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Two forms of bone lymphomas can be distinguished: the primary bone lymphoma (PBL) and the secondary bone lymphoma (SBL). PBL is a rare disease with a good prognosis. Clinical manifestations and imaging findings are usually non-specific. Patient can present with pain, swelling of affected bone or pathologic fracture. Positron emission tomography-CT scan is a sensitive imaging modality and very useful for staging, restaging, surveillance of recurrence, and monitoring of treatment response of lymphoma. The diagnosis of PBL is often difficult and made after biopsy examination. Most patients have diffuse large B-cell lymphoma. Patients have been treated with radiotherapy, chemotherapy or combination of both. Localized disease, low IPI (International Prognostic Index) and complete remission after initial treatment were associated with a better outcome. Management of late sequelae deserves particular attention. SBL is more common than PBL; this is a disseminated lymphoma with concomitant involvement of the skeleton. We review the clinical, imaging and pathologic features of bone lymphomas; and discuss therapeutic modalities as well as prognosis of these lymphomas in the era of immunochemotherapy., (Copyright © 2021 Société Française du Cancer. Published by Elsevier Masson SAS. All rights reserved.)

External beam radiation therapy is an efficient treatment, which relieves pain associated with bone metastases, and is prescribed in worldwide. Although bone metastases palliative irradiation recommendations exist, international clinical practices remain variable. The purpose of this article is to show the clinical practices evolution though clinical trials, cost studies and techniques' progression., (Copyright © 2018. Published by Elsevier Masson SAS.)

Bone pain associated with bone marrow infiltration is often present at diagnosis of pediatric acute lymphoblastic leukemia (ALL). It sometimes signs the presence of pathological fracture, lytic lesions, arthritis, or osteitis associated to ALL that can delay the diagnosis. During treatment, bone complications (pain, osteopenia, fracture, avascular necrosis, ...) are also reported. In order to describe bone involvement (BI) of pediatric LLA, we reviewed the records of 104 patients followed in our unit. The overall incidence of BI was 67 %. At diagnosis, 50 % of patients had BI and in 19 %, the diagnosis of ALL was delayed. During and after treatment, respectively 28 % and 37 % of patients presented bone complications (pain, fractures, avascular necrosis, osteopenia). Patients with BI had a lower leukocytosis inferior to 10x109/l (p = 0.005) and an ALL of average risk (p = 0.019). 38 % of patients with BI during treatment were over 10 years old and 55 % were girls (vs. 21 % and 38 % in the entire cohort, respectively). Osteoporosis was more severe at diagnosis than during treatment, suggesting the presence of constitutional promoting factors. In our cohort, the majority of BI was resolved at the end of treatment with no long-term sequelae.

Purpose: Bone metastases cause pain and affect patients' quality of life. Radiation therapy is one of the reference analgesic treatments. The objective of this study was to compare the current practices of a French radiotherapy department for the treatment of uncomplicated bone metastases with data from the literature in order to improve and optimize the management of patients., Material and Methods: A retrospective monocentric study of patients who underwent palliative irradiation of uncomplicated bone metastases was performed., Results: Ninety-one patients had 116 treatments of uncomplicated bone metastases between January 2014 and December 2015, including 44 men (48%) and 47 women (52%) with an average age of 63years (25-88years). Primary tumours most commonly found were breast cancer (35%), lung cancer (16%) and prostate cancer (12%). The regimens used were in 29% of cases 30Gy in ten fractions (group 30Gy), in 21% of cases 20Gy in five fractions (group 20Gy), in 22% of cases 8Gy in one fraction (group 8Gy) and in 28% of cases 23.31Gy in three fractions of stereotactic body irradiation (stereotactic group). The general condition of the patient (P<0.001), pain score and analgesic (P<0.001), oligometastatic profile (P=0.003) and practitioner experience (P<0.001) were factors influencing the choice of the regimen irradiation. Age (P=0.46), sex (P=0.14), anticancer treatments (P=0.56), concomitant hospitalization (P=0.14) and the distance between the radiotherapy centre and home (P=0.87) did not influence the decision significantly. A total of three cases of spinal compression and one case of post-therapeutic fracture were observed, occurring between one and 128days and 577days after irradiation, respectively. Eight percent of all irradiated metastases were reirradiated with a delay ranging between 13 and 434days after the first irradiation. The re-irradiation rate was significantly higher after 8Gy (P=0.02). The rate of death was significantly lower in the stereotactic arm (P<0.001) and overall survival was significantly greater in the stereotactic arm (P<0.001)., Conclusion: This study showed that patients' analysed was comparable to the population of different studies. Predictive factors for the choice of the treatment regimen were identified. Non-fractionnated therapy was underutilised while stereotactic treatment was increasingly prescribed, showing an evolution in the management of patients., (Copyright © 2018. Published by Elsevier SAS.)

