Purpose

To investigate the prognostic effect of surgical margins in soft tissue sarcoma on Local Recurrence (LRFS), Metastasis (MFS) and Disease Free Survival (DFS).

Purpose of the study: Follow-up of patients with a total hip arthroplasty with an Atlas^® cup revealed unique acetabular osteolytic defects which remained asymptomatic for long periods. We thus conducted a systematic review.

Material and method: Our retrospective analysis included 217 Atlas^® elastic impactable cups implanted consecutively from January 1993 to June 1995 and reviewed clinically and radiographically at mean 13.1 years.

Results: The incidence of acetabular osteolysis was 16%, the leading cause of replacements which occurred on average 8.8 years after the initial implantation. The overall actuarial cup survival was 76% at 13.5 years and 81% taking revision for periprosthetic osteolysis as the endpoint. Univariate analysis found a significant link between osteolysis defects and significant wear (p< 0.0001), Devane activity 4 or 5 (p=0.0005), low thickness polyethylene (p=0.006), and use of Zircone or alumina heads versus metal heads (diameter 22). There was no statistical link between the presence or not of a hydroxyapatite coating, despite a trend for less osteolysis with hydroxyapatite coating. At multivariate analysis, the only factors significantly linked with the presence of osteolysis were significant wear and thin polyethylene insert in the metal back.

Discussion: Mid-term follow-up appeared sufficient to assess the development of osteolysis considering the delays describe by others. The incidence of osteolysis, despite the high incidence and early appearance in our series, was very probably underestimated by the radiographic analysis. These results suggest we should search for defects systematically with this type of implant, especially if there is measurable wear. Although it is difficult to set a cut off, a polyethylene thickness less than 10mm should be avoided to limit the high risk of osteolysis defects. A more powerful statistical analysis and examination of explants is advisable in order to ascertain the reasons for this abnormally high level of failure by osteolysis at 13 years follow-up.

Conclusion: Systematic radiological and clinical review of all patients demonstrated an insufficient overall actuarial survival and an important rate of periprosthetic osteolysis. The association between periprosthetic osteolysis and polyethylene were was confirmed. Thin inserts appear to play an important role in this osteolysis via an abnormal wear and poor tolerance to wear debris from these implants.

Planning resection margins for soft tissue sarcomas is a compromise between functional sacrifice and therapeutic safety. In practice, the histological analysis of the resection margins often shows that the preoperative objective has not been achieved. We studied the prevalence and factors of risk of this surgical outcome.

This was a prospective monocentric study of 133 patients. The resection objectives, pathological results and operative reports were examined. Margins were classified according to the UICC (R0, R1, R2). Data were included in a grid which also included patient related and tumour related preoperative information. Inadequate resection was noted as planned R0 with R1 or R2 outcome. Statistical analysis was performed with Statview 5.0.

The prevalence of inadequate resection was 25.2%. Among the factors analysed, the aspect of tumor limits (badely or well defined) was significantly related to poor surgical results (odds ration 2.85 [1.47–5.52], p < 0.005). No other significant risk factor could be identified. Margins greater than two mm were associated with adequate surgery in every case.

No preoperative risk factor predictive of inadequate resection margins was clearly identified in this study. Postoperatively, the microscopic aspect of the proliferation limits at the final pathology examination is for us significantly associated with inadequate resection. However the current classification for resection margins lacks precision, especially regarding R0 and R1 when margins are small, in defining the risk of inadequate resection. This appears to be the source of the difficulties encountered in interpreting pathology samples and therefore in choosing the right treatment. Further follow-up is needed to clarify such questions.

We conclude that where resection margins are thin (less than two mm), the definition of R0 or R1 resections should be clarified to optimize patient care. To achieve this, potential risk factors for inadequate resection such as tumor limits should be taken into account and further studied.

Purpose of the study: Planning resection margins for soft tissue sarcomas is a compromise between functional sacrifice and therapeutic safety. In practice, the histological analysis of the resection margins often shows that the preoperative objective has not been achieved. We defined this as anatomo-surgical discordance and studied its prevalence and factors of risk.

