Summary. Our meta-analysis showed that pooled mean blood loss during spinal tumour surgeries was 2180 ml. Standardised methods of calculating and reporting intra-operative blood loss are needed as it would be beneficial in the pre-operative planning of blood replenishment during surgery. Introduction. The vertebral column is the commonest site of bony metastasis, accounting for 18,000 new cases in North America yearly. Patients with spinal metastasis are often elderly, have compromised cardiovascular status, poor physiological reserve and altered immune status, all of which render them more susceptible to the complications of intra-operative blood loss and associated transfusion. Currently no consensus exists regarding the expected volume of blood lost during metastatic spine tumour surgery with various papers quoting anywhere between 1L to 6L. Knowledge of the expected blood loss prior to surgery however is important as it facilitates pre-operative planning, intra- and post-operative management of fluid balance and blood transfusion. We conducted a meta-analysis of published literature on spine tumour surgery to answer the question: “What is the expected blood loss in major spinal tumour surgery for metastatic spinal disease?”. Methods. A comprehensive online search of the English literature using Medline, Embase, and the Cochrane Central Register of Controlled Trials was performed. We included articles published from 31 January 1992 until 31 January 2012. This initial online search yielded 98 relevant articles. Two senior investigators independently reviewed all abstracts. The full text of articles that were deemed eligible for further consideration obtained and reviewed. Eighty five articles were excluded at this stage, largely due to lack of clear blood loss data, leaving 13 eligible articles. A hand search of the reference lists of relevant articles yielded 5 more articles. A total of 18 articles were included in the final meta-analysis of blood loss data. Disagreements regarding eligibility of articles for analysis were resolved by consensus. Selected articles for final analysis were independently graded according to the Centre for Evidence-Based Medicine (CEBM) Levels of Evidence. We evaluated the possibility of publication bias by obtaining a funnel plot (created by plotting the sample size against the effect estimate). The Egger's regression asymmetry test was used to assess the existence of publication bias. Results. Eighteen selected articles had a total of 785 patients who had undergone major spine tumour surgery for metastatic spinal disorders. The pooled estimate of the blood loss occurring during spinal tumour surgeries was calculated to be 2180ml (95%CI: 1805–2554ml). Apart from two studies which reported significant mean blood loss of more than 5500 ml, the resulting funnel plot suggested absence of publication bias. This was confirmed by Egger's test which did not show any small-study effects (p=0.119). However, there was strong evidence of heterogeneity between studies with I2=90% (p<0.001). Conclusions. The expected blood loss of a patient undergoing major surgery for spinal tumour constitutes more than a third of the circulating blood volume in a typical cancer patient with significantly impaired physiological reserve. Moreover, cases of catastrophic blood loss exceeding 5L exist in almost every series evaluated in this paper, with some reaching as much as 17–18L. Blood loss is a significant problem during spine tumour surgery and concerted effort is needed to address it

Massive cemented endoprosthesis are used to enable early resumption of activity after tumour surgery. The longevity of the prosthesis varies with anatomical site, pros-thesis type, and mode of þxation. Revision surgery will be required in approximately 50% of cases of endopros-thetic replacements around the knee by 10 years because of aseptic loosening. Insertion of a second cemented endoprosthesis is a challenge because of the poor quality of the remaining bone and loosening recurs quickly. The use of extracortical plate þxation in joint sparing surgery where the remaining bone after tumour resection will not accept an intramedullary stem is also described. The þrst series of 14 patients with extracortical plate þxation in difþcult revision or joint-sparing tumour surgery with a mean follow-up of 5 years are described. The three-plate design incorporates well within a remodelled cortex to achieve osseomechanical integration with all patients regaining their premorbid level of function within 5 months. At 5 years the Enneking scores averaged 27.3. One revision was required in a femoral replacement because of loosening. It was possible to insert a new endo-prosthesis as the intramedullary bone had reconstituted. The preliminary results suggest that this technique may provide an easy, biomechanically friendly alternative to a device with an intramedullary stem, which has a shorter lifespan in revision tumour surgery

