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Introduction: The anatomy of the proximal femur at the time of total hip arthroplasty has been widely studied but the horizontal plane was never considered, or only limited to the torsion of the femoral neck., Methods: Using CT-scan images from a group of 178 patients scheduled for cementless total hip arthroplasty (THA), we analysed the evolution of the torsion of the proximal femoral metaphysis, in reference to the posterior bicondylar plane of the femur. The evolution of the torsion, between 20 mm below the centre of the lesser trochanter and 20 mm above, was evaluated., Results: In cases of primary osteoarthritis, osteonecrosis, rheumatoid arthritis and epiphysiolysis capitis femoris, the mean torsion decreased from 46° to 20° without significant differences in average values between the different diagnoses, but important individual variations were found. In the groups of dysplasia and congenital hip dislocation, the torsion values were significantly higher, decreasing in mean from 59° to 25° and 63° to 34° respectively, and with important individual variations., Conclusions: These data are important when using cementless femoral stems, since an ideal fit-and-fill in the proximal femur zone has been shown to positively influence bone ingrowth of the stem. However, a strict adaptation of the stem to the medullary canal, without considering its torsion, can lead to an increased or decreased torsion of the prosthesis neck and thus to an instability of the arthroplasty. For these reasons, if a perfect adaptation of the stem to the intramedullary anatomy and an optimal reconstruction of the extramedullary anatomy are to be achieved, 3-dimensional planning should ideally be obtained for every patient. This will allow the best stem choice adapted to every single patient and every kind of anatomy.

The aim of the present study is to assess the disease profile, outcome and prognostic factors in patients treated with surgery combined with radiotherapy (RT), with or without chemotherapy (CXT), for soft-tissue sarcoma (STS) in a multidisciplinary setting. One hundred and sixty-four patients with STS treated between 1980 and 2010 at the Centre Hospitalier Universitaire Vaudois were enrolled in this retrospective study. Seventy-six percent of patients underwent postoperative RT with (24%), or without (52%) CXT, 15% preoperative RT with (5%), or without (10%) CXT, surgery alone (7%), or RT alone (2%) with or without CXT. The median follow-up was 60 months (range 6-292). Local failure was observed in 18%, and distant failure in 21% of the patients. Overall survival (OS), diseasefree survival (DFS), local control (LC) and distant metastases-free survival (DMFS) were 88%, 68%, 83%, and 79% at 5 years, and 80%, 56%, 76%, and 69% at 10 years, respectively. In univariate analyses, favorable prognostic factors for OS, DFS, and DMFS were tumor size 6 cm or less, World Health Organization (WHO)/Zubrod score 0, and stage 2 or less. Age and superficial tumors were favorable only for OS and DMFS respectively. STS involving the extremities had a better outcome regarding DFS and LC. Histological grade 2 or less was favorable for DFS, DMFS, and LC. Radical surgery was associated with better LC and DMFS. RT dose more than 60 Gy was favorable for OS, DFS, and LC. In multivariate analyses, independent factors were age for OS; tumor size for OS, DFS and DMFS; WHO/Zubrod score for OS, DFS and LC; hemoglobin level for DFS; site for DFS and LC; tumor depth for DMFS; histological grade for DFS and LC; surgical procedure for LC and DMFS; and RT dose for OS. This study confirms that in a multidisciplinary setting, STS have a fairly good prognosis. A number of prognostic and predictive factors, including the role of surgery combined with RT, were identified. Regarding RT, a dose of more than 60 Gy was associated with a better outcome, at the price of a higher toxicity. We could not demonstrate a superiority of preoperative RT over postoperative RT.

Freehand positioning of the femoral drill guide is difficult during hip resurfacing and the surgeon is often unsure of the implant position achieved peroperatively. The purpose of this study was to find out whether, by using a navigation system, acetabular and femoral component positioning could be made easier and more precise. Eighteen patients operated on by the same surgeon were matched by sex, age, BMI, diagnosis and ASA score (nine patients with computer assistance, nine with the regular ancillary). Pre-operative planning was done on standard AP and axial radiographs with CT scan views for the computer-assisted operations. The final position of implants was evaluated by the same radiographs for all patients. The follow-up was at least 1 year. No difference between both groups in terms of femoral component position was observed (p > 0.05). There was also no difference in femoral notching. A trend for a better cup position was observed for the navigated hips, especially for cup anteversion. There was no additional operating time for the navigated hips. Hip navigation for resurfacing surgery may allow improved visualisation and hip implant positioning, but its advantage probably will be more obvious with mini-incisions than with regular incision surgery.

