A case report of an 11 year old boy who underwent tibial osteotomy to prevent angulation of his right tibia.

As a 7 year old, LH sufered a minor injury to his right tibia. A lump appeared at the same site. Soon the lump grew to be similar to “a second knee cap”. However, it only caused him pain when he traumatised it. He and his parents were disturbed by the lump, and the fact that it was creating an anterior-posterior bowing of his tibia. They sought medical advice. His original hospital carried out X rays that demonstrated the deformity and a cloud like lump at the tibial tuberosity.

A bone scan confirmed a solitary osseous lesion. In July 2002 he was referred to the RNOH, where the decision was taken to resect the tibial tuberosity and undertake a corrective osteotomy. Post surgery in August 2002, LH was mobilised in a full cast for 9 weeks and graduated slowly from non to full weight bearing. Histology revealed a probable endchondroma, or unusual growth plate reaction.

A year after the procedure LH is a symptom free, happy and active boy. Radiographs confirm normal angulation of his Tibia.

In conclusion an osteotomy can be a very successful treatment for a childhood lesion that leads to progressive deformity.

Pathological fractures in children can occur as a result of a variety of conditions, ranging from metabolic diseases and infection to tumours. Fractures through benign and malignant bone tumours should be recognised and managed appropriately by the treating orthopaedic surgeon. The most common benign bone tumours that cause pathological fractures in children are unicameral bone cysts, aneurysmal bone cysts, non-ossifying fibromas and fibrous dysplasia. Although pathological fractures through a primary bone malignancy are rare, these should be recognised quickly in order to achieve better outcomes. A thorough history, physical examination and review of plain radiographs are crucial to determine the cause and guide treatment. In most benign cases the fracture will heal and the lesion can be addressed at the time of the fracture, or after the fracture is healed. A step-wise and multidisciplinary approach is necessary in caring for paediatric patients with malignancies. Pathological fractures do not have to be treated by amputation; these fractures can heal and limb salvage can be performed when indicated

Since1986 we have monitored the actual diagnosis of all cases referred to our Unit with the diagnosis of ‘possible primary malignant bone tumour’. We have excluded all patients referred with a known diagnosis of either a benign condition or known to have bone metastases. In most cases the suspected diagnosis was based on X-rays alone, sometimes supported by further imaging. Method. Retrospective review of a prospective database that was started in 1986 identifying the actual diagnosis. Results. There were 5922 patients with a confirmed diagnosis over the 23 year time period of this study. 2205 (37%) were found to have a primary malignant bone sarcoma and 1309 (22%) had a benign bone tumour. 992 patients had a general orthopaedic condition (e.g. geode or a vascular necrosis) whilst 303 (5%) had a haematological malignancy and 289 (4.9%) infection. 533 patients (9%) had metastases. There was a similar pattern of frequency of all diagnoses except for metastatic disease and haematologic malignancy at different ages. The incidence of metastases increased from the age of 35 onwards. Discussion. Analysis of this data has led to an algorithm for investigating ‘worrying’ bones that should lead to earlier diagnosis whilst avoiding unnecessary investigations

Aim. Bumps and lumps of the hand are a common cause for consultation in general practice. However not all of these lesions are of true neoplastic nature and malignant tumours are a rarity in this location. Method. The records of all tumours of the hand and wrist treated surgically at our institution in the period 1994 to 2009 were reviewed. Because of their non-neoplastic nature typical lesions of the hand such as ganglion cysts or palmar fibromatosis and the like were not included in this study. Histological entity, location, radiographic and clinical findings were analysed; malignant tumours were followed up by X-ray and MRI. Results. Out of 142 cases which were further investigated, there were 86 bone tumours and 56 soft tissue lesions. The mean age was 41 years (range 8 to 85), there were 57 male and 85 female patients.122 cases (86%) were benign lesions, 71 cases located in the bone and 52 cases in the soft tissue respectively. There were twenty malignant lesions, sixteen of which were bone tumours; the most common being chondrosarcoma (11), followed by metastases (3) and osteosarcoma (2). The group of malignant soft tissue tumours (4) was comprised of synovial sarcoma (2), Ewing sarcoma (1) and extraosseus myxoid chondrosarcoma (1). Out of 52 benign soft tissue tumours, pigmented villonodular synovitis (32), haemangioma (6) and lipomatous tumours (6) have been the most frequent entities. Chondroma (48), osteoid-osteoma (4) and giant cell tumour (3) were the most common benign bone tumours. Conclusion. Knowledge of tumour prevalence under consideration of the patient's age and location of the tumour is an important prerequisite for identifying neoplastic lesions of the hand

