Introduction: Metal-on-metal arthroplasties are being used for their increased durability and reduced requirement for revision. Previous data reports that metal-on-metal bearing surfaces release three times more cobolt and chromium ions than metal-on-polyethelene hip replacements. Data also suggests that these metal ions can cause DNA damage.

Method: A prospective study of patients (aged 60–80), meeting exclusion criteria were selected and randomised to metal-on-metal or metal-on-polyethylene articulation. Patients were reviewed preoperatively (control model) and at 3 months, 6 months and one year postoperatively. On each occasion blood tests were taken to quantify metal ion levels (chromium, cobalt, nickel, vanadium and titanium) and chromosome aberrations in T lymphocytes using 24 colour fluorescent in situ hybridization (FISH).

Results: The number of chromosome aberrations increased with time; in particular there was a statistically significant increase in aneuploidy after one year, there was also an increase in chromosome translocations. There was a similar increase in blood concentration of metal ions over this same time period which proved significant. Higher levels of metal ions were seen in the metal-on-metal group when compared with the metal-on-polyethylene.

Conclusion: This study has highlighted the effects of metal ions on chromosome replication in particular causing aneuploidy aberrations. This provides evidence of the short-term effects of metal-on-metal arthroplasty but further research needs to be undertaken to assess long-term risk and also the risk associated to other cell lines.

Medical records of children < /=5 years, treated by the London sarcoma service for malignant primary bone tumours (average new cases osteosarcoma (OS)/Ewings sarcoma (ES), all ages: 125/year) between 1999 and 2009, were reviewed.

Results: 5 OS and 6 ES. Mean age – 4.2 years (range 2.1–5.8), 8/11 males. OS primary sites: distal femur (2), proximal femur (1) and proximal humerus (2); localised tumours only. Primary sites in the ES cohort included 1 distal femur, 2 chest wall (1 – spinal extension), 1 buttock (spinal extension), 1 temporal bone and 1 ulna; 1 had bone/bone marrow involvement, 1 had chest metastases. 4/5 OS (Euramos, MRC B007) and 5/6 ES (Euro-Ewings 99) were entered into phase III clinical trials. Delayed surgery for OS occurred at mean 12.1 weeks (range 11–13) – 4 limb salvage prostheses with 2/4 non-invasive growers, 1 forequarter amputation. All had a good (> 90% necrosis) histologic response to neoadjuvant therapy. Delayed surgery for ES occurred at mean 21.7 weeks (range 12.8 – 35), 1 limb salvage with prosthesis (non-invasive grower), 1 biological reconstruction; remainder had tumour resections. Histologic response: 50% good. In the OS cohort, 1 child died a toxic death; 1 developed pulmonary metastases and died 2 years from diagnosis; 1 has a metastatic recurrence in the opposite humerus 2 years from diagnosis and starts 2nd line therapy; 1 had local recurrence 1 year from diagnosis but alive at 7.4 years;1 alive/disease free at 2.5 years. In the ES cohort 5/6 are alive disease free -1, 4.1, 5.2, 6.9 and 7 years from diagnosis; 2 needed 2nd line therapy for recurrent distant disease 4.5 and 5.8 years off therapy, 1 of whom has just recurred again (6.1 years from diagnosis).

Conclusion- improving early survival rates in the very young with OS remains a significant challenge. Quality of survival requires further age-appropriate study.

Introduction: The non-invasive growing prosthesis continues to be used successfully for the treatment of limb salvage operations in tumour patients. We report our continued experience in 17 skeletally immature patients with osteosarcoma of the distal femur.

Methods: Patients had a mean age of 10.2 years (range 6 to 15) at the time of surgery. The endoprosthesis was lengthened at appropriate intervals in outpatient clinics without anaesthesia using the principle of electromagnetic induction.

Results: The mean follow-up was 28 months (range 2 to 55). The prostheses were lengthened by a mean of 47.4 mm (range 0.5 to 208) and maintained a mean knee flexion of 110 degrees (range 90 to 120 degrees).

Complications developed in seven patients: two implants failed requiring revision, one peri-prosthetic fracture occurred, one developed a flexion deformity of 25 degrees at the knee joint, which was subsequently overcome and three died of disseminated disease.

Discussion: The medium term results from patients treated with this device have continued to show a promising outcome. Four patients successfully completed desired lengthening, six patients are continuing with ongoing lengthening. The implant avoids multiple surgical procedures, general anaesthesia and assists in maintaining leg-length equality.