Background and Objectives: Isolated limb perfusion with TNF-alpha and melphalan (TM-ILP) is a limb salvage therapy for non-resectable soft tissue sarcomas (STS) of the extremities. It is indicated for patients for whom amputation or debilitating surgery is the only alternative. It can be used either as an exclusive therapy (in palliation) or as a neo-adjuvant treatment, followed by marginal resection of tumor remnants with minimal functional impairment., Methods: Between February 1992 and March 2006, 57 TM-ILPs were performed on 51 patients with 88% high grade and 84% advanced stage tumors., Results: Mean follow-up is 38.9 months (4-159, median 22 months). Twenty-one percent patients had significant early complications, with 3 major re-operations, and 23% suffered long-lasting complications. Complete response was observed in 25%, partial response in 42%, stable disease in 14% and progressive disease in 14%. Resection of the tumor remnants was possible in 65%. A complementary treatment was necessary in 31%, mostly radiation therapy. A local recurrence was observed in 35%, after a mean of 20.3 months (2-78), and distant relapse was seen in 45%, after a mean of 13.4 months (5-196). Mean Disease-free survival was 14.9 months, and overall 5-year-survival 43.5%. Amputation rate at 5 years was 24%., Conclusions: TM-ILP is a conservative treatment with a high complications rate, but it can be successful even for the most severe STS of extremities. As a consequence the limb can be spared from amputation or debilitating surgery on the long term in about 75% of patients.

One of the most demanding steps of an intramedullary nailing is the distal locking. The aim of this study is to evaluate clinically and prospectively a new targeting guide. Twenty-five patients were treated consecutively in two different trauma centres (level one and one general hospital) by two different surgeons who were instructed on using the new device. Reduction of the fracture, intramedullary nailing and proximal locking are performed according to standard procedures. Then the new targeting device is used for distal locking. Evaluations are focused on the time it takes to perform the distal locking, the duration of the irradiation exposure and the duration of the complete procedure. In terms of duration, our results are comparable to those reported in the literature but this new device has more advantages than any other system. This new device is fully mechanical and is solidly linked to the patient. It can be used with any existing radioscopic equipment in any hospital. The guide is manually adjustable out of the X-ray field avoiding the surgeon being irradiated. The procedure is easy to learn and reproducible.

Background: Preoperative anemia is frequent in patients undergoing orthopedic surgery. The purpose of this study was to assess the preoperative increase of hemoglobin in iron deficiency anemia patients treated with intravenous iron., Methods: After obtaining written informed consent, 20 patients with iron deficiency anemia received 900 mg intravenous iron sucrose over 10 days starting 4 weeks before surgery. Changes of hemoglobin and iron status were measured over 4 weeks and at discharge. In the last 11 patients, endogenous erythropoietin was also measured. Data were analyzed using the Friedman test followed by pairwise Wilcoxon signed rank tests with Bonferroni correction., Results: Hemoglobin increased significantly (P < 0.0001) after intravenous iron treatment. Overall, the mean maximum increase was 1.0 +/- 0.6 g/dl (range, 0.2-2.2 g/dl). Ferritin increased from 78 +/- 70 to 428 +/- 191 microg/l (P = 0.0001), ferritin index decreased from 2.7 +/- 2.4 to 1.5 +/- 1.0 (P = 0.0001), and soluble transferrin receptor decreased from 4.1 +/- 2.3 mg/l to 3.7 +/- 2.3 mg/l (P = 0.049), whereas transferrin saturation (20.5 +/- 9.0 to 22.9 +/- 9.0%) and serum iron (13.3 +/- 4.6 to 13.1 +/- 4.5 microm) did not change significantly after intravenous iron treatment. Endogenous erythropoietin decreased from 261 +/- 130 pg/ml to 190 +/- 49 pg/ml 2 weeks after intravenous iron treatment (P = 0.050, not significant after Bonferroni correction). No adverse events related to intravenous iron were observed. The maximum increase of hemoglobin was observed 2 weeks after the start of intravenous iron treatment, indicating that administration of intravenous iron 2-3 weeks before surgery may be optimal., Conclusion: Treatment with intravenous iron allows correcting iron deficiency anemia before elective surgery.

