Satisfactory mid- to long-term outcomes of TKA aligned using conventional instrumentation for flexion gap balancing with minimal soft tissue release.

PURPOSE: To describe a technique for flexion gap management in total knee arthroplasty (TKA) using conventional instrumentation with minimal soft tissue release, by aligning the femoral component to restore close-to-native posterior condylar angle (PCA). The hypothesis was that this technique renders consistent outcomes, regardless the preoperative deformity or intraoperative parameters. METHODS: In a consecutive series of 152 TKAs, the femoral component was rotated to restore anatomic PCA of 2° ± 2° and the flexion gap was balanced with a final lateral flexion laxity of 1-3 mm. Patients were assessed using the Knee Society Score (KSS), the Oxford Knee Score (OKS) and University of California Los Angeles (UCLA) activity score at a minimum follow-up of 4 years. Uni- and multivariable analyses were performed to determine associations between clinical scores and patient demographics, PCA, laxity, pre- and postoperative hip-knee-ankle (HKA) angle, and preoperative femoral mechanical angle (FMA) and tibial mechanical angle (TMA). RESULTS: Intraoperative measurements indicated a target PCA of 2.9° ± 1.0° (range 0°-6°) with a final lateral flexion laxity of 1.5 ± 0.6 mm (range 0-3). The target PCA was achieved in 145 knees (95%) and the desired final lateral flexion laxity was achieved in 151 knees (99.3%). There were no significant differences in postoperative clinical outcomes between knees within the target PCA range and outliers. KSS function decreased with age and preoperative HKA angle, and was lower for women, while KSS satisfaction improved with follow-up. OKS increased with target PCA and follow-up, decreased with preoperative TMA, was lower for women and better for knees with resurfaced patellae. UCLA activity decreased with age, preoperative HKA angle and BMI, and was lower for women. CONCLUSIONS: In this consecutive series of 152 TKAs performed with minimal ligament release, the target PCA and final lateral flexion laxity were simultaneously achieved in 95% of knees. At a minimum follow-up of 4 years, adequate clinical scores and patient satisfaction were achieved, even in knees outside the target PCA range. LEVEL OF EVIDENCE: IV.

Postoperative pain and infection are the most frequent reasons for legal action after knee arthroscopy: a 5-year review based on two private insurance French companies after arthroscopy.

PURPOSE: The objective of this study was to determine the reasons for complaints and describe the judicial means upstream of France's courts following arthroscopy. METHODS: This is a retrospective observational study including all compensation records related to arthroscopic surgery, collected from the two leading French insurance organizations: MACSF and Branchet companies, from 2014 to 2018. Three medical experts performed the protocol and analysis. RESULTS: Finally, 247 procedures were included. The most common motives were: the appearance or persistence of pain (43.7%), postoperative infection (29.1%), technical errors (10.5%), nerve damage (5.7%), arterial lesions (2.8%), side errors (2.4%). Knee arthroscopies were more at risk of legal action for infection (p = 0.0006), and for disappointing results or persistent pain (p = 0.001). The first recourse was the conciliation and compensation commission (CCI) in 136 cases (55.1%), the civil court (TGI) in 88 cases (35.6%) and amicable settlement in 23 cases (9.3%). The mean time between surgery and the complaint was 32.8 ± 25.7 months, and was shorter in the case of an amicable procedure (p < 0.001). The lawsuit's mean duration was 15.6 ± 11.2 months, but longer in case of civil proceedings (p < 0.0001). The experts found no negligence in 81.8% of cases (n = 202). Infections were the leading cause of recourse to the conciliation and compensation commission (p < 0.0001), while technical errors were the main reason for complaints settled in an amicable procedure (p = 0.035). It was found more proven negligence in case of amicable procedures (p < 0.0001). The mean amount of compensation was 60,968.45€. No significant difference could be found regarding the median values of compensation between the reason of complaint. The amount of compensation was higher in civil court proceedings than in any others (p = 0.02). CONCLUSION: The main reasons for arthroscopy litigation in France are reported in this study, specifying how they are managed upstream of possible legal proceedings. The knee is the main joint involved. Patient information, close follow-up associated with early and appropriate management of complications are the main ways to reduce complaints. LEVEL OF EVIDENCE: IV.

Differences in limb alignment and femoral mechanical-anatomical angles using two dimension versus three dimension radiographic imaging.