Introduction: Pathological fractures commonly undergo biopsy to establish tissue diagnosis and plan definitive surgical management.

Methods: 129 patients undergoing image-guided needle biopsy of a pathological fracture between 1998 and 2007 were prospectively identified. Imaging was by CT, ultrasound or fluoroscopy. Biopsy was by Jamshedi, Temno or Trucut needle. The outcome measure was ability to make a tissue diagnosis by this method.

Results: The median age at diagnosis was 43 years. 59% were male, 41% female. The four most common sites of pathological fracture were the femur (35%), humerus (28%), tibia (12%) and pelvis (11%).

The five most common histopathological diagnoses were chondrosarcoma (9%), osteosarcoma (9%), meta-static renal carcinoma (8%), giant-cell tumour (6%), lymphoma (5%).

77% of biopsies yielded a tissue diagnosis. The remaining 23% underwent open biopsy, repeat image-guided needle biopsy or were not further investigated.

In the 30 cases (23%) of non-diagnostic biopsies 80% of these lesions had no extra-osseous component to them and the remaining 20% had a very small extra-osseous component.

Discussion: A tissue diagnosis of a pathological fracture can be obtained by primary image-guided needle biopsy in 77% of cases referred to a specialist bone tumour service. The majority (80%) of unsuccessful biopsies were of lesions with little or no extra-osseous component to the lesion.

We retrospectively studied 67 patients who underwent proximal humeral replacement with the Bayley-Walker prosthesis, for tumour of the proximal humerus between 1997 and 2007. Of the 67 patients 10 were lost to follow up. Of the 41 surviving patients, function was assessed using the Musculoskeletal Tumour Society (MSTS) Score and the Toronto Extremity Salvage Score (TESS) questionnaire.

4 of the 41 patients received the new Bayley-Walker ‘captured’ proximal humeral replacement. The mean age was 46 years (7–87). The mean MSTS score at follow-up was 72.0 % and the mean TESS score was 77.2 %. The sub-group of 4 pts who received the new captured prosthesis had a mean MSTS score of 77.7 %. There was no mechanical failure of any prostheses in the follow up period.

Endoprosthetic replacement for tumour of the proximal humerus with the Bayley-Walker prosthesis, is a reliable operation yielding reasonable functional results and good long-term prosthesis survivorship. The performance of this prosthesis is expected to improve further with the new ‘captured’ prosthesis.

Introduction: Experimental studies in anatomic full size hip models indicate that larger femoral heads offer potential in providing greater hip range of motion and joint stability. We studied the effects of increasing head diameter from 28mm to 36 mm in total hip replacement (THR) on the range of flexion and abduction.

Methods: 243 patients who underwent primary total hip replacement with S ROM prosthesis between July 1996 and June 2004 were studied. 151 patients (77 male and 74 female) underwent THR with 28 mm head and 92 patients (38 male and 54 female) underwent THR with 36 mm head. The range of flexion and abduction were studied and statistical analysis was performed using the Student t-test. We monitored the dislocation rate in both groups.

Results: The mean flexion is 87.0 for the 28 mm group and 89.6 for the 36 mm group. The mean abduction is 27.77 and 27.98 for 28mm and 36mm groups respectively. Even though there is a slight increase in the mean flexion and abduction from the 28mm to 36mm group, this increase in not found to be statistically significant. For flexion (2.6 (−0.85 to 3.2); p=0.377), and for abduction (0.02 (−2.37 to 1.94); p=0.847). Three hips dislocated in the 28mm group (2%) but none of the hips in 36mm group has dislocated.

Discussion: Even though experimental studies indicate improvement in range of motion with increasing head diameter in THR, this effect is not reflected in our clinical study. But there is improvement in the joint stability by using a prosthesis with larger head diameter as evidenced by a reduction in the dislocation rate.

Study Design: Prospective analysis of a cohort of patients who underwent a Spinal Fitness Exercise Program in a nurse led spinal assessment clinic in a University Hospital.

Objective: To determine if psychological status affects the outcome of a spinal fitness exercise program in patients with low back pain.

Background: Evidence for the effectiveness of exercise programs in the treatment of chronic mechanical low back pain is well documented. In this study, the effect of psychological status on the outcome of a self-help spinal fitness exercise programme was studied.