Summary. This is the first ever study to report the successful elimination of malignant cells from salvaged blood obtained during metastatic spine tumour surgery using a leucocyte depletion filter. Introduction. Catastrophic bleeding is a significant problem in metastatic spine tumour surgery (MSTS). However, intaoperative cell salvage (IOCS) has traditionally been contraindicated in tumour surgery because of the theoretical concern of promoting tumour dissemination by re-infusing tumour cells into the circulation. Although IOCS has been extensively investigated in patients undergoing surgery for gynaecological, lung, urological, gastrointestinal, and hepatobiliary cancers, to date, there is no prior report of the use of IOCS in MSTS. We conducted a prospective observational study to evaluate whether LDF can eliminate tumour cells from blood salvaged during MSTS. Patients & Methods. After Institutional Review Board (IRB) approval, 21 consecutive patients with metastatic spinal tumours from a known epithelial primary (defined as originating from breast, prostate, thyroid, renal, colorectal, lung, nasopharyngeal) who were scheduled for MSTS were recruited with informed consent. During surgery, a IOCS device (Dideco, Sorin Group, Italy) was used to collect shed blood from the operative field. Salvaged blood was then passed through a leucocyte depletion filter (RS1VAE, Pall Corporation, UK). 15-ml specimens of blood were taken from each of three consecutive stages: (i) operative field prior to cell saver processing (Stage A); (ii) transfusion bag post-cell saver processing (Stage B); (iii) filtered blood after passage through LDF (Stage C). Cell blocks were prepared by the pathology department using a standardised laboratory protocol. From each cell block, 1 haematoxylin and eosin (H&E) slide, and 3 slides each labelled with one of the following monoclonal mouse cytokeratin antibodies AE1/3, MNF 116 and CAM 5.2 were prepared. The cytokeratin antibodies are highly sensitive and specific markers to identify tumour cells of epithelial origin. These slides were read by one of two consultant pathologists who were provided full access to information on operative notes, but were blinded to the actual stages from which the slides were derived. Results. One case was excluded when the final diagnosis was revised to infection instead of metastatic spine tumour. Of the remaining cases, 7/21 tested positive for tumour cells in Stage A, 2 positive in Stage B. No specimen tested positive for tumour cells in Stage C. In 5 cases, posterior instrumentation without tumour manipulation was performed. Discussion/Conclusion. In this first-ever study of cell saver use in spine tumour surgery, we prove that leucocyte-depletion filters (LDF) can effectively eliminate tumour cells from blood salvaged during MSTS. It is now possible to conduct a clinical trial to evaluate IOCS-LDF use in MSTS. Our results are consistent with published results of similar studies performed on IOCS and LDF use outside the field of orthopaedic surgery. Spinal metastases originate from a myriad of primary cancers across various organ systems. If LDF can remove tumour cells from blood salvaged during surgery for spinal metastasis of different histological origin, then the finding can likely be extrapolated to several other fields of surgery where IOCS and LDF have not yet been attempted such as: neurosurgery, otolaryngology and general musculoskeletal oncology. Our results form a proof-of-concept for a paradigm shift in thinking regarding autotransfusion during spine tumour surgery