PURPOSE: The purpose of this study was to compare the femoral mechanical-anatomical (FMA) and mechanical femoro-tibial (MFT) angles in an osteoarthritic population using the 2D (two dimension) and the 3D (three dimension) EOS low-dose biplanar radiographic system (EOS). METHODS: FMA and MFT angles were calculated in 127 adults with osteoarthritis. In 2D, FMA angle was measured between the femoral mechanical axis and the femoral anatomical axis, and MFT angle between the femoral mechanical axis and the tibial mechanical axis. In 3D, the measurement of FMA angle consisted of identifying specific anatomical landmarks on X-rays. MFT angle was then measured between the femoral mechanical axis and the tibial mechanical axis. The distribution of 2D and 3D values was assessed in terms of means and variances. RESULTS: Mean age was 69 ± 12 years. A total of 10% of the patients having a 3D FMA angle between 4° and 7° have a 2D-measured FMA over or underestimated. Particularly, FMA values tend to be underestimated in women in 2D. Finally, we found that men showed a tendency to a more varus morphology, with MFT values being significantly underestimated in 2D. CONCLUSIONS: The EOS 3D reconstruction system is a reliable method to measure FMA and MFT angles in an osteoarthritic population.

Differentially activated macrophages orchestrate myogenic precursor cell fate during human skeletal muscle regeneration.

Macrophages (MPs) exert either beneficial or deleterious effects on tissue repair, depending on their activation/polarization state. They are crucial for adult skeletal muscle repair, notably by acting on myogenic precursor cells. However, these interactions have not been fully characterized. Here, we explored both in vitro and in vivo, in human, the interactions of differentially activated MPs with myogenic precursor cells (MPCs) during adult myogenesis and skeletal muscle regeneration. We showed in vitro that through the differential secretion of cytokines and growth factors, proinflammatory MPs inhibited MPC fusion while anti-inflammatory MPs strongly promoted MPC differentiation by increasing their commitment into differentiated myocytes and the formation of mature myotubes. Furthermore, the in vivo time course of expression of myogenic and MP markers was studied in regenerating human healthy muscle after damage. We observed that regenerating areas containing proliferating MPCs were preferentially associated with MPs expressing proinflammatory markers. In the same muscle, regenerating areas containing differentiating myogenin-positive MPCs were preferentially coupled to MPs harboring anti-inflammatory markers. These data demonstrate for the first time in human that MPs sequentially orchestrate adult myogenesis during regeneration of damaged skeletal muscle. These results support the emerging concept that inflammation, through MP activation, controls stem cell fate and coordinates tissue repair.

Bone morphogenetic protein and orthopaedic surgery: can we legitimate its off-label use?

PURPOSE: Bone morphogenetic proteins (BMP) are recombinant osteoinductive proteins with their primary role being to promote bone formation. The off-label use of BMP in orthopaedic surgery has dramatically increased. However, reports of complications with BMP have emerged, and the safety of these proteins in orthopaedics is questioned. The purpose of this review was to evaluate safe situations in which BMP should be used and situations in which their use should be restricted. METHOD: We recorded all studies from PubMed database from 2002 (date of first authorisation for both BMPs) until January 2014 using "BMP" or "bone morphogenetic protein". Then we screened and extracted all studies dealing with orthopaedic surgery. All situations in which BMP were used, even cases reports, were considered, and complications reported were then listed. RESULTS: Situations in which it seems safe and efficient to use BMP are long-bone nonunions, or arthrodesis as an alternative or combined to autograft in small-bone loss. Surgeons and patients should be aware of transient aseptic wound swelling when BMP is located superficially. The use of BMP in spine surgery for intersomatic fusion is efficient but should be restricted to approaches that respect the vertebral canal to avoid neurological complications. CONCLUSION: This review is an off-label map of BMP use in orthopaedics during the past 10 years. Our results could provide a useful tool to help decisions around when to use a BMP in a specific complex, and sometimes off-label, situation.

Reasons for malpractice claims after primary total hip arthroplasty in France: Insurance data from 240 claims from 2014 to 2017.

INTRODUCTION: Total hip arthroplasty (THA) is one of the most frequent orthopedic surgery procedures, and orthopedic surgeons are among the most frequently accused of malpractice by their patients. Identifying the main reasons for malpractice claims after THA is a prior condition to reducing their frequency. The quality of the preoperative risk information given to the patient by the surgeon is crucial for these purposes. Data specific to THA are sparse in France, and we therefore conducted a retrospective study (1) to determine whether the outcome of medico-legal expert appraisal correlated with the quality and traceability of preoperative information, and (2) to identify the most frequent grounds for complaint after primary THA. HYPOTHESIS: The quality of patient information partly determines expert appraisal. MATERIAL AND METHOD: A retrospective study was conducted based on data from the Branchet medical professional insurance agency for malpractice claims following THA over the period 2014-2017, with 240 complete files, for 125 women and 115 men. Data comprised: type of procedure, main grounds of complaint (complications), positive or negative expert appraisal, quality of preoperative patient information, amounts of compensation accorded and fees paid, and the practitioner's liability. We assessed correlations between information quality and liability. RESULTS: Surgical site infection and neurologic deficit were the two main grounds for malpractice claims. In the 240 files, cases for 106 operations (44.2%) were submitted to arbitration, 95 (39.6%) were brought to court, and 39 (16.2%) were settled out of court. The practitioner was held at least partly liable in 40 files (16.7%). Information to the patient was deemed imperfect or poor for 119 files (49.6%) and good in 121 (50.4%). Mean compensation was €30,940 (range, €0 to €198,100). In 27 of the 40 cases of liability (67.5%), the information to the patient was deemed imperfect or poor. Twenty-six of the 40 cases (65%) were settled out of court. In case of poor information, there was a significant risk for the practitioner to be held liable: 7.5 vs. 25% (p=0.003). DISCUSSION: The present study listed the main complications underlying malpractice claims after THA: infection, neurologic complications, and limb-length discrepancy. This should enable practitioners to improve patient information so as to reduce the rate of malpractice claims or at least decrease the practitioner's liability, as the study found a correlation between information quality and expert appraisal. LEVEL OF EVIDENCE: IV; retrospective study.

