Aims

Resection of the proximal humerus for the primary malignant bone tumour sometimes requires en bloc resection of the deltoid. However, there is no information in the literature which helps a surgeon decide whether to preserve the deltoid or not. The aim of this study was to determine whether retaining the deltoid at the time of resection would increase the rate of local recurrence. We also sought to identify the variables that persuade expert surgeons to choose a deltoid sparing rather than deltoid resecting procedure.

Introduction

Total hip replacement (THR) is one of the most widely used and most successful orthopedic procedures performed in developed countries. The burden of revision surgery, however, has become a major issue in terms of both volume and cost. Technical errors at the time of the index operation are known to be associated with an increased rate of revision.

Statistical methods, such as the CUSUM test, which have been developed for the manufacturing industry to monitor the quality of products, have come to the attention of health-care workers as a result of centers with protracted periods of inadequate performance. In orthopedics, these methods have been used to monitor the quality of total hip replacement in a tertiary care department using conventional imaging techniques.

Biplane low-dose X-ray imaging (EOS) may allow an easy, patient-friendly, way to retrieve data on the position of implants immediately postoperatively. Therefore real-time feedback is provided to surgeons and performance adjusted accordingly

Introduction

Fibromatosis is a disorder characterised by a spectrum of biological behaviour from relative indolence to aggressive local infiltration. With aimed to describe the pre and post-operative functional status of these patients managed with surgery and analyse the effect of radiotherapy on functional outcome.

Fibromatosis represent a highly heterogeneous group of tumours in growth pattern, location and management. Our aim was to describe the demographics of the patient population who had undergone surgical resection and to identify predictors of local recurrence. Any lesion that was infiltrating the chest or abdominal cavity was excluded. Patients were also not included if they had a plantar or palmar lesions or had received hormonal or chemotherapy.

67 men and 88 women aged from 16 to 77 with a median age of 39 were analyzed. 121 patients had no prior resective operative intervention. 34 patients had undergone an attempted resection procedure at another unit of which 30 had locally recurred. 3 were located in the abdominal wall, 5 chest wall, 15 paraspinal, 56 lower and 76 upper limb. 40 patients did not receive XRT, 18 in the post-operative period and 97 in the pre-operative period. 67 operations produced margin negative resection, 85 were positive and 3 in which the margin status was unknown. Follow-up ranged from 1 day post op to 23.3 years. 23 patients had a local recurrence. Following subsequent re-resections, the total number of patients who were alive with evidence of disease was 16.

6 pts had deceased. 149 were alive with no evidence of disease. No factors were found to be statistically significant for predicting local recurrence, including the use of radiation (0.06) and margin status (0.81). Although radiation, given either pre or post-operatively did trend towards preventing local recurrence (HR 0.40; 95% CI 0.15 to 1.06; p = 0.06).

Purpose of the study: The objective was to assess the diagnostic yield of angioscanner evaluation of arterial invasion of limb tumours before surgery.

Material and methods: This was a prospective study conducted from January 2005 to May 2008 designed to assess 55 arterial segments and limb or pelvic tumours on the preoperative angioscan. Screen displays of the radiographic images were reread conjointly but radiologists using vascular analysis software. Contact of a large vessel with the tumour was classified as follows: fatty line, contact less than 90° of the vessel circumference, contact less than 180°, contact ≥ 180°. Intraoperative vessel-tumour contact was classified as follows: cleavable, non-dissectible. Agreement between the angioscan and the operative findings was analysed.

Results: Forty-five arteries were cleavable and ten non-dissectible. All arteries that were separated from the tumour by a fatty plane or were in contact over less than 90° of the circumference of the vessel were cleavable at surgery (n=37/37). The sensitivity, specificity and diagnostic accuracy and the rate of positive scan for probable arterial contact > 180° were 90, 93, 93 and 13.5% respectively.

Conclusion: The angioscanner provides a satisfactory means for predicting vascular invasion of limb and pelvic tumours and contributes pertinently to the pre-operative work-up.

Purpose of the study: Secondary chondrosarcoma is rare (1% of malignant bone tumours). Most cases develop from solitary exostosis or concern an exostosis disease. Localisations predominate in the girdles. Management is difficult and no consensus has been reached. The purpose of this study was to present a series of 25 secondary chondrosarcomas in order to improve diagnostic and therapeutic management.