Methods: Patients who were referred by their primary care physicians to the nurse led spinal assessment clinic and met the inclusion criteria were given a spinal exercise booklet, which describes with the aid of diagrams how to perform a series of lumbar core stability exercises for them to practise at home. Back pain related disability was assessed before and 3 months after the exercise program using the Oswestry Disability Index (ODI). Psychological status was measured using the Distress and Risk Assessment Method (DRAM). This classifies patients into 4 groups based on the combination of scores from the Modified Somatic Perception Questionnaire (MSPQ, 13 questions, scored 0–13) and Modified Zung Questionnaire (23 questions scored 0–69): normal, at risk, distressed somatic and distressed depressive.

Results: Forty one patients were enrolled into the study (19 male, 22 female, mean age at treatment 45.8 years, age range 22–78 years). The DRAM scores showed that 9 had no psychological disturbance (normal), 17 were at risk, 4 were distressed somatic and 11 distressed depressive. Even though there was a statistically significant improvement in the mean ODI after the exercise program for all DRAM groups, the improvement in the ODI was not significantly different between the four groups (ANOVA, p = 0.596).

Conclusions: Our study suggests that the outcome of a spinal fitness exercise programme is not affected by the psychological status of the patient. We conclude that patients should not be excluded from spinal fitness exercise programs on the basis of psychological status.

We aimed to determine whether proximal femoral bone remodelling, as measured by DEXA scan for each Gruen Zone, differed for 3 different femoral stem designs. These were:

Group 1 – Triple taper polished (C-stem J& J DePuy)

Ethical Committee approval was obtained and all patients gave informed consent. All operations were performed by 3 surgeons using a standard lateral approach, third generation cementing technique and a standard post-operative regime.

Seventy-five patients were randomised prospectively using a stratified randomisation programme for known risk factors in bone density. The randomisation was stratified by age, sex, Charnley Group (A or B), BMI and femoral neck bone mineral density. There were 25 patients in each Group, 5 patients did not have complete data sets and were therefore withdrawn from evaluation.

The Groups were similar with regard to age, sex, BMI, BMD and Charnley Group. Patients were followed up at 3, 6, 12 and 24 months by Nurse Practitioners for clinical and radiological evaluation and DEXA scan at each time of follow-up. There were no catastrophic failures of sepsis or dislocation. All patients functioned well at 24 months by Harris Hip Score.

The bone remodelling pattern will be described for each stem design. Findings are summarised thus. In the lateral Gruen Zones the triple taper and collared stem design faired better and both behaved differently to the double taper design. In Gruen Zone 7, all stems demonstrated reduced bone density as compared to pre-operative scans but this was less with the triple taper design.

Purposes: To determine the effect of gravity on outcome in sacral epidurals injected in the prone compared to the lateral position in patients with unilateral back related leg pain.

Methods: A randomised controlled trial with 2 arms. This pilot study was conducted to determine the standard deviation (SD) of the primary outcome measure to allow calculation of a final sample size. Forty patients who met the inclusion/exclusion criteria were randomly allocated to prone or lateral sacral epidural injection. Twenty patients were allocated to the prone and 20 to the left or right lateral position dependent on their radicular back pain. The primary outcome measure of back and leg pain severity was assessed using a visual analogue scale (VAS) (0= none, 10 = worst imaginable). The Oswestry disability index, SF-36 and straight leg raise were also measured. Outcomes were assessed at baseline and at 6 and 12 week follow-up. A repeated measures analysis using mixed model methodology was used to determine statistical significance.

Results: The 2 groups were comparable in gender and age. The prone group had a mean improvement in VAS back pain score at 6 weeks follow-up of 0.5 compared to 1.6 in the lateral group. At 12 weeks follow-up there was a negative response of 0.1 compared to baseline in the prone group and 1.4 improvement in the lateral group. Repeated measures analysis showed no significant difference in back pain scores between the groups at the 5% level (F2,38 = 3.24; P = 0.0797). Similarly mean improvement in VAS leg pain scores at 6 weeks follow-up were 1.4 in the prone group and 1.7 in the lateral group. At 12 weeks follow-up the scores were 1.1 for the prone and 2.4 for the lateral group. Repeated measures analysis showed no significant difference in leg pain scores between the groups (F1,38= 0.76; P = 0.3898). A post-hoc power calculation using the sample VAS SD showed we had reached only 65% power.

