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Background: Owing to recent advances in cancer therapy, updated data are required for clinicians counselling patients on treatment of spinal metastases.Objective: To analyse the outcomes of surgical treatments of spinal metastases.Methods: Prospective and multicentric study that included consecutively patients operated on for spinal metastases between January 2016 and January 2017. Overall survival was calculated with the Kaplan-Meier method. Cox proportional hazard model was used to calculate hazard ratio (HR) analysing mortality risk according to preoperative Karnofsky performance status (KPS), mobility level and neurological status.Results: A total of 252 patients were included (145 males, 107 females) aged a mean 63.3 years. Median survival was 450 days. Primary cancer sites were lung (21%) and breast (19%). Multiple spinal metastases involved 122 patients (48%). Concomitant skeletal and visceral metastases were noted in 90 patients (36%). Main procedure was laminectomy and posterior fixation (57%). Overall, pain and mobility level were improved postoperatively. Most patients had normal preoperative motor function (50%) and remained so postoperatively. Patients "bedbound" on admission were the less likely to recover. In-hospital death rate was 2.4% (three disease progression, one septic shock, one pneumonia, one pulmonary embolism). Complication rate was 33%, deep wound infection was the most frequent aetiology. Higher mortality was observed in patients with poorest preoperative KPS (KPS 0-40%, HR = 3.1, p < 0.001) and mobility level ("bedbound", HR = 2.16, p < 0.001). Survival seemed also to be linked to preoperative neurological function.Conclusion: Surgical treatments helped maintain reasonable condition for patients with spinal metastases. Intervention should be offered before patients' condition worsen to ensure better outcomes. [ABSTRACT FROM AUTHOR]

The correct name of F. Saihlan should be F. Sailhan. [ABSTRACT FROM AUTHOR]

The aim of this paper is to present a unique, to the best of our knowledge, case of a patient with a fracture of the first lumbar vertebra (L1), which occurred through a pre-existing Schmorl's node (SN), with histopathological characteristics mimicking a low-grade chondrosarcoma that initially led to a false diagnosis. A 54-year-old woman tripped and fell to the ground, sustaining a fracture of the L1 vertebral body. She was treated conservatively with gradual mobilization using a thoracolumbar brace for six weeks. Due to persistent pain and her inability to achieve full mobilization, she was offered vertebral kyphoplasty. During the same operative session and just before the kyphoplasty, she underwent a core-needle biopsy of the affected area. Following her operation, she reported a gradual, yet quick and full remission of her symptoms. The pathology report indicated findings consistent with a low to mid-grade chondrosarcoma. A re-evaluation of the specimen by a different pathologist confirmed the diagnosis of low-grade chondrosarcoma. Subsequently, she underwent full oncological staging, which was negative for metastases. Additional imaging studies failed to show signs of local disease progression. Due to the discordance between the pathology reports and the imaging and clinical findings, her case was referred to our specialized center for spinal tumor surgery. A new pathological re-evaluation of the biopsy samples was performed, and the diagnosis of low-grade chondrosarcoma was once again confirmed. However, during the multidisciplinary tumor (MDT) meeting that followed, and after careful evaluation of subsequent imaging studies that showed signs of local improvement and due to the complete lack of symptoms, the histopathological findings were re-evaluated and attributed to the fracture occurring through a pre-existing SN penetrating the cancellous bone of the vertebra. This complex situation contributed to histopathological findings consistent with a well-differentiated chondrosarcoma. The patient remains symptom-free 10 months following her operation and has fully returned to her previous activities. Our unique case highlights the importance of an MDT meeting when evaluating patients with musculoskeletal tumors and emphasizes the need for increased awareness when clinical findings and imaging studies are in discordance with histopathology reports., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Papavasiliou et al.)

Purpose: To describe the technique and review the oncological and surgical results of the En Bloc resection assisted by retroperitoneal laparoscopy in a single prone position for tumors in the thoracolumbar region., Methods: Monocentric retrospective case study. Procedure was performed in a single prone position by a dual team of spine and thoracovascular surgeons. An endoscopic balloon was inflated in the right retroperitoneal cavity. A plan was developed between the anterior spine and vena cava as well as abdominal aorta with segmental vessels ligation. Structures at risk were safely protected under endoscopy during horizontal or sagittal osteotomies., Results: From 2021, seven patients aged a median 52 years old (range, 34-67) were included. Involved spinal segments went from T11 to L3. Surgery was aborted in one case due to massive bleeding and ventilating difficulties. There were two partial and four total vertebral resections. Median operating duration and estimated blood loss were 405 min (range, 360-540) and 2.1 L (range, 1.2-19), respectively. Postoperative complications consisted of 1 urinary infection; 1 transient urinary retention; 1 posterior wound infection; 1 pneumothorax; 1 persistent partial motor deficit; 1 transient confusion; 1 pulmonary embolism; 1 CSF leak; 1 subdural hematoma; 1 retroperitoneal lymphocele. All margins were uncontaminated. All patients were alive and ambulatory at last follow-up., Conclusion: Early results suggest En Bloc resection assisted by retroperitoneal videoscopy in tumors from T11 to L3/4 disk space is feasible, less invasive and safe. Careful surgical planning and experience in endoscopic vascular surgery are mandatory., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

The paraspinal region encompasses all tissues around the spine. The regional anatomy is complex and includes the paraspinal muscles, spinal nerves, sympathetic chains, Batson's venous plexus and a rich arterial network. A wide variety of pathologies can occur in the paraspinal region, originating either from paraspinal soft tissues or the vertebral column. The most common paraspinal benign neoplasms include lipomas, fibroblastic tumours and benign peripheral nerve sheath tumours. Tumour-like masses such as haematomas, extramedullary haematopoiesis or abscesses should be considered in patients with suggestive medical histories. Malignant neoplasms are less frequent than benign processes and include liposarcomas and undifferentiated sarcomas. Secondary and primary spinal tumours may present as midline expansile soft tissue masses invading the adjacent paraspinal region. Knowledge of the anatomy of the paraspinal region is of major importance since it allows understanding of the complex locoregional tumour spread that can occur via many adipose corridors, haematogenous pathways and direct contact. Paraspinal tumours can extend into other anatomical regions, such as the retroperitoneum, pleura, posterior mediastinum, intercostal space or extradural neural axis compartment. Imaging plays a crucial role in formulating a hypothesis regarding the aetiology of the mass and tumour staging, which informs preoperative planning. Understanding the complex relationship between the different elements and the imaging features of common paraspinal masses is fundamental to achieving a correct diagnosis and adequate patient management. This review gives an overview of the anatomy of the paraspinal region and describes imaging features of the main tumours and tumour-like lesions that occur in the region., (© 2023. The Author(s).)

