Revision of trapeziectomy failures in thumb base osteoarthritis: retrospective analysis of ten cases and review of the literature.

Controversy persists around trapeziectomy as standard of care in thumb base osteoarthritis. The difficulty of management of failure requires the utmost caution in choice of the initial technique. We here report a retrospective series of 10 revision procedures following trapeziectomy, supported by a review of literature. The main cause of revision was collapse of the thumb column resulting in arthrogenic contact of the first metacarpal with the scaphoid. At a mean 73.3 months' follow-up, 5 patients had to undergo additional surgery. Mean VAS pain score was 2.9; 5 patients were pain-free. Strength was more severely impaired than joint motion, resulting in disappointing functional results. The present outcomes are consistent with the literature, which mostly comprises heterogeneous series, making it impossible draw conclusions to guide practice. The most common option seems to be to perform a new ligament procedure, with or without tendon or pyrocarbon interposition, and was the one that provided the only good result in the present series. Other techniques (composite graft, non-autogenic interposition, scaphometacarpal prosthesis) seem promising, and deserve large-scale evaluation. Thus, the gold-standard status of trapeziectomy should be weighed against the observation of these multi-operated patients in situations of therapeutic impasse. Should indications for first-line trapeziectomy be restricted, especially in patients with a revision risk factor? LEVEL OF EVIDENCE: 4.

Percutaneous cryoablation of osteoblastoma in the proximal femur.

A 37-year-old man presented with a 2-year history of left hip pain. Pretherapeutic imaging demonstrated a 4 cm osteoblastoma located in the intertrochanteric region of the proximal femur, surrounded by extensive bone marrow edema. After multidisciplinary meeting, percutaneous cryoablation was decided and performed under computed tomography guidance using three cryoprobes to match the exact size and shape of the tumor, resulting in complete resolution of symptoms. Magnetic resonance imaging follow-up demonstrated resolution of the bone marrow edema pattern and ingrowth of fat at the periphery of the ablation zone consistent with long-term healing of the tumor.

Amputation versus conservative treatment in severe open lower-limb fracture: A functional and quality-of-life study.

INTRODUCTION: Severe lower-limb trauma is a major event in a patient's life, and treatment is a challenge that has not been sufficiently studied. The main objective of the present study was to assess the difference in disability between amputees and patients who kept their leg after severe open lower-limb fracture. HYPOTHESIS: The study hypothesis was that amputation allows better functional recovery and quality of life, in the same time-frame. MATERIALS AND METHODS: All male and female patients aged over 18 years admitted to one of the trauma centers of Marseille (France) for major lower-limb trauma with Gustilo IIIb or IIIc fracture were included. Minimum follow-up was 2 years. Two groups were distinguished according to primary treatment: lower-limb salvage, or amputation. Rates of infection and of surgical revision, hospital stay, functional parameters (walking distance, standing, use of canes, running, jumping, driving, and physical and occupational activity) and quality of life (MOS SF-36 score) were compared between groups. RESULTS: The conservative treatment group comprised 27 patients, and the amputation group 24. Rates of infection and of surgical revision and hospital stay were significantly lower in the amputation group (P<0.02). All functional parameters (except return to work) and overall quality of life were significantly better in the amputation group. There was no significant inter-group difference in MOS mental score. CONCLUSION: In severe lower-limb trauma, amputation seems to give better functional and quality-of-life results. It did not, however, improve return to work, and was not better accepted psychologically than long and complex conservative management. LEVEL OF EVIDENCE: IV, retrospective study.

Management of soft tissue tumors of the musculoskeletal system.

A palpable mass in the musculoskeletal system is a common reason for consultation. The main issue is that a malignant tumor must not be missed. Inappropriate initial treatment can have direct consequences on the risk of local recurrence, the patient's future function and life expectancy. A mass more than 5cm in diameter, a subfascial location and a recent increase in size are signs that should lead the physician to question whether the lesion is truly benign and to carry out diagnostic examinations. MRI is the gold standard imaging exam. Biopsy, which is now mainly percutaneous and imaging-guided, must be performed for any subfascial mass more than 5cm long or a smaller mass with a high risk of postoperative functional sequelae. Referring the patient to a specialized cancer center has direct benefits on the patient's recurrence-free survival and reduces time lost during the diagnostic and treatment phases. For malignant tumors, surgical treatment requires resection margins that comply with cancer guidelines. Preservation of the limb and its function may require multidisciplinary reconstruction techniques. Pre- or post-operative radiation therapy or chemotherapy should be proposed only after discussion in a multidisciplinary team meeting.

Does curettage-cement packing for treating giant cell tumors at the knee lead to osteoarthritis?

