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Introduction The capacity of the hydroxyapatite-coated trochanteric screwed plates used with modular hip implants to restore abductor system efficacy after proximal femoral tumor resection has never been assessed. We therefore conducted a retrospective study aiming to: (1) quantitatively evaluate abduction conservation on dynamometry according to use of digastric reinsertion, conserving continuity between the gluteus medius and vastus lateralis muscles, or not, and of standard versus small-offset; (2) assess radiographic trochanteric plate fixation; (3) assess functional scores; and (4) assess complications. Hypothesis Trochanteric reinsertion better conserves abduction strength when reinsertion is digastric. Patients and methods Thirty-one patients undergoing proximal femoral tumor resection between 2006 and 2016 with reconstruction by Stanmore METS™ modular implant with trochanteric plate were included. Twenty-one had digastric fixation between the gluteus medius and vastus lateralis and 10 had simple trochanteric fixation without digastric continuity. Abduction strength was compared between sides on dynamometer. Sixteen patients had full assessment of muscle strength, by a single observer; there were 8 deaths, 5 patients lost to follow-up, and 2 cases of material removal. Results Abduction strength conservation versus the contralateral side was 55.2 ± 23.3% (range, 5.8–86.1%): 66.6 ± 13.0% (46.4–86.1) with versus 36.0 ± 24.7% (5.8–63.2%) without digastric continuity (p = 0.01); severe limp rate was 4/21 when digastric continuity was preserved (19%) versus 6/10 (60%) (p = 0.04), and radiologic trochanteric reinsertion stability rate was 19/21 (90%) versus 4/10 (40%) (p = 0.005). Standard femoral offset conserved greater abduction strength: 64.9 ± 20.0% versus small-offset 45.4 ± 23.2% (p = 0.05). Toronto Extremity Salvage Score (TESS) was 89 ± 9.4%, and Musculoskeletal Tumor Society (MSTS) score 75.4 ± 5.4%. There were 6 complications (19%): 4 infections, 1 dislocation, and 1 plate removal; the single dislocation (3%) was in the digastric conservation group. TESS (90.7 ± 7.8% vs 88.3 ± 4) and MSTS score (75.6 ± 4.0% vs 75.1 ± 3.7) and complications [4/21 (19%) vs 2/10 (20%)] did not differ according to digastric or non-digastric reinsertion (p = 1). Conclusions Abduction strength with a modular implant using a hydroxyapatite-coated trochanteric plate was better conserved by digastric trochanteric reinsertion, resulting in less limping, although the complications rate and functional scores were unaffected. Longer term assessment is needed to confirm this conservation of abduction strength. Level of evidence IV, retrospective study without control group.

Background Aneurysmal bone cyst (ABC) is a benign tumour whose progression involves the RANK/RANKL signalling pathway. Surgery is the reference standard treatment but carries risks that vary with the site of the tumour. Denosumab is a human monoclonal IgG2 antibody that targets the RANK/RANKL pathway and may therefore hold promise for inhibiting ABC progression. The objective of this study was to evaluate denosumab use in paediatric patients (younger than 18 years) with ABC and to describe the clinical and radiological outcomes, as well as the side effect profile. Hypothesis Denosumab is a viable option in children with ABC refractory to standard treatments. Material and methods We retrospectively reviewed the medical files of paediatric patients given denosumab to treat ABC in any of 32 centres affiliated with the French Paediatric Cancer Society (Societe Francaise du Cancer de l’Enfant, SFCE) and French Sarcoma Group (Groupe Sarcome Francais, GSF-GETO). We identified 5 patients treated between March 2015 and June 2018. Median age was 8 years (range, 7–17 years). Pain was a symptom in all 5 patients and neurological deficits were present in 3 patients. Surgery was performed in 4 patients, either before (n = 3) or after (n = 1) denosumab therapy; the remaining patient had no surgery. Denosumab was given as monthly injections in a dosage of 70 mg/m2 for a median of 12 months (range, 4–23 months). The clinical outcomes and changes in computed tomography and/or magnetic resonance imaging findings were evaluated. Results Abnormalities in calcium and phosphate levels secondary to the ABC occurred in 2 patients. At median of 24 months (range, 0–28 months) after denosumab initiation, all 5 patients were free of pain, and the neurological deficits in 3 patients had improved. Central remineralisation and cortical reconstitution were demonstrated consistently by the imaging studies. Discussion Denosumab is a viable treatment option in selected paediatric patients with inoperable ABC. The immediate adverse effect profile is acceptable. A larger study with a longer follow-up would be welcome to further assess the contribution of denosumab to the treatment of ABC. Level of evidence IV.

