Objective: This study was performed to review the current treatment and outcome of extra abdominal fibromatosis in our hospital, supplemented by a current review of the literature.

Method: A retrospective study of 72 patients with fibromatosis seen at the Royal National Orthopaedic Hospital (RNOH) between 1980 and 2009 was performed. Patients were identified using the databases at the peripheral nerves injury (PNI) unit and the histopathology department. Medical and radiological records were reviewed.

Results: There were 72 patients treated at the Sarcoma and PNI units. 40 patients were primary referrals, and 32 more had operations at the referring hospital. An operation was not carried out in 5 patients. 48 patients were treated by operation alone and this was supplemented by adjuvant therapy in 19 patients. Recurrence was seen in 24 (50.0%) of the operation alone group and 10 (52.6%) in the operation and adjuvant therapy group. The rate of recurrence was lower with complete excision. However, complete excision was impossible in some cases because of extension into the chest or spinal canal, or involvement with the axial vessels and lumbosacral or brachial plexus.

Conclusion: We suggest that operative excision should seek to preserve function and that supplementary adjuvant therapy may reduce the risk of recurrence, although excision margin appears to be the most important factor. The aggressive, infiltrative behaviour of deep fibromatoses and the associated genetic mutations identified, clearly distinguish them from the superficial fibromatoses and makes their treatment more difficult and dangerous, especially where vital structures are involved. We agree with the recent recommendation that these lesions should be treated in regional soft tissue sarcoma units.

46 Sacral chordoma patients treated between 1987 and 2004 are reviewed. The importance of early diagnosis, adequate surgical margin and post operative radiotherapy for optimum outcome and survival is stressed.

There were 33 male and 13 female patients, with a mean age of 61 years (38–73 years). The surgical approach depended on the level and extent of the lesion, with an anteroposterior approach used in 23 and posterior approach in 17 patients. 20 had partial sacrectomy, 17 had subtotal sacrectomy and 3 underwent total sacrectomy. 6 patients were deemed inoperable and received palliative therapy. 14 patients received radiotherapy post-operatively. The length of average follow up was 4.27 years (range 2–15.7 years).

Low back pain was the most common presenting symptom (80%), and 50% patients had a palpable mass. The mean duration of symptoms prior to diagnosis was 2 years (range 1 month–10 years). Examination revealed a palpable mass in 7 both externally and on rectal examination. 10 had a palpable mass on rectal examination but not externally. 2 patients presented with multiple metastases and another 2 with widespread local disease. Excision was complete in 23 patients and incomplete in 17. Histology revealed dedifferentiation in 4. Complete excision margin was achieved in 69.6% through combined approach and 52.9% through posterior approach only. 24 patients (52%) had local recurrence. Without adjuvant radiotherapy the mean disease free period following complete excision was 3.5 years, compared to 0.9 years following incomplete excision. Adjuvant radiotherapy extended the mean disease free period following incomplete excision to 1.8 years.

The authors conclude that an early diagnosis and careful examination is important. Wide excision remains the mainstay of treatment. If excision is incomplete radiotherapy increases the disease free period although local recurrence is inevitable. The use of a combined approach increases the likelihood of complete excision.

Purpose: To report the importance of early diagnosis, adequate surgical margin and postoperative radiotherapy for optimum outcome and survival.

Study Design: A retrospective review of 46 sacral chordoma patients treated between 1987 and 2004.

Methods: There were 33 male and 13 female patients, with mean age of 61 years (38 to 73 year). The surgical approach depended on the level and extent of the lesion, with an anteroposterior approach used in 23 and posterior approach in 17 patients. 20 had partial sacrectomy, 17 had subtotal sacrectomy and 3 underwent total sacrectomy. 6 patients were deemed inoperable and received palliative therapy. 14 patients received radiotherapy postoperatively. The length of average follow up was 4.27 years (range 2–15.7 years).

Results: Low back pain was the most common presenting symptom (80%), and 50% patients had a palpable mass. The mean duration of symptoms prior to diagnosis was 2 years (range 1 month–10 years). Examination revealed a palpable mass in 7 both externally and on rectal examination. 10 had palpable mass on rectal examination but not externally. 2 patients presented with multiple metastases and another 2 with widespread local disease.

Excision was complete in 23 patients and incomplete in 17. Histology revealed dedifferentiation in 4. Complete excision margin was achieved in 69.6% through combined approach and 52.9% through posterior approach only. 24 patients (52%) had local recurrence. Without adjuvant radiotherapy the mean disease-free period following complete excision was 3.5 years, compared to 0.9 years following incomplete excision. Adjuvant radiotherapy extended the mean disease-free period following incomplete excision to 1.8 years.

Conclusion: An early diagnosis and careful examination is important. Wide excision remains the mainstay of treatment. If excision is incomplete radiotherapy increases the disease free period although local recurrence is inevitable. Use of combined approach increases the likelihood of complete excision.

Aim: To describe a new cosmetic and simple approach to harvest hamstring tendons in arthroscopic ACL reconstruction which reduces anterior knee sensitivity and patient morbidity.

