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We report the case of a 28-year-old female who complained of groin pain and restricted range of motion of the hip for the previous two months. A plain radiograph, CT scan and MRI of the pelvis showed a bone mass of uncertain origin around the lesser trochanter, simulating malignancy. An open biopsy was performed to obtain a correct diagnosis. The histological examination excluded a malignant lesion. Two months later, the mass was surgically excised and at follow-up, 9 years after surgery, the patient was completely asymptomatic, without any radiographic sign of recurrence. This is a rare case of heterotopic ossification of the proximal part of the femur, that appeared without any significant trauma or other predisposing risk factors; because the lesion led us to suspect a malignant disease, an open biopsy was needed to make the diagnosis. From an accurate review of the literature, heterotopic ossifications mimicking a malignant lesion that appeared without any predisposing factors are extremely rare., (Copyright 2020 Biolife Sas. www.biolifesas.org.)

Background: Limb lengthening using an external fixator requires a long period of external fixation and may be associated with several complications such as axial deformity, fracture of the regenerated bone, and joint stiffness. With the goal of reducing the time of external fixation as well as some of these complications, we performed femoral or tibial lengthening over an intramedullary nail, according to Paley's technique, in 28 patients, followed up after a mean period of 8 years., Materials and Methods: Twenty-eight patients treated for lower limb discrepancy by limb lengthening over an intramedullary nail were reviewed from 5 to 11 years after healing of regenerated bone. There were 20 femurs and 8 tibiae, with average age at surgery of 14.2 years and average length inequality of 6.1 cm for femurs and 5.3 cm for tibiae., Results: The mean lengthening was 5.8 cm for femurs and 4.8 cm for tibiae. The mean period of radiographic consolidation of the regenerated bone was 6 months for femoral lengthening and 4.5 months for tibial lengthening. At follow-up, we observed 8 excellent results, 15 good results, 4 fair results, and 1 poor result, based on Paley's evaluation criteria. The main complications were one deep infection, one nonunion of the distracted segment, one breakage of the distal fiche of the external fixator, and one breakage of both distal locking screws of the intramedullary nail., Discussion: We believe that limb lengthening over an intramedullary nail still represents a good method to treat limb length discrepancy because it reduces the time of external fixation, prevents axial deformities and fractures of regenerated bone, and allows early rehabilitation. The new intramedullary lengthening nails, which theoretically are the ideal device for treating limb length inequality, are still very expensive and need longer follow-up for definitive evaluation., Level of Evidence: 4.

Background: In polyostotic fibrous dysplasia (PFD) affecting the femur, 6 types of stable femoral deformities have been identified, ranging from the mild type 1 to the most severe type 6. The purpose of our study was to identify the type of deformity present at diagnosis in children with PFD affecting the femur, and to investigate possible changes in the original type with growth., Methods: Twenty-seven children affected by either PFD or McCune-Albright syndrome, with 46 affected femurs, were consecutively observed from 1994 to 2010. Radiographs of the pelvis and femurs were taken at diagnosis, and afterward at regular intervals of 6 to 12 months depending on the clinical evolution of each case. Radiographs of the femurs taken at 3 and 7 years after diagnosis were selected to assess the evolution of the femoral deformity. Deformities were classified according to the femoral shape, neck-shaft angle value, and the presence of shepherd's crook deformity evaluated on AP radiographs., Results: The average age of the patients at diagnosis was 5 years (range, 2 to 11 y). At diagnosis, 30 femurs were type 1; 12, type 2; 1, type 3; 1, type 4; and 2, type 5. Three years later, 39% of the femurs had maintained the original deformity present at diagnosis, whereas only 13% did so 7 years after diagnosis.Predictors of change to a more severe type were: younger age at diagnosis, McCune-Albright syndrome, rapid spreading of fibrodysplastic tissue from the trochanteric area to the proximal femoral shaft, cortical thinning of the proximal femur, calcar osteolysis, and presence of an intertrochanteric cystic-like lesion eroding the calcar., Conclusions: In children with PFD affecting the femur, 61% of the femoral deformity present at diagnosis switched to a more severe type of deformity within 3 years from diagnosis, whereas 87% either shifted to a more severe type of deformity or already had corrective surgery within 7 years after diagnosis., Level of Evidence: Level IV.

