Introduction

Up to 70% of patients with symptomatic Morton's neuroma proceed to surgery having failed non-operative management. The success of surgical excision is up to 85% but carries with it significant morbidity. Radiofrequency ablation (RFA) is a less invasive alternative.

Background and objective

Metatarsals stress fractures are common in athletes and dancers. Occasionally, such fractures could occur without trauma in peripheral neuropathic patients. There is no published series describing outcome of stress fractures in these patients. This study analyse these fractures, treatment and outcome.

Introduction

There is less literature reporting outcomes following total ankle replacement (TAR) in patients presenting with a coronal plane deformity preoperatively. This study compares clinical and patient reported outcomes at 1 year between TAR patients with and without coronal plane deformity.

Background

The recommended indications for total ankle replacement (TAR) are limited, leaving fusion as the only definitive alternative. As longer-term clinical results become more promising, should we be broadening our indications for TAR?

Introduction

There is no published series described change in bone mineral density (BMD) after ankle replacement. We present the results of a prospective study examining the effect of total ankle replacement (TAR) upon local bone mineral density (BMD).

Total ankle replacement (TAR) is increasingly offered as an alternative to ankle fusion for the management of severe ankle arthritis. As with all other types of joint arthroplasty, there are risks involved and complications that occur; these increase with case complexity. We present the complications and management from a single-centre series.

Since 2006, we have performed 150 Mobility TARs with up to 4 years' follow-up. We have excluded 16 that are part of a separate RCT and 10 with less than 3 months' follow-up. 124 TARs were included in our study (117 patients). Three ankles (2.4%) had superficial wound infections treated successfully with antibiotics. One ankle (0.8%) required an arthroscopic washout and debridement but the implant was retained. 11 ankles (8.9%) had a periprosthetic fracture: One was intraoperative; 10 were postoperative (2 fixed). Four patients (3.2%) developed CRPS. One ankle required fusion surgery (following subsidence of the talar component) with another one pending revision (ligament instability causing implant displacement). No patient had a symptomatic deep vein thrombosis or thromboembolic event.

Our figures are comparable with other series. Our complication rate has not changed significantly over time. Our results, at present, suggest that most complications (98%) with the Mobility TAR can be satisfactorily managed without having a detrimental effect on the implant.

There have been proven and promising results with total ankle replacement. However, there is a significant complication rate that must be made clear to the patient via informed consent; the rate still remains higher than for hip and knee arthroplasty.

Introduction

The standard practice of uncomplicated total ankle replacement (TAR) involves postoperative immobilisation. Periprosthetic fracture is a well-recognised complication following ankle arthroplasty. It occurs predominantly as a stress reaction on the medial tibial metaphysis during the postoperative rehabilitation period. Occasionally it occurs during surgery. We present fractures from a single-centre series of Mobility TARs.

Background

Postoperative pain following (Mobility TM) ankle arthroplasty (AA) is recognised problem. This study aimed to determine pattern of postoperative pain following Ankle arthroplasty (AA).

Introduction

The standard practice of uncomplicated total ankle replacement (TAR) involves post-operative immobilisation. Periprosthetic fracture is a well-recognised complication following ankle arthroplasty. It occurs predominantly as a stress reaction on the medial tibial metaphysis during the post-operative rehabilitation period. Occasionally it occurs during surgery. We present fractures from a single-centre series of Mobility TARs.

Background

Total ankle replacement (TAR) is increasingly offered as an alternative to ankle fusion for the management of severe ankle arthritis. As with all other types of joint arthroplasty, there are risks involved and complications that occur; these increase with case complexity. We present the complications and management from a single-centre series.

Introduction

Primary Total Elbow Replacement (TER) is gaining popularity as a primary treatment option for osteoporotic fractures of the elbow, particularly in patients with low demand. The aim of this study was to assess the clinical and functional efficacy of TER as a primary treatment for comminuted distal humerus fractures in the elderly.

Introduction: The workload of a bone and soft tissue tumour (BSTT) multidisciplinary team (MDT) is varied. Only a proportion of the workload attracts specific funding from the National Commissioning Group (NCG) but many patients who do not have primary malignant bone tumours are also seen and treated. We analysed the workload of our supra-regional BSTT MDT to determine the variety of conditions seen, the proportion that does not attract specific funding and the expertise required to run the service.

Methods: A prospective database was used to identify all new patients discussed at our weekly BSTT MDT meetings between 2004 and 2008 inclusively. Patients were divided by diagnosis into eight categories and further identified as to whether or not they attracted funding under NCG regulations.

Results: 1743 new patients were identified of which 83 were excluded. Of the remaining 1660, 65% were non-sarcoma and 50% were benign. 31% of the malignant workload was non-sarcoma. Only 9% of treated patients were eligible for NCG funding. Of those requiring surgery, the orthopaedic team managed 93% of benign and 77% of malignant cases; general, plastic, or thoracic surgical teams managed the remainder.