Material and methods: This was a retrospective analysis of 25 cases of secondary chondrosarcoma (10 on solitary exostosis and 15 on exostosis disease) treated by one surgical team from 1970 to 2008. The epidemiological features, clinical signs, radiographic findings, type of treatment and outcome at last follow-up were analysed for the two groups.

Results: Patients with secondary chondrosarcoma were 10 to 20 years young than those with primary chondrosarcoma. There were an equivalent number of men and women and the predominant sites involved flat bones in both groups. The radiographic signs of sarcomatous degeneration most widely observed included heterogeneous calcifications, irregular contours, and soft tissue invasion. Tumours were generally well differentiated. The rate of local recurrence after surgery was 15% at five years and 20% at ten years. Mortality was 2% at five years and 5% at ten years. Most of the deaths occurred after local recurrence. Metastases were identified in four patients after the initial resection. The rate of local recurrence was lower after wide surgical resection.

Discussion: The real objective with secondary chondrosarcoma is to ensure a regular effective follow-up of these patients with a known risk of recurrence (exostosis disease) in order to recognise early signs of sarcomatous degeneration. One of the most reliable signs is recent development of unusual pain on a known exostosis. Education of at-risk patients is crucial and should enable early screening and detection.

Conclusion: Secondary chondrosarcoma occurs 10 to 20 years earlier than primary sarcoma and generally involves the girdles. Outcome and management practices are similar to primary chondrosarcoma. The most important issue is to ensure good patient follow-up in order to enable early diagnosis in patients at risk.

Purpose of the study: Percutaneous screw fixation is widely used for the treatment of non-displaced fresh fractures of the carpal scaphoid. This screw fixation can be achieved either via a volar approach (retrograde insertion) or via a dorsal approach (antegrade insertion). The purpose of our study was to define the best approach as a function of the orientation of the fracture line (types B1 or B2 in the Herbert classification).

Material and methods: We used 12 upper limbs. For each wrist we obtained three scanner images: in maximal flexion, in the neutral position, and in maximal extension. For each scanner image, the parasagittal slice corresponding to the ideal plane for screw position was identified by digital reconstruction. On each slice, the type B1 and B2 fractures were modellised, as was the displacement of the corresponding screws introduced via the volar incision (S1) or the dorsal incision (S2). Each virtual screw was positioned as perpendicular as possible to the fracture line. For each slice corresponding to a given wrist position, we measured the angles between the fracture line (B1, B2) and the screws (S1, S2), giving four angles V1 (S1-B1), V2 (S1-B1), D1 (S2-B1), D2 (S2-B2). Thus the angle closest to 90° was considered the most satisfactory.

Results: For B2 fractures, the position of the virtual screw perpendicular to the fracture line was possible via both the volar and the dorsal incision. For B1 fractures, it was impossible to position the screw perpendicular to the fracture line, but the dorsal approach with the wrist in maximal flexion gave the best position.

Conclusion: For B2 fractures, the dorsal and volar approach allow optimal screw insertion so the choice of the incision depends on the surgeon’s experience. For B1 fractures, we recommend the dorsal approach.

Purpose of the study: Certain patients with a total knee arthroplasty (TKA) require large range of flexion postoperatively to enable squatting and sitting cross-legged. Several factors have an effect on this flexion, including prosthesis design. The purpose of this study was to examine the influence of prosthesis design on intra- and postoperative flexion of three modes of TKA with a pure rotational mobile plateau: two NexGen posterostabilised (PS) prostheses (LPS-Standard and LPS-Flex) and one ultracongruent prosthesis (SAL). It was hypothesised that PS prostheses would have a better flexion than the ultracongruent prosthesis and that the flexion would be greater with the LPS-Flex than the LPS-standard.

Material and methods: This was a prospective randomised study of consecutive patients from January 2006 to January 2007 to compare maximal flexion for each model. All patients requiring a first-intention TKA were included in this study. Seventy-tow TKA were studied: LPS-standard (n=24), LPS-Flex (n=22), SAL (n=26). Flexion was measured pre and postoperatively goniometrically. Intraoperative measures were made with the navigation system (Navitrack-Orthosoft). Minimum follow-up was one year.