Conclusion: This pilot study has shown that sacral epidural injection for sciatica in the lateral position gives superior pain relief compared to the prone position but the difference is not statistically significant. More patients will now be recruited in order to minimise a type II error that may have occurred.

Introduction: Pain after total hip arthroplasty (THA) can be caused by infection, aseptic loosening, heterotopic ossification, and referred pain. Psoas tendonitis is a rare cause of groin pain after THA and resurfacing arthroplasty. It is believed to be caused by psoas tendon impingement against a malpositioned acetabular component due to defective anteversion or centring and the use of oversized cups. We report 4 cases of psoas tendonitis following resurfacing arthroplasty and hybrid surface arthroplasty.

Methods: Between April 2004 and June 2005, we diagnosed 4 cases (3 female and 1 male) of psoas tendonitis among 152 cases of resurfacing arthroplasty and hybrid surface arthroplasty (2.6%). 116 patients had a hip resurfacing with ASR prosthesis (2 cases, 1.7%) and 36 patients had hybrid surface arthroplasty with ASR unipolar head on S ROM stem (2 cases, 5.6%). All these patients presented 2–5 months postoperatively with severe groin pain which was exaggerated when moving from the sitting position to the upright position and when going up stairs. Common causes of pain after hip arthroplasty, infection and loosening were ruled out. Radiological and ultrasound examination were performed.

Results: Ultrasound examination revealed thickening of psoas tendon in all cases and fluid collection around the tendon in one case. All cases were treated with corticosteroid injection under ultrasound guidance. Significant but temporary symptomatic relief was achieved in all cases.

Discussion: Psoas tendonitis should be considered in the differential diagnosis of groin pain after hip resurfacing procedures. Ultrasound examination is the initial investigation of choice and corticosteroid injection around the tendon is initial method of treatment. Computerized tomography and surgical options of management should be considered in resistant cases.

Aims: The main purpose of this study was to evaluate hemiplevis replacements in patients with periacetabular tumours in terms of the functional results and implant survivorship of the prosthesis. The second aim was to evaluate the complications and how they might be prevented in the future.

Methods: Case notes, hospital databases and radiographs were reviewed in 51 patients treated in a 16 year period with a custom made hemipelvis replacement (Stanmore Implants Worldwide). There were 13 deaths and 4 were lost to follow up. Of the remaining 34 patients there were 18 males and 16 females with a mean age of 48.6 (range 14 – 71).

Results: At a mean follow-up of 78 months (range 7 – 204), 70% of patients were still alive and the most common diagnosis was chondrosarcoma (17 cases). There were 2 cases of prosthesis failure and 22 of the 34 patients had one or more complications (12 cases of infection (8 deep and 4 superficial), 4 nerve palsies, 2 dislocations and 7 others). 13 patients had to have a second operation. The mean MSTS score was 63.8% and the TESS score was 59.8%

Conclusion: Infection was the most common complication and was the most significant reason for reoperation. This method of reconstruction is associated with a high morbidity rate and should be performed only at specialist centres, but the functional and oncological outcomes are satisfactory.

Introduction: Experimental studies in anatomic full size hip models indicate that larger femoral heads offer potential in providing greater hip range of motion and joint stability. We studied the effects of increasing head diameter from 28mm to 36 mm in total hip replacement (THR) on the range of flexion and abduction.

Methods: 243 patients who underwent primary total hip replacement with S ROM prosthesis between July 1996 and June 2004 were studied. 151 patients (77 male and 74 female) underwent THR with 28 mm head and 92 patients (38 male and 54 female) underwent THR with 36 mm head. The range of flexion and abduction were studied and statistical analysis was performed using the Student t-test. We monitored the dislocation rate in both groups.

Results: The mean flexion is 87.0 for the 28 mm group and 89.6 for the 36 mm group. The mean abduction is 27.77 and 27.98 for 28mm and 36mm groups respectively. Even though there is a slight increase in the mean flexion and abduction from the 28mm to 36mm group, this increase in not found to be statistically significant. For flexion (2.6 (−0.85 to 3.2); p=0.377), and for abduction (0.02 (−2.37 to 1.94); p=0.847). Three hips dislocated in the 28mm group (2%) but none of the hips in 36mm group has dislocated.

