We have investigated whether improvements in design have altered outcome for patients undergoing endoprosthetic replacement of the distal femur following tumour resection.

Survival of the implant and ‘servicing’ procedures has been documented using a prospective database and review of the implant design records and case records.

A total of 335 patients underwent a distal femoral replacement with 162 having a fixed hinge design and 173 a rotating hinge. The median age of the patients was 24 years (range 13–82yrs). With a minimum follow up of 5 years and a maximum of 30 years, 192 patients remain alive with a median follow up of 11 years. The risk of revision for any reason was 17% at 5 years, 34% at 10 years and 58% at 20 years. Aseptic loosening was the most common reason for revision in the fixed hinge knees whilst infection and stem fracture were the most common reason in the rotating hinges. The risk of revision for aseptic loosening in the fixed hinges was 32% at ten years compared with 4% for rotating hinge knees with a hydroxyapatite collar. The overall risk of revision for any reason was halved by use of the rotating hinge.

Conclusion: Improvements in design of distal femoral replacements have significantly decreased the risk of revision surgery. Infection remains a serious problem for these patients.

Aim: To investigate the outcome of prosthetic pelvic replacements., analyzing complications and suggesting ways of avoiding these

Method: We reviewed the records of all 52 patients undergoing custom made hemipelvic replacement of the pelvis at our centre over the past 30 years.

Results: The mean age of the patients was 40 (range 13 to 75) and the most common diagnosis was chondrosarcoma followed by Ewing’s sarcoma. 4 patients had metastases at the time if diagnosis. All tumours involved the acetabulum (P2) and 9 had a significant extension up into the ilium with 28 involving the pubis. There was a very high incidence of complications – local recurrence arose in 40% and infection in 32% at 5rs, there was a 10% risk of amputation (all for local recurrence). The overall survival of the patients was 69% at 5yrs and 59% at 10 yrs and the survival of the prosthesis without a major complication (infection or local recurrence) was only 40% at 5 and 10 yrs. Local recurrence was related to effectiveness of chemotherapy and margins whilst infection was increased by tumours involving the pubic area.

Discussion: Although a successful hemipelvic replacement can produce a good functional outcome, the incidence of complications is very high. Steps to reduce these risks should be carefully considered including the use of wider margins and the use of silver coated prostheses as well as greater use of local or free flaps in selected cases.

99 patients with new diagnosed soft tissue sarcomas involving the pelvic region were studied to determine the outcome and prognostic factors for survival and local recurrence.

The mean age at diagnosis was 57 years. There were 55 males and 44 females. The mean tumor size was 12cm. The tumor was deep in 79 patients and superficial in 20. Surgical treatment was excision in 93 patients and hindquarter amputation in 6 patients. Histological grade was low grade in 23 and high grade in 75 patients. 7% of the patients had metastases at presentation.

The 5 year overall survival was 57% and local recurrence occurred in 22% of the patients. The risk of inadequate surgical margins in patients with tumors within the pelvic brim was 50% compared to 18% for those with tumors located outside the pelvic brim. The significant predictors of local recurrence were inadequate margins and location of the tumor within the pelvic brim. Tumor size, grade and depth did not influence development of local recurrence. Significant predictors of survival included metastases at presentation, tumor grade and depth. The cumulative 5 year survival for patients with deep high grade tumors, deep low grade tumors, superficial high grade and superficial low grade tumors were 45%, 74%, 63% and 100% respectively (p=0.01). The 5-year overall survival was 66% in those patients without local recurrence compared to 37% in those who develop local recurrence (p=0.005). Multivariate analysis revealed that development of local recurrence was the most important determinant of overall and metastases free survival.

We conclude that patients with pelvic soft tissue sarcoma who develop local recurrence have an extremely poor prognosis. Patients with high grade and inadequate surgical margins represent a particular group with very high risk of metastases and death even with radiotherapy and perhaps should be considered for other adjuvant treatment.

130 consecutive patients with metastastic tumours of the extremity bones treated with resection with or without major endoprosthetic reconstruction were studied retrospectively to determine the indication for surgery, complications, clinical outcome and oncological results of treatment.

The mean age at diagnosis was 61 (22 – 84). The tumours originated from a variety of organs. Lower extremity was involved in 104 and upper extremity in 26. Metastatic disease was solitary in 55 patients and multiple in 75 at the time of surgery. The median follow-up possible from the time of operation to review was 48 months (0-103).

The indication for surgery was radical treatment of solitary metastases with curative intent in 33, pathological fracture in 46, impending fracture in 27, failure of prior fixation devices in 17, painful swelling or extremity in 37. Surgical treatment included excision of expendable bones without reconstruction in 20 patients and resection with endoprosthetic reconstruction in 110 patients. 7 patients received adjuvant chemotherapy and the majority received adjuvant radiotherapy.

At the time of review, 58 patients had died at a mean time of 23 months (0–90) from surgery (53 from progressive metastatic disease and 5 from other causes). 72 were alive at mean follow-up of 22 months (1–103) from surgery. 36 patients (28%) were alive at 2 years post-surgery and 8 (6%) at 5 years. One patient died intra-operatively. Post-operative complications occurred in 32 patients (25%). 18 patients required further surgical procedures for dislocation, infection haematoma, stiff joint, plastic surgical procedures. All the patients had control of pain and 90% achieved desired mobility.

There was no difference in the survival of patients who presented with solitary and multiple metastases, renal and non-renal metastases, and upper or lower limb metastases.

Conclusion: Selected patients with bone metastases can benefit from resection and major bone reconstruction with acceptable morbidity. We have not identified predictable prognostic factors in these selected patients.

Only 1% of all primary bone tumours are situated in the distal humerus. Destruction of the distal humerus by tumour is rare and reconstruction of the distal humerus is challenging. Because of the amount of bone loss following tumour excision, excision arthroplasty or arthrodesis is impossible and hence some form of reconstruction is usually required. Allograft reconstruction and hemiarthroplasty are uncommon and lead to an unpredictable outcome.

Ten patients underwent endoprosthetic replacement of the distal humerus for bone tumours over a thirty one-year period. There were 8 primary and 2 secondary tumours and male to female ratio was 2:3. Average age of the patients was 47.5 years (15–76 years). Mean follow up was 8 years (9 months - 31 years). Four patients required further surgery, three having revision for asceptic loosening and two of these and one other later needing a rebushing. There were no permanent nerve palsies, infections, local recurrences or mechanical failures of the implant. Four patients died of their disease between 12 and 71 months after operation, all with their prosthesis working normally.

Average flexion deformity was 15 degrees (0–35) and average flexion of these patients was 115 degrees (110–135). The average TES Score for these patients was 73% (29% to 93%). The activities which the patients found to be no problem (TES score more than 4.5 out of 5) were: brushing hair, drinking from a glass, putting on make up or shaving, picking up small items, turning a key in a lock, doing light household chores and socialising with friends, whilst activities that proved difficult (TES score less than 3 out of 5) were: gardening and lifting a box to an overhead shelf. Pain was not a problem and only 1 of the surviving patients reported ever having to use regular analgesics.

Conclusions: Endoprosthetic replacement of the distal humerus and elbow joint is a satisfactory method of dealing with these unusual tumours in the long term.

To identify the incidence of a cortical breech on the initial presentation X-rays of patients with distal femoral GCTs, and whether this lead to a higher rate of local recurrence of tumour, a prospective database is kept of all patients seen in the unit. Initial presentation X-rays on 54 patients with distal femroal GCTs were reviewed. The size of the tumour was estimated by measuring the largest dimensions of the tumour (depth, breadth & height). The volume of the distal femur was estimated using the same X-ray and computer programme. The X-rays were then carefully studied for evidence of a cortical breach. The records were also checked for evidence of subsequent locally recurrent disease and subsequent surgery.

X-rays were reviewed on 54 patients (29 male, 25 female), range of 18–72 years. All patients had a biopsy-proven GCT of the distal femur, X-rays (prior to biopsy) were reviewed. 34 (63%) patients with a cortical breech on X-ray. The mean tumour volume: distal femoral volumes (TV:DFV) was statistically greater between those patients with a cortical breach and those without, using ANOVA (p< 0.0001). There were 13 patients with local recurrent disease but no statistical difference in subsequent local recurrence rates between the two patient groups. There was also no statistical differences between the number of operations for those who presented with a cortical breach or without. There was no evidence that more radical surgery was required if a patient presented with a cortical breach.

The risk of cortical breech in patients with GCTs of the distal femur is dependant upon the tumour volume to distal femur volume ratio. If the ratio is above 54% then present with a cortical breech on X-ray is likely (95% confidence interval).There is no evidence those patients with a cortical breach have a higher rate of local recurrence, an increased number of operations or more radical surgery.

Conclusion: The risk of cortical breech in patients with GCTs of the distal femur is dependent upon the tumour volume to distal femur volume ratio.

The unusual phenomenon of histological grade change in locally recurrent soft tissue sarcomas is examined by retrospective review of a large sarcoma database. Increased histological grade was found to occur in 20% of recurrent tumours. Several possible factors predisposing to grade change were examined, and only the histologic diagnosis of myxoid malignant fibrous histiocytoma was found to be significant. Despite increased histologic grade, these tumours do not appear to have a worse prognosis in terms of developing systemic disease.

