B. Tomeno

Knee reconstruction with prosthesis and muscle flap after total arthrectomy

A massive prosthesis and medial gastrocnemius muscle transfer were used to reconstruct the knee after extracapsular en bloc excision for bone sarcoma. Magnetic resonance images showed intraarticular involvement. This technique was used in nine patients, six men and three women aged 18 to 51 years, with primary malignant bone tumors of the knee. Extraarticular resection of the knee, including the patella, was done in every case. A knee prosthesis was implanted, and the extensor mechanism was reconstructed by transfer of the medial gastrocnemius muscle and pes anserinus tendons. All resections had negative margins. There were no local recurrences, but metastases occurred in two patients. Infection was the only major complication and was seen in two patients. The mean postoperative Musculoskeletal Tumor Society score was 61% (range, 36%–100%). The mean postoperative range of flexion was 62° (range, 30°–90°), and the mean extensor lag was 12° (range, 0°–40°). Three patients required a crutch to walk. The functional outcome was poor in the two patients whose proximal tibia was removed with the joint, suggesting that arthrodesis may be best in this situation. In properly selected patients, prosthesis and muscle flap reconstruction provides acceptable function and a good cosmetic result.

Malignant giant-cell tumours of bone. Clinico-pathological types and prognosis: a review of 29 cases.

Summary. Twenty-nine patients with malignant giant-cell tumours of bone (GCT) were followed- up for between 6 months and 18 years. Seventeen of the tumours were primary and 12 were due to malignant degeneration of initially benign lesions. The clinical features did not differ from those of benign GCT, except for a higher incidence in the distal tibia and sacrum. Anaplastic GCTs were included in the study because their clinical and radiographic features and prognosis were no different from those of the GCT grade III of Jaffe. Eighteen of the tumours were grade III, and 11 were anaplastic. This retrospective study was intended to assess the effects of chemotherapy and surgery for malignant GCT. Three treatment groups were selected, in which treatment was either by surgery alone, surgery plus chemotherapy, or radiotherapy alone. – The prognosis was poor and the 5 year tumour-free survival rate in the series was 50%. The prognosis was the same for primary as for secondarily malignant tumours. There was no statistical difference in survival between malignant grade III and anaplastic malignant tumours. The one-year survival rate for patients treated by chemotherapy and surgery was statistically higher (chi 2 test) than for persons treated by surgery alone. However, the five-year survival rate and the actuarial survival curves were not statistically different in the two groups (log rank test). – Chemotherapy appears to be of some value in the treatment of these malignant tumours but a larger series is required to confirm the efficacy of this approach.Résumé. Les auteurs rapportent vingt-neuf cas de tumeurs à cellules géantes (TCG) malignes dont le suivi s’étalait de 6 mois à 18 ans. Dix-sept étaient malignes d’emblée et douze le sont devenues lors de la récidive d’une TCG initialement bénigne. La clinique de ces tumeurs diffère peu de celle des TCG bénignes, hormis la plus grande fréquences des localisations du tibia distal et du sacrum. Nous avons inclus dans cet étude les TCG dédifférenciées car leur aspect clinique, radiographique et leur pronostic est similaire aux TCG grade III, nous avions dix-huit TCG grade III et douze TCG dédifférenciées. Le but de cet travail était de tenter de mettre en évidence l’intérêt de la chimiothérapie dans le traitement de ces tumeurs malignes, pour cela trois groupes de patients ont étéétudiés en fonction de leur traitement: chirurgie seule, chirurgie et chimiothérapie, et radiothérapie seule. Le pronostic de ces tumeurs est mauvais avec un taux de survie à 5 ans qui est de 50% dans notre série. Nous n’avons pas mis en évidence de différence statistiquement significative entre les TCG d’emblée malignes et celles devenues malignes secondairement, il n’y a pas non plus a différence de survie entre les TCG grade III et les TCG dédifférenciées. Dans le groupe des patients traités par chirurgie et chimiothérapie, le taux de survie à un an est supérieur à celui des autres groupes (test du chi 2 ), par contre la comparaison des courbes de survie (par le test du Log Rank) et de la survie à cinq ans (test du chi 2 ) ne met pas en évidence de différence significative entre les groupes traités avec et sans chimiothérapie. La chimiothérapie néo-adjuvante semble avoir un intérêt dans le traitement de ces tumeurs malignes. L’efficacité de ce traitement devra cependant être confirmée par une étude sur une plus grande série de patients.