Materials and Methods: This was a prospective mono-centric study of 133 patients. The resection objectives, pathological results and operative reports were examined. Margins were classified according to the UICC (R0, R1, R2). Data were included in a grid which also included patient related and tumour related preoperative information. Discordance was noted as planned R0 with R1 or R2 outcome. Statistical analysis was performed with Statview 5.0.

Results: The prevalence of anatomo-surgical discordance was 25.2%. Among the factors analysed, the aspect of the margins was significantly related to poor surgical results (odds ration 2.85 [1.47–5.52], p=0.0031). No other significant risk factor could be identified. Margins greater than 2mm were associated with adequate surgery in every case.

Discussion: No preoperative risk factor predictive of inadequate resection margins was clearly identified in this study. Postoperatively, the microscopic aspect of the proliferation margins at the final pathology examination is for us significantly associated with inadequate resection. But the current classification of resection margins (R0 and R1), especially for poorly delimited tumours lacks precision. This appears to be the source of the difficulties encountered in interpreting pathology samples and therefore in choosing the right treatment. Further follow-up is needed to clarify such questions.

Conclusion: We were unable to identify any preoperative factor predictive of inadequate resection. A poorly-defined microscopic aspect of the tumour is significantly associated with inadequate resection but the current classification system raises certain interpretation problems for resections with margins less than 2 mm. Concerning these cases, the definition of margins must be clarified to optimize patient care.

Purpose of the study: We conducted a prospective randomized study to compare use of macroporous biphasic calcium phosphate ceramic and bone autografts for filling medial open wedge osteotomies of the proximal tibia.

Material and methods: This phase III pragmatic clinical trial was designed for direct patient benefit. Randomization was performed in the operating room after completing the osteotomy. Twenty-six men and 14 women, mean age 51 years (range 19–75 years) were included. A biomaterial implant was used for 22 patients and an autograft for 18. Mean correction was 10 mm (range 6–15). One patient was excluded from the analysis, no patient was lost to follow-up. All patients were reviewed at minimum two years follow-up.

Results: At three months, knees were less painful with less subjective functional impact after filling with an autograft (pain VAS 3.1 versus 2.1 and function VAS 3.4 versus 2.5). These results were more balanced at six months (pain 1.6 versus 1.8 and function 1.8 versus 2.1) and remained stable at one and two years. The IKS knee scores were symmetrical at one at two years for both groups (IKS1 93 versus 86 and IKS2 90 versus 90). Bone healing was achieved within the usual delay. Axial alignment was stable at two years in both groups. There were eleven complications (28%), nine requiring revision: infected hematoma (n=1), intraoperative vascular injury without serious consequences (n=1), loss of correction (n=2), nonunion after filling with biomaterial (n=1), iliac abscess after filling with autograft (n=2) and painful calcification of the iliac region requiring resection (n=1).

Discussion: We observed three factors which can favor mechanical failure after filling with a ceramic material: intraoperative rupture of the lateral hinge, obesity, and excessively early unprepared weight bearing.

Conclusion: Although the difference did not reach significance, the risk of mechanical complications appears greater with macroporous en bloc ceramic filling. This material is less tolerant to comorbid conditions (obesity) and requires very precise technique as well as careful observance of postoperative care (no early weight bearing). Nevertheless, this method does have the advantage of avoiding painful sequelae and complications related to harvesting the iliac graft.

Purpose of the study: The relative role for anterograde nailing in relation to retrograde nailing has become a highly debated issue. Bifemoral fractures would appear to be a priority indication for the later method.

Material and methods: From January 1997 to December 2003, 19 bifemoral shaft fractures were treated by simultaneous retrograde nailing (group 1, eight cases, five males, three females) or by anterograde nailing in a one-stage procedure (group 2, eleven cases, six males, five females). Patient age was 23 years 7 months on average (range 16.6–40.5 years) in group 1 and 26 years 7 months (range 17.8–42.3 years) in group 2. The ISS was 30.6 (13–50) in group 1 and 16.8 (10–27) in group 2.