Tenosynovial giant cell tumor (TSGCT) is a rare benign tumor arising from joint synovia, bursae and tendon sheaths. Their variable clinical presentation is related to variations in site and progression. Localized forms are most frequent in the hands, and diffuse forms in the knee. MRI is necessary and sometimes sufficient for diagnosis. Treatment strategy is guided by progression, symptomatology, location and diathesis. Optimally complete resection is the principle of first-line treatment. Radiation therapy is effective and targeted therapies are promising; both should especially be considered in case of relapse.

BackgroundRadiographic measurement of the alpha angle (AA) in femoroacetabular impingement (FAI) is not well codified and invasive techniques such as MR- or CT-arthrography remain the gold standard. Excessive acetabular coverage described in pincer-type FAI can be seen on plain radiographs but has never been quantified and anterior center edge (ACE) angle, described on the false-profile view (FP) to measure anterior acetabular coverage has never been evaluated in FAI.HypothesisIn this study we wanted to determine if a plain radiograph could efficiently measure AA compared to CT-arthrography and if ACE could quantify the acetabular coverage in FAI.Materials and methodsWe developed a hip view combining a lateral view and a FP, called profile view in impingement position (PIP). Twenty-six patients operated for FAI had CT-arthrography, PIP and FP. Nineteen control subjects had the PIP. AA were measured twice by three raters and ACE once. We compared AA measured on patients between CT and PIP, on PIP between patients and controls, ACE measured on patients between PIP and FP, and did a reproducibility analysis. Means were compared by paired or unpaired t-tests; reproducibility was measured by intraclass correlation coefficient (ICC).ResultsMean AA was 65.8° (range, 48–85°) on CT-arthrography and 63.9° (range, 50–87°) on PIP (P>0.05). ICC for PIP measures were 0.8–0.9 for intra-rater and 0.6–0.9 for inter-rater reliability. Mean AA on PIP in patients was 63.3° (range, 52–87°) and 44.9° (range, 34–67°) in controls (P50°. PIP was not efficient to measure ACE.Level of evidenceLevel III, case-control study.

Background Scapulo-humeral arthrodesis (SHA) is a proven reconstruction method in patients with proximal humerus malignancies requiring resection of the shoulder abduction apparatus (rotator cuff and deltoid muscles) or its nerve supply. Standard practice consists in using a pedicled fibular flap. We use instead a pedicled autologous bone graft harvested from the ipsilateral scapular pillar. Hypothesis The objective of this study was to assess functional outcomes and radiological healing after SHA using a pedicled scapular pillar graft. Materials and methods We retrospectively reviewed the charts of the 12 patients managed at a single center by a single surgeon between 1994 and 2011. SHA was performed using a vascularised ipsilateral scapular pillar graft after proximal humerus resection to treat a bone malignancy. The graft was harvested from the ipsilateral scapular pillar, pedicled on the circumflex scapular artery, fitted into the remaining proximal humerus, and secured to the glenoid using screws. A humerus-scapular spine plate was added to stabilize the arthrodesis. Radiographic results were assessed on standard radiographs obtained at last follow-up. Functional outcomes were evaluated using the MusculoSkeletalTumour Society (MSTS) score and Toronto Extremity Salvage Score (TESS). Results After a mean follow-up of 4.9 years, 87.5% of SHA junctions were healed, mean MSTS score was 71%, and mean TESS score was 70%. Discussion The outcomes in our patients were similar to those reported after SHA using a pedicled fibular flap. However, our technique does not require microsurgery. It is simple, reproducible, and effective. Its indications of choice are intra- or extra-articular resection of the proximal humerus including the attachments of the rotator cuff and deltoid muscle tendons or the nerves supplying these muscles. Level of evidence Level IV (retrospective study).

