Search

The survival of irradiated allograft-prosthesis composites at the proximal tibia is mostly unknown. However, allograft-prosthesis composites have proved beneficial at other reconstruction sites. We presumed allograft-prosthesis composites at the proximal tibia would improve survival and facilitate reattachment of the extensor mechanism compared with that of conventional (megaprostheses) reconstructions. We retrospectively reviewed 26 patients who underwent resection of proximal tibia tumors followed by reconstruction with allo-graft-prosthesis composites. Patients received Guepar massive custom-made fully constrained prostheses. Allografts were sterilized with gamma radiation, and the stems were cemented into the allograft and host bone. The minimum followup was 6 months (median, 128 months; range, 6-195 months). Fourteen patients had one or more components removed. The median allograft-prosthesis composite survival was 102 months (95% confidence interval, 64.2-infinity). Of the 26 allografts, seven fractured, six showed signs of partial resorption, and six had infections develop. Seven allografts showed signs of fusion with the host bone. Six extensor mechanism reconstructions failed. Allograft-prosthesis composites sterilized by gamma radiation yielded poor results for proximal tibial reconstruction as complications and failures were common. We do not recommend irradiated allograft-prosthesis composites for proximal tibia reconstruction.

We previously compared by microarray analysis gene expression in rheumatoid arthritis (RA) and osteoarthritis (OA) tissues. Among the set of genes identified as a molecular signature of RA, clusterin (clu) was one of the most differentially expressed. In the present study we sought to assess the expression and the role of CLU (mRNA and protein) in the affected joints and in cultured fibroblast-like synoviocytes (FLS) and to determine its functional role. Quantitative RT-PCR, Northern blot, in situ hybridization, immunohistochemistry, and Western blot were used to specify and quantify the expression of CLU in ex vivo synovial tissue. In synovial tissue, the protein was predominantly expressed by synoviocytes and it was detected in synovial fluids. Both full-length and spliced isoform CLU mRNA levels of expression were lower in RA tissues compared with OA and healthy synovium. In synovium and in cultured FLS, the overexpression of CLU concerned all protein isoforms in OA whereas in RA, the intracellular forms of the protein were barely detectable. Transgenic overexpression of CLU in RA FLS promoted apoptosis within 24 h. We observed that CLU knockdown with small interfering RNA promoted IL-6 and IL-8 production. CLU interacted with phosphorylated IkappaBalpha. Differential expression of CLU by OA and RA FLS appeared to be an intrinsic property of the cells. Expression of intracellular isoforms of CLU is differentially regulated between OA and RA. We propose that in RA joints, high levels of extracellular CLU and low expression of intracellular CLU may enhance NF-kappaB activation and survival of the synoviocytes.

Context: Adrenocortical carcinomas (ACC) are rare tumors with a poor prognosis. Few reports concerning large and homogeneous series are available., Objective: We aimed to determine the clinical characteristics and outcome of ACC and to identify prognostic factors., Design and Setting: This study is a descriptive and multivariate analysis of a cohort from a single endocrinology center., Patients: A total of 202 consecutive patients with ACC were studied., Results: The sex ratio (female to male) was 2.7. Mean age at diagnosis was 44 +/- 16 yr (range, 11-88 yr). We found that 154 patients (76%) had hypersecreting tumors [mostly cortisol and androgens (47%), cortisol alone (27%), or androgens alone (6%)] and 43 patients (21%) had metastases at diagnosis. At initial staging or during follow-up, 85 patients (42%) had liver metastases, 79 patients (39%) had lung metastases, and 20 patients had bone metastases (10%). The survival rate was 37% at 5 yr. Multivariate analysis identified the following independent prognostic factors associated with shorter survival: older age at diagnosis [hazard ratio (HR), 1.03; P < 0.0001], initial MacFarlane extension stages 3 (HR, 4.42; P = 0.005) and 4 (HR, 7.93; P < 0.0001), and cortisol hypersecretion (HR, 3.90; P < 0.0001). Treatment with 1,1-dichlorodiphenildichloroethane (o,p'DDD) in the 3 months after surgery increased the survival rate of patients with cortisol-secreting tumors (HR, 0.40; P = 0.04)., Conclusion: This study highlights the better prognosis of ACC diagnosed at a noninvasive local stage, the particularly poor prognosis of patients with cortisol-secreting tumors, and the beneficial effect of o,p'DDD therapy in this subgroup of patients.

Growth or radiologic modification of an osteochondroma after the epiphyseal plate closes suggests the diagnosis of malignant transformation to a chondrosarcoma. However, extensive growth of an osteochondroma in a skeletally mature patient whose tumor proved benign has been reported. We report a similar case in an adult who had a solitary osteochondroma of the calcaneus. The lesion showed marked growth and was removed. Histologic examination showed no evidence of malignancy, and there was no recurrence during the 4-year followup.

Background: The use of a megaprosthesis has become the method of choice for reconstruction after bone tumor resection at the knee. However, the long-term survival of megaprostheses is poor. In this study, we sought to identify factors that were associated with implant failure and amenable to interventions designed to improve implant survival., Methods: A retrospective review of the charts of ninety-one patients who had undergone resection of a tumor of the knee followed by reconstruction with a custom-made megaprosthesis was performed. The distal part of the femur was resected in fifty-six patients and the proximal part of the tibia, in thirty-five patients. The reconstruction was performed with an allograft-prosthesis composite in thirty-three patients and with metal or plastic sleeves in fifty-eight patients. Reconstruction of the extensor mechanism was necessary in all thirty-five patients with a tibial tumor., Results: The median duration of follow-up was sixty-two months. The extensor mechanism was significantly less likely to rupture when partial continuity had been preserved at the time of the resection. Intra-axial laxity (an arc of motion of >5 degrees in the frontal plane) was significantly more common when the prosthesis had an antirotation pin than when it did not have an antirotation pin (p = 0.0023). There was mechanical failure of ten allograft-prosthesis composites and ten sleeve reconstructions. Thirty-six patients had removal of at least one component of the prosthesis. When revision due to local tumor recurrence was excluded, the median duration of prosthetic survival was 130 months following the distal femoral resections and 117 months following the proximal tibial resections. The median duration of survival was 117 months for the allograft-prosthesis composites and 138 months for the sleeve reconstructions. Body weight and activity level were independent predictors of early revision., Conclusions: The long-term survival of the knee megaprostheses in this study was poor. Mechanical failure was multifactorial and the leading cause of revision. Use of allograft-prosthesis composites and use of bushings or an antirotation pin appeared to have no mechanical benefits. We recommend that weight control programs and advice about adapting their activity level be offered to patients preoperatively.

Purpose of the Study: Several studies have been devoted to the effect of proprioception on joint function. Modifications in feedback control from the cord have been observed in unstable joints due to capsule and ligament laxity. A few studies have examined the effect of knee and hip arthroplasty on proprioception, but none have established whether stretch reflexes affect function of a prosthetic joint. The purpose of the present study was to demonstrate the electromyographic characteristics of stretch reflexes of the normal hip joint and to compare them with those observed in the prosthetic hip., Material and Methods: Two groups of patients were studied. The first included eleven subjects free of neurological disorders whose studied limb was healthy. The second group included ten subjects with a total hip prosthesis who had undergone extensive capsulectomy during the arthroplasty. Voluntary muscle contraction was noted in each subject. In addition, electromyographic recordings were made to note response of the ipsilateral and contralateral quadriceps crural and tensor of the fascia lata during changes in joint position. Recordings were made with the subject in the supine position, the limb suspended, hip flexed at 45 degrees and knee extended. Three series of ten recordings were made in random order to measure the latency of muscle response to free fall of the limb, accelerated fall of the relaxed limb, and accelerated fall associated with calibrated contraction of the quadriceps. Mean latency of muscle response was calculated for each trial., Results: In the conditions of this study, there was no statistically significant difference (p = 0.05) in the reflex time course between natural and prosthetic hips., Discussion: Changes due to joint replacement and capsulectomy do not appear to affect the stretch reflexes of the hip joint.