Discussion: Even though experimental studies indicate improvement in range of motion with increasing head diameter in THR, this effect is not reflected in our clinical study. But there is improvement in the joint stability by using a prosthesis with larger head diameter as evidenced by a reduction in the dislocation rate.

Aim: To study the remodelling of cortical bone around the passive growing component of an expandable endoprosthesis.

Introduction: When inserting the passive component of an expandable prosthesis a polyethylene sleeve is commonly used. The sleeve migrates towards the lateral cortex and causes a cortical reaction and hence the use of the sleeve has been discarded recently. This study quantifies the amount of cortical reaction and degree of cortical drift in patients that had sleeves and those that did not.

Material And Methods: We reviewed X-rays and case notes of all patients that had an expandable endoprosthesis in a 20 year period. The thickness of medial and lateral cortices of the tibial diaphysis was measured at 6 months and on the last follow up radiograph. The distance from the edge of the sleeve (or prosthesis) from the cortical edge was also compared. Retrieved components also had their histology reviewed.

Results: The sleeve shifted laterally on average by 2mm (range 0.5 – 3mm) and touched the cortex. This was associated with an increase in lateral cortical thickness by 2.27mm (range 1 – 3mm). When the sleeve was used the prosthesis was inserted in the mid-line. When the sleeve was not used the tibial component tended to be inserted in valgus.

Conclusions: The presence of a sleeve is associated with a cortical reaction and the sleeve tends to migrate laterally. The clinical implications of this and the evolution of the design will be discussed in the meeting.

Background: Advances in adjuvant and neoadjuvant therapies have rendered many tumours that previously necessitated amputation amenable to limb salvage procedures. However, a significant proportion of tumours are still treated by hindquarter amputation in an attempt to cure the patient, or to reduce the tumour load. This tends to be lengthy, mutilating and is associated with high morbidity and poor survivorship.

Aims: To review the survivorship, quality of life and functional assessment following hindquarter amputations performed in this centre in the last 10 years.

Methods: This was a retrospective study of 51 consecutive patients who had hindquarter amputations for tumours between 1996 to 2006. Available patients were evaluated using contemporary functional outcome assessments (Musculoskeletal Society Tumour Score, Toronto Extremity Salvage Score, SF36).

Results: Fifty-one patients (31 males, 20 females) had palliative(8) or curative hindquarter amputations(43) for Chondrosarcoma(18), Malignant Fibrous Histiocytoma(6), Osteosarcoma(4) and other sarcoma sub-types(23). The mean age was 50.7 years (range 24–78). The mean duration of symptoms until referral was 5.2 months, the mean time from referral to tissue diagnosis was 16.2 days (range 2–80) and the time from confirmed histological diagnosis to surgery was 39.2 days (range 2–190) on average. Significant complications included phantom limb pain(15), wound problems(24), urinary problems(6), cardiopulmonary events(5) and erectile dysfunction(3). 33 of the 51 patients have passed away, with a mean survival postoperatively of 10.7 months (range 2–43), with carcinomatosis the main cause of death. The mean cumulative survival following hindquarter amputation in this hospital is 17.3 months.

Conclusions: Patients with no metastasis and clear margins at amputation had a better cumulative survival rate. Therefore the decision to proceed for hindquarter amputation to achieve a curative resection is justified but has to be weighed up against the associated significant complications, morbidity and functional deterioration.

Purpose: We report a series of 58 patients with metastatic bone disease treated with resection and endoprosthetic reconstruction over a 5 year period at our institution.

Introduction: The recent advances in adjuvant and neo-adjuvant therapy in cancer treatment has resulted in improved prognosis of patients with bone metastases. Most patients who have an actual or impending pathological fracture should have operative stabilisation or reconstruction. According to BOA guidelines patients should undergo a single procedure which allows early full weight bearing and lasts the expected lifespan of the patient. The use of modern modular endoprostheses allows these criteria to be met.

Methods and Results: We retrospectively identified all patients diagnosed with metastatic disease to bone between 1999 to 2003. 171 patients were diagnosed with bone metastases. Metastatic breast and renal cancer accounted for 47% of the lesions. 58 patients with bone metastasis to the appendicular skeleton had an endo-prosthetic reconstruction. There were 28 males and 30 females. 11 patients had lesions in the upper extremity and 47 patients had lesions in the lower extremity. Mean age at presentation was 62 years (24 to 88 years). 19 patients are still alive, 34 patients had died and 5 were lost to follow-up. Patients died of disease at a mean of 22 months (2 to 51 months) from surgery. Mean follow-up was 55 months (24 to 78 months). There were 5 wound infections, 1 aseptic loosening, 3 dislocations, 1 subluxation and 1 prosthesis rotated requiring open repositioning. Patients were followed up and evaluated using the Musculoskeletal Society Tumour Score (MSTS) and the Toronto Extremity Salvage Score. The mean MSTS score was 73% (57 to 90%) and TESS was 71% (84 to 95%).