Summary. There is emerging evidence of successful application of IOCS and leucocyte depletion filter in removing tumour cells from blood salvaged during various oncological surgeries. Research on the use of IOCS-LDF in MSTS is urgently needed. Introduction. Intra-operative cell salvage (IOCS) can reduce allogeneic blood transfusion requirements in non-tumour related spinal surgery. However, IOCS is deemed contraindicated in metastatic spine tumor surgery (MSTS) due to risk of tumour dissemination. Evidence is emerging from different surgical specialties describing the use of IOCS in cancer surgery. We wanted to investigate if IOCS is really contraindicated in MSTS. We hereby present a systematic literature review to answer the following questions: 1. Has IOCS ever been used in MSTS? 2. Is there any evidence to support the use of IOCS in other oncologic surgeries?. Methods. A systematic review of the English literature was conducted using computer searching of databases: Medline, Embase, the Cochrane Central Register of Controlled Trials for articles published between 1 January 1986 and 31 Dec 2012. Results. Question 1: A comprehensive literature search did not provide any publication describing the use of IOCS in MSTS. The application of IOCS in MSTS has never been described before. Question 2: Our systematic review shows that the use of IOCS has been extensively investigated in patients undergoing surgery for gynaecological, lung, urological, gastrointestinal, and hepatobiliary cancers. The literature review considered 281 abstracts from the initial search. After consideration by consensus, 30 articles were included in the final analysis. We included in our review -prospective, retrospective studies and in vitro studies. The selected articles were then classified according to the surgical specialty: gynaecological, lung, urological, gastrointestinal, and hepatobiliary cancers and type of studies: reinfusion studies, non-reinfusion studies and in vitro studies. 23 Reinfusion studies: Studies where salvaged blood was actually re-infused into patients and analyzed on the basis of clinical outcomes like survival, recurrence, metastasis rates, and transfusion requirements, etc. IOCS has been extensively investigated in several large cohort studies and large case series with considerable follow-up duration across urological, gynaecological, hepatobiliary and gastrointestinal cancers. Patients receiving salvaged blood have been shown to perform as well or better across a variety of clinical outcome measures as mentioned above. 2 in vitro studies and 5 non-reinfusion studies: Studies where salvaged blood was not re-infused into patients but was analyzed for the presence or viability of tumour cells in the processed blood. They consistently demonstrated the utility of LDF in either greatly reducing the number of tumour cells or even completely eradicating tumour cells from blood-tumour admixtures or salvaged blood. This provides the “proof-of-concept” that LDF is able and is effective in removing tumour cells from blood. Discussion/Conclusion. There is strong evidence that LDF can safely remove tumour cells from salvaged blood. IOCS in patients undergoing cancer surgery is not associated with any adverse clinical outcomes. The reluctance of spine surgeons to use IOCS in MSTS appears to be unsupported. There is ample evidence supporting the use of IOCS in oncological surgeries. Research is needed to evaluate the application of IOCS in MSTS

Introduction and Objectives: The success rate of bone allografts in the medium term when used in cancer surgery is 63% to 90% according to the different series. Our aim was to analyze the results and the complication rate seen in bone allografts as used in our center. Materials and Methods: We collected follow-up data from 35 patients who received 37 allografts. The variables analyzed include diagnosis, age, bone and side affected, type of allograft, complications, additional surgery, time of follow-up, and allograft and patient survival. Results: Mean age at surgery: 10.6 years. 48.64% were osteosarcomas, 48.64% were Ewing sarcomas, 2.7% were other diagnoses. 52.94% were strut grafts, 29.41% were osteoarticular, 2.94% were composite, 2.94% were arthrodesis and 11.76% were other types. Of these, 88.88% suffered some type of complication and 81. 48% required additional surgery. We achieved allograft survival in 85.29% of cases with a mean follow-up of 55.45 months. Most frequent complications were non-union (25%), postoperative metastasis (25%) length discrepancy (25%), followed by degenerative arthritis (24%) graft resorption and infection (16.6%). Discussion and Conclusions: Allografts are a reconstructive option with good results in the medium term. In spite of the high complication rate, additional surgeries applying rescue procedures have made it possible to obtain allograft survival similar to that seen in published series

Background: Intramedullary spinal cord tumours (ISCT) are rare with an annual incidence of less than 1 per 100,000 population. This makes assessing the efficacy of any treatment regimen difficult. Goals of management currently focus on obtaining a histological diagnosis for prognostic and therapeutic planning, and long-term tumour control. However, current outcome measures are crude and the quality of life outcome after surgery for intramedullary spinal cord tumours remains uncertain. Aim: The aims of this study are to assess disability and outcome in patients undergoing surgery for ISCT. We aim to provide prospective quality of life data on patients with spinal cord tumours. Patients and Methods: Data was collected prospectively on patients undergoing surgery for ISCT between 1995–2006 under the care of the senior author. The Short Form 36 (SF36) Health Survey Questionnaire was self-administered prior to surgery and again at 3, 12 and 24 months after surgery. All patients were also classified using the Frankel disability score. SF36 data were analysed using the Friedman test with Dunn’s post-test for multiple comparisons and the Wilcoxon signed rank test for matched pairs. Results: Sixty-five patients (35 men, 30 women) had surgical interventions for ISCT. The mean age at first operation was 43y and median follow-up time was 60 months. 15% had astrocytomas, 45% ependymomas, 7 haemangioblastomas and 19 miscellaneous tumours. Seventy-two percent of patients (47/65) were graded Frankel D pre-operatively and 65% (42/65) remained so after surgery. SF36 data were obtained for 17 patients. Pre-operatively, patients with ISCT had significantly lower SF36 physical domain scores when compared with normative data from age-matched population controls (p=0.0096). There was no difference between post-operative scores and those of normal controls. Matched pairs analysis on the patients with complete SF36 data sets (n=12) demonstrated a significant improvement in physical function post-operatively. Eleven of these 12 did not show an improvement in their Frankel grade, remaining Grade D pre- and post-operatively. Conclusion: From this preliminary study it appears that patients with spinal cord tumours have significantly impaired physical function compared to the normal population. More importantly, we have demonstrated that the SF36 can detect changes in function associated with spinal cord tumour surgery that other, cruder measures, cannot