Background: In patients with polyostotic fibrous dysplasia with extensive femoral involvement, severe coxa vara may cause complex femoral deformities that are difficult to treat with a single-stage surgical procedure. We evaluated the results of treatment of such patients with a two-stage procedure., Methods: Eleven patients with polyostotic fibrous dysplasia and severe coxa vara (including one who required bilateral treatment and one who required repeat treatment) were treated surgically at a mean age of fourteen years and four months. A two-stage surgical procedure was planned to correct the deformity. The first stage involved correction of the coxa vara and fixation with a hip plate. The second stage involved correction of a shepherd's crook deformity if present and definitive fixation with an interlocking cervicodiaphyseal nail. All patients were evaluated clinically and radiographically at a mean of four years and seven months after the second-stage procedure., Results: The femoral neck-shaft angle averaged 83° before surgery and was corrected to a mean of 130° after the first-stage procedure. In two patients, cutout of the hip screw-plate caused acute postoperative loss of correction (by 40° in one patient and 20° in the other). After the second-stage procedure, the neck-shaft angle was either fully corrected or improved and the shepherd's crook deformity was fully corrected in all patients. At the time of the latest follow-up, the mean neck-shaft angle was 124°, with a mean loss of correction of 5° relative to the angle measured at the end of the second-stage procedure. The mean estimated blood loss was 625 mL in the first stage and 979 mL in the second., Conclusions: The two-stage surgical procedure designed to treat patients with polyostotic fibrous dysplasia with complex femoral deformity and severe coxa vara restored a nearly normal femoral alignment that was maintained at a mean of four years and seven months of follow-up. The clinical benefits were pain relief in all of the patients and gait normalization or improvement in most. The estimated blood loss was substantial in both stages., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence., (Copyright © 2015 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Fibrous dysplasia of bone is a skeletal dysplasia with a propensity to affect the femur in its polyostotic form, leading to deformity, fracture, and pain. The proximal femur is most commonly involved with a tendency to distal progression, thereby producing the typical shepherd's crook deformity. However, there are few data on the spectrum and progression of femoral deformities in polyostotic fibrous dysplasia., Questions/purposes: The purposes of this study were (1) to develop a radiographic classification for polyostotic fibrous dysplasia; (2) to test this classification's intra- and interobserver reliability; and (3) to characterize the radiographic progression of polyostotic fibrous dysplasia in a population of patients with the condition who were treated with a variety of approaches at several centers., Methods: We retrospectively reviewed radiographs of 127 femurs from 84 adult patients affected by polyostotic fibrous dysplasia. Fifty-nine femurs had undergone one or more operations. The radiographs were evaluated in the coronal plane for neck-shaft angle and angular deformities along the whole femoral shaft down to the distal epiphysis. Four observers evaluated each film two times at intervals; intra- and interobserver reliability testing was performed using the kappa statistic. Eighty-nine femurs (70%) were available for followup to evaluate for progression at a mean of 10 years (range, 6-20 years)., Results: Six reproducible patterns of deformity were identified in both untreated and operated femurs: type 1 (24%), normal neck-shaft angle with altered shape of the proximal femur; type 2 (6%), isolated coxa valga with neck-shaft angle > 140°; type 3 (7%), isolated coxa vara with neck-shaft angle < 120°; type 4 (20%), lateral bowing of the proximal half of the femur associated with normal neck-shaft angle; type 5 (14%), like in type 4 but associated with coxa valga; and type 6 (29%), like in type 4 but associated with coxa vara. Interobserver and intraoberver kappa values were excellent, ranging from 0.83 to 0.87. In 46 of the 89 femurs (52%) for which longitudinal radiographic documentation was available, there was progressive worsening of the original deformity, although the pattern remained the same; types 1 and 2 tended not to progress, whereas types 3 to 6 did., Conclusions: A reproducible radiographic classification of polyostotic fibrous dysplasia-associated femoral deformities is proposed, which can serve as a tool for assessing and treating these deformities. After reviewing the radiographs of 127 femurs, we identified six reproducible patterns of femoral deformities., Level of Evidence: Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.