The purpose of this study is to investigate the causes and characteristics of the aggressive solitary bone lesion in patients over the age of forty. Over a four year period, 318 patients over the age of forty were referred to our institution with what we would define as an aggressive solitary bone lesion. Further investigation and diagnostic biopsy as appropriate were performed in all patients. The lesions were then defined according to their radiological appearance, pathology and site. The nature of these lesions was then subdivided into several broad groups. A diagnosis of primary bone sarcoma was found in 30% of these lesions. Plasmacytoma, lymphoma and metastases accounted for 13% each. Benign bone tumours, infection and non-oncological diagnoses accounted for 9%, 6% and 16% of lesions respectively. Aggressive solitary bone lesions are often due to primary bone sarcomas. Metastases from a previously unrecognised primary malignancy account for less than one sixth of lesions. This study emphasises the need for appropriate investigation and biopsy of the aggressive solitary bone lesion

Limb salvage is the gold standard to treat sarcoma patients, but bone stock should be retained for the future, as many of these patients are young and active. For this observational clinical study, 107 patients that presented with 108 malignant or locally aggressive benign bone tumours were treated by wide en-bloc resection of the affected bone, extracorporeal irradiation with 300 Gy to eradicate the tumour, and reimplantation of the bone as an orthotopic autograft. The irradiated bone was rigidly fixed to the remaining bone with classical intramedullary or extramedullary osteosynthesis material. We made a subdivision between intercalary, composite and osteoarticular grafts. The pelvis was considered a third separate entity, as it was considered both an intercalary and an osteoarticular graft when the acetabulum was involved. The incidence of local recurrence with the use of an orthotopic autograft comprised the primary endpoint of this study. Secondary endpoints: preservation of bone stock with graft healing and evaluation of factors that determine preservation. No local recurrences could be detected in the irradiated grafts. One local recurrence was detected in the surrounding soft tissue. At 5 years follow-up, graft healing occurred in 64% of cases, providing stable and lasting reconstruction. Eleven percent of the grafts had to be removed due to several incidents, but none could be proven significant. All patient subgroups displayed comparable results. Early infection appeared to be a significant determinant for the development of pseudarthrosis. Pelvic reconstructions showed a worse outcome. According to the results, guidelines for indications and surgical guidelines, such as rigid fixation and bridging of the graft, are proposed for using this technique. In general sarcoma resection, extracorporeal irradiation, and reimplantation provides a stable and lasting reconstruction with preservation of bone stock

Aim. To study the efficacy of Zoledronic acid in the treatment of benign osteolytic tumours or tumour like conditions of bone as a therapeutic or as an adjuvant agent. Method. 31 patients- 19 female, 12 male, age from 8 yrs to 42 yrs, were treated with intravenous zoledronic acid. In 17 patients (fibrous dysplasia-10, nonossifying fibroma- 4, UBC- 3) zoledronic acid alone was used as a therapeutic agent. In 14 patients (ABC- 3, GCT- 11), it was used as an adjuvant agent after curettage. Four patients presented with pathological fracture. In all patients, 4 mg. zoledronic acid was given at 2 monthly intervals. In 12 adult patients, in addition oral bisphosphonates - alendronate was given weekly for at least 6 months. Results. Patients were evaluated using visual analog pain scale and x-rays. At last follow-up (6-40 months), in 15 patients, treated with zoledronic acid alone, there was thickening of cortices and reduction in the size of the lesion. Pain score decreased from an average of 8 to 2. All four fractures healed. In 2 patients, there was progression in size of the lesion. In 14 patients, where it was used as an adjuvant agent, there was early thickening of bone cortices. There was no local recurrence in this group. There was no adverse reaction to the drug in any of the patient. Conclusion. Zoledronic acid is a third generation bisphosphonates and a proven anti-osteolytic agent. It has proved effective in the treatment of number of osteolytic conditions. Our study also suggests that Zoledronic acid not only help to stabilize these lesions but also resulted in pronounced healing in majority of the patients. It also reduced recurrence rate in aggressive benign bone tumours such as ABC or GCT when used as an adjuvant treatment