Epidemiology of the causes of complaints after discectomy collected from a French insurance company.

INTRODUCTION: Lumbar discectomy is a frequent procedure performed by surgeons from specialties at risk of patient complaints. The objective of the study was to analyze the causes of litigations following lumbar discectomy to be able to reduce their frequency. MATERIAL AND METHODS: This observational, retrospective study was carried out at a French insurance company (Branchet). All files opened between the 1st of January 2003 and the 31st of December 2020, following lumbar discectomy without instrumentation and without any other associated code, undertaken by a surgeon insured by Branchet, were analyzed. The data was extracted from the database by a consultant from the insurance company and analyzed by an orthopedic surgeon. RESULTS: One hundred and forty-four records met all inclusion criteria and were complete and available for analysis. Infection was the leading cause of litigation, responsible for 27% of complaints. Residual postoperative pain was the second cause of complaint with 26% of cases, of which 93% had persistent pain. Neurological deficits were the third cause of complaint with 25% of cases among which 76% were related to the appearance of a deficit and 20% related to the persistence of an existing deficit. Early recurrence of herniated disc also appeared as a cause of complaint, accounting for 7% of cases. CONCLUSION: Surgical site infection, persistence of pain, and the appearance or persistence of neurological disorders are the primary causes of complaints leading to investigation in the aftermath of lumbar discectomy. It seems essential to us that this information be brought to the attention of surgeons to enable them to better adapt their explanations in the delivery of preoperative information. LEVEL OF EVIDENCE: IV.

Secondary structure of rhBMP-2 in a protective biopolymeric carrier material.

Efficient delivery of growth factors is one of the great challenges of tissue engineering. Polyelectrolyte multilayer films (PEM) made of biopolymers have recently emerged as an interesting carrier for delivering recombinant human bone morphogenetic protein 2 (rhBMP-2 noted here BMP-2) to cells in a matrix-bound manner. We recently showed that PEM made of poly(l-lysine) and hyaluronan (PLL/HA) can retain high and tunable quantities of BMP-2 and can deliver it to cells to induce their differentiation in osteoblasts. Here, we investigate quantitatively by Fourier transform infrared spectroscopy (FTIR) the secondary structure of BMP-2 in solution as well as trapped in a biopolymeric thin film. We reveal that the major structural elements of BMP-2 in solution are intramolecular ß-sheets and unordered structures as well as α-helices. Furthermore, we studied the secondary structure of rhBMP-2 trapped in hydrated films and in dry films since drying is an important step for future applications of these bioactive films onto orthopedic biomaterials. We demonstrate that the structural elements were preserved when BMP-2 was trapped in the biopolymeric film in hydrated conditions and, to a lesser extent, in dry state. Importantly, its bioactivity was maintained after drying of the film. Our results appear highly promising for future applications of these films as coatings of biomedical materials, to deliver bioactive proteins while preserving their bioactivity upon storage in dry state.

Surgical treatment of bone metastasis from osteophilic cancer. Results in 401 peripheral and spinal locations.

