Aims:We sought to develop and validate a classiþcation system for assessing PFJ status prior to revision surgery. Methods: The classiþcation system grades the condition of the PFJ by describing both the patella bone stock and the patello-femoral tracking. The system was analysed for its reliability by assessing both intra- and inter-observer variability. From our database of 110 patients who underwent revision knee arthroplasty, 66 cases were selected at random. Each patient had both pre and post-operative radiographs to classify. 145 sets of radiographs, each set consisting of an AP, lateral and skyline patella view, were studied. Three clinicians graded all radiographs according to the classiþcation system on 2 separate occasions. These assessments were performed at least 6 weeks apart. The results were analysed by an independent observer who was blinded. Both intra- and inter-observer agreement was quantiþed using kappa values. Results: Inter-observer kappa values between observers A& B, B& C and C& A were 0.89, 0.96 and 0.82 respectively. Intra-observer kappa values were 0.94, 0.87 and 0.97 for the 3 clinicians. This indicates excellent levels of agreement. Conclusions: The proposed classiþcation system provides a convenient, spe-ciþc, descriptive and reproducible method of denoting PFJ status. Our system may be used to accurately communicate and compare PFJ characteristics. This will aid planning of surgical intervention and allow comparison of results and techniques in revision knee arthroplasty.

Aims: We reviewed 100 paediatric lateral condylar fractures of the elbow treated with k-wire þxation. We compared the complication rates of wires left percutaneous versus wires buried beneath the skin. Methods: 68 patients had wires left percutaneous and 32 patients had their wires buried. Fractures were classiþed as displaced or undisplaced. Lengths of time for Ôwires in situñ, limb immobilisation and follow up were recorded. All complications of treatment and outcomes were recorded. Results were analysed using Chi-square tests. Results: Buried k-wires stayed in situ longer than percutaneous wires (average 6.7 versus 4.9 weeks). Fracture types along with mean lengths of immobilisation and follow up were similar for both groups. In the Ôburiedñ group 6 (19%) patients wires migrated through the skin although only 1 (3%) case became infected. 1 (3%) patient developed an uncomfortable heterotrophic ossiþcation. In the Ôpercutaneousñ group 20 (29%) patients developed wire infection and/or granulation tissue requiring treatment. 3 (4%) of these cases severely compromised treatment. Delayed union requiring re-operation occurred in 1(1%) patient. Conclusion: Burying the wires after open reduction and þxation of lateral condylar fractures signiþcantly (p=0.0026) reduces the incidence of infection and overgranulation associated with the wires.

Introduction: Many soft tissue sarcomas undergo initial inadequate excision (the Whoops! procedure) and are then referred to specialist services. The outcome of 108 such patients is presented.

Method: Records of 108 patients were traced from the prospectively collected database at our institute who had reexcisions of soft tissue sarcomas. We investigated outcome both in terms of local control and overall survival following treatment to assess the significance of an inadequate initial excision.

Results: Over a ten-year time period we was 887 new patients with soft tissue sarcoma of whom 140 patients (11%) presented following previous inadequate excision. Of these, 108 patients underwent re-excision in an attempt to achieve clear margins. 80% tumours were high grade and 40% were deep. After reexcision, 57% patients were found to have residual tumour. 32% patients had close margins after re-excision. Over all survival of patients was 80% at 5 years and local recurrence rate was 10%. Local recurrence of patients with marginal excision was 15% at 5 years but for clear margins was 6.7%. Of 108 patients 22 (20%) had metastasis at 5 years of which 16.6% were in the lung. 81% of metastasis occurred in patients with close margins of reexcisions. Survival of patients with close margins was worse than wide margins (p = 0.0025).

Conclusion: Local recurrence was statistically associated with grade, depth, margins of re excision and presence of residual tumour. Overall survival was influenced by close margins and residual tumour but not by local recurrence. Re-excision of soft tissue sarcoma to clear margins improves survival of the patients at 5 years.

Purpose: The purpose of this work was to analyse survival and prognostic factors in a series of patients treated for pelvic chondrosarcoma.

Material and methods: This series included 67 patients (27 women and 40 men) treated between 1971 and 1996 for pelvic chondrosarcoma. Mean age at diagnosis was 45 years (range 18–78). Forty percent of the tumours were grade I. The most frequent localisation was the iliac bone. Conservative surgery was performed in 45 patients. The only surgical treatment possible in 22 patients was an inter-ilioabdominal disarticulation. Resection margins were adequate for only 19 patients (wide resection). Marginal resection was noted in 14 patients with intra-tumour resection in 17.

