Purpose: We set four objectives: compare compression plate with locking screw, assess bone graft usefulness, assess utility of resection and compression of fracture site, and determine prognostic factors.

Materials and methods: A multicentre study was carried out including Sant Pau, Valle de Hebròn and IMAS hospitals in Barcelona. 54 surgical cases treated from 1994 to 2003 were included for retrospective study. Three groups of factors were analysed: familial, factors associated with the initial trauma and those associated with the surgical procedure. We studied the statistical relation to consolidation, consolidation time and postoperative complications.

Results: The following factors significantly enhanced consolidation (p< 0.05): treatment with nail in atrophic pseudoarthrosis and plate in hypertrophic. Consolidation time was significantly shortened (p< 0.05) if fractures were initially simple (type A) and for those initially treated conservatively. Postoperative complications were reduced (p< 0.05) in fractures that were initially simple (type A).

Conclusions: There were no differences between the two implants studied in terms of consolidation, consolidation time and complications. However, cases of atrophic pseudoarthrosis had a better outcome with nails and the hypertrophic cases with plates. Bone grafts did not improve results. Compression of the fracture site was a determining factor in achieving consolidation; therefore, open intramedullary nailing should be performed to this end. Simple fractures and fractures initially receiving conservative treatment were good prognostic factors following pseudoarthrosis surgery.

Purpose: We carried out a biomechanical study by finite element analysis to compare treatment with a plate and treatment with a nail in pseudoarthrosis of the humeral shaft.

Materials and methods: We used a cadaver humerus and the two fixation devices to generate the geometry with design software (CATIA® v4.2). We then modelled the shapes with finite element analysis software (MSC.Patran®) and created three experimental models: healthy humerus, humerus with shaft pseudoarthrosis stabilised with AO plate and humerus with shaft pseudoarthrosis stabilised with locking nail. Both implants were titanium. The three models were subjected to nine different load conditions and the results compared.

Results: The nail model is stiffer than the plate in compression (3002.80 vs 789.68 N/mm), traction (6576.73 vs 1559.90 N/mm) and torsion (4.67 vs 2.73 N/mm). However, the plate model is biomechanically superior to the nail under other load conditions (mediolateral flexion, anteroposterior flexion, anteroposterior shear and mediolateral shear).

Conclusions: Although we can understand and compare the stability of the plate model with the nail, joint clinical and biomechanical studies are needed to determine the minimum stiffness required so that it will not interfere with the process of union under different load conditions.

Aims: Extraskeletal bone tumours are rare and high-grade tumours including osteosarcoma (OS), chondrosarcoma (CHO) and Ewingñs sarcoma (EW) of the soft tissues and its variants. A retrospective study of 22 cases were made in our Hospital in the period from 1983–2000. Methods: The study of 22 cases revealed that this tumours affect adults (median age 50.86; range 17 to 70 years). The thigh (36.36%) and the arm-elbow (18.18%) were the most common tumour locations. For diagnostic type of tumours 11 were CHO, 8 OS and 3 EW. The median follow-up was 48.9 months with a range 6 to a97 months. All of the cases of OS and EW were treated with preoperative chemotherapy and postoperative radiotherapy. Results: The preoperative duration of symptoms was ranged from 6 weeks to 6 years (median 6 months). Local recurrences after wide and radical surgery developed in 8 cases Ð35.45%- (3 CHO, 4 OS and 1 EW) and distant metastases developed in 3 cases (13.18%). 14 cases were alive with no evidence of recurrence (63.6%), 5 were alive with one or more recurrences (22.72%), 1 were alive with metastases (4.59%) and 2 ulcerated tumours were exitus form metastases (10.05%). Five amputations were performed. Conclusions: 1. All cases were high-grade tumours. 2. The prevailing sites of metastases were the lung, the regional lymph nodes and the skeleton. 3. Cure may be achieved by wide or radical local excision of the tumour at and early stage of the disease (combined with radiation and chemotherapy).