Soft tissue sarcomas (STS) have a reported local recurrence rate of between five and thirty percent. Recurrent tumours are often similar histologically to the initial tumour, however they are occasionally of higher histological grade than the original lesion. Factors that predispose to this change in grade are not known.

We sought to identify the frequency at which locally recurrent STS demonstrate a change in histological grade, and to investigate the possible factors leading to this change. We also investigate whether a change in grade is associated with a poorer prognosis.

We identified one hundred and seventy-three patients who developed locally recurrent STS, one hundred and twenty-four of which met inclusion criteria and who will form the basis of this study. Ninety-two patients (74%) had no change in histological grade, twenty-four (19%) demonstrated an increase in histological grade and eight (7%) a decreased histological grade. Univariate analysis of time to local recurrence, histological diagnosis and use of radiotherapy and chemotherapy did not reveal significant differences between the groups who did and did not undergo change in grade. When the diagnosis of myxoid MFH was looked at separately, there was a higher proportion in the group that developed increased histological grade. Development of a change in grade was not associated with a poorer survival rate.

Increase in histological grade occurs in approximately 20% of locally recurrent STS, but this phenomenon is not associated with a poorer prognosis than if the grade remains the same. A histological diagnosis of myxoid MFH predicts for an increase in histological grade.

Non-union of long bone fractures can be a challenging problem. There are several methods of treatment and they depend upon various patient factors, biology of non-union, and presence of infection. When faced with failure of treatment with biological reconstructive procedures patients have little choice. At our institute we have treated 10 such patients with radical excision and reconstruction using tumour endoprostheses as a last attempt to save the limb.

Median age of the patients was 71 years (25–85). 2 patients were male and 8 were female. Median follow-up was 49 months (8–229). 5 had infected non-union. Resection and massive endoprosthetic reconstruction involved the distal femur in 4 patients, proximal femur 3, distal humerus 2 and total Humerus in 1 patient. Time from diagnosis of non-union to treatment was 0 to 96 months (median 11 months) and patients had had 0 to 6 (median 3) previous operations 5 infected non-unions were operated as 2 stage procedures and received long term antibiotics. 4 out of 5 infected non-unions were salvaged. There were 5 complications, namely periprosthetic fracture, infection, a dislocated shoulder, radial nerve palsy, suture of bosing.

All the patients achieved immediate mobility and stability. Extendible prosthesis allowed partial correction of limb shortening.

Conclusion: Resection of established non-union and reconstruction with endoprostheses is a good salvage operation for elderly and low demand patients in whom time consuming biological reconstruction is not desirable.

Pathological fracture occurs in 5–10% of all primary malignant bone tumours. It is thought that they unfavourably influence survival, because the fracture haema-toma may contaminate adjacent tissues. Management is often more aggressive and one is less inclined to consider limb saving surgery.

Aim of this study was to determine whether the presence of pathological fracture had an effect on rate of limb salvage surgery, role of adjuvant treatment and survival.

A retrospective study was done on all patients with a pathological fracture through localised Ewing’s sarcoma, treated between 1979 and 2001. Of 289 patients with localised Ewing’s sarcoma, 27 had a pathological fracture. Eighteen presented with fracture, in 9 fracture occurred after biopsy. All were treated with chemotherapy according to protocol. Two fractures were already treated by osteosynthesis elsewhere, the rest healed with conservative treatment. After chemotherapy, 20 patients were treated surgically: 19 with limb saving surgery, 1 with amputation. Apart from chemotherapy, treatment was surgery alone in 15, surgery and radiotherapy in 5, and radiotherapy alone in 7 patients. Indications for radiotherapy were close margins, poor chemotherapy response, or pelvic tumours. Surgical margins were wide in 16 patients, marginal in 2, and intralesional in 1 patient. Local recurrence occurred in 2 patients, primarily treated with chemotherapy and radiotherapy alone. Five year survival was 60%, metastasis free survival 59%, both comparable with rates reported in literature.

Conclusion: Chemotherapy allows fractures to consolidate with conservative treatment. Adequate surgical margins can be achieved in the majority of patients with limb saving surgery. Adjuvant radiotherapy does not seem necessary if margins are wide. Survival is not negatively influenced by pathological fracture. The survival rate following limb saving surgery in these patients is similar to that of patients in literature where amputation is done. Limb saving surgery seems a safe option.

Introduction: The anterior drawer test for anterior cruciate ligament (ACL) deficiency, requires a subjective assessment of joint movement, as the tibia is pulled forward. The aim of this study was to objectively quantify this movement using a magnetic tracking device.

Materials and Methods: Ten patients aged 24 to 44 years were assessed as having unilateral ACL deficiency with conventional clinical tests. These patients were then re-assessed using a magnetic tracking device (Polhemus Fastrak). Patients had magnetic sensors attached around their femurs and tibias using elasticated Velcro straps. The Anterior Drawer test was then performed with the patient lying within range of the system’s magnetic source. The test was performed three times on the normal and injured knees of each patient, using a spring balance to apply a standard 20 lb (=89 N) force. During the tests, sensor position and orientation data was collected with an accuracy better than 1 mm and 1 degree, respectively. The data was sampled at 10Hz and stored on a computer for post-test analysis. This analysis deduced the tibial displacement resulting from each anterior drawer.

Results: During the anterior drawer test the supine patient’s knee is in 90 degrees flexion, with the foot planted on the examination couch. As the tibia is pulled anteriorly, it rotates upwards from the foot and the femur experiences a corresponding rotation from the hip. These complex coupled movements are best quantified in terms of absolute displacement of the tibia from the femur. In the normal knees, the mean displacement of the tibia from the femur was 4.2 mm (SD=1.6). In comparison the ACL deficient knees had a mean displacement of 6.3 mm (SD=2.9). This is 50 % more. A paired t test of this data showed a highly significant difference, with P = 0.005.

Conclusion: This study has quantified the movement produced during the Anterior Draw test for ACL deficiency. The tracker’s lightweight sensors caused minimal disturbance to the established clinical test. The system therefore provides objective measurement data to augment the clinicians subjective assessment.

Aim: To identify prognostic for patients who develop local recurrence after initial attempted curative treatment for a soft tissue sarcoma (STS).

Method: All patients who developed a local recurrence (LR) after initial primary treatment of a STS were identified from a prospective database. Their management and outcome were analysed to find prognostic factors.

Results: 178 patients were identified. They had a median age at original diagnosis of 53 and 102 of the patients had high grade tumours, 50 intermediate grade and 23 low grade. The median time to LR was 14 months but extended up to 11.5 years. 47 of the patients developed metastases either before or synchronously with the LR. In these patients the median survival was 20 months with only 4% surviving to 5 years. In the 131 patients who did not have identifiable metastases at the time of diagnosis, 74 subsequently developed metastases at a median time of 12 months following the development of LR.

The median survival for patients without metastases at the time of LR was 3 years with a 31% survival at 10 years. The most important prognostic factor in this group was grade with low grade tumours having a much better outlook (70% survival at 10 years) than intermediate or high grade tumours (24% at 10 years). Complete control of the first local recurrence could not be shown to be a prognostic factor.

Conclusion: Local recurrence has a poor prognosis but this is because it frequently arises in patients who have other bad prognostic factors. Whilst obtaining local control is important, overall survival is poor, but not as bad for those patients who develop metastases.

Aims: To establish the frequency and demographics of soft tissue sarcomas (STS) presenting in the lower limb.

Methods: Patients presenting to a tertiary referral orthopaedic oncology unit over a 10-year period were prospectively entered into a computerised database. The site of primary STS and demographic details were also recorded.

Results: 1519 STS in all body regions were treated. 1067 (70.2%) within the lower limb. 57.0% thigh, 13.0% calf, 8.2% foot and ankle, 7.7% buttock, 5.7% knee, 4.6% pelvis and 3.8% in the groin. There was a male predominance (56.2%). M:F ratio was 2.5:1 for the groin and 1.3:1 for the thigh with the other body regions approximately equal.

Conclusion: The majority of STS are found in the lower limb. In this large series there was a male predominance most marked in groin presentations.

Aims: Soft tissue sarcomas (STS) of the foot and ankle are rare tumours. The aims of this study were to examine the presenting features and highlight those associated with a delay in diagnosis.

Methods: Patients presenting during a 10-year period were identified using a computerised database within the Orthopaedic Oncology Unit at the Royal Orthopaedic Hospital, Birmingham, UK. Additional information was obtained from a systematic case note review.

Results: 1519 patients were treated for STS of which 87 (8.2%) had tumours sited in the foot and ankle. Of these, 75 (86.2%) had presented with a discrete lump (42 (56%) of them having an inadvertent “whoops” excision biopsy), 3 (3.4%) with ulceration and the remaining 9 (10.3%) with symptoms more commonly associated with other benign foot and ankle pathology. Within the group of 9 patients they had previously been treated as plantar fasciitis (3), tarsal tunnel syndrome (2), Morton’s neuroma (1) and none specific hind foot pain (3). Median delay from onset of symptoms to diagnosis as STS was 26 months for this group (mean 50; range 6–180 months) compared to 12 months (mean 32; range 3–240) for the “whoops” biopsy group and 10 months (mean 16; range 2–60 months) for the unbiopsied discrete lump group.