INTRODUCTION: Peripheral and spinal bone metastases arise mainly from 5 osteophilic cancers: lung, prostate, kidney, breast and thyroid. Few studies combined results for the two types metastatic location (peripheral and spinal). Therefore we performed a multicenter retrospective study of surgically managed peripheral and spinal bone metastases to assess: (1) global function at a minimum 1 year's follow-up and; (2) factors affecting survival. HYPOTHESIS: Global function is improved by surgery, with acceptable survival. MATERIAL AND METHOD: Between 2015 and 2016, 386 patients were operated on in 11 centers for 401 metastases: 231 peripheral, and 170 spinal. Mean age was 62.6±12.5 years in the 212 female patients (54%) versus 66.4±11.5 years in the 174 males (46%) (p=0.001). Pre- to postoperative comparison was made on pain on VAS (visual analog scale), WHO (World Health Organization) score, Karnofsky score, walking and global upper-limb function. Survival was estimated at 4 years' follow-up. RESULTS: The most frequent locations were in the femur (n=146, 36%) and thoracic spine (n=107, 27%). The primary cancer was revealed by the metastasis in 82 patients (21%). There were 55 general complications (14%) and 48 local complications (12%). Twenty-one patients (5.4%) died during the first month. VAS and Karnofsky sores improved: respectively, 6.6±2.3 vs. 3.4±2.1 (p<0.001) and 65±14 vs. 72±20 (p=0.01). Walking, upper-limb function and Frankel grade improved in respectively 49/86 (57%), 19/29 (66%) and 31/84 (37%) patients. Median survival was 13.3 months (95% CI: 10.8-17.1), and was related to the primary (log-rank, p<0.001): lung 6.5 months (95% CI: 5.2-8.9), prostate 11.1 months (95% CI: 5.3-43.6), kidney 12.9 months (95% CI: 8.4-22.6), breast 26.5 months (95% CI: 19.0-34.0), and thyroid 49.0 months (95% CI: 12.2-NA). On multivariate analysis, independent factors for death comprised internal fixation rather than prosthesis (OR=2.20; 95% CI: 1.59-3.04 (p<0.001)), high preoperative ASA score (OR=1.78; 95% CI: 1.40-2.28 (p<0.001)), preoperative chemotherapy (OR=1.26; 95% CI: 1.13-1.41 (p<0.001)) and major visceral metastasis (lung, brain, liver) (OR=11.80; 95% CI: 5.21-26.71 (p<0.001)). CONCLUSION: Although function improved only slightly, pain relief and maintained autonomy suggest enhanced comfort in life, confirming the study hypothesis only partially. Factors affecting survival and clinical results argue for preventive surgery when possible, before general health status deteriorates. LEVEL OF EVIDENCE: IV; retrospective observational.

High rate of fracture in long-bone metastasis: Proposal for an improved Mirels predictive score.

INTRODUCTION: Pathologic fracture is the most feared complication in long-bone metastasis. Various radiographic tools are available for identifying at-risk patients and guide preventive treatment. The Mirels score is the most frequently studied and widely used, but has been criticized, many patients not being operated on until the actual fracture stage. We therefore conducted a French national multicenter prospective study: (1) to determine the proportion of patients operated on at fracture stage versus preventively; (2) to compare Mirels score between the two; and (3) to identify factors for operation at fracture stage according to Mirels score and other epidemiological, clinical and biological criteria. HYPOTHESIS: Simple discriminatory items can be identified to as to complete the Mirels score and enhance its predictive capacity. MATERIAL AND METHODS: A non-controlled multicenter prospective study included 245 patients operated on for non-revelatory long-bone metastasis, comparing patients operated on for fracture versus preventively according to body-mass index (BMI), ASA score, Katagiri score items and the 4 Mirels items. RESULTS: One hundred and twenty-six patients (51.4%) were operated on at fracture stage: 106 (84.1%) showed high risk on Mirels score (score>8), and 15 (11.9%) moderate risk (score=8). On multivariate analysis, 4 independent factors emerged: in increasing order, advanced age (OR=1.03; 95%CI 1.01-1.06), VAS pain score>6 (OR=1.47; 95%CI 1.02-2.11), WHO grade>2 (OR=2.74; 95%CI 1.22-6.15), and upper-limb location (OR=5.26; 95%CI 2.13-12.84). DISCUSSION: The present study confirmed that more than half of patients with long-bone metastasis are operated on at actual fracture stage, in agreement with the literature. Several studies highlighted the weakness of the Mirels score as a predictive instrument. Comparison between preventive and fracture-stage surgery showed that upper-limb location, intense pain, advanced age and impaired functional status were associated with fracture-stage surgery, and should be taken into account alongside the original Mirels criteria. This improved scoring instrument remains to be validated in a prospective study. LEVEL OF EVIDENCE: IV, prospective cohort study without control group.

Surgical treatment of tibial metastases: Retrospective, multicenter, observational study of 25 patients.