Summary Introduction Total hip replacement (THR) following hip tumor resection incurs a high risk of dislocation. We assessed the incidence of dislocation associated with use of a dual mobility cup, and the functional results achieved. Hypothesis Use of a dual mobility cup would reduce the risk of THR instability following hip tumor resection. Material and methods We analyzed dislocation rates in a retrospective series of 71 dual mobility cup THRs implanted following the resection of a tumor hip condition: 33 primary bone tumors and 38 bone metastases. The presenting pathology was diagnosed anatomically, and surgery classified in terms of adopted abductor system strategy. Functional results were assessed in terms of pain (analgesia on the World Health Organisation [WHO] scale), assisted walking and Musculoskeletal Tumor Society (MSTS) score. Results An overall rate of 9.8% dislocation was observed, taking into account all etiologies and contexts together. More precisely, this rate resulted from a compound figure of 5.2% in bone metastasis and 15% in primitive bone tumor. Dislocation risk depended less on etiology than on the surgical management of the abductor system, being 3.5% in the case of abductor conservation, 9.5% in the case of abductor sectioning/reinsertion, and 18% in case of gluteus medius muscle or nerve resection. Functional improvement was consistently observed, especially in bone metastasis. At the maximal follow-up, 32 patients were not using analgesics, six were taking WHO class III analgesics, 10 class II and 23 class I. Mean MSTS score was 68.1% ± 23.5% in bone metastasis and 59.6% ± 17.5% in primary bone tumor. Fourteen patients could walk without assistance, 33 with a single cane, 15 with two canes and eight with a walker; one patient had not been able to resume walking. Discussion In these indications, dual mobility cups use lead to lower dislocation rates than those reported in the literature. It proved especially effective in the case of bone metastasis and consolidation surgery. In the case of primary bone tumor, it failed to prevent dislocation following acetabular resection, especially when involving the abductor muscles and/or abductor innervation, although it provided lower dislocation rates, comparable to those experienced with other techniques, when applied to limited resection. Level of evidence IV. Retrospective therapeutic study.

SummaryThe authors report an isolated case of right sacrospinous ligament ossification causing sciatic pain because of compression of the proximal sciatic nerve. The initial conservative treatment of injections in the conflict zone and the intervertebral joints was insufficient. Surgical exploration was undertaken via a posterior approach, demonstrating the conflict between the nerve and the ossified ligament. Resection of the ossified ligament eliminated the symptoms at the cost of transitory buttock hypesthesia. The anatomic and pathologic exam identified simple osseous metaplasia. Lumbar-pelvic coxometry analysis showed sagittalization of the acetabular roofs, excessive bilateral femoral torsion, and a step-off attenuation at the anterior cervicocephalic junction (low anterior cervico-cephalic femoral offset). In addition, reduced lumbar lordosis and accentuated sacral slope were noted, factors that could be related to modifications in the static balance of the lumbar-pelvic complex. This imbalance could be correlated to an increase in the forces applied to the pelvic ligament layers. The etiological hypothesis retained was that this osseous metaplasia was a reaction to excessive stresses on the sacrospinous ligament.

Summary In Tape Locking Screw (TLS®) ligamentoplasty, transplant bone fixation uses polyethylene terephthalate (PET). We report two cases of aseptic arthritis following anterior cruciate ligament (ACL) reconstruction using this material. Diagnosis was founded on negative sampling and complete cure following arthroscopic lavage and synovectomy without curative antibiotherapy. This complication was also described with other synthetic materials used in this indication (Dacron, PFTE, carbon), and with PET as transplant material but never as bone fixation material. The physiopathological hypothesis is in terms of PET particle release in the suprapatellar bursa; sinking the strips into the bone as fully as possible on implantation could avoid impingement. Longer TLS® ligamentoplasty series with adequate follow-up will be needed in order to estimate the true incidence of this complication.

SummaryIntroductionResection margins constitute a recognized risk factor for local recurrence, but their impact on survival is less clear.HypothesisInfiltrative proliferation and satellite nodules are prognostic factors for local and systemic aggressiveness.Type of studyRetrospective cohort study.Patients and methodsIn 105 patients under curative treatment, resection quality was assessed on UICC criteria (R0/R1) and on a modified version (R0M/R1M) taking account of proliferation contours and satellite nodules for narrow margins (