Conclusion: Soft tissue sarcoma in the foot and ankle may present insidiously and with symptoms of other benign pathologies. Failure to respond to initial treatment of suspected common benign pathology should be promptly investigated with further imaging e.g. MRI scan or high resolution ultrasound, or with specialist consultation.

Purpose: To identify the risk of metastases at the time of diagnosis in patients with soft tissue sarcomas and to estimate the cost effectiveness of identifying these.

Methods: A retrospective database review was used to identify all new soft tissue sarcoma patients referred to our unit and to find those identified to have metastases at diagnosis. Data of tumour size, depth, grade, age, type of tumours, Chest x-ray (CXR)/CT chest results were available in all patients. We estimated the efficacy of CXR in identifying metastases and the costs of various staging strategies.

Patients: 1170 with newly diagnosed STS in 7.5 years (1996–2004) were included.

Results: The incidence of metastases at diagnosis was 10% (116 patients), 8.25% (96 patients) had lung metastases and 20 had metastases elsewhere. The risk of having lung metastases at diagnosis was 11.8% in high grade tumours, 6.95% in intermediate grade and 1.2% in low grade tumours. The risk increased almost linearly with size at presentation and was higher in deep tumours and older patients. CXR alone detected 2/3 of all lung metastases. The positive predictive value of the CXR was 93.7%, the negative predictive value was 96.7%, the sensitivity 62.5% and the specificity 99.6%.

The accuracy was 96.9%. CT overestimated metastases in 4%.

Discussion: We recommend that all patients with a newly diagnosed STS should have a CXR and only those with an abnormality or who have large, deep high grade tumours should have a CT chest. This strategy will save £7500 per 100 new patients with STS and will detect 93% of all chest metastases, missing 1 patient with metastases per 166 patients.

Limb preserving surgery following segmental resection of the distal end of the radius and its articular surface presents a major challenge. We have studied 11 consecutive patients with aggressive tumours located in the distal radius that required segmental resection of the distal radius and its articular surface to evaluate the clinical and functional outcome of reconstruction of such defects.

The mean age at the time of diagnosis was 33 years (7–60). Follow up ranged from 12 to 306 months (median 56). Histological diagnosis was osteosarcoma in 4 patients, chondrosarcoma in 2, giant cell tumour in 5 and meta-static carcinoma in 1 patient. Four patients received chemotherapy. The length of excised bone ranged from 6 to 14cm. Reconstruction was performed with non-vascularised proximal fibula strut graft in 6 patients, ulna transposition in 3 and custom made endoprosthesis in 2 patients. The wrist joint was arthrodesed in 5 patients.

At the time of review 2 patients had died of disease, one was alive with disease and 8 were alive and free of disease. Non-union of the graft occurred in one patient, reflex sympathetic dystrophy in 2 and prosthetic dislocation in one. One patient had local recurrence. Four patients required further surgery including one patient who needed an amputation for severe reflex sympathetic dystrophy, one graft revision for non-union, one secondary wrist arthrodesis and one closed reduction of dislocated endoprosthesis. Patients without arthrodesis often had clinical and radiological signs of wrist instability. The majority of the patients achieved satisfactory function with little or no discomfort and ability to perform activities of daily living.

We conclude that limb salvage surgery is worthwhile in patients with resectable tumours of the distal radius.

Myxoid liposarcoma (MLS) is an unusual type of soft tissue sarcoma as it tends to metastasize frequently to sites other than the lungs. This study was aimed to investigate the natural history of patients with MLS to try and identify prognostic factors which could help predict outcome and aid earlier detection of metastases.

Data was prospectively collected from patient notes and analysed retrospectively. Prognostic factors and metastatic pattern were examined using Kaplan-Meier curves. There were 124 patients with MLS, aged between 28 and 93, the median size of the tumours was 12cm and the most common site was the thigh. Following treatment with excision and radiotherapy the 5yr survival was 65%. Survival was related to younger age (p=0.010) and proximal site (p=0.003) and was also related to the % round cell component of the tumour but was not related to either size or depth of the tumour. Site and margins of excision were significant prognostic factors for local recurrence of disease. 32% of patients developed metastases, of whom 18 cases (46.2%) developed pulmonary metastases and 21 (53.8%) developed extra pulmonary metastases. The sites of these varied hugely and was not significantly related to the site or size of the primary tumour. There was no difference in time to develop metastases or in overall survival between the two groups. Median survival following metastases was 24 months.

Although MLS has an unusual pattern of metastases the site of metastases does not predict a better or worse outcome. Intensive follow up for extraskeletal metastases is probably not justified until they become symptomatic.

Purpose: The aim of this study was to understand the effect of endoprosthetic reconstruction in treatment of solitary bone plasmacytoma threatening structural integrity of bone.

Materials and methods: We retrospectively studied 11 patients who underwent endoprosthetic reconstruction for solitary bone plasmacytoma between 1988 and 2003 with more than 1 year follow up. Most had radiotherapy and those who sustained structural damage to a joint or thought to be salvageable were treated with endoprosthetic replacement.

Results: There were 7 males and 4 females, with M: F ratio of 1.75:1, the median age at diagnosis was 53.61years (35–74). Average duration of symptoms prior to presentation at oncology unit was 7.27 months. We had 4 proximal femoral, 2 pelvic, 4 humeral and one tibial Plasmacytomas that were treated with endoprosthetic replacements.8/11 had preoperative radiotherapy for at least 4weeks and 3 did not. Two had postoperative radiotherapy and one adjuvant chemotherapy. Average follow up is 5.45 years (range 1–16years). We had one death due to unrelated causes, one progression to Myeloma treated with adjuvant chemotherapy, two revisions and one dislocation which was reduced by open method. The cumulative overall survival for all patients was 91% at 5 years. The cumulative risk of failure of reconstruction including; infection, dislocation, local recurrence/progression to Myeloma was 27% at 5 years.

Conclusion: Literature review shows that nearly 53% of SBP progress despite radiotherapy to Myeloma at a median time of 1.8 years (2–4 years). But despite average follow up of 5.45 years, progression to Myeloma after endoprosthetic replacement at our unit is 9.09%. We concluded that the use of endoprostheses for reconstruction after excision of solitary bone plasmacytomas threatening structural integrity of bone combined with radiotherapy decreases the disease progression to Myeloma than radiotherapy alone and offers a reasonable but not absolute chance of cure.

Large benign lytic lesions of the proximal femur present a significant risk of pathological fractures. We report our experience of treating 9 consecutive patients with such defects treated with curettage and fibula strut grafting without supplementary osteosynthesis to evaluate the outcome of this type of reconstruction..

The mean age at the time of diagnosis was 13 years (8–21). Follow up ranged from 2 to 215 months (median 15). Histological diagnosis was fibrous dysplasia in 10 patients and unicameral cyst in 2. All the patients were at risk of pathological fracture. None of the patients developed pathological fracture after surgery and the lesions consolidated fully within one year. Local recurrence occurred in one patient (8%). Minor donor site complications occurred four patients.

All the patients were able to fully weight usually within 3 months of surgery.

At the time of review all but one patient were completely asymptomatic and fully weight bearing. The only symptomatic patient was the patient with local recurrence which has recently been treated.

We conclude that fibula strut graft is a good method of reconstruction of cystic defects in the proximal femut. It prevents pathological fracture, allows mechanical reinforcement of the lesion and delivers biological tissue allowing early consolidation of the defect.

Aims Soft tissue sarcomas (STS) of the foot and ankle are rare tumours. The aims of this study were to examine the presenting features and highlight those associated with a delay in diagnosis.

Methods Patients presenting during a 10-year period were identified using a computerised database within the Orthopaedic Oncology Unit at the Royal Orthopaedic Hospital, Birmingham, UK. Additional information was obtained from a systematic case note review.

Results 1519 patients were treated for STS of which 87 (8.2%) had tumours sited in the foot and ankle. Of these, 75 (86.2%) had presented with a discrete lump (56% of them having an inadvertent whoops excision biopsy), 3 (3.4%) with ulceration and the remaining 9 (10.3%) with symptoms more commonly associated with other benign foot and ankle pathology. The 9 had previously been treated as plantar fasciitis (3), tarsal tunnel (2), Morton’s neuroma (1) and none specific hind foot pain (3). Median delay from onset of symptoms to diagnosis as STS was 26 months for this group (mean 50; range 6–180 months) compared to 12 months (mean 32; range 3–240) for the “whoops biopsy group and 10 months (mean16; range 2–60 months) for the unbiopsied discrete lump group.

Conclusion Soft tissue sarcoma in the foot and ankle may present insidiously and with symptoms of other benign pathologies. Failure to respond to initial treatment of suspected common benign pathology should be promptly investigated further with an MRI scan.

