Aims. Orthopaedic surgeries are complex, frequently performed procedures associated with significant haemorrhage and perioperative blood transfusion. Given refinements in surgical techniques and changes to transfusion practices, we aim to describe contemporary transfusion practices in orthopaedic surgery in order to inform perioperative planning and blood banking requirements. Methods. We performed a retrospective cohort study of adult patients who underwent orthopaedic surgery at four Canadian hospitals between 2014 and 2016. We studied all patients admitted to hospital for nonarthroscopic joint surgeries, amputations, and fracture surgeries. For each surgery and surgical subgroup, we characterized the proportion of patients who received red blood cell (RBC) transfusion, the mean/median number of RBC units transfused, and exposure to platelets and plasma. Results. Of the 14,584 included patients, the most commonly performed surgeries were knee arthroplasty (24.8%), hip arthroplasty (24.6%), and hip fracture surgery (17.4%). A total of 10.3% of patients received RBC transfusion; the proportion of patients receiving RBC transfusions varied widely based on the surgical subgroup (0.0% to 33.1%). Primary knee arthroplasty and hip arthroplasty, the two most common surgeries, were associated with in-hospital transfusion frequencies of 2.8% and 4.5%, respectively. RBC transfusion occurred in 25.0% of hip fracture surgeries, accounting for the greatest total number of RBC units transfused in our cohort (38.0% of all transfused RBC units). Platelet and plasma transfusions were uncommon. Conclusion. Orthopaedic surgeries were associated with variable rates of transfusion. The rate of RBC transfusion is highly dependent on the surgery type. Identifying surgeries with the highest transfusion rates, and further evaluation of factors that contribute to transfusion in identified at-risk populations, can serve to inform perioperative planning and blood bank requirements, and facilitate pre-emptive transfusion mitigation strategies. Cite this article: Bone Jt Open 2021;2(10):850–857

Introduction. Around the knee high-energy fractures/dislocation may present with vascular injuries. Ischaemia time i.e. the time interval from injury to reperfusion surgery is the only variable that the surgeon can influence. It has been traditionally taught that 6-8 hours is revascularisation acceptable. There are only limited case series that have documented the time-dependent lower limb salvage rate (LSR) or the lower limb amputation rate (LAR). We have conducted a meta-analysis to look at LSR and LAR to inform clinical standard setting and for medicolegal purposes. Methods. Two authors conducted an independent literature search using PubMed, Ovid, and Embase. In addition the past 5 years issues of Journal of Trauma, Injury and Journal of Vascular surgery were manually scrutinised. Papers included those in the English language that discussed limb injuries around the knee, and time to limb salvage or amputation surgery. The Oxman and Guyatt index was used to score each paper. Results. 21 retrospective case series articles were identified from 8 different journals. A total of 1575 patients were compiled, 92 patients were lost or died. 263 lower limbs underwent amputation and 1220 limbs were salvaged. 984 lower limbs were salvaged within the 8 hours. The LAR increased with time from 3% with reperfusion surgery in less than 4 hours to 13% at 6 hours and 32% at 8 hours. A lower LAR of 20% for patients presenting after 12 hours was seen

Introduction: Complex extremity injury remains a challenge to those involved in both its emergent and definitive care. Anecdotal concerns exist regarding exposure of orthopaedic trainees to such cases in the light of recent changes in surgical training. We aim to establish the perceived confidence, exposure to caseload and adequacy of training of United Kingdom (UK) Orthopaedic Specialist Trainees in the management of significant extremity trauma. Method: A web-based survey was sent to a sample of orthopaedic trainees. 222 responses from 888 trainees were required to achieve a 5% error rate with 90% confidence. 232 responses were received. Results: Perceived confidence and adequacy of training in wound debridement and fasciotomy is high despite infrequent exposure and training is perceived as adequate. With regards to assessment of limb viability and amputation for extremity injury, exposure is minimal, perceived confidence is lower, particularly in the case of amputation and for this scenario over a third of trainees report their training as inadequate. Perceived confidence in dealing with hand trauma is low and is associated with sparse exposure to cases resulting in a quarter of trainees reporting their training as inadequate. For all scenarios, confidence is seen to increase with time spent in training with the notable exception of post-CCT trainees whom report a lower confidence to their colleagues in the latter years of training. Discussion: Despite infrequent exposure, it has been demonstrated that perceived confidence and adequacy of training in many aspects of extremity injury is high. Concerns are apparent with the management of hand trauma and amputation surgery. This study is the first of its kind to offer a valuable insight into the current training perceptions and requirements of junior orthopaedic surgeons at a national level

