Percutaneous Tenolig(®) repair under intra-operative ultrasonography guidance in acute Achilles tendon rupture.

BACKGROUND: Acute Achilles tendon rupture can be treated conservatively or surgically. Open surgery restores tendon continuity but carries a risk of skin complications. Tenolig(®) is a device designed for the percutaneous biological treatment of acute Achilles tendon rupture. Earlier studies found high rates of recurrent tears and nerve injury after Tenolig(®) repair. HYPOTHESIS: We hypothesised that intra-operative ultrasonography during Tenolig(®) repair would decrease the post-operative complication rate and improve functional outcomes. MATERIALS AND METHODS: We studied 75 consecutive patients with a mean age of 39.9 years. The injury was sports-related in 82.8% of cases. Mean distance from the calcaneal tendon attachment to the tear was 5cm and mean time from injury to repair was 4.2 days. All patients underwent Tenolig(®) repair under ultrasound guidance followed by early rehabilitation therapy with partial weight bearing started after 3 weeks. RESULTS: Mean follow-up was 20.7 months and no patient was lost to follow-up. A single patient (1.3%) experienced rerupture and none had permanent sural nerve damage. Mean time to sports resumption was 8.6 months, with two-thirds of patients returning to their previous level of sporting activities. The mean AOFAS functional score was 95 and the mean ATRS score was 91.3. DISCUSSION: Our experience suggests that intra-operative ultrasonography, a non-invasive, widely available, and accurate tool, provided improved control of Tenolig(®) suture position. Ultrasonography provided valuable guidance during this demanding procedure and allowed the very early initiation of rehabilitation therapy. Another crucial factor is patient education about the physical therapy programme. Attention to this point allowed us to obtain robust and reliable functional outcomes in a population predominantly composed of athletes. LEVEL OF EVIDENCE: Level IV.

Primary total knee arthroplasty in the management of epiphyseal fracture around the knee.

INTRODUCTION: Over the past few years the use of arthroplasty was broadened to treating complex epiphyseal fractures at the shoulder and elbow joints. Similar trends to treat this type of fractures at the knee are less documented. Based on a multicenter retrospective series study, the aims of this work is to evaluate the short term clinical results of total knee prostheses in the management of comminuted epiphyseal fractures around the knee, to identify the technical issues and fine tune the indications. MATERIAL AND METHODS: Following the initiative of the French Hip and Knee Society (SFHG) and the Traumatology Study Group (GETRAUM), 26 charts from eight different centers in France were included in this multicenter retrospective series. Inclusion criteria were: primary total knee arthroplasty (TKA) in the management of complex articular fractures involving the proximal end of the tibia or distal end of the femur. Surgical features were identified and complications were analyzed. The assessment protocol at last follow-up was standardized and included patient demographic data, analysis of the Parker and IKS scores. RESULTS: During the immediate postoperative period, six patients (23%) reported a general complication and four patients (15%) a local arthroplasty-related complication. At last follow-up (mean 16.2 months), the overall final Parker score was 6.3 (a mean decrease of 1.7) and the mean IKS knee score was 82 points for a mean function score of 54 points. DISCUSSION: Primary TKA is a suitable management option for complex fractures in autonomous elderly patients suffering from knee osteoarthritis. The key technical details of this procedure should be respected and meticulously planned to achieve optimal results and limit the risk of complications. This risk in these acute complex fractures remains higher than after conventional TKA but comparable to that observed after TKA for post-traumatic arthritis. LEVEL OF EVIDENCE: IV; retrospective cohort study.

Complex proximal humeral fractures: a prospective study of 22 cases treated using the "Bilboquet" device.