In young patients, lumbosacral fractures result primarily from high-energy traumas. Life-threatening lesions (e.g. visceral organs) are frequently associated with these fractures. Management consists of medical intensive care for adequate resuscitation and specialized surgical input. Lumbosacral junction represents a frontier between the spine and pelvic ring. Any injury in this area implies a thorough examination of both spine and pelvis through clinical examinations and CT scans. Patients must be assessed specifically for neurological and bladder/bowel symptoms. Several surgical classifications may be required to describe the entire fracture pattern. In unstable fracture with large displacements, definitive surgical fixation is often recommended. Various pelvic and spine surgery techniques can be used depending on the fracture pattern, surgeon's experience, and available equipment. The use of intraoperative navigation may enhance placement of instrumentation, especially in cases of complex fractures, percutaneous fixations, and/or atypical patients' anatomy. The fracture itself can cause debilitating complications with long-term consequences such as pain, neurological deficits, and bladder/bowel impairments. Wound infection remains the most common postoperative complication and prominent posterior instrumentation is frequently a source of pain. Irrespective of the treatment, leg discrepancy can be problematic in the case of malunion. Management of lumbosacral fractures requires a thorough understanding of both lumbar spine and pelvic injuries. Surgical treatment may involve a combination of spine and pelvic surgery techniques. Therefore, this implies for the surgeon to be trained specifically for these fractures, or else a close cooperation between the pelvic surgeon and the spine surgeon in managing the patients.

Purpose: To compare two teaching methods of a forearm cast in medical students through simulation, the traditional method (Trad) based on a continuous demonstration of the procedure and the task deconstruction method (Decon) with the procedure fragmenting into its constituent parts using videos., Methods: During simulation training of the below elbow casting technique, 64 medical students were randomized in two groups. Trad group demonstrated the entire procedure without pausing. Decon group received step-wise teaching with educational videos emphasizing key components of the procedure. Direct and video evaluations were performed immediately after training (day 0) and at six months. Performance in casting was assessed using a 25-item checklist, a seven item global rating scale (GRS Performance), and a one item GRS (GRS Final Product)., Results: Fifty-two students (Trad n = 24; Decon n = 28) underwent both day zero and six month assessments. At day zero, the Decon group showed higher performance via video evaluation for OSATS (p = 0.035); GRS performance (p < 0.001); GRS final product (p < 0.001), and for GRS performance (p < 0.001) and GRS final product (p = 0.011) via direct evaluation. After six months, performance was decreased in both groups with ultimately no difference in performance between groups via both direct and video evaluation. Having done a rotation in orthopaedic surgery was the only independent factor associated to higher performance., Conclusions: The modified video-based version simulation led to a higher performance than the traditional method immediately after the course and could be the preferred method for teaching complex skills., (© 2022. The Author(s) under exclusive licence to SICOT aisbl.)

Background: Simulation is among the tools used in France to train residents specialising in orthopaedic and trauma surgery (OTS). However, implementing simulation-based training (SBT) is complex and poorly reported. The objective of this study was to describe the use of simulation for OTS training in France., Hypothesis: Nationwide, SBT is not used to its full capacity for teaching OTS in France, and differences in opinions about SBT may exist between surgeon educators and residents., Study Design: Nationwide questionnaire survey in France., Materials and Methods: We built two specific self-questionnaires then e-mailed them between December 2020 and February 2021 to the surgeon educators who were members of the national university council and to the residents specialising in OTS during the current academic year. The questions were about the 2018-2019 academic year, before the COVID-19 pandemic. Two classes of residents who were still medical students during this period were not included, leaving three classes for the analysis., Results: The participation rates were 57% (67/117) for the educators and 24% (87/369) for the three classes of residents. Of the 67 educators, 47 (70%) reported being involved in SBT and identified the university (70%) and industry (53%) as the main funders of this teaching modality. The educators indicated that the mean number of SBT laboratories in their region was 1.4±0.9 (range, 0-4). The main types of simulators were saw bones (77%); cadavers (85%); and commercial simulators (74%), notably for the knee (87%) and shoulder (78%). The educators estimated that they had achieved a mean of 33%±23% (range, 0%-100%) of the teaching objectives set out in the OTS curriculum and that the main obstacles were insufficient funding (81%) and lack of time (67%). Only 21% of educators reported conducting SBT research. The residents reported that they accessed SBT via the OTS teaching module (28/87, 32%), local university degrees (23/87, 26%), their hospital department (17/87, 18%), or the industry (15/87, 17%); 25/87 (29%) had never received SBT. On a 0-10 scale (0, completely disagrees; 10, completely agrees), the mean score for SBT effectiveness was 8.6±2.1 for residents and 7.1±3.0 for educators (p<0.001); the corresponding values for the quality of SBT integration in the region were 1.5±1.8 and 3.8±2.6, respectively (p<0.001)., Conclusion: SBT is not yet used to its full potential for teaching OTS in France. Insufficient funding and lack of time were identified by the educators as the main obstacles to greater use of SBT. Both the residents and the educators felt that SBT mightbe beneficial for training., Level of Evidence: IV, nationwide survey., (Copyright © 2022. Published by Elsevier Masson SAS.)

Purpose: Bone healing in femoral reconstructions using intercalary allografts can be compromised in a tumour context. There is also a high revision rate for non-union, infection, and fractures in this context. The advantages and disadvantages of an associated vascularised fibula graft (VFG) are still a matter of debate., Methods: In a multicentre study, we retrospectively analysed 46 allograft reconstructions, operated on between 1984 and 2017, of which 18 were associated with a VFG (VFG+) and 28 without (VFG-), with a minimum follow-up of 2 years. We determined the cumulative probability of bone union as well as the mid- and long-term revision risks for both categories by Kaplan-Meier survival analysis and a multivariate Cox model. We also compared the MSTS scores., Results: Significant differences in favour of VFG+ reconstruction were observed in the survival analyses for the probability of bone union (log-rank, p = 0.017) and in mid- and long-term revisions (log-rank, p = 0.032). No significant difference was observed for the MSTS, with a mean MSTS of 27.6 in our overall cohort (p = 0.060). The multivariate Cox model confirmed that VFG+ was the main positive factor for bone union, and it identified irradiated allografts as a major risk factor for the occurrence of mid- and long-term revisions., Conclusion: Bone union was achieved earlier in both survival and Cox model analyses for the VFG+ group. It also reduced the mid- and long-term revision risk, except when an irradiated allograft was used. In case of a tumour, we thus recommend using VFG+ from a fresh-frozen allograft, as it appears to be a more reliable long-term option., (© 2022. The Author(s).)