Introduction: Non-invasive expandable prostheses for limb salvage tumour surgery was first used in 2002 and has now been implanted in a series of 40 skeletally immature patients. Method: Our review of these includes 24 distal femoral replacements, 5 proximal femoral replacements, 3 total femoral replacements and 8 proximal tibial replacements. These were used to treat 31 osteosarcomas, 7 Ewing’s sarcomas, 1 chondrosarcoma and 1 aneurysmal bone cyst. Patients had a mean age of 11.7 years (7–16). Follow-up extended to 88 months with a mean of 26.3 months. Results: There has been 1 failure of the prosthesis gearbox which required revision surgery. 4 of the prostheses reached their maximum length and were successfully re-operated to exchange components of the prosthesis and resume lengthening. 3 patients had disseminated meta-static disease (1 being present before primary surgery) and another developed infection of the prosthesis that required an above-knee amputation. There have been 233 lengthenings overall with 1 patient requiring reversal on one occasion due to intractable pain; this pain rescinded 30 minutes after lengthening was reduced by 10mm. Otherwise lengthening was well tolerated despite the significant growth of the limbs: mean 21.2mm (0.5–84mm). At latest follow-up the mean Musculoskeletal Tumour Society score was 75% (26–93%). Discussion: The results achieved are equivalent to our series of minimally invasive growers which require repeated surgery. Our non-invasive growing prostheses remain reliable and negate the need for recurrent operations, thus resulting in low infection rates. Our results remain encouraging up to 7 years after first use, maintaining leg-length equality and function

Non-invasive expandable prostheses for limb salvage tumour surgery were first used in 2002. These implants allow ongoing lengthening of the operated limb to maintain limb-length equality and function while avoiding unnecessary repeat surgeries and the phenomenon of anniversary operations. A large series of skeletally immature patients have been treated with these implants at the two leading orthopaedic oncology centres in England (Royal National Orthopaedic Hospital, Stanmore, and Royal Orthopaedic Hospital, Birmingham). An up to date review of these patients has been made, documenting the relevant diagnoses, sites of tumour and types of implant used. 87 patients were assessed, with an age range of 5 to 17 years and follow up range of up to 88 months. Primary diagnosis was osteosarcoma, followed by Ewing's sarcoma. We implanted distal femoral, proximal femoral, total femoral and proximal tibial prostheses. All implants involving the knee joint used a rotating hinge knee. 6 implants reached maximum length and were revised. 8 implants had issues with lengthening but only 4 of these were identified as being due to failure of the lengthening mechanism and were revised successfully. Deep infection was limited to 5% of patients. Overall satisfaction was high with the patients avoiding operative lengthening and tolerating the non-invasive lengthenings well. Combined with satisfactory survivorship and functional outcome, we commend its use in the immature population of long bone tumour cases