INTRODUCTION: Long bone metastasis to the tibia is somewhat rare and has only been studied in a few publications with a limited number of cases. This led us to carry out a large multicenter, observational, retrospective study to 1) evaluate the clinical and radiological outcomes of surgical treatment at this location and 2) highlight the specific risks associated with this condition. HYPOTHESIS: We hypothesized that the clinical outcomes and survivorship were comparable to those reported in the literature. MATERIAL AND METHODS: The case series included 15 men and 10 women with a mean age of 66±11.7 years. The most common primary cancers were kidney (10 patients) and lung (4 patients). Thirteen patients had a concurrent visceral metastasis and sixteen had metastasis in another bone. The tibial metastasis was the initial sign of cancer in seven patients. The surgical procedure was done to prevent an impending fracture in 19 patients and to treat a pathological fracture in 6 patients (initial sign of cancer in 4 patients). Osteolysis occurred in the proximal epiphysis/metaphysis in 12 patients, diaphysis in 9 patients and distal epiphysis/metaphysis in 4 patients. We performed fixation with a lateral cortex plate and cementoplasty in 14 patients, locked intramedullary nailing in 8 patients, cementoplasty only in 2 patients and knee arthroplasty in 1 patient. RESULTS: Three surgical site infections, one pulmonary embolism and one cardiac rhythm disturbance occurred. Four patients died before the 3rd month postoperative. At their best clinical status, 2 patients had not resumed walking, 10 could walk short distances with two canes or a walker, 3 had altered gait but could walk without aids and 6 could walk normally. The mean survival was 14±11.7 months (95% CI: 8.1-19.8) for all patients, 4±4 months (95% CI: 3-14) for those with a lung primary and 32±14 months (95% CI: 20-47) for those with a kidney primary. The survival was 15 months (95% CI: 4-29) after preventative treatment and 5 months (95% CI: 4-26) after fracture treatment. CONCLUSION: Our clinical outcomes are comparable overall to the three main published articles on this topic. The risk of infection and benefits of preventative fixation were apparent in our cohort. LEVEL OF EVIDENCE: IV, retrospective study.

Influence of preoperative biological parameters on postoperative complications and survival in spinal bone metastasis. A multicenter prospective study.

INTRODUCTION: Onset of spinal bone metastasis is a turning point in the progression of tumoral disease; although incidence is increasing, management is not standardized. Various prognostic scores are available, but advances in medical and surgical treatment have made them less well adapted, and sometimes discordant for a given patient. It would therefore be useful to develop new prognostic instruments. The aim of the present study was to identify biologic risk factors for onset of postoperative complications and death following spinal bone metastasis surgery. MATERIAL AND METHODS: A prospective multicenter study included all patients operated on for spinal bone metastasis between November 2015 and May 2017. The main epidemiologic data and biologic data (CRP, albuminemia, calcemia) were collected preoperatively. Surgical strategy, death and/or postoperative complications were collected prospectively. RESULTS: Five of the initial 264 patients died during the immediate postoperative course, and 107 within 6 months. At 1 year, 57 patients remained alive. Twenty-six (10%) were lost to follow-up. Preoperative albuminemia<35g/L (29% of patients), calcemia>2.6 nmol/L (8%) and CRP>10mg/L (47.5%) were associated with significantly elevated mortality. Only CRP elevation correlated with postoperative complications rate. CONCLUSION: The study confirmed the prognostic value of 3 biologic parameters (CRP level, albuminemia, calcemia) for survival after spinal bone metastasis surgery. A hybrid score taking account of not only clinical but also biologic parameters should be developed to improve estimation of survival.

Surgical treatment of peri-acetabular metastatic disease: Retrospective, multicentre study of 91 THA cases.

INTRODUCTION: The occurrence of peri-acetabular metastasis (PAM) is a turning point in the progression of cancer because the disabling pain prevents the patient from walking or makes it difficult. Recent progress in controlling cancers that spread to the bone and controlling local bone destruction justify this national study. Since the data in France is incomplete or based on small studies, we analysed a multicentre retrospective cohort of patients with PAM who underwent total hip arthroplasty (THA) to evaluate 1) the clinical and radiological outcomes and 2) the factors impacting patient survival. HYPOTHESIS: The clinical outcomes, complication rate and survivorship are comparable to that of recent published studies. METHODS: Ninety-one patients (27 men, 64 women) with a mean age of 62.7±10.5 years (extremes 38 and 88) with PAM secondary to breast cancer [42 patients (46%)] or lung cancer [20 patients (22%)] underwent THA. The metastasis was the first sign of cancer in 33 cases (36%). Concurrent visceral metastases were present in 30 patients (33%), multiple peripheral bone metastasis in 48 patients (53%) and synchronous spine metastasis in 39 patients (43%). The most common construct was a cemented stem with metal reinforcement cage and cemented dual mobility cup [71 times (78%), while 85/91 had a dual mobility cup (93%)]. RESULTS: Elimination or reduction of pain was reported in 81 patients (91%). Overall walking ability was deemed normal or acceptable in 74 patients (83%). Six patients died (7%) before the end of the 3rd month. There were seven general complications (8%) including five thromboembolic events. There were 22 complications related to the surgical procedure in 20 patients (22%) that required surgical revision, including 10 surgical site infections (11%) and 3 dislocations (3%) (one concerning a dual mobility cup and 2 after single mobility cup). The median survivorship all causes combined was 19.5 months; it was 23.7 months for patients with breast cancer and 8.9 months for those with lung cancer. CONCLUSION: Despite different endpoints being used, the clinical outcomes in our study are like those in other published studies, as were the incidence of surgery-related complications and the survivorship. The recommended surgical technique is the implantation of an acetabular reinforcement cage, curettage with cement filling of osteolytic areas, dual mobility cup and cemented stem followed by radiation therapy. The role of THA versus interventional radiology procedures must still be determined. LEVEL OF EVIDENCE: IV, retrospective study without control group.

