204 (14%) of the participants were juvenile (4-9 yrs) at time of diagnosis. 1236 (86%) were adolescents (10-19 yrs) at time of diagnosis. 141 of the 204 patients (69%) with juvenile scoliosis had been treated (73 brace, 68 surgery) and 817 of the 1236 patients (66%) with adolescent scoliosis had been treated (490 brace, 327 surgery). 23% had at least one parent and 13% had at least one grandparent with scoliosis. When comparing female and male patients there was no difference in proportion of parents with scoliosis (p=0.97, Chi-square) or grandparents with scoliosis (p=0.35). 26% of patients with juvenile scoliosis had at least one parent with scoliosis compared to 22% for patients with adolescent scoliosis (p=0.23). 18% of patients with juvenile scoliosis had at least one grandparent with scoliosis compared to 12% for patients with adolescent scoliosis (p=0.04). When dividing the patients into groups according to treatment (observed, brace, or surgery), there was no difference in proportion of parents with scoliosis (p=0.59) or in proportion of grandparents with scoliosis (p=0.99). Conclusion. It is unlikely that information on heredity is of importance for the prognosis of idiopathic scoliosis. We found no difference in heredity among patients with juvenile and adolescent scoliosis or between males and females

Purpose: In our records on bone tumours, secondary chondrosarcomas account for slightly less than 15% of all chondrosarcomas (20/150). The presentation is quite variable making diagnosis relatively difficult. We reviewed our experience to evaluate diagnosis, frequency, and prognosis. Material and methods: From 1981 to January 2002, we had 20 chondrosarcomas which developed on pre-existing lesions: solitary exostoses (n=11), solitary chondroma (n=1), multiple exostosis (n=6), multiple enchondromatosis (n=2). Localisations were: pelvis (n=9), femur (n=3), humerus (n=2), tibia (n=3), spine (n=2), scapula (n=1). Histological classification was: grade I (n=7), grade II (n=9), grade III (n=1), and dedifferentiated sarcoma (n=3). Surgery was performed in all patients, alone for grade I and II chondrosarcoma, in association with chemotherapy (n=3) and radiotherapy (n=1) in three patients with dedifferentiated sarcoma. Results and prognostic factors: At last follow-up (mean 9 years 10 months), five patients had died after local recurrence (n=3) or metastatic dissemination (n=2). The other fifteen patients were living (mean follow-up 155 months). The main prognostic factor was histological grade of chondrosarcoma. All patients with grade I chondrosarcoma (n=7) survived versus only two-thirds of those with grade II chondrosarcoma and half (2/4) of those with grade III or dedifferentiated chondrosarcoma. The second prognostic factor was initial management. Inadequate care initially led to misdiagnosis or delayed diagnosis (n=4), local recurrence (n=3) and loss of chance of survival (n=3). Grade I chondrosarcoma was occasionally taken for benign exostosis despite a cartilage cuff measuring more than 1 cm, normally a sign of chondrosarcoma. Conclusion: 1. Because of the severity of secondary dedifferentiated chondrosarcoma, resection should be performed in adults presenting exostosis with a large residual cartilage cuff, particularly in high-risk locations (pelvis). 2. Because of the difficulty in recognising the histological features of grade I chondrosarcoma, the diagnosis of degeneration should be retained in adults if the cartilage cuff exceeds 1 cm. Lesions are suspicious if the cartilage cuff exceeds 5 mm

Purpose: Osteosarcoma is a rare disease after the age of 40 years. Most malignant bone tumours at this age are secondary lesions and the primary tumours observed are generally chondrosarcomas. We report a small retrospective series to study the characteristic features and point out diagnostic difficultis as well as the prognosis in this age group. Material and methods: We included in this series histologically proven osteosarcomas observed in patients over the age of 40 years who had been treated between 1990 and September 2002, excluding tumours occurring in patients with predisposing conditions (radiation, paget). The series included six women and nine men, mean age 54 years (41–79). Only three patients were over 60. Results: During this same period, 59 osteosarcomas were treated. Diagnosis before 40 years corresponded to 25% of the cases reported at our interdisciplinary reunion. Three patients were referred after inadequate treatment, i.e. curettage-filling without diagnosis. Two others had undergone surgery for symptoms related to the osteosarcoma. Finally three patients had an erroneous or doubtful pathological diagnosis. There was no histological specificity or tumour localisation. The lower femur predominated. Ten patients had undergone neo-adjuvant chemotherapy with only two responders. Marginal surgery was achieved in three cases, intralesional surgery with immediate revision in one and large resection in ten. Six patients died from their disease (within two years of diagnosis) and one developed postoperative pulmonary embolism (46%). Two patients were living with active disease. Only six patients were living disease-free (40%). These included one patient with resected pulmonary metastasis and one patient who had experienced two episodes of locoregional recurrence which were operated (follow-up 12 and 8 months from last event). Four patients (26%) were in complete remission without any event since treatment (including two low-grade tumours). Conclusion: Osteosarcoma after 40 years is, in our experience, more frequent than reported in the literature. In at least six of our patients (40%) this tumour was mis-diagnosed leading to non-optimal treatment. The prognosis is very poor with only 26% of the patients in complete remission without an event since treatment