Introduction and Aims: There are more than 200,000 anterior cruciate ligament (ACL) ruptures each year in the United States. The replacements used for ACL repair do not fully recreate the ACL’s function and histological appearance. Therefore, a novel tissue-engineered ligament was designed and evaluated after ACL reconstruction in a rabbit model.

Method: Rabbits received tissue-engineered ligaments or tissue-engineered ligaments seeded with primary rabbit ACL cells. The tissue-engineered ligaments were composed of multifilament poly-L-lactide yarn (70 denier) fabricated into novel 24 yarn 3-D braids. Scaffolds were designed to be easily handled and fixed by the surgeon in ACL reconstructions using the suture over the button technique. A continuous scaffold design accommodated the flexibility of intra-articular loads and the rigours of the bone tunnels. The contralateral legs were used as controls. A key parameter for tissue ingrowth was scaffold porosity at 58 ± 9% and mode pore diameter of 183 ± 83 μm.

Results: Histological evaluations showed slow collagen tissue infiltration at the surface of the replacement at the four-week time point for both the tissue-engineered ligament and cell-seeded tissue-engineered ligament. At the 12-week time point, both replacements showed collagen ingrowth and remodelling across the entire implant occurred with a thin fibrous capsule. The cell-seeded tissue-engineered ligament demonstrated greater levels of mature collagen ingrowth and healing compared to the non-cell seeded tissue-engineered ligament. The initial tensile strength properties of the scaffold were 332 ± 20 N and 354 ± 68 MPa, which compared well to the rabbit ACL control (314 ± 66 N). The tensile properties of the tissue-engineered ligament and seeded tissue-engineered ligament at four weeks were 67% and 76%, respectively of control. The tensile properties of the biodegradable implant decreased with time for the tissue-engineered and cell seeded tissue-engineered ligament and by 12 weeks was 9% and 30% respectively, as compared to the rabbit ACL control. The 30% strength retention for the tissue-engineered ligament replacements at 12 weeks was greater than reported by others using poly(lactic acid) and polypropylene ligament augmentation devices (LAD) at 12 weeks, with values of 13% and 16% of control strength retention, respectively.

Conclusion: The results of this study demonstrate the promise of a novel cell seeded tissue-engineered ligament for anterior cruciate ligament regeneration.

Study Design: A prospective cohort study of patients undergoing surgery for prolapsed intervertebral disc.

Objective: To assess a patient’s ability to recall information discussed pre-operatively at the time of informed consent six weeks following surgery.

Subjects: Sixty-one consecutive patients undergoing discectomy for prolapsed intervertebral disc with follow up six weeks after surgery.

Outcome measures: Patients were assessed, using a pre-prepared questionnaire, to establish their understanding of disc surgery prior to signing a consent form. All information on the questionnaire had previously been given to the patient at the time of being put on the waiting list via a copy of the clinic letter to the general practitioner. If patients were unable to complete the questionnaire, they were then tutored using visual aids such as posters and models until they were able to answer the questions correctly. The consent form was then signed. Six weeks following surgery, patients were then asked the same questionnaire to establish their ability to recall the information discussed pre-operatively about disc surgery.

Results: Prior to tutoring, 20 % of patients were unable to recall that their symptoms were due to disc pathology and that surgery to remove the disc would relieve their symptoms. They were also unable to recall the success rate of surgery. Following surgery, only half of this group of patients could recall these facts. Only 32% of patients were able to recall two or more risk factors of surgery prior to tutoring. This improved to 45% following surgery. Pre- and post-operative questionnaire scores were analysed using a paired t-test. There was no statistical improvement in questionnaire scores long term following tutoring.

Conclusion: In this group of patients, extensive tutoring with the use of visual aids as an adjunct, does not statistically improve their ability to recall important information about surgery for prolapsed intervertebral disc and the risks associated with it.

Introduction and Aims: The aim of this study is to identify specific risk factors for developing haemophilia-related orthopaedic complications and to provide a qualitative and quantitative analysis of the orthopaedic management of haemophilia complications.

Method: A postal survey was sent to 48 patients on the Wellington region haemophilia database. The questionnaire covered both qualitative and quantitative questions covering the participants’ current condition and treatment, past and present orthopaedic and non-orthopaedic management, support, education, employment and leisure activities.

Results: Twenty-five patients returned the questionnaire, a response rate of 52%. Most of the participants (68%; 17/25) felt that their education had been compromised as a result of haemophilia complications. Of those participants that were 16 years or older, 68.4% (13/19) felt that their working opportunities had been compromised as a result of haemophilia complications. Despite patients less than 18 years of age receiving prophylactic Factor VIII replacement (n=7) and all patients having Factor VIII available on demand, 18 patients had significant bleeds in the previous six months. Most bleeds were into joints, 13 knees, 13 ankles, 12 elbows, six shoulders and three hips, but a significant number of intra-muscular bleeds (n=22) also occurred. There were 62 painful joints reported by 19 patients, the ankle being most common (n=21), followed by hip (n=13), elbow (n=12), and knee (n=8). Twenty-five orthopaedic operations were described by eight patients, mainly knee (n=11) and hip (n=5) replacements, and synovectomies (n=9). In the last year, two patients who have factor VIII inhibitor had been successfully operated on, one for a large pseudotumor of the thigh, and the other for contralateral hip and knee joint replacement.

Conclusion: Despite good medical management, recurrent joint bleeds are a major problem in haemophilia. Many study patients commented that orthopaedic procedures were not performed readily enough, and that by the time they received their operation, their function had deteriorated significantly.

Introduction and Aims: Endoprosthetic replacement (EPR) following Bone Tumor excision is common. A major complication is infection with serious consequences. The aim is to investigate the cause of infection, management and sequalae.

Method: Over 11, 000 patients have been treated in our unit over 35 years. Information collected prospectively on a database, includes demographic data, diagnosis, treatment (including adjuvant), complications, and outcomes. Data was analysed to identify any infection in EPRs, its management and outcome. Factors such as operating time, blood loss, adjuvant therapy, type of prosthesis were investigated. Outcomes of treatment options were evaluated.

Results: Data was analysed on 1265 patients undergoing EPR over 34 years. Giving a total follow-up time of over 6500 patient years. One hundred and thirty-seven (10.8%) patients had deep infection (defined by a positive culture [n=128] or a clinically infected prosthesis with pus in the EPR cavity [n=9]). Forty-nine (34%) required amputations for uncontrollable infection. The commonest organisms were Coagulase Negative Staphylococcus, Staphylococcus aureus and Group D Streptococci. The only satisfactory limb salvaging operation was two-stage revision, with a 71% success in curing infection. Systemic antibiotics, antibiotic cement or beads and surgical debridement had little chance of curing infection. Infection rates were highest in tibial (23.1%) and pelvic (22.9%) EPRs (p< 0.0001). Patients who had pre- or post-operative radiotherapy had significantly higher rates of infection (p< 0.0001), as did patients with extendable EPRs (p=0.007). Patients who had subsequently undergone patella resurfacing and rebushing also had a higher rate of infection (p= 0.019 & p=0.052).

Conclusion: Infection is a serious complication of EPRs. Treatment is difficult and prolonged. Two-stage revision is the only reliable method for limb salvage following deep infection. Prevention must be the key to reducing the incidence of this serious complication.

Introduction and Aims: An important prognostic factor in neonatal brachial plexus injury is the timing of biceps recovery. Although the natural history is not clear, biceps recovery after three months has been used to predict universally poor long-term shoulder function. The absence of biceps function at three months has been adopted as an indication for early microsurgery, in an attempt to improve upper limb function. e

Method: Between 1980 and 1992, 170 patients with neonatal brachial plexus injury were entered into a prospective study, which recorded details of the birth and serial examinations. Patients were grouped according to the level of injury and timing of biceps return. Twenty-nine patients were observed to have absent biceps at three months. Twenty-eight of 29 patients were available for long-term review at an average of 11 years and one month (range 5yrs 7mths–16 years). At follow-up, patients answered a questionnaire, underwent muscle strength testing, sensory evaluation, and had their shoulder function graded according to Gilbert’s modification of the Mallet score. The level of injury and time of biceps return were compared to the final outcomes.

Results: The level of injury was C5/6 in 13/28 (46%), C5/6/7 in 5/28 (18%) and pan-plexus in 10/28 (36%), with a Horner’s syndrome in four patients. Of the 28 patients with absent biceps function at three months, biceps contraction was observed in 20 patients (71%) by six months. 13/13 C-5,6 patients, 3/5 C-5,6,7 patients, and 4/9 pan-plexus patients (0/4 of those with a Horner’s syndrome) regained biceps by six months. Twenty-two patients did not have plexus surgery, nine of these had subsequent shoulder surgery. At follow-up, 27 of 28 patients had at least anti-gravity biceps function. Patients who regained biceps function between three and six month had better scores for abduction (p=0.04), hand to neck (p=0.05) and hand to back (p< 0.001) than patients who regained biceps after six months. Patients with C-5, 6 lesions had better scores for external rotation (p=0.04), hand to neck (p=0.05), hand to mouth (p< 0.01) and hand to back (p< 0.001) than patients with pan-plexus lesions. Twelve of the 22 (55%) patients who did not have plexus surgery had Mallet class IV shoulders (good function). Of the C-5, 6 patients who did not have plexus surgery, 8/12 had class IV shoulders.