Retrospective, multicenter, observational study of 112 surgically treated cases of humerus metastasis.

INTRODUCTION: The humerus is the second most common site for metastasis in the peripheral skeleton. These humeral metastases (HM) occur in the midshaft in 42% to 61% of cases and theproximal humerus in 32% to 45% of cases. They are often secondary to primary breast (17-31%), kidney (13-15%) or lung (11-24%) cancer. The optimal surgical treatment between intramedullary (IM) procedures, fixation or arthroplasty is still being debated. HYPOTHESIS: We hypothesized that fixation and/or arthroplasty are safe and effective options for controlling pain and improving the patients' function. MATERIALS AND METHODS: Between 2004 and 2016, 11 French hospitals included 112 continuous cases of HM in 54 men (49%) and 57 women (51%). The average age was 63.7±13.4 years (30-94). The HM occurred in the context of primary breast (30%), lung (23%) or kidney (21%) cancers. The HM was proximal in 35% of cases, midshaft in 59% and distal in 7% of cases. Surgery was required in 69% of patients because of a pathological fracture. The surgical procedure consisted of bundle pinning, plate fixation, arthroplasty or locked IM nailing in 6%, 11%, 14% and 69% of patients, respectively. RESULTS: Seven patients (6%) had to be reoperated due to surgical site complications including two infections and four fractures (periprosthetic or away from implant). Twelve patients (11%) experienced a general complication. The overall survival was 16.7 months, which was negatively and significantly impacted by the occurrence of a fracture, a diaphyseal location and the type of primary cancer. At the final assessment, 75% had normal or subnormal function and more than 90% were pain-free or had less pain. The final function was not related to the occurrence of a fracture or etiology of the metastasis. In epiphyseal and metaphyseal HM, there was a trend to better function after shoulder arthroplasty than after plate fixation or IM nailing. CONCLUSIONS: Our initial hypothesis was confirmed. Our findings were consistent with those of other published studies. Based on our findings, we recommend using static locked IM nailing with cementoplasty for mid-shaft lesions and modular arthroplasty for destructive epiphyseal or metaphyso-epiphyseal lesions. The criteria for assessing humeral fracture risk should be updated to allow the introduction of a preventative procedure, which contributes to better survival. LEVEL OF EVIDENCE: IV, retrospective study.

Surgical management of proximal femoral metastasis: Fixation or hip replacement? A 309 case series.

INTRODUCTION: The proximal femur is the most frequent operative site for metastasis, but there is no consensus between internal fixation and hip replacement. The present multicenter retrospective observational study sought: (1) to compare early clinical results between internal fixation and hip replacement for proximal femoral metastasis (PFM), and (2) to assess events affecting survival. HYPOTHESIS: The study hypothesis was that internal fixation and hip replacement give comparable clinical results, operative site complications rates and survival. MATERIAL AND METHODS: The series comprised 309 cases, 10 of which were bilateral, in 182 females and 117 males, with a mean age of 67.2±11.5 years and 62.5±13.2 years, respectively. Primaries were mainly breast (118; 38.2%), lung (85; 25.5%) or kidney (40; 12.9%). PFM was revelatory in 114 cases (36.9%). There was visceral involvement in 142 patients (46%), multiple peripheral bone involvement in 212 (68.6%), and spinal involvement in 134 (43.4%). There were 124 pathologic fractures (40%), 51 of which were revelatory. Metastases were cervicocephalic in 135 cases (43.7%), metaphyseal in 166 (53.7%) and both in 8 (2.6%). PFM was osteolytic in 90% of cases, managed by hip replacement in 161 cases and internal fixation in 148 (12 screwed plates, 136 nails). Seventy-seven patients had postoperative radiation therapy. RESULTS: After hip replacement (n=144), walking was normal in 35 cases (24.3%), impaired but unassisted in 53 (36.8%), with 1 forearm crutch in 24 (16.6%), 2 crutches or a frame in 26 (18%), and impossible in 6 (4.1%). After nailing (n=125), results were respectively 38 (30.4%), 47 (37.6%), 15 (12%), 18 (14.4) and 7 (5.6%). Recovery of normal walking capacity did not significantly differ according to technique (p=0.162); nor did pain or function. Recovery of normal walking capacity was better after preventive surgery (p<0.001). Perioperative complications comprised: 10 cases of severe blood loss, 7 pulmonary embolisms, 6 digestive hemorrhages, and 5 lung infections. Secondarily, there were 11 infections (7 after hip replacement, 2 after nailing, 2 after plate fixation), 7 progressive osteolyses and 5 fractures. Complications rates were significantly higher with plate fixation, with no difference between nailing and hip replacement. Survival did not significantly differ between hip replacement (12 months [95% CI: 7-19]), nailing (7 months [95% CI: 6-11]) and plate fixation (16 months [95% CI: 6-not calculable]). CONCLUSIONS: Clinical results and survival were comparable between hip replacement and nailing, confirming the study hypothesis, in agreement with the literature. Each technique has its indications. Patients with severely impaired walking capacity benefited greatly from surgery. The importance of preventive surgery was highlighted. LEVEL OF EVIDENCE: IV, retrospective study.