INTRODUCTION: Giant cell tumors (GCTs) make up 15 to 20% of bone-related tumors in adults. They are often found around the knee in the metaphysis and epiphysis area, contacting the joint cartilage. The aims of our study were to evaluate the presence of early knee osteoarthritis (OA) in patients with GCTs in the knee area treated by curettage-cement packing, and to evaluate whether replacing subchondral bone with acrylic cement has an effect on the functional outcomes and quality of life. MATERIAL AND METHODS: This was a retrospective study of all patients operated between 2000 and 2010 by the same specialized surgical team. Functional outcomes and quality of life were evaluated in each patient using the Knee Injury and Osteoarthritis Outcome (KOOS), the Musculoskeletal Tumor Society Score (MSTS) and the Short Form-36 (SF-36). The presence of OA was evaluated in a full radiological work-up comparing the operated knee with the healthy contralateral knee. Knee OA was defined as grade 3 or grade 4 radiographic findings based on the Kellgren and Lawrence classification, and a significant difference between the operated and contralateral knee. RESULTS: Nineteen patients were included in this study. The average follow-up was 120 months (range 60-180). Four patients (21%) had radiographic KL-3 and one patient (5%) had KL-4. Eight patients (42%) had recurrence of the GCT. The distance between the tumor and cartilage, and the area of the subchondral bone invaded by the tumor appeared to contribute to OA progression. DISCUSSION: Resection of GCTs around the knee by curettage-cement packing did not have an effect on development of OA. In the four patients who developed knee OA, the tumor was located less than 3mm from the joint cartilage and took up more than 90% of the epiphysis. Based on these observations, there seems to be a strong correlation between the development of knee OA and the small quantity of subchondral bone left after curettage. The functional outcomes and quality of life were similar no matter the knee OA grade in patients. Replacing subchondral bone by cement had no effect on quality of life in this study. LEVEL OF EVIDENCE: IV (retrospective study).

Natural killer cells in acute myeloid leukemia patients: from phenotype to transcriptomic analysis.

Chemotherapies allow complete remission in more than 50 % of patients with acute myeloid leukemia (AML), however, with frequent relapse. This suggests that residual leukemic cells may escape to chemotherapy and immune system. Natural killer (NK) cells from AML patients (AML-NK) have a weaker natural cytotoxicity-activating receptors (NCRs) expression than NK cells from healthy donors (HD-NK). Coding genes for NCR1/NKp46, NCR2/NKp44 and NCR3/NKp30 are located at different loci on two different chromosomes; however, their expression is tightly coordinated. Most NK cells express either high (NCRbright) or low levels (NCRdull) of all three NCRs. This suggests the existence of negative/positive regulation factor(s) common to the three receptors. In order to find transcription factor(s) or pathway(s) involved in NCRs co-regulation, this study compared the transcriptomic signature of HD-NK and AML-NK cells, before and after in vitro NK cells culture. Microarrays analysis revealed a specific NK cells transcriptomic signature in patients with AML. However, in vitro NK cells expansion erased this signature and up-regulated expression of central molecules of NK functions, such as NCR, NKG2D and also ETS-1, regardless of their origin, i.e., AML-NK vs HD-NK. ETS-1 transcription factor was shown to bind to a specific and common region in the NCRs promoters, thus appearing as a good candidate to explain the coordinated regulation of three NCRs. Such results are encouraging regarding in vitro AML-NK cytotoxicity restoration and provide a new conceptual support for innovative cellular therapy based on in vitro NK cells expansion before their reinfusion in AML patients.

Prognostic factors for the recurrence of myxoid liposarcoma: 20 cases with up to 8 years follow-up.

INTRODUCTION: Myxoid liposarcomas (MLS) are the second most common type of liposarcoma. Although some MRI findings are distinctively characteristics of MLS, the diagnosis can be tricky in tumors with a large portion of round cells (RC). Known predictors of an unfavorable outcome include age, tumor size, high RC content and positive resection margins. The goal of this retrospective study was to define prognostic factors for recurrence, with special emphasis on the percentage of RCs and medical care provided in a non-specialized center. PATIENTS AND METHODS: Twenty patients (11 women, 9 men) with a mean age of 44.3 years (18-73) were reviewed after a mean of 55.9 months. Six of these patients had been operated at a non-specialized center. The diagnostic MRI was read by a specialized radiologist and the resection procedures performed by two specialized surgeons. Tumors were labeled as either "pure myxoid liposarcoma" or "myxoid/round-cell liposarcoma". The local recurrence-free survival rate and mortality rate were calculated. RESULTS: Fifteen patients had undergone an MRI during the initial assessment. The typical MRI findings of MLS were present in four of them. The MRI suggested a non-specific lesion in the other 11 patients. After correlation with pathology findings, these tumors contained more than 5% round cells. The fourteen patients treated at our facility had undergone a biopsy, while none of the ones treated outside did. Five patients had R0 resection margins and 15 had R1 margins. Prognostic factors for recurrence consisted of age, tumor size >10 cm, R1 resection margins, FNCLCC grade 2+R1 margins, medical care at a non-specialized center, and >5% round cells. There were eight local recurrences and three metastases (15%). Two patients died (90% overall survival rate). DISCUSSION: The risk of local recurrence was 3.86 times greater in this study when the tumor contained more than 5% RCs, which is consistent with published data. The MLS diagnosis was made only four times based on the initial MRI because misleading nature of high RC tumors. R1 resection margins are a risk factor for local recurrence. However, cases with R1 margins have a recurrence rate that is similar to R0 cases when the surgery is performed at a specialized cancer center. Treatment of MLS in a non-specialized center is a key negative prognostic factor. The reported rate of metastasis varies. Atypical extrapulmonary localizations are common, and often multifocal. MRI has been shown to be superior at detecting secondary lesions and some have suggested that a full-body MRI should be performed. CONCLUSION: Prognostic factors for the recurrence of myxoid liposarcomas have been identified. MRI analysis is not definitive and must be supplemented by a biopsy.