Introduction: For prolonged survival, primary malignant sacral tumors (PMST) are treated by En Bloc sacrectomy. Few studies analyzed specifically the surgical site infections (SSI) for this condition and whether they impact on the patients' survivals., Objectives: The objectives were to (1) describe their characteristics; (2) compare the survivals of infected and non-infected patients; (3) identify patients- and surgery-related risk factors., Methods: We conducted a retrospective single center study on 51 consecutive patients with PMST who underwent an En Bloc sacrectomy. Mean follow-up was 89±68months (range, 13-256months). Histology consisted of 46 chordoma, 3 chondrosarcoma, 1 Ewing tumor, 1 malignant peripheral nerve sheet tumor. Mean age was 57.4±13.7years with 26 (51%) male. Approaches were mainly anterior-and-posterior with, for the anterior approach, 18 laparotomy and 32 laparoscopy. Other surgical characteristics included 39 (76%) sacrectomy above S3; 7 (14%) instrumented cases; 8 (16%) colostomy. A pedicled omental flap with artificial mesh was used for posterior wall reconstruction. Overall and disease-free survivals were compared between infected and non-infected patients using Kaplan-Meier curves and log-rank test., Results: A total of 29 (57%) patients developed a SSI (7 deep, 22 organ/space) at mean 13.2±7.7days. One patient had also an infected intraperitoneal hematoma at day 150. SSIs were polymicrobial in 26 (90%) cases with Enterococcus sp. (27%) and E. coli (24%) as predominant organisms. Overall and disease-free survivals were not statistically different between infected and non-infected patients. Factors associated with increased likelihood of SSI included age>65years (OR=3.64; 1.06-12.50; p=0.04) and an elevated ASA score (OR=3.28, 1.05-10.80; p=0.046). Neoadjuvant radiotherapy (OR=2.86; 0.97-9.37; p=0.08) demonstrated a trend towards increased risk of SSI. Tumor volume, sacrectomy level, operating time, laparoscopy, colostomy, instrumentation, bowel incontinence were not associated to an increased risk of SSI., Conclusion: En Bloc sacrectomy for PMST led to frequent and early SSI which, however, did not seem to impact survivals. Preoperative frailty was the predominant risk factor found in this series. Further studies are required to identify protective measures., Level of Evidence: III, case-control study., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

Introduction: Expandable endoprostheses are used to restore limb function and compensate for the sacrifice physis involved in carcinologic resection. Long-term outcomes of the last generation of knee "non-invasive" expandable endoprostheses are required. Objectives were to report on oncologic results of bone sarcoma resection around the knee with expandable endoprosthesis reconstruction and to compare the surgical outcomes of the "non-invasive" expandable endoprostheses used in our department., Materials and Methods: Retrospective study that included all children with bone sarcoma around the knee that underwent tumor resection reconstructed with non-invasive expandable prosthesis. Phenix-Repiphysis was used from 1994 to 2008 followed by Stanmore JTS non-invasive from 2008 to 2016. Survival and complications were recorded. Functional outcomes included Musculoskeletal Tumor Society (MSTS) score, knee range of motion, lower limb discrepancy (LLD)., Results: Forty children (Sex Ratio = 1) aged a mean 8.8 years (range, 5.6-13.8) at surgery were included in the study. There were 36 osteosarcoma and 4 Ewing sarcoma that involved 33 distal femur and 7 proximal tibia. Cohort (n = 40) consisted of 28 Phenix-Repiphysis and 12 Stanmore with a mean follow-up of 9.8 ± 5.8 years and 6.1 ± 3.1 years, respectively. Postoperative infection rate was 7.5% in the cohort (3 Repiphysis). Functional results were significantly better in the Stanmore group with a mean MSTS of 87.6 ± 5.4% and knee flexion of 112 ± 38°. At last follow-up, implant survival was 100% in Stanmore group, whereas all living Phenix-Repiphysis were explanted. Mechanical failure was the primary cause for revision of Phenix-Repiphysis. Limb length equality was noted in 79% patients with Phenix-Repiphysis and 84% with Stanmore at last follow-up., Conclusion: Chemotherapy and limb-salvage surgery yield good oncologic outcomes. Expandable endoprostheses are effective in maintaining satisfactory function and lower limb equality. With improvements made in the last generation of "non-invasive" prostheses, implants' survival has been substantially lengthened., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH, DE part of Springer Nature.)

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., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Chordoma is a very rare, poorly known malignancy, with slow progression, mainly located in the sacrum and spine. All age groups may be affected, with a diagnostic peak in the 5th decade of life. Clinical diagnosis is often late. Histologic diagnosis is necessary, based on percutaneous biopsy. Specific markers enable diagnosis and prediction of response to novel treatments. New radiation therapy techniques can stabilize the tumor for 5 years in inoperable patients, but en-bloc resection is the most effective treatment, and should be decided on after a multidisciplinary oncology team meeting in an expert reference center. The type of resection is determined by fine analysis of invasion. According to the level of resection, the patients should be informed and prepared for the expected vesico-genito-sphincteral neurologic sequelae. In tumors not extending above S3, isolated posterior resection is possible. Above S3, a double approach is needed. Anterior release of the sacrum is performed laparoscopically or by robot; resection uses a posterior approach. Posterior wall reconstruction is performed, with an associated flap. Spinopelvic stabilization is necessary in trans-S1 resection. Total or partial sacrectomy shows high rates of complications: intraoperative blood loss, infection or mechanical issues. Neurologic sequelae depend on the level of root sacrifice. No genital-sphincteral function survives S3 root sacrifice. Patient survival depends on initial resection quality and the center's experience. Immunotherapy is an ongoing line of research., (Copyright © 2021. Published by Elsevier Masson SAS.)