Introduction: Spinal metastasis are getting more frequent. This raises the question of pain and neurological complications, which worsen the functional and survival prognosis of this oncological population patients. The surgical treatment must be the most complete as possible: to decompress and stabilize without delaying the management of the oncological disease. Minimal invasive surgery techniques are by definition, less harmful on musculocutaneous plan than opened ones, with a comparable efficiency demonstrated in degenerative and traumatic surgery. So they seem to be applicable and appropriate to this patient population., Material and Methods: We detailed different minimal invasive techniques proposed in the management of spinal metastasis. For this, we used our experience developed in degenerative and traumatic pathologies, and we also referred to many authors, establishing a literature review thanks to Pubmed, Embase., Results: Thirty eight articles were selected and allowed us to describe different techniques: percutaneous methods such as vertebro-/kyphoplasty and osteosynthesis, as well as mini-opened surgery, through a posterior or anterior way., Discussion: We propose a surgical approach using these minimal invasive techniques, first according to the predominant symptom (pain or neurologic failure), then characteristics of the lesions (number, topography, type…) and the deformity degree. Whatever the technique, the main goal is to stabilize and decompress, in order to maintain a good quality of life for these fragile patients, without delaying the medical management of the oncological disease., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Primary hyperparathyroidism, widely prevalent in women after menopause, remains rare in children and adolescents. Sporadic forms are the most frequent. Clinical manifestations are general, renal, gastrointestinal, cardiac, or bony. Diagnosis is biological and radiological. The imaging modalities allow assessment of the disease impact and identification of the parathyroid adenoma., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Background: Due to technical requirements and cost, hemodiafiltration (HDF) is not widely used in pediatrics. We have been using online HDF (oHDF) since 2009 and we observed low parathyroid hormone (PTH) levels despite the accurate management of CKD-MBD., Methods: We reviewed the medical charts and parameters of mineral metabolism assessed on a before/after session basis in the 6 children undergoing chronic oHDF in our centre., Results: We observed low (<80pg/mL) PTH levels in all 6 patients and very low (<45pg/mL) PTH levels in 5, two of them presenting with pathological fractures. These low PTH levels were reversed after decreasing calcium concentration to 1.25 mmol/L in the dialysate, suggesting that high-efficiency oHDF may expose children to calcium during sessions in a too important amount when using 1.5 mmol/L dialysates. Last, C-terminal FGF23 levels before sessions were relatively low (<1600RU/mL), with a 32% clearance by oHDF., Conclusion: PTH levels should be closely monitored in pediatric oHDF and solutions with a calcium concentration of 1.25 mmol/L should be used as first line in these patients., (Copyright © 2013 Association Société de néphrologie. Published by Elsevier SAS. All rights reserved.)

Purpose: To study epidemiological, clinical, pathological anatomy and therapeutic results of localized primary bone lymphoma., Patients and Methods: Between February 1993 and February 2013, four patients were treated for localized primary bone lymphoma in Sfax's hospitals (Tunisia). Treatment was decided regarding to the age of the patient, his performance status, stage of the disease, lactate dehydrogenase (LDH) and socio-economical conditions of the patient. The therapeutic evaluation was done after chemotherapy and after radiotherapy. There was a clinical, biological and radiological follow-up., Results: The mean age was 59.5 years. The sex-ratio was 3. Bone localizations were clavicula, femur, humerus and mandibula. All patients had stage I large cell B lymphoma. In 3 cases, imaging showed osteolytic lesions with cortical destruction and extension to soft tissues. One patient had a fracture of the humerus. The treatment consisted in chemotherapy followed by radiotherapy. Three patients were alive with complete remission after a mean follow-up of 76 months., Conclusion: The treatment of primary bone lymphoma is based on a combination of chemotherapy (with or without anti-CD20) and radiotherapy. The prognosis is excellent when it is localized., (Copyright © 2013 Société française de radiothérapie oncologique (SFRO). Published by Elsevier SAS. All rights reserved.)

The recent use of vemurafenib, a specific inhibitor of BRAF, has led to a significant improvement in disease-free survival and overall survival of patients treated for a BRAF-mutated metastatic melanoma. This new class of drugs is not devoid of side effects, including skin effects. In particular, its association with concomitant radiotherapy should be taken into consideration, vemurafenib appearing to be radiosensitizer. The radiation oncologist must be aware of this potential toxicity, which is not uncommon in clinical practice., (Copyright © 2013 Société française de radiothérapie oncologique (SFRO). Published by Elsevier SAS. All rights reserved.)