Purpose: To prospectively evaluate the accuracy of contrast material-enhanced magnetic resonance (MR) angiography in the evaluation of vascular invasion by bone and soft-tissue tumors, with surgery serving as the reference standard., Materials and Methods: This study was approved by the regional ethics committee, and all patients gave informed consent. Preoperative MR angiograms and MR images of 31 sites in 30 patients with bone or soft-tissue sarcomas (n = 21) or other tumors (n = 9) were assessed for features of vascular invasion. All images were prospectively evaluated by two musculoskeletal radiologists working in consensus. MR images were evaluated for the presence of a fat plane between the vessels and the tumor and partial or total encasement of vessels. MR angiograms were evaluated for the presence of vascular displacement, stenosis, or occlusion. MR imaging and MR angiographic features of vascular invasion were graded. Imaging findings were correlated with surgical findings and classified as negative if there was no vascular invasion and as positive if there was vascular invasion., Results: Among the 31 cases, 20 were classified as negative and 11 were classified as positive at surgery. All but three cases with a gap between the tumor and the vessels on MR images were classified as free and without adhesions at surgery. All cases with arterial stenoses at MR angiography had tumoral adhesion or tumoral encasement at surgery. MR imaging had a sensitivity of 64%, a specificity of 95%, a positive predictive value of 88% a negative predictive value of 83%, and an accuracy of 84% in the detection of vascular invasion on the basis of findings of partial or total encasement. MR angiography had a sensitivity of 82%, a specificity of 85%, a positive predictive value of 75%, a negative predictive value of 90%, and an accuracy of 84% in the detection of vascular invasion on the basis of the findings of a stenosis., Conclusion: On contrast-enhanced MR angiograms, findings of stenosis were sensitive and specific in the detection of arterial invasion. MR imaging evidence of partial or total encasement is highly specific in the detection of vascular invasion, while MR imaging evidence of a gap between the tumor and the vessels excludes an arterial invasion., ((c) RSNA, 2006)

Since the proteome of osteoarthritic articular cartilage has been poorly investigated as yet, we adapted proteomic technologies to the study of the proteins secreted or released by fresh human osteoarthritic cartilage in culture. Fresh cartilage explants were obtained from three donors undergoing surgery for knee joint replacement. The explants were dissected out, minced, and incubated in serum-free culture medium. After 48 h, proteins in the medium were identified by two-dimensional or off-gel electrophoresis coupled to tandem mass spectrometry, or by using an antibody-based protein microarray designed to detect angiogenic factors, growth factors, chemokines, and cytokines. We identified a series of 43 proteins. Some of these proteins were already described as secretion products of chondrocytes, such as YKL-39 or osteoprotegerin, while several other were known proteins but have never been reported previously in cartilage, such as the serum amyloid P-component, the vitamin D binding protein, the pigment epithelium derived factor, the pulmonary and activation-regulated chemokine, lyl-1, thrombopoietin, fibrinogen, angiogenin, gelsolin, and osteoglycin/mimecan. While this study enabled the identification of novel proteins secreted or released by human osteoarthritic cartilage, the goal of the present work was essentially to describe the technical approach necessary for a systematic study of osteoarthritic cartilages from a large population of donors, in order to be able to select the good markers and/or targets for this poorly explored disease.

Endothelial cells play a central role in chronic inflammation: for example, they express adhesion molecules and present chemokines leading to enhanced leukocyte recruitment into tissues. Numerous markers of endothelial cells have been reported but there has been a lack of comparative data on their specificity. The present study compared the specificity of seven endothelial cell markers in the rheumatoid synovium and the colon of patients with Crohn's disease. These markers were: the sulphated epitope MECA-79, the Duffy antigen receptor for chemokines (DARC), von Willebrand factor, CD31 (PECAM-1), CD34, CD105 (endoglin) and CD146. MECA-79, DARC and von Willebrand factor showed a specific endothelial cell distribution. MECA-79, which recognizes sulphated ligands for leukocyte adhesion receptor L-selectin (CD62L), was selective for a subset of venules in highly inflamed tissue and was present in rheumatoid but not control osteoarthritic synovia. DARC was also specific for venules but had a more widespread distribution than MECA-79, and was present in rheumatoid and control synovia. The other markers all labelled endothelial cells in venules, arterioles and capillaries. However, they also localized to other cell types. For example, CD34 stained fibroblasts, CD146 was expressed by the pericytes and smooth muscle cells of vessel walls and CD31 and CD105 labelled a broad range of cell types., (Copyright 2005 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.)

Ewing tumors remain of poor prognosis, with 5-year overall survival of 55% to 65% in localized patients and not exceeding 25% in primarily metastatic disease. Several reports, mainly in children, have reported that some patients with poor-risk Ewing tumors may benefit from high-dose chemotherapy (HDCT) with autologous stem cell rescue. This retrospective study analyzed 46 patients treated in our institution between 1987 and 2000 for localized or primary metastatic Ewing tumors by HDCT followed by stem cell rescue. Median follow up was 7.1 years. Median age was 21 years (range, 15-46 years). Twenty-two percent of patients had metastases at diagnosis. The tumor site was axial in 56% of patients. Median tumor size was 9.5 cm. The treatment regimen consisted of induction chemotherapy, local treatment, maintenance chemotherapy, and consolidation HDCT based on alkylating agents. No toxic death was observed in the intensive therapy phase. Five-year overall survival and progression-free survival were 63 +/- 7.7% and 47 +/- 7.6%, respectively. Pejorative prognostic factors in this population were metastases at diagnosis (5-year overall survival 34% vs.71%, P = 0.017) and poor pathologic response (5-year overall survival 44% vs.77%, P = 0.03). This retrospective study shows a high long-term survival rate with high-dose chemotherapy in adults.

DNA double-strand break (DSB) repair pathways are implicated in the maintenance of genomic stability. However the alterations of these pathways, as may occur in human tumor cells with strong genomic instability, remain poorly characterized. We analyzed the loss of heterozygosity (LOH) and the presence of mutations for a series of genes implicated in DSB repair by non-homologous end-joining in five radiation-induced sarcomas devoid of both active Tp53 and Rb1. LOH was recurrently observed for 8 of the 9 studied genes (KU70, KU80, XRCC4, LIG4, Artemis, MRE11, RAD50, NBS1) but not for DNA-PKcs. No mutation was found in the remaining allele of the genes with LOH and the mRNA expression did not correlate with the allelic status. Our findings suggest that non-homologous end-joining repair pathway alteration is unlikely to be involved in the high genomic instability observed in these tumors.

Disseminated extrapulmonary tuberculosis is uncommon, particularly among immunocompentent individuals. We report the case of a 38-year-old woman from the Ivory Coast who had osteomyelitis in the right humerus, a cold abscess in the pectoralis major muscle, T11 spondylitis, deep lymphadenopathies, peritoneal nodules, and hepatitis. She had no evidence of immune deficiency, and her only risk factor for tuberculosis was her origin from an endemic area. The outcome was favorable after treatment with antitubercular drugs. This case illustrates the recent changes in the epidemiology of tuberculosis in France, where the incidence among immigrants is rising. It also serves as a reminder that tuberculosis can run a chronic and extremely insidious course. At diagnosis, our patient had a 2-year history of chronic pain in her right shoulder and back, suggestive of a minor mechanical disorder.

Chondroblastoma is a benign cartilaginous neoplasm that generally affects the appendicular skeleton. Twenty-six cases of spinal chondroblastoma have been reported in the past 50 years, only six of which were located in the lumbar region. The authors report two cases involving this exceptional location. In both patients, low-back pain, in the absence of radicular pain, was the presenting symptom. In both cases, plain radiography and computerized tomography scanning revealed an osteolytic lesion surrounded by marginal sclerosis. Magnetic resonance imaging allowed the authors to study the tumor's local extension. Examination of a percutaneous fluoroscopy-guided biopsy sample revealed the following typical histological features of chondroblastoma: chondroid tissue, focally alternating with cellular areas, and no nuclear atypia or pleomorphism. To reduce the risk of local recurrence, vertebrectomy and anterior-posterior fusion were performed in both cases. In one case, a structural lumbar scoliosis was corrected during the posterior procedure. There was no postoperative complication. No recurrence was observed during the 3- to 6-year follow-up period. The surgery-related results were deemed successful. Although exceptional, the diagnosis of chondroblastoma is possible in lesions involving the lumbar spine. Other spinal locations are described in the literature, and frequency of recurrence is stressed. A vertebrectomy is advised to reduce the risk of local recurrence.