Results: Overall 5- and 8-year survival was 65% and 58% respectively. Local recurrence rate was 40%, occurring a mean 27 months after initial surgery. Statistical analysis did not reveal any correlation between tumour size, tumour grade, type of surgery, resection margin, and local recurrence. Results were nevertheless less favourable in case of inadequate surgical margins. Tumour grade, tumour size, patient age, gender, and quality of resection did not have a significant effect on overall survival. Local recurrence was the only negative factor predictive of survival (p< 0.05).

Discussion: Development of local recurrence appears to be the most important negative predictive factor in patients with pelvic chondrosarcoma. In this localisation, satisfactory resection margins are often difficult to achieve. Most authors propose inter-ilioabdominal disarticulation as a last resort procedure. The question of the indication for more aggressive initial surgery to obtain more radical resection margins remains open.

Purpose: Primary bone tumours situated at the distal end of the humerus are exceptional and observed in only 1% of the cases. Reconstruction at this level is often difficult due to the wide bone resection. Choosing a massive prosthesis is an interesting method allowing correct carcinological and functional results. We report a series of ten patients who underwent reconstruction of the lower end of the humerus between 1970 and 2001 with a massive prosthesis after tumour resection.

Material and methods: This series included four men and six women, mean age 51 years (15–76). Eight patients had primary bone tumours and two had secondary bone lesions. Mean follow-up was 79 months (9–372). The custom-made constrained hinge prosthesis composed of chromium-cobalt and titanium was cemented. Regular clinical and radiological follow-up data were recorded. The Henneking score and the Toronto Extremity Survival Score (TESS) were used to assess functional outcome.

Results: Three patients underwent revision for aseptic loosening of the humeral component at 48, 56 and 366 months with problem of polyethylene insert wear for two of them. There were no infctions or local recurrences and no secondary amputations. The posterior or anterolateral approach was used for humeral resection (mean 153 mm, 63–160 mm). Postoperatively, three patients developed transient palsy (one radial and two ulnar) which regressed. Four patients died from metastasis and had a satsifactory prosthesis result at time of death. The mean TESS was 73% (29–93%) at last follow-up

Discussion: Although this is a small series, the long-term results appear to indicate that reconstruction of the lower extremity of the humerus with a massive prosthesis is a satisfactory option for this rare tumour localisation.

A case of pencil-gore granuloma occurring 45 years after the initial injury is described. The clinical and radiological presentation was suggestive of a soft-tissue sarcoma. The diagnosis was confirmed by biopsy, which also revealed foreign body fragments which, on spectometric analysis, had high concentrations of carbon and aluminium.

We studied 100 patients who had undergone endoprosthetic replacement of the proximal humerus between 1976 and 1998. The outcome was assessed with regard to the survivorship of the patients, the salvaged limbs and the prostheses. Function was determined in the 47 surviving patients, of whom 30 were assessed using the Musculo-Skeletal Tumour Society (MSTS) rating scale and 38 completed the Toronto Extremity Salvage Score (TESS) questionnaire.

The median age of the patients was 34 years (10 to 80). The mean follow-up period for surviving patients was nine years (2 to 20). The mean MSTS score at follow-up was 79% and the mean TESS score was 72%. The length of bone which was resected influenced the functional outcome. Abduction of the shoulder was to 45° in most patients. The overall survival was 42% at ten years and that of the limb without amputation 93%. The survival of the prostheses using mechanical failure as the endpoint was 86.5% at 20 years.

Endoprosthetic replacement of the proximal humerus is a predictable procedure providing reasonable function of the arm with a low rate of complications at long-term follow-up.

Aim: The purpose of this retrospective study was to analyse the risk factors, causes, bacteriology of deep infection following extensible endoprosthetic replacement for bone tumours in children and to review our experience in the treatment of 20 patients with infected prostheses.

Materials and methods: 123 patients with extensible endoprostheses were treated between 1983 and 1998. Three types of prostheses, which differed in the lengthening mechanism used, were implanted. 20 of these were diagnosed to have deep infection. Patients were divided into 3 groups: group I- 5 patients were treated with a single stage revision, group II- 13 patients were treated with a two stage revision procedure, group III- 2 patients had a primary amputation. Control of infection was assessed clinically and with inflammatory markers. Function was assessed using the MSTS score.