Conclusion: This study supports the associations between prolonged neurological recovery, more extensive level of injury and worse long-term shoulder function. In patients with C-5, 6 injuries and absent biceps function at three months, good shoulder function is common in the long-term without plexus surgery. This finding is important in considering the indications for and the results of early microsurgical intervention.

Purpose: The purpose of this work was to analyse follow-up and prognostic factors in a series of patients treated for soft tissue tumours as a function of the type of facility providing initial care: a supra-regional referral centre (Royal Orthopaedic Hospital, Birmingham), and 38 regional hospitals in the referral area.

Material and methods: This series included 260 patients (111 women and 149 men) treated between 1994 and 1996. Mean age at diagnosis was 61 years. Primary care was given to 96 patients (37%) in the referral centre and 164 (63%) in other centres. Minimum follow-up was five years. The risk of local recurrence and survival prognosis were studied by risk factor: grade, localisation (supra versus infra aponeurotic), tumour size, quality of resection margins.

Results: High-grade tumours were found in 73% of patients with a supra-aponeurotic localisation in 59%. Mean tumour size was 8.6 cm. Tumours in patients treated in the referral centre were larger (10.3 cm versus 7.5 cm) (p< 0.05). Frequency of local recurrence was 20% for the referral centre versus 37% for the other centres. Overall five-year survival rate was 58% and was correlated with grade, tumour size, and localisation (p< à.05). Overall survival of patients given primary care in the referral centre was not statistically different from those treated in the other centres, but for high-grade tumours (UICC grade III), five-year survival was 41% for the referral centre and 14% for the other centres (p< 0.05).

Discussion: Soft tissue sarcomas are rare tumours. For high-grade sarcomas, the rate of recurrence after treatment and the survival rate were better for patients given primary care in the referral centre. The question of centralising patients with this type of disease in referral centres is raised.

Introduction: Referrals for Low Back Pain (LBP) are common and many patients appear to see more than one specialist. In one acute trust, a dedicated Spinal Assessment Clinic (SAC) run by nurse practitioners was developed.

Objective: To determine patterns of referral for LBP from primary to secondary care.

Method: All new referrals to the hospital for LBP in an index period June–November 1998 were included. Consultations for these patients in the preceding six months and the subsequent two years were studied.

Results: A total of 801 patients were referred in the audit period. The patients were seen in the SAC 75%, orthopaedics 5.5%, rheumatology 4.5%, neurosurgery 12% and the pain clinic 4%. Onward referrals made after the initial appointment from the SAC 4.9%, from orthopaedics 26.7%, from rheumatology 8.6%, from neurosurgery 33.7% and from the pain clinic 10.3%. Subsequent repeat referrals made by the GP occurred in 3.7%of patients initially seen in the SAC, 11.1% from orthopaedics, 2.9% from Rheumatology, 3.2% from Neurosurgery and 17.2% from the pain clinic. The average wait in days for a first appointment was SAC 42, orthopaedics 103, Rheumatology 82, Neurosurgery 78 and pain clinic 77.

Conclusion: The SAC offers a shorter wait for patients and an extremely low “churn” rate, implying high rates of satisfaction in patients and GP’s. The wait for other specialities is longer, and in orthopaedics and neurosurgery the re-referral rate is almost one third. Referral procedures to secondary care might need to be streamlined for more efficiency.

Purpose: Hand localisations predominate in Ollier disease. There have however been few studies devoted to this topic and the one report available only presented a few cases. Treatment of multiple enchondromatosis is sometimes discussed with the treatment of solitary enchondromas despite different recurrence behaviour and aggressiveness. A specific approach is indicated.

Material and methods: We present a retrospective series of 22 children treated for multiple enchondromatosis of the hand. One hand was involved in 11 and both hands in 11. We thus identified 246 enchondromas on 33 hands. One girl with Maffucci syndrome died at the age of six years due to angiosarcomatous degeneration of the leg.

Results: At diagnosis, mean age was six years nine months. Pain and pathological fractures were exceptional, observed in three patients. Overall hand function remained satisfactory. We performed surgery for 14 patients (mean age 8 yr 8 mo) due to increasing symptoms and tumour volume. Five patients required two operations and one a third. We thus performed 18 interventions on 37 hand bones (51 surgical procedures). Simple curettage was performed in 21 cases, combined with autologous cancellous grafting in 30 others. One finger had to be amputated due to aggressive recurrence. Radio-lucent residual lesions were found in 62% of the children at mean 19 months follow-up.

Discussion: Hand function remained satisfactory despite a worrisome radiographic aspect. The decision for surgery was basically made to improve the aesthetic aspect of the hand. Many surgical techniques have been proposed. In our experience, it is difficult to eradicate a treated lesion but grafting appears to be more effective than simple curettage.

Conclusion: Function remains good during growth, fractures are exceptional. Lesions stabilise at the end of growth. We have not observed any case of chondrosarcomatous degeneration in our series of paediatric patients. There is however a risk of malignant degeneration which should be suspected in the event of pain, increased tumour volume or pathological fracture.

Aims: Tumours of the distal humerus are rare but a challenge to treat. Options for treatment are excision and flail elbow, arthrodesis with considerable shortening, allograft replacement or endoprosthetic replacement (EPR). A retrospective analysis of 10 cases of EPR distal humerus was done to assess their success in treating tumours.

Methods: A retrospective analysis of 10 distal humeral tumours operated between 1970 and 2001 was done by retrieving data from notes. No patient was lost to follow up. The Toronto Extremity Salvage Score (TESS) was used to assess function in patients still alive.

Results: There were 4 male and 6 female patients, with ages ranging from 15 to 76 years. The period of follow up ranged from 5 months to 31 years. 8 patients had primary tumours and 2 had secondary tumours. 4 out of 10 patients died of metastatic disease 12 to 71 months after operation. None of the 10 patients had local recurrence, infection, amputation or permanent nerve palsy. There were 3 revisions at 48, 56 and 366 months for aseptic loosening. There were 3 rebushings of the plastic inserts at 62,78 and 113 months. Two of the three rebushings were done after revision of the humeral component at 6 months and 30 months. The average TESS Score for these patients was 72.91 out of 100 (29.2 to 93.33).

Conclusion: Custom-made EPR for distal humeral tumours are an effective way of replacing the diseased bone leading to a reasonable level of function and an acceptable failure rate.

We reviewed our experience with diaphyseal endoprostheses to determine the survival of this type of reconstruction and factors affecting that survival.

Method: We retrospectively studied 44 patients who underwent endoprostheticreconstruction of diaphyseal bone defects after excision of primary sarcomas between 1979 and 2002 with more than 2 years follow up.

Results: There were 27 males and 17 females, the median age at diagnosis was 25 years (8–75) and the median bone defect was 18cm (10–27.6).There were 33 femoral reconstructions, 6 tibial and 5 humeral. The cumulative overall survival for all patients was 67% at 10 years and prosthetic reconstruction using revision surgery as an end point was 62% at 10 years. The cumulative risk offailure of reconstruction including; infection, fracture, aseptic loosening, local recurrence and amputation was 45% at 10 years but for amputation only was 13% at 10 years. The patient age, the type of prosthesis ;whether cemented oruncemented, site of defect (femur, tibia, and humerus) and length of defect did not influence prosthetic survival.

Conclusion: We concluded that the use endoprostheses for reconstruction of diaphyseal bone defects remains a valuable method of reconstruction with predictable results and compares favourably with other forms of reconstruction of massive diaphyseal bone defects.

Purpose: To see if current guidelines for the early diagnosis of sarcomas can be improved.

Method: Data on 1100 patients referred to our unit with a lump suspicious of sarcoma was analyzed to try and identify clinical features more common in malignant than benign lumps. The following five items were analysed: size, history of increasing size, presence of pain, depth, age. For each of these items sensitivity, specificity, accuracy and weights of evidence were collected. ROC curves were used to identify the most sensitive cut off for continuous data.

Results: The best cut off predicting malignancy for size was 8cm and for age 53 years

The weights of evidence (WE) are logs of the likelihood ratios and can be added and a probability then calculated. e.g. a 36 yr old with a 10cm, deep, painless lump that is increasing in size scores −0.39 + 0.4 + 0.4 – 0.11 + 0.58 = 0.88. This equates to a risk of the lump being malignant of 70%.

Conclusion: This analysis shows that increase in size is the strongest predictor of malignancy/benignancy followed by age > 53 and size > 8cm. This data can help formulate strategies for earlier detection of soft tissue sarcomas.

Introduction: A ‘whoops’ procedure is when a lump, which subsequently turns out to be a soft tissue sarcoma (STS), is shelled out by a surgeon who is not aware of the diagnosis. In many cases residual tumour will be left behind necessitating further surgery. The significance of a whoops procedure in terms of survival and local control remains uncertain. This study has used case matched controls to compare outcome between two groups.