Purpose of the Study: Techniques available for shoulder reconstruction after resection of a tumor of the proximal humerus include scapulohumeral arthrodesis, humerus prosthesis with or without an allograft, inverted prostheses, and massive allografts. The purpose of this study was to review clinical and radiological outcomes in a series of 29 patients (20 men and 9 women) who underwent resection-reconstruction of the proximal humerus and to establish from these cases a decision making algorithm for therapeutic indications as a function of tumor invasion., Material and Methods: The tumors were 20 chondrosarcomas, five osteosarcomas, two Ewing sarcomas and one malignant hemangiopericytoma. In 17 patients epiphyso-metaphyseal or epiphyso-metaphyso-diaphyseal resection was performed with preservation of the abductor muscles (type S34A or S345A according to the Musculoskeletal Tumor Society classification). For 12 patients epiphyso-metaphyseal or epiphyso-metaphyso-diaphyseal resection was performed without preservation of the abductor muscles (type S34B or S345B). Reconstruction was achieved using a centromedullary cemented nail in one patient, scapulohumeral arthrodesis in three, a massive humerus prosthesis in 15, and composite humerus prosthesis in three and an inverted prosthesis in seven. The functional score of the Musculoskeletal Tumor Society (MSTS) and standard x-rays were used to assess outcome., Results: Mean follow-up was 85 months (range 16-300). The mean MSTS score was 88% for inverted prostheses, 76% for composite prostheses, 72.6% for massive prostheses, 75% for scapulohumeral arthrodeses, 67% for massive prostheses, and 80% for cemented centromendullary nail. Five patients died from their malignant disease and one from another cause. Four patients are alive but with active disease after a mean follow-up of 108 months and 19 patients (65.5%) are alive and free of locoregional recurrence or metastasis after a mean 83.5 months. We had 28 complications. Glenohumeral instability was the most frequent (11 cases)., Discussion: Resection of the upper portion of the humerus should be performed to achieve cancerologically satisfactory tumor resection and enable shoulder resection, if possible, with preservation of a viable and functional abductor system. The functional outcome after such reconstruction depends on the type of bony resection, but also on the sacrifice of the rotator cuff and the deltoid muscle. In light of our experience and results in the literature, we advocate, despite the small number of cases for the different reconstructions, the following decision-making algorithm after resection of the proximal humerus without joint invasion: when the resection removes the rotator cuff and the deltoid (or the axillary nerve), there are two options: scapulohumeral arthrodesis or massive humerus prosthesis for patients who do not desire a complex therapy with a long postoperative period; when the resection preserves the rotator cuff and/or the deltoid muscle, reconstruction can be achieved with a composite (inverted or not) prosthesis with suture of the cuff tendons. We prefer the inverted composite prosthesis; if the deltoid muscle can be preserved but not the rotator cuff, the composite inverted prosthesis appears to be the most logical solution, but scapulohumeral arthrodesis can be proposed in selected cases.

Objective: To study the effects of a matrix metalloproteinase (MMP) inhibitor (S-34219) on osteoarthritis (OA) cartilage cultures and in the meniscectomized guinea pig model of OA., Methods: The inhibitory activity of S-34219 on MMPs and aggrecanase was studied by fluorimetry and immunoassay, respectively. The effects of S-34219 on proteoglycan and collagen degradation were studied in cultures of rabbit and human cartilage. Medial meniscectomy was performed on 29 Hartley male guinea pigs, and these animals were randomly allocated to 1 of 3 groups: a control meniscectomized group (MNXc) receiving the vehicle, or a meniscectomized group receiving either 10 mg/kg or 20 mg/kg S-34219, administered twice per day by oral gavage for 12 weeks from day 1 after surgery. An additional group comprised sham-operated animals. Tibial cartilage from the operated left knee was processed for histologic assessment of OA lesions., Results: The 50% inhibitory concentration (IC(50)) of S-34219 on MMPs 1, 2, 3, 8, 9, and 13 was 55, 0.1, 0.5, 0.1, 0.03, and 0.2 nM, respectively; the IC(50) on aggrecanase 1 was 190 nM. In cultured rabbit cartilage, 100 nM S-34219 strongly inhibited MMP-dependent degradation of collagen and proteoglycans. A concentration 100 times higher was needed to inhibit aggrecanase-dependent degradation. In cultures of human OA cartilage, 100 nM S-34219 inhibited spontaneous type II collagen degradation by 66% and proteoglycan degradation by only 22%. For in vivo studies, treated groups were compared with the MNXc group and the results, expressed as the percentage variation versus MNXc, were as follows: in the 10 and 20 mg/kg groups, a significant decrease (P < 0.05) in global histologic score (-12% and -14%, respectively) was observed, and this was associated with a significant increase (P < 0.05) in cartilage thickness (+19% and +18%, respectively). Neither dose level changed the proteoglycan content., Conclusion: In both treated animal groups, S-34219 significantly prevented the loss of cartilage thickness, probably by inhibiting collagen breakdown that normally leads to the erosion of fibrillated superficial areas. The absence of a protective effect on glycosaminoglycan loss, both in vitro and in vivo, suggests that aggrecanases may have an important role in cartilage loss. This study reinforces the relevance of these models for testing chondroprotective drugs, and the potential role of dual inhibitors of collagenase and aggrecanase as disease-modifying drugs in the management of OA.

This study was undertaken to evaluate the possibility to obtain a molecular signature of rheumatoid arthritis (RA) comparatively osteoarthritis (OA), and to lay the bases to develop new diagnostic tools and identify new targets. Microarray technology was used for such an analysis. The gene expression profiles of synovial tissues from patients with confirmed RA, and patients with OA were established and compared. A set of 63 genes was selected, based, more specifically, on their overexpression or underexpression in RA samples compared to OA. Results for six of these genes have been verified by quantitative PCR using both samples identical to those used in the microarray experiments and entirely separate samples. Expression profile of the 48 known genes allowed the correct classification of additional RA and OA patients. Furthermore, the distinct expression of three of the selected genes was also studied by quantitative RT-PCR in cultured synovial cells. Detailed analysis of the expression profile of the selected genes provided evidence for dysregulated biological pathways, pointed out to chromosomal location and revealed novel genes potentially involved in RA. It is proposed that such an approach allows valuable diagnosis/prognostics tools in RA to be established and potential targets for combating the disease to be identified.

Although being largely used for pathobiological models of cartilage diseases such as osteoarthritis (OA), human chondrocytes are still enigmatic cells, in as much as a large part of their secretome is unknown. We took advantage of the recent development of antibody-based microarrays to study multiple protein expression by human chondrocytes obtained from one healthy and five osteoarthritic joints, in unstimulated conditions or after stimulation by the proinflammatory cytokines interleukin-1 (IL-1) or tumour necrosis factor (TNF). The secretion media of chondrocytes were incubated with array membranes consisting of 79 antibodies directed against cytokines, chemokines, and angiogenic or growth factors. Several proteins were identified as new secretion products of chondrocytes, including the growth or angiogenic factors EGF, thrombopoietin, GDNF, NT-3 and -4, and PlGF, the chemokines ENA-78, MCP-2, IP-10, MIP-3alpha, NAP-2, PARC, and the cytokines MIF, IL-12, and IL-16. Most of the newly identified chemokines were increased intensely after stimulation by IL-1 or TNF, as for other proteins of the array, including GRO proteins, GM-CSF, IL-6, IL-8, MIP-1beta, GCP-2, and osteoprotegerin. The up-regulation by cytokines suggested that these proteins may participate in the destruction of cartilage and/or in the initiation of chemotactic events within the joint during OA. In conclusion, the microarray approach enabled to unveil part of an as yet unexplored chondrocyte secretome. Our findings demonstrated that chondrocytes were equipped with a proinflammatory arsenal of proteins which may play an important part in the pathogenesis of OA and/or its drift towards an inflammatory, rheumatoid phenotype.

