Background

The Enhanced Recovery Programme (ERP) is an evidence based initiative aimed at speeding up patient recovery after major surgery and improving their outcomes. The Royal National Orthopaedic Hospital, Stanmore (RNOH) is a specialist orthopaedic and implemented an ERP for primary knee arthroplasties from October 2010.

Aims

Present the outcomes of those patients diagnosed with Ewing's Sarcoma of the foot within the past 10 years and treated at the Royal National Orthopaedic Hospital's Bone Tumour Unit, Stanmore.

Orthopaedic problems are common in patients with Ehlers-Danlos Syndrome (EDS). Articular hypermobility can be particularly disabling leading to instability in the appendicular skeleton. We present a case of an EDS patient presenting with knee pain and instability. It highlights important lessons to be learned when considering joint replacement in this patient group.

A 51 year old lady with EDS underwent a posterior cruciate retaining total knee replacement for pain and instability. She dislocated her knee replacement three months post-operatively after a fall. Her knee was reduced at her local emergency department causing injury to the popliteal artery. She required urgent popliteal artery repair and fasciotomies. The common peroneal nerve was also irreversibly damaged by the dislocation. She has since had one further dislocation and is now awaiting revision surgery. When considering total knee replacement (TKR) in EDS, the patient must be warned of the inferior results compared to TKR for other causes. The increased risk of complications must be explained and a more constrained TKR design considered to address the inherent joint laxity. The potential consequences of a dislocated TKR can be disastrous and therefore relocation must be performed in a controlled environment in the operating theatre.

Skeletal Cryptococcosis although rare has been reported in immunodeficient individuals and in particular those with HIV. We present a case in a HIV- negative patient who presented to the London Sarcoma service masquerading as a primary bone tumour and review the relevant literature.

A 71 year old lady presented with a three month history of right submammary pain associated with a new lump. Chest radiographs showed an osteolytic lesion in the right 6^th rib. CT scans demonstrated mediastinal lymphadenopathy and numerous lung nodules. Differential diagnosis of the lesion included TB abscess, myeloma, lymphoma or as a primary lung tumour presenting with hilar lymphadenopathy and necrotic skeletal metastasis. CT guided biopsy was performed with histology showing necrotising granulomatous inflammation with numerous yeast like organisms in keeping with Cryptococcus fungal infection. She was treated successfully with a six week course of voriconazole.

Cryptococcal skeletal infections can cause significant morbidity and mortality and should be considered as a rare cause of lytic osseous lesions.