Method: 794 patients of soft tissue sarcoma with minimum follow up of 5 years were found on our prospectively collected database. 113 were whoops cases, 96 had restaging and reexcision. An observer blinded to the outcome of patients matched the whoops cases with virgins by known prognostic factors i.e. grade, depth, patient age, site, size and diagnosis of the tumour. We have investigated outcome in terms of local control, metastatic disease and survival by known prognostic factors and by their status at presentation.

Results: 96 patients with a whoops procedure were compared with 96 referred directly to our unit. Despite attempts to match patients with as many variables as possible there was a tendency for the patients with whoops to have smaller tumours that were subcutaneous, they were however well matched for grade and stage at diagnosis. 64% of whoops patients had adequate final margin whereas only 44% of virgins had adequate margins. Overall 1.43 additional operations were needed to achieve final margins for whoops cases as against 0.21% for virgin cases. Overall 27% patients had amputation 20% for whoops and 34% for virgin cases nearly 60% were ray amputations of foot or hand. Overall 50% had radiotherapy and 25% had chemotherapy. There was no statistical difference in local recurrence or survival of patients between whoops and virgins at 5 years follow up. Inadequate margins and residual tumour were significant risk factors for local recurrence and high grade, size more than 5 cm, and age more than 50 years were significant prognostic factors for overall survival of the patients.

Conclusion: Inadvertent surgical excision of a STS is not desirable but does not seem to lead to an adverse outcome in this series in which wide re-excision of the area involved has been carried out.

Purpose; To show that Distal Femoral Endoprosthetic Replacement for metastatic disease can be performed with relatively few complications and allows good pain control and mobilisation for otherwise severely compromised patients.

Method; This is a retrospective study, using the oncology database, patient records and local correspondence, looking at 23 patients with distal femoral metastases who had limb salvage with a Distal Femoral Endoprosthesis (DF EPR).

Results; There were 10 males (43%) and 13 females (57%), mean age 65 (38–84). 13 (57%) had Renal, 6 (26%) Breast and 5 other primaries identified. Five had additional metastases. 8 (35%) had pathological fractures. The mean time for diagnosis of mets was 67 months ranging from 0 (i.e. at the time of primary tumour) to 30 years since the original diagnosis. 15 patients had surgery alone. 3 patients were lost to follow up. 15 patients have diseased at a mean of 26 months (4–58) post op. There was one intra-op and four post-op complications. The majority of the patients were satisfied post op with regards to pain and mobility.

The generally unfavourable prognosis and perceived risks have led surgeons to palliate, stabilise in situ or amputate for distal femoral metastases despite recognised morbidity and life style restrictions. We conclude that DF EPR should be considered as a limb salvage option in patients with distal femoral mets.

The purpose of this paper is to present the rare occurrence of clear cell chondrosarcoma in a patient suffering from Niemann-Pick disease (NPD).

NPD is a rare autosomal recessive inborn error of metabolism. It is a lysosomal storage disorder affecting children and adolescents often causing death in early childhood although in milder form patient may survive up to adulthood. Although chondrosarcoma is a relatively common malignant bone lesion, these lesions rarely affect patients suffering from Niemann-Pick disease. This article presents the case of a 50-year-old man with a chondrosarcoma in the olecranon of the left ulna who also suffered from milder form of Niemann-Pick disease. Radiography and MRI showed cortical disruption and an expansile lesion. Histologically, the tumour was classified as grade 2 clear cell chondrosarcoma with classical differentiation according to the American Joint Committee of Cancer pathologic staging system. Amputation of an above elbow type was performed to obtain clear surgical margins. A case report and discussion of this rare association of a patient suffering from milder form of NPD who developed a clear cell chondrosarcoma is presented here. NPD and clear cell chondrosarcoma are rare diseases and together their occurrence was not found reported in the literature. NPD patients rarely live to the age of 50 years. This raises a possibility that if Niemann-Pick patients survived long enough they might develop chondrosarcoma. Alternatively this could just be coincidental. More research is needed to clarify this possibility.

130 consecutive patients with metastatic tumours of the extremity bones treated with resection with or without major endoprosthetic reconstruction were studied retrospectively to determine the indication for surgery, complications, clinical outcome and oncological results of treatment.

The mean age at diagnosis was 61 (22 – 84). The tumours originated from a variety of organs. Lower extremity was involved in 104 and upper extremity in 26. Metastatic disease was solitary in 55 patients and multiple in 75 at the time of surgery. The median follow-up possible from the time of operation to review was 18 months (0–103)

The indication for surgery was radical treatment of solitary metastases with curative intent in 33, pathological fracture in 46, impending fracture in 27, failure of prior fixation devices in 17, painful swelling or extremity in 37. Surgical treatment included excision of expendable bones without reconstruction in 20 patients and resection with endoprosthetic reconstruction in 110 patients. 7 patients received adjuvant chemotherapy and the majority received adjuvant radiotherapy.

At the time of review, 58 patients had died at a mean time of 23 months (0–90) from surgery (53 from progressive metastatic disease and 5 from other causes). 72 were alive at mean follow-up of 22 months (1–103) from surgery. 36 patients (28%) were alive at 2 years post-surgery and 8 (6%) at 5 years. One patient died intra-operatively. Post-operative complications occurred in 32 patients (25%). 18 patients required further surgical procedures for dislocation, infection haematoma, stiff joint, plastic surgical procedures. All the patients had control of pain and 90% achieved desired mobility.

There was no difference in the survival of patients who presented with solitary and multiple metastases, renal and non-renal metastases, and upper or lower limb metastases.

We conclude that selected patients with bone metastases can benefit from resection and major bone reconstruction with acceptable morbidity. We have not identified predictable prognostic factors in these selected patients.

Aims: Tumours of the distal humerus are rare but a challenge to treat. Options for treatment are excision and ßail elbow, arthrodesis with considerable shortening, allograft replacement or endoprosthetic replacement (EPR). A retrospective analysis of 10 cases of EPR distal humerus was done to assess their success in treating tumours.

Methods: A retrospective analysis of 10 distal humeral tumours operated between 1970 and 2001 was done by retrieving data from notes. No patient was lost to follow up. The Toronto Extremity Salvage Score (TESS) was used to assess function in patients still alive.

Results: There were 4 male and 6 female patients, with ages ranging from 15 to 76 years. The period of follow up ranged from 5 months to 31 years. 8 patients had primary tumours and 2 had secondary tumours. 4 out of 10 patients died of metastatic disease 12 to 71 months after operation. None of the 10 patients had local recurrence, infection, amputation or nerve palsy. There were 3 revisions at 48, 56 and 366 months for aseptic loosening. There were 3 rebushings of the plastic inserts at 62,78 and 113 months. Two of the three rebushings were done after revision of the humeral component at 6 months and 30 months. The average TESS Score for these patients was 72.91 out of 100 (29.2 to 93.33).

Conclusion: Custom-made EPR for distal humeral tumours are an effective way of replacing the diseased bone leading to a reasonable level of function and an acceptable failure rate.

Aim: To investigate the versatility of ßexible intramedullary nails (FIN) in the surgical treatment of forearm fractures in children. Methods: 28 children were treated using FIN for displaced forearm fractures over a period of 5 years. There were 18 boys and 10 girls. The mean age was 11.5 years and the mean follow up were 7.9 months. Two nails were used one each for radius and ulna. 12 children were operated for unstable displaced fractures, 14 were operated after failed initial reduction and 2 were operated for open fractures. 16 were nailed by closed method, 12 had mini open technique in cases of failed initial closed reduction. The nails were removed on an average of 6–8 months. Results: All the children achieved bony union in excellent position. The average time for union was 5.6 weeks. All but 2 patients had full range of movements and none had any functional difþculty. 3 children had transient hypo aesthesia in the area of superþcial radial nerve distribution and one child developed compartment syndrome which needed fasciotomy. There were no long term sequel. Conclusions: Use of FINs in paediatric forearm fractures should be encouraged when surgical intervention is needed. They are axially and rotationally stable. They are safe to introduce and remove at a later date. Their ßexibility allows remodelling of the fracture and growth of the long bones.

Aims:We sought to develop and validate a classiþcation system for assessing PFJ status prior to revision surgery. Methods: The classiþcation system grades the condition of the PFJ by describing both the patella bone stock and the patello-femoral tracking. The system was analysed for its reliability by assessing both intra- and inter-observer variability. From our database of 110 patients who underwent revision knee arthroplasty, 66 cases were selected at random. Each patient had both pre and post-operative radiographs to classify. 145 sets of radiographs, each set consisting of an AP, lateral and skyline patella view, were studied. Three clinicians graded all radiographs according to the classiþcation system on 2 separate occasions. These assessments were performed at least 6 weeks apart. The results were analysed by an independent observer who was blinded. Both intra- and inter-observer agreement was quantiþed using kappa values. Results: Inter-observer kappa values between observers A& B, B& C and C& A were 0.89, 0.96 and 0.82 respectively. Intra-observer kappa values were 0.94, 0.87 and 0.97 for the 3 clinicians. This indicates excellent levels of agreement. Conclusions: The proposed classiþcation system provides a convenient, spe-ciþc, descriptive and reproducible method of denoting PFJ status. Our system may be used to accurately communicate and compare PFJ characteristics. This will aid planning of surgical intervention and allow comparison of results and techniques in revision knee arthroplasty.