Giant cell tumor is colonized by aneurismal bone cyst in only 15% of cases and cervical localisation accounts for less than 1% of giant cell tumors. We are reporting a rare case of a C2 hypervascularized giant cell tumor colonized by an aneurismal bone cyst treated with an effective preoperative Onyx embolization followed by a full tumor resection. The patient experienced a moderate cervical spine injury 2 months prior admission followed by a progressive stiff neck and cervicalgia. CT and MRI identified a lytic lesion of the body and lateral masses of the C2 with encasement of both vertebral arteries. The angiography showed a hypervascularization of the lesion from the vertebral and external carotid arteries as well as a thrombosis of the V3 segment of the right vertebral artery at the C1 level. A posterior occipito-C3/C4 fixation and a tumor biopsy were performed. Histopathological examination concluded to a giant cell tumor colonized by an aneurismal bone cyst. Three weeks later, the patient developed a right upper extremity deficit. The MRI showed an increased C1-C2 stenosis and an increase of the hypervascularization. Three sessions of embolization by the onyx were performed. During surgery a near total tumor devascularisation was observed and a complete resection of the tumor was achieved through an anterolateral approach. Reconstruction consisted of a cementoplasty of the C2 body and odontoïd process with an anterior C3-prosthesis plate. The postoperative course was uneventful., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Unlabelled: Osteoporosis is a common complication in children with motor impairments. They have a higher risk of fractures (20% during their lifetime) mostly at femoral level. Furthermore, these children have pain yet no clear relation has been established between osteoporosis and pain. The efficacy of bisphosphonates has been validated in adults and for children with osteogenesis imperfecta (OI). However, its use in children with motor impairments has not yet been validated., Patients and Methods: Retrospective study on the medical charts of children presenting neurological diseases and motor impairments associated to secondary symptomatic osteoporosis. These children underwent treatment with Pamidronate(®) intravenous infusions (I.V.) in Lyon and Valence between 2002 and 2008. Data were collected on pain control, incidence and frequency of fractures and bone mass density (BMD). Data on adverse events were also collected to evaluate treatment's tolerance., Results: Twelve children's charts were studied for a total of 50 Pamidronate(®) I.V. infusions. Regarding treatment's efficacy, we observed a clear decrease and even total relief of the pain with improvement reported after 98% of perfusions. Regarding BMD, there was a real improvement after the treatment (e.g., lumbar BMD measures, -46.5% before treatment and -27% after treatment). The adverse events, flu-like syndrome, muscle pain and asymptomatic hypocalcemia, were minor and quickly reversible., Conclusion: It seems quite essential to screen for osteoporosis-related pain in these children and treat them quickly to avoid a negative impact on their quality of life. Treatment with I.V. bisphosphonates has shown its relevance, yet practical modalities still need to be defined. It would be interesting but quite difficult to implement, in light of the positive effect of this study, a prospective, randomized, controlled, double-blind vs. placebo study on a large enough sample of patients., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Increasing evidence indicates that COPD and osteoporosis are strongly linked. Both diseases share common risk factors like age, smoking and inactivity but the typical presence in COPD of systemic inflammation, vitamin D deficiency and the frequent use of corticosteroids catalyse ongoing bone resorption. Osteoporosis in its turn may lead to vertebral compression fractures with a consequent further decline of forced vital capacity and forced expiratory volume in one second. In addition, fragility fractures in disabled COPD patients may cause further immobility and increased morbidity. Prevention and treatment of osteoporosis in COPD should therefore be based on population specific risk assessments which combine measures of bone mineral density and clinical factors. Unfortunately, intervention studies specifically designed for patients with COPD are currently lacking and no specific guidelines have yet been established. Hence, a rigorous application of the current treatment guidelines with respect to osteoporosis in general would already be a major step forward in the treatment of COPD., (Copyright © 2010 SPLF. Published by Elsevier Masson SAS. All rights reserved.)

Objective: The management of osteoporosis in spinal cord injury that is a recurring issue in daily practice, but unfortunately, no standard protocol is provided by the literature review, either for screening or for a strategy of prevention and even for therapy. We assessed the practices of the physicians in physical medicine and rehabilitation from all over France, with the ultimate aim to propose a consensus for preventive and curative cares of that osteoporosis., Methods: A questionnaire was sent to practitioners engaged with spinal cord injury (SCI) patients residing in the center and patients in medical monitoring. The questionnaire consisted mainly of closed questions., Results: Twenty-six questionnaires are analyzed. The screening for osteoporosis is made routinely by only 19.2% of the practitioners and after a fracture in only 80.2% of the cases. The diagnosis of osteoporosis is based on bone densitometry (DEXA) (96%). Standing still remains a means of prevention for 88% of physicians in the acute phase and for 77% in the chronic phase. Ninety-two percent of practitioners treat at the stage of established osteoporosis., Conclusion: There is generally no standardized management of osteoporosis in practice for SCI patients. The searching for osteoporosis is usually performed after a fracture. All the literature data and results of the questionnaire led us to propose a protocol consisting in a systematic monitoring of the bone mineral density for the screening of osteoporosis, but also a procedure for early diagnosis and for preventive treatment of osteoporosis in the acute phase., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

Spinal fractures in patients with ankylosing spondylitis may be the result of minor trauma. These fractures may lead to severe neurological deficits, and they are difficult to detect using standard radiography. Often, CT-scans and MRI are required for diagnosis., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

Aneurysmal bone cyst is a pseudotumoral bone dystrophy which accounts for 1.5 to 4% of benign bone tumours. We report the case of a bulky aneurismal cyst of the left superior humeral metaphysis in a seven year old child revealed by a repeated pathologic fracture. Exeresis of the cyst was performed with reconstruction by a non vascularized fibula. After a follow up of one year the patient recovered safely with normal range of motion and anatomically. The cystic exeresis sparing the growth cartilage with fibula graft is indicated in the management of active and aggressive aneurismal cyst of long bones.