Osteosarcoma is the most common tumor among the primitive malignant bone tumors. When different features of these lesions are considered, we can find several varieties of this tumor, with distinct anatomo-clinical presentation, treatment and prognosis. Until the 70s, its prognosis was very poor, the standard surgical treatment was amputation and 80% of the patients died from metastatic disease. With the development of new surgical techniques, the advent of combined chemotherapy and more accurate imaging, the outcome of these patients has improved significantly. Consequently, approximately 90% of the surgical cases are treated with limb salvage procedures. The authors reviewed 22 cases of Osteosarcoma treated in HGSA, 20 being submitted to the T20 Rosen protocol. Trocar biopsy was performed in 19 of the patients and 3 of the patients were submitted to incisional biopsy in order to complete diagnosis. Regarding the anatomo-clinical pattern, Classic Osteosarcoma was present in 19 patients, 2 of the cases were Parosteal and 1 was Central low-grade Osteosarcoma. The majority of patients underwent limb salvage surgery; only 2 had amputation surgery and 1 patient was submitted to palliative chemotherapy. Considering limb salvage procedures, several techniques were performed: arthrodesis (n=1), grafts (n=4), prosthesis (n=13) and compound prosthesis (n=1). The resection margins were wide in 19 cases, marginal in 2 cases and in 1 case intra-luminal. Among the treated patients: 12 patients are still alive and cured, 3 have metastatic disease, 6 are deceased and 1 didn’t complete the follow-up. The final functional score obtained was 84% for the superior limb (DASH) and 81% for the inferior limb (TESS). Although the scarce number of cases described were not enough to make any kind of correlation, it was possible to establish the accuracy of the multidisciplinary approach involved both in the diagnosis and treatment, in agreement with the “state of art”

Between 1944 to 2003, ninety cases of Paget’s sarcoma from the Scottish Bone and Soft Tissue Tumour Registry were reviewed. The mean age of patients was 72.3 years (range, 30 to 85 years). There were 59 males and 30 females. The most frequent sites were the femur (26), pelvis (19), humerus (13), tibia (11), and thoraco-lumbosacral spine (9). Biopsy was done in 69 cases. In the remainder 20 cases, the histological diagnosis was confirmed either from examining amputated limb or at autopsy. The most common type was osteosarcoma. Local excision was performed in seven cases. Resection in two cases and prosthetic replacement in two cases was carried out. Twenty nine patients underwent amputation surgery. Chemotherapy was administered to 15 patients (including 2 preop chemotherapy). Fifty one patients received radiotherapy (preoperatively in eight patients). All the patients died within one year from the date of biopsy with an average survival time of 7.5 months. Patients with Paget’s sarcoma tend to have a very poor prognosis inspite of improvements in therapy strategies including surgery, radiation therapy, and chemotherapy. We emphasise the need for more research by a combined oncosurgical, oncological, radiological and histological approach in the management of Paget sarcoma to improve the prognosis

Between 1944 to 2003, eighty nine cases of Paget’s sarcoma from the Scottish Bone and Soft Tissue Tumour Registry were reviewed. The mean age of patients was 72.3 years (range, 30 to 85 years). There were 59 males and 30 females. The most frequent sites were the femur (26), pelvis (19), humerus (13), tibia (11), and thoracolumbosacral spine (9). Biopsy was done in 69 cases. In the remainder 20 cases, the histological diagnosis was confirmed either from examining amputated limb or at autopsy. The most common type was osteosarcoma. Local excision was performed in seven cases. Resection in two cases and prosthetic replacement in two cases was carried out. Twenty nine patients underwent amputation surgery. Chemotherapy was administered to 15 patients (including 2 preop chemotherapy). Fifty one patients received radiotherapy (preoperatively in eight patients). All the patients died within one year from the date of biopsy with an average survival time of 7.5 months. Patients with Paget’s sarcoma tend to have a very poor prognosis inspite of improvements in therapy strategies including surgery, radiation therapy, and chemotherapy. We emphasise the need for more research by a combined oncosurgical, oncological, radiological and histological approach in the management of Paget sarcoma to improve the prognosis

Background: Adult rhabdomyosarcoma is a relatively rare tumour. Good prognosis has been reported in children with multimodality of management. Because of its rarity, very little has been written about this tumour in adults especially on extremities. Aim- To analyse the results of multimodality treatment of rhabdomyosarcoma of extremities in adults treated over a period of ten years in a UK regional centre. Material and Methods – Between 1991 and 2002, eight patients underwent enbloc resection for rhabdomyosarcoma of extremities. There were four men and four women. Age of these patients ranged from 21 to 78years. Locations of these tumours were thigh in 5 patients, legs in 2 patients and shoulder in one. Treatment consisted of surgical resection in all patients combined with radiotherapy or chemotherapy or both. These patients were studied retrospectively for surgical and treatment details, tumour recurrence, secondary and mortality. Results are analysed in relation to histological subtype, size of the tumour (less or more than 5cm) and stage of the disease. Conclusion: Our experience shows a significant incidence of metastatic recurrence and mortality in these patients. Major determinant of disease control (local and distant) seems to be the size of the tumour at presentation. Treatment must be individualized, but complete local excision with a tumour-free margin should be the goal. Major ablative amputation surgery was not performed