We report the results of contained bone defects after curettage of benign bone tumours of the distal radius treated without bone grafting or the use of bone substitute. 11 consecutive patients treated with follow-up of 3 to 11 years (mean 5.7 years) were studied. The mean age at diagnosis was 27 (range 11 to 55). There were7 males and 4 females. Histological diagnosis was giant cell tumour in 8 and aneurismal bone cyst in 3 patients. The mean bone defect at diagnosis was 23.7cm3 (9.2 – 68cm3). Pathological fracture was present in 5 patients prior to surgery. We observed full radiological consolidation of the defects in all the patients within 12 months of surgery. Radiologically detectable osteoarthritis was noted in 5 patients (grade 1 in two patients, grade 2 in one and grade 4 in two patients). Development of osteoarthritis was significantly related to size of the defect and involvement of the joint by the original tumour. No patient without joint involvement developed osteoarthritis. There was no relationship between pathological fracture and development of osteoarthritis. We conclude that contained bone defects in the distal radius do rapidly consolidate without the use of bone grafting or bone substitute. The bone remodels nicely over time. Development of osteoarthritis is related to the damage to the articular defect caused by the tumour

In proximal humerus reconstructions, osteoarticular massive allograft (OA) allows a biologic reattachment of tendineous structures of the host providing stability and functional recovery. Allograft-prosthesis composites (APC) are more technically demanding, but functional advantages with new prosthetic design are expected with lower fracture and failure rate with time. We compared the outcome of patients treated with OA reconstruction (group A) and patients treated with an APC (group B) after humerus resection for bone tumours. Thirty six patients treated between 1996 and 2009 were included in the study (18 group A; 18 group B). The diagnosis was a malignant bone tumour in 28 cases, an aggressive benign bone tumour in 6 and a bone metastasis in 2. Three total humerus resections were performed (two in group A and one in group B). Three different type of prosthesis were used (conventional, reverse and resurfacing). In group A, at an average follow-up of 66 months (2-116), 16 patients were continuously disease free. Ten patients (56%) had no complication; in 6 cases (33%) we observed a fracture of the graft and in 3 cases (17%) a pseudoarthrosis. In group B, at an average follow up of 44 months (3-164), 16 patients were continuously disease free. Thirteen patients (72%) had no complication, in 2 cases (11%) stem loosening, in 2 cases (11%) dislocation, in 1 case pseudoarthrosis and in 1 case resorption and detachment of allograft's great tuberosity was observed. Functional outcome was evaluated using MSTS scoring system: a mean score of 24 (13-30) in group A and 23 (15-27) in group B was observed. In our experience, proximal humerus APC showed functional results comparable to OA allograft with lower complication rate. In conclusion, in biologic reconstruction of the proximal humerus, APC seems to provide a more reliable solution than OA allograft at long term

Purpose: The purpose of this study was to determine factors predictive of tumour recurrence, or refracture, following curettage as treatment for pathological fracture of the proximal humerus through a benign bone lesion. Methods: From a cohort of patients held on a national database the factors predictive of recurrence following surgical curettage in patients with pathological fractures through benign bone tumours of the proximal humerus were examined. Thirty nine cases were identified. The diagnosis was simple bone cyst in 27 patients (69.2%), aneurysmal bone cyst in 4 patients (10.3%), (en)chondroma in 4 patients (10.3%), giant cell tumour in 2 patients (5.1%), benign chondroblastoma in 1 patient (2.6%) and fibroma in 1 patient (2.6%). The mean age was 16.5 years and 70% were male. Results: Most of the patients presented with a history of trauma (77%). Five patients were excluded as their fractures were not treated with surgical curettage. Twenty two patients (65%) had recurrence of the lesion or re-fracture following curettage. None of the patients in whom the fracture occurred after skeletal maturity had a recurrence. Obliteration of the lesion occurred more frequently in those with greatest initial fracture displacement on pre-operative radiographs and in those with impacted fractures. The average time to union and obliteration of the lesion was 4 months (range 1 to 13 months). Conclusions: Factors predictive of recurrence following curettage were age under 21 years, undisplaced fractures and fractures without impaction on initial radiographs. Patients with these features should be followed up until obliteration of the lesion or skeletal maturity

