Results of the treatment of proximal femoral periprosthetic fractures

Proximal femoral periprosthetic fractures are an uncommon but a major complication of hip arthroplasty. They occur in a particular population combining bad general conditions caracterised by an advanced age and the frequency of comorbidities, and bad local conditions with osteopenia and bone stock loss. The aim of this study was to evaluate the results while treating proximal femoral periprosthetic fractures regarding the recent literature recommendations. Material and methods: This was a retrospective study of 22 proximal femoral periprosthetic fractures treated operatively. According to the Vancouver system modified by the French Society of Orthopaedic Surgery and Traumatology, fractures were classified as AG (n=1), B(n=10), and C(n=11). The mean ASA physical status was 1.6.The average Parker score was 7.8 before the fracture. Ten fractures had open reduction and internal fixation and 12 revision procedures. Morcellised bone grafting was used in 5 cases. The evaluation at last follow up was based on the Parker score, fracture healing, and the screening of the complications. Results: Three patients (4 hips) died post operatively. The average Parker score was 8.3. Eighteen hips in 16 patients were reviewed with a mean follow up of 58,4 months. Union was achieved in nine cases of type B and seven of type C. Four patients presented screw plate or screw pull-out and had treatment failures. Infection occurred in three patients. One patient had pulmonary embolism. Conclusion: Our results showed that treatment of proximal femoral periprosthetic fractures is a highly demanding technique with a high rate of complications. Fractures with loosened implants have to be treated by revision procedure whenever possible

Locked posterior dislocation of the shoulder: A report of three cases.

Posterior shoulder dislocations account for 4% of all shoulder dislocations. In two-thirds of the cases, the diagnosis is made only once the shoulder is locked, which radically changes the treatment and prognosis. We report three clinical cases of locked posterior shoulder dislocation. Closed reduction was attempted in one case but failed. All patients underwent open reduction and subscapularis transfer according to either Neer's (2 cases) or McLaughlin's technique (1 case). The functional outcome was satisfactory in two cases despite recurrent dislocation on the third day after surgery. The third patient eventually developed post-traumatic shoulder osteoarthritis. The best treatment consists of detecting posterior dislocations immediately when they occur under suggestive circumstances (electrocution, epileptic seizure, severe trauma shoulder).

Surface osteosarcoma: Clinical features and therapeutic implications.

INTRODUCTION: Surface osteosarcoma are rare variant of osteosarcoma that include parosteal osteosarcoma, periosteal osteosarcoma and high grade surface osteosarcoma. These lesions have different clinical presentation and biological behavior compared to conventional osteosarcoma, and hence need to be managed differently. GOAL: The aim of this study is to analyze the clinico-pathological features and outcome of a series of surface osteosarcoma in an attempt to define the adequate treatment of this rare entity. PATIENT AND METHOD: It is a retrospective and bicentric study of 18 surface osteosarcoma that were seen at the KASSAB's Institute and SAHLOUL Hospital from 2006 to 2013. The authors reviewed the clinical and radiologic features, histologic sections, treatments, and outcomes in this group of patients. RESULTS: Seven patients were male (38.9%) and 11 were female (61.1%) with mean age of 25 years (range from 16 to 55 years). Eleven lesions were in the femur and 7 in the tibia. We identified 11 parosteal osteosarcoma (six of them were dedifferentiated), 3 periosteal osteosarcoma and 4 high grade surface osteosarcoma. Six patients had neoadjuvant chemotherapy and all lesions had surgical resection. Margins were wide in 15 cases and intra lesional in 3 cases. Histological response to chemotherapy was poor in all cases. The mean follow up was 34.5 months. Six patients (33.3%) presented local recurrence and 8 patients (44.4%) presented lung metastases. Six patients (33.3%) died from the disease after a mean follow up of 12 months (6-30 months); all of them had high grade lesions. CONCLUSION: Histological grade of malignancy is the main point to assess in surface osteosarcoma since it determines treatment and prognosis. Low grade lesions should be treated by wide resection, while high grade lesions need more aggressive surgical approach associated to post operative chemotherapy.

Ewing-like adamantinoma.

The Ewing-like variation of adamantinoma is a rare entity, leading to challenge its differential diagnosis, notably with Ewing's sarcoma. We are reporting a case of a 20-year-old male who presented with swelling in the left leg that had progressed over a 2-year period. X-rays revealed a tumour in the tibia that was intracortical, osteolytic, multilocular and invaded the soft tissues. A surgical biopsy was performed. Histopathology examination showed a tumour growth with small round cells expressing CD99. A diagnosis of Ewing's sarcoma was made. Since the patient declined surgical treatment, chemotherapy was administered. Two years later, the patient returned because the tumour had grown in size. A second biopsy was performed. Microscopic evaluation showed a tumour growth with osteofibrous and epithelial components, which expressed pankeratin and vimentin, but was negative for CD99. A diagnosis of Ewing-like adamantinoma was made.

Dedifferentiated adamantinoma associated with fibrous dysplasia.