Results: There was a significant difference in flexion, intraoperatively and at last follow-up, in favour of the PS models over the ultracongruent SAL. Conversely, there was no significant difference between the LPS-standard and the LPS-Flex. The analysis of factors predictive of flexion were the SAL model with a negative influence (loss of 8° intraoperatively [p< 10-4] and 15° at one year [p< 10-4] compared with the LPS models). Preoperative flexion appeared to be a positive predictive factor (p=0.00023).

Discussion: The design of the TKA has an influence on knee flexion: from implantation, flexion of the PS models was superior to the ultracongruent model, a difference which persisted late after the operation. For the PS models, the LPS-Flex model presented as a large flexion model did not, in our study, demonstrate its superiority over the LPS-standard model, irrespective of the time of the comparison. It should be noted that for implantation the LPS-Flex model required a posterior cut 2mm more than for the LPS-standard. Good preoperative flexion is an essential factor for obtaining good postoperative flexion, irrespective of the model implanted.

Disruption of the interosseous membrane is easily missed in patients with Essex-Lopresti syndrome. None of the imaging techniques available for diagnosing disruption of the interosseous membrane are completely dependable.

We undertook an investigation to identify whether a simple intra-operative test could be used to diagnose disruption of the interosseous membrane during surgery for fracture of the radial head and to see if the test was reproducible.

We studied 20 cadaveric forearms after excision of the radial head, ten with and ten without disruption of the interosseous membrane. On each forearm, we performed the radius joystick test: moderate lateral traction was applied to the radial neck with the forearm in maximal pronation, to look for lateral displacement of the proximal radius indicating that the interosseous membrane had been disrupted. Each of six surgeons (three junior and three senior) performed the test on two consecutive days.

Intra-observer agreement was 77% (95% confidence interval (CI) 67 to 85) and interobserver agreement was 97% (95% CI 92 to 100). Sensitivity was 100% (95% CI 97 to 100), specificity 88% (95% CI 81 to 93), positive predictive value 90% (95% CI 83 to 94), and negative predictive value 100%).

This cadaveric study suggests that the radius joystick test may be useful for detecting disruption of the interosseous membrane in patients undergoing open surgery for fracture of the radial head and is reproducible. A confirmatory study in vivo is now required.

Enchondromatosis is a non-hereditary disease, characterised by the presence of multiple enchondromas. While Ollier Disease is typified by multiple enchondromas, in Maffucci Syndrome they are combined with haemangioma.

Due to the rarity of these diseases, systematic studies on clinical behaviour providing information how to treat patients are lacking.

This study intends to answer the following questions: What are predictive factors for developing chondrosarcoma? When is extensive surgery necessary? How often patients die due to dedifferentiation or metastasis?

Twelve institutes in eight countries participated in this descriptive retrospective EMSOS-study. 118 Patients with Ollier Disease and 15 patients with Maffucci Syndrome were included. Unilateral localization of disease was found in 60% of Ollier patients and 40% of patients with Maffucci Syndrome.

One of the predictive factors for developing chondrosarcoma is the location of the enchondromas; the risk increases especially when enchondromas are located in the scapula (33%), humerus (18%), pelvis (26%) or femur (15%). For the phalanges, this risk is 14% in the hand and 16% in the feet. The decision whether or not to perform extensive surgery is difficult, especially in patients who suffer multiple chondrosarcomas.

Malignant transformation was found in fourty-four patients with Ollier Disease (37%) and eight patients with Maffucci Syndrome (53%). Multiple synchronous or metachronous chondrosarcomas were found in 15 patients.

Nine patients died (range 21–54 yrs). Seven of them died disease related due to pulmonary metastasis (2 humerus, 2 pelvis, 3 femur). Two patients died from glioma of the brain.

In conclusion, one important predictive factor for developing chondrosarcoma is the location of the enchondromas; interestingly, only patients with chondrosarcoma outside the small bones died of their disease. In this series, no dedifferentiation of chondrosarcoma was seen. A first design flow-chart how to approach chondrosarcoma in patients with Ollier Disease and Maffucci Syndrome is in preparation.