Background: The efficient detection and characterization of micrometastatic cells in the bone marrow of patients with breast carcinoma are of prognostic and therapeutic importance. The technique used must overcome the challenges that result from the small number of target cells (1 per 1 million hematopoietic cells) and the heterogeneous expression of micrometastatic cell markers. In this study, the authors assessed and improved the current methods for purifying and characterizing rare disseminated carcinoma cells., Methods: The authors developed a single-step assay that does not require density-gradient separation. This assay can be performed directly on crude human bone marrow aspirates and is based on the use of immunomagnetic beads coated with an antibody that recognizes an epithelial cell-surface epitope, the epithelial cell adhesion molecule (EpCAM). To determine the specificity of the assay, the authors evaluated bone marrow specimens from 46 control patients., Results: The novel method was highly reproducible and was capable of detecting as few as 10 carcinoma cells among 50 million hematopoietic cells. The yield was nearly 100%, with only 0.01% nonspecific cell draining. The authors found that 68 +/- 51 cells were trapped per 50 million cells in control crude aspirates and that density-gradient separation increased this number by 2-fold to 29-fold. These trapped cells expressed EpCAM, represented 1.4 x 10(-4) % of the sample, and were characterized as of hematopoietic cell origin (CD45 positive) or progenitor cell origin (CD34 positive)., Conclusions: The authors developed a highly efficient and reproducible, single-step immunomagnetic assay that may be performed directly on crude human bone marrow aspirates. The authors believe the current study is the first to demonstrate that some rare bone marrow cells (CD45-positive or CD34-positive cells) may express EpCAM and, to some extent, may contaminate the purified micrometastatic cell fraction. Thus, a universal marker for micrometastatic cells remains to be discovered., (Copyright 2004 American Cancer Society.)

Objective: Aggrecan is degraded by Aggrecanases (ADAMTS-4 and -5) and MMPs, which cleave its core protein at different sites. Transforming growth factor (TGF)beta is known to stimulate matrix formation in cartilage, and ADAMTS-4 production in synoviocytes. The aim of this in-vitro study was to examine the effects of TGFbeta on aggrecanase production in human cartilage., Design: Expression of ADAMTS-4 and -5 in chondrocyte cultures from normal or osteoarthritic cartilage was studied at mRNA level by RT-PCR. Aggrecanase activity was examined by western blot of aggrecanase-generated neoepitope NITEGE, and by measure of proteoglycan degradation in cartilage explants., Results: TGFbeta strongly increased mRNA levels of ADAMTS-4, while ADAMTS-5 was expressed in a constitutive way in chondrocytes from normal and osteoathritic cartilage. TGFbeta also increased NITEGE levels and proteoglycan degradation. Addition of an aggrecanase inhibitor blocked the increase of NITEGE, and partially inhibited proteoglycan degradation., Conclusions: TGFbeta stimulates ADAMTS-4 expression and aggrecan degradation in cartilage. This catabolic action seems to be partially mediated by aggrecanases. It is, therefore, proposed that the role of TGFbeta in cartilage matrix turnover is not limited to anabolic and anti-catabolic actions, but also extends to selective degradation of matrix components such as aggrecan.

Purpose of the Study: A torn quadriceps tendon is an exceptional finding generally observed after high-energy knee trauma in patients over 40 who present a sprain-like syndrome or after low-energy trauma in elderly subjects who experience knee instability. We reviewed a series of 47 cases of traumatic quadriceps tendon tears treated between 1976 and 1996 in order to evaluate outcome after surgical repair., Material and Methods: Clinical diagnosis was the rule. Forty-two patients, mean age 55 years (range 17-92) were treated for tears of one or both quadriceps tendons subsequent to low-energy trauma (40 tears) or high-energy trauma in younger subjects. The diagnosis was established early in all cases except eight (diagnosis at three weeks to one year). Surgical repair was performed in all cases except one. After surgery, the knee was either immobilized with a plaster cast or held in a removable splint to allow early mobilization., Results: Average time to recovery compatible with daily life or occupational activities was four months. Recovery was not complete at this time. Long-term follow-up revealed that complete recovery with very good or good subjective results was achieved in 90% of the cases. Complete joint motion and normal quadriceps force was achieved in 80% of the cases. Patients who started rehabilitation exercises early generally achieved less satisfactory results although no significant correlation was identified with objective clinical variables., Discussion: Quadriceps tendon tear is a clinical diagnosis which does not require complementary exploration for confirmation. Plain x-rays may be useful to identify associated bony lesions and specific signs of tendon tears. Early surgical repair followed by complete immobilization appears to be preferable for functional recovery allowing better recovery of muscle force without compromising flexion.

The aim of this study was to investigate the relationship between the detection of micrometastatic cells by immunocytochemistry (ICC) with an anticytokeratin antibody and cytokeratin fragment (CYFRA 21-1) expression detected by an immunofluorescent assay in bone marrow of breast cancer patients. Micrometastatic CK+ cells were screened with a pancytokeratin antibody A45 B/B3 from bone marrow aspiration samples of 102 breast cancer patients (65 primary tumors, 10 local recurrences and 27 distant metastases). CYFRA 21-1 levels were assessed in bone marrow supernatant of these patients before collection of the mononucleated interface cells on a Ficoll-Hypaque density gradient and in 20 control patients. CYFRA 21-1 and CK+ cell detection by ICC were both correlated with clinical stage. CYFRA 21-1 was significantly elevated in patients with micrometastatic disease detected by ICC: 4.77 ng/mL (+/- 10.87 SD) versus 1.00 ng/mL (+/-1.36 SD) in patients with negative ICC (p=0.01). In univariate analysis, a CYFRA 21-1 value > or =1 ng/mL and the presence of CK+ cells were associated with a poorer survival for patients with stage I to III breast cancer (n=65). On multivariate analysis, only pathological nodal status and presence of CK+ cells in bone marrow were independent prognostic factors for overall survival. In conclusion, in this series CYFRA 21-1 was correlated with detection of CK+ cells by ICC in bone marrow, but cannot replace ICC. The presence of CK+ cells in bone marrow remains a strong independent prognostic factor in primary breast cancer.

Insulin-like growth factor 1 (IGF-1) has poor anabolic efficacy in cartilage in osteoarthritis (OA), partly because of its sequestration by abnormally high levels of extracellular IGF-binding proteins (IGFBPs). We studied the effect of NBI-31772, a small molecule that inhibits the binding of IGF-1 to IGFBPs, on the restoration of proteoglycan synthesis by human OA chondrocytes. IGFBPs secreted by human OA cartilage or cultured chondrocytes were analyzed by western ligand blot. The ability of NBI-31772 to displace IGF-1 from IGFBPs was measured by radiobinding assay. Anabolic responses in primary cultured chondrocytes were assessed by measuring the synthesis of proteoglycans in cetylpyridinium-chloride-precipitable fractions of cell-associated and secreted 35S-labeled macromolecules. The penetration of NBI-31772 into cartilage was measured by its ability to displace 125I-labeled IGF-1 from cartilage IGFBPs. We found that IGFBP-3 was the major IGFBP secreted by OA cartilage explants and cultured chondrocytes. NBI-31772 inhibited the binding of 125I-labeled IGF-1 to IGFBP-3 at nanomolar concentrations. It antagonized the inhibitory effect of IGFBP-3 on IGF-1-dependent proteoglycan synthesis by rabbit chondrocytes. The addition of NBI-31772 to human OA chondrocytes resulted in the restoration or potentiation of IGF-1-dependent proteoglycan synthesis, depending on the IGF-1 concentrations. However, NBI-31772 did not penetrate into cartilage explants. This study shows that a new pharmacological approach that uses a small molecule inhibiting IGF-1/IGFBP interaction could restore or potentiate proteoglycan synthesis in OA chondrocytes, thereby opening exciting possibilities for the treatment of OA and, potentially, of other joint-related diseases.

