Ceramic bearing fractures are rare events, but mandate revision and implantation of new bearings. Revisions using metal heads have been reported to lead to gross volumetric head wear (due to abrasive retained ceramic micro-debris), cobalt toxicity, multi-organ failure and death. Such complications are widely published (50+ reports), yet we know that patients continue to be put at risk. Using data from the NJR and AOANJRR, this study seeks to compare the risk of re-revision and death by revision bearing combination following a ceramic bearing fracture.

Data were extracted from the NJR and AOANJRR, identifying revisions for ceramic bearing fracture. Subsequent outcomes of survival, re-revision and death were compared between revision bearing combinations (ceramic-on-ceramic, ceramic-on-polyethylene, and metal-on-polyethylene).

366 cases were available for analysis from the NJR dataset (MoP=34, CoP=112, CoC=221) and 174 from the AOANJRR dataset (MoP=17, CoP=44, CoC=113). The overall incidence rate of adverse outcome (revision or death) was 0.65 for metal heads and 0.23 for ceramic head articulations (p=0.0012) across the whole time period (NJR). Kaplan-Meir survival estimates demonstrate an increased risk of both re-revision and death where a metal head has been used vs a ceramic head following revision for ceramic fracture.

There are few decisions in arthroplasty surgery that can lead to serious harm or death for our patients, but revision using a metal head following ceramic bearing fracture is one of them. This study enhances the signal of what is already known but previously only reported as inherently low-level evidence (case reports and small series) due to event rarity. Use of a metal head in revision for ceramic fracture represents an avoidable patient safety issue, which revision guidelines should seek to address.

Introduction

Renal impairment following major surgery is a formidable complication. There is recent evidence suggesting increasing risk of progression to chronic kidney disease and mortality after transient renal impairment. We aimed to evaluate the impact of pre-operative comorbidities on long-term outcomes of renal-function following hip arthroplasty.

This paper aims to provide evidence-based guidance for the general orthopaedic surgeon faced with the presentation of a potential soft tissue sarcoma in an extremity.

Aims

To evaluate the incidence, patient demographics, primary tumour characteristics and treatment modalities of patients with radiation induced soft tissue sarcoma (RISTS) presenting to the East Midlands Sarcoma Service at Nottingham City Hospital.

We reviewed 100 consecutive primary sarcoma patients identified from coding records from January 2009 to April 2011. A computerised system was used to access theatre records, and operative details were checked against patient notes to ensure accuracy. Data on demographics, pathology, surgical and oncological management was collected.

Of the 100 patients reviewed, 52 were male and 48 female with an average age of 64.9 years (range 23–102 years). Of the 100 operations performed, 13 had primary reconstruction with a myocutanoeus flap, of which 9 varieties were used. Twenty-five patients had reconstruction with a split or full thickness skin graft and 9 patients had a limb amputation. Length of inpatient stay ranged from 0 to 63 days and was greatest for our amputee's. Mean operative time did not increase significantly with rise in case complexity. 31 of our patients received post-operative radiotherapy, one patient had induction radiotherapy whilst another had induction chemotherapy.

5 out of the 100 patients underwent re-excision due to incomplete margins being obtained at primary wide local excisions. We had one patient with a failed free latissimus dorsi flap, in which secondary reconstruction with pedicled gastrocnemius and skin grafting was successful. One patient had a scalp flap following a re-excision of a positive margin of an angiosarcoma.

Using a combined oncological orthopaedic and reconstructive plastic surgery approach, in our centre 38% of patients require some form of soft tissue reconstruction following tumour resection, with 13% of all patients requiring microvascular flap reconstruction. We have a 9% amputation rate, which is comparable with other published series.

Reconstruction following soft tissue sarcoma is complex and highly demanding, the challenges being best met by a combined orthoplastic surgical team.

Introduction

We aimed to ascertain the oncological outcome of patients undergoing an amputation for sarcoma in our unit.

Background

The National Institute of Clinical Excellence (NICE) published clinical guidelines in 2006 defining urgent referral criteria for soft tissue sarcoma to help improve the diagnostic accuracy and overall outcome. Despite these guidelines inadvertent excisions of soft tissue sarcomas continue to occur with alarming frequency potentially compromising patient outcomes.

Aim

The aim of this study was to assess the financial implications of managing skeletal metastases in a tertiary hospital and explore its impact on the provision of acute care trauma services.

