Objectives. Guidelines for the management of patients with metastatic bone disease (MBD) have been available to the orthopaedic community for more than a decade, with little improvement in service provision to this increasingly large patient group. Improvements in adjuvant and neo-adjuvant treatments have increased both the number and overall survival of patients living with MBD. As a consequence the incidence of complications of MBD presenting to surgeons has increased and is set to increase further. The British Orthopaedic Oncology Society (BOOS) are to publish more revised detailed guidelines on what represents ‘best practice’ in managing patients with MBD. This article is designed to coincide with and publicise new BOOS guidelines and once again champion the cause of patients with MBD. . Methods. A series of short cases highlight common errors frequently being made in managing patients with MBD despite the availability of guidelines. Results. Despite guidelines for the management of patients with MBD being available for more than a decade basic errors in management continue to be made, affecting patient survival and quality of life. Conclusions. It is hoped that by publicising the new BOOS guidelines the management of patients with MBD will improve over the next decade, significantly more than it has over the last decade

Introduction. The rising incidence of metastatic bone disease (MBD) in the UK poses a significant management problem. Poorly defined levels of service provision have meant that improvements in patient prognosis have been mediocre at best. For that reason the British Orthopaedic Association (BOA) in conjunction with the British Orthopaedic Oncology Society (BOOS) issued guidelines in 2002 on good practice in the management of MBD. Despite the availability of these standards, there is very little robust data available for audit. The aim of this study was to conduct a regional survey of how these guidelines are being used in the management of MBD. Methods. A questionnaire was designed with 9 multiple choice questions representing the most common MBD scenarios. This was posted to 106 Consultant Orthopaedic Surgeons in 12 NHS Trusts in the South East of England. Results. The overall response rate to the questionnaire was 44%. There was considerable variation in the management of solitary femoral diaphyseal lesions, pathological subtrochanteric and intertrochanteric femoral neck fractures and vertebral metastases. Furthermore only 2 out of the 12 Trusts surveyed had a designated MBD lead as per the BOA/BOOS guidelines. Discussion. Our study reflects the variation in the management of MBD throughout the region, which may in turn be linked to poorer clinical outcomes. The results demonstrate the possibility of (i) inappropriate initial treatment, (ii) subsequent late tertiary referral and (iii) poor understanding of the biomechanical basis of orthopaedic implants, with the potential for inappropriate choice of prostheses and high failure rates. Streamlining cancer care will involve establishing regional MBD units within large centres where multidisciplinary services are available. Consequently all surrounding hospitals will need a designated MBD lead that can function as a conduit to this integrated care for selected patients

Introduction: The rising incidence of metastatic bone disease (MBD) in the UK poses a significant management problem. Poorly defined levels of service provision have meant that improvements in patient prognosis have been mediocre at best. For that reason the British Orthopaedic Association (BOA) in conjunction with the British Orthopaedic Oncology Society (BOOS) issued guidelines in 2002 on good practice in the management of MBD. Despite the availability of these standards, there is very little robust data available for audit. The aim of this study was to conduct a regional survey of how these guidelines are being used in the management of MBD. Methods: A questionnaire was designed with 9 multiple choice questions representing the most common MBD scenarios. This was posted to 106 Consultant Orthopaedic Surgeons in 12 NHS Trusts in the South East of England. Results: The overall response rate to the questionnaire was 44%. There was considerable variation in the management of solitary femoral diaphyseal lesions, pathological subtrochanteric and intertrochanteric femoral neck fractures and vertebral metastases. Furthermore only 2 out of the 12 Trusts surveyed had a designated MBD lead as per the BOA/BOOS guidelines. Discussion: Our study reflects the variation in the management of MBD throughout the region, which may in turn be linked to poorer clinical outcomes. The results demonstrate the possibility of. inappropriate initial treatment,. subsequent late tertiary referral and. poor understanding of the biomechanical basis of orthopaedic implants, with the potential for inappropriate choice of prostheses and high failure rates. Streamlining cancer care will involve establishing regional MBD units within large centres where multidisciplinary services are available. Consequently all surrounding hospitals will need a designated MBD lead that can function as a conduit to this integrated care for selected patients

Pediatric patients with lower extremity sarcoma often experience long lasting restrictions concerning physical activity and walking due to the required off-loading of the limb and other consequences of surgeries. Activity promotion during treatment in addition to physiotherapy could improve patients’ activity levels and walking capabilities.