Background: The alumina ceramic femoral head was introduced for total hip arthroplasty approximately thirty years ago. One of its main drawbacks was the risk of implant fracture. The aim of this study was to examine the results of revision total hip replacement performed specifically to treat a fracture of a ceramic femoral head and to identify technical factors that affected the outcomes., Methods: One hundred and five surgical revisions to treat a fracture of a ceramic femoral head, performed at thirty-five institutions, were studied. The patients were examined clinically by the operating surgeon at the time of the last follow-up. The surgeon provided the latest follow-up radiographs, which were compared with the immediate postoperative radiographs. The success of the revisions was assessed with Kaplan-Meier survivorship analysis, with the need for repeat revision as the end point. We evaluated the complication rate and radiographic changes indicative of implant loosening. The average duration of follow-up between the index revision and the last clinical and radiographic review was 3.5 years (range, six months to twenty years)., Results: Following the revisions, radiographic evidence of cup loosening was seen in twenty-two hips (21%) and radiographic evidence of femoral loosening was seen in twenty-two (21%). One or several repeat revisions were necessary in thirty-three patients (31%) because of infection (four patients), implant loosening (twenty), osteolysis (eight), or fracture of the revision femoral head component (one). The survival rate at five years was 63% (95% confidence interval, 51% to 75%). The survival rate was significantly worse when the cup had not been changed, when the new femoral head was made of stainless steel, when a total synovectomy had not been done, and when the patient was less than fifty years old., Conclusions: Fracture of a ceramic femoral head component is a rare but potentially serious event. A suitable surgical approach, including total synovectomy, cup exchange, and insertion of a cobalt-chromium or new ceramic femoral ball minimizes the chance of early loosening of the implants and the need for one or more repeat revisions., Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]).

The authors describe a new approach to the hip joint arthroplasty performed in 127 cases of total hip arthroplasty without major complication. A small anterior fragment of greater trochanter, maintaining the insertions of the gluteus minimus and vastus lateralis muscles, is detached. The whole insertion of the gluteus medius is preserved intact, providing good prosthetic stability and rapid recovery of abductor power and gait. Three months after surgery, 74% of patients had recovered good abductor strength with a Merle d'Aubigné and Postel score of 17 points. This surgical approach is technically easy to perform and provides good exposure of the hip. The osteotomized fragment is easily reattached using 2 cerclage wires, and upward displacement after operation was rarely seen., (Copyright 2003 Elsevier Inc. All rights reserved.)

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.

The aim of this study was to determine whether assessment of back surgery with disability scores is relevant. We also attempted to answer the question of whether this evaluation should be conducted by a surgeon or a medical doctor. This retrospective study analyzes the long-term outcome (average follow-up 7 years, range: 3-12) of 40 patients (mean age: 46.2 years) treated by posterior surgical decompression, posterolateral arthrodesis, with or without instrumentation, for symptomatic low-grade spondylolisthesis. All patients were interviewed postoperatively and examined the same day by an orthopedic surgeon, who was not involved in the patients' treatment, as well as by a medical doctor rehabilitation specialist. Impairment was assessed by a standardized clinical examination and by visual analog scales (VAS) of pain. Disability was assessed using two scales: the Quebec disability scale and the Beaujon scale. Anxiety and depression were assessed with a validated specific questionnaire (HAD). Patient's perceived handicap was assessed on a 100-mm VAS. Our results show that the scores of the two disability scales were highly correlated with the patient's overall satisfaction ( r = 0.73 and 0.77 for the Quebec scale and the Beaujon scale, respectively). The intraclass correlation coefficient showed very good or excellent correlation between the data collected by the surgeon and the rehabilitation specialist, ranging from 0.8 to 0.97. This finding clearly demonstrates that interview by a surgeon who is not involved in the patient's treatment does not influence the patient's assessment in terms of impairment, disability, or handicap. Moreover, our results suggest that disability scales are the most relevant outcome measures in the assessment of spine surgery.

Seventeen saddle prostheses were inserted between 1988 and 1997 after resection of periacetabular tumors. The tumors involved the zones II and III of Enneking classification in 13 patients, the zones I and II in 2 patients, and the zone II in 2 patients. The tumors included 11 chondrosarcomas, 3 Ewing sarcomas, 2 giant cells tumors, and 1 metastasis of renal carcinoma. The tumoral resection was wide "en bloc" in 14 cases, marginal in 2 cases, and intratumoral in 1 case. The mean follow-up period of the patients is 42 months ranging from 8 to 84 months. Local recurrences occurred in five cases and metastases in four cases. Five patients died of tumoral disease and one of intercurrent disease. Complications were observed in 11 cases (65%) including nerve damages (3 cases), deep infections (3 cases), upward migrations of the saddle (4 cases), saddle dislocations (3 cases), sacroiliac subluxations (2 cases), and mechanical failures (2 cases). The modified Musculoskeletal Tumor Society Score (MSTS) and the Toronto Extremity Salvage Score (TESS) were used for functional analysis. Functional results were available for only nine patients of the series with a mean MSTS of 17 points ranging from 11 to 23 points and a mean TESS of 58 points ranging from 39 to 95 points. The saddle prosthesis provided in all cases of this series an early painfree weight-bearing reconstruction with minimal limb shortening, but the functional results remained fair in most patients due to a limited range of motion and a poor abductor strength., (Copyright 2001 Wiley-Liss, Inc.)

A massive prosthesis and medial gastrocnemius muscle transfer were used to reconstruct the knee after extracapsular en bloc excision for bone sarcoma. Magnetic resonance images showed intraarticular involvement. This technique was used in nine patients, six men and three women aged 18 to 51 years, with primary malignant bone tumors of the knee. Extraarticular resection of the knee, including the patella, was done in every case. A knee prosthesis was implanted, and the extensor mechanism was reconstructed by transfer of the medial gastrocnemius muscle and pes anserinus tendons. All resections had negative margins. There were no local recurrences, but metastases occurred in two patients. Infection was the only major complication and was seen in two patients. The mean postoperative Musculoskeletal Tumor Society score was 61% (range, 36%-100%). The mean postoperative range of flexion was 62 degrees (range, 30 degrees-90 degrees), and the mean extensor lag was 12 degrees (range, 0 degrees-40 degrees). Three patients required a crutch to walk. The functional outcome was poor in the two patients whose proximal tibia was removed with the joint, suggesting that arthrodesis may be best in this situation. In properly selected patients, prosthesis and muscle flap reconstruction provides acceptable function and a good cosmetic result.

Purpose of the Study: Chordoma is a malignant neoplasm believed to arise from notochord remnants. It accounts for approximately 3 to 4 p. 100 of primary bone tumors and is localized along the axial skeleton, 50 p. 100 being sacrococcygeal. Clinical, radiographical and histological findings have been well established since the first description by Ribbert in 1894. Sacral chordomas are however difficult to manage and remain a challenge for surgeons and radiotherapists alike. The purpose of this study was to evaluate the long-term results of surgical treatment and patterns of failure in patients treated for chordoma of the sacrum in our department., Materials and Methods: This retrospective study included 11 cases of sacral chordomas treated from 1973 to 1998. Patient age ranged from 36 to 77 years (mean 59 years). Six patients were female and five male. The initial treatment was surgery in all cases including intralesional removal in two cases, marginal resection in seven and complete en bloc resection in two., Results: Median follow-up was 6 years (1 month to 14 years). Tumoral recurrences were observed in nine cases 5 months to 8 years after treatment. In two cases, recurrence was observed 8 years after radical sacrectomy. Treatment of recurrences was partial surgical removal with radiotherapy (40 to 70 Grays). Three patients developed metastases in lungs, liver and bone, respectively. Seven patients died, two from metastatic disease. The 5-year overall survival was 64 p. 100 but only 18 p. 100 of the patients survived 10 years. Average disease-free survival was 18 p. 100 at 5 years and 0 p. 100 at 10 years., Discussion: Chordoma is a slow-growing tumor allowing survival for several years despite recurrent disease. However, only 10 to 20 p. 100 of the patients survive free of disease at 5 years. Recurrences are frequent (45 to 80 p. 100) and often multiple. Chordoma inevitably recurs and eventually leads to death after intralesional removal or marginal resection. Radical surgery should be attempted whenever technically feasible. When performed early, particularly for smaller lesions, it offers the best chance for cure. However, tumoral recurrence can occur postoperatively despite a macroscopically complete resection. Because radiation therapy seems to be more successful in controlling microscopic disease, it should be considered as a pre- or postoperative adjuvant to a macroscopically complete resection.