Non-invasive expandable prostheses for limb salvage tumour surgery were first used in 2002. These implants allow ongoing lengthening of the operated limb to maintain limb-length equality and function while avoiding unnecessary repeat surgeries and the phenomenon of anniversary operations. A large series of skeletally immature patients have been treated with these implants at the two leading orthopaedic oncology centres in England (Royal National Orthopaedic Hospital, Stanmore, and Royal Orthopaedic Hospital, Birmingham). An up to date review of these patients has been made, documenting the relevant diagnoses, sites of tumour and types of implant used. 74 patients were assessed, with an age range of 7 – 16 years and follow up range of 4 – 88 months. We identified five problems with lengthening. One was due to soft tissue restriction which resolved following excision of the hindering tissue. Another was due to autoclaving of the prosthesis prior to insertion and this patient, along with two others, all had successful further surgery to replace the gearbox. Another six patients required mechanism revision when the prosthesis had reached its maximal length. Complications included one fracture of the prosthesis that was revised successfully and six cases of metalwork infection (two of which were present prior to insertion of the implant and three of which were treated successfully with silver-coated implants). There were no cases of aseptic loosening. Overall satisfaction was high with the patients avoiding operative lengthening and tolerating the non-invasive lengthenings well. Combined with satisfactory survivorship and functional outcome, we commend its use in the immature population of long bone tumour cases

Primary malignant bone and soft tissue tumours often occur in the lower extremities of active individuals including children, teenagers and young adults. Survivors routinely face long-term physical disability. Participation in sports is particularly important for active young people but the impact of sarcoma treatment is not widely recognised and clinicians may be unable to provide objective advice about returning to sports. We aimed to identify and summarise the current evidence for involvement in sports following treatment of lower limb primary malignant bone and soft tissue tumours.

A comprehensive search strategy was used to identify relevant studies combining the main concepts of interest: (1) Bone/Soft Tissue Tumour, (2) Lower Limb, (3) Surgical Interventions and (4) Sports. Studies were selected according to eligibility criteria with the consensus of three authors. Customised data extraction and quality assessment tools were used.

22 studies were selected, published between 1985 – 2020, and comprising 1005 patients. Fifteen studies with data on return to sports including 705 participants of which 412 (58.4%) returned to some form of sport at a mean follow-up period of 7.6 years. Four studies directly compared limb sparing and amputation; none of these were able to identify a difference in sports participation or ability.

Return to sports is important for patients treated for musculoskeletal tumours, however, there is insufficient published research to provide good information and support for patients. Future prospective studies are needed to collect better pre and post-treatment data at multiple time intervals and validated clinical and patient sports participation outcomes such as type of sports participation, level and frequency and a validated sports specific outcome score, such as UCLA assessment. In particular, more comparison between limb sparing and amputation would be welcome.

Aims

Prevalence of artificial intelligence (AI) algorithms within the Trauma & Orthopaedics (T&O) literature has greatly increased over the last ten years. One increasingly explored aspect of AI is the automated interpretation of free-text data often prevalent in electronic medical records (known as natural language processing (NLP)). We set out to review the current evidence for applications of NLP methodology in T&O, including assessment of study design and reporting.

Primary malignant bone tumor often requires a surgical treatment to remove the tumor and sometimes restore the anatomy using a frozen allograft. During the removal, there is a need for a highest possible accuracy to obtain a wide safe margin from the bone tumour. In case of reconstruction using a bone allograft, an intimate and precise contact at each host-graft junction must be obtained (Enneking 2001). The conventional freehand technique does not guarantee a wide safe margin nor a satisfying reconstruction (Cartiaux 2008). The emergence of navigation systems has procured a significant improvement in accuracy (Cartiaux 2010). However, their use implies some constraints that overcome their benefits, specifically for long bones. Patient-specific cutting guides become now available for a clinical use and drastically simplify the intra-operative set-up. We present the use of pre-operative assistances to produce patient-specific cutting guides for tumor resection and allograft adjustment. We also report their use in the operative room.

We have developed technical tools to assist the surgeon during both pre-operative planning and surgery. First, the tumor extension is delineated on MRI images. These MRI images are then merged with Computed Tomography scans of the patient. The tumor and the CTscan are loaded in custom software that enables the surgeon to define target (desired) cutting planes around the tumor (Paul 2009) including a user-defined safe margin. Finally, cutting guides are designed on the virtual model of the patient as a mould of the bone surface surrounding the tumor, materialising the desired cutting planes. When required, a massive bone allograft is selected by comparing shapes of the considered patient's bone and available allografts. The resection planes are transferred onto the selected allograft and a second guide is designed for the allograft cutting. The virtually-designed cutting guides are then manufactured by a rapid prototyping machine using biocompatible material. This procedure has been used to excise a local recurrence of a tibial sarcoma and reconstruct the anatomy using a frozen tibial allograft.