Goals of Work: Long-term outcomes of osteosarcoma have dramatically improved with the use of modern combination therapies. Such aggressive treatments, however, entail chronic complications. In the present study, we assessed the functional, psychological, and familial status of long-term survivors of osteosarcoma treated at our institution., Materials and Methods: Fifteen long-term survivors of osteosarcoma were evaluated for functional and psychological sequelae. Functional assessment was based on a method described by Enneking et al. Psychological assessment was based on General Health Questionnaire 28, Inventory Scale for Traumatic Neurosis, and Family System Test., Main Results: Ten patients showed mild functional impairments; only five patients were handicapped more seriously. Depressive symptoms were diagnosed in four patients. A total of six patients revealed unbalanced family structures, including three of the four patients with depressive symptoms, all four patients with symptoms of posttraumatic stress disorder, and five of seven patients who showed poor emotional acceptance., Conclusions: Osteosarcoma survivors will generally recover good functional performance. Only a minority of them remain seriously impaired. One third of the patients present depressive symptoms and posttraumatic stress disorder. Poor coping is closely associated with unbalanced family structures. Therefore, the psychological and familial situation of patients with newly diagnosed osteosarcoma should be carefully assessed.

Objective: To report a rare case of lumbar vertebral subluxation associated with spontaneous reduction in an adolescent treated conservatively., Clinical Presentation and Intervention: A 14-year-old male victim of a snowboard accident, which caused a lumbar spinal injury, was referred to the emergency room with significant lumbar pain. Neurologic examination was normal. Radiographic assessment at admission showed a unilateral left lateral subluxation of the L2-L3 vertebrae without associated fractures. These findings were confirmed by CT scan and a surgical management was decided. The preoperative MRI performed 24 h after the accident, however, revealed the spontaneous reduction of the subluxation, and an associated tear of the quadratus lumborum and the psoas muscles on the right side at the level of L2, L3 and L4. Following these findings conservative treatment with a plaster brace for 2 months was carried out. The brace was removed after 2 months. The patient had no pain and the range of motion of his lumbar spine was normal. Three months after injury, sports activities were resumed. At follow-up of 24 months, the patient was free of pain and radiographs showed a right positional bending without rotational or translation anomaly., Conclusion: To date, this is the first case of subluxation without fracture in a child, presenting without neurological deficit and where spontaneous reduction occurred. In this case, conservative treatment was effective and the outcome at 2-year follow-up was excellent., (Copyright (c) 2007 S. Karger AG, Basel.)

We report preliminary results for unstable sacral fractures treated with a modified posterior triangular osteosynthesis. Seven patients were admitted to our trauma center with an unstable sacral fracture. The average age was 31 years (22-41). There were four vertical shear lesions of the pelvis and three transverse fracture of the upper sacrum. The vertical shear injuries were initially treated with an anterior external fixator inserted at the time of admission. Definitive surgery was performed at a mean time of 9 days after trauma. The operation consisted in a posterior fixation combining a vertebropelvic distraction osteosynthesis with pedicle screws and a rod system, whereby the transverse fixation was obtained using a 6 mm rod as a cross-link between the two main rods. Late displacement of the posterior pelvis or fracture was measured on X-ray films according to the criteria of Henderson. The patients were followed-up for a minimum time of 12 months. Four patients who presented with a pre-operative perineal neurological impairment made a complete recovery. No iatrogenic nerve injury was reported. One case of deep infection was managed successfully with surgical debridement and local antibiotics. All patients complained of symptoms related to the prominence of the iliac screws. The metalwork was removed in all cases after healing of the fracture, at a mean time of 4.3 months after surgery. No loss of reduction of fracture was seen at final radiological follow-up. The preliminary results are promising. The fixation is sufficiently stable to allow an immediate progressive weight-bearing, and safe nursing care in polytrauma cases. The only problem seems to be related to prominent heads of the distal screws.