Aims: The aim of this retrospective study was determine the survivorship of bipolar arthroplasty for femoral neck and what kind of associated factors could inßuence this survival rate. Methods: From 1980 until 2000, a total of 271 bipolar hemiarthroplasties were inserted for displaced femoral neck fractures in 269 patients, 207 were women and 64 were men, 62,4% cemented and 37,6% uncemented. The median age was 67,5 years (range: 28–93). The median follow-up was 74.6 months (range: 1–232). They were excluded pathologic fractures, osteoarthritis and dysplasic hips. We have studied the relationship between survivorship and presumed prognostic factors like age, sex and cementation. We used Kaplan-Meier method for calculating survival rates and Log-Rank test to assess prognostic factors. Results: Twenty-three (8,5%) hips required revision surgery, 3 were septic (1,1%) and 20 were aseptic (7,4%). In aseptic group we could þnd stem loosening (4,1%), polyethylene failure (1,4%), acetabular erosion (1,1%) and dislocation (0,7%). The 5- and 10-year hemiarthroplasty survival (HS) rates were 96% and 93% respectively. We found that only age< 60 years was signiþcant prognostic factor for HS (p< 0.05). Sex and cementation has not inßuenced signiþcantly on survival rate (p> 0,05). Conclusions: According to the outcomes in our group, we feel bipolar arthroplasty should be the technique of choice in patients over 60 years with sufþcient walking ability, when they have a displaced femoral neck fracture.

Aims: The purpose of this report is to asses the prognostic factors that could influence management and clinical outcome of malignant fibrous histiocytoma (MFH) of soft tissues. Methods: Between 1990 and 2000, 79 patients diagnosed with localized disease by MFH, seen at Santa Creu i Sant Pau Hospital, have been reviewed. 45 were women and 34 were men. The median age at presentation was 62 years (range: 20–85). The median follow-up was 60 months (range: 1–119). Low grade tumors constituted 8% and the remaining 92% were high grade. Several treatment modalities with or without radiotherapy and/or chemotherapy were associated and assessed. We used Kaplan-Meier method for calculating survival rates and Log-Rank test to assess presumed prognostic factors like sex, age, anatomic side, Enneking stage and associated quimio/radiotherapy. Results: Thigh were the most common location (50%). Isolated local recurrence occurred in 19 patients (24%), isolated meta-static disease without local recurrence in 4 patients (5%), and combined local and metastatic disease occurred in 4 patients (5%). The 2- and 5-year relapse-free survival (RFS) rates were 71% and 67%, respectively.

The 2- and 5-year overall survival (OS) rates were 92% and 86% respectively. We found that only Enneking stage was significant prognostic factor (p< 0.05). The best results in SLE were found in surgery + radiotherapy group but it was not statistically significant (p> 0.05). Conclusions: In our opinion, wide complete surgical resection at the time of primary tumor in combination with local radiotherapy is likely to afford the best chance for RFS and OS. Enneking stage seems to be the most important prognostic factor.

The role of adyuvant chemotherapy remains investigational.

Introduction and Objectives: From January 1983 to December 2000 we treated a total of 542 intermediate to high-grade primary bone tumours. We present our experience in reconstruction following tumour resection from the hip, excluding cases of pelvic reconstruction and cases of localised benign bone tumours of the hip.

Materials and Methods: This study included 49 cases of primary bone tumours localised to the proximal humerus (9% of the total). Of all cases treated by means of massive structural allograft for femoral reconstruction (44), only 11 cases were in the hip region. We performed 28 hip tumour resections for high-grade bone tumors with the following diagnoses: osteosarcoma (7), chondrosarcoma (9), Ewing’s sarcoma (6), malignant fibrous histiocytoma (2), and selected cases of metastasis-myeloma (4). Limb salvage procedures (22) with reconstruction after the first surgery included: modular megaprosthesis (11), megaprosthesis associated with massive structural allograft of the proximal third of the femur (8), and osteoarticular allografts (3). The remaining cases (6) required immediate agressive surgery including coxofemoral disarticulation (4) and hemipelvectomy (2).

Results: Limb salvage cases treated by means of mega-prosthesis associated with a composite allograft presented the following complications: 1 case of deep infection with local recurrence and immediate postoperative dislocation (12.5%), 3 isolated coxofemoral dislocations (37.5%), and one case of homograft osteolysis (12.5%). Mean follow-up time was greater than 5 years, and two patients died due to dissemination of the primary tumour (1 chondrosarcoma and 1 osteosarcoma). Cases of limb salvage treatment using modular mega-prosthesis had the following complications: 2 isolated coxofemoral dislocations (18%) and 2 cases of recurrence or local tumour progression (18%). Mean follow-up time was greater than 3 years, and two patients died due to progression of the primary tumour. Cases of salvage treatment using osteoarticular allografts had a mean follow-up time of 2 years and showed no significant complications.