Numerous epidemiological approaches are used to demonstrate the efficacy of a new chemical entity. In postmenopausal osteoporosis, anti-fracture efficacy can be assessed through prospective, randomized controlled trials, meta-analyses or real-life setting studies. Intravenous ibandronate was recently marketed, with the aim of optimizing drug absorption and adherence to treatment. Furthermore, this new formulation avoids gastrointestinal side effects and constrains linked to the oral intake of the medication. Spinal anti-fracture efficacy of IV ibandronate derives from a non-inferiority bridging study, using surrogate endpoints, i.e., bone mineral density and biochemical markers of bone turnover, compared to the oral daily formulation, previously registered for the treatment of osteoporosis in Europe. Coherent results from two separate meta-analyses have suggested that the non-vertebral anti-fracture efficacy of IV ibandronate is similar to that observed with oral, daily and weekly bisphosphonates. Similarly, a recent real-life setting study, based on claims from an US database, suggests that hip fractures are reduced, with IV ibandronate, to the same extend as they are with oral bisphosphonates. Notwithstanding, those results should probably be confirmed in an European setting, before being extrapolated, in daily practice, to the Belgian population.

Context: Traditional treatment of sacrum osteoporotic fractures is mainly based on antalgics and rest in bed. But complications are frequent, cutaneous, respiratory, thrombotic or digestive and mortality at 1 year significant., The Aims: We wanted to define the interest of sacroplasty when treating osteoporotic fracture of sacrum., Method: We reviewed literature while studying a clinical case in an elderly patient., Results: Sacroplasty was efficient at short and mean delay to control the pain due to osteoporotic sacrum fracture. Rate of complications is low in the centers mastering the procedure., Conclusion: Sacroplasty is of evident interest for elderly patients suffering of an osteoporotic fracture of sacrum. It reduces decubitus complications, secondary effects of antalgics and allows an early reeducation.

Collapsing focal segmental glomerulosclerosis is well described in its idiopathic form, mostly seen in young African American patients, and in association with HIV virus. Its clinical presentation typically includes proteinuria and renal failure rapidly progressing to end stage renal disease. However, a new form has recently been described related to treatment with high doses of intravenous bisphosphonates, especially pamidronate. We report two cases of collapsing focal segmental glomerulosclerosis in patients treated with intravenous pamidronate. In opposition to previous reports, interruption of pamidronate administration did not improve renal function. The latter should be evaluated before initiating treatment with bisphosphonates and regularly monitored. For patients with chronic kidney disease, introduction of bisphosphonates should be reconsidered given the risk of rapid progression to end stage renal disease and the lack of evidence for reduction of fracture risk in this population.

Percutaneous vertebro-plasty is an efficient treatment of the symptomatic vertebral compression fracture refractory to optimal medical therapy. The procedure is used for neoplastic lesions, aggressive angioma, but also osteoporotic compression fractures. In order to adequately advice our patients, it is essential to know its indications and possible complications. However, to practice a vertebro-plasty for an osteoporotic compression fracture without any long term management of the osteoporotic disease is useless. Unfortunately, it still happens too often and it is essential that orthopedic surgeons, general practitioner, radiologist, rheumatologist, and any practitioners work together to guarantee the optimal management of our patients.

Aneurysmal bone cyst is a tumor-like lesion which accounts for about 1% of all biopsied tumors and tumor-like lesions of bone. We report an extremely rare case of aneurysmal bone cyst of the patella in an 18-year-old patient revealed by a pathological fracture. The unexpected appearance of a pathological fracture affects the whole therapeutical management. However, in the case of a well-preserved articular surface, curettage and corticocancellous grafting are considered to be successful methods of treatment for aneurysmal bone cyst of the patella, as revealed in our study.

Osteoporosis is a systemic disease and results in progressive bone mineral loss and concurrent change in bone architecture that leave bone vulnerable to fracture. In one third of patients with acute vertebral fracture, severe pain and limited mobility persist despite appropriate nonoperative management. Vertebroplasty is a minimally invasive method that involved the percutaneous injection of cement into a collapsed vertebral body to stabilize the fractured vertebra. The indication of this technique is a painful fracture after 8 weeks of conservative treatment. Contraindications include coagulopathy, absence of facilities to perform emergency decompressive surgery, a vertebral collapse greater than 65 % and a fracture of the vertebra posterior wall. The procedure results in quick, effective pain relief and complications as epidural leakage or thermal necrosis by cement extravasation are rare. Vertebroplasty does not expand the collapsed vertebra. Kyphoplasty is a modification of this first technique and offers potential advantages as lower risk of cement extravasation and better restoration of the vertebral body height. A cannula is introduced into the vertebral body via a transpedicular approach like for the vertebroplasty technique but it is followed by insertion of an inflatable bone tamp, which when deployed reduces partially the compression fracture. This then creates a cavity to be filled with bone cement. Considering the higher rates of morbidity or mortality that is associated with osteoporotic fractures, early mobilization in these patients is of prime importance and can be achieved by using each of this two techniques with a relative low complication rate.