Surgical treatment of the low-back pain remains controversial in term of efficacy. Surgical treatment is advocated only when conservative management fails, a clearly identifiable cause of lumbar pain is identified, worker's compensations are detected, psychological disorders are treated and disability and pain are still present. In addition, we used a preoperative external diagnostic immobilisation with hip spica cast to select the patients. Posterior instrumented fusion is more often used, however several studies demonstrated the interest of interbody fusion when an inflammatory signal of the disc was detected on the MRI. Spinal fusion provide 50-93% of clinical success in the literature, spondylolisthesis remains the better indication. Only 30% returning to work were obtained.

In the last decade, indications for bone allografting in orthopedic surgery have progressively increased, related to, on the one part, treatment of benign or malignant tumors, but, on another (major) part, to treatment of major bone defects due to loosening of hip or knee total prostheses. In France, legislation and control concerning donated human tissues, safety precautions, and the uses for human tissues have been greatly modified over the last few years. The authors describe the various obligations implicated by these activities and the consequences for tissue banks and surgeons; They describe different processes for bone inactivation and their action on allograft mechanical properties, or the biological capability for integration to the host bone. The authors then discuss different current techniques for bone stock reconstruction and the results in prosthetic or tumoral surgery, as well as their consequences on current surgical indications. In conclusion, they emphasize the optimal conditions for the success of allografts in orthopedic use: stability of the host bone-graft junction, vitality of the bone support, and a favourable mode of constraint of the graft, which have to be protected by osteosynthesis, but should not, however, miss partial bearing.

Purpose of the Study: To compare femoral reconstruction using megaprosthesis versus allograft prosthesis composite., Material and Methods: Forty-one consecutive proximal femoral reconstructions with an allograft-prosthesis composite (21 cases) or a megaprosthesis (20 cases) after tumor resection were reviewed in a retrospective study. The following criteria were considered: functional outcome; long term survival; complications. Chi-square test and Wilcox tests were used to compare groups. The medium and long-term survival curves for these reconstructions were made using the Kaplan-Meier standard methods. The failure of prosthesis was defined as revision for mechanical failure (either aseptic loosening or dislocation), for infection or local recurrence. The comparison of the curves was performed using the Log-Rank test., Results: Infection (10 p. 100) and instability, in both groups, and loosening, in the megaprosthesis group, were the common causes of failure. There was difference between functional results in the two groups (limping and crutches using was more lower in allograft-prosthesis composite group). Survival analysis showed a 5 and 10-year survival of 77 +/- 12 p. 100 for the patients with composites. Five and ten - year survival were 73 +/- 11 p. 100 and 0 p 100 respectevely for those with megaprostheses. No significant difference was noted between survival of these two groups but a tendancy (p =0.09). Radiological allograft resorption was noted for more than 50 p. 100 of allograft composite prosthesis without modification of functional result or symptomatic loosening., Discussion: The functional results seem better in the composite group when compared to the megaprosthesis group. Reconstruction of the abductor mechanism is essential to stabilize the prosthesis and to decrease the limp. When the great trochanter cannot be preserved, we used suture of gluteus medius tendon to tensor of fascia lata, which is re-enforced using a piece of biceps femoris. The dislocation rate was approximately the same in our two groups. Several authors reported a lower dislocation rate with composite reconstructions than massive prosthesis. The rate of infection is similar to other reported series. In our study it has been possible to show a tendancy for superior survival of the composite reconstruction. When the review was later than 5 years the radiological appearance of the graft in our series was often concerning with resorption or fragmentation present in six of the eight cases. This radiological appearance is not as yet responsible for any revision or any change in the functional result however it does remain a worry., Conclusion: Composite reconstructions probably allow a better functional result when considering proximal reconstruction of the femur. The radiological appearance of these allografts in the long term is however worry some without any evidence so far of worsening functional level or any evidence of prosthetic loosening. It would seem to us that the current level of knowledge would advocate the use of massive allografts together with prosthesis. This does seem still to remain the best choice for proximal femoral reconstruction.

Introduction: Leiomyosarcoma is a malignant smooth muscle tumor occurring most frequently in uterus or soft tissues and more rarely in bone., Materials and Methods: We report the clinicopathologic, immunohistochemical and ultrastructural findings of five cases of primary leiomyosarcoma of bone treated in our Department between 1991 and 1994. The pertinent medical literature is discussed., Results: The tumors were located respectively in the distal tibia (n=2), the distal femur, the sternum and the ilium (n=1). Four lesions were high-grade and one low-grade. All patients (3 women and 2 men) underwent wide surgical resection associated with polychemotherapy in four cases. Two patients died of metastatic disease, two had local recurrence and one is alive with no evidence of disease at the last follow-up., Discussion: Excluding cases which involve the facial skeleton, there are to our knowledge 95 cases of primary leiomyosarcoma of bone reported in the literature. This tumor arises more commonly in adults (mean age: 49 years) with an equal gender distribution and involves predominantly the long bones near the knee. In the majority of cases, plain X-rays exhibit an osteolytic lesion with cortical penetration and indistinct margins. The diagnosis is based on microscopic features demonstrating fusiform tumor cells arranged in interwoven bundles, and the immunohistochemical results of widespread cytoplasmic positivity for smooth muscle actin. The best pronostic parameter is the histologic grade correlated with both the recurrence and metastatic rates as well as the survival rate. Surgery constitutes the main treatment since chemotherapy or radiotherapy did not provide an improved prognosis over a wide resection.

Study Design: Anulus fibrosus cells from rabbits were grown in primary culture 1) to study their ability to produce prostaglandin E2 and Type II phospholipase A2, and to express stromelysin-1 messenger ribonucleic acid; and 2) to study the effect of interleukin 1 beta on this production and on proteoglycan aggregation., Objectives: To investigate the potency of anulus fibrosus cells to respond to interleukin 1 beta by producing degradative and inflammatory agents as compared with the potency of articular chondrocytes in the same animal., Summary of Background Data: Interleukin 1 beta has been implicated in the degradation of intervertebral discs. The way anulus fibrosus cells differ from articular chondrocytes in their responses to interleukin 1 beta remains to be established., Methods: Anulus fibrosus cells and articular chondrocytes were obtained from young rabbits, grown in primary culture, and incubated with interleukin 1 beta. The newly synthesized proteoglycan was measured by labeling with [35S]-sulfate. Proteoglycan aggregation was analyzed by the elution profile on Sepharose 2B columns. The contents of collagen Type II and stromelysin-1 messenger ribonucleic acid were assessed by Northern blot analysis. The Type II phospholipase A2 activity was measured using a fluorometric substrate. Prostaglandin E2 production was evaluated by radioimmunoassay., Results: Anulus fibrosus cells had 2.5-fold less Type II collagen messenger ribonucleic acid than articular chondrocytes, and interleukin 1 beta had no significant effect on this. Anulus fibrosus cells synthesized and secreted four-fold less proteoglycan than articular chondrocytes. Interleukin 1 beta reduced the anulus fibrosus content of total [35S]-sulfated proteoglycan by 35% (P < 0.01), and that of articular cells by 41% and decreased proteoglycan aggregation. Interleukin 1 beta induced the production of stromelysin-1 messenger ribonucleic acid in both cell types. The stromelysin-1 messenger ribonucleic acid content of anulus fibrosus cells was one half that of articular cells. Interleukin 1 beta increased the production of prostaglandin E2 and caused a dose-dependent secretion of Type II phospholipase A2 activity in both cell types. Its effect was 2.5-fold lower in anulus fibrosus cells than in articular chondrocytes., Conclusion: Anulus fibrosus cells can be stimulated by interleukin 1 beta to produce factors implicated in local degradative and inflammatory processes. This production is associated with decreased proteoglycan aggregation. Anulus fibrosus cells respond slightly less well to interleukin 1 beta in vitro than do articular cells.