Introduction: Intramedullary humeral nailing (IMHN) is appropriate for metastatic lesions and fractures as it stabilizes the whole bone and allows immediate mobilization. We report the results of a patient cohort with metastatic lesions/fractures treated by IMHN.

Methods: We included patients who were treated with IMHN between June 2001 and December 2007 for metastatic lesions/fractures. We noted the source of referrals, site of fracture/lesion, primary lesion, metastasis elsewhere, operative complications, post-operative patient satisfaction and pain control, fracture healing and post-operative survivorship.

Results: We identified 38 patients. The median age was 71 years (50–87). Four patients presented with lytic lesions involving more than 50% of cortical diameter while 34 patients had a fracture. 10 patients had pain in their arm for at least 2 weeks before presentation. Primary malignancies were breast (9), Non-Hodgkins B-cell Lymphoma (4), prostate (4), kidney (5), myeloma and lung (2 each), bladder, leiomyosarcoma and oesophagus (1 each) and unknown (9). There were 22 proximal, 13 midshaft and 3 distal humeral lesions. All had metastasis elsewhere in addition to the humerus except six. 12 patients were without co-morbidities. Senior grade surgeons operated on all the patients. There were no intra-operative complications. Post-operative complications included sepsis (2), frozen shoulder(1), elbow stiff-ness(1), pneumonia(2), and transient radial nerve palsy (2). Three patients developed a second fracture distal to the first one and had revision surgery. Post-operative pain control was satisfactory in 34 and unsatisfactory in 3 patients. Difficulty in pain assessment occurred in 1 patient with brain metastasis. 36 patients died, with median survival from date of surgery of 12 weeks (range 1 – 62 weeks). Two patients are alive 2.5 and 1.7 years after surgery. The median follow-up period by the orthopaedic outpatient department was 2 months (1–26.5) for 33 patients as 5 patients died with in two weeks of operation. At follow up; 9 fractures had healed, 17 were healing, 2 had not united, and 5 patients did not have x-ray at follow up.

5 Out of 8 patients, who died with in 4 weeks of surgery, had a combination of at least one co morbidity, one area of metastasis other than the humerus and were in - patients. There was no co relation between mortality and sex, age, type of tumour, or presence of metastasis.

Conclusion: IMHN for metastatic lesions and fractures is effective for pain relief and fracture healing. However a long IM nail should be used and the whole arm should be radiated. Deviations from these principles lead to 3 surgical revisions in our cohort of patients. Also one group of patient had a high mortality rate and in this specific group non-operative treatment should be thought about.

Introduction: The most appropriate protocol for biopsying musculoskeletal tumours is controversial. Some authors advocate the use of CT-guided core biopsy. At the Royal Prince Alfred Hospital, Sydney, Australia, initial biopsies of most musculoskeletal tumours involve a surgeon-led operative core biopsy technique with frozen section evaluation. The latter is used to determine whether diagnostic tissue has been obtained and, if possible, to establish a definitive diagnosis.

Aims: To determine the accuracy and cost effectiveness of a surgeon-led biopsy protocol for biopsying musculoskeletal tumours.

Methods: A retrospective audit of biopsies of musculoskeletal tumours performed in the bone and soft tissue sarcoma unit at the Royal Prince Alfred Hospital over a two year period was performed.

Results: One hundred and four patients had biopsies performed under the protocol. There were no non-diagnostic biopsies and one minor error resulting in no change in the patient’s management. There was no requirement to re-biopsy any of the patients. A surgeon-led operative core biopsy with frozen section evaluation was 38% more costly than a CT-guided core biopsy (AU$1804 versus AU$1308).

Conclusions: Surgeon-led biopsy with intra-operative frozen section evaluation is effective and accurate and, despite being labour intensive, the reduction in the need for repeat biopsies justifies its use. Whilst the technique is approximately 38% more costly, there is no requirement for re-biopsy and anxiety associated with the need for this is allayed.

INTRODUCTION. We conducted a review of the Leeds Regional Bone Tumour Registry for primary bone tumours of the spine since establishment in 1958 until year 2000.

AIM. To analyze the incidence of primary tumours of the spine and to record the site of occurrence, sex distribution, survival and pathology of these tumours.

Summary of the Background Data. Primary tumours of the spine are particularly rare, accounting for between 4% and 13% of published series of primary bone tumours.