Allograft-prosthesis composites after bone tumor resection at the proximal tibia.

The survival of irradiated allograft-prosthesis composites at the proximal tibia is mostly unknown. However, allograft-prosthesis composites have proved beneficial at other reconstruction sites. We presumed allograft-prosthesis composites at the proximal tibia would improve survival and facilitate reattachment of the extensor mechanism compared with that of conventional (megaprostheses) reconstructions. We retrospectively reviewed 26 patients who underwent resection of proximal tibia tumors followed by reconstruction with allograft-prosthesis composites. Patients received Guepar® massive custom-made fully constrained prostheses. Allografts were sterilized with gamma radiation, and the stems were cemented into the allograft and host bone. The minimum followup was 6 months (median, 128 months; range, 6-195 months). Fourteen patients had one or more components removed. The median allograft-prosthesis composite survival was 102 months (95% confidence interval, 64.2-infinity). Of the 26 allografts, seven fractured, six showed signs of partial resorption, and six had infections develop. Seven allografts showed signs of fusion with the host bone. Six extensor mechanism reconstructions failed. Allograft-prosthesis composites sterilized by gamma radiation yielded poor results for proximal tibial reconstruction as complications and failures were common. We do not recommend irradiated allograft-prosthesis composites for proximal tibia reconstruction.Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Les reconstructions après résection tumorale de l’extrémité supérieure de l’humérus: À propos d’une série de 29 reconstructions avec un recul moyen de 7 ans

PURPOSE OF THE STUDY Techniques available for shoulder reconstruction after resection of a tumor of the proximal humerus include scapulohumeral arthrodesis, humerus prosthesis with or without an allograft, inverted prostheses, and massive allografts. The purpose of this study was to review clinical and radiological outcomes in a series of 29 patients (20 men and 9 women) who underwent resection-reconstruction of the proximal humerus and to establish from these cases a decision making algorithm for therapeutic indications as a function of tumor invasion. MATERIAL AND METHODS The tumors were 20 chondrosarcomas, five osteosarcomas, two Ewing sarcomas and one malignant hemangiopericytoma. In 17 patients epiphyso-metaphyseal or epiphyso-metaphyso-diaphyseal resection was performed with preservation of the abductor muscles (type S34A or S345A according to the Musculoskeletal Tumor Society classification). For 12 patients epiphyso-metaphyseal or epiphyso-metaphyso-diaphyseal resection was performed without preservation of the abductor muscles (type S34B or S345B). Reconstruction was achieved using a centromedullary cemented nail in one patient, scapulohumeral arthrodesis in three, a massive humerus prosthesis in 15, and composite humerus prosthesis in three and an inverted prosthesis in seven. The functional score of the Musculoskeletal Tumor Society (MSTS) and standard x-rays were used to assess outcome. RESULTS Mean follow-up was 85 months (range 16-300). The mean MSTS score was 88% for inverted prostheses, 76% for composite prostheses, 72.6% for massive prostheses, 75% for scapulohumeral arthrodeses, 67% for massive prostheses, and 80% for cemented centromendullary nail. Five patients died from their malignant disease and one from another cause. Four patients are alive but with active disease after a mean follow-up of 108 months and 19 patients (65.5%) are alive and free of locoregional recurrence or metastasis after a mean 83.5 months. We had 28 complications. Glenohumeral instability was the most frequent (11 cases). DISCUSSION Resection of the upper portion of the humerus should be performed to achieve cancerologically satisfactory tumor resection and enable shoulder resection, if possible, with preservation of a viable and functional abductor system. The functional outcome after such reconstruction depends on the type of bony resection, but also on the sacrifice of the rotator cuff and the deltoid muscle. In light of our experience and results in the literature, we advocate, despite the small number of cases for the different reconstructions, the following decision-making algorithm after resection of the proximal humerus without joint invasion: when the resection removes the rotator cuff and the deltoid (or the axillary nerve), there are two options: scapulohumeral arthrodesis or massive humerus prosthesis for patients who do not desire a complex therapy with a long postoperative period; when the resection preserves the rotator cuff and/or the deltoid muscle, reconstruction can be achieved with a composite (inverted or not) prosthesis with suture of the cuff tendons. We prefer the inverted composite prosthesis; if the deltoid muscle can be preserved but not the rotator cuff, the composite inverted prosthesis appears to be the most logical solution, but scapulohumeral arthrodesis can be proposed in selected cases.