Introduction: Acute traumatic separation of the greater trochanter is a rare childhood injury with associated morbidity. Although the risk for femoral head avascular necrosis and morbidity following femoral neck fractures in childhood is well understood, the risk to femoral head blood supply in the much less common greater trochan-teric fracture is not widely known. Materials and Methods: Three adolescents with greater trochanteric fracture were evaluated and treated. The first, a complete separation incurred in football, was fixed by open surgery using two large A-O screws plus washers. The patient developed severe avascular necrosis requiring further treatment including bone grafting of the femoral head plus shelf acetabuloplasty. The prognosis is guarded. A second patient had a similar injury following a fall from a ladder. Because of our experience with the prior case, she was treated with a careful, minimal open reduction with greater trochanter reat-tachment using a tension band technique. Follow-up has shown a normal femoral head. A third patient presented with progressive pain in the greater trochanter in sporting activities with early separation documented by radiograph. This picture was similar to slipped capital femoral epiphysis. Treatment was by emergent in-situ screw fixation. The hip has developed normally. Discussion: The growth centers of the femoral head and greater trochanter are conjoined at birth with a similar blood supply The blood supply to the femoral head and neck as well as to the greater trochanter have been carefully studied but with little attention paid to the effect that greater trochanteric fracture might have on femoral head blood supply. The ascending branches of the medial femoral circumflex, which supply the blood to the femoral head via their course to the posterior femoral neck, can readily be injured with traumatic avulsion of the greater trochanter. Femoral head avascular necrosis can result from the fracture itself and/or to the methods of re-attachment. Recognizing the risk , patients with this injury should be treated with a gentle open reduction with a minimal added trauma from reduction methods or fixation. K-wires and a tension band technique may be the best choice. The child should then be immobilized in a hip spica cast to allow full healing, rather than relying on large internal fixation devices in an attempt to avoid cast immobilization. Adolescents with this injury must be followed for two years to be certain that avascular necrosis does not develop

Osteosarcoma rarely affects young children. To determine the clinical characteristics and the prognosis of this cancer in children of less than 5 years at diagnosis, we retrospectively analysed medical records of these patients treated in French centers between 1980 and 2007. A centralised histological review was carried out. Fifteen patients were studied. Long bones were involved in 14 cases. Metastases at diagnosis were observed in 40% of patients. Histologic type was 74% osteoblastic. In 3 cases (20%) tumours occurred on a particular background (tall constitutional size, treatment with growth hormone and pregnancy induced by clomiphene). One child had a second cancer 13 years after the first diagnosis. Twelve children received pre-operative chemotherapy including high dose methotrexate: 5 of them had progressive disease; only 36% had good histological response (less than 10% viable cells). Limb salvage surgery was performed in six cases (40%). Chemotherapy was well tolerated in most patients. A one-year-old child developed a severe late convulsant encephalopathy with lesions of the white substance that could be due to methotrexate despite adjustment of doses to his weight. The functional recovery of the three analysable children who underwent limb salvage surgery is uneven and shows frequent mechanical or infectious complications (2 to 5 reinterventions per patients). First complete remission (CR) was obtained in 12 children, six of them relapsed. With a median follow-up of 15 years, six are alive in CR, six died of disease (40%), two were lost to follow-up and one has stable disease with metastasis. This study shows that osteosarcoma seems to be more aggressive in children under five years of age. Surgical management remains difficult in this population. Prospective studies are still needed to confirm these observations