Purpose of the Study: Several studies have demonstrated better prognosis of chondrosarcomas arising in hereditary multiple exostosis or Ollier's disease. The aim of this study was to evaluate their clinical, radiological and histological features and compare their prognosis with other chondrosarcomas., Material and Methods: We reviewed twenty nine secondary chondrosarcomas among seventeen patients with osteochondroma (group A), and eight with Ollier's disease (group B). These tumors represented 12 p. 100 of all chondrosarcomas treated between 1950 and 1994 in Cochin Hospital. Two group B patients successively developed three multicentric chondrosarcomas. Twenty six resections (eight intra and eighteen extra-lesional), two disarticulations and one amputation were performed as primary treatment. The average follow-up of the study was 10.5 years. The results were evaluated by means of survival curves. The significance of the difference between the curves was determined by the log-rank test., Results: The mean age of malignant change was 36 years old. The most frequent tumoral site was the innominate bone for group A and the femur for group B. In three cases, radiographs showed no malignant features. All chondrosarcomas were classified as grade 1 or 2. The ten-year survival rate was 82 p. 100 with no significant difference between the two groups. The survival rates were significantly different after carcinologic surgery (extra-lesional resection or amputation) and contaminated surgery (intralesional resection), with 5 and 88 p. 100 of local recurrences respectively., Discussion and Conclusion: These secondary chondrosarcomas represent about 10 p. 100 of all chondrosarcomas. They appear 15 years earlier. According to O'Neal and Ackerman classification, most of the tumors are well-differentiated (60 p. 100 grade I, 39 p. 100 grade II and 1 p. 100 grade III). Carcinologic surgery is generally curative. Ten-year survival rate is 94 p. 100. With equivalent grade and surgery, their prognosis is better as compared to primary chondrosarcomas.

A case of epithelioid sarcoma localized in the palm of the left hand in a 32-year-old woman is reported. The tumor evolved for many years, clinically and microscopically simulating palmar fibromatosis. Epithelioid sarcoma is an uncommon malignant tumor, often misdiagnosed by surgeons and pathologists. It occurs in young patients and is often localized at the upper distal extremity. Microscopically, epithelioid sarcoma shows nodules manifesting fibrous hyaline cores with central necrosis. It contains epithelioid and spindle cells immunoreactive to keratin, epithelial membrane antigen and vimentin. Recurrences, lymph node metastases and lung metastases are frequent. Surgical literature tends to recommend wide "en bloc" excision or amputation, combined or not with adjuvant radiation therapy.

Some particularities of cancerous conditions in bone surgery have profound psychological implications for the patients involved: their angst of death is compounded by the fear of mutilation or physical impairment. All medical treatment is undertaken to save the patient's life, but at what cost? The reactions of some patients at different stages of the process, before the diagnosis is established--during a brief stay at the hospital, when biopsy is performed--, when the diagnosis is disclosed and later, during the period of treatment, affect the medical team and are apt to seriously undermine the relationship between doctors and patients. The emergence of a tumor is a major event in a patient's life, even if this tumor eventually turns out to be of the non-malicious kind. Psychological counseling and even the prescription of psychotropic medication may prove necessary: the patient must be helped to cope with a newly acquired sense of powerlessness and the awareness of his or her own mortality. At every step of this personal experience, whether before, during or after the performance of the biopsy, the patient is likely to need help to cope with a sense of anxiety, uncertainty, loneliness, or the consequences of a brutal disclosure of his or her medical condition. Some psychic reactions may take us by surprise. In the first place, we have been puzzled by the discrepancy between the simplicity of the biopsy in operative, surgical terms and the highly emotional reaction it elicited among some patients. To the surgeon, biopsy often amounts to a quick surgical gesture. During their brief stay at the hospital, patients whose condition commands no particular attention are likely to suffer a sense of loneliness while they expect the verdict of the biopsy, and these emotions may be harder to cope with than the implications of serious surgery, should the preliminary analysis require it. Even if it turns out that surgery is not necessary, the anxiety just won't go away and a reactive depression may settle in, oddly enough, one could think. Occasionally, some patients may become aggressive in their dealings with the surgeon, who must remain calm and amenable to have them accept the terms of the treatment. Once the treatment options are reviewed (most of which are stereotypical and codified, a fact that is barely belied by the detailed explanations patiently provided by the medical staff), the patient is left alone to ponder the course and the meaning of life. At this point, life cannot go on under the best possible terms if patients are not offered the opportunity to discuss their physical and moral suffering and if no one is there to listen to complaints that transcend the scope their physical condition.

Study Design: Intervertebral disc cells were extracted from the surrounding matrix, and their metabolic activities and phenotypes were studied., Objectives: To compare the metabolic activities and phenotypes of cell populations extracted from the intervertebral discs of young rabbits with those of articular and growth plate chondrocytes from the same animals., Summary of Background Data: The phenotype of intervertebral disc cells has been poorly studied and still is debated., Methods: The intervertebral discs as well as articular and vertebral growth plate cartilage of rabbits were digested enzymatically. The morphology of freshly isolated cells was examined. Their contents of collagen II and X mRNAs were determined by Northern blot analysis, and their sulfation activity by 35S-sulfate incorporation as chondrocytic markers. Cells were cultured at high density or low density and grown in primary culture. The stability of their phenotype was monitored by evaluating the collagen I and II mRNA ratio. The proteoglycans newly synthesized by the cells also were quantified, and their elution profile analyzed on Sepharose 2B columns., Results: The anulus fibrosus cells were morphologically undistinguishable from articular chondrocytes. The nucleus pulposus contained mainly large vacuolated cells and a few smaller cells. All freshly extracted cells expressed different levels of collagen II mRNA. Anulus fibrosus and nucleus pulposus cells contained, respectively, 22% and 8% of collagen II mRNA compared with that found in articular or growth plate chondrocytes from the same animal. Only growth plate chondrocytes expressed collagen X. When anulus fibrosus cells were incubated for 48 hours at high density, they had collagen II mRNA contents similar to those of articular and growth plate chondrocytes, but synthesized five to six times fewer sulfated proteoglycans. When seeded at low density, anulus fibrosus cells divided more slowly than articular chondrocytes and incorporated four times fewer 35S-sulfate into proteoglycans. Their collagen II mRNA content was 2.75-fold lower than that of chondrocytes, and the procollagen alpha 1II/alpha 1I mRNA ratio was 3.1 for anulus fibrosus cells and 7 for chondrocytes. No collagen X mRNA was detected. When incubated for 48 hours at high density, the nucleus pulposus giant cells had four times less collagen II mRNA content than cartilage cells but synthesized the same amounts of sulfated proteoglycans. They did not divide during 21 days in culture and still contained collagen II mRNA but no collagen X mRNA., Conclusions: Findings showed that intervertebral disc cells all express cartilage-specific matrix proteins with quantitative differences, depending on their anatomic situation. It is suggested that anulus fibrosus cells are chondrocytic cells at a different stage of differentiation than articular and growth plate chondrocytes. The phenotype of nucleus pulposus cells still is unclear. They could be chondrocytic or notochordal. A definitive answer to this important question requires differentiating markers of notochordal cells.

A 51 year-old man developed an extensive osteolytic response to wear debris in an uncemented porous-coated total hip arthroplasty, with metal/polyethylene interface, which had been implanted eighteen years previously. This reaction, which involved the upper femur and the ilium, produced a mass which compressed the pelvic viscera.