A 21-year-old patient presented with an aggressive lesion of the left tibia associated to lymph nodes and lung metastasis. Histological examination revealed a high grade spindle cell sarcoma involving some areas of cytokeratine positive cells. Ultrastructural examination showed the presence of epithelial features in the sarcomatoid cells. The diagnosis of dedifferentiated spindle-celled adamantinoma was established. A second lesion of the right tibia was diagnosed as fibrous dysplasia. The patient had a leg amputation. He died 2 years later with multiple lung and bone metastases. The diagnosis of dedifferentiated adamantinoma should be considered when a clinician is confronted with a tibial biopsy of a "keratin-positive sarcoma". The association with fibrous dysplasia in this case is discussed.

Calcitonin use in giant cell bone tumors.

INTRODUCTION: As osteoclast, giant cell tumors express calcitonin receptors. The aim of this paper is to assess treatment using salmon calcitonin after curettage. MATERIAL AND METHODS: We retrospectively reviewed 25 patients with giant cell tumor of the appendicular skeleton treated with a single protocol of calcitonin administration following curettage in order to assess the effectiveness of calcitonin in reducing the rate of local recurrence. RESULTS: The mean duration follow-up was 68 months. Thirteen patients (52%) had local recurrence. Eight of them were treated successfully after repeated curettage and calcitonin. Four patients had bone resection and one patient had curettage and cement filling. All patients with cavity left empty had ossified and the functional score as assessed by the MSTS score was 28.02/30. CONCLUSION: This study suggests that the use of calcitonin as adjuvant is not effective and that filling agents are not required after curettage of giant cell tumors. LEVEL OF EVIDENCE: Level 4.

Giant cells tumor recurrence at the third lumbar vertebra.

Giant cell tumors (GCT) of the spine are rare. We report a case of (GCT) of the third lumbar vertebra revealed by left lumbar radiculopathic thigh pain in a 47 year old man. Imaging showed an osteolytic process invading the vertebral body, the posterior arch and compressing the dural sac left side. Neurological decompression was first performed including stabilization by an instrumented postero-lateral graft. A surgical biopsy was obtained at the same time to confirm the diagnosis. A secondary L2-L4 tumor curettage and graft procedure did not prevent, 5 years later, tumor recurrence. We believe that the simple tumor curettage is insufficient to prevent giant cell tumors recurrence.

Knee arthrodesis using a vascularized fibular rotatory graft after tumor resection.

INTRODUCTION: Knee arthrodesis is one of the reconstruction options for limb preservation after malignant tumor resection. Vascularised rotatory fibular transfer allows biological and, thus,definitive reconstruction. The goal of this work was to analyse the results of knee arthrodesis with vascularised fibular graft after tumor resection and to discuss the reliability of this technique. PATIENTS AND METHODS: We report a retrospective series of 13 patients with an average age of 29.6 years. The pathological diagnosis was bone sarcoma in 12 cases and synovial chondrosarcoma in one case. Resection/arthrodesis was undertaken as the primary procedure in 11 cases.In two cases, arthrodesis was indicated after failure of an endoprosthesis. Reconstruction was achieved with a vascularised fibular rotatory transfer in all cases. For stabilisation, an external fixator was utilised in eight cases, a femorotibial nail in three cases, and a plate in two cases.Mean follow-up was 6 years. RESULTS: We encountered infection in 53% of cases, mechanical complications in 53% of cases,and nerve palsy in 23% of cases. Four patients died from metastases (only one had arthrodesis complete union). In the nine surviving patients, arthrodesis was fully united in seven cases,after an average period of 36 months. The functional score average (Enneking classification)was 20 points. DISCUSSION: Knee arthrodesis after tumor resection is a complex technique. Septic complications and mechanical failure are frequent regardless of the technique employed. They are related to the extent of bone sacrifice but also to that of soft tissues. The use of vascularised fibula alone and stabilisation by external fixation were the main shortcomings in this series. TYPE OF STUDY RETROSPECTIVE: Level IV.

[Costovertebral echinococcosis: a case report and review of the literature]. / Le kyste hydatique costovertébral primitif: une observation et revue de la littérature.

The bone involvement is uncommon in hydatid disease and represents less than 2 % of cases. Vertebral hydatidosis is the most common bone localization (44 %). The severity of vertebral echinococcosis is related to the neurological complications and therapeutic problems especially in advanced stages. The treatment relies on the actual surgical removal of hydatidosis. In endemic countries, prevention and health education are the best measures. We report a 17-year-old male who presented with an incomplete paraplegia with thoracic deformation, revealing a costovertebral hydatidosis.

[Intraosseous capillary hemangioma of the radial bone]. / Une tumeur osseuse rare au radius : hémangiome capillaire.