Osteoid osteoma is a classically described benign bone tumour. Traditionally, the surgical treatment of choice was excision, but this can have significant morbidity. In recent years, percutaneous Radiofrequency Ablation (RFA) has grown in popularity as an alternative treatment. This study reports the outcomes using this technique in our regional bone tumour unit. Between May 2003 and October 2007, 14 patients (female, n=4; male, n = 10) aged 15 - 32yrs (mean age, 20.4yrs) underwent CT guided radiofrequency ablation treatment. These patients had typical radiograph, CT, MRI or isotope bone scan features of osteoid osteoma and had significant pain symptoms. The protocol for ablation in our institute is heating the tip of the electrode to 90°C for 6 minutes. All patients were subsequently offered follow up in the out-patient clinic. Outcomes were taken from the Scottish Bone Tumour Registry database. 11 patients (78.6%) patients had complete resolution of symptoms after one RF treatment. 3 (21.4%) cases were unsuccessful but 1 of these was due to technical failure. All 3 of the above patients had complete relief of symptoms after one further RF treatment. 1 (7.1%) patient initially had complete relief of symptoms, but suffered a recurrence after 9 months. This patient also had a second curative treatment. Follow up ranged from 3 – 18 months (mean 10 months). Percutaneous RFA for osteoid osteoma is an attractive treatment due to its efficacy and low morbidity. Our results showed a primary success rate of 78%, a secondary success rate of 100% (after one additional procedure) and a recurrence rate of 7.1%. These are comparable to previous reported series. We believe our results add to the growing literature supporting radiofrequency ablation as the treatment of choice for osteoid osteoma

Introduction. Hand tumors are usually rare and there is not much literature about series of cases. We have studied a series of 110 cases. Hand tumors do consists of both benign and malignant cases. Methods. We studied series of 110 cases at Karnataka Institute of Medical Sciences, Hubli and Mysore Medical College & Research Institute, Mysore. We retrospectively reviewed the records of 110 patients who underwent double ray amputations at our center over few years: few had amputations of the fourth and fifth rays and others amputation of the second and third rays. Mean age at surgery was 34 years (range, 10–45 years), and minimum follow up was 64 months (mean, 98 months; range, 64–136 months). Some patients had high-grade soft tissue sarcomas of the hand, synovial sarcomas, malignant peripheral nerve sheath tumors, and undifferentiated sarcoma. No patients had detectable metastases at surgery. Results. All patients were completely disease-free at latest follow up. One patient was alive with lung metastases detected 32 months after surgery. No patients developed local tumor recurrence. Functional assessment showed a mean Musculoskeletal Tumor Society score of 24 (range, 19–28) and mean grip strength 24% of the contra lateral side (range, 17%–35%). Conclusions. The majority of osseous tumors of the hand are benign. The surgeon who evaluates and treats osseous tumors of the hand has to be familiar with limb anatomy, tumor biology, various presentations of the tumors and the range of treatment possibilities and their limitations. Lesions in the hand more often present earlier in their course than those at other sites, just because they are more likely to superficial and easily noticed. Ganglion cyst is the most frequently encountered comprising 50–70% of benign tumors of hand. Enchondroma was the next common benign bone tumour followed by osteoid osteoma, osteoblastoma, aneurismal bone cyst, giant cell tumor, epidermoid cyst, and osteochondroma. Although malignant neoplasms in the hand that arise from tissues other than the skin are very rare, the hand may be the site of distant breast, lung, kidney, esophagus, or colon adenocarcinoma metastases, most of which have a predilection for the distal phalanges. Malignant tumours of the hand are rare, although there remain many instances in which marginal excisions are performed for unsuspected malignant hand lesions. Suboptimal biopsy incisions and inadvertent contamination during these excisions may result in larger resections or amputations being necessary to ensure complete removal of the tumour with negative margins