Conclusions: We conclude that endoprosthetic replacement for the treatment of bone metastases in selected cases achieves the aims of restoring function, allowing early weight bearing and alleviating pain. The complication rate is low.

Introduction: Since 1975, 6 types of extendable endo-prostheses have been developed at Biomedical Engineering, UCL, and Stanmore Implants Worldwide in conjunction with the surgeons at this centre.

Aims: To establish whether developments in design have had the desired effect of improving both implant survivorship and functional outcome.

Methods: This was a retrospective study using case notes, hospital databases and a radiological review, combined with contemporary functional outcome assessments (MSTS, TESS, SF36).

Results: 161 consecutive prostheses in 138 paediatric patients, between the years of 1983 – 2005, were implanted for primary bone tumours. Mean age was 10.3 (3 – 18), 81 were males and 57 females. There were 136 primary procedures and 25 revisions.

6 prostheses that used ball bearings to achieve length (designed in 1981) were implanted, 3 (50 %) were revised due to mechanical failure.

19 prostheses that utilised external C-washes (1998) to achieve length were implanted, 6 (32 %) were revised, half of these for mechanical failure.

Of the 98 minimally invasive prostheses (1992) that utilized an Allan key and screw-jack mechanism to lengthen, 14 (14 %) were revised, half of these for infection.

17 non-invasive extendable endoprostheses (2001) that are lengthened by electromagnetic coupling have been implanted so far. There has only been 1 (6 %) revision. This was due to full extension being reached.

Conclusions: Design improvements in growing endoprostheses since 1983 have led to improved survivorship. Initially this led to a reduction in mechanical failure and latterly to a reduction in infection, as indications for revision.

Key Words: Bone tumour, children, endoprosthesis, survivorship.

Purpose: We report a series of patients with malignant tumours of the pelvis that had a tissue expander inserted in the pelvis to facilitate radical radiotherapy, and report functional outcomes following treatment.

Introduction: Surgery for malignant tumours affecting the pelvis is challenging. Some tumours are suitable for internal hemipelvectomy and reconstruction, some require hindquarter amputation and some are inoperable. Overall prognosis is poor with high morbidity and mortality rates. There may be a place for alternative treatment with the insertion of pelvic spacers to facilitate radical radiotherapy. This is indicated in patients who have an inoperable tumour, who decline amputation, or who had an internal hemipelvectomy with close margins and high risk of local recurrence.

Methods & Results: We performed a retrospective review of all patients who presented with a malignant tumour of the pelvis and who underwent an insertion of a pelvic spacer followed by local high dose radiotherapy. Available patients were followed up and evaluated using the Musculoskeletal Society Tumour Score (MSTS) and the Toronto Extremity Salvage Score (TESS). There were ten patients; 5 had Ewing’s sarcoma, 3 had osteosarcoma, 1 had spindle cell sarcoma and 1 had alveolar soft part sarcoma. 4 patients had metastases on presentation. The average age was 30 years (14 to 56 years), and average follow-up was 15 months (12 to 24 months). 4 patients died and 6 are still alive. There were no surgical complications. The average length of hospital stay was 6 days (2 to 10 days). Patients averaged an MSTS score of 63% and a TESS of 67%.

Conclusion: Radical radiotherapy after spacer insertion offers an alternative to morbid surgery and is associated with good functional outcomes.

Background: Extra-compartmental limb soft tissue sarcomas are notoriously difficult to treat. These tumours can exhibit macro or microscopic spread beyond the confines of normal anatomical barriers and require radical resection, often necessitating excision of bone as well as soft tissue. This will inevitably affect the patient’s functional outcome. The primary operations for these aggressive sarcomas include wide local excision of soft tissue and adjacent involved bone, radical resection with endoprosthetic reconstruction and amputation.