Hemangioma is a rare benign vascular tumor composed of dystrophic capillaries, preferentially located in the spinal region (70 %). Bony localizations are exceptional, less than 1 % of cases in large series of bone tumors. We report the case of a 35-year-old male who complained of pain the right forearm for two months. The pain was of an inflammatory type and was triggered by palpation and mobilization. The plain x-ray revealed a bony defect involving the posterior cortical of the mid-third of the radius. Magnetic resonance imaging revealed a defect of the shaft cortex without involvement of the central part of the bone, the endostium or the soft tissue. Surgical resection was limited to the tumor. Histology reported intraosseous capillary hemangioma. The course was favorable with bone healing and gap filling, with normal elbow and wrist function. The patient resumed occupational activities three months after surgery. This case illustrates a rare localization of this tumor rarely reported in major series.

[Osteoid osteoma of the tarsal navicular bone: an uncommon localization]. / Ostéome ostéoïde de l'os naviculaire tarsien: une localisation rare.

We report a case of subchondral osteoid osteoma of the tarsal navicular bone. Osteoid osteomas are often located in the foot, mainly in the talus. This is the first report in the literature of a tarsal navicular bone localization. Diagnosis was difficult and established late due to misleading clinical presentation simulating mediotarsal arthritis.

Hydatid cyst of bone: diagnosis and treatment.

Osseous hydatidosis is a rare occurrence of hydatid disease. Anatomoclinical changes are, however, peculiar to this localization. From the anatomopathologic standpoint, this localization marks the torpid, insidious progression of the parasite into bone tissue, leading to an immediate diffuse, extensive, invasion process, so complete surgical eradication is rarely possible. From the clinical standpoint, whatever the localization may be, we are surprised by the latency of this affection, the patient being treated at an advanced stage, when radiologic lesions are already extensive, and the complications, especially in the spinal area, are severe. Owing to the poor biologic findings, the diagnosis of osseous hydatidosis is still primarily based on roentgenographic findings. Sometimes, however, the diagnosis is established only after surgery. Treatment of osseous hydatidosis is closer to oncologic therapy than to the usual surgical treatment of visceral hydatid cysts. Because of the poor results with medical treatment, osseous hydatidosis must be treated by a radical operation with wide excision, adapted to each localization. In the main, the prognosis of osseous hydatidosis remains poor, especially with spinal and pelvic localizations, which are the most frequent ones. The prognosis and treatment of osseous hydatidosis belong in the same category as a locally malignant lesion.

[Tumorous calcinosis in hemodialysis: anatomo-clinical study apropos of 3 cases]. / La calcinose tumorale des hémodialysés: étude anatomoclinique: à propos de trois cas.

Three patients (2 females, 1 male) with a mean age of 51.4 years receiving long term hemodialysis affected by tumoral calcinosis were analysed. Clinical, radiological and pathological features were evaluated and pathogenic were reviewed. The joints involved int the cases presented in this report were the hip shoulder and finger. The lesions were bilateral in shoulder. An increased calcium-phosphorus product (Ca x P) was observed in all patients with secondary hyperparathyroidism in one case. Surgery was carried out in all patients. No relapse of the tumoral calcinosis was observed after surgery. The most important pathogenic factor involved in uremic tumoral calcinosis is an increase in calcium-phosphorus product (Ca x P) not necessarily related to hyperparathyroidism. Therefore, maintaining the calcium x phosphate product within the normal range appears to be the most important factor ito prevent the appearance of uraemic tumoral calcinosis.

[Lipoma arborescens of the knee: contribution of x-ray computed tomography. Apropos of a new case]. / Le lipome arborescent du genou: apport de la tomodensitométrie. A propos d'un nouveau cas.

The authors report a case of a synovial lipoma of the knee in a 40 years old man who suffered from chronic instability of the right knee associated to an extensive joint swelling and recurrent hydarthrosis. Ultrasonography and arthrography showed a synovial process and the computerized tomography showed an inhomogeneous low density due to its fat content suggesting a synovial lipoma arborescens of the knee. Final diagnosis was confirmed by histological examination of the arthroscopic biopsy. The authors discuss, through out their case and a review of the literature, modern investigation findings and indication for surgical treatment of this disease.

Methods for clinical assessment of expectorants: a critical review.

The purpose of the paper is to discuss some aspects of the methods that are most appropriate for the clinical assessment of new expectorants. Expectorants are drugs devised to help in the removal of bronchial secretions. The evaluation of these drugs is aimed at demonstrating, in controlled trials, their efficacy, safety and, if possible, mechanism of action. Unfortunately, there is no universally accepted assessment technique available. Evaluation of symptoms with the use of self-reported measures is imprecise. Studies of quality of life can assist as a means of assessing the usefulness of this class of drug for patients. Lung function tests evaluate only the possible indirect effects of expectorants; the changes observed are often minor and they do not correlate with other methods of evaluation. Mucociliary clearance studies evaluate bronchial drainage by mucociliary transport and cough. They are a useful pharmacological approach but they cannot replace therapeutic trials. In vitro and ex vivo studies of bronchial secretion, while improving knowledge of the mechanisms of bronchial secretion, fail to predict the modifications of bronchial drainage produced in vivo by cough or mucociliary transport. To be considered efficient, expectorants should not only ease the removal of bronchial secretions, but also improve the patient's condition for the duration of treatment.