Introduction: Tumours of the foot are rare, representing only 4 to 8 per cent of all bone and soft tissue tumours: a negligible number compared to degenerative, posttraumatic, vascular and metabolic diseases of this exposed region. Hence neoplasms of the foot are often diagnosed late and treated inadequately. Methods: The records of all tumours of the foot and ankle treated surgically at our institution in the period 1993 to 2007 were reviewed. Because of their non-neoplastic nature typical lesions of the foot such as plantar fibromatosis or Morton neuroma as well as ganglion and the like were not included in this study. History, location, radiographic and clinical findings were analysed, malignant tumours were followed up by X-ray and MRI. Results: Of the eighty-eight cases which were further investigated, there were forty-four bone tumours and forty-four neoplastic soft tissue lesions. Sixty-nine cases (78%) were benign tumours, half of them (35 cases) located in the bone and in the soft tissue (34 cases) respectively. There were forty-four male and female patients each, the mean age being 40 years (range 4 to 85) for all cases, 39 years for benign and 45 years for malign tumours respectively. There were nineteen malignant lesions, nine of which were bone tumours; the most common being chondrosarcoma (3) and osteosarcoma (3). Malignant soft tissue tumours (10) were very heterogeneous, clear cell sarcoma being the only tumour appearing at least twice. Out of thirty-four benign soft tissue tumours, pigmented villonodular synovitis (11), fibrous (9) and lipomatous (5) tumours have been the most frequent. Thirty five benign bone tumours included chondroma (10), solitary bone cyst (10), aneurysmatic bone cyst (3), osteoid-osteoma (3) and giant cell tumour (3). Conclusion: Knowledge of tumour prevalence under consideration of the patient’s age and location of the tumour is an important prerequisite for identifying neoplastic lesions of the foot

In this paper, a retrospective review was undertaken of a large musculoskeletal tumour database to identify patients who presented with tumours of the foot and ankle. Soft tissue tumours occurred more frequently than bone tumours, and were also more frequently malignant than bone tumours. In contrast to the more recent trend towards limb-preserving surgery in other anatomic areas, malignant tumours of the foot and ankle were frequently unresectable and were treated with amputation. Although the majority of extremity tumours that present to the orthopaedic surgeon are found in the proximal limbs or around the knee, tumours of the ankle and foot are also relatively common. The purpose of this study is to identify the frequency with which benign and malignant bone and soft tissue tumours occur in the foot and ankle and the oncologic and surgical outcomes of these patients. A retrospective review of a large musculoskeletal tumor database in a tertiary referral center from the years 1986–2002 was undertaken. For oncologic outcomes, a minimum two-year follow up was considered. A total of one hundred and sixteen bone and one hundred and seventy-one soft tissue tumours were identified. Seventy-seven bone tumours were benign and thirty-nine were malignant. Sixty-six soft tissue tumours were benign and one hundred and five were malignant. The most common benign bone tumour was giant cell tumour and osteosarcoma was the most common malignancy. Malignant fibrous histiocytoma was common in the distal leg but synovial sarcoma and clear cell sarcoma were more common in the foot. Twenty patients with bone malignancies (51%) and twenty-four with soft tissue sarcomas (23%) had amputation as definitive surgical management. Death from metastases occurred in 25% of patients with bone malignancies and 10% of soft tissue sarcomas. At this center, the majority of bone tumours treated are benign but the majority of soft tissue tumours are malignant. Limb salvage is often not possible and amputation for local tumour control is necessary far more often than in other anatomic sites