Results: The time for installation of the two femurs was 30 min (range 20–40 min) in group 1 and 70 min (range 60–80 min) in group 2. The operative time for the two femurs was 144 min (range 110–170) in group 1 and 156 min (range 140–180 min) in group 2. One patient in group 1 died on day 2 postop; none in group 2. First-intention bone healing was achieved at 14 weeks (range 12–16) in all patients in group 1. In group 2, there were two nail replacements and two grafts. Healing time was 24 weeks (range 10–130). Follow-up was 24 months (range 13–54 months). Knee flexion was 138° (range 130–140°) in group 1 (removal of patellar tendon calcification in one patient) and 123° (range 110–150°) in group 2. The difference in length between the two femurs was 6.2 mm (range 0–6 mm) in group 1 and 5.3 mm (range 0–11 mm) in group 2. The functional outcome (Thorensen criteria) was excellent in nine femurs, good in five in group one and excellent in nine, good in nine and fair in four in group 2.

Conclusion: Retrograde nailing provides clinical and radiographic results which are comparable to antero-grade nailing. However, the time required and the ease of installation is in favor of retrograde nailing.

Purpose of the study: Revision acetabular surgery with bone stock deficiency is a difficult problem. The use of cementless component and bioactive ceramics seemed to be a promising alternative.

Since 1996, we have been filling bone defect at the time of revision with macroporous calcium phosphate ceramic. We reported our first experience between 1996 and 1999.

Material and methods: The procedure was carried out in 35 hip reconstructions ( 35 patients ) at a mean follow-up of 6 years ( range 5 to 7,4). The average age of the patients was 56 years( range 28 to 83).

2 patients died of a cause unrelated to the procedure and 2 patients were lost of follow-up. Bone defect were classified into type I ( 4 hips), type IIA ( 8 hips ), type IIB ( 5 hips), type IIC ( 9 hips), IIIA ( 4 hips ), type IV ( 5 hips ) according to Paprosky classification.

The functional status of the patients was evaluated according to the Merle d’Aubign ip rating.. The interfaces bioactive ceramics/bone base and bioactive ceramics/cementless component, as well as the homogeneity and the density of the graft were examined radiologically.

Results: Functionally, the Merle d’Aubigné hip rating improved, increasing from11,3 to 15,9. Failure of fixation of the acetabular component occurred in 11,4 % of the acetabular reconstructions ( 4 hips in 35 patients). One was diagnosed as loose on the basis of radiographic criteria alone and the other three hips had a loose acetabular component at reoperation. We observed no failed reconstruction when the acetabular component is in direct contact with host bone on 50 % or more of its surface area.

We saw no radiolucent lines or spaces at the interface between bioactive ceramics and the host bone. Morphological changes or a decreased in graft volume were not seen, except for the patient with the loose cup.

Discussion-Conclusion: The findings of the present study support the use of bioactive ceramics and cement-less acetabular component in the presence of loss bone in order to achieve the goals of a revision hip replacement, provided that at least 50 % support of the cup can be obtained with host-bone.

Purpose: We studied a consecutive multicentric series retrospectively to assess outcome after one-stage revision total hip arthroplasty without cement for infection-related failed total hip arthroplasty in patients with chronic infection (> 30 days).

Material and method: Thirty-four patients (12 women and 22 men) underwent primary arthroplasty between 1992 and 1998. Mean age was 67.8 years (range 45 – 89). Indications were primary hip degeneration (n=17), neck fracture (n=5), secondary hip degeneration (n=12). Twenty-two patients had risk factors for infection. The same treatment protocol was used for all patients: single-phase replacement of the infected implant with insertion of a hydroxyapatite coated implant without cement and a three-month antibiotic regimen adapted to intraoperative samples. Seven femorotomies were performed. Clinical, laboratory and radiological findings were used to assess outcome. Patients were considered to be cured when laboratory tests were normal and x-rays showed no signs of suspected complications.

