Aims: The authors reported an original technique for proximal humerus reconstruction followed tumor resection using a delta composite prosthesis. Seven patients undergoing this technique Technique: Proximal humeral resection was conducted usually. The host tendons of rotator cuff were resected; the deltoid muscle must be preserved. The glenosphere was inserted with three screws. A long humeral stem was used to provide a distal anchorage of 10 cm; this stem was cemented into the allograft and into the humerus host. The patient was immobilized in 90¡ of abduction during 6 weeks. Results: 7 patients aged 38 to 56 years, who presented a chondro-sarcoma or an osteosarcoma of the proximal humerus were enrolled in this study. The mean follow-up was 20 months (6 to 24). None patient presented with pain and the mean of active abduction was 120¡. No local or general recurrence was detected. Discussion: The Delta prosthesis of Gramon is usually used for shoulder arthritis with rotator cuff rupture. In our experience, reconstruction of the proximal humerus with composite prosthesis provides good functional results but after 3 years, a graft resorption was observed and the functional results decrease. The delta prosthesis could provide good functional results without reconstruction of the rotator cuff. In our technique, we sutured the rotator cuff to avoid dislocation. However, the glenoid þxation is incertain for a long term because its a constrained prosthesis. This technique could be used when the deltoid muscle can be preserved.

Purpose of the study: Chordoma is a malignant neoplasm believed to arise from notochord remnants. It accounts for approximately 3 to 4 p. 100 of primary bone tumors and is localized along the axial skeleton, 50 p. 100 being sacrococcygeal. Clinical, radiographical and histological findings have been well established since the first description by Ribbert in 1894. Sacral chordomas are however difficult to manage and remain a challenge for surgeons and radiotherapists alike. The purpose of this study was to evaluate the long-term results of surgical treatment and patterns of failure in patients treated for chordoma of the sacrum in our department.

Materials and methods: This retrospective study included 11 cases of sacral chordomas treated from 1973 to 1998. Patient age ranged from 36 to 77 years (mean 59 years). Six patients were female and five male. The initial treatment was surgery in all cases including intralesional removal in two cases, marginal resection in seven and complete en bloc resection in two.

Results: Median follow-up was 6 years (1 month to 14 years). Tumoral recurrences were observed in nine cases 5 months to 8 years after treatment. In two cases, recurrence was observed 8 years after radical sacrectomy. Treatment of recurrences was partial surgical removal with radiotherapy (40 to 70 Grays). Three patients developed metastases in lungs, liver and bone, respectively. Seven patients died, two from metastatic disease. The 5-year overall survival was 64 p. 100 but only 18 p. 100 of the patients survived 10 years. Average disease-free survival was 18 p. 100 at 5 years and 0 p. 100 at 10 years.

Discussion: Chordoma is a slow-growing tumor allowing survival for several years despite recurrent disease. However, only 10 to 20 p. 100 of the patients survive free of disease at 5 years. Recurrences are frequent (45 to 80 p. 100) and often multiple. Chordoma inevitably recurs and eventually leads to death after intralesional removal or marginal resection. Radical surgery should be attempted whenever technically feasible. When performed early, particularly for smaller lesions, it offers the best chance for cure. However, tumoral recurrence can occur postoperatively despite a macroscopically complete resection. Because radiation therapy seems to be more successful in controlling microscopic disease, it should be considered as a pre- or postoperative adjuvant to a macroscopically complete resection.

Purpose: Primary bone tumours located in the upper limb are mainly found in the proximal portion of the humerus. Tumour resection raises difficult situations due to the sacrifice of the cuff tendons. We propose a decision making scheme for determining the best reconstruction strategy.

Material and methods: This retrospective analysis was based on 35 cases (19 massive prostheses, ten composite prostheses, three inverted prostheses and three composite arthrodeses). All the clinical and radiographic data were reviewed to examine function, active motion, pain, and use of the upper limb in everyday activities.

Results: Massive humeral prostheses provided a technically simple solution but produced mediocre functional results: painless shoulder without active motion, but preservation of elbow and forearm function. Composite humeral prostheses (prosthesis + allograft) did not, in our experience provide any gain in function compared with massive prostheses. Allografts were resorbed after four to five years. Composite arthrodesis with allograft and vascularised fibular graft provided a mobile shoulder with a useful amplitude and a pain free joint. Results persisted. The inverted Delta prostheses (Grammont) covered with allografts and with preservation of the rotator cuff tendons offered an interesting alternative with functional results superior to arthrodesis and similar to those with shoulder prostheses implanted for degenerative disease. The persistence of the glenoid anchorage remains uncertain.

Conclusions: We use the following scheme for reconstruction of the proximal humerus. Resection of the proximal humerus with preservation of the deltoid in patients in good general health: inverted composite prosthesis. Resection of the proximal humerus without preservation of the deltoid in patients in poor general health: composite arthrodesis. Resection of the proximal humerus in patients in very poor general health when complex surgery with long post-operative care is not possible: massive prosthesis.

Purpose: The difficulty of successive reconstructions of the anterior cruciate ligament (ACL) using an autologous graft depends on many factors. The choice of the new transplant is crucial. The purpose of this study was to assess outcome in 17 patients who underwent successive repairs of the ACL after failed patellar tendon graft where the same patellar ligament site was used to harvest the graft. This choice resulted from the width of the existing bone tunnels (irrespective of the type of screw used) that were often correctly positioned by contraindicated a relatively narrow transplant.

Material and method: The graft was obtained from the patellar ligament at the same site as used for the primary repair in 19 patients. The graft was medialised so half of the fibres were cicatricial and half were tendon with bone prolongations. Arthroscopy revealed a lesion of the distal portion of the transplant near the tibial inertion in nine cases, a proximal lesion in five cases and distension in five cases. Five patients had also had a contralateral plasty of the ACL. Mean age was 31 years. Symptoms included instability, alone or with pain. In 12 cases, partial meniscectomy was performed before or during the repeat plasty procedure. Minimum follow-up was one year for 17 patients with a mean of 21 months. IKCD and Lysholm-Tegner criteria were assessed. Laxity was measured at maximal manual traction using a KT 1000.

Results: Overall IKDC outcome was 2A, 10B, 4C, and 1D. Differential laxity at maximal manual traction, evaluated for the 12 patients with a healthy contralateral knee was 2.7 ± 1.3 mm (versus 1.7±1.9 mm in the control series). Mean pre-postoperative gain in the 17 patients was 5.4 ± 3 mm (versus 5.6 ± 2.4 mm in the control series). The predominant sign was residual pain (11/17). Pain was generally moderate and induced by exercise. Pain at the site of graft harvesting was frequent during the six months after surgery (11 cases) but rare after one year (2 cases).

Discussion: Due to the cartilage and meniscal history of this population of patients who had undergone several repairs of the ACL, the results were satisfactory and little different from those obtained with the same primary procedure in a control group. The residual laxity study showed that the mechanical quality of the transplant was good. Histology studies published on repeat patellar tendon harvesting have been discordant.

Conclusions: Repeat harvesting of the patellar tendon for ACL repair appears to be an excellent alternative since it is thicker than the primary transplant and thus fills the bone defects better than other transplants (particularly hamstring).