Results: The overall incidence of infection was 16%. The incidence of infection at the proximal tibia and distal femur was 27% and 14% respectively. Staphylococcus epidermi-dis was the most common organism. The most common clinical features were pain and swelling around the pros-theses. Infection in most cases was immediately preceded by an operative procedure or by distant a focus of infection. The number of operative procedures and the site of the prosthesis were significant risk factors. The success rate was 20% in Group I and 84.6% Group II. Amputation was the salvage procedure of choice for failed revision procedures. The mean MSTS functional score was 83% in patients in whom the infection was controlled.

Conclusion: The incidence of deep infection is high following extensible endoprostheses. The site of the pros-thesis and the number of operative procedures are significant risk factors.

Ten patients underwent endoprosthetic replacement of the distal humerus for bone tumours over a period of 30 years. There were eight primary and two secondary tumours in four men and six women with a mean age of 47.5 years (15 to 76). The mean follow-up was eight years (9 months to 31 years). Four patients required further surgery, three having revision for aseptic loosening; two of these and one other later needing a rebushing. There were no cases of postoperative nerve palsy, infection, local recurrence or mechanical failure of the implant. Four patients died from their disease, all with the prosthesis functioning satisfactorily. At follow-up the mean flexion deformity of the elbow was 15° (0 to 35) and the mean range of flexion was 115° (110 to 135). The functional results showed a mean Toronto extremity salvage score of 73% of normal. Endoprosthetic replacement of the distal humerus and elbow is a satisfactory method of treating these rare tumours.

About one third of patients who require one knee replacement have significant bilateral symptoms and will require surgery on both knees before achieving their full functional potential. The options for these patients are either to have one-stage bilateral knee replacements or two-stage knee replacements. Our aim was to compare the relative local and systematic morbidity of patients who had one-stage bilateral knee arthroplasty with those of patients who had unilateral total knee arthroplasty in a retrospective, consecutive cohort of patients to evaluate the safety of one-stage bilateral total knee arthroplasty. Seventy-two patients treated with one-stage bilateral knee replacements were matched for age, gender and year of surgery with 144 patients who underwent unilateral knee arthroplasty. We found one-stage bilateral arthroplasty was associated with significantly increased risks of wound infection, deep infection, cardiac complications and respiratory complications compared to unilateral knee arthroplasty.

No increased risk of thromboembolic complications or mortality was found.

We conclude that one-stage bilateral total knee arthroplasty is associated with increased risk of both systematic and local complications compared with unilateral knee replacement and therefore should be performed on only selective cases.

Our centre has used a specially designed custom-made endoprostheses with curved stems to reconstruct femoral defects in patients with residual short proximal femur after excision of primary bone sarcoma over the last 18 years. Two designs of endoprostheses with curved intramedullary stems were used: the rhinohorn stem type and the bifid stem type. We report the safety, survival and functional outcome of this form of reconstruction.

Twenty six patients who had these special endoprosthesis reconstruction were studied. The median age was 16 years (range 7 to 60 years). Prostheses with rhino horn stems were used in 15 patients and bifid-stem in 1 1 patients. Twenty patients had the prostheses inserted as a primary procedure after excision of primary bone sarcoma, and in six patients the prostheses were inserted after revision surgery of failed distal femur endoprostheses. Seventeen patients (65%) were alive and free of disease at a median follow-up of 98 months (12 to 203 months) and nine patients had died of metastatic disease. Local recurrence developed in two patients (1 0%) out of the 20 patients. Surgical complications occurred in five patients (191/o). Deep infections occurred in two patients (8%) requiring revision surgery in one patient. Prosthetic failure, occurred in nine patients (35%). The cumulative survival of prostheses was 69% at five years and 43% at 10 years. Musculoskeletal Tumour Society mean functional score was 83% (53% to 97%).

In conclusion, preservation of a short segment of the proximal femur and the use of endoprostheses with curved stems for reconstruction of the femur is technically possible. There is an increased risk of fracture of the prostheses decreasing the survival rate. Functional outcome of patients with this form of reconstruction is not significantly different from the functional outcome of patients who have proximal femur or total femur endoprosthetic reconstruction. This operation is particularly desirable in skeletally immature patients and allows normal development of the acetabulum.