Functional results and survival after surgery for peripheral skeletal metastasis: A 434-case multicenter retrospective series.

INTRODUCTION: Peripheral skeletal metastasis (PSM) has a negative impact on quality of life. New treatments for the primary tumor or the osteolysis hold out hope of improved survival. The few published French series were small, and we therefore undertook a multicenter retrospective analysis of PSM surgery between 2005 and December 2016, with the aim of assessing: 1) rate and type of complications, 2) functional results, and 3) overall survival and corresponding risk factors. HYPOTHESIS: The French data for clinical results, survival and complications are in agreement with the international literature. MATERIALS AND METHOD: The series comprised 391 patients with 434 metastatic locations. There was female predominance: 247 women (63%). Two sites were treated in 46 patients (12%), and three in 5. The main etiologies were breast cancer (151/391: 39%), lung cancer (103/391: 26%) and kidney cancer (52/391: 13%). There was synchronous visceral metastasis in 166 patients (42.5%), other peripheral locations in 137 (35%) and spinal location in 142 (39%). One hundred (27%) had ASA score>3; 61 (16%) had WHO score>3. The reason for surgery was pathologic fracture (n=137: 35%). Locations were femoral (274: 70%), acetabular (58: 15%), humeral (40: 0%), tibial (12: 3%) or other (7: 2%). RESULTS: There were surgery site complications in 41 patients (9.4%), including 13 surgery site infections, and general complications in 47 patients (11%), including 11 cases of thromboembolism, 6 of blood loss, 9 pulmonary complications and 6 perioperative deaths. Overall survival, taking all etiologies and sites together, was 10 months (range, 5 days to 9 years; 95% CI, 8-13 months), and significantly better in females (14 versus 6 months; p=0.01), under-65 year-olds (p=0.001), and in preventive surgery versus fractured PSM (p=0.001). Median survival was 22 months (95% CI, 17-28 months) after breast cancer, 3 months (95% CI, 2-5 months) after lung cancer, and 17 months (95% CI, 8-58 months) after kidney cancer. Preoperatively, walking was impossible for 143 patients (38%), versus 23 (6.5%) postoperatively; 229 patients (63.5%) could walk normally or nearly normally after surgery, versus 110 (28%) before. After surgery, 3 patients (6%) were not using their operated upper limb, versus 27 (45%) before; 30 patients (54%) had normal upper limb use after surgery, versus 8 (5%) before. CONCLUSION: The study hypothesis was on the whole confirmed in terms of survival according to type of primary and whether surgery was indicated preventively or for fracture. LEVEL OF EVIDENCE: IV, retrospective study without control group.

Case reports: lengthening of a vascularized free fibular graft.

Wide bone resection is sometimes necessary for bone tumors, and reconstruction is a major challenge. Vascularized fibular graft is one alternative but may result in progressive limb-length discrepancy (LLD) in children with substantial growth left. Progressive distraction lengthening with an external fixator is now a standard procedure to generally correct LLD. However, lengthening of free vascularized fibular grafts for lower limb reconstruction has not been reported frequently and then only in small series or case reports. We report our experience with three patients with lengthening after tibial reconstruction with a free vascularized fibular graft and review the literature.

Slotted acetabular augmentation, alone or as part of a combined one-stage approach for treatment of hip dysplasia in adolescents with cerebral palsy: results and complications in 19 hips.

BACKGROUND: Surgical correction for the challenging combined deformities in hip dysplasia associated with cerebral palsy remains controversial. The purpose of this study was to assess the efficacy and determine the role of slotted acetabular augmentation (SAA) for the treatment of neuromuscular hip dysplasia in comparison with other treatment options. METHODS: We retrospectively analyzed 19 dysplastic hips in 19 patients with cerebral palsy who underwent SAA, alone or as part of a combined 1-stage approach, consisting of soft tissue lengthening and/or a proximal femoral osteotomy, during a 20-year period. RESULTS: The mean age at the time of operation was 14 years and 7 months (range: 12 to 17 years and 11 months). All had a closed triradiate cartilage. In 13 hips, preoperative radiographs showed major aspheric femoral head deformities. All had subluxation or dislocation of the hip and severe acetabular dysplasia, associated with a painful hip in 15 patients. Before operation, the mean migration index was 64+/-18%, the mean Sharp angle was 51+/-4 degrees, and the mean center-edge angle was -4+/-13 degrees. On immediate postoperative radiographs, they were 3+/-5%, 35+/-5 degrees, and 42+/-11 degrees. At final follow-up, the average migration index was 10+/-8%, the mean Sharp angle was 35+/-6 degrees, and the mean center-edge angle was 39+/-13 degrees. Eleven hips required soft tissue lengthening and 5 hips had a proximal femoral osteotomy at the time of the shelf procedure. At the latest follow-up (mean duration: 5 years and 5 months), 16 of the 19 hips remained anatomically reduced. CONCLUSIONS: Our results suggest that SAA is a successful procedure to treat advanced neurogenic acetabular dysplasia with or without femoral head deformities in skeletally mature patients.