Purpose: To prospectively compare the incidence of new fractures (as demonstrated on MR) within the first 3 months after an initial fracture in a population treated with low cement volume vertebroplasty and a population treated conservatively., Materials and Methods: From 49 patients admitted for osteoporotic vertebral compression fracture, 22 underwent CT guided vertebroplasty with injection of 1-3 ml of PMMA, and 27 were treated conservatively. All patients underwent MR at presentation and at 3 months to detect new compression fractures., Results: Twelve patients (54%) treated with vertebroplasty showed new fractures at 3 months compared to 10 (37%) in the control group. This was not statistically different (p=0.049). In the vertebroplasty group, the new fractures involved vertebrae adjacent to the treated vertebra in 77% of cases (p=0.009) compared to only 15% in the control group. During the 3-month period, 3 patients, including 2 treated with vertebroplasty, required hospital admission due to fracture related acute lumbar back pain., Conclusion: The small amount of injected cement does not prevent fractures of adjacent vertebrae but does reduce the extravasation of PMMA in adjacent tissues.

Objectives: To identify stress fracture frequency and the associated risk factors in disabled female athletes preparing the Paralympic Games in Athens in 2004., Material and Method: The study is focused on four athletes (including one with a vision impairment) among the 31 women selected to participate in the Paralympic Games. The medical records of selected athletes not having been able to participate in the Games due to a stress fracture were analyzed., Results: One case of stress fracture to the first metatarsal was reported of one below-knee amputee and an additional case to the second metatarsal of one hemiplegic athlete. Two of three athletes with physical disability were unable to participate in the Games because of stress fracture occurring during the preparatory phase., Discussion - Conclusion: Among four athletes selected to take part in the Paralympic Games. If morphological predispositions are inherent to the sportswomen, the main favouring factor to be retained is their running asymmetry. Training programmes must therefore take this characteristic into account and must not offer heavy-load repetitive exercise (such as endurance or jogging) at the expense of technique. Over-intense training exposes the disabled athlete to this type of pathology and is likely to affect his chances of competing.

Giant cell tumours (GCT) of bone are frequent, with variable behaviour, high risk of recurrence and an often benign histological appearance. Their location in the hand is uncommon, and there are few publications on the subject. Surgical treatment as described in the literature is very variable. We report a case of recurrent grade II GCT, arising in the proximal phalanx of the thumb, aggressive and causing a pathological fracture. After a surgical biopsy, we performed an "en bloc" resection of the first phalanx, with an iliac crest graft reconstruction and a double arthrodesis of the metacarpophalangeal and interphalangeal joint. No recurrence or lung metastasis was seen at 18 months follow-up.

This retrospective and prospective study over 49 months has permitted us to count 43 cases of pathologic fractures: the population concerned is a population of adults whose average age is 43.5 years old. The social groups, which are more affected, are these having poor economical revenue. The male sex is predominating lightly with 22 cases (51.2%). Within 16 cases (37.2%) the pathologic fracture has revealed the causal affection and 27 cases (62.8%) where the affection was already known before the occurrence of pathologic fracture. Pain, tumefaction and functional impotence constitute the main reason (motive) for consultation. Femur is the most affected bone with 26 cases over 43 cases. The principal etiologies are represented by malignant bone tumors 37.2%, osteoporosis 23.2%, and osteomyelitis 23.2%. Imperfect osteogenosa 6.9%, ricket 6.2%. The standard face and profile radiography and biopsy are the principal complementary exams. The treatment is surgical in 81.4% of cases and orthopedic in 18.6% of cases.

Purpose of the Study: The vascularized fibular graft is a widely used technique for the reconstruction of long bone defects after tumor resection. Complications are not uncommon despite the presence of a good vascular supply. We report our experience with long bone reconstructions in children and adolescents after resection of primary malignant bone tumors., Material and Methods: This retrospective analysis included thirteen patients aged 4-17 years (mean age 12 years). Preoperatively, the pathological diagnosis was Ewing tumor (n=7), osteogenic sarcoma (n=5), neuroepithelioma (n=1). All patients except one were given chemotherapy preoperatively and postoperatively and four received adjuvant radiotherapy. Tumor resection created a gap (n=8) or involved resection-arthrodesis (n=5, three knees, one ankle, one elbow). All reconstructions used a vascularized fibular flap with a complementary corticocancellous autograft for seven., Results: Complete carcinological resection was achieved in all cases. Mean follow-up was 50 months (range 12-144 months). There were no cases of local recurrence. Three patients presented lung metastasis; two patients died. Eleven of the twelve patients who underwent tumor resection involving the lower limb were able to walk with full weight bearing at 13.9 months (range 841 months), half of them without any supportive device. The MSTS score was 21/30 (range 7-29). Both ends healed for eleven of thirteen grafts. Outcome was good in four cases at 7.7 months (range 6-11), fair in seven (with 1-5 complementary procedures) at 14.8 months (range 10-45) and poor in two (nonunion at last follow-up). Among the fibular grafts which healed, primary healing of the distal end was noted in all cases, but not for the proximal end. Significant transplant hypertrophy was noted in 62% of patients, measured at mean 77.1% (range 25-128%). Complications were: skin necrosis (n=2), nonunion (n=4, three aseptic and one septic), disassembly (n=3 with two transplant fractures), and spontaneous fracture which healed (n=5, all but one treated orthopedically). There were four donor site complications: retraction of the hallux flexor (n=3), regressive paresia of the common fibular nerve (n=1)., Discussion: The rate of healing in this series was similar to earlier reports. Healing was always achieved for the distal focus but not for the proximal focus which receives its blood supply from a branch of the anterior tibial artery which is not harvested. The defective blood supply can thus hinder bone healing. It is necessary to spare the proximal quarter of the fibula or harvest a bipediculated graft. The rate of graft hypertrophy was also similar, as was the rate of complications. The MSTS score was lower due to the poor results obtained with resection-arthrodesis of the knee joint. Graft fractures and aseptic nonunion are the most common complications but septic complications are more serious and can threaten graft survival. Complications at the donor site are exceptional., Conclusion: Long bone reconstruction using an autologous vascularized fibular graft is a reliable technique providing satisfactory functional results. Complications can be prevented by making solid fixation and using a corticocancellous graft creating a favorable osteoinducing environment. A massive allograft is another solution providing good immediate mechanical stability.