The purpose of this retrospective study was to analyze the risk factors, causes, bacteriology of deep infection following extensible endoprosthetic replacement for bone tumours in children and to review our experience in the treatment of 20 patients with infected prostheses.

123 patients with extensible endoprostheses were treated between 1983 and 1998. Three types of prostheses, which differed in the lengthening mechanism used, were implanted. 20 of these were diagnosed to have deep infection. Patients were divided into 3 groups: group I 5 patients were treated with a single stage revision, group 11– 13 patients were treated with a two stage revision procedure, group Ill- 2 patients had a primary amputation. Control of infection was assessed clinically and with inflammatory markers. Function was assessed using the MSTS score.

The overall incidence of infection was 16%. The incidence of infection at the proximal tibia and distal femur was 27% and 14% respectively. Staphylococcus epidermidis was the most common organism. The most common clinical features were pain and swelling around the prostheses. Infection in most cases was immediately preceded by an operative procedure or by distant a focus of infection. The number of operative procedures and the site of the prosthesis were significant risk factors. The success rate was 20% in Group 1 and 84% in Group II. Amputation was the salvage procedure of choice for failed revision procedures. The mean MSTS functional score was 83% in patients in whom the infection was controlled.

The incidence of deep infection is high following extensible endoprostheses. The site of the prosthesis and the number of operative procedures are significant risk factors. The type of prosthesis used is not a risk factor. Two-stage revision is successful in controlling infection in a majority of these cases.

This is a retrospective study of 70 patients with chondroblastoma treated between 1973 to 2000. Of these 70 patients, 53 had their primary procedure performed at our unit in the form of an intralesional curettage. The purpose of this study was to determine the rates of recurrence and the functional outcomes following this technique. Factors associated with aggressive tumour behaviour were also analysed. The patients were followed up for at least 22 months, up to a maximum of 27 years. 6 out of these 53 cases (11. 3%) had a histologically proven local recurrence. Three patients underwent a second intralesional curettage procedure and had no further recurrences. Two patients had endoprosthetic replacement of the proximal humerus and one patient underwent a below knee amputation following aggressive local recurrences. One patient had the rare malignant metastatic chondroblastoma and died eventually. The mean MSTS score was 94. 1%. We conclude that meticulous primary intralesional curettage without any additional procedure can achieve low rates of local recurrence and excellent long-term functional results.

Malignant peripheral nerve sheath tumours (MPNSTs) constitute 10% of soft tissue sarcomas. A significant proportion arise in neurofibromatosis type 1 (NF1). Several publications have compared MPNST survival in sporadic and NF1 patients, without consensus on whether NF1 is an independent factor for poor prognosis.

Clinical and histological data from 135 proven MPNSTs were analysed from 2 national centres for soft tissue tumour surgery diagnosed from 1979 to 2000. 129 patients had follow-up data from 6 months to 21 years. 35 were from patients with NF1. Local treatment involved surgery in surgery in 95%, radiotherapy in 44% and chemotherapy in 21%.

NF1 patients were younger than those with sporadic tumours (median age 26 years vs 53 years, p< 0. 001). Overall MPNST survival was almost identical to that in soft tissue sarcomas as a whole, but was worse in NF1 than in sporadic tumours (33% vs 72% at 30 months [p< 0. 01], 17% vs 39% at 60 months, 6% vs 21% at 120 months). A trend towards shorter time to local recurrence was seen in NF1, but not time to metastasis. Superficial tumours gave improved prognosis. Tumour volume over 100ml was associated with worse survival (46% vs 91% at 30 months, p< 0. 02), as was histological grade (80% high grade vs 25% low grade at 60 months, p< 0. 01). In terms of location, a non-significant over-representation of NF1 MPNSTs in the sciatic and brachial plexii was identified.

NF1 and sporadic MPNSTs exhibited no difference in depth or tumour volume profile, although NF1 tended towards higher grade. Analysis of survival in only high grade tumours, however, still resulted in a significant survival disadvantage in NF1 (33% vs 70% at 30 months, p< 0. 01). Removal of brachial and sciatic plexus tumours from analysis did not affect survivorship profiles in NF1 and sporadic MPNSTs.

Grade, volume and tumour depth correlate with survival; only 7 of 45 patients with deep high grade tumours over 100ml volume were observed to survive beyond 2 years. MPNST survival is worse in NF1 than sporadic tumours. Grade, depth, site and volume differences could not explain this disadvantage.