The pre-operative planning using virtual models of the patient's bone, tumor and the available allografts enabled the surgeon to localise the tumor, define the desired cutting planes and select the optimal allograft. Patient- and allograft-specific guides have been designed and manufactured. A stable and accurate positioning of guide onto the patient's tibia was made easier thanks to the plate formerly put in place during the previous surgery. An accurate positioning of the allograft cutting guide has been obtained thanks to its design. The obtained reconstruction was optimal with a adjusted allograft that was perfectly fitting the bone defect. The leg alignment was also optimally restored.

Computer assistances for tumor surgery are progressively appearing. We have presented at CAOS 2010 an optical navigation system for tumor resection in the pelvis that was promising. However, such a tool is not well adapted for long bones. We have used patient-specific guides on a clinical case to assess the feasibility of the technique and check its accuracy in the resection and reconstruction. The surgeon has benefited from the 3D planning to define his strategy. He had the opportunity to select the optimal transplant for his patient and plan the same cuttings for the allograft and the patient. During the surgery, guide positioning was straightforward and accurate. The bone cuttings were very easy to perform. The use of custom guides decreases the operating time when compared to the conventional procedure since there is no need for measurements between cutting trajectories and anatomical landmarks. Furthermore, the same cutting planes were performed around the tumor and onto the allograft to obtain a transplant that optimally fills the defect. We recommend the use of such an intra-operative assistance for tumor surgery.

CT and MRI scans are complementary preoperative imaging investigations for planning complex musculoskeletal bone tumours resection and reconstruction. Conventionally, tumour surgeons analyse two-dimensional (2-D) imaging information, mentally integrate and formulate a three-dimensional (3-D) surgical plan. Difficulties are anticipated with increase in case complexity and distorted surgical anatomy. Incorporating computer technology to aid in this surgical planning and executing the intended resection may improve precision. Although computer-assisted surgery has been widely used in cranial biopsies and tumour resection, only small case series using CT-based navigation are recently reported in the field of musculoskeletal tumor surgery. We investigated the results of CT/MRI image fusion for Computer Assisted Tumor Surgery (CATS) with the help of a navigation system.

We studied 21 patients with 22 musculoskeletal tumours who underwent CATS from March 2006 to July 2009. A commercially available CT-based spine navigation system (Stryker Navigation; CT spine) was used. Of the 22 patients, 10 were males, 11 were females, and the mean age was 32 years at the time of surgery (range, 6–80 years). Five tumours were located in the pelvis, seven sacrum, eight femurs, and two tibia. The primary diagnosis was primary bone tumours in 16 (3 benign, 13 sarcoma) and metastatic carcinoma in four. The minimum follow-up was 17 months (average, 35.5 months; range, 17–52 months). Preoperative CT and MRI scan of each patient were performed. Axial CT slices of 0.0625mm or 1.25mm thickness and various sequences of MR images in Digital Imaging and Communications in Medicine (DICOM) format were obtained. CT and MR images for 22 cases were fused using the navigation software. All the reconstructed 2-D and 3-D images were used for preoperative surgical planning. The plane of tumour resection was defined and marked using multiple virtual screws sited along the margin of the planned resection. We also integrated the computer-aided design (CAD) data of custom-made prostheses in the final navigation resection planning for eight cases.

All tumour resections could be carried out as planned under navigation guidance. Navigation software enabled surgeons to examine all fused image datasets (CT/MRI scans) together in two spatial and three spatial dimensions. It allowed easier understanding of the exact anatomical tumor location and relationship with surrounding structures. Intraoperatively, image guidance with the help of fusion images, provided precise visual orientation, easy identification of tumor extent, neural structures and intended resection planes in all cases. The mean time for preoperative navigation planning was 1.85 hours (1 to 3.8). The mean time for intraoperative navigation procedures was 29.6 minutes (13 to 60). The time increased with case complexity but lessened with practice. The mean registration error was 0.47mm (0.31 to 0.8). The virtual preoperative images matched well with the patients' operative anatomy. A postoperative superficial wound infection developed in one patient with sacral chordoma that resolved with antibiotic whereas a wound infection in another with sacral osteosarcoma required surgical debridement and antibiotic. After a mean follow-up of 35.5 months (17–52 months), five patients died of distant metastases. Three out of four patients with local recurrence had tumors at sacral region. Three of them were soft tissue tumour recurrence. The mean functional MSTS score in patients with limb salvage surgery was 28.3 (23 to 30). All patients (except one) with limb sparing surgery and prosthetic reconstruction could walk without aids.