Objective: Rheumatoid arthritis (RA) is a risk factor of lumbar spine surgical failure. The interest of anterior lumbar fusion in this context remains unknown. This retrospective study aimed to compare the outcome of anterior-only fusions between RA patients and non-RA (NRA) patients to treat lumbar spine degenerative disorders., Methods: NRA and RA groups including anterior-only fusion were compared. Clinical data (Visual Analog Scale score axial back pain scale, the Oswestry Disability Index, and a questionnaire of satisfaction regarding the surgical result); radiologic data (bone fusion, sagittal balance analysis); and adverse events were assessed using repeated measure 1-way analysis of variance., Results: The mean follow-up was 9.5 years (95% confidence interval [7.1-12.2]) for the RA group (n = 13) and 9.4 years (95% confidence interval [8.7-10.3]) for the NRA group (n = 36). Anterior fusion improved clinical outcome without any effect of RA (Visual Analog Scale score axial back pain scale; P < 0.001/Oswestry Disability Index; P = 0.01). The presence of RA influenced neither the satisfaction as the regards the surgical result nor spine balance nor bone fusion. Context of RA increased the surgical revision rate (10 patients [76.9%] for RA group vs. 3 patients [8.8%] for the NRA group; P = 0.001) because of the occurrence of an adjacent segment disease needing surgical revision (P = 0.028), especially the occurrence of intervertebral frontal dislocation (P = 0.02)., Conclusions: As noticed for posterior-only fusion, the anterior lumbar approach in RA patients does not seem to avoid the occurrence of an adjacent segment disease., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: In en bloc vertebrectomy, the posterior approach is associated with limited access to anterior structures (vertebral body, esophagus, aorta, azygos vein). Video-assisted thoracoscopic surgery (VATS) might prove to be advantageous during thoracic en bloc vertebrectomy by allowing a combined anterior-posterior access in the prone position. We describe the technique and review the outcomes of 33 cases of video-assisted thoracoscopic en bloc vertebrectomy., Methods: A retrospective, single-center cohort study included all cases of VATS with a minimum follow-up of 1 year. A team of thoracic and orthopaedic surgeons performed the surgical procedure with the patient in a single, prone position. Anterior release was carried out thoracoscopically, followed by posterior en bloc tumor removal., Results: From 2003 to 2019, 33 patients were included. Nine patients underwent total vertebrectomy (8 had single-level and 1 had 3-level), and 24 patients underwent partial vertebrectomy (1 had single-level, 8 had 2-level, 13 had 3-level, and 2 had 4-level). Ten patients had pulmonary resection. Histology revealed 18 cases (55%) of primary bone tumors, 6 cases (18%) of lung cancer invading the spine, 6 cases (18%) of solitary metastasis, and 3 other cases (9%). The margins were tumor-free in 28 cases (85%). The median operative time was 240 minutes (range, 150 to 510 minutes), with a median blood loss of 1,200 mL (range, 400 to 6,700 mL), and there were 2 cases of conversion to thoracotomy. A total of 33 complications occurred in 18 patients (55%), and these were predominantly pulmonary. One death was surgery-related (infection). One patient had a persistent monoplegia. At a median follow-up of 63 months (range, 12 to 156 months), there were 21 surviving patients (64%) with 2 local recurrences and 1 distant recurrence, and 2 patients (6%) were lost to follow-up. The survival rates were 94% at 1 year, 71% at 2 years, and 68% at 5 years., Conclusions: VATS en bloc vertebrectomy may be indicated for T2-to-T11 spine tumors with the exception of massive tumors, substantial chest wall and/or mediastinal invasion, and lung cancer exceeding 7 cm. The technique yielded satisfactory surgical and oncologic outcomes., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The authors indicated that no external funding was received for any aspect of this work. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (http://links.lww.com/JBJS/G387)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Introduction: Whether damage control orthopedics (DCO) or early total care (ETC) is the best way to treat polytrauma patients who have suffered a bilateral femoral shaft fracture remains unanswered. The aim of this study was to evaluate the morbidity of bilateral femur fractures treated by simultaneous intramedullary (IM) nailing according to ETC principles., Materials and Methods: This retrospective single-centre study included all polytrauma patients who had suffered a femoral shaft fracture and were treated at our level I trauma centre. Demographic data, associated lesions, injury severity score (ISS) and occurrence of acute respiratory distress syndrome (ARDS) were collected prospectively in our trauma database. Unilateral fractures (UF) were compared to bilateral fractures (BF). The risk of ARDS was evaluated by multivariate logistic regression., Results: Between 2010 and 2019, 176 UF (88%) and 25 BF (12%) were included. Patients with BF had a higher ISS (36 vs. 25, p<0.001) and more brain injuries (44% vs. 15%, p=0.001) than patients with a UF. More blood transfusions were done in BF than UF (4.0 vs. 1.6 units, p=0.002). The incidence of ARDS was higher in BF patients than UF (36% vs. 4%) with longer stay in intensive care (18 vs. 12 days, p=0.02) and in the hospital (32 vs. 23 days, p=0.006). There were no deaths in either group. The risk of ARDS was correlated to ISS, but not to bilaterality., Discussion: Studies on DCO and ETC report similar mortality and ARDS rates for BF. ISS appears to determine the postoperative morbidity irrespective of how the patients are managed. In contrast with DCO, perioperative intensive care has a predominant role in ETC, allowing early definitive fixation of fractures, even in severely injured patients., Conclusion: Bilateral femoral shaft fractures are a sign of severe trauma leading to high postoperative morbidity. The patient is likely to have concomitant severe injuries. Simultaneous ECM can be done emergently providing appropriate perioperative intensive care management., Level of Evidence: IV; retrospective study., (Copyright © 2021. Published by Elsevier Masson SAS.)

Purpose: There is an increasing number of reports on the treatment of knee osteoarthritis (OA) using mesenchymal stem cells (MSCs). However, it is not known what would better drive osteoarthritis stabilization to postpone total knee arthroplasty (TKA): targeting the synovial fluid by injection or targeting on the subchondral bone with MSCs implantation., Methods: A prospective randomized controlled clinical trial was carried out between 2000 and 2005 in 120 knees of 60 patients with painful bilateral knee osteoarthritis with a similar osteoarthritis grade. During the same anaesthesia, a bone marrow concentrate of 40 mL containing an average 5727 MSCs/mL (range 2740 to 7540) was divided in two equal parts: after randomization, one part (20 mL) was delivered to the subchondral bone of femur and tibia of one knee (subchondral group) and the other part was injected in the joint for the contralateral knee (intra-articular group). MSCs were counted as CFU-F (colony fibroblastic unit forming). Clinical outcomes of the patient (Knee Society score) were obtained along with radiological imaging outcomes (including MRIs) at two year follow-up. Subsequent revision surgeries were identified until the most recent follow-up (average of 15 years, range 13 to 18 years)., Results: At two year follow-up, clinical and imaging (MRI) improvement was higher on the side that received cells in the subchondral bone. At the most recent follow-up (15 years), among the 60 knees treated with subchondral cell therapy, the yearly arthroplasty incidence was 1.3% per knee-year; for the 60 knees with intra-articular cell therapy, the yearly arthroplasty incidence was higher (p = 0.01) with an incidence of 4.6% per knee-year. For the side with subchondral cell therapy, 12 (20%) of 60 knees underwent TKA, while 42 (70%) of 60 knees underwent TKA on the side with intra-articular cell therapy. Among the 18 patients who had no subsequent surgery on both sides, all preferred the knee with subchondral cell therapy., Conclusions: Implantation of MSCs in the subchondral bone of an osteoarthritic knee is more effective to postpone TKA than injection of the same intra-articular dose in the contralateral knee with the same grade of osteoarthritis.