Aims: We reviewed 100 paediatric lateral condylar fractures of the elbow treated with k-wire þxation. We compared the complication rates of wires left percutaneous versus wires buried beneath the skin. Methods: 68 patients had wires left percutaneous and 32 patients had their wires buried. Fractures were classiþed as displaced or undisplaced. Lengths of time for Ôwires in situñ, limb immobilisation and follow up were recorded. All complications of treatment and outcomes were recorded. Results were analysed using Chi-square tests. Results: Buried k-wires stayed in situ longer than percutaneous wires (average 6.7 versus 4.9 weeks). Fracture types along with mean lengths of immobilisation and follow up were similar for both groups. In the Ôburiedñ group 6 (19%) patients wires migrated through the skin although only 1 (3%) case became infected. 1 (3%) patient developed an uncomfortable heterotrophic ossiþcation. In the Ôpercutaneousñ group 20 (29%) patients developed wire infection and/or granulation tissue requiring treatment. 3 (4%) of these cases severely compromised treatment. Delayed union requiring re-operation occurred in 1(1%) patient. Conclusion: Burying the wires after open reduction and þxation of lateral condylar fractures signiþcantly (p=0.0026) reduces the incidence of infection and overgranulation associated with the wires.

Introduction: Many soft tissue sarcomas undergo initial inadequate excision (the Whoops! procedure) and are then referred to specialist services. The outcome of 108 such patients is presented.

Method: Records of 108 patients were traced from the prospectively collected database at our institute who had reexcisions of soft tissue sarcomas. We investigated outcome both in terms of local control and overall survival following treatment to assess the significance of an inadequate initial excision.

Results: Over a ten-year time period we was 887 new patients with soft tissue sarcoma of whom 140 patients (11%) presented following previous inadequate excision. Of these, 108 patients underwent re-excision in an attempt to achieve clear margins. 80% tumours were high grade and 40% were deep. After reexcision, 57% patients were found to have residual tumour. 32% patients had close margins after re-excision. Over all survival of patients was 80% at 5 years and local recurrence rate was 10%. Local recurrence of patients with marginal excision was 15% at 5 years but for clear margins was 6.7%. Of 108 patients 22 (20%) had metastasis at 5 years of which 16.6% were in the lung. 81% of metastasis occurred in patients with close margins of reexcisions. Survival of patients with close margins was worse than wide margins (p = 0.0025).

Conclusion: Local recurrence was statistically associated with grade, depth, margins of re excision and presence of residual tumour. Overall survival was influenced by close margins and residual tumour but not by local recurrence. Re-excision of soft tissue sarcoma to clear margins improves survival of the patients at 5 years.

Purpose: The purpose of this work was to analyse survival and prognostic factors in a series of patients treated for pelvic chondrosarcoma.

Material and methods: This series included 67 patients (27 women and 40 men) treated between 1971 and 1996 for pelvic chondrosarcoma. Mean age at diagnosis was 45 years (range 18–78). Forty percent of the tumours were grade I. The most frequent localisation was the iliac bone. Conservative surgery was performed in 45 patients. The only surgical treatment possible in 22 patients was an inter-ilioabdominal disarticulation. Resection margins were adequate for only 19 patients (wide resection). Marginal resection was noted in 14 patients with intra-tumour resection in 17.

Results: Overall 5- and 8-year survival was 65% and 58% respectively. Local recurrence rate was 40%, occurring a mean 27 months after initial surgery. Statistical analysis did not reveal any correlation between tumour size, tumour grade, type of surgery, resection margin, and local recurrence. Results were nevertheless less favourable in case of inadequate surgical margins. Tumour grade, tumour size, patient age, gender, and quality of resection did not have a significant effect on overall survival. Local recurrence was the only negative factor predictive of survival (p< 0.05).

Discussion: Development of local recurrence appears to be the most important negative predictive factor in patients with pelvic chondrosarcoma. In this localisation, satisfactory resection margins are often difficult to achieve. Most authors propose inter-ilioabdominal disarticulation as a last resort procedure. The question of the indication for more aggressive initial surgery to obtain more radical resection margins remains open.

Purpose: Primary bone tumours situated at the distal end of the humerus are exceptional and observed in only 1% of the cases. Reconstruction at this level is often difficult due to the wide bone resection. Choosing a massive prosthesis is an interesting method allowing correct carcinological and functional results. We report a series of ten patients who underwent reconstruction of the lower end of the humerus between 1970 and 2001 with a massive prosthesis after tumour resection.

Material and methods: This series included four men and six women, mean age 51 years (15–76). Eight patients had primary bone tumours and two had secondary bone lesions. Mean follow-up was 79 months (9–372). The custom-made constrained hinge prosthesis composed of chromium-cobalt and titanium was cemented. Regular clinical and radiological follow-up data were recorded. The Henneking score and the Toronto Extremity Survival Score (TESS) were used to assess functional outcome.

Results: Three patients underwent revision for aseptic loosening of the humeral component at 48, 56 and 366 months with problem of polyethylene insert wear for two of them. There were no infctions or local recurrences and no secondary amputations. The posterior or anterolateral approach was used for humeral resection (mean 153 mm, 63–160 mm). Postoperatively, three patients developed transient palsy (one radial and two ulnar) which regressed. Four patients died from metastasis and had a satsifactory prosthesis result at time of death. The mean TESS was 73% (29–93%) at last follow-up

Discussion: Although this is a small series, the long-term results appear to indicate that reconstruction of the lower extremity of the humerus with a massive prosthesis is a satisfactory option for this rare tumour localisation.

Aim: The purpose of this retrospective study was to analyse the risk factors, causes, bacteriology of deep infection following extensible endoprosthetic replacement for bone tumours in children and to review our experience in the treatment of 20 patients with infected prostheses.

Materials and methods: 123 patients with extensible endoprostheses were treated between 1983 and 1998. Three types of prostheses, which differed in the lengthening mechanism used, were implanted. 20 of these were diagnosed to have deep infection. Patients were divided into 3 groups: group I- 5 patients were treated with a single stage revision, group II- 13 patients were treated with a two stage revision procedure, group III- 2 patients had a primary amputation. Control of infection was assessed clinically and with inflammatory markers. Function was assessed using the MSTS score.

Results: The overall incidence of infection was 16%. The incidence of infection at the proximal tibia and distal femur was 27% and 14% respectively. Staphylococcus epidermi-dis was the most common organism. The most common clinical features were pain and swelling around the pros-theses. Infection in most cases was immediately preceded by an operative procedure or by distant a focus of infection. The number of operative procedures and the site of the prosthesis were significant risk factors. The success rate was 20% in Group I and 84.6% Group II. Amputation was the salvage procedure of choice for failed revision procedures. The mean MSTS functional score was 83% in patients in whom the infection was controlled.

Conclusion: The incidence of deep infection is high following extensible endoprostheses. The site of the pros-thesis and the number of operative procedures are significant risk factors.

About one third of patients who require one knee replacement have significant bilateral symptoms and will require surgery on both knees before achieving their full functional potential. The options for these patients are either to have one-stage bilateral knee replacements or two-stage knee replacements. Our aim was to compare the relative local and systematic morbidity of patients who had one-stage bilateral knee arthroplasty with those of patients who had unilateral total knee arthroplasty in a retrospective, consecutive cohort of patients to evaluate the safety of one-stage bilateral total knee arthroplasty. Seventy-two patients treated with one-stage bilateral knee replacements were matched for age, gender and year of surgery with 144 patients who underwent unilateral knee arthroplasty. We found one-stage bilateral arthroplasty was associated with significantly increased risks of wound infection, deep infection, cardiac complications and respiratory complications compared to unilateral knee arthroplasty.

No increased risk of thromboembolic complications or mortality was found.

We conclude that one-stage bilateral total knee arthroplasty is associated with increased risk of both systematic and local complications compared with unilateral knee replacement and therefore should be performed on only selective cases.

Our centre has used a specially designed custom-made endoprostheses with curved stems to reconstruct femoral defects in patients with residual short proximal femur after excision of primary bone sarcoma over the last 18 years. Two designs of endoprostheses with curved intramedullary stems were used: the rhinohorn stem type and the bifid stem type. We report the safety, survival and functional outcome of this form of reconstruction.