Introduction: Osteoid Osteomas are not uncommon, benign bone tumours which have well-defined clinical, radiological and pathological characteristics. These tumours can potentially affect any bone in the body, but show a predilection for long tubular bones. The clinical presentation can easily be confusing, if the site in question is rare and the presentation atypical. Lesions occurring in the foot often pose particular problems in diagnosis, often leading to delays in treatment. Although there have been accounts of the post traumatic presentations of osteoid osteomas, no direct link has been established between trauma and its incidence. Case Report: A 38 year old gentleman was referred by his GP with an eighteen month history of right midfoot pain after a football injury which forced his right foot into hyperextension and abduction. Initial radiographs after the injury were normal. The pain did not respond to non-steroidal anti-inflammatory drugs (NSAIDs) and there were no nocturnal exacerbations. Examination at presentation showed an antalgic gait with medial mid-foot tenderness centred over the first tarso-metatarsal joint (TMTJ). Repeat radiographs showed mild degenerative changes in the first TMTJ. A bone scan showed a hot spot over the right cuneiform bones. Subsequent computed tomography (CT) showed an osteoid osteoma, with a characteristic central calcific nucleus within the nidus, of the medial border of the lateral cuneiform bone. The osteoma was treated with en-bloc excision and the diagnosis was confirmed by histology. Conclusion: Despite the advances in its treatment, osteoid osteoma of the foot can pose a difficult diagnostic puzzle. This condition should always be kept in mind when faced with persistent, post-traumatic foot pain, even in the absence of roentgenographic findings. In such cases a high index of suspicion and a low threshold for appropriate imaging can lead to the timely diagnosis and treatment of this tumour

Purpose: Fibrous dysplasia is a rare condition accounting for about 1% of benign bone tumours. Both mono- and polyostotic dysplasia is described. Treatment of small tumours is not particularly difficult, but extensive or complicated tumours are another problem. The purpose of this work was to present the results of surgical treatment of a consecutive series of 64 patients. Particular focus was placed on complications. Material and methods: This retrospective series included 64 patients with fibrous dysplasia. Mean age was 32 years. There were 37 women and 27 men. Monostotic dysplasia was noted in 58 cases. The femur was the most frequent localisation (n=19). Seven patients had a fracture. Histological proof was obtained in 61 patients. In three patients, fibrous dysplasia was associated with another tumour (aneurysmal cyst or adamantinoma). Several therapeutic strategies were proposed: abstention for three patients, biopsy alone for 13, resection for six, curettage for 34. The curettage was filled in 23 cases with osteosynthesis in 11. Eight patients were given other surgical treatments (prosthesis, osteosynthesis, amputation). Results: We had five postoperative complications. At mean follow-up of 45 months, 14% of the patients still suffered from generally mild to moderate pain. Radiologically, there were four recurrences, 12 unchanged, 18 regressions, and 19 remissions (generally after resection or curettage with filling). Long-term follow-up revealed malignant transformation in two patients. Discussion: Lesions treated by biopsy alone cured or regressed in 30% of the cases while curettage with filling led to cure or regression in 70% of the cases. We did not include patients treated by bisphosphonates in this series because of insufficient follow-up. Nevertheless, this treatment appears to have a promising effect on pain. Conclusion: Results of treatment for fibrous dysplasia are not as good as might be suspected for this benign disease. The role of surgery appears to be on the decline, to be replaced by bisphosphonates whose long-term efficacy must be evaluated