Purpose: Multiple synostoses syndrome (MSS) is a rare genetic condition. Classical features consist of joint fusions which notably start at the distal phalanx of the hands and feet with symphalangism progressing proximally to carpal, tarsal, radio-ulnar, and radio-humeral joints, as well as the spine. Usually, genetic testing reveals a mutation of the NOG gene with variable expressivity. The goal was to present the anatomical, functional, and radiological presentations of MSS in a series of patients followed since childhood., Methods: Patients with more than 3 synostoses affecting at least one hand joint were included. When possible, genetic screening was offered., Results: A retrospective study was performed from 1972 to 2017 and included 14 patients with a mean follow-up of 18.6 years. Mutation of the NOG protein coding gene was seen in 3 patients. All presented with tarsal synostoses including 9 carpal, 7 elbow, and 2 vertebral fusions. Facial dysmorphia was seen in 6 patients and 3 were hearing-impaired. Surgical treatment of tarsal synostosis was performed in 4 patients. Progressing joint fusions were invariably seen on x-rays amongst adults., Conclusion: Long radiological follow-up allowed the assessment of MSS progression. Feet deformities resulted in a severe impact on quality of life, and neurological complications secondary to spine fusions warranted performing at least one imaging study in childhood. As there is no treatment of ankylosis, physiotherapy is not recommended. However, surgical arthrodesis for the treatment of pain may have reasonable outcomes.

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., (Copyright © 2019. Published by Elsevier Masson SAS.)

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., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

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., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

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., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

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., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Purpose: To compare the outcomes of simple versus complicated femoral shaft fracture (FSF) treated by early intramedullary nail., Methods: Retrospective cohort study in level 1 trauma center including patients with FSF. Management consisted of intramedullary nailing (IMN) after adequate resuscitation within 24 h. Data were prospectively collected on admission (trauma base) consisted of demographics, biological parameters, associated injuries and injury severity score (ISS). Complicated fractures consisted of type C fracture or any type associated with bilateral femur fracture, floating knee, associated femoral neck fracture, dislocated hip, concomitant neurovascular injury. Simple fractures were Isolated type A and B fracture. Simple and complicated fracture groups were compared using stratification by ISS (ISS < 16; 16 ≤ ISS < 25; ISS ≥ 25)., Results: Inclusion of 191 consecutive patients: simple FSF (N = 109) versus complicated FSF (N = 82) (type 32C, n = 36; bilateral, n = 44; associated neck of femur fracture, n = 15; floating knee, n = 36; concomitant femoral artery injury, n = 3 or sciatic nerve injury, n = 7). Complicated fractures were associated with higher rate of associated injuries (thoracic, 56.1 vs. 40.4%, p = 0.04; head 25.6 vs 10.1%, p = 0.005) and ARDS (12.2% vs. 3.7%, p = 0.046); longer ICU stay (12.8 vs. 7.3 days, p = 0.019) and hospital stay (24.3 vs. 15.7 days, p < 0.001). After stratification, differences in morbidity between simple and complicated FSF were significant solely in range 16≤ISS < 25. Complicated fractures had longer operation duration (297 vs. 151 min, p < 0.001) due to additional IMN (tibial, humeral) requirements (24% vs. 1.8%, p < 0.001) and longer femoral IMN duration (133 vs. 104 min, p < 0.05). Pseudarthrosis was higher in complicated fracture group (9.6 vs. 3.7%, p = 0.002)., Conclusion: Complicated femoral fractures are associated with higher morbidity, especially in less severely injured polytrauma, which eventually results in longer hospital stay. Patients with moderate ISS and complicated fracture may have an increased risk of ARDS.

Objective: Early-onset scoliosis (EOS) is not uncommon in patients with neurofibromatosis type 1 (NF1). Despite conservative treatment, spinal deformities progress and require early surgical intervention. To avoid potential interference with chest and trunk growth, growing rods (GRs) have been used effectively in EOS of various etiologies. In this study the authors sought to analyze the outcomes of GRs in EOS patients with NF1., Methods: This was a retrospective single-center cohort study that included consecutive EOS patients with NF1 who were treated with GRs and were followed up for a minimum of 2 years. Clinical and radiological analyses were performed preoperatively and until the last follow-up., Results: From to 2008 to 2017, 18 patients (6 male, 12 female) underwent GR surgery (14 single GRs, 4 dual GRs) at a mean age of 8 ± 2.1 years. Mean follow-up was 5 ± 2.4 years. Fifty-five lengthenings were performed at a mean rate of 3 lengthenings per patient (range 0-7). Ten of 14 single GRs (71%) were converted into dual GRs during treatment. No patient underwent definitive posterior spinal fusion (PSF) at GR treatment completion. The mean initial and last follow-up major curves were 57° and 36°, respectively (p < 0.001, 37% correction). The average T1-S1 increase was 13 mm/yr. Six of 9 hyperkyphotic patients had normal kyphosis at last follow-up. There were 26 complications involving 13 patients (72%), with 1 patient who required unplanned revision. The primary complications were instrumentation related, consisting of 17 proximal hook dislodgments, 6 distal pedicle screw pullouts, and 2 rod fractures. Only 1 patient experienced a mechanical complication after dual GR implantation. There were no wound infections., Conclusions: The GR technique provided satisfactory spinal deformity control in EOS patients with NF1 while allowing substantial spinal growth. Adequately contoured dual GRs with proximal hooks placed in nondystrophic regions should be used to minimize implant-related complications. Surgeons should not attempt to correct kyphosis at GR implantation.