The authors report a new case of African Histoplasmosis in a 60-year-old patient. It was an humeral localization revealing a pathological fracture which grew into an extension of osteolysis and a cutaneous fistulization likely to be a malignant bone tumor. The case has been diagnosed by surgical biopsy and histological analysis. Its antifungal treatment in progress resulted in the drainage of the out-flow that should permit the bone reconstruction by graft. The authors stress on the need to focus on this affection whenever, in a tropical area, one is faced with any chronic bone fistula that cannot positively be cured in spite of sound medical cares.

Purpose of the Study: Osteoporotic fractures are an important public health problem due to significant morbidity and mortality and the socioeconomic burden. In Tunisia, the impact of such fractures is often underestimated due to lack of epidemiological data. We evaluated the prevalence of these fractures in a sample population at risk in order to better ascertain the amplitude of this problem in our country., Material and Methods: This prospective study involved 2,000 menopaused women aged 50 years or more. The sample was randomly selected among the population of Manouba, an urban administrative district of the capital of Tunisia. One thousand three hundred eleven women agreed to participate in this survey. Women with a risk of secondary osteoporosis were excluded. We retained for study fractures related to primary osteoporosis. History taking recorded anthropometric data and medical history, particularly gyn-ob history. All fractures occurring after minor trauma, in women aged 50 years or more, and involving the femoral neck, the wrist, or the proximal humerus were noted. Lateral x-rays of the thoracolumbar spine were studied to search for unrecognized vertebral fractures., Results: The study population included 1,311 women, mean age 64.07 +/- 9.31 years, menopaused at mean 48.29 +/- 3.84 years. Among these women, 212 (16.2%) had presented a fracture at one of the localizations retained for study. Vertebral wedge fractures accounted for 59.83% of all fractures, wrist fractures 31.96%, proximal femoral fractures 4.51% and proximal humeral fractures 3.69%., Discussion: Osteoporotic fractures are not uncommon in women in Tunisia. Increasing life expectancy in our country suggests this public health problem will grow in the years to come, pointing out the importance of better management of osteoporosis to prevent fractures.

Hyperthyroidism is an important cause of secondary osteoporosis and therefore of fractures. Nevertheless, facing an osteoporotic fracture, we do not systematically seek after such thyroid disorder in our daily practice. In this purpose, we report the case of 73 year old women, presented with a bilateral pathological femoral neck fracture. Investigations find a hyperthyroid related osteoporosis. Beyond orthopaedic treatment, radioiodine and bisphosphonate drugs were prescribed.

We present a case of Ilizarov reconstruction after en bloc resection of the distal radius. An 8-cm resection was required to remove a giant-cell tumor. Reconstruction was based on the ascension technique using an Ilizarov external fixator after corticotomy of the proximal fragment of the radius. Satisfactory reconstruction with formation of a neoarticulation between the radius and the carpus was achieved. Satisfactory wrist function was achieved and the patient was recurrence free at five years. The arguments leading to this therapeutic option are discussed.

The malignant bone tumours in children are rare, concerning 5% of the all paediatric tumours. Among all paediatric bone tumours, 15% of them are malignant. The main bone tumours in children are the osteosarcoma and the Ewing sarcoma. The diagnosis and treatment need a multidisciplinary medical team. It is essential in front of potential clinical or radiological signs, to perform quickly the specific medical exams and biopsy. The treatment needs a paediatric medical and surgical staff.

The carpal scaphoid is an uncommon localization for chondroma. Ten cases have been reported in the literature. We report a new case of right carpal scaphoid chondroma complicated by fracture in a 30 year-old man. The diagnosis was strongly suggested by the computed tomography scan and confirmed at pathology examination of the operative specimen. Treatment consisted in tumor enucleation and a cortico-cancellous graft to fill the gap followed by plaster case immobilization. Clinical and radiological outcome was favorable.

We observed a pathological fracture of the femur in a 21-year-old woman with a venous malformation. Physical examination and plain x-rays disclosed a pathological bone. Biopsy revealed the venous malformation. The extent of the lesion that involved the entire quadriceps muscle was detailed with duplex-Doppler, computed tomography and arteriography. The patient was treated with an intramedullary nail. Intra-operative bleeding necessitated transfusion (packed cells and frozen plasma). Outcome was favorable. Bone healing was achieved at seven months.

