Does screwless scarf osteotomy for hallux valgus increase the risk of transfer metatarsalgia?

INTRODUCTION: The scarf osteotomy is a reliable surgical technique for treating hallux valgus. The aim of our study was to analyze the occurrence of transfer metatarsalgia after surgery on the first ray using a screwless Scarf osteotomy technique that we have been using in our department since 1995, which consists of stabilization by axial impaction without internal fixation. We hypothesized that the alleged shortening of the first metatarsal produced by this technique may be at the origin of postoperative metatarsalgia. PATIENTS AND METHODS: This was a case series of first ray metatarsal screwless Scarf osteotomies reviewed in the medium term. We did a clinical and radiological review of all patients operated using this technique between 2012 and 2017 who did not meet the following exclusion criteria: procedure on the other lateral metatarsals, concurrent hindfoot pathology, incomplete medical records. RESULTS: Of 114 feet, 96 were included in the study and 18 were excluded. The mean follow-up was 1 year and 8 months [1-4years]. The mean AOFAS score was 90.3 and 96% of patients were either satisfied or very satisfied with the outcome. All the parameters improved significantly: shoe wearing, pain, function, alignment. Fourteen feet had transfer metatarsalgia, which appeared during the first year postoperative (AOFAS 75/100). Ten other complications occurred: two Morton's neuromas, three cases of complex regional pain syndrome, one superficial infection, one paresthesia, two recurrences with surgical revision, one nonunion. No general complications were found. Based on radiographs, the mean M1 shortening was 3.3mm (6.3mm in metatarsalgia group versus 3.0 mm in the non-metatarsalgia group, P=0.2) and the mean angular correction was 16.2° (±6°). DISCUSSION: The overall results of screwless Scarf osteotomy are comparable and satisfactory, allowing large deformities to be corrected (28°±8° preoperatively in our cohort). M1 shortening and the transfer metatarsalgia rate appear to be higher than with other techniques. CONCLUSION: Screwless scarf osteotomy of M1 yields good functional and radiological outcomes in the medium term. However, it appears to cause more shortening and transfer metatarsalgia. LEVEL OF EVIDENCE: IV Retrospective, non-interventional in current practice (Recommendation grade C, low level of scientific proof).

[Surgery in «around the knee¼ bone tumors]. / Stratégie chirurgicale dans les tumeurs osseuses « du genou ¼

Distal femur and proximal tibia are the main localization of primary malignant bone tumor. Osteosarcoma and Ewing sarcoma are the most frequent. New techniques in imaging, recent development in chemotherapy protocols and surgery sharpening led to major improvement in their management, which allowed to minimize amputation ratio. The complexity of their treatment and their rarity imply the involvement of multidisciplinary approach, in terms of both surgical and medical points of view. After resection, total knee arthroplasty has become the gold standard of reconstruction in such localizations. It uses press fit against healthy bone, thanks to long centromedullar stems, because of major soft tissues resection due to carcinologic surgery rules. The incision is usually antero-medial and the main difficulty is mostly linked to the care of vascular and nervous systems and the extensor apparatus. The conservation (or not) of the latter modifies the surgical technique. Articular invasion will impose to perform a one-piece-articular resection, which will complicate the conservation of the extensor apparatus. There are lots of different techniques and prosthesis. Arthrodesis indications are seldom because prosthesis reconstructions have made proof of their efficacy and their longevity. Functional and oncologic results of this excision and reconstructive surgery are now clearly established. However, this represents complex and risky interventions which will often lead to secondary surgical revision because of the young age of patients and their functional demands. This can only stress the necessity of addressing patients to specialized, network-organized sarcoma teams.

Complete pathological response after sequential therapy with sunitinib and radiotherapy for metastatic clear cell renal carcinoma.

Despite great improvements in the management of metastatic clear cell renal carcinoma, complete responses with antiangiogenic therapies are infrequent and complete pathological responses remain anecdotal. We report the complete pathological response of a solitary bone metastasis from a clear cell renal carcinoma after sequential treatment with sunitinib and radiotherapy. In February 2009, a female patient was diagnosed with clear cell renal carcinoma of the left kidney, bearing only one metastatic site localized in the proximal extremity of the left tibia. Radical nephrectomy was performed at first. Thereafter, sunitinib was administered at standard dose level for four weeks followed by two weeks free at each cycle. The patient underwent palliative radiotherapy between the fifth and the sixth cycle. Due to stable status, a radical surgery of the left knee was then performed and pathological analysis concluded a complete response. This case highlights potential synergy between sunitinib and radiation therapy in clear cell renal carcinoma.

Ezrin and alpha-smooth muscle actin are immunohistochemical prognostic markers in conventional osteosarcomas.

Ezrin is a cytoskeleton linker protein that is actively involved in the metastatic process of cancer cells. We have searched for a prognostic value of ezrin and some of its partners: alpha-smooth muscle actin and CD44H in 37 patients with an osteosarcoma. Automate immunohistochemistry (IHC) with anti-ezrin, alpha-smooth muscle actin and CD44H antibodies was performed in 66 specimens: 37 biopsies before chemotherapy, 16 resected tumours of "poor" responders and 13 metastases. The messenger RNA (mRNA) levels of ezrin of 13 frozen biopsies and 4 metastases were evaluated by real-time quantitative reverse transcriptase polymerase chain reaction (RT-PCR). All results were correlated to the following clinical data. Ezrin expression by IHC was found in 62% of 37 biopsies in the different histological subtypes. A good correlation was found between positive or negative samples by IHC and mRNA levels. Ezrin expression was recorded in 84.5% of metastastic samples. The mean expression of ezrin was higher in metastases than biopsies (p = 0.024). In multivariate analysis, ezrin was an independent prognostic marker for event-free survival and overall survival (OS) with p < 0.001 and p = 0.003, respectively, and alpha-smooth muscle actin for OS only (p = 0.024). Our findings suggest that ezrin and alpha-smooth muscle actin are predictive IHC prognostic markers for patients with an osteosarcoma.