En Bloc Resection of Thoracic Tumors Invading the Spine: A Single-Center Experience.

BACKGROUND: Vertebral involvement by a thoracic tumor has long been considered as a limit to surgical treatment, and despite advances, such an invasive operation remains controversial. The aim of this study was to characterize a single-center cohort and to evaluate the outcome, focusing on survival and complications. METHODS: We retrospectively reviewed the data of all patients operated on for tumors involving the thoracic spine in an 8-year period. En bloc resection was generally performed by a double team involving thoracic and orthopedic surgeons. Distant follow-up was recorded for oncologic and functional analysis. RESULTS: There were 31 patients operated on. An induction therapy was administered in 20 patients. Spinal resection (mostly including ≥2 vertebral levels) was combined with lobectomy in 48.3% of the patients, and osteosynthesis was required in 22 patients. We observed no in-hospital death and a major complications rate of 32.3%, including 5 patients with early neurologic complications. There were 61.3% primary lung carcinomas, 12.9% extrapulmonary primaries, 9.7% metastases, and 16.1% benign tumors. Mean follow-up was 32.1 months. The 5-year overall survival rate was 81.3% in the entire cohort and 75.0% in patients with a malignant tumor. Occurrence of an early postoperative major complication was the only factor significantly associated with shorter overall survival (p = 0.03). The 5-year disease-free survival rate was 37.0% in malignancies. Delayed complications occurred in 35.5% of patients, including persistent neurologic deficit in 12.9%, instrumentation migration in 19.4%, and local infection in 12.9%. CONCLUSIONS: En bloc resection of spinal thoracic tumors offers long-term survival and few recurrences in highly selected patients but is associated with significant delayed mechanical or infectious complications.

rhBMP-2 (Recombinant Human Bone Morphogenetic Protein-2) in real world spine surgery. A phase IV, National, multicentre, retrospective study collecting data from patient medical files in French spinal centres.

BACKGROUND: This is a Phase IV, national, multicentre, retrospective study to observe the real-world use of rhBMP-2 in France. HYPOTHESIS: There was no statistical hypothesis, the statistical analyses were descriptive in nature. PATIENTS AND METHODS: Data was collected from patient medical files in 10 French spinal centres. Primary objectives were to understand which patients were treated with rhBMP-2, commercialised in Europe as InductOs™ and how rhBMP-2 was used during spinal fusion surgery in France between 2011 and 2012. RESULTS: Four hundred patients (634 levels) treated with rhBMP-2 were included in the analysis. The most frequent primary diagnostic indication for rhBMP-2 use was degenerative disc disease (DDD; 129/400; 32.3% of patients) followed by spondylolisthesis (119/400; 29.8%), deformity (59/400; 14.8%) and pseudoarthrosis (29/400; 7.3%). The most frequently treated level was L4-L5 (33.8% of levels in 53.5% of patients); followed by L5-S1 (29.8%, 47.3%), L3-L4 (16.7%, 26.5%), and L2-L3 (7.3%, 11.5%), all other levels (less than 5% of patients). No interbody fusion device was used in 42.7% of levels. Wetted matrix of rhBMP-2 was placed in the interbody space in 58.4% of levels (370/634). The most common procedure for rhBMP-2 treatment was posterior lumbar fusion (PLF) (221/634; 34.9% of levels), followed by anterior lumbar interbody fusion (ALIF) (188/634; 29.7%), posterior lumbar interbody fusion (PLIF) (111/634; 17.5%), lateral lumbar interbody fusion (LLIF) (106/634; 16.7%), transforaminal lumbar interbody fusion (TLIF) (4/634; 0.6%) and 'other' (4/634; 0.6%). Thirty-one adverse events of Interest (AEI) were recorded in 27 patients. One AEI was considered related to rhBMP-2. Unplanned secondary spine interventions at index level treated with rhBMP-2 were required in 4 patients. DISCUSSION: In years 2011 and 2012 when the surgeries captured in this retrospective study were done, rhBMP-2 was indicated for single level (L4-S1) anterior lumbar spine fusion as a substitute for autogenous bone graft in adults with DDD. The most common procedure for the treatment with rhBMP-2 was PLF (off-label use), followed by ALIF (on-label use). The safety findings confirm a predictable and manageable safety profile. LEVEL OF EVIDENCE: IV.