Acetabular cup orientation is a key factor determining hip stability, and standard mechanical guides have shown little help in improving alignment. An in vitro study was carried out to compare the accuracy and precision of a new gravity-assisted guidance system with a standard mechanical guide. Three hundred ten cups were impacted by 5 surgeons, and the final cup orientation was measured. With the new guide, the average error in anteversion was 0.4 degrees , compared with 10.4 degrees with the standard guide and 0.3 degrees and -4.7 degrees , respectively, for abduction angles. The average time required for orienting the cups was similar for both guides. The accuracy and reproducibility obtained with the new guide were better (P < .0001). These good results would require a clinical validation.

Objective: To report and highlight the potential diagnostic pitfalls and consequences of leg textiloma., Case Report and Intervention: A soft tissue pseudotumor of the left leg diagnosed in a 58-year-old man is described. The lesion was caused by a retained surgical gauze after surgery for varicose veins. The surgical gauze had remained in the subcutaneous tissue for 3 years and led to the formation of a 3-cm, well-circumscribed, pseudotumoral foreign body granuloma which appeared like a soft tissue tumor. A surgical intervention was performed and the mass was excised. During the procedure an old surgical gauze was found. The histologic examination revealed that a large foreign body granuloma (pseudotumor) had developed in contact with foreign material birefracting under polarized light (gauze). No sign of malignancy was noted., Conclusion: Although no fatal complications have been described in the musculoskeletal localization, the diagnosis is difficult and costly. According to clinical presentation, a differential diagnosis should be made between a tumoral lesion, such as a sarcoma, or a pseudotumoral lesion, such as a gossypiboma. Focal myositis or infections should also be suspected., (Copyright 2006 S. Karger AG, Basel.)

Objective: To evaluate the results of closed and open grade I and II tibial shaft fractures treated by reamed nail and unreamed nailing., Subjects and Methods: Between 1997 and 2000, 119 patients with tibial shaft fractures were treated with reamed tibial nails. Postoperatively 96 patients (70 closed and 26 grade I and II open fractures) were followed clinically and radiologically for up to 18 months. The nail was inserted either by patellar tendon splitting or by nonsplitting technique. The nail was inserted after overreaming by 1.5 mm. Postoperatively, patients with isolated tibial fracture were mobilized by permitting partial weight bearing on the injured leg for 6 weeks. Patients with associated ankle fractures were allowed to walk with a Sarmiento cast., Results: Postoperatively, 6 (6.3%) patients developed a compartment syndrome after surgery. In 48 (50%) cases, dynamization of the nail was carried out after a mean period of 12 weeks for delayed union. Overall, a 90.6% union was obtained at a mean of 24 weeks without difference between closed or open fractures. Two (2.1%) patients with an open grade II fracture developed a deep infection requiring treatment. A 9.4% rate of malunion was observed. Eight (8.3%) patients developed screw failure without clinical consequences. At the last follow-up, 52% of patients with patellar tendon splitting had anterior knee pain, compared to those (14%) who did not have tendon splitting., Conclusion: Reamed intramedullary nail is a suitable implant in treating closed as well as grade I and II open tibial shaft fractures., (Copyright 2006 S. Karger AG, Basel.)

Osteoid osteoma and radiofrequency Osteoid osteoma relates to a benign skeletal neoplasm, smaller than 2 cm in diameter, composed of osteoid, highly vascularized connective tissue and surrounded by a ring of bone sclerosis. Its aetiology remains unknown. It affects twice more males than female patients and occurs usually between 5 and 40 years old. Long bones and spine are the most involved areas but the whole skeleton can be involved. Clinical manifestations can include local pain (increased at night and decreased by activity) and relief with salicylates administration. CT guided radiofrequency ablation of osteoid osteoma is in comparison to surgery less invasive, time saving and economic technique with excellent long term results.