Multimodal image fusion yields hybrid images that combine the key characteristics of each image technique. Back conversion of custom prosthesis in CAD to DICOM format allowed fusion with navigation resection planning and prosthesis reconstruction in musculoskeletal tumours. CATS with image fusion offers advanced preoperative 3-D surgical planning and supports surgeons with precise intraoperative visualisation and identification of intended resection for pelvic, sacral tumors. It enables surgeons to reliably perform joint sparing intercalated tumor resection and accurately fit CAD custom-made prostheses for the resulting skeletal defect.

The authors offer their personal experience with long term results on 71 patients (72 allografts) operated between 1961 and 1990. 23 were large osteoarticular grafts, 28 intercalary grafts and 20 fibular grafts. We used one composite hip endoprosthesis in 1988 after 16cm proximal femur resection due to Ewing sarcoma in a 10 year old girl. From the 23 osteoarticular grafts 14 (60%) are long term survivals including one after fracture salvage. Six had to be removed due to infection. From the 28 intercalary grafts 16 (57%) are surviving over 15 years. Infection occurred in 6 patients with chemotherapy. Two of them had intra-arterial CDDP and one additional radiation. All of the proximal humerus allograft had complete resorption of the proximal head within 3 years. The diaphyseal reconstructions with additional cancellous autografts incorporated within 3 years. The patient with the composite stem had two cup revisions, but the stem is doing well and we observed only a mild osteolysis at the proximal part of the graft between the 2nd and 5th year that remains stable. Fractures of the graft can be salvaged in most cases.

Infection leads to the removal of the graft in almost all cases. Factors influencing the survival, remodeling and complications of the grafts are discussed. The regime of cryopreservation, fixation and loading of the graft influence these factors together with the use of autologous bone chips around the allograft-host junction as well as the application of chemotherapy or radiation. Fracture of the graft can be salvaged in most cases in contrary to infection that remains the most severe complication that can occur at any time period. Even with the improvement of tumor endoprostheses the use of allografts remains an optional solution especially in young patients.

Purpose

Durable fixation may be difficult to achieve when significant bone loss is present, as it occurs in pelvic sarcoma resection and revision surgery of tumor implants. Purpose of this study was to review clinical results of primary and revision surgery of the pelvis and lower extremity in the setting of severe bone loss following limb salvage procedures for bone sarcoma using modular porous tantalum implants.

Introduction/Aim

Numerous lumbo-pelvic reconstruction methods based on posterior construct and anterior cages have been proposed for cases involving total sacrectomy and lumbar vertebrectomy. These constructs create long lever arms and generate high cantilever forces across the lumbo-sacral junction resulting in implant failure or breakage. Biomechanical studies have shown that placing implants anterior to lumbo-sacral pivot point provide a more effective moment arm to resist flexion force and improve the ultimate strength of the construct. As a result more emphasis is placed on screws in the pelvis.

We report a new and novel technique that allows for the placement of a pelvic ring construct to augment the posterior construct in a lumbo-pelvic reconstruction.

The use of massive endoprostheses following bone tumour resection is well recognised. Where possible, joint salvage rather than joint replacement is usually attempted. However cases arise where there may be insufficient bone stock following tumour resection to allow fixation of a joint sparing prosthesis. We report a series of 4 patients (age4–12) treated between 1994 and 2008, in which irradiated autologous bone has been combined with a diaphyseal or distal femoral replacement in order to preserve the native hip joint. There were 3 cases of osteosarcoma and 1 cases of Ewings sarcoma. After a mean follow up of 53 months (range 9–168) all patients had survived without evidence of local recurrence or metastases. One implant was revised after 14 years following fracture of the extending component of the growing endoprosthesis. There have been no cases of loosening or peri-prosthetic fracture. This is the first report of irradiated autologous bone with joint sparing endoprostheses in the skeletally immature patient.