Hyalinizing spindle cell tumor with giant rosettes is a slowly growing tumor with a risk of local recurrence in case of incomplete surgical excision that could be regarded as a distinctive type of low-grade fibroblastic tumor. We report a case involving the presacral area. This tumor was composed of areas of bland spindle cell proliferation with a fascicular pattern in a fibrous or myxoid stroma, intermixed with giant rosettes consisting of rounded cells surrounding a central collagen core. The tumor expressed vimentin, and, for cells comprising the rosettes, S-100 protein, NSE and CD-57. These latter cells exhibited ultrastructural features of Schwann cells, the tumoral cells of fascicular area exhibiting features of fibroblastic cells. Flow cytometry showed DNA-aneuploidy and a very low S-phase fraction. This tumor appeared to be composed of two cellular components, fibroblastic and Schwann cells, located, at the opposite of neurofibroma, in two distinct areas.

Background: Desmoid tumors are uncommon fibromatous tumors arising from musculoaponeurotic tissue characterized by spindle cell fibroblast and myofibroblast proliferation. The cause is unknown (trauma, hormonal factors, genetic anomaly...). Locally invasive, they tend to recur increasing morbidity or even mortality., Case Report: Stiff shoulder resulting from blockage of the scapulothoracic articulation was the inaugural sign. Three-phase bone scintigraphy demonstrated early uptake in the soft tissue in contact with the scapula. Magnetic resonance imaging and biopsy confirmed the diagnosis of desmoid tumor. Complete resection was performed. No adjuvant radiotherapy nor hormone treatment were given since no antiestrogen receptor antibodies were identified on the surgical specimen., Discussion: The clinical manifestation (stiff shoulder) and the scapular localization observed in this case are unusual for desmoid tumors. Initially tendinopathy of the shoulder, acromio-clavicular arthropathy and capsular retraction of the shoulder joint had been entertained. Early diagnosis and wide surgical resection are indicated in desmoid tumors.

Purpose: The purpose of this study was to present the complications which occurred in knee replacement with the GUEPAR prosthesis, after bone tumor resection. We tried to point out complications in relation to prosthetic design and surgical technique., Material and Method: Between 1972 and 1993, 90 patients had a knee resection, for 80 malignant and 10 benign tumors. There were 51 males and 49 females, aged 12 to 75 years (mean age 35). Fifty-six distal femur resections and 34 proximal tibial resections were performed. Length of resection averaged 16 cm (9 to 30). The reconstruction was always achieved with a cemented, custom-made GUEPAR prosthesis. Including revisions, there was a total of 102 prostheses in 90 patients. A patellar resurfacing was performed in 64 cases. An allograft reconstruction was associated in 39 knees. In all tibial resections and in two extra-articular femoral resections, the extensor mechanism had to be reconstructed. Several reconstruction techniques were associated, in which 19 medial gastrocnemius transfers. The prosthesis design was slightly modified with time. Ten patients received radiotherapy, and 55 had chemotherapy., Results: Results and complications were retrospectively assessed, with an average follow-up of 4.3 years (1 to 22). Six patients were lost for follow-up, 62 patients were alive, with no evolutive disease, 13 had an evolutive disease and 10 were deceased from disease. Nineteen patients had distant metastasis and 17 had local recurrences. Apart from intraoperative complications, late mechanical complications included: 13 aseptic loosening, 2 femoral shaft fractures, 18 knee contractures, 5 femoral stem fractures and, 18 intra-articular instabilities related to wear of the hinge-axis. In the 39 allograft-composite prostheses, only 15 had a favorable evolution. There were 15 extensor mechanism failures and 13 knees had persistent infection. There was a total of 94 reoperations in the 90 patients. In 28 cases, the initially implanted prosthesis was removed. There were also 18 revisions, 7 amputations and 3 arthrodeses. Survivorship analysis showed a 60 per cent probability for the initial prosthesis not to be revised at 10 year-follow-up, apart from oncologic complications., Discussion: Results with allograft-composite reconstruction were not better than with massive prosthesis. When needed, soft tissue coverage and patellar tendon augmentation would better be performed with gastrocnemius plasty. Polyethylene and steel bushes were not solution for hinge axis wear.

Giant sacral schwannoma is a very rare tumor (25 cases reported). The authors report 3 cases of giant sacral schwannoma treated by curettage through posterior approach and discuss symptoms and treatment. These tumors were characterized by their minimal symptoms compared to radiographic findings. Magnetic resonance imaging must be performed in order to detect extraosseous tissue component and intradural invasion. A biopsy was performed to confirm the diagnosis before definitive treatment. Wide resection was proposed by many authors because of the high recurrence rate. We believe that a wide resection is too sever as it causes neurologic sacrifices. A curettage through posterior approach preserves nerve function, and if a local recurrence occurs it remains possible to perform a wide resection. When sacroiliac joint instability is detected, a lumboiliac arthrodesis is indicated. Osteosynthesis could be performed with spine device (using pedicular and iliac screws).

Purpose of the Study: The purpose of the study was to adjust a palliative transfer using the Tibialis Posterior (TP) tendon in case of foot dorsiflexion palsy. The surgical procedure emphasized some functional features, in an attempt to lessen parasitical motion of the foot in abduction or in adduction when patients bear the ankle joint in dorsiflexion, and to strengthen the transfer., Material and Methods: The surgical technique was carried out four times in patients, with a follow-up of six to eighteen months. One 20 cm long leg incision, on the antero-lateral part of tibia, up to the retinaculum of extensors tendons, allowed a section of Tibialis Anterior (TA) tendon as proximal as possible, and an aperture through the tibiofibular fascia in its lower third. One 15 cm long leg incision, along the postero-medial edge of the tibia, toward medial malleolus, allowed a release of the TP tendon after distal section. The tendon was rerouted across the former fascia aperture. One 6 cm foot medial incision face to navicular bone, where the TA tendon was thoroughly extracted and diverted, close to the sole side of the medial cuneiforme, and the two medial metatarsal bones. One 5 cm foot dorsal incision was performed, opposite to the 2d intermetatarsal space, where the diverted TA tendon end was recovered and pulled along a tunnel beneath the retinaculum of extensors. It was thus sutured, with a satisfactory tension to the TP tendon transferred across the tibiofibular fascia. Weight bearing in a short leg cast was allowed., Results, Discussion, Conclusion: In the four cases, the results fulfilled the goal, with a satisfactory evaluation of the efficacy of the transfer, even the TA tendon was once intentionally diverted through the 1st metatarsal space instead of the second one, without any damage for the vessels pedicle. Among the widespread use of TP tendon, we think that a more neutral position of the tendon should be adopted with a curse coming along the extension of the leg axis, to the 2d intermetatarsal space. The more distally the transfer may be bound, the much efficient it will be. Obviously, there is no change in a correct automatic use of the transfer in gait. Even though it requires more experience and much longer follow-up time, this technique ensure a reliable and comfortable attachment of the transferred tendon, by a tendon-to-tendon suture, and secure a better restored foot dorsiflexion.

A retrospective review of 168 consecutive total hip arthroplasty procedures done in 1983 at the Cochin Teaching Hospital, Paris, France, was conducted to determine the rate of occurrence of heterotopic paraarticular ossification and to look for risk factors for this complication. None of the patients received preventive therapy for heterotopic ossification. Mean age was 66.2 years. The reason for arthroplasty was hip osteoarthritis in every case. The index operation was the first arthroplasty procedure. Heterotopic ossification was noted in 61.3% of patients and was high-grade in 8.3%. The rate of occurrence of heterotopic ossification was not influenced by age, gender, joint destruction, preoperative osteophytosis, duration of the arthroplasty or the occurrence of complications during or after the arthroplasty. However, severe ossification was more common in men that in women (12.7% men versus 5.7% women had grade III ossification) and in patients operated on by relatively inexperienced surgeons (28/8% grade II and III ossifications, versus 14.7% in patients operated on by experienced surgeons). The rate of occurrence of heterotopic ossification in the patients who had no risk factors (60.9%) was not significantly different from that in the overall study population. These data suggest that preventive strategies targeted to specific patient subgroups would probably be ineffective, and that routine preventive therapy of all total hip arthroplasty patients is warranted.