Methods: Pre-operatively, the path of the hamstring tendons is identified and marked by asking the patient to flex their knee against resistance.

The thigh is placed over a bolster and the leg is allowed to hang over the end of the table.

The hamstring tendons are harvested through the pre-determined 2 centimetres horizontal incision on the posterior medial aspect of the thigh. The hamstring tendons which are individually identifiable at this point are isolated using a tendon hook. The fascial expansions of the tendons, which are easily accessible by this approach, are divided using dissecting scissors. A tendon stripper is then used to free the tendon from its muscular origin proximally and from its insertion at the pes anserinus distally.

Only a 5mm stab incision anteromedially is now required to make the tibial tunnel. The rest of the procedure is performed as described by EM Wolfe (1). The posteromedial incision is closed with subcuticular stitches. All other wounds are closed with steristrips including the 5mm anteromedial stab incision.

Conclusion: This new approach has a short learning curve with the harvesting time falling from 22 minutes to 9 minutes within the first 4 procedures, making it a good technique for the trainee surgeon. This approach provides an alternative to the traditional approach by being cosmetically pleasant, reducing anterior knee sensitivity and thereby improving the outcome.

Aim: Sacral tumours are rare and can form a wide variety of differential diagnoses. We present a series of sacral tumour patients treated at a regional tumour centre; describing our experience of their management. Method: A retrospective study reviewing 76 sacral tumour patients, presenting to the Royal National Orthopaedic Hospital, Stanmore, from April 1976 to April 2002. The minimum follow-up period was 6 months. For each tumour type we looked at the incidence, diagnosis and outcome. Results: 69 of the lesions were primary bone tumours, 3 metastatic and 4 haematopoietic tumours. 33% of all tumours were chordomas. Osteosarcoma (10%), chondrosarcoma (8%) and giant cell tumour (8%) were the next most common. The commonest presenting symptom was lower back pain (64 cases). Good survival was demonstrated with chordomas and giant cell tumours. Osteosarcomas and chondrosarcomas had poor survival. Tissue diagnosis was accurately achieved with image-guided needle biopsy (61 cases). Magnetic resonance imaging (MRI) and computed tomography (CT) provided sufficient details for preoperative planning. Conclusion: The symptoms and signs of sacral tumours are non-specific and may lead to a misdiagnosis of degenerative disease of the spine. In our series chordomas account for only a third of all sacral tumours. Early diagnosis and staging are essential in order to determine definitive management and infl uence outcome. Surgery remains the most effective method for treating the malignant tumours.

Aim: Chordomas are relatively rare, malignant and strictly found in the midline. This study is to review our experience in the diagnosis, treatment and outcome of sacral chordomas. Method: A retrospective study reviewing 25 sacral chordoma patients treated at the Royal National Orthopaedic Hospital between August 1987 and April 2002, with a minimum follow-up of 6 months. Results: Of the 25 patients, 17 were male and 8 were female. The mean age at diagnosis was 61 years, and the mean duration of symptoms was 2 years. The commonest presenting symptom was lower back pain (20 cases). Three patients had inoperable tumours at the time of referral; the remaining 22 underwent surgical excision. A complete excision (based on microscopic examination) was achieved in11 cases, 2 of whom received adjuvant radiotherapy. Of the11 who had an incomplete excision 8 received adjuvant radiotherapy. Complete excision extended the mean disease free period to2.92 years, compared to 0.67 years following incomplete excision. The disease free period following an incomplete excision was extended from a mean of 0.67 years to 2.82 years with radiotherapy. 10 patients had postoperative neurological complications. Conclusion: We believe that the aim of surgical resection should be a microscopically complete excision margin, having documented an increased time to recurrence in patients in whom this has been achieved, compared to those treated with an incomplete excision. Radiation therapy should be given after an incomplete excision as we have shown that it lengthens the disease free interval in these cases.

Aims: Damage to articular hyaline cartilage may predispose to earlyonset osteoarthritis. Hyaline cartilage has not been shown to spontaneously regenerate and previous methods of stimulating repair have often yielded þbrocartilage. Autologous chondrocyte implantation (ACI) offers the potential for hyaline cartilage repair. Methods: A prospective study of 31 patients undergoing ACI using the chondrogide membrane. Patients were assessed clinically using validated knee scores pre-operatively and post-operatively at yearly intervals. Arthroscopy was carried out at one year post implantation and a biopsy of the transplanted area was sent for histological examination. Results: 32 knees (including 2 bilateral) were reviewed clinically at one year, and 15 were reviewed at 2 years. 33 defects (including 2 defects in one knee) were assessed arthroscopically at one year. Only one repair showed hypertrophy at one-year arthroscopy, and 8 had poor integration. Hyaline-like cartilage was demonstrated in 70% of the repairs. Patients showed improvement in the Verbal Numerical Pain scores and in the Lysholm and Gillquist score. Conclusions: In our series, the use of chondrogide membrane shows a low incidence of hypertrophy when compared to periosteum. Improvement in knee scores was statistically signiþcant at one and two years.