In the present study we investigated the ambulatory activity of 31 pediatric patients (13.7 ± 3.1 years, 1.63 ± 0.15 m, 51.9 ± 15 kg, 19.3 ± 3.7 kg/m2) with Osteosarcoma or Ewing sarcoma at the lower limb using the StepWatch™ Activity monitor (SAM; Orthocare Innovations, USA). Sixteen patients regularly underwent supervised exercise interventions during inpatient stays, 15 did not receive any additional intervention. Step activities were measured for seven consecutive days during home stays at five different points in time, to determine a possible transfer of activity to everyday life.

Patients without intervention assembled considerably less steps than those in the intervention group. Before surgery they reached 25.4% of the intervention group (total n=16), six weeks after surgery 40% (total n= 8), after three months 46% (total n=10), after six months 72% (total n=13) and after one year 90%. However differences only reached significance at the first measurement.

Data presented must be considered as preliminary. Not all patients could be measured at all appointments due to impaired walking ability. Nevertheless activity promoting interventions during inpatient stays seem to have a positive influence on patients’ daily walking activity. Though the differences between the groups are not significant they are considerable. Especially during treatment – as reflected by the first three measurements- patients could benefit from additional interventions exceeding typical therapy regimes. Interventions should be individualized to the patients’ capabilities. Conclusions concerning tumor location or surgical procedures are not yet possible. Future research should furthermore concentrate on the effects of activity promotion on other fields of well-being.

Several studies report a diminished BMD as a consequence of childhood cancer treatment. The aim of this study was to investigate the effects of an exercise intervention on BMD during treatment, since limited mobility is characteristic for cancer therapy and is a major determinant for bone loss.

We analysed DXA scans (Lunar Prodigy, GE Healthcare) of 53 patients (range 8 to 21 years at time of diagnosis) perioperatively (n=49), six (n=38) and twelve months (n=18) after surgery. Scans were performed for the established sites of the lumbar spine and both femora, as well as experimentally for both calcanei. Areal BMD was corrected to obtain volumetric BMD using the model of Kröger.

For both groups, areal and calculated volumetric BMD values were similar at the lumbar spine at time of surgery, as were the differences between affected and not affected femur and calcaneus. The six and twelve months postoperative measurements revealed higher volumetric and areal BMD at the lumbar spine for the intervention group, although significant differences were only found for volumetric BMD values six months postoperatively.

Furthermore, a comparison of both groups showed that the loss in bone density of the affected lower extremity was less pronounced for the intervention group: differences between affected and not affected femur were 9% to 73% higher in the femur and 20% to 29% higher in the calcaneus for the control group.

Previous reports dealing with diminished BMD in pediatric cancer patients were confirmed in this study. However, differences found in BMD between both groups indicate that an exercise intervention during treatment, consisting primarily of strength and endurance training, may inhibit bone loss in pediatric sarcoma patients. Furthermore, the calcaneal site may be an alternative when the determination of femur BMD is not feasible.

Hypertrophy of lumbar articular facets and dorsal joint capsule are well documented in degenerative instability, the molecular changes occurring in the extracellular matrix (ECM) are however unknown.

The L4/L5 posterior articular complex was removed from seven individuals undergoing fusion for degenerative instability. After methanol fixation and decalcification in EDTA, specimens were cryosectioned at 12 μm and immunolabelled with monoclonal antibodies for collagen types I, II, III, V and VI; chondroitin-4 and 6 sulphates; dermatan and keratan sulphate; versican, tenascin, aggrecan and link-protein. Antibody binding was detected using the Vectastain ABC ‘Elite’ kit. Labelling patterns were compared to corresponding healthy specimens examined previously.

In comparison, the degenerative capsule was more dense and hypertrophied and the enthesis more fibrocartilaginous, with immunolabelling extensive for collagen type II, chondroitin–6-sulfate, chondroitin-4-sulfate, aggrecan and link-protein. The articular surface showed extensive evidence of degeneration, while the thickened capsular entheses encircled the articular facets dorsally. Bony spurs capped with regions of cartilaginous metaplasia were prominent in this region, the ECM labelling strongly for type II collagen and chondroitin-6-sulfate.

The hypertrophy of lumbar facet joints subject to instability of the functional spinal unit therefore appears to be due to proliferation of the capsular enthesis rather than the actual articular facet. In view of the physiological function of the dorsal joint capsule as a wrap-around ligament in assisting the limitation of axial rotation, the molecular changes found in degenerative instability suggest rotational instability, such as results from degenerative disc disease, to be a decisive factor in the development of spondylarthropathy. It is furthermore probable, that the pronounced sagittal joint orientation in degenerative instability is the result of reactive joint changes rather than a predisposing factor of instability.