Methods: 85 patients who underwent such an operation between 1995 to 2000 were reviewed and categorised according to whether they received wide local excision, endoprosthesis reconstruction or amputation. Patient demographics, sarcoma details, recurrence and survival rates were identified and compared between the three groups. Functional outcomes in the 45 patients still alive were assessed using TESS and MSTS scores.

Results: Mean age was 61 years (range 8 to 92). There were 51 males and 34 females. Anatomical distribution was as follows: arm 26, leg 47, pelvis 8 and other 4. The commonest histology subtypes were MFH, leiomyosarcoma and undifferentiated soft tissue sarcoma. 17 had wide local excision of bone and soft tissue, 32 underwent endoprosthesis reconstruction and 36 underwent primary amputation. Recurrence rates were highest in the endoprosthesis group at 19%. Five year survival was worst in the amputation group at 49%. Functional outcomes were highest in the wide local excision group, and similar in the other two surgical groups.

Conclusions: Unsurprisingly survival is poorest in the primary amputee group because of the highly aggressive nature of these sarcomas, despite having the most radical treatment. The similar functional outcomes shown between endoprosthesis reconstruction and primary amputation may be influential when considering cases in which this decision is unclear and function is the main issue at stake.

Purpose: We report the clinical and functional outcome of limb salvage surgery and endoprosthetic reconstruction of the distal tibia and ankle joint in 5 patients.

Introduction: The distal tibia is an uncommon site for primary malignant bone tumours and the treatment of choice for most patients is a below knee amputation. Patients who decline an amputation may be offered an endoprosthetic replacement. This is a technically challenging operation and may be associated with high morbidity.

Methods and Results: Over 25 years at our centre, 5 patients underwent distal tibial replacements for bone or soft tissue sarcomas. Two had osteosarcoma, one had a recurrence of Ewing’s sarcoma, one had malignant fibrous histiocytoma, and one had an adamantinoma. The mean age was 37 years (13 to 69 years). There were no tumour recurrences. Four patients developed complications with wound infection. Two of these resulted in below knee amputations. Average follow-up was 31 months (19 to 55 months) with 1 patient lost to follow-up. Patients were evaluated using the Toronto Extremity Salvage Score (TESS) and the Musculoskeletal Tumour Society (MSTS) score. The mean MSTS score was 88% and the mean TESS was 88.5%. Two patients who later had a below knee amputation and who were using a prosthesis averaged an MSTS score of 86.3% and a TESS of 89.3%.

Conclusion: For those patients who are unwilling to undergo an amputation for malignant tumours of the distal tibia, endoprosthetic reconstruction is an alternative, but at the cost of increased risk of significant complications, functional deterioration and morbidity. There was little difference between functional scores for patients who proceeded to have a below knee amputation compared to patients who still had their endoprosthesis

Background/Aims: Biopsy of musculo-skeletal tumours is hazardous and, when poorly performed, may compromise limb salvage surgery and patient survival. The aim of this paper is to examine the early management of such patients referred to our unit with particular reference to the biopsy.

Methods: We conducted a prospective audit of all patients referred to our musculo-skeletal tumour service during 2002. Inclusion criteria were patients with primary tumours of the musculo-skeletal system. Patients with metastases were excluded. We compared the outcome of patients biopsied prior to referral with that of patients biopsied in a recognised treatment centre. Statistical analysis was performed using the chi-squared test and accepting a p value of 0.05 as significant.

Results: One hundred and forty two patients were included. There were 72 men and 70 women with a mean age of 40 years (6–88). The referring surgeon performed biopsies in 29 cases of which 20 were malignant lesions. The senior author biopsied the remaining 113 cases of which 57 were malignant. In 38% of patients biopsied by the referring surgeon definitive treatment was hindered by a badly performed biopsy. In 25 % the definitive treatment had to be changed either to a more radical procedure than would have originally been necessary or to palliative rather than curative intent. Three patients underwent unnecessary amputation. Patients biopsied elsewhere were more likely to a non-diagnostic biopsy (p< 0.0001), more likely to have an incomplete excision (p< 0.0001), more likely to require amputation (p< 0.03) and more likely to require adjuvant radiotherapy (p< 0.05) than those biopsied in our unit.

Conclusions: There is a high complication rate when patients with musculo-skeletal tumours are biopsied by surgeons inexperienced in the management of such lesions. These patients are best served by early referral to a specialist centre where the biopsy can be performed quickly, safely and accurately and definitive treatment can be administered.