Discussion and Conclusions: 1) In cases of disease up to 12 years of age (primarily Ewing’s sarcomas) we prefer osteoarticular reconstruction. 2) In cases of young adults (from 12 to 60 years of age) we prefer reconstruction using a megaprosthesis (Wagner type) with massive structural allograft. 3) In cases of older adults (greater than 60 years of age) we perform reconstruction using a modular megaprosthesis for tumour treatment.

Introduction and Objectives: This study analyses the results of our experience in reconstruction of high-grade sarcomas of the proximal humerus.

Materials and Methods: A total of 37 patients were treated from March 1983 to December 2001. Average age was 24 years (19–38), with 21 males and 16 females, all presenting with high-grade sarcomas of the proximal humerus. The primary tumour was osteosarcoma in 49% (n=18) of cases, chondrosarcoma in 22% (n=8), Ewing’s sarcoma in 13% (n=5), parosteal sarcoma in 8% (n=3), malignant fibrous histiocytoma in 5% (n=2), and adamantinoma in 3% (n=1). All cases were classified as Type 1 Malawer resections (intraarticular resections of the proximal humerus).

Results: During this period, scapulohumeral or scapulothoracic disarticulation was performed in 32% of cases (12 patients). In the remaining 68% (25 cases), limb salvage surgery was performed (relative limb salvage rate: 67.5%). In terms of reconstruction type, 6 cases received megaprotheses, and the remaining 19 cases received osteoarticular allografts of the humerus. Four of the 25 patients had reconstructions with sufficient follow-up time to be considered survivors without recurrence. Results were “acceptable” based on the Enneking-MTS functional scale (overall movement arcs in all directions between 60–120° with tolerable subluxations.) From a subjective point of view, all the patients obtained good results in terms of physical health and mobility of distal joints. No analysis was done of survival due to the varied nature of the neoplasias and adjuvant therapies. The main complication was fracture of the osteoarticular allograft, which occurred in 4 of 19 cases (21%). Subluxation was practically constant throughout our series but was of relatively minor clinical significance.

Discussion and Conclusions: The results obtained in this study in terms of local and functional control are similar to those reported in the literature. In spite of the poor functional results for the shoulder joint, the functional results for distal joints and the cosmetic appearance of the extremity are satisfactory. However, the high rate of allograft fractures forces us to reconsider our reconstruction technique, placing priority on a mixed reconstruction using both allograft and mega-prosthesis.

Introduction and Objectives: Half of primary tumors tend to disseminate to bones, and metastasis to bone is the third most common localisation for disseminated disease, after the lungs and liver. It is also the most common form of neoplasia in the skeleton. Treatment of bone metastasis is essentially palliative, and in select cases improves patient survival. We present results from the last 15 years in our centre.

Materials and Methods: Between the years 1988–2003, our surgical oncology unit has treated 451 patients with bone metastasis. Of these, 49% were male, and 51% were female. Average age was 64 years (19–98). The most common causes were metastatic breast cancer (34%), unknown tumours (17%), multiple myeloma (9%), prostate cancer (9%), lung cancer (7%), bladder cancer (6%), and others (18%). Tumours localised to the following locations: femur (31%), spine (27%), multiple locations (13%), pelvis (11.5%), humerus (9%), and other locations (8.5%). In 69% of cases the first symptom was pain, in 28% pathologic fracture, and in the remaining 3% medullary compression. Of the 125 pathologic fractures, 71% were on the femur, 18% on the humerus, and the remaining 11% in other locations.

Results: In 60% of cases (271 patients) conservative treatment was used, and in the remaining 40% (180 patients) surgical treatment was used. Of the 180 surgeries, 50.5% were for pathologic fractures, and 49.5% were prophylactic surgeries. Of the 125 pathologic fractures, 91 (73%) received surgical treatment, and the other 34 (27%) were treated conservatively. Intramedullary nailing was the most commonly used form of osteosynthesis (47%). Total resolution of pain was achieved in 86.5% of cases, and partial resolution in 13.5%. Mean time in bed from prophylactic surgery was 3 days. Mean time for recovery of function was 7 days for the arms and 11 days for the legs.

Discussion and Conclusions: The fundamental goal is to offer short-term individualized treatment to control pain and avoid bedrest and hospitalization of these patients. Prophylactic surgery does not increase life expectancy of these patients. However, it does alleviate pain, avoids bedrest, and improves functionality. It should be kept in mind that the least aggressive surgical technique possible should be used.