Introduction: Although a number of methods have been described to treat recurrent dislocation following total hip arthroplasty, this complication remains a challenging problem. The purpose of this retrospective study was to evaluate the minimum 2-year outcome in a consecutive series patients treated with a cemented tripolar unconstrained acetabular component for recurrent dislocation.

Patients and Methods: Fifty-one patients presenting with recurrent dislocation following primary or revision total hip arthroplasty in the absence of an identifiable curable cause were treated with a cemented tripolar unconstrained acetabular component. There were thirty-nine females and twelve males with a mean age at the time of the index procedure of 71.3 years. A single acetabular component design was used consisting of a stainless steel outer shell with grooves for cement fixation with a highly polished inner surface. This shell articulated with a mobile intermediate component with an opening diameter smaller than the 22.2-mm femoral head. No locking ring or other mean of constraint was associated.

Results: Of the fifty-one patients, forty-seven have had complete clinical and radiological evaluation data at a mean follow-up of 31.2 months (twenty-four to 56.3 months). The cemented unconstrained tripolar acetabular component restored complete stability of the hip in forty-nine patients (96%). The mean Merle d’Aubigné hip score was 15.8 ± 2.0 at the latest follow-up. Radiographic analysis revealed no or radiolucent lines less than 1 mm thick located in a single acetabular zone in forty-three of forty-seven hips (91.5%). The cumulative survival rate of the acetabular component at 36 months using revision for dislocation and/or mechanical failure as the end point was 93.3 ± 4.6% (95% confidence interval, 84.4% to 100%).

Conclusion: A cemented tripolar unconstrained acetabular component was highly effective in the treatment of recurrent dislocation with none of the complications associated with constrained devices. However, because longer term follow-up is needed to warrant that dislocation and loosening rates will not increase, the use of such a device should be limited to strict indications.

Purpose of the study: Primary bone tumors of the sacroiliac joint are difficult to diagnose. We present the procedure used to resect these tumors and reconstruct the pelvic ring, and the carcinological and functional outcome.

Materials and Methods: This was a retrospective analysis of a consecutive series of patients treated for a tumor of the iliac bone or of the sacrum which involved the sacroiliac joint. Tumor grading was based on the Enneking classification and the functional outcome on the MSTS score.

Results: From 1986 to 2003, 24 patients were treated for a a tumor involving the sacroiliac joint. Six with invasion of the sacral body. The histology was osteosarcoma (n=8), chondrosarcoma (n=8), malignant hystiocytofibroma (n=3), Ewing’s sarcoma (n=2), schwannoma (n=1), leiomysarcoma (n=1) and haemangiopericytoma (n=1). Seventeen patients were given neoadjuvant chemotherapy. A wide crest approach was used to access both aspects of the pelvic ring. Neurological sacrifice was required in six patients. Operative time was 5.27 hours on average. Reconstruction was achieved with an autograft and instrumentation. The resection was wide in 11 cases, marginal in 12, and contaminated in one. The mean follow-up was 4.77 years. Ten patients died from their disease. Survival was correlated with the quality of the resection and with the initial tumor stage. Hemisacrectomy did not affect survival. Bone healing was achieved in 13 patient, ten who survived. The mean MSTS score was 48% at last follow-up in 14 survivors. For the nine patients who did not require neurological sacrifice, the mean score was 58%. For the five other patients, the mean score was 38% This score was 65% in patients with bone healing and 8% in those with nonunion.

Discussion: The survival of patients with a tumor of the sacroiliac joint is basically related to the histological diagnosis and the quality of the resection. If the disease can be controlled, the method of the reconstruction proposed here enables bone healing with a satisfactory functional result when neurological sacrifice can be avoided.

Background: Quality control has found an important application in assessing learning curves of trainees and controlling innovative technologies as they are initiated.

Objective: To develop a quantitative and individualized statistical tool that may help trainees and tutors to define when a procedure is adequately learned and supervision may be safely stopped.

