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have been 233 lengthenings overall with 1 patient requiring reversal on one occasion due to intractable pain; this pain rescinded 30 minutes after lengthening was reduced by 10mm.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.

Introduction: Intramedullary cementless fixation of massive tumor prostheses was developed to combat the high incidence of aseptic loosening in a young population of tumor patients. Its use has also expanded to include reconstruction of failed major knee arthroplasty. Our system uses a hydroxyapatite coated titanium stem in conjunction with a hydroxyapatite collar to obtain fixation.

Methods: We present a series of 72 patients (34 females, 38 males) with a mean follow-up of six years (2 months – 14 years). The mean age at the time of surgery was 17 (5 – 77). Within this group, 51 patients had osteosarcomas, 10 had giant cell tumors, eight had Ewing’s sarcoma and one each had malignant fibrous histiocytoma, spindle cell sarcoma and failed total knee arthroplasty. Non-invasive and minimally invasive growing prostheses were used in 33 patients.

Results: Nine patients required revision of the prosthesis at a mean of 5.2 years; 5 for aseptic loosening and four for infection. Twelve patients died at a mean of 20 months (1 – 84) post-operatively. Radiological evidence demonstrated remodelling around both the stem and the collar. There was gap closure to the hydroxyapatite coated collar in cases where seating was not complete. Consistent loss of cortical bone around the mid-stem was noted in the first 12 months but remained stable beyond this time frame.

Discussion: This study highlights our experience with cementless distal femoral endosprostheses. We demonstrate good results with regard to revision rate, gap closure and osseointegration.

Introduction: Alveolar soft part sarcoma (ASPS) is a soft tissue tumour found primarily in adolescents and young adults. It has an incidence of 0.5 – 1.0 % of all soft tissue sarcomas and a predilection for females. The lesion is inherently malignant and may occur throughout the body however, reports suggest they are predominantly detected in the anterior thigh. Symptoms include a painless slow-growing mass but ASPS can commonly present with brain or lung metastases due to the high vascularity of the lesion. Microscopically, cellular groups exist with centralised areas of necrosis, thus resulting in a pseudoalveolar appearance.

Methods: We identified six cases of histologically proven ASPS. The mean age was 28.5 years (21–36). Four patients were male. All patients had a primary presentation of a mass, two of which were painful. All patients, except one, presented within 8 months of the onset of symptoms (mean 3.8 months) with the other seeking medical advice only after 72 months. The location of the mass included the thigh in three patients and the triceps, soleus and retroperitoneal space in the others. Four patients underwent pre-operative diagnostic biopsies. Surgical excision was performed in all patients.

Results: The mean size of tumour was 9.4 x 9.4 x 6.3cm but there was no correlation between lesion size and duration of symptoms. The patient who presented late was found to have multiple lung metastases prior to surgery. Despite appropriate adjuvant therapy, three patients developed post-operative metastases at a mean of 5.2 months (1–24), two of which died along with the patient who presented with metastases at a mean of 2.6 years.

Discussion: This series demonstrates that this tumour may present as a painful mass. Despite early detection and appropriate treatment, ASPS remains a highly malignant neoplasm with a high associated mortality rate.

Free, vascularised fibular grafting is well described in limb salvage surgery. The mechanical properties of the fibula make it ideal for replacement of bony defects after tumour resection and it can be sacrificed with minimal morbidity. We review the outcome of a consecutive series of 24 patients.

Between 1993 and 2002 we performed free vascularised fibular grafts in 24 patients as part of a limb salvage procedure following tumour excision. Pre-operatively patients were staged using the Musculoskeletal Tumour Society (MSTS) system. Post-operatively patients were followed up with radiographs and clinical examination. From the radiographs graft hypertrophy and time to bony union was documented. Functional outcome was assessed using the MSTS scoring system. Complications were recorded.

There were 15 women and 9 men with a mean age of 26 years (6–52). Mean follow up was 51 months (12–106). There were 19 malignant tumours, all stage 2b, and 5 giant cell tumours. The mean length of graft was 12.5 cm. (4.5–25). 16 grafts were used in the upper limb and 8 in the lower limb. Arthrodesis was performed in 8 cases and intercalary reconstruction in 16 cases. Fixation of grafts was achieved with a plate and screws in 21, a blade plate in 2 and an IM nail in 1. In 6 cases the resected tumour bone was reinserted as autograft after extracorporeal irradiation. In all but one patient the tumour margins were clear. Primary bony union was achieved in 22 patients (92%) at a mean of 35 weeks (12–78). Graft hypertrophy was seen in 7/29 cases (24%). Complications included 2 wound breakdowns, 3 stress fractures, 1 muscle contracture, 1 malunion and 1 painful plate. Overall 8 patients (33%) required second operation. 2 patients died of recurrent disease and one has metastases. The mean MSTS functional score was 87% (80–93).

Free vascularised fibula grafts offer a reliable method of reconstruction after excision of bone tumours. The complication rate appears high and some patients require a revision procedure. However, the problems are relatively easy to correct, bony union is achieved in the majority and functional outcome is good.