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.

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: The purpose of this retrospective study was to assess the carcinological and functional results of resection-arthrodesis procedures for giant-cell tumours of the lower extreminty of the radius.

Material and methods: This series included 16 patients, nine men and seven women, mean ate 39 years (19–63). The initial symptom was pain in all patients. Nine of the 16 patients were referred for recurrence after primary curettage-filling: the seven others presented voluminous tumours encompasing nearly all of the epiphyseome-taphyseal region rendering curettage-filling impossible. En bloc resection of the tumour with reconstruction using two tibial splints applied proximally on the radius and distally on the first ray (eight cases) or the second ray (eight cases) of the carpus was performed in all cases. A plaster cast or external fixation protected the construct. All tumours were benign. Nine patients were reviewed for function (pain, motion, force) and radiographic assessment (lateral view of wrist in maximal flexion and extension). We collected data recorded at the last visit for the other patients.

Results: Mean follow-up was 70 months (12–205). The functional outcome was good with 15 patients totally pain free. For the eight patients whose mediocarpus could be preserved, dorsal flexion was 30° and palmar flexion was 15°. Pronosupination varied from 10° to 170°. Bone fusion was obtained in 15 patients. One developed nonunion which was revised with a bone graft and plate fixation and finally healed. Two graft fractures secondary to trauma consolidated normally after plate-screw fixation associated with a new graft. Three of the patients developed local recurrence in the form of subcutaneous nodules which were resected. One of these three patients had a bony recurrence at the graft-radius junction which was treated by a new bone resection and achieved cure.

Discussion: Resection-arthrodeis is indicated for recurrence after curettage-filling and for voluminous giant-cell tumours with extraosseous extension and failure of curetae-filling. Curettage is rarely possible in this location due to invasion of soft tissues and destruction of the joint surface which occurs early. It appears preferable to perform an arthrodesis between the radius and the first ray of the carpal bones to preserve partial motion of the wrist and good function.

Purpose: Fibrous dysplasia is a rare condition accounting for about 1% of benign bone tumours. Both mono- and polyostotic dysplasia is described. Treatment of small tumours is not particularly difficult, but extensive or complicated tumours are another problem. The purpose of this work was to present the results of surgical treatment of a consecutive series of 64 patients. Particular focus was placed on complications.

Material and methods: This retrospective series included 64 patients with fibrous dysplasia. Mean age was 32 years. There were 37 women and 27 men. Monostotic dysplasia was noted in 58 cases. The femur was the most frequent localisation (n=19). Seven patients had a fracture. Histological proof was obtained in 61 patients. In three patients, fibrous dysplasia was associated with another tumour (aneurysmal cyst or adamantinoma). Several therapeutic strategies were proposed: abstention for three patients, biopsy alone for 13, resection for six, curettage for 34. The curettage was filled in 23 cases with osteosynthesis in 11. Eight patients were given other surgical treatments (prosthesis, osteosynthesis, amputation).

Results: We had five postoperative complications. At mean follow-up of 45 months, 14% of the patients still suffered from generally mild to moderate pain. Radiologically, there were four recurrences, 12 unchanged, 18 regressions, and 19 remissions (generally after resection or curettage with filling). Long-term follow-up revealed malignant transformation in two patients.

Discussion: Lesions treated by biopsy alone cured or regressed in 30% of the cases while curettage with filling led to cure or regression in 70% of the cases. We did not include patients treated by bisphosphonates in this series because of insufficient follow-up. Nevertheless, this treatment appears to have a promising effect on pain.

Conclusion: Results of treatment for fibrous dysplasia are not as good as might be suspected for this benign disease. The role of surgery appears to be on the decline, to be replaced by bisphosphonates whose long-term efficacy must be evaluated.

Purpose: This retrospective analysis was based on observations in 15 patients, seven men and eight women, mean age 48 years (19–72) treated between 1988 and 2000 at the Curie Institute. The tumour was located in limbs in eight patients (one humerus, two femurs, four tibias, one fibula), in the axial skeleton in five (four pelvi, one sacrum), and in the rib cage and the scapula in one each. Histology examination of the dedifferentiated component displayed fibrosacroma in six cases, HFM in two, rhabdomyosarcoma in two and leiomyosarcoma and osteosarcoma in one each. Six patients were given neoadjuvant and adjuvant chemotherapy of the osteosarcoma type and underwent conservative surgery of the affected limb in three out of four cases. Total histological necrosis was observed in three out of six cases. Six patients were given adjuvant treatment alone using an osteosarcoma protocol. Three unoperable patients were given palliative chemotherapy and radiotherapy.

Results: Nine patients died from their disease. The most frequent metastatic site was the lung; mean survival was 20 months. Six patients survived including five with no progression (1+, 5+, 6+, 7+, 12+ years). Three out of five had had preoperative chemotherapy with a complete histological response and two out of five had had osteosarcoma protocol adjuvant chemotherapy.

Conclusion: Dedifferentiated chondrosarcoma is generally considered to have very poor prognosis and should lead to an adapted therapeutic strategy. In our series, the osteosarcoma protocol provided complete histological response in three out of six patients. Five patients had prolonged survival, all had been given an osteosarcoma type chemotherapy protocol.

Purpose: We report cancerological and functional outcome in 41 patients who underwent interilioabdominal disarticulation for malignant tumours.

Material and methods: This retrospective series included 27 men and 14 women, mean age 49 years, most of whom underwent surgery for chondrosarcoma. In ten patients, the disarticulation followed a resection-reconstruction procedure. In five patients, it followed curettage or contaminated margin resection. For seven patients it was performed after radiotherapy alone. None of the patients had metastatic dissemination prior to surgery. The resection margins were in healthy tissue in 24 cases and contaminated in 17. Mean follow-up was 62 months.

Results: Twenty-eight patients died from their disease and one died from pulmonary embolism. At last follow-up, among the 13 living patients, five had local or general relapse. For the 17 patients who had contaminated resection margins, ten developed a recurrent tumour compared with five recurrent tumours among the 25 patients with resection margins in healthy tissue. Mean five-and ten-year survival rates were 30% and 25% respectively. Initial treatment, tumour size and tumour histology did not have any significant effect on prognosis. The only factor with a significant effect on survival was the quality of the resection margins. All patients were able to walk with two crutches.

Discussion: Interilioabdominal disarticulation is a very mutilating procedure. Since the development of conservative surgery of the pelvis, indications for interilioabdominal disarticulation are generally limited to very voluminous endopelvic tumours with vessel and nerve invasion. For local recurrence after surgical resection of the pelvis or proximal femur, especially in patients with infection or radiated tissue, interilioabdominal disarticulation may be the only solution providing satisfactory cancerological resection. Careful exploration of the locoregional and general extension is necessary before proposing this mutilating procedure, with its inherent psychological and functional impact, in order to properly select patients free of metastasis who could benefit from the cancerological resection provided by inter-ilioabdominal disarticulation.

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 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.