The purpose of this study is to present a series of soft tissue sarcomas requiring complex vascular reconstructions, and to describe their management and outcomes. Soft tissue sarcomas are rare mesodermal malignancies accounting for approximately 1% of all cancers diagnosed annually. Sarcomas involving the pelvis and extremities are of particular interest to the orthopaedic surgeon. Tumours that encase and invade large calibre vascular structures present a major surgical challenge in terms of safety of excision with acceptability of surgical margins. Technical advances in the fields of both orthopaedic and vascular surgery have resulted in a trend towards limb salvage with vascular reconstruction in preference to amputation. Limb-salvage surgery is now feasible due to the variety of reconstructive options available to the surgeon. Nevertheless, surgery with concomitant vascular reconstruction is associated with higher rates of complications including infection and amputation. We present a case series of soft tissue sarcomas with vascular compromise, requiring resection and vascular reconstruction. We treated four patients (n = 4, three females, and one male) with soft tissue masses, which were found to involve local vascular structures. Histology revealed leiomyosarcoma (n = 2) and alveolar soft part sarcomas (n = 2). Both synthetic graft and autogenous graft (long saphenous vein) techniques were utilised. Arterial reconstruction was undertaken in all cases. Venous reconstruction was performed in one case. One patient required graft thrombectomy at one month post-operatively for thrombosis. We present a series of complex tumour cases with concomitant vascular reconstructions drawn from our institution's experience as a national tertiary referral sarcoma service

Background Osteosarcoma is the most common bone sarcoma, and the 3rd most common malignancy in children and adolescents. It accounts for 20% of primary malignant bone tumors. Methods A retrospective review of osteosarcomas from the Scottish National Bone Tumor Registry (1940–2000) involving the upperlimb bones is presented. Patient demography, type and location of lesions, treatment options, recurrence and survival rates, and metastasis have been analysed. Results 75 cases were identified from the registry. Sex incidence showed a slight male preponderance with male: female ratio 1.14: 1.Age at presentation ranged from 4–88 Yrs (mean 28.44 Yrs). 46.7% sarcomas occurred in the second decade (11–20 Yrs). The humerus was the bone most frequently involved (78.6% of lesions), and the proximal humerus the commonest site (60%). The scapula was involved in 9.3% and the forearm in 8%.A rare solitary lesion of the clavicle was encountered.17% presented with pathological fractures at diagnosis. Patients typically present with dull aching pain of weeks to months. All patients underwent radiological studies and diagnostic biopsy. Treatment modalities included amputation, limb-sparing surgery, adjuvant/neoadjuvant chemotherapy and radiotherapy. The cumulative 5 year survival for the series was 32%.Death was usually due to pulmonary and skeletal metastasis, and the mean survival in such patients was 21.5 mts. Patients presenting with metastatic pulmonary disease had poor prognosis. Limb-sparing surgery with wide margins does not compromise survival. Results with custom endoprosthesis are encouraging. Discussion Osteosarcomas require a multidisciplinary approach to diagnosis and treatment to optimise survival. During the first half of the study period amputation was the mainstay of treatment with high incidence of mortality due to metastatic disease. Recent advances in neoadjuvant/adjuvant chemotherapy have improved the ability to perform limb –sparing resections, and disease free and overall survival rates have improved. Regular, long follow-up is indicated in these patients

Hallux valgus deformity may cause overriding of the second toe. Hallux valgus correction surgery in the elderly can be debilitating and patients may suffer a long period of morbidity. We show the outcomes of amputation of over-riding second toe caused by gross hallux valgus in the elderly. Eight patients underwent amputation of their overriding second toe, one of these patients underwent bilateral second toe amputations. All surgery was performed as a day case. Six patients had surgery under a local anaesthetic, two patients had surgery under a general anaesthetic. Patients selected had asymptomatic or minimally symptomatic hallux valgus with an overriding second toe and did not want hallux valgus correction surgery. A disease specific questionnaire using a Visual Analogue Scale (VAS) was implemented measuring pain, discomfort, deformity and walking distance. Patients were followed up for a minimum nine of months. Eight patients (nine feet) underwent amputation of their second toe. There were seven females and one male. The age range was 63–90 years (median 83 years). All patients had a painful second toe on wearing footwear. Skin ulceration occurred on the dorsum of second toe in two patients. The mean VAS for pain, deformity, discomfort and walking distance before and after surgery are:- (before/after); pain = (7.00/0.94), deformity = (7.44/2.78), discomfort = (7.78/1.22) and walking distance = (6.89/6.44). There were no cases of post-operative infection, wound dehiscence, bleeding or deep vein thrombosis. One patient complained of a painful neuroma after one year. Amputation of the second toe significantly reduces pain, discomfort and the appearance of deformity (p< 0.01), there was no difference in the patient’s walking distance after surgery. We recommend this type of surgery as an alternative to hallux valgus correction surgery in the elderly if the first ray is not causing significant symptoms

The February 2014 Oncology Roundup³⁶⁰ looks at: suspicious lesions; limb salvage in pelvic sarcomas; does infection affect oncological survival?; cancer patient pathways; radiological arthritis with cement augmentation in GCT; and post-chemotherapy increase in tumour volume as a predictor of poor prognosis.