Purpose of the study: Resection of a malignant primary tumour of the proximal humerus implies sacrifice of a large part of the humeral shaft and the periarticular muscles. Reconstruction can be difficult and raises the problem of preserving function. Recent work has demonstrated the pertinence of combining a glenohumeral prosthesis with an allograft. Several complications are nevertheless reported: non-union, allograft resorption, loosening. We report three cases of malignant primary tumours requiring wide resection of the humerus which were treated by reconstruction with a shoulder arthrodesis applying the induced membrane technique.

Material and methods: Three patients (mean age 15 years) presented a malignant primary tumour of the proximal humerus (Ewing sarcoma or osteosarcoma) which was locally extensive but not metastatic. Resection implied resection of 16 cm of the humerus (mean). The same procedure was used for the three patients: first phase: wide resection of the tumour and neighbouring soft tissues which removed the majority of the proximal end of the humerus and the glenohumeral joint, then insertion of a cement spacer; second phase: reconstruction with a shoulder arthrodesis using cancellous grafts positioned inside the induced membrane. Stabilisation was ensured by insertion of a non-vascularised fibula inside the membrane and with a plate fixation on the scapular spine.

Results: Mean follow-up is five years. There has been no local recurrence and no distant spread. The arthrodeses and the reconstructions healed without reoperation within six to eight months. The functional outcomes were not different from those obtained with shoulder arthrodesis with a mean elevation of 90°.

Discussion: There are many advantages of reconstruction with shoulder arthrodesis using the induced membrane technique: possible wide initial resection, more satisfactory carcinological resection, the periarticular muscles are not pertinent after arthrodesis; there is no need for prosthetic elements or an allograft exposing to later complications; the reconstruction time is a simple procedure; elevation remains satisfactory.

Conclusion: This technique should be included in the surgical armamentarium just like vascularised transfers, allografts and massive prostheses. The indication should be reserved for extensive resection.

Purpose of the study: Clinical assessment of the upper limb in the cerebral palsy child remains difficult, and minimally reproducible. Thus many authors use for the upper limb, as for the lower limb, movement analysis to aid in decision making and obtain an objective measurement of postoperative results.

Material and method: Kinematic analysis and EMG were performed with the Vicon system in 27 cerebral palsy children with a spastic upper limb. The patients were compared with data obtained in a control population of 12 children. Eight patients had a second assessment after treatment. The experimental protocol followed the recommendations of the International Society of Biomechanics. The muscles targeted by the treatment were the pronator teres, the flexor carpi ulnaris, and the adductor pollicis (lengthening, transfer, toxin injection).

Results: Significant kinematic anomalies (p< 0.05) found were: excessive homolateral inclination and flexion/extension of the trunk, excessive abduction and external rotation of the arm/trunk, excessive elbow flexion, excessive pronation of the forearm, and flexion and ulnar inclination of the wrist. There was significant improvement postoperatively in the group of treated patients (p< 0.05) regarding the kinematics of the trunk, shoulder and elbow, as well as the EMG behaviour of the biceps/triceps couple despite the fact that the procedure had not affected these muscles or joints.

Discussion: Kinematic and EMG anomalies involving the trunk, shoulder and elbow represent motor strategies compensating for distal anomalies: – recruitment of the biceps allows improved supination, pulls the elbow in flexion. Since the patient cannot extend the elbow to achieve a task, compensation with the trunk increases the amplitude of the flexion-extension movement; – ‘extrinsic’ supination is achieved via an increase in external rotation of the arm in relation to the trunk and homolateral inclination of the trunk.

Conclusion: These observations have therapeutic implications: clinical, kinematic or EMG anomalies involving the trunk, shoulder, and elbow should not be treated per se but reevaluated after treatment of more distal anomalies.

Objective: To evaluate the effectiveness of distal rectus femoris (RF) release versus transfer to treat gait abnormalities of the knee in ambulatory children with cerebral palsy.

Methods: Ninety-three children were included in this study. Thirty-two patients underwent RF transfer at a mean age of 11.8 years and sixty-one underwent distal RF release at a mean age of 12.5 years. Indications for surgery included RF contractures, abnormal RF activity during swing phase (EMG) and kinematic characteristics of stiff-knee gait. All patients had pre–and postoperative 3D gait analysis and EMG at one year follow up. To evaluate outcomes, patients were grouped by pre-operative knee kinematics (swing-phase peak knee flexion (PKF) < 50º or PKF > 50º occurring later than 77% of the cycle). All data was analyzed statistically.

Results: For the group of patients with PKF< 50º, this value increased significantly after RF transfer (p=.005) and after RF release (p=.03). Children with PKF later than 77% of the cycle also showed significant improvement after both procedures (p=.001; p=.02). All patients experienced a significant decrease of muscle contractures.

Discussion: According to the results of this study, both RF transfer and release brought significant results. We opt for distal RF release, since is technically easier, particularly when one-stage multilevel procedures are being performed.