Results: There were three failures and 31 successful revisions. Intraoperative fracture of the femur required osteosynthesis in six patients. five patients developed a drug-related complication. Isolated germs were: meticillin-sensitive staphylococcus (n=18), meticillin-resistant staphylococcus (n=6), multiple germs (n=2), other germs (n=6), undetermined (n=2). The three failures occurred in patients with meticillin-resistant staphylococcal infections.

Discussion and conclusion: Our 88% success rate is in line with data in the literature. For us, one-phase revision is the best first intention option: other techniques may be required for patients with severe infections, after failure of one-stage revision, or massive loss of bone stock. Based on the present results, we have continued to prefer this therapeutic option but long-term follow-up is needed to further support these early findings.

Purpose: Combining biomaterials with non-cemented cups is a new approach to acetabular construction in patients with bone stock loss after failure of conventional techniques. We evaluated our early results and attempted to ascertain limitations.

Material and methods: Between January 1, 1996 and December 31, 2000, we changed 229 cups. The reconstruction combined biomaterials with a non-cemented cup for 48 patients (mean age 57 years, age range 29–84). Mean retrospective follow-up was 37 months (7–67) with two patients lost to follow-up early.

Two types of cups coated with hydroxyapatite were used depending on the acetabular potential for retaining the implant: 26 ATLAS press-fit cups (four screwed) and 22 Cerafit cups with Surfix anchor screws. Bony defects were filled with grains of macroporous calcium phosphate ceramic, alone or in combination with an autol-ogous bone graft (five patients) and/or an iliac bone marrow graft (24 patients). The Harris and modified PMA clinical scores were used for assessment. According to the Antonio classification, preoperative bone loss was grade II in 18, grade III in 27, grade IV in 3. We attempted to determine the percent of bone support under the cup before reconstruction. The centre of the prosthesis rotation and the interfaces with the biomate-rials were checked regularly.

Results: At short-term, this technique provided a clear functional improvement (Harris improved from 53.7 to 81.3 points). The bone-biomaterial interface did not show any lucent lines and tended to become homogeneous (31 cases). Seven patients (15.2%) developed millimetric lucent lines around stable implants. We had nine failures (19.6%) and performed four surgical revisions (8.7%) for major inclination of the cup in three and recurrent dislocation in one. There were also five patients with an asymptomatic implant migration. Excepting one case, the cup inclinations occurred when the bony support was less than 50% of the acetabulum while only one migration was noted with less than 50% bony support (p=0.02).

Discussion: At short-term this technique, which is easy to perform and less costly and safer than allografting, provides similar results. We observed a continuous construct between the receiver bone and the macroporous biomaterial in all cases. Mechanically, the cup was stable when the bony support was healthy and involved more than 50% of the acetabulum. Other reconstruction strategies should be considered in other cases.

Purpose: We report a retrospective monocentric evaluation of surgical lavage for early infection(≤ 30 days) after total hip arthroplasty.

Material and methods: Thirty-four patients, mean age 67.8± 12.1 years) who developed grade II infection in the Gustillo and Tsukayama classification were treated between 1992 and 1995 by surgical debridement and adapted antibiotherapy for a limited duration. Arthroplasty was indicated for primary hip degeneration (n=17), secondary hip degeneration (n=11), or neck fracture (n=6). There were 25 first-intention arthroplasties and nine revision arthroplasties. Seventeen patients had risk factors for infection.

All patient were followed for at least four years. Therapeutic efficacy was assessed on the basis of clinical and laboratory findings and radiographic results. We searched for biological or bacteriological factors predictive of good outcome. The chi-square test and Fisher exact tet were used to compare population distributions and Student’s t test and Mann Whitney test to compare means.

Results: Mean follow-up was five year, 74% of the patients developed recurrent infection. A second treatment protocol was implemented for only 56% of these patients and was effective against the infection and satisfactory for functional outcome (28% of the patients underwent revision for extraction of the prosthesis and 16% were given continuous antibiotics). There was a significant difference in the efficacy of the surgical lavage for delay ≤ 21 days (p = 0.02). Statistical analysis suggested the type of germ (p = 0.006), and presence of risk factors (p= 0.0052) had a significant influence.