Discussion: NCG funds the management of all malignant primary bone tumours and the investigation and/or treatment of other selected conditions; the majority of our workload does not qualify. Despite fluctuations in the total workload, the ratio of benign to malignant cases remains relatively constant. An effective MDT requires expertise across many specialties.

Introduction: The ‘Two Week Wait’ (2ww) process has been in force since the year 2000, with the subsequent implementation of 32-day diagnosis and 62-day treatment ‘rules’ in 2005. The aims of this study were to compile a definitive diagnostic profile of 2ww referrals, establish whether a histological biopsy was required for diagnosis and consider the current 2ww impact on services in our centre.

Materials and Methods: Two hundred and nine patients were referred under 2ww to the North of England Bone and Soft Tissue Tumour service and prospectively recorded on a computerised multidisciplinary tumour database from 2006–8. The data was reviewed and verified using pathology, radiology reports and patient records.

Results: Malignancy was diagnosed in 41(20%) patients. This comprised 21 soft tissue sarcomas (10%), 11 primary bone tumours (5%), and 9 metastatic bone tumours (4%). 63 (30%) benign bone or soft tissue neoplasia and 80 (38%) non-neoplastic conditions were diagnosed. No mass lesion was identifiable in 25 patients (12%). A diagnostic or therapeutic biopsy was required in 108 (52%) patients.

Discussion and Conclusion: 15% of 2ww referrals to our centre have a primary bone or soft tissue sarcoma but over half of all 2ww patients require biopsy for diagnosis creating additional strains on resources under the 32- and 62-day rule. Emphasis is placed on obtaining a rapid diagnosis, to ease pressure on time to treatment, utilising a ‘one-stop clinic’ approach for biopsies of accessible tumours where applicable. The availability of timely radiological resources, facilitated by an MDT involving a designated coordinator (‘patient-tracker’), is key to ensure treatment is not delayed for any cancer patient regardless of referral route. Our centre is 100% compliant for waiting times for sarcoma according to the Department of Health 2008 data.

Introduction: Well-differentiated liposarcomas have a tendency to recur locally but do not metastasise unless dedifferentiation occurs. In this study, a tumour superficial to the deep fascia of the trunk or limb is termed an atypical lipoma (AL) and one deep to fascia, a lipoma-like liposarcoma (LL) reflecting increased difficulty in wide local excision.

Methods: We prospectively collected data for 87 well-differentiated liposarcomas excised at our institution from 1998–2008. Data was recorded on a multidisciplinary team database and verification was undertaken using patient records. Any radiological investigation performed was determined retrospectively. Primary excisions performed elsewhere were excluded. The aim was to produce recommendations on the clinical and radiographical post-operative management of these common tumours.

Results: LL was seen in 74 patients and AL in 13 (mean age 58 years, mean follow up 5 years). The mean size of LL excisional biopsy was 148mm and 54mm for AL (p< 0.05). There were no AL recurrences. Five LL (7%) locally recurred within a mean of 5 years (range 2–10 years). All were deeply related to neurovascular structures (4 thigh-marginal/complete excisions and 1 upper arm-piecemeal excision). One recurrence was detected by MRI from 26 LL patients (35%), the other four being clinically suspected prior to re-scanning. During follow up, a chest radiograph was performed in 21 LL patients (27%) and no metastases were detected.

Discussion: Patients with a completely excised superficial AL need no routine follow up. Follow up of LL is determined by the patient, the tumour size and the location. The routine use of interval MRI to detect local recurrence of uncomplicated LL is not necessary. MRI provides ‘base-line’ post-operative information where a neurovascular bundle was closely related to the tumour or excision was incomplete. Chest radiographs are not indicated in screening for metastases in these tumours unless locally recurrent.

Introduction: The ‘Two Week Wait’ (2ww) process has been in force since the year 2000, with the subsequent implementation of 32-day diagnosis and 62-day treatment ‘rules’, as part of reforms to NHS cancer services. The aims of this study were to compile a definitive diagnostic profile of 2ww referrals, establish whether a histological diagnosis was required and consider the current 2ww impact on services in our centre.

Methods: Two hundred and nine patients were referred to the North of England Bone and Soft Tissue Tumour service and prospectively recorded on a computerised multidisciplinary tumour database from 2006–8. The data was reviewed and verified using pathology, radiology reports and patient records.

Results: Malignancy was diagnosed in 41(20%) patients (n=209). This comprised 21 soft tissue sarcomas (10%), 11 primary bone tumours (5%), and 9 metastatic bone tumours (4%).

63 (30%) benign bone or soft tissue neoplasia and 80 (38%) non-neoplastic conditions were diagnosed. No mass lesion was identifiable in 25 patients (12%). A diagnostic or therapeutic biopsy was undertaken in 108 (52%) patients.

Discussion: Fifteen percent of 2ww referrals to our centre have a primary bone or soft tissue malignancy. The 2ww caseload has increased significantly in recent years and non-malignant conditions (80%) must still be diagnosed within the 31 day rule. We utilise a ‘one-stop clinic’ approach, with access to ultrasound guided biopsy, and a weekly multidisciplinary meeting to facilitate timely investigation and treatment of all patients regardless of referral route.