Diagnosis and treatment of osteoporosis are focused on demineralisation but bone mineral density is not directly correlated with bone strength. As with every material, the mechanical strength of bone depends upon its Young's modulus and its cross-sectional moment of inertia. In the clinical situation, bone strength can be quantified using peripheral quantitative computed tomography imaging (pQCT), a non-invasive imaging method, which allows calculation of a strength index. In this study, we tried to increase the fracture threshold of the distal radius by directly increasing bone strength rather than density. Twenty wrists in 10 cadavers were filled percutaneously with a calcium phosphate cement. Fluoroscopy and pQCT were performed twice, once before cementing and again 24 h after cement crystallisation to hydroxyapatite. We obtained measurements of trabecular and total bone density, and also stress strain index (SSI). Our results showed that trabecular bone density increased by a factor of 2.85, whereas total bone density increased by 1.61 and SSI by 1.99. Fluoroscopy showed two small leaks of cement at the point of injection. This study demonstrated that percutaneous injection of calcium phosphate cement increased distal radius strength, and consequently its fracture threshold. This technique could be employed in the future to prevent the occurrence of fractures in osteoporotic patients.

Osteoporosis is a general disorder of the skeleton characterised by a decrease in bone mass, with damage to the microarchitecture leading to an increase in bone fragility and fracture risk. The incidence of this illness will increase in the future because of the aging of the population and increasing risk factors. Many guidelines have been proposed by qualified authorities--those of the European Agency for the Evaluation of Medicinal Products (EMEA) being the latest published. The aim of treatment of the osteoporosis is to increase, maintain or improve bone mass as well as its strength, with a view to decreasing the incidence of bone fractures. With regard to preclinical studies, in vitro studies--such as those using osteoblast or osteoclast cultures--allow a better understanding of the mechanism of action of drug treatment. The evaluation of bone quality should be performed in two species, such as the ovariectomised female rat model and larger animals (ewe, sow, primate etc.). Phase I studies are designed to enable determinations of pharmacokinetic profiles and bone diffusion and to offer indications of the putative clinical relevance of the dosages. For phase II studies (double-blind controlled studies versus placebo, ideally with a duration of 24 or sometimes 12 months), tests of three dosages are recommended, and the bone mass is considered as a relevant substitution criterion. The aim of secondary osteoporosis prevention studies (randomised double-blind and comparative controlled design versus placebo) is to avoid the occurrence of new bone fractures, and the main evaluation criterion is the number of patients with new fractures. The study length should not be less than 3 years. For evaluation of primary osteoporosis prevention, efficacy in the prevention of bone fracture is the prerequisite--before the use of bone mass as the main evaluation criterion. This criterion can be evaluated by alterations in bone mineral density at the rachis level. Reference drugs such as estrogens can be an alternative to placebo comparison. The tolerability of drugs for the treatment of osteoporosis requires evaluation in long-term studies and the collection of postmarketing data. The International Conference on Harmonisation (ICH) could lead to uniform guidelines for the US, Europe and Japan.

After initial calcification in matrix vesicles or collagen fibrils, bones are continually modified by modelling then remodelling. In bone tissue, the degree of mineralisation of bone structural units is heterogeneous, reflects the rate of bone remodelling, and can be measured using microradiography. Our model is based on the fact that bone remodelling activity and thus the duration of the secondary mineralisation of bone tissue would influence its mineral status (mainly its degree of mineralisation or bone density at tissue level). When the bone remodelling rate increases (menopause, parathyroid hormone), the degree of mineralisation of bone tissue decreases. Conversely, after a diminution of the remodelling rate induced by antiresorptive treatments, the degree of mineralisation of bone tissue increases. Strontium ranelate (PROTELOS) has been tested to date as a potential therapeutic agent in patients suffering from postmenopausal osteoporosis. Recent phase III studies (the Spinal Osteoporosis Therapeutic Intervention [SOTI] study and the TReatment Of Peripheral Osteoporosis Study [TROPOS]) show a decrease in the vertebral and extravertebral fracture risk and an increase in bone mineral density measured at lumbar spine and femoral levels. Strontium ranelate has a unique mechanism of action, since it decreases bone resorption and increases bone formation ('decoupling' agent). Our preliminary observations in animal and man reveal that, because of this dual mechanism of action, the degree of mineralisation of bone tissue and the crystal characteristics of bone mineral are maintained at normal levels. More generally, these data indicate that the mineral status of bone tissue should be systematically taken into account during histomorphometric studies of bone.