Twenty six patients who had these special endoprosthesis reconstruction were studied. The median age was 16 years (range 7 to 60 years). Prostheses with rhino horn stems were used in 15 patients and bifid-stem in 1 1 patients. Twenty patients had the prostheses inserted as a primary procedure after excision of primary bone sarcoma, and in six patients the prostheses were inserted after revision surgery of failed distal femur endoprostheses. Seventeen patients (65%) were alive and free of disease at a median follow-up of 98 months (12 to 203 months) and nine patients had died of metastatic disease. Local recurrence developed in two patients (1 0%) out of the 20 patients. Surgical complications occurred in five patients (191/o). Deep infections occurred in two patients (8%) requiring revision surgery in one patient. Prosthetic failure, occurred in nine patients (35%). The cumulative survival of prostheses was 69% at five years and 43% at 10 years. Musculoskeletal Tumour Society mean functional score was 83% (53% to 97%).

In conclusion, preservation of a short segment of the proximal femur and the use of endoprostheses with curved stems for reconstruction of the femur is technically possible. There is an increased risk of fracture of the prostheses decreasing the survival rate. Functional outcome of patients with this form of reconstruction is not significantly different from the functional outcome of patients who have proximal femur or total femur endoprosthetic reconstruction. This operation is particularly desirable in skeletally immature patients and allows normal development of the acetabulum.

The purpose of this retrospective study was to analyze the risk factors, causes, bacteriology of deep infection following extensible endoprosthetic replacement for bone tumours in children and to review our experience in the treatment of 20 patients with infected prostheses.

123 patients with extensible endoprostheses were treated between 1983 and 1998. Three types of prostheses, which differed in the lengthening mechanism used, were implanted. 20 of these were diagnosed to have deep infection. Patients were divided into 3 groups: group I 5 patients were treated with a single stage revision, group 11– 13 patients were treated with a two stage revision procedure, group Ill- 2 patients had a primary amputation. Control of infection was assessed clinically and with inflammatory markers. Function was assessed using the MSTS score.

The overall incidence of infection was 16%. The incidence of infection at the proximal tibia and distal femur was 27% and 14% respectively. Staphylococcus epidermidis was the most common organism. The most common clinical features were pain and swelling around the prostheses. Infection in most cases was immediately preceded by an operative procedure or by distant a focus of infection. The number of operative procedures and the site of the prosthesis were significant risk factors. The success rate was 20% in Group 1 and 84% in Group II. Amputation was the salvage procedure of choice for failed revision procedures. The mean MSTS functional score was 83% in patients in whom the infection was controlled.

The incidence of deep infection is high following extensible endoprostheses. The site of the prosthesis and the number of operative procedures are significant risk factors. The type of prosthesis used is not a risk factor. Two-stage revision is successful in controlling infection in a majority of these cases.

This is a retrospective study of 70 patients with chondroblastoma treated between 1973 to 2000. Of these 70 patients, 53 had their primary procedure performed at our unit in the form of an intralesional curettage. The purpose of this study was to determine the rates of recurrence and the functional outcomes following this technique. Factors associated with aggressive tumour behaviour were also analysed. The patients were followed up for at least 22 months, up to a maximum of 27 years. 6 out of these 53 cases (11. 3%) had a histologically proven local recurrence. Three patients underwent a second intralesional curettage procedure and had no further recurrences. Two patients had endoprosthetic replacement of the proximal humerus and one patient underwent a below knee amputation following aggressive local recurrences. One patient had the rare malignant metastatic chondroblastoma and died eventually. The mean MSTS score was 94. 1%. We conclude that meticulous primary intralesional curettage without any additional procedure can achieve low rates of local recurrence and excellent long-term functional results.

Malignant peripheral nerve sheath tumours (MPNSTs) constitute 10% of soft tissue sarcomas. A significant proportion arise in neurofibromatosis type 1 (NF1). Several publications have compared MPNST survival in sporadic and NF1 patients, without consensus on whether NF1 is an independent factor for poor prognosis.

Clinical and histological data from 135 proven MPNSTs were analysed from 2 national centres for soft tissue tumour surgery diagnosed from 1979 to 2000. 129 patients had follow-up data from 6 months to 21 years. 35 were from patients with NF1. Local treatment involved surgery in surgery in 95%, radiotherapy in 44% and chemotherapy in 21%.

NF1 patients were younger than those with sporadic tumours (median age 26 years vs 53 years, p< 0. 001). Overall MPNST survival was almost identical to that in soft tissue sarcomas as a whole, but was worse in NF1 than in sporadic tumours (33% vs 72% at 30 months [p< 0. 01], 17% vs 39% at 60 months, 6% vs 21% at 120 months). A trend towards shorter time to local recurrence was seen in NF1, but not time to metastasis. Superficial tumours gave improved prognosis. Tumour volume over 100ml was associated with worse survival (46% vs 91% at 30 months, p< 0. 02), as was histological grade (80% high grade vs 25% low grade at 60 months, p< 0. 01). In terms of location, a non-significant over-representation of NF1 MPNSTs in the sciatic and brachial plexii was identified.

NF1 and sporadic MPNSTs exhibited no difference in depth or tumour volume profile, although NF1 tended towards higher grade. Analysis of survival in only high grade tumours, however, still resulted in a significant survival disadvantage in NF1 (33% vs 70% at 30 months, p< 0. 01). Removal of brachial and sciatic plexus tumours from analysis did not affect survivorship profiles in NF1 and sporadic MPNSTs.

Grade, volume and tumour depth correlate with survival; only 7 of 45 patients with deep high grade tumours over 100ml volume were observed to survive beyond 2 years. MPNST survival is worse in NF1 than sporadic tumours. Grade, depth, site and volume differences could not explain this disadvantage.

Few studies of wound complications following limb salvage surgery for soft tissue sarcomas separate anatomical compartments. Forty-nine patients with adductor compartment sarcomas underwent limb salvage surgery, 43% developing significant wound complications, 25% requiring further surgery and 20% had delays in adjuvant radiotherapy as a result. Prior surgery by non tumour surgeons and previous radiotherapy led to an increased risk of wound healing problems. In this particular group of patients, special attention should be made to prevent wound healing complications, possibly involving plastic surgeons at an earlier stage of management.

Between 1982 and 1997, twenty-six children between the age of 2 and 15 (mean age 10. 6 years) underwent proximal femoral replacement. Twenty have survived and all but three have reached skeletal maturity.

Sequential radiographs have been reviewed with particular reference to acetabular development and fixation of the prostheses. Initially a cemented acetabular component was inserted, but recently uncemented implants and unipolar femoral heads that exactly fit the acetabulum have been used.

In older children the acetabulum develops normally and the components remain well fixed. One of nine children over thirteen years with a cemented acetabulum needed revision for loosening and one suffered recurrent dislocations.

In younger children the acetabulum continues to develop at the triradiate cartilage, so a cemented acetabulum grows away from the ischiopubic bar. As the component is fixed proximally, it becomes increasingly vertical and will almost inevitably loosen. In our study six of eight children under 13 years of age with a cemented acetabulum needed revision for loosening.

Unipolar replacements in younger children tend to erode the superior acetabular margin. Femoral head cover is difficult to maintain, and of four unipolar implants in children under thirteen, two required acetabular augmentation.

Cemented cups may be unsuitable for children under thirteen years but our results are not statistically significant. In this age group, unipolar implants may be more appropriate but they have serious potential complications. In children over thirteen, cemented implants survive longer. The number of uncemented implants in our study is too small to comment on long-term survival.

Reconstruction of the shoulder joint following resection of the proximal humerus for bone tumours remains controversial. We report the long term functional results of the simplest form of reconstruction – an endoprosthesis.

One hundred patients underwent endoprosthetic replacement of the proximal humerus between 1976 and 1998. Thirty eight had osteosarcoma, 17 had chondrosarcoma, 16 had metastases and 9 had Ewing’s sarcoma. Mean age was 36 years (range 10 to 80 yrs). Survivorship of patients and prostheses were calculated. Function was assessed using the Musculoskeletal tumour society (MSTS) and Toronto extremity salvage (TESS) scoring systems. Thirty patients could come to the clinics for MSTS scoring and 38 out of 49 alive patients replied to the TESS questionnaires sent out to them.

The overall survival of the patients was 42% at 10 years. Local recurrence (LR) arose in 16 patients, being most common in chondrosarcoma (26%) and osteosarcoma (22%) and arose in 50% of patients with these tumours who had marginal excisions. Of these 16 patients, 8 had forequarter amputations whilst the remainder had excisions and radiotherapy. Mean time to LR was 12 months and all but two of these 16 patients subsequently died within a mean of 18 months.

The prostheses proved reliable and dependable. Only 9 required further surgery of any sort, 2 needing minor surgery to correct subluxation and 7 needing revisions, one for infection after radiotherapy and six for loosening – three after trauma. The survivorship of the prosthesis without any further surgery was 86. 5% at 20years. The survivorship of the limb without amputation was 93% at 20 years.

The functional outcome was very predictable. Most patients had only 45 degrees of abduction although three patients had normal movements. The mean MSTS functional score was 79% and the mean TESS score was also 79%. There was a high level of patient satisfaction but difficulty was encountered especially in lifting and in all activities above shoulder height. Endoprosthetic replacement of the proximal humerus is a predictable procedure providing reasonable function of the arm below shoulder height. The endoprostheses have proved highly dependable with a low re-operation rate. There is a high risk of local recurrence after inadequate surgery which should be avoided if possible.