Malignant Fibrous Histiocytoma at the Site of a Previously Treated Aneurysmal Bone Cyst: A Case Report

Jaffe and Lichtenstein1 described aneurysmal bone cyst as a benign non-neoplastic lesion of unknown etiology. Aneurysmal bone cysts can be primary or secondary to other bone tumors, including nonossifying fibroma, chondroblastoma, giant-cell tumor of bone, osteoblastoma, fibrous dysplasia, fibromyxoma, osteoblastoma, solitary bone cyst, hemangioendothelioma, osteosarcoma, and metastatic carcinoma2,3. Although several cases of malignant transformation have been reported, most were either radiation-induced sarcomas or telangiectatic osteosarcomas that had been misdiagnosed as aneurysmal bone cyst. To our knowledge, the literature contains only one report of satisfactorily documented malignant transformation of an aneurysmal bone cyst4. We describe a patient who had a malignant fibrous histiocytoma at the site of a femoral aneurysmal bone cyst that had been treated twelve years earlier by curettage and internal fixation after a pathological fracture. A twenty-eight-year-old man was admitted to our institution in December 1986 because of a pathological supracondylar fracture of the left femur. Anteroposterior and lateral tomograms revealed a pathological fracture in the distal part of the left femur through a large lytic lesion in the diaphysis and epiphysis (Fig. 1). There was no periosteal reaction. The limb was placed in an above-the-knee cast. No evidence of metastasis was seen on a computed tomographic scan of the chest, and a technetium-99m polyphosphate bone scan showed a single focus of hyperactivity only at the site of the pathological fracture. Routine laboratory data were normal. Fig. 1: Tomograms showing the pathological fracture through the aneurysmal bone cyst. An open biopsy of the femoral lesion was performed. Histological examination revealed the typical features of an aneurysmal bone cyst, with multiple blood-filled cavities separated by fibrous septa containing osteoid, giant cells, and fibroblasts (Figs. 2-A and 2-B). Fig. 2-A: Fig. 2-A Photomicrograph of the aneurysmal bone cyst, showing septa delimiting cavernous spaces filled with blood …

Massive pelvic and femoral pseudotumoral osteolysis secondary to an uncemented total hip arthroplasty