Background. Giant cell tumours of bone (GCT) are benign bone tumours with a locally aggressive character. Local recurrence is considered the main complication of surgical treatment and is described in up to 50% of patients. Intralesional curettage with the use of adjuvants like phenol or polymethylmetacrylate (PMMA) is recommended as initial treatment, significantly decreasing the risk of recurrence. However, risk factors for local recurrence in skeletal GCT have not yet been firmly established and a golden standard for local therapy remains controversial. Objective. The identification of risk factors predisposing for an increased risk of local recurrence. In addition, different surgical techniques are compared to identify the optimal surgical approach for the identified risk factors. Methods. In a retrospective study all 215 patients with bone GCT treated between 1964 and 2009 in one centre were included, of which 193 were suitable for analysis. All patients had minimal follow-up of 12 months (mean 115; range 12–445). Using a Kaplan Meier survival analysis recurrence free survival rates were calculated. Cox-regression was used to determine the influence of different types of therapy, the use of adjuvants, and various patient and tumour characteristics. Results. The mean local recurrence rate for all patients was 35.2% (n=68, 95%CI: 28.3–42.1). Recurrence rate after wide resection was 0.17 (n=6, 95%CI: 0.04–0.29), after curettage with adjuvants 0.32 (n=42, 95%CI 0.24–0.41) and after curettage alone 0.74 (n=20, 95%CI: 0.57–0.91, p < 0.001). Soft tissue extension (Hazard Ratio: 3.8, p < 0.001), localisation in radius and ulna (HR: 2.6, p=0.013), and surgical experience (HR: 2.2, p=0.022) were identified as significant general risk factors for local recurrence. For intralesional resection, Campanacci grade III (HR: 3.9, p=0.019) and location in axial skeleton (HR: 3.3, p=0.016) additionally significantly increased this risk. Comparing treatments our data showed that curettage followed by adjuvants was superior to curettage alone (p < 0.004), and the application of both phenol and PMMA did not present a significantly better outcome than curettage and PMMA alone (HR: 1.07, p=0.881). Conclusion. Of all possible risk factors only soft tissue extension, localisation in radius and ulna and non-radical resections significantly influenced the risk of local recurrence for all treatments. In addition, we found that high-grade tumours and localisation in the axial skeleton were additional risk factors for local recurrence after intralesional surgery. Although wide resection increases patient morbidity, it can be the therapy of choice in high risk patients. Intralesional therapy can be advised for low recurrence risk patients using curettage and PMMA only, whereas our study could not confirm the predicted effect of phenol as an additional adjuvant

Background: Juxta-articular intraosseous cystic lesions (JAICL) are common lesion in patients with rheumatoid arthritis (RA) and could cause spontaneous pathological fractures and extensive joint destruction. Although surgical treatment is well indicated for benign bone tumour such as solitary bone cyst, RA induced JAICL have been rarely treated surgically because of following reasons. The first is the possible re-absorption of grafted bone due to disease progression. The second is donor site problem of iliac bone autografting. The third is limitation of autograft for possible operations in the future. The fourth is the lack of bone graft substitutes with good osteoconductivity. We have developed the interconnected porous calcium hydroxyapatite ceramic (IP-CHA) with excellent osteoconductivity. The IP-CHA achieved major incorporation with host bone much more rapid than the other porous calcium hydroxyapatite ceramics. We evaluated the feasibility and effectiveness of curettage and packing with the IP-CHA for the treatment of JAICL in RA patients. Methods: Nine JAICL in 7 RA patients were treated by curettage and packing with IP-CHA. Eight lesions were impending pathological fractures. Two were male and five were female, the average age of operation was 57.8 years (range, forty-nine to seventy-two years). Follow-up assessment was based on final radiography at an average of 10.9 months after surgery (range, five to seventeen months). The expansion of the cystic lesions around the implanted IP-CHA and the re-absorption of the IP-CHA itself, which means erosion or increasing porosity of implanted IP-CHA, were assessed on the basis of the radiographies at just after operation and final follow up. Results: The locations were as follows: distal radius, 6 lesions; distal ulna, 1; proximal tibia, 1; distal fibula, 1. No lesions showed the re-absorption of implanted IP-CHA itself. One of 9 lesions showed out-expansion of radiolucent area around the implanted IP-CHA without re-absoption of IP-CHA itself at the final follow-up. There were no postoperative fractures as complication. Conclusions: These results suggested that surgical intervention with the IP-CHA could be useful for prevention of pathological fractures due to arthritis related JAICL. The efficacies of this technique might be augmented by amelioration of disease activity with concomitant drug therapy including biologics, since there was one case with out-expansion of cystic lesions in RA patients