Total knee replacement is nowadays a surgical technique that has reached maturity and is used as frequently as total hip replacement. It is mainly aimed at patients suffering from knee osteoarthrosis when it becomes invalidating and painful and does not respond anymore to medical conservative treatment and physiotherapy. Long term results are excellent in patients aged over 70 years old. They are still amenable to improvement in young patients who are more active and who put under stress their implants in a longer and more intense way. Infection, loosening and malpositioning of the implants are the most common complications.

Objectives: To evaluate the results of retrograde percutaneous screw fixation (PSF) in minimally or undisplaced acetabular fractures in a geriatric population., Patients and Methods: Between July 1998 and July 2001, 21 consecutive patients with an acetabular fracture underwent fluoroscopic guided percutaneous fixation. The mean age was 81 years (range 67--90 years). In all cases, the fracture was minimally or undisplaced (<2mm). Two cannulated cancellous 7.3mm screws were inserted in a retrograde fashion to stabilise the posterior and the anterior column. Bed to chair transfer began after 24h. Weight bearing as tolerated was allowed at 4 weeks., Results: Eighteen patients were reviewed at a mean of 3.5 years (range 2--5 years). Soft tissue dissection was minimal. There were no intraoperative or postoperative complications. At the latest follow-up there was no radiographical evidence of secondary displacement of fragments, degenerative changes, or screw failure. Fractures healed at a mean time of 12 weeks (range 8--15 weeks). Clinical results were satisfactory in 17 patients., Conclusion: Our results show that percutaneous screw fixation under fluoroscopic control is a safe technique to treat some pattern of acetabular fracture.

The purpose of this study is to clinically validate a new two-dimensional preoperative planning software for cementless total hip arthroplasty (THA). Manual and two-dimensional computer-assisted planning were compared by an independent observer for each of the 30 patients with osteoarthritis who underwent THA. This study showed that there were no statistical differences between the results of both preoperative plans in terms of stem size and neck length (<1 size) and hip rotation center position (<5 mm). Two-dimensional computer-assisted preoperative planning provided successful results comparable to those using the manual procedure, thereby allowing the surgeon to simulate various stem designs easily.

Unlabelled: We prospectively evaluated the results of our custom cementless femoral stems to ascertain whether this technology produced reasonable clinical function, complication rates, and loosening rates at midterm. Fifty-seven consecutive patients had surgery in 62 hips for primary osteoarthritis at a mean age of 57 years using a three-dimensional computed custom cementless stem. Patients were reviewed at a mean followup of 94.9 months. At review, the mean Harris hip score was 98.8 points (range, 84-100) compared with 61.1 (range, 28-78) points preoperatively. No patient complained of thigh pain. No migration or subsidence was observed. All stems were considered stable according to the radiographic criteria defined by Engh et al. There were no dislocations, no infections, and no reoperations. Our results are comparable with published results from clinical and radiologic points of view. Two problems remain unsolved: the price of a custom stem is twice as expensive as a standard stem; and we need longer term results before definitely recommending this technology as a reasonable alternative to current arthroplasties in younger patients. The data support the continued exploration of this technology with controlled clinical followup., Level of Evidence: Therapeutic study, Level II-1 (prospective cohort study). See the Guidelines to Authors for a complete description of levels of evidence.

The results of the total hip prostheses in terms of cost-efficiency make one of the surgical procedures the most efficient. Usually, the articular pains disappear completely and the patient function improves. Outside, turned out failures, which require a revision, some patients present residual pain persisting after the intervention or appearing secondarily. Considering the important number of total hip arthroplasties, this clinical situation is not so rare and the generalist, as the specialist, can be confronted there. The experience shows that the surgical revisions, in the absence of a precise diagnosis are disappointing and often do not improve the patient. This article presents the diagnostic and therapeutic steps advised to face this problem.