INTRODUCTION: Despite recent improvements in surgical devices, complex proximal humerus fractures internal fixation still encounters frequent mechanical failures. HYPOTHESIS: The aim of this study was to confirm that the Bilboquet device (a design mimicking the cup-and-ball game) helps solving mechanical difficulties associated with these fractures internal fixation and to present a simplified version of the original surgical procedure. PATIENTS AND METHOD: This non-randomised prospective study included 22 fractures in 22 patients, mean age: 70 years. According to the Neer classification there were three-part fractures in seven cases and four-part fractures in 15 cases. Fractures were all reduced and treated by internal fixation in a simplified surgical procedure using the Bilboquet device. RESULTS: Mean postoperative follow-up was 34 months. The mean Constant score was 66 and the weighted Constant score was 86. Mean active forward elevation was 108° and mean active external rotation was 28°. No per- or postoperative complications occurred. Initial reduction of the tuberosity was incomplete in four cases. Union was obtained in all fractures. There was no secondary tilting of the head, and no migration or pseudarthrosis of the tuberosities. Five patients developed postoperative avascular necrosis of the humeral head. DISCUSSION: The Bilboquet staple component provides a supporting platform for the entire humeral head area. This peripheral stabilization associated with tension band wiring explains the lack of secondary displacement in these cases. Although the Bilboquet device provides a solution to the mechanical problems of complex fractures of the proximal humerus, it does not solve the problem of secondary avascular necrosis of the humeral head, which occurred in 23% of the patients in this series and in 33% of patients in the four-part fractures subgroup. LEVEL OF EVIDENCE: IV (non-randomised prospective study).

Phenotypic and functional analysis of lymphocytes infiltrating osteolytic tumors: use as a possible therapeutic approach of osteosarcoma.

BACKGROUND: Osteosarcoma is the most common type of primary bone tumor. The use of aggressive chemotherapy has drastically improved the prognosis of the patients with non-metastatic osteosarcomas, however the prognosis of the patients with metastasis is still very poor. Then, new and more effective treatments for curing osteosarcoma, such as immunotherapy are needed. Tumor-infiltrating lymphocytes (TIL) have been involved in the control of tumor development and already assessed with success for the treatment of several cancers including melanoma. While TIL represent a fascinating therapeutic approach in numerous malignant pathologies, there is few report concerning adult bone-associated tumors including osteosarcoma. METHODS: Human TIL were isolated and characterized (phenotype, lytic activity) from twenty-seven patients with bone-associated tumors (osteosarcoma, Ewing's sarcoma, giant cell tumor, chondrosarcoma, plasmocytoma and bone metastases). Similar experiments were performed using rat osteosarcoma model. RESULTS: While TIL with a main CD4+ profile were easily isolated from most of the tumor samples, only TIL extracted from osteosarcoma were cytotoxic against allogeneic tumor cells. In all cases, TIL lytic activity was significantly higher compared to autologous peripheral blood leukocytes. Similar data were observed in rat osteosarcoma model where TIL were characterized by a main CD4+ profile and high lytic activity against allogeneic and autologous tumor cells. Moreover, rat TIL expansion was not accompanied by refractoriness to further activation stimulus mainly by tumor antigens. CONCLUSION: These results demonstrated that TIL therapy could be a very efficient strategy for the treatment of adult osteosarcoma.

A new experimental rat model of osteosarcoma established by intrafemoral tumor cell inoculation, useful for biology and therapy investigations.

Satisfactory experimental models for preclinical cancer studies must follow several criteria: (1) reproducibility of the method used to induce the tumor and (2) clinical, pathological and kinetic similarity with the corresponding human tumors. We developed a model of osteosarcoma locally induced by the intrafemoral injection of osteosarcoma (OSR) cells in Sprague-Dawley rats. This method yields nearly 80% of bone tumors at the injection site. These tumors double their volume fairly slowly (in approximately 20 days) and lung metastases occur in 96% of the animals. The OSR cell-induced tumor is characterized by a direct production of mineralized matrix by the tumor cells themselves, as revealed by histochemical analysis. The microarchitectural parameters which were quantified by a microscanner show an increased trabecular bone volume (+238%) when OSR cells were injected in the femur, as compared to controls injected with vehicle. Osteoblastic markers such as alkaline phosphatase, osteopontin, osteocalcin and bone sialoprotein were expressed by the tumor in vivo, whereas the initially injected OSR cells did not express some of these markers, suggesting that OSR cells reacquired an osteoblastic phenotype in a favorable environment. The clinical, radiological and histological data show that this model shares high similarities with the osteocondensing forms of osteosarcoma in humans.