Abstract A 51 year-old man developed an extensive osteolytic response to wear debris in an uncemented porous-coated total hip arthroplasty, with metal/polyethylene interface, which had been implanted eighteen years previously. This reaction, which involved the upper femur and the ilium, produced a mass which compressed the pelvic viscera.Résumé Nous rapportons un cas d’ostéolyse massive réactionnelle aux débris d’usure d’une prothèse totale de hanche non cimentée avec un revêtement poreux et un couple de frottement métal/polyéthylène implantée dix-huit ans auparavant chez un patient de 51 ans. L’ostéolyse détruisait l’extrémité supérieure du fémur et l’aile iliaque produisant une masse pelvienne qui refoulait les organes avoisinants. Le produit de curetage contenait des amas d’histiocytes ainsi que des corps étrangers constitués de débris de métal et de polyéthylène. Les cultures bactériologiques en milieux aérobie et anaérobie étaient stériles. L’examen histologique excluait une ostéolyse tumorale. L’ostéolyse péri-prothétique est fréquente et a étéégalement observée autour d’implants fémoraux et acétabulaires, cimentés et non cimentés, bien fixés et descellés. Bien que la plupart des ostéolyses restent stables et asymptomatiques pendant plusieurs années, certaines d’entre elles peuvent devenir massives entraînant une destruction osseuse importante et une reprise chirurgicale difficile. Une surveillance radiographique régulière est le meilleur moyen pour diagnostiquer et mesurer la taille d’une ostéolyse, les examens sanguins et la scintigraphie n’ayant pas de valeur prédictive pour identifier une lésion au potentiel évolutif. Une reprise chirurgicale précoce devrait être réalisée dès qu’une ostéolyse, même asymptomatique, s’accroît.

Psychological management, prevention and treatment of phantom pain after amputations for tumours.

Summary.Amputation for tumours is rarely carried out nowadays and has few specific technical features, apart from the rare cases where ingenuity is required to gain a few centimetres in length of a stump. As far as possible, the decision for amputation should not be imposed; it is better that the patient himself should take the initiative. The prosthesis and its constraints should be described honestly to avoid subsequent disappointment. Prevention of a painful phantom limb must always be undertaken, and based on certain operative and perioperative precautions. The most important factors are treatment by psychotropic agents and the quality of the human relationships between patient and surgeon.Résumé.Les amputations pour tumeurs sont devenues rares et ne comportent guère de particularités techniques, en dehors de quelques cas rares où il faut faire preuve d’imagination pour gagner quelques centimètres. C’est ce qui se passe autour de l’os (infection, sequelles d’irradiation, gros envahissement des parties molles) qui fait préferer l’amputation aux procédés de résection-reconstruction. La prévention du membre fantôme douloureux doit être systématique. Elle repose sur quelques précautions opératoires et peri-opératoires. Les éléments les plus importants en sont: le traitement par les psychotropes et la qualité des relations humaines entre le patient et les thérapeutes. Il faut tout faire pour ne pas imposer la décision d’amputation: il faut faire en sorte que ce soit le patient lui-même qui en prenne l’initiative. L’appareillage et ses servitudes doivent être présentés avec une grande honneteté pour éviter les désenchantements ulérieurs.

Tumeur à cellules géantes multifocale

Resume Les tumeurs a cellules geantes sont solitaires dans plus de 99 % des cas. Les cas de TCG multifocales sont relativement rares et mal compris. Les auteurs rapportent le cas d’un patient ayant presente 5 localisations survenues sur 11 ans (tibia droit, 4 e metacarpien gauche, au sacrum, femur droit et femur gauche) et dont ils ont etabli les index de proliferation. La revue de la litterature nous indique que la survenue d’une nouvelle localisation apres traitement d’une TCG est toujours possible avec des presentations tres variables en siege, en nombre et en delai d’apparition des lesions. Les donnees les plus recentes tendent a montrer que chaque localisation semble etre independante et evoluer pour son propre compte. Devant l’absence de transformation histologique et la rarete des formes multifocales, nous ne recommandons pas un depistage specifique, mais une simple information des probabilites pour le patient atteint de TCG.

