Aim: To review our experience with epiphysiodesis using three different methods to correct LLD and to establish the efficacy of these procedures.

Method: A retrospective review of 42 patients from 1999 to 2008 with at least one year follow-up recorded type and location of the epiphysiodesis, average operating time and hospital stay, complications, method of prediction, timing and the final LLD. CT scanograms and mechanical axis view with grids were used to assess LLD.

Results: Epiphysiodesis was as per Canale for 26, by Metaizeau screw in 14 and by staples in 2. Average operation time was 42 minutes for Canale type, 45 minutes for the screws and 56 minutes for the staple cases. The pre operative LLD of 3.7 cms In the Canale group, improved to 1.2 cms over an average follow-up of 2.1 yrs. There were 4 minor and 2 major complications with a 92% success rate. For the screw group, the mean change was 1.8 cms over 2.2 yrs with 2 minor and 2 major complications giving a success rate of 85%. With staples the success rate was 100% and the mean change was 1.8 cms at an average of 2.3 yrs. In 14 cases where bone age reports were available, the multiplier method seemed better at predicting estimated LLD at skeletal maturity and timing of epiphysiodesis than the Moseley chart.

Conclusions: Percutaneous epiphysiodesis by any method is reliable, minimally invasive and with acceptable complication rate when compared to a corrective osteotomy or open Phemister-type epiphysiodesis. Our experience suggests that the Canale method has the least complications and best success rate. Paleys multiplier method was better at predicting LLD and timing of epiphysiodesis than the Moseley Chart.

Aim: To review our experience with hemi-epiphysiodesis using different methods for the correction of angular deformity about the knee.

Method: This was a retrospective review of 73 patients (101 knees) who underwent hemi-epiphysiodesis from 1999 to 2008. Assessment looked at the type and degree of deformity, implants used, average operating time and hospital stay, complications, degree of correction and the average time to correction.

Results: There were 50 boys and 23 girls with bilateral deformity in 28 cases. There were 88 valgus and 13 varus knees. Average follow-up was 17 months. Staples were used in 28 cases, “8” Plates in 24, Screws in 16 and Drilling in 5 cases. The distal femoral physis was involved in 46 knees, the proximal tibial physis in 21 and both physes in 34 knees (total 135 physes). Average operation time and hospital stay were similar for all methods. There were 6 minor and 3 major complications with staples with an average correction time of 14 months, 3 minor complications with an average correction time of 11 months with “8” plates, 3 minor and 1 major complication with an average correction time of 14 months with screws and 1 minor complication with drilling with an average correction time of 13 months. The outcome was considered as resolved in 47 and pending in 26 cases, with all showing progressive correction of deformity.

Conclusions: Hemi-epiphysiodesis by any method is an effective way to correct angular deformities about the knee in skeletally immature individuals within a reasonable time limit and with minimal morbidity when compared to a corrective osteotomy. Our experience suggests that “8” plates achieve faster correction with the least complications when compared to other methods. Valgus knee deformities corrected faster than varus ones.

Purpose: The literature on management of advanced soft tissue tumours is limited because of the rarity of cases following increased awareness and improved diagnostic resources.

Method: Our experience of managing 18 patients with fungating soft tissue tumours of the extremities and one patient with a sarcoma involving the scapular region (limb girdle) is presented. There were 14 males and 5 females. Average age was 70.6 yrs ranging between 37 – 98 years. 13 tumours involved lower limb and 6 the upper limb.

Results: The follow-up ranged from a minimum of 6 months to 10 years from the initial referral. The histological diagnosis was Sarcoma in 15 patients (Spindle cell sarcoma in 4, Fibrous Histiocytoma in 2, Pleomorphic sarcoma in 3, liposarcoma in 2, leiomyosarcoma in 2, Fibrosarcoma in 1 and 1 Round cell sarcoma). In the remaining 3 patients immunohistochemistry studies confirmed a Metastatic Squamous cell Sarcoma, a Metastatic Malignant Melanoma and a Metastases from a poorly differentiated upper GI malignancy each. Primary wide local excision was performed in 15 patients and primary amputation was performed in two patients. In 2 patients when tumour was unresectable due to the location and local spread, an embolisation was performed in both for palliation. Lung Metastases were present at the time of referral in 6 patients and developed later during follow-up in 4 patients. A histologically proven recurrence occurred in 6 patients after an average of 15.83 (4 to 41) months. Revision surgery was needed in 9 patients for either a positive margin on histology or a recurrence, including 3 secondary amputations. Local adjuvant Radiotherapy was given for 7 patients and a combination of radio and chemotherapy was used in 2 patients for metastases. Mortality was 53 % (9 patients) by the end of 32 months of follow-up.

Conclusion: Fungation in soft tissue tumours is rare and often a sign of locally advanced disease and a high grade nature, patients either have systemic spread by the time or develop later inspite of good local disease control. Primary wide local excision in such patients is difficult and has a high chance of a positive margin hence primary amputation may be better for local clearance. Recurrence of tumour and revision surgery is common and the mortality was > 50% at the end of 3 years from presentation to treatment in our series.

Objective: We report an unusual presentation of telangiectatic osteosarcoma of distal femur in a preadolescent boy.

Methods: A 9 year old boy fell down heavily while he was on holiday and fractured his distal femur. He was given above knee plaster locally and then transferred him to hospital where he lives normally. He developed increasing pain over next two weeks over fracture site (4 weeks after injury) and was reviewed in clinic. X ray of his femur showed permeative pattern of bone destruction with new bone formation. Subsequent biopsy of his lesion confirmed telangiectatic osteosarcoma. His subsequent MRI scan of thigh and CT scan of his chest showed pulmonary metastasis and dissemination of tumour to proximal femur. He never noticed any pain, discomfort or swelling before fracture and until four weeks after fracture apart from symptoms of fracture. Retrospective review of his x ray which was taken at the time of fracture demonstrated not very obvious osteolytic lesion in distal femur.

Conclusion: Telangiectatic osteosarcoma is a rare subtype of osteosarcoma and represents nearly 2% of all osteosarcomas. The incidence peaks in early to mid-adolescence and is not commonly encountered in very young and preadolescent patients.

Osteosarcoma usually presents with pain at night and precedes tumour by weeks or months. Some times there may be only a history of a tired feeling, a slight limp or a history of trauma.

Our case did not have any symptoms at all until two weeks before the presentation. The fracture made the tumour extra compartmental and led to metastasis and poor prognosis. We should always aware of this possibility of rare presentation when we see a preadolescent patient with increasing pain following fracture.