Methods: A series of 78 consecutive computer assisted-based navigation total knee replacements in patients with osteoarthritis or rheumatoid arthritis was monitored to control surgical performance. The primary outcome was limb alignment in the frontal plane. The target for alignment was 180° and the standard deviation for limb alignment for this series was 2.35°. Knees implanted with a deviation of more than 3 degrees from the target value were considered as failures. A new statistical tool, the CUSUM for Learning Curve (LC-CUSUM) was used to monitor surgical performance. The LC-CUSUM was developed to test whether a process has reached a predefined level of performance. Therefore, the LC-CUSUM presumes the process is not controlled (not learned) at the start of monitoring and the test will signal when the process can be considered as in-control (learned). For continuous data, two LC-CUSUMs are drawn simultaneously.

Results: The first 20 prostheses were more often implanted in varus alignment. Subsequently, the surgeon tried to correct this problem but tended to implant the prostheses more in valgus alignment (overcorrection). After a few more procedures the surgeon found a balance, and the implants were positioned around the target value with no apparent tendency to favour one side or the other. The positive LC-CUSUM signalled first at the fifth procedure; however, the negative LC-CUSUM had not crossed the lower limit and the surgeon could not be deemed as having achieved the required level of performance. It is not until the 25th procedures that the negative LC-CUSUM crossed the lower boundary. At this point, enough evidence had accumulated to state that the surgeon had reached proficiency. A standard CUSUM was initiated to monitor the process to the end and ensure it would not deviate from the required performance. After the seventy-eighth procedure, monitoring was discontinued.

Conclusion: The LC-CUSUM is an innovative tool that allows quantitative monitoring of individual surgical performance during learning process. It allows stating when a predefined acceptable level of performance is reached.

Background From individual randomized studies it is unclear which of patellar (PT) tendon or hamstring (HS) tendon grafts yields the best functional results after ACL reconstruction. Therefore, we performed a meta-analysis to provide quantitative data to compare PT (control group) to HS (treatment group) grafts after ACL reconstruction with regards to knee function.

Methods We searched computerized databases for randomized controlled trials reporting one of the following outcome related to function: final overall International Knee Documentation Committee (IKDC) score and return to pre-injury level of activity. Studies were abstracted independently by two reviewers. Random effect models were used to pool the data.

Results Fourteen trials (1263 patients) met the inclusion criteria. There was no difference in final overall IKDC and in the number of patients returning to full activity after PT and HS graft reconstruction. Relative risk was 0.90 for final overall IKDC score class A in favor of PT grafts (not significant, P=0.13), and 0.94 for return to pre-injury level of activity in favor of PT grafts (not significant, P=0.28). Quantitative interaction tests on the effect of treatment based on study quality, randomization status, number of strands used, and length of follow-up were not significant. At last follow-up, only 41% and 33% of PT and HS graft reconstructed patients were respectively reported as normal using the final overall IKDC.

Conclusion There was no difference in the final overall IKDC and in the number of patients returning to full activity after HS tendon graft and PT graft reconstructions. It should be emphasized that more than 60% of the patients will not make full recovery after their reconstruction and patients should be informed accordingly.

Purpose of the study: The rate of failure can be high for massive reconstruction prostheses after tumor resection. We studied the causes and possible factors of failure.

Material and methods: The series included 91 patients who underwent surgery from 1972 to 1994 for resection of a bone tumor involving the knee joint. A GUEPAR prosthesis was implanted in all cases for reconstruction (megaprosthesis in 58 cases and composite prosthesis in 33). The extensor system had to be reconstructed in 37 patients. A GUEPAR II implant was used in 73 patients; 48 of these implants had an antirotation system. The analysis was retrospective. Outcome was studied in terms of survival and independent factors predictive of failure unrelated to the tumor.

Results: Mean follow-up was 72 months. At last follow-up, 68 patients were living disease free. There were nine cases of rupture of the extensor system. Preservation of a continuous extensor system at the time of bone resection reduced the risk of rupture (p=0.036). Seven allografts fractured, two loosened, and six became infected. Use of an allograft did not reduce the risk of loosening (p=0.17). Intraxial laxity was observed in 17 patients. Use of an antirotation system was a factor of risk of intraxial laxity (p=0.0023) but not of aseptic loosening. Aseptic loosening was observed in 18 patients: 10 femur reconstruction and 8 tibia reconstruction. The difference was not significant (p=0.6). In all, 104 revisions were required in 53 patients; 36 revisions of the prosthesis, 23 of them for mechanical causes. Overall median survival, excepting tumor-related causes, was 130 months. It was 130 months for femur reconstructions and 117 for tibia reconstructions (p=0.57). Age, length of resection, tumor location, use of an allograft, and use of an antirotation system were not found to be significant prognostic factors for implant survival.