Ruptures traumatiques du tendon quadricipital: À propos de 47 cas

PURPOSE OF THE STUDY A torn quadriceps tendon is an exceptional finding generally observed after high-energy knee trauma in patients over 40 who present a sprain-like syndrome or after low-energy trauma in elderly subjects who experience knee instability. We reviewed a series of 47 cases of traumatic quadriceps tendon tears treated between 1976 and 1996 in order to evaluate outcome after surgical repair. MATERIAL AND METHODS Clinical diagnosis was the rule. Forty-two patients, mean age 55 years (range 17-92) were treated for tears of one or both quadriceps tendons subsequent to low-energy trauma (40 tears) or high-energy trauma in younger subjects. The diagnosis was established early in all cases except eight (diagnosis at three weeks to one year). Surgical repair was performed in all cases except one. After surgery, the knee was either immobilized with a plaster cast or held in a removable splint to allow early mobilization. RESULTS Average time to recovery compatible with daily life or occupational activities was four months. Recovery was not complete at this time. Long-term follow-up revealed that complete recovery with very good or good subjective results was achieved in 90% of the cases. Complete joint motion and normal quadriceps force was achieved in 80% of the cases. Patients who started rehabilitation exercises early generally achieved less satisfactory results although no significant correlation was identified with objective clinical variables. DISCUSSION Quadriceps tendon tear is a clinical diagnosis which does not require complementary exploration for confirmation. Plain x-rays may be useful to identify associated bony lesions and specific signs of tendon tears. Early surgical repair followed by complete immobilization appears to be preferable for functional recovery allowing better recovery of muscle force without compromising flexion.Resume Les ruptures traumatiques du tendon quadricipital sont peu frequentes et s’observent chez des patients ayant passe la quarantaine apres un traumatisme indirect du genou pouvant faire evoquer une entorse, ou chez des personnes plus âgees se plaignant de derobements du genou, a la suite d’un traumatisme minime. Quarante-deux patients (47 genoux), âges de 55 ans en moyenne (extremes : 17 et 92 ans), ont ete traites pour une rupture uni ou bilaterale du tendon quadricipital et suivis avec un recul moyen de 56 mois (extremes : 12 et 252 mois), afin d’apprecier l’evolution a court et a long terme apres la reparation chirurgicale de la lesion. Le delai de recuperation a ete de 4 mois en moyenne. A cette echeance, 40 % des patients avaient une recuperation quadricipitale encore incomplete, compatible cependant avec la reprise de leurs activites professionnelles ou habituelles. La revision au plus long recul montre une recuperation complete avec de bons et tres bons resultats subjectifs dans 90 % des cas, une mobilite articulaire complete et une force du quadriceps normale dans 8 cas sur 10. Le diagnostic de rupture du tendon quadricipital est clinique et ne necessite aucun examen complementaire, a l’exception de cliches radiographiques a la recherche de lesions osseuses associees et de signes specifiques temoignant de la rupture tendineuse. Le traitement chirurgical doit etre realise precocement afin d’obtenir une recuperation fonctionnelle complete. Apres l’intervention, une immobilisation stricte est recommandee : elle a permis une meilleure recuperation de la force du quadriceps, sans entrainer de deficit de mobilite en flexion.

OA8 Tumeurs fibreuses solitaires des parties molles : a propos de 4 cas

Objectifs Recemment, certaines tumeurs des parties molles anterieurement classees dans le groupe des hemangiopericytomes ont ete renommees tumeurs fibreuses solitaires (TFS) par analogie histologiques avec les tumeurs fibreuses solitaires de la plevre. Elles sont benignes dans 90 % des cas. On rapporte les aspects cliniques, IRM et anatomo-pathologiques de ces tumeurs. Materiels et methodes Etude retrospective de 4 cas prouves histologiquement de TFS des parties molles (epaule, bras, cuisse, paravertebral). Resultats Les patients presentaient une tumefaction palpable de croissance tres lente. L’IRM montrait une masse tissulaire intramusculaire reguliere, bien limitee, de 3,5 a 11 cm, de signal peu specifique (isosignal Tl au muscle, hypersignal T2, rehaussement moderement heterogene). En peripherie de la tumeur, on retrouvait dans tous les cas des images serpigineuses avec vide de signal en rapport avec des vaisseaux a flux rapide. Anatomo-pathologiquement les lesions etaient benignes, bien limitees, avec une architecture de type hemangiopericytaire et un marquage positif au CD 34 permettant le diagnostic de TFS. Conclusion II faut evoquer le diagnostic de tumeur fibreuse solitaire des parties molles devant une masse reguliere intramusculaire richement vascularisee avec des images intratumorales de flux rapide.