The prevention and treatment of osteoporosis are now a necessary goal because of the aging of the population and the social and economic costs of fracture complications. The publication of guidelines by registration agencies during the last 10 years has provided precise rules for evaluating new drugs designed for the prevention and treatment of postmenopausal osteoporosis. The benefit of combination treatment with calcium and vitamin D in osteoporotic patients has clearly been proven, especially among the oldest patients, but results of prospective studies designed for the prevention of fracture risk are conflicting. In the Fracture Intervention Trial (FIT), treatment with alendronate 10 mg/day reduces the risk of vertebral fracture by 48% and increases bone mineral density (BMD) in patients with vertebral fractures. In the Vertebral Efficacy with Risedronate Therapy Multi-National (VERT-MN) and VERT-NA (North America) studies, treatment with risedronate 5 mg/day reduces the risk of vertebral fracture by 49% and 41%, respectively. Risedronate 5 mg daly for 3 years leads to an increase in BMD. The Prevent Recurrence Of Osteoporotic Fractures (PROOF) study has shown a significant decrease in the risk of vertebral fracture in patients treated with calcitonin 200 IU. However, numerous criticisms of the methodology of this study design have been identified. Selective estrogen receptor modulators could act as agonists or antagonists of estrogens, depending on the target tissue. In the Multiple Outcomes of Raloxifene Evaluation (MORE) study, treatment with raloxifene reduces the risk of vertebral fracture by 50% in patients without prevalent vertebral fracture and by 30% in patients with prevalent vertebral fracture. PTH treatment leads to an increase in BMD and reduces the risk of vertebral fracture by 65%. Strontium ranelate has a novel mechanism of action (stimulation of bone synthesis and decrease in bone resorption), and administration of 2 g daily has a proven positive effect, leading to an increase in bone mass among women with osteoporosis. This effect was especially evident in the Spinal Osteoporosis Therapeutic Intervention phase III (SOTI) study, in which a significant decrease in the incidence of vertebral fracture of 41% over 3 years has been shown. Thus, effective therapeutic strategies now enable improved treatment of postmenopausal osteoporosis. However, this condition is still poorly diagnosed and not all patients are correctly treated. Preventing the occurrence of the first fracture should remain the prime concern.

Purpose of the Study: The clinical, biological, radiological, MRI, and histological features of 22 primary bone lymphomas were reviewed retrospectively., Material and Methods: The standard pathology slides were reexamined with an immunohistochemistry study. Results of two treatments, chemotherapy alone versus chemotherapy then radiotherapy, were compared in terms of local control and patient survival., Results: Mean age of the patients was 53 years; male gender predominated (M/F=2/1). The most frequent clinical sign was pain and 32% of the patients had a pathological fracture. The long bones were generally involved. The typical radiographic image was a permeable bone defect. MRI demonstrated heterogeneous signals on the T2 images. Technetium scintigraphy (performed in all patients) was very sensitive. Histology generally described diffuse large centroblastic lymphoid cells, all with B phenotype. Twelve patients were treated with chemotherapy alone and eight with chemotherapy and radiotherapy. One patient was only given palliative treatment with corticosteroids due to major immunodepression. The last patient, a 79-year-old woman, developed a tumor of the femoral neck; at surgery section of the neck removed the entire tumor, but radiotherapy (30 Gy) centered on the femur was nevertheless performed. Only patients with fractures were operated. Mean follow-up in this series was 48 months (range 4-120). Mean 5-year Kaplan-Meier survival was 74.41% for the overall series, 83.33% for the chemotherapy group and 82.50% for the chemotherapy-radiotherapy group., Discussion: We were unable to demonstrate any significant difference in survival between the two types of treatment. None of the patients experience local relapse. Our observations suggest that technetium scintigraphy is more sensitive than MRI and more specific for diagnosis. Radiography, together with clinical examination and is indicated to monitor these patients during and after treatment. Based on this series, patients with primary bone lymphoma should be given chemotherapy, either alone or combined with radiotherapy, rather than radiotherapy alone. Surgery is not indicated except to obtain a biopsy and to treat mechanical complications.

Introduction: Proximal femoral fractures are the most severe medical and social consequence of osteoporosis. The bone loss in the proximal femur can be assessed with the Singh Index, which represents a cheap and reproducible method and which quantifies the osteoporosis on a 1-6 scale. The purpose of the study is to correlate the Singh Index with the anatomical forms of fracture (extra and intracapsular) in a series of patients., Material and Method: Three hundred consecutive patients over 60 years were operated for a proximal femur fracture. 284 radiological records were included in the study. They were classified in 4 age groups (60-69, 70-79, 80-89, 90 and more). The anatomic forms were classified following the AO scheme in extracapsular (A1, A2, A3) and respectively intracapsular fractures (B1, B2, B3). For each case the Singh Index was assessed twice on a standard AP view of the controlateral hip by a single examiner., Results: There were 154 extracapsular fractures and 130 intracapsular fractures. The average Singh Index was 2.6/6. It decreases from 3.7/6 for males and 3.2/6 for females in age between 60-69 to 1.6 for males and 1.3 for females over 90. In all age groups females are more osteoporotic (0.3-0.5 of difference, p=0.003). The extracapsular fractures presented with a lower average Singh Index (2,34/6) compared to the intracapsular types 2,55/6 (excepting the impacted coxa-valga B1. This finding is seen in both male (2,50 vs 2,66) and female patients (2,33 vs 2,48)., Discussion and Conclusion: In this series patients with extracapsular proximal femur fractures show a lower Singh Index compared to the intracapsular types (p=0.03). The choice for the type of osteosynthesis or arthroplasty should take into account the mechanical solidity of the femur.