Purposes:. See if permanent damage of the growth plate after physeal distraction is the rule and. Identify factors with influence on the viability of the physis after physeal distraction. Introduction: Surgeons have always been concerned about the fate of the growth plate after physeal distraction and for that reason this technique has usually been considered only in patients nearing maturity. Previous experimental work has shown that the velocity of distraction has an influence on the viability of the growth plate at follow-up (recommended rate: 0.5 mm/day). Clinically, it has also been our observation that the condition of the physis prior to distraction is another important factor related to physeal function in the long term. Patients and methods: Since 1987 we have used low velocity physeal distraction in 43 bone segments of which 37 cases have been followed-up at least for 24 months and this has been the group included in this study. The indications were lengthening (14), angular deformity correction (19) and resection of benign bone tumours (4). Most patients (24) were older than 10 y.o. and 22 of them were followed-up until maturity. We have retrospectively reviewed these patients looking at the radiological morphology and function of the distracted growth plate at follow-up. Results: Out of the 24 children older than 10 y.o., twenty showed a premature complete physeal closure. We looked with interest at the 13 cases younger than 10 y.o. since the repercussions of iatrogenic physeal damage would obviously be bigger in this age group. Five out of the 13 showed premature closure and in the remnant eight an open growth plate was observed at follow-up. All patients with open and/or functioning physes after distraction had no local injuries in the growth plate prior to distraction (4 congenital short femora and 4 normal physes). On the contrary, four out of the five cases with prematurely closed physes, had a local physeal damage prior to distraction (3 bony bridges and one non-union), and the remnant was a congenitally short femur. Growth after distraction was difficult to assess in the congenitally short femora but it has been very satisfactory in the 4 cases of previously normal physes (2 benign tumours and 2 femoral shortenings due to hip disorders). In three cases of congenital short femur in pre-teenagers we were able to repeat distraction twice through the same physis, since it had remained open after the first distraction. Conclusions: Physeal premature closure often follows physeal distraction, but not always. The condition of the physis prior to lengthening is an important factor with influence on its viability after distraction

Introduction and Objectives: From January 1983 to December 2000 we treated a total of 542 intermediate to high-grade primary bone tumours. We present our experience in reconstruction following tumour resection from the hip, excluding cases of pelvic reconstruction and cases of localised benign bone tumours of the hip. Materials and Methods: This study included 49 cases of primary bone tumours localised to the proximal humerus (9% of the total). Of all cases treated by means of massive structural allograft for femoral reconstruction (44), only 11 cases were in the hip region. We performed 28 hip tumour resections for high-grade bone tumors with the following diagnoses: osteosarcoma (7), chondrosarcoma (9), Ewing’s sarcoma (6), malignant fibrous histiocytoma (2), and selected cases of metastasis-myeloma (4). Limb salvage procedures (22) with reconstruction after the first surgery included: modular megaprosthesis (11), megaprosthesis associated with massive structural allograft of the proximal third of the femur (8), and osteoarticular allografts (3). The remaining cases (6) required immediate agressive surgery including coxofemoral disarticulation (4) and hemipelvectomy (2). Results: Limb salvage cases treated by means of mega-prosthesis associated with a composite allograft presented the following complications: 1 case of deep infection with local recurrence and immediate postoperative dislocation (12.5%), 3 isolated coxofemoral dislocations (37.5%), and one case of homograft osteolysis (12.5%). Mean follow-up time was greater than 5 years, and two patients died due to dissemination of the primary tumour (1 chondrosarcoma and 1 osteosarcoma). Cases of limb salvage treatment using modular mega-prosthesis had the following complications: 2 isolated coxofemoral dislocations (18%) and 2 cases of recurrence or local tumour progression (18%). Mean follow-up time was greater than 3 years, and two patients died due to progression of the primary tumour. Cases of salvage treatment using osteoarticular allografts had a mean follow-up time of 2 years and showed no significant complications. Discussion and Conclusions: 1) In cases of disease up to 12 years of age (primarily Ewing’s sarcomas) we prefer osteoarticular reconstruction. 2) In cases of young adults (from 12 to 60 years of age) we prefer reconstruction using a megaprosthesis (Wagner type) with massive structural allograft. 3) In cases of older adults (greater than 60 years of age) we perform reconstruction using a modular megaprosthesis for tumour treatment