Background: Primary malignant tumors of the thoracic and lumbar spine are rare. They are mainly hematologic malignancies and more rarely sarcomas or chordomas. Giant-cell tumors and osteoblastomas, while benign, are locally very aggressive and their excision should be discussed as an option. Other possibilities are tumors from nearby organs invading the spine, which are actually carcinomas, but may benefit from radical excision in select cases., Methods: Excision of these tumors is complex and must be integrated in the diagnostic and therapeutic strategy established by a specific multidisciplinary tumor board at a designated cancer center. Surgical resection must combine tumor excision with long-lasting reconstruction of the spine and neighboring soft tissues. The initial excision must be as complete as possible as the possibilities of repeat excision are nearly impossible if the first resection is not complete., Results: An exhaustive preoperative imaging workup is essential for determining the tumor's spread and for determining the best surgical strategy. This will often require participation of other surgical specialties, which are well versed in teamwork. Thanks to this multidisciplinary care, especially the participation of thoracic and plastic surgeons, significant progress has been made recently. The first is the possibility of doing very extensive tumor excisions at the spine and in the neighboring organs, thus expanding the surgical indications to patients who were previously considered as being inoperable. We will discuss the surgical strategy and surgical approaches by spine level. Bone and soft tissue reconstruction is more effective thanks to the introduction of new spinal instrumentation and coverage flaps, which have drastically reduced the intra- and postoperative complications. Lastly, the risk factors for neurological complications are better understood, making them easier to prevent and to treat, if they were to occur., Conclusion: These advances have translated to better cancer outcomes, especially better control of the tumor with neoadjuvant therapies (targeted chemotherapy) and preoperative conformal radiotherapy., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Study Design: Retrospective case series., Objectives: To analyze the outcomes at skeletal maturity of patients treated with a single traditional growing rod (GR). To compare results of patients according to whether posterior spinal fusion (PSF) was performed at treatment completion., Summary of Background Data: Few studies examined the end results of GRs at skeletal maturity. There is no agreement on requirement of PSF at GR treatment completion., Methods: Clinical and radiological analysis of consecutive patients with severe and/or progressive scoliosis treated initially with traditional single GR. Group comparisons of patients with PSF and without fusion surgery at treatment completion., Results: Thirty-four patients underwent traditional single GR implantation at a median age of 11.7 years. Median follow-up was 6.5 years. At last follow-up, T1-S1 distance was increased by a median 116 mm (P < 0.001) and median major curve Cobb angle was changed from 55° preoperatively to 30° (P < 0.001). Complications included 26 rod fractures, 1 implant prominence, 4 proximal junctional kyphosis, 2 proximal hook dislodgments, and 2 wound infections. At the beginning our experience, PSF was performed systematically in 17 patients. Relying on spinal ankylosis, 17 patients were subsequently not fused at GR treatment completion (single GR removed N = 2, single GR retained N = 7, dual GR surgery N = 8). There were no statistical differences between groups in improvements of radiological parameters from preoperative GR insertion to last follow-up. No GR fracture occurred after dual GR surgery., Conclusion: Single GR allows curve control and promotes spinal growth. Dual GR is, however, recommended for rod fracture prevention and better correction maintenance. In patients with satisfactory deformity correction at skeletal maturity, one may consider retaining dual GR instead of performing PSF., Level of Evidence: 4.

Background: Sacral chordomas are rare primary bone tumors and represent more than half of all primary malignant sacral tumors. Surgical resection is the only treatment with close to 50% of remission at 10 years, with or without radiotherapy. This tissue removal can be very extensive and morbid, particularly for evolved tumors. The reconstruction mostly uses myocutaneous flaps, notably the gluteus maximus flap and the latissimus dorsi flap, increasing morbidity of the surgical procedure. To avoid a muscular sacrifice and reduce the post-surgical morbidity, we describe the case of a patient who underwent a giant sacral chordoma resection and a reconstruction with a superior gluteal artery perforator flap., Case Report: A 57-y.o. patient with a voluminous sacral chordoma had undergone a partial sacrectomy and abdomino-perineal resection. Firstly, a laparoscopy was realized to create a colostomy, to dissect an omental flap and to prepare the monobloc resection. In a prone position, the resection of the tumor was achieved and a de-epithelialized superior gluteal artery perforator flap was performed to fill the space and to support pelvic organs., Conclusion: For resections of sacral chordomas, coelioscopy has considerably reduced the surgical morbidity. However, the majority of reconstructions use myocutaneous flaps, specifically gluteus maximus and latissimus dorsi, which their postural function is considerable. Muscular sacrifice can lead to functional impotence with difficulty walking and standing up and run contrary to the diminution morbidity initiated by oncologic surgeons., (Copyright © 2018. Published by Elsevier Masson SAS.)

Background: Surgical treatment of thoracic disc herniation (TDH) is technically demanding due to its proximity to the spinal cord., Methods: Literature review., Results: Symptomatic TDH is a rare condition predominantly localized between T8 and L1. Surgical indications include intractable back or radicular pain, neurological deficits, and myelopathy signs. Giant calcified TDH (> 40% spinal canal occupation) are frequently associated with myelopathy, intradural extension, and post-operative complications. Careful pre-operative planning helps reduce the risk of complications. Pre-operative CT and MRI identify the hernia's location and size, calcifications, and intradural extension. The approach must provide adequate dural sac visualization with minimal manipulation of the cord. Non-anterior approaches are favoured if they provide at least equal exposure than anterior approach owing to higher risk of pulmonary morbidity associated with anterior approach. A transthoracic approach is recommended for central calcified herniated discs. A posterolateral approach is often suitable for non-calcified lateralized TDH. Thoracoscopic approaches are less invasive but have a substantial learning curve. Retropleural mini-thoracotomy is an acceptable alternative. Pre-operative identification of the pathological level is confirmed by intra-operative level check. Intra-operative cord monitoring is preferable but warrant further studies. Magnification and adequate lightening of the surgical field are paramount (microscope, thoracoscopy). Intra-operative CT scan with navigation is becoming increasingly popular since it provides real-time control on the decompression. Indications of fusion consist of pre-operative back pain, Scheuermann's disease, multilevel resection, wide vertebral body resection (> 50%), and herniation at thoracolumbar junction. Neurological deterioration, dural tear, and subarachnoid-pleural fistula are the most severe complications., Conclusion: Further improvements are still warranted in thoracic spine surgery despite the advent of minimally invasive techniques. Intra-operative CT scan will probably enhance the safety of the TDH surgery.