Introduction: Reconstruction of segmental skeletal defects after malignant bone tumour removal has been a topic of much debate. Autoclaved or irradiated autologous bone used in the treatment of malignant bone tumours of the proximal femur in skeletally mature patients has been well reported with a high incidence of fracture and non-union. On follow up, our series of skeletally immature patients showed excellent osteo-integration with native bone and allowed preservation of the native hip joint.

Results: We review survival of the patient, implant, any complication and the presence of disease progression.

Introduction: Massive endoprostheses are widely employed in limb salvage surgery for malignant bone tumours. Whilst joint preservation rather than replacement is usually attempted, cases arise where there is insufficient bone following tumour resection to allow adequate fixation of a joint sparing prosthesis.

Method: We report a series of four patients (aged 4–12), in which irradiated autologous bone was combined with distal femoral replacement in order to preserve the native hip joint.

Results: There were three cases of Osteosarcoma and one Ewing’s sarcoma. After a mean follow-up of 53.5 months (range 9–168), all four patients are alive without evidence of local recurrence or metastases. One implant was revised after 14 years following fracture of the extending component of the growing endoprosthesis. There were no cases of loosening or peri-prosthetic fracture.

Discussion: This is the first report of a new technique utilising irradiated autologous proximal femoral bone combined with distal femoral replacement in skeletally immature patients.

Percutaneous biopsies can lead to seeding of tumour cells along the biopsy tract.

Correct surgical management requires preoperative identification and excision of the biopsy tract at time of surgery. These tracts become increasingly difficult to identify with time, leading to risk of inadequate excision of the biopsy tract and recurrence of the tumour at the biopsy site. We conducted a prospective study involving 45 patients who had tissue biopsies for bone and soft tissue tumours between February and May 2008. All the biopsies were performed by consultant radiologist under ultrasound or CT guidance. Case note analysis, patient history and examination at the time of surgery were used to collect data. 23 of 45 patients had accurate identification of the biopsy tract by the surgeon at the time of excision. The mean time between biopsy and excision was 52 days (range 6–140). 22 of 45 patients had unidentifiable biopsy site, with the mean time between biopsy and excision being 98 days(range 13–164) p=0.0004(paired t test). All 4 patients who received post-biopsy radiotherapy had unidentifiable biopsy site tract (mean duration 104 days) and 11 of the 18 patients who underwent neoadjuvant chemotherapy had an unidentifiable biopsy tract (mean duration 108 days). We concluded that identification of biopsy site was more difficult after 50 days, especially in patients who underwent radiotherapy and chemotherapy.

Following this study, all the patients who had biopsies of tumours had the site marked with India ink tattoo. We, then prospectively reviewed 36 patients between July and September 2010 who underwent excision of bone and soft tissue tumours and had their biopsy sites marked with India ink tattoo. After needle biopsy, one drop of the dye was applied at the site of the biopsy. This was taken up by capillary action beneath the dermis and remained present until the patient returned for their definitive surgery. The biopsy site was easily identifiable by the patients and the operating surgeon in all 36 patients. The mean time between biopsy and surgery was 77 days (range 10–299 days). Tattooing of the skin enabled the surgeon to accurately excise the biopsy tract along with the tumour. We recommend this technique of tattooing of the biopsy site with India ink, as it is safe, easily recognisable and permits accurate excision of the tract (including the tattoo), therefore preventing biopsy tract recurrence.

The use of massive endoprostheses following bone tumour resection is well recognised. Where possible, joint salvage rather than joint replacement is usually attempted. However cases arise where there is insufficient bone following tumour resection to allow adequate fixation of a joint sparing prosthesis. We reporta series of 4 patients (aged 4–12), treated between 1994 and 2008, in which irradiated autologous bone has been combined with a diaphyseal or distal femoral replacement in order to preserve the native hip joint.

There were 3 cases of osteosarcoma and 1 case of Ewing‘s sarcoma. After a mean follow-up of 53.5 months (range 9–168), all four patients are alive without evidence of local recurrence or metastases. One implant was revised after 14 years following fracture of the extending component of the growing endoprosthesis. There have been no cases of loosening or periprosthetic fracture.

This is the first report of irradiated autologous bone with joint sparing endoprostheses in skeletally immature patients.