Discussion: As reported by many others, we found that the rate of failure of massive prostheses for infectious and mechanical causes remained high in patients treated for bone tumors involving the knee joint. Survival of massive implants is much lower than that of gliding prostheses.

Conclusion: Technical progress is required to improve the survival of massive implants used for the treatment of bone tumors involving the knee joint.

Purpose of the study: Composite knee prostheses using a massive implant and an allograft is one option for joint reconstruction after extensive resection of the knee joint for bone tumor. Implant survival after resection of the proximal tibia is not well documented. We analyzed survival and complications in 26 composite knee prostheses.

Material and methods: A composite prosthesis was implanted in 26 patients after resection of a tumor of the proximal tibia. Median length of resection was 14 cm (range 9–20 cm). A GUEPAR massive implant was used in all cases. Allografts were sterilized with gamma radiation. Median length of the tibial stem was 30 cm (range 20–38 cm). The stem was cemented in the allograft and in the tibia.

Results: Median patient survival was 68 months. At last follow-up, 19 patients were living disease free. Among the 26 allografts, seven had fractured and five were partially resorbed. Seven allografts exhibited signs of fusion at the junction with the recipient bone. Seven reconstructions of the extensor system failed (rupture). Conversely, there were no ruptures in patients whose extensor system could be preserved (continuity) at tumor resection. Six composite prosthesis were infected, four early (< 2 months) and two late. There were four cases of local recurrence. Globally, 48 secondary procedures were required in 21 patients: 26 for mechanical defects, 13 for infection, 7 for local recurrence and 2 for postoperative complications (necrosis of the tibialis anterior in both). There were 14 revisions: 9 composite prostheses were replaced, fusion was performed in 2 patients, and 3 patients required amputation. Median survival of the reconstructions, considering all failures together, was 102 months (95%IC 64.3-Inf). Median survival, including all failures for local recurrence, was 105 months (95%IC 101-Inf).

Discussion: The rate of failure and of complications is high for massive knee prosthesis combined with a radiated allograft for reconstruction of the proximal tibia. There is no series reported in the literature. When possible, the extensor system should be preserved.

Conclusion: We currently use massive knee prostheses without allografts, reconstructing the extensor system with a vastus medialis flap.

Purpose: Appropriate management of complex trauma of the upper limb (CTUL) is a significant therapeutic challenge. The main difficulty is to determine in an emergency situation when ambitious conservative surgery is legitimate and when amputation in necessary. We propose a prognostic lesion score to determine the best option in the emergency setting.

Material and methods: This study included 48 patients operated on between 1987 and 1997. These patients presented total or partial amputation (n=23), devascularising injury with continuous limb (=7), complex non-devascularising injury with continuous limb (n=18) (Gustilo IIIa and IIIb). Isolated hand trauma was excluded. Each patient was attributed retrospectively a lesion score taking into account each tissue (bone, vessels, nerves, muscles, skin). At minimum two-year follow-up, the outcome was evaluated for the amputated or non-amputated limb. For each non-amputated patient, a more precise outcome was established using the Chen classification. Operative procedures used the same protocol for all patients.

Results: Considering the functional results, the statistical analysis enabled identifying prognostic factors for amputation among the five variables studied. Analysis using a classification tree enabled development of a decisional algorithm based on the muscle, nerve and skin injuries which provided 64.7% sensitivity and 100% specificity with a 100% positive predictive value and an 83.8% negative predictive value. A multiple logistic model was used to confirm these results and led to the selection of the same variables.

Discussion: The CTUL score is easy to use and is the only one in the literature using only variables statistically proven to have significant prognostic value for CTUL. Surgical experience is however indispensable for appropriate decision making in these emergency situations. This score thus provides an important therapeutic aid useful in borderline cases where amputation is discussed.

Conclusion: A prospective study including a larger number of patients would be helpful to better detail indications and preserve the 100% specificity for an irreversible therapeutic decision.