Background: A new growing rod (GR) design, the semiconstrained growing rod (SCGR), with the added advantage of axial rotation freedom within the components, has been introduced at our center which has been shown to be growth friendly. We hypothesize that the SCGR system would reduce autofusion in vivo, thereby maximizing the coronal plane correction, T1-S1 growth, and the final correction achieved at definitive fusion for children with an early onset scoliosis., Methods: In total, 28 patients had either single or dual 5.5 mm diameter SCGR placed minimally invasively through a submuscular approach. Surgical lengthening procedures occurred approximately every 6 months until the definitive fusion procedure was performed for 18 patients. Scoliosis, kyphosis, and lordosis angles, T1-S1 trunk length, and any complications encountered were evaluated., Results: For the full cohort, before GR insertion, the mean major Cobb curve angle was 72.4 degrees (SD, 18.8; range, 45 to 120), mean T1-S1 trunk length was 282 mm (SD, 59; range, 129 to 365), and at the latest follow-up (mean 6.9 y, SD 3.3, range 2.0 to 13.0), 38.8 degrees (SD, 17.5; range 10 to 90) and 377 mm (SD, 62; range, 225 to 487), respectively. For the subset of 18 patients who have had their final instrumented fusion surgery, the definitive surgery procedure alone produced a correction of the major Cobb curve angle by mean 20.3 degrees (SD, 16.1; P<0.0001), and an increase in the T1-S1 trunk length of mean 31.7 mm (SD, 23.1; P<0.0001). There were 14 complications involving 11 of the 28 patients, giving rise to 5 unplanned surgical interventions and 1 case where GR treatment was abandoned., Conclusions: SCGR patients exhibited statistically significant increase in T1-S1 trunk length and statistically significant decrease in the severity of scoliosis over the course of GR treatment and again, importantly, with the definitive fusion surgery, suggesting that autofusion had been minimized during GR treatment with relatively low complication rates., Level of Evidence: Level IV-case series.

Purpose: Degenerative disc disease involves sequential events that lead to the loss of cells, a decrease in disc matrix production, disc dehydration, and alteration of its biomechanical properties. The aim of this study was to determine whether cryoinjury of the nucleus pulposus performed through endplate perforation contributes to disc degeneration and to compare this technique with standard methods., Method: Under general anesthesia, the lumbar discs of six pigs were exposed and randomly submitted to needle puncture of the annulus fibrosus (NeP), isolated endplate injury (EP), or cryoinjury using a 2.5-J Thompson cryoprobe applied through a single endplate perforation (EP+cryo). The remaining discs served as controls. Animals were sacrificed at two months and the harvested lumbar spines were submitted to CT scan and MRI investigations. Histologic analysis was performed to assess the degree of disc degeneration., Results: CT scan showed that decrease in average disc height was more important after cryoinjury (49.3%) than after endplate perforation (16.9%) (P < 0.0001) or needle puncture (19.4%) (P < 0.0001). On MRI, the dehydration ratio was significantly more important after EP+cryo (60%) than after NP (40%) or EP (30%) (P < 0.0001). After cryoinjury, the histologic score developed for this study was significantly higher than after needle puncture or endplate perforation (P < 0.0001)., Conclusions: Imaging and histological analysis showed that disc cryoinjury applied through endplate perforation was superior to the classical NeP and EP models to induce experimental disc degeneration. This model appears suitable for testing safety and efficacy of novel treatments of intervertebral disc degeneration.

Based on the exceptional tribological behaviour and on the relatively low biological activity of ceramic particles, Ceramic-on-Ceramic (CoC) total hip arthroplasty (THA) presents significant advantagesCoC bearings decrease wear and osteolysis, the cumulative long-term risk of dislocation, muscle atrophy, and head-neck taper corrosion.However, there are still concerns regarding the best technique for implantation of ceramic hips to avoid fracture, squeaking, and revision of ceramic hips with fracture of a component.We recommend that surgeons weigh the potential advantages and disadvantages of current CoC THA in comparison with other bearing surfaces when considering young very active patients who are candidates for THA. Cite this article: Hernigou P, Roubineau F, Bouthors C, Flouzat-Lachaniette C-H. What every surgeon should know about Ceramic-on-Ceramic bearings in young patients. EFORT Open Rev 2016;1:107-111. DOI: 10.1302/2058-5241.1.000027., Competing Interests: Conflict of Interest: None declared.

The objective of this article is to review data on joint distraction used to treat knee osteoarthritis. Joint distraction is a surgical procedure in which the two bony ends of the joint are gradually pulled apart then kept separated for 2 months in an external fixation frame. Weight bearing is continued to ensure variations in hydrostatic pressure within the joint. In published studies, joint distraction provided substantial clinical and structural improvements in patients with knee osteoarthritis, delaying joint replacement surgery for at least 2 years. Animal studies showed that joint distraction was associated with decrease in the secondary inflammatory response, cartilage breakdown, and subchondral bone remodeling. In vitro, the intermittent application of hydrostatic pressure stimulated the production of extracellular matrix, particularly in joints with osteoarthritis. Nevertheless, several considerations invite caution when considering the more widespread use of joint distraction. Published studies have short follow-ups and small sample sizes. In addition, the high frequency of pin tract infection is of concern, since most patients eventually require knee replacement surgery. These two considerations indicate a need for longer-term prospective studies of patient cohorts., (Copyright © 2016 Société française de rhumatologie. Published by Elsevier SAS. All rights reserved.)

Purpose: Infected, long bone non-unions present a significant clinical challenge. New and alternative therapies are needed to address this problem. The purposes of this study were to compare the number of circulating granulocyte-macrophage colony-forming units (CFU-GM) in the peripheral blood of polytraumatic patients with infected tibial non-unions and in the peripheral blood of control patients with the hypothesis that their number was decreased in polytraumatic patients; and to treat their infection without antibiotics and with local transplantation of bone marrow concentrated granulocytes precursors., Methods: Thirty (18 atrophic and 12 hyperthrophic ) infected tibial non-unions (without bone defect) that occurred after open fractures in polytraumatic patients were treated without antibiotics and with percutaneous injection of autologous bone marrow concentrate (BMC) containing granulocytes precursors (CFU-GM). CFU-GM progenitors were assessed in the bone marrow aspirate, peripheral blood, and fracture site of these patients. The number of these progenitors was compared with the CFU-GM progenitors of control patient samples (healthy donors matched for age and gender). Outcome measures were: timing of union, callus formation (radiographs and CT scan), and recurrence of clinical infection., Results: As compared to control patients, the number of CFU GM derived colonies was lower at peripheral blood in patients with infected nonunions. The bone marrow graft injected in nonunions contained after concentration 42 621 ± 20 350 CFU-GM-derived colonies/cc. Healing and cure of infection was observed at six months for 25 patients and at one year follow up for 30 patients. At the median ten year follow-up (range: 5 to 15), only one patient had clinical recurrent infection after healing (between 6 months and last follow-up)., Conclusion: The peripheral blood of these polytraumatic patients with infected nonunions had a remarkable decrease in CFU-GM-derived colonies as compared with normal controls. Local transplantation of concentrated CFU-GM-derived colonies aspirated from bone marrow allowed cure of infection and healing without antibiotics.