METHOD. The Leeds Bone Tumour Registry was reviewed and a total of 2750 cases of bone tumours and tumour-like cases were analyzed. Consultants in orthopaedic surgery, neurosurgery, oncology and pathology in North and West Yorkshire and Humberside contribute to the Registry.

RESULTS. Primary bone tumours of the osseous spine constitute only 126 of the 2,750 cases (4.6%). Chordoma was the most frequent tumour in the cervical and sacral regions, while the most common diagnosis overall was multiple myeloma and plasmacytoma. Osteosarcoma ranked third. The mean age of presentation was 42 years and pain was the most common presenting symptom, occurring in 95% of malignant and 76% of benign tumours. Neurological involvement occurred in 52% of malignant tumours and usually meant a poor prognosis,

CONCLUSIONS. The establishment of Bone Tumour Registries is the only way that sufficient data on large numbers of these rare tumours can be accumulated to provide a valuable and otherwise unavailable source of information for research, education and clinical follow-up.

Purpose: We conducted a review of the Leeds Regional Bone Tumour Registry for primary bone tumours of the axial skeleton since establishment in 1958 until year 2000 to analyze the incidence of primary tumours of the axial skeleton and to record their site of occurrence, sex distribution, survival and pathology.

Method: Primary tumours of the axial skeleton are particularly rare, accounting for between 4% and 13% of published series of primary bone tumours. The Leeds Bone Tumour Registry was reviewed and a total of 2750 cases of bone tumours and tumour-like cases were analyzed. Consultants in orthopaedic surgery, neurosurgery, oncology and pathology in North and West Yorkshire and Humberside contribute to the Registry.

Results: Primary bone tumours of the axial skeleton constitute only 126 of the 2,750 cases (4.6%). Chordoma was the most frequent tumour in the cervical and sacral regions, while the most common diagnosis overall was myeloma. Osteosarcoma ranked third. Mean age of presentation was 42 years. Pain was the most common presenting symptom, occurring in 95% of malignant and 76% of benign tumours. Neurological involvement occurred in 52% of malignant tumours and usually meant a poor prognosis,

Conclusions: The establishment of Bone Tumour Registries is the only way that sufficient data on large numbers of these rare tumours can be accumulated to provide a valuable and otherwise unavailable source of information for research, education and clinical follow-up.

Hip resurfacing is a procedure designed to conserve bone stock in the younger patient and facilitate revision to a total hip arthroplasty if the need arises. The Wagner Hip Resurfacing (WHR) was a metal-on- poly implant introduced in 1978.

The notes and radiographs of 16 patients who underwent 19 WHR procedures performed by a single surgeon between 1980 and 1984 were reviewed.

The mean age at primary surgery was 54 (range 41–68). 16 of the WHRs required revision at a mean time of 45 months (range 1–144 months). 3 WHR had not been revised: one is functioning at 22 years, one functioning well 20 years after implantation when the patient died and 1 non-functional 9 years after implantation due to femoral head reabsorption.

The reason for revision was femoral neck fracture (3), femoral head collapse / avascular necrosis or loosening (8), acetabular loosening (5).

Subsequent problems with the revision were noted in 6 patients (2 dislocations, 2 infections, 1 acetabular loosening and 1 femoral loosening). 3 patients ended with a Girdlestone excision arthroplasty and 2 required re-revision.

Hip resurfacing is designed as a conservative option for the young arthritic hip. This prosthesis not only failed catastrophically at an early stage but had a major subsequent impact on revision surgery and complications associated with it.

Primary bone tumours in the elderly population are relatively rare.

We reviewed the Leeds regional bone tumour registry between 1990–1999 and found them to constitute only 43 of the 341 (12%) bone tumour cases.

Malignant tumours (65%) were more common than benign tumours with primary tumours accounting 92 % and metastatic tumours only 8 % of all the malignancies. Females were more affected than males (55% versus 45 %).

Chondrosarcoma was the most frequent tumour, constituting 24% of primary malignant tumours and 18 % of all bone tumours.

Chondroma was the most common benign tumour accounting for 50% of all benign tumours, and 11% of all tumours.

Survival rate was relatively poor in elderly population with primary malignant tumours.

The majority of malignant tumours were in the lower limb (femur 25%, tibia 14 %).The upper limb accounted for 14% and the axial skeleton 5%.

Bone tumour registries provide a valuable source of cumulative information about both common and uncommon tumours. Such information could not easily be gathered by personal experience. It is also a very good source of information for research education and service.