Purpose: Infection after resection and total knee arthoplasty for malignant bone tumours in children is a serious complication which may compromise limb salvage. The purpose of this work was to study the aetiology, treatment and prognosis of this event. Material and methods: Among the 169 total knee arthroplasties performed for malignant bone tumours between 1981 and 1999, we selected 17 patients meeting the following criteria: proven infection with identified germ on deep samples or presence of a fistula more than two years after surgery. All of the patients had osteogenic sarcomas (excluding Ewing sarcomas which account for 30% of the tumours in this localisation). The bone tumour involved the femur (n=11) or the tibia (n=6) and required extraarticular (n=14) or transarticular (n=2) resection. Infections were primary (n=9) developing after the first operation, or secondary (n=8) to surgical revision in six, joint wound in one, or haematogeneous dissemination in one patient. The causal germ was identified in thirteen patients (76%) and was a staphylococcus in all cases. Treatment included systemic antibiotics and lavage (n=10), one-procedure change in prosthesis (n=3), removal of the implant with replacement by a spacer (n=2), surgical abstention (n=2), or amputation (n=1). Results: Mean follow-up was eight years (2 – 16 years). On the average, treatment of infection lasted 51 months and required a 3.9 surgical interventions. At last follow-up, infection was considered cured in 70% of the patients who were free of clinical or laboratory signs of infection without antibiotics for at least one year. The arthroplasty could be preserved in one-third of the cases (22% of the primary infections and 50% of the secondary infections). Another treatment, arthrodesis (n=6), Borggreve procedure (n=1), or amputation (n=4), was given in the other two-thirds. Discussion: The 10% complication rate observed here is in agreement with data in the literature. Development of primary infection is influenced more by the histology of the tumour and the presence of skin wounds (methotrexate) than by tumour site or type of resection. The diagnosis of primary infection is made late, often at the end of the postoperative chemotherapy protocol. Changing the implant is the ideal treatment. Secondary infection is characteristically less difficult to diagnose; infection is recognised earlier and the chances of preserving the implant are better

Introduction and Aims: Prospective review of the patients who underwent stabilisation of displaced acetabular fractures in our unit in order to evaluate the presence of neurological lesions and functional outcome. Method: Out of 136 patients operated over six years we identified 27 patients with neurological lesions. A standard protocol was followed for the clinical and neurophysiological evaluation of nerve injuries. Electromyography (EMG) was used to determine the anatomical location of the neurological lesions and the type of lesion, which act as a valuable tool in the diagnosis of double crush lesion in the sciatic nerve. Neurological recovery was evaluated with EMG studies and clinically rated as described by Clawson et al. Functional outcome was graded by the system proposed by Fassler and Swiontkowski. Results: EMG studies revealed sciatic nerve lesions in all the cases. Additionally, in nine patients with a dropped foot there was evidence of a proximal (sciatic notch) and distal (neck of fibula) lesion – ‘double crush syndrome’. At final follow-up, clinical examination and associated EMG studies revealed full recovery in five cases with initial muscle weakness, and complete resolution of sensory symptoms (burning pain, hyposthesia) in four cases. There was improvement of functional capacity (motor and sensory) in two cases with initial complete drop foot and in four cases with muscle foot weakness. In 11 of the cases with dropped foot (all nine with double crush) at presentation, there was no improvement in function. Functional outcome was unsatisfactory in all patients with double crush injury. Conclusion: In cases where there is evidence of ‘double crush lesions’ the prospect of functional recovery is low as seen in this group of patients. The patients with double crush syndrome are not expected to recover and could be considered as a sign of unfavourable outcome following neurological impairment after acetabular fractures. Single lesions appear to be associated with a more favourable prognosis

Giant cell tumor (GCT) of bone is an aggressive tumor with high rate of recurrence. Bad prognosis factors were inquired, without a definite identification: type of treatment, soft tissue invasion, high proliferation rate at histology, pathologic fracture. From January 2000 to February 2008, 38 patients affected by GCT were treated in a regional reference centre, 17 male, mean age 32 (range 16–69, median 29); one patient had 2 localizations (tarsal bone and proximal tibia); 3 were recurrences previously treated in other hospitals. Seven cases were in upper limb, 1 case in the sacrum, 30 in lower limb (20 around the knee); fracture at presentation was present in 6 cases; bone aneurismal cyst (ABC) was associated in 4 cases. Five cases in stage 3 were treated by bone resection followed in 4 cases by allograft and/or prosthesis (no reconstruction in 1 proximal fibula excision); 33 cases were treated by curettage, local chemical (phenole) and mechanical adjuvants (burring), filling with bone grafts in 13 cases, cement in 8 cases, cement and allografts in subchondral area in 11 cases. The sacral lesion was only curetted. Seven patients developed a local recurrence, in 2 patients twice, for a total of 9 recurrences (19% of treatments). Recurrences occurred in 2 proximal tibia, in 2 distal femurs, in 1 proximal femur, in 1 distal radius and in 1 proximal fibula. The first treatment was bone grafts in 3 cases (23% of recurrence), bone cement and grafts in 2 cases (18% of recurrence), cement in 1 case (12% of recurrence), resection in the proximal fibula with severe soft tissue invasion. Two patients with associated ABC developed a recurrence and two with fracture at presentation. In this study, increased rate of recurrences occurred with pathologic fracture at presentation, soft tissue invasion and ABC association