We envision the use of human fetal bone cells for engineered regeneration of adult skeletal tissue. A description of their cellular function is then necessary. To our knowledge, there is no description of human primary fetal bone cells treated with differentiation factors. The characterization of fetal bone cells is particularly important as the pattern of secreted proteins from osteoblasts has been shown to change during aging. In the first part of this work, human primary fetal bone cells were compared to adult bone cells and mesenchymal stem cells for their ability to proliferate and to differentiate into osteoblasts in vitro. Cell proliferation, gene expression of bone markers, alkaline phosphatase (ALP) activity, and mineralization were analyzed during a time-course study. In the second part of this paper, bone fetal cells behavior exposed to osteogenic factors is further detailed. The doubling time of fetal bone cells was comparable to mesenchymal stem cells but significantly shorter than for adult bone cells. Gene expression of cbfa-1, ALP, alpha1 chain of type I collagen, and osteocalcin were upregulated in fetal bone cells after 12 days of treatment, with higher inductions than for adult and mesenchymal stem cells. The increase of ALP enzymatic activity was stronger for fetal than for adult bone cells reaching a maximum at day 10, but lower than for mesenchymal stem cells. Importantly, the mineralization process of bone fetal cells started earlier than adult bone and mesenchymal stem cells. Proliferation of fetal and adult bone cells was increased by dexamethasone, whereas 1alpha,25-dihydroxyvitamin D3 did not show any proliferative effect. Mineralization studies clearly demonstrated the presence of calcium deposits in the extracellular matrix of fetal bone cells. Nodule formation and calcification were strongly increased by the differentiation treatment, especially by dexamethasone. This study shows for the first time that human primary fetal bone cells could be of great interest for bone research, due to their fast growth rate and their ability to differentiate into mature osteoblasts. They represent an interesting and promising potential for therapeutic use in bone tissue engineering.

This prospective study addresses early results of the treatment of acute acetabular fractures in elderly patients by total hip arthroplasty and cerclage wiring. Fifteen patients with an average age of 81 years were treated at our institution between February 1998 and December 2000. There were two transverse fractures, eight T-shaped fractures, two transverse fractures with associated posterior wall fracture, two posterior column fractures with associated posterior wall fracture, and one fracture of both columns. Treatment consisted of cerclage wiring of the fracture and primary non-cemented total hip replacement. All of the patients were followed for a mean of 36 months. Although there was one patient with three hip dislocations during the first 10 months after the operation, we found an excellent or good result for the entire group. During this relatively short follow-up period, we have not found a radiological loss of fracture reduction of more than 1 mm or a cup migration of more than 3.2 mm. All of the fractures healed and no loosening of the implant was evident. Primary total hip arthroplasty combined with internal fixation is a valid treatment option for acetabular fractures in the elderly. Preliminary results are convincing, but a bigger patient population and a longer follow-up time are necessary before we are able to draw final conclusions.

A radiologist should be included in the multidisciplinary approach which will allow optimal diagnostic evaluation and treatment of sarcoma. The appropriate use of ultrasound, computed tomography and magnetic resonance imaging plays a significant role in the evaluation of these tumors and their recurrences. The potential role of dynamic magnetic resonance imaging has also been evaluated. A review of diagnostic imaging and their clinical utility is discussed.

We report a case of acute fracture of both sesamoids of the great toe in an athlete. The fractures healed uneventfully after non-surgical treatment.

When a soft tissue tumor is initially misdiagnosed as a simple trauma or a mass, treatment may be adversely affected by the delay in diagnosis or an inappropriate invasive procedure that results in extension of a probable malignant tumor. Patients with soft tissue tumors present a diagnostic challenge to the clinician. A systematic approach to the evaluation and biopsy is necessary in order to minimize diagnostic errors and biopsy complications. With a multidisciplinary approach and adequate surgical management, the prognosis with a five-year survival rate can be excellent.

Heterotopic ossification, mostly of the hip, is a frequent complication after reconstructive surgery. Most common prophylactic therapies are non-steroidal anti-inflammatory medication (AINS) applied post-operatively and external radiotherapy (RT) administered in the pre- or post-operative setting. Both treatments proved to be efficient in several randomised clinical trials. Prevailing trend regarding RT is a treatment prior to surgery. It is appreciated by both physician and the patient because it is simple and comfortable. In this article, we present the literature linked to the subject together with the benefit and the inconvenience of both therapeutic methods.