Background: Obesity is associated with an increased risk of dislocation after total hip arthroplasty (THA). However, in patients with obesity, it is not known whether the risk is only in the early postoperative period or whether it persists several years after surgery, and whether having bariatric surgery before undergoing THA and/or receiving a specific device (such as a dual-mobility or constrained acetabular liner) is more effective in terms of decreasing the risk of dislocation., Question/purposes: (1) What is the cumulative risk of dislocation in patients with obesity after THA in the absence of a dual-mobility or constrained liner, and is this related to component positioning? (2) Does bariatric surgery before undergoing THA decrease dislocation risk in patients with obesity? (3) Are dual-mobility and constrained liners efficient in preventing dislocation in patients with obesity?, Methods: At our university-based practice, all surgeons adhered to the following treatment approaches: Before 2000 no dual-mobility implants or constrained liners were used for primary THAs. Between 2000 and 2008, all patients whose body mass index (BMI) was greater than 30 kg/m(2) received dual-mobility liners (or constrained liners), except when they had previously had bariatric surgery. After 2008, all patients with BMIs over 30 kg/m(2) as well as those patients who were previously treated with bariatric surgery (regardless of BMI at the time of the index THA) received dual-mobility or constrained liners. This case-control study compared the dislocation percentage between 215 hips in nonobese patients (BMI ≤ 30 kg/m(2)), 215 hips in patients with obesity (BMI > 30 kg/m(2)) who received standard cups, 85 hips in patients with bariatric surgery before THA using standard cups (with reduction to a BMI < 30 kg/m(2)), and 155 hips in patients with obesity who received dual-mobility (when younger than 70 years) or constrained liners (when older than 70 years). All patients received the same implants except for different femoral head diameters (32-mm head with standard cups and 28-mm head with dual-mobility or constrained liners). The patients were followed at routine intervals and were specifically queried about dislocation. All the 670 hips had a minimum followup of 5 years with a mean followup of 14 years (range 5-25 years). At the most recent followup, 101 (15%) hips were lost to followup (respectively, 36 of 215, 34 of 215, five of 85, 24 of 155), which is the same ratio as observed among the underlying populations from which the patients were drawn., Results: With standard liners, more hips in patients with BMI > 30 kg/m(2) dislocated than did hips in nonobese (BMI < 30 kg/m(2)) patients. The cumulative number of dislocations (first time without recurrent dislocation) was 6% (13 of 215) at 1-year followup in obese patients compared with 2% (four of 215) in nonobese patients (odds ratio [OR], 3.4; 95% confidence interval [CI] 1.09-10.58; p = 0.03) and was 13% (28 of 215) at 15 years followup compared with 4% (eight of 215) in nonobese patients (OR, 3.9; 95% CI 1.72-8.71; p = 0.001). When bariatric surgery was performed before THA, BMI declined from 42 kg/m(2) to 28 kg/m(2), but with the same standard liners, more hips after bariatric surgery dislocated at 1-year followup than did hips in patients with obesity without preoperative bariatric surgery (13% [11 of 85] compared with 6% [13 of 215]; OR, 0.43; 95% CI 0.18-1.01; p = 0.05). Dual-mobility or constrained implants decreased the risk of dislocation, and fewer hips in patients with obesity with dual-mobility or constrained liners at 7 years followup had dislocated than did hips with standard liners (2% [three of 155] compared with 9% [20 of 215]; OR, 0.19; 95% CI 0.05-0.66; p = 0.01) bringing this number in line with the number observed in nonobese subjects with standard cups., Conclusions: With standard liners, the risk of dislocation is increased in patients with obesity. Preoperative decrease of BMI (with bariatric surgery) in patients with obesity did not prevent the risk of dislocation with standard liners. Use of dual-mobility or constrained liners in these patients is an effective technique to reduce the risk of postoperative hip dislocation. However, we do not yet know the full risks of loosening of dual-mobility and constrained liners in this obese population., Level of Evidence: Level III, therapeutic study.

Purpose: There is a significantly higher incidence of delayed unions, non-unions, and increased healing time in diabetic patients compared with non-diabetic patients. Studies suggest that diabetics suffer from deficiencies of pancreatic stem/progenitor cells, and a clinically relevant question arises concerning the availability and functionality of progenitor cells obtained from bone marrow of diabetics for applications in bone repair., Methods: We have evaluated the cellularity and frequency of osteogenic mesenchymal stem cells (MSCs) in bone marrow from 54 diabetic patients (12 with type 1 and 42 with type 2) with tibial non-unions. These patients were treated with bone marrow MSCs (BM-MSCs) delivered in an autologous bone marrow concentrate (BMC). Clinical outcomes and marrow cellularity were compared to 54 non-diabetic, matched patients with tibial non-unions also treated with BMC., Results: After adjusting for age and sex, no differences were identified with respect to bone marrow cellularity and MSC number among the diabetic and non-diabetic groups and both groups received approximately the same number of MSCs on average. BMC treatment promoted non-union healing in 41 diabetic patients (76 %) and 49 non-diabetic patients (91 %), but the non-diabetic patients healed more quickly and produced a larger volume of callus., Conclusion: We recommend that diabetic patients be treated with an increased number of progenitor cells by increasing the bone marrow aspiration volume. We also anticipate a need to extend the time of casting and non-weight bearing for diabetic patients as compared with non-diabetic patients.

Purpose: No study has reported the risk of other site osteonecroses after the diagnosis of multifocal osteonecrosis related to corticosteroids in patients who continue this corticosteroid treatment. An analysis of the time-course to other sites of osteonecrosis, as well as the effects of underlying corticosteroid risk factor on the evolution of asymptomatic lesions at the time of diagnosis, is presented., Methods: Two hundred patients were followed prospectively every year during a minimum ten years with a radiograph if a joint became symptomatic. In absence of evidence of osteonecrosis on radiographs of a symptomatic or non-symptomatic joint (hips, shoulders, knees, ankles), patients had an MRI performed at the most recent follow up. The average duration of follow-up after inclusion of the patient in the study was 15 years (range 10-20)., Results: Of the 200 patients followed for an average of 15 years (minimum 10 years, maximum 20 years), 35 patients developed new osteonecrosis lesions during the period of study. Asymptomatic lesions became symptomatic and a high number of collapse was observed resulting in 258 arthroplasties (187 hips, 51 shoulders, 20 knees) at the most recent follow up., Conclusion: The continuation of peak doses (>200 mg) of corticosteroids predicted (p = 0.04) occurrence of new lesions and the continuation of corticosteroids without peak dose was a risk for quicker progression to collapse.