Discussion: Attractive because minimally invasive, surgical lavage appears to limit acute symptoms without eradicating infection. Furthermore, if the failure is recognised late after infection has become chronic, the efficacy of revision is compromised and may lead to poor mid-term function. Like other authors, we identified delay to treatment as the one significant factor. These poor results have incited us to limit indications for surgical lavage to cases of infection diagnosed very early, programming secondary revision for very debilitated patients. Close and prolonged follow-up is indispensable.

Purpose: Shaft fractures are not uncommon in elderly subjects who have proximal osteosynthesis material. There are several options for the surgical technique and the fixation method, the choice depending on their aggressiveness.

Material and methods: Between January 1998 and January 2002, retrograde nailing with proximal locking using the fixation screws already in the femur was used for eight women aged 79–99 years (mean 92). The classical ascending nailing procedure was used to insert a Russell-Taylor nail in six patients and a supracondylar Stryker nail in two. The proximal locking was used by apposing the fixation screw, which implied coinciding the locking holes in the nail with the plate screws. This required using only one screw for locking in some cases because of the distances between the holes.

Results: There were no infectious complications. Fracture alignment was correct in all cases. Subjectively, total recovery of motion and independence was achieved. Likewise for pain relief although assessment was difficult. Bone healing was achieved in four months. Secondary varus displacement occurred due to insufficient hold of the proximal locking screw in the medial cortical.

Conclusion: Although not perfect, the retrograde nail locked in the proximal implant provides a satisfactory solution for these often debilitated elderly patients. This option enables a minimally aggressive operation allowing a composite osteosynthesis protecting the entire femur without imposing points of peak stress.

Purpose: Retrograde nailing is emerging among methods proposed or stabilisation of femoral fractures above total knee arthroplasties (TKA).

Material and methods. Between June 1994 and may 2000, 12 fractures above TKA were treated by retrograde nailing. These fractures occurred 43 months (4–51) after implantation of the TKA in three men and women aged 74 years (43–88). The fracture was situated just above the prosthetic trochlea in ten, and distant from the implant in two. The posterior cruciate ligament was preserved in six TKA and six were posterior stabilised prostheses. Indications for arthroplasty were degenerative joint disease in nine and rheumatoid polyarthritis in three. Four patients had proximal implants (one fixation and three prostheses). A percutaneous approach was used except for three cases in order protect the tibial component. Closed reduction was achieved, but required an open reduction for completion in two cases. the nail was advanced just to the trochlea in patients with a preserved posterior cruciate ligament and beyond the posterior stabilisation cage for the posterior stabilised implants. The knee was mobilised immediately after surgery and total weight-bearing was encouraged four to six weeks later.

Results: There was one error in the proximal aiming, one metastatic infection from a leg ulcer at three months and one tibial loosening in a polyarthritic woman 66 months after arthroplasty, i.e. 51 months after the fracture. Bone healing was achieved at two to four months. Frontal deviation was less than 5°. Recurvatum was less than 5° in eight cases, between 5° and 10° in two cases and between 10° and 20° in two others. At mean follow-up of 23 months (3–60), maximal moss of mobility was 10°. There was not worsening of pain.

Discussion: Retrograde nailing leads to bone healing with satisfactory frontal alignment and minimal loss of mobility. The approach uses the initial incision, facilitating complementary procedures or revision if needed. The main problem is controlling recurvatum, even though at the follow-up reported there was no clinical impact or loosening. The limitations of this method are well defined: free medullary canal, sufficient knee flexion, compatible femoral component. The tibial obstacle in posterior stabilised implants is less well known; It should be protected during the nailing if it is high. The polyethylene insert may have to be removed temporarily in certain cases.

Conclusion: The two principal problems with retrograde nailing are recognising implants compatible with this technique and controlling recurvatum. Results are acceptable with a minimally invasive technique.