Few studies of wound complications following limb salvage surgery for soft tissue sarcomas separate anatomical compartments. Forty-nine patients with adductor compartment sarcomas underwent limb salvage surgery, 43% developing significant wound complications, 25% requiring further surgery and 20% had delays in adjuvant radiotherapy as a result. Prior surgery by non tumour surgeons and previous radiotherapy led to an increased risk of wound healing problems. In this particular group of patients, special attention should be made to prevent wound healing complications, possibly involving plastic surgeons at an earlier stage of management.

Between 1982 and 1997, twenty-six children between the age of 2 and 15 (mean age 10. 6 years) underwent proximal femoral replacement. Twenty have survived and all but three have reached skeletal maturity.

Sequential radiographs have been reviewed with particular reference to acetabular development and fixation of the prostheses. Initially a cemented acetabular component was inserted, but recently uncemented implants and unipolar femoral heads that exactly fit the acetabulum have been used.

In older children the acetabulum develops normally and the components remain well fixed. One of nine children over thirteen years with a cemented acetabulum needed revision for loosening and one suffered recurrent dislocations.

In younger children the acetabulum continues to develop at the triradiate cartilage, so a cemented acetabulum grows away from the ischiopubic bar. As the component is fixed proximally, it becomes increasingly vertical and will almost inevitably loosen. In our study six of eight children under 13 years of age with a cemented acetabulum needed revision for loosening.

Unipolar replacements in younger children tend to erode the superior acetabular margin. Femoral head cover is difficult to maintain, and of four unipolar implants in children under thirteen, two required acetabular augmentation.

Cemented cups may be unsuitable for children under thirteen years but our results are not statistically significant. In this age group, unipolar implants may be more appropriate but they have serious potential complications. In children over thirteen, cemented implants survive longer. The number of uncemented implants in our study is too small to comment on long-term survival.

Reconstruction of the shoulder joint following resection of the proximal humerus for bone tumours remains controversial. We report the long term functional results of the simplest form of reconstruction – an endoprosthesis.

One hundred patients underwent endoprosthetic replacement of the proximal humerus between 1976 and 1998. Thirty eight had osteosarcoma, 17 had chondrosarcoma, 16 had metastases and 9 had Ewing’s sarcoma. Mean age was 36 years (range 10 to 80 yrs). Survivorship of patients and prostheses were calculated. Function was assessed using the Musculoskeletal tumour society (MSTS) and Toronto extremity salvage (TESS) scoring systems. Thirty patients could come to the clinics for MSTS scoring and 38 out of 49 alive patients replied to the TESS questionnaires sent out to them.

The overall survival of the patients was 42% at 10 years. Local recurrence (LR) arose in 16 patients, being most common in chondrosarcoma (26%) and osteosarcoma (22%) and arose in 50% of patients with these tumours who had marginal excisions. Of these 16 patients, 8 had forequarter amputations whilst the remainder had excisions and radiotherapy. Mean time to LR was 12 months and all but two of these 16 patients subsequently died within a mean of 18 months.

The prostheses proved reliable and dependable. Only 9 required further surgery of any sort, 2 needing minor surgery to correct subluxation and 7 needing revisions, one for infection after radiotherapy and six for loosening – three after trauma. The survivorship of the prosthesis without any further surgery was 86. 5% at 20years. The survivorship of the limb without amputation was 93% at 20 years.

The functional outcome was very predictable. Most patients had only 45 degrees of abduction although three patients had normal movements. The mean MSTS functional score was 79% and the mean TESS score was also 79%. There was a high level of patient satisfaction but difficulty was encountered especially in lifting and in all activities above shoulder height. Endoprosthetic replacement of the proximal humerus is a predictable procedure providing reasonable function of the arm below shoulder height. The endoprostheses have proved highly dependable with a low re-operation rate. There is a high risk of local recurrence after inadequate surgery which should be avoided if possible.

This retrospective clinical study describes our experience of the use of growing endoprostheses in children with primary malignant tumours of the proximal femur and analyses the results.

Between 1983 and 1996 we treated nine children with primary bone tumors of the proximal femur by resection and proximal femoral extensible replacements. Outcomes measured were function of the limb using Musculoskeletal Tumor Society score, oncologic outcome, complications and equalization of limb length. Results: Four patients died as a result of pulmonary metastases. The remaining five patients were observed for an average follow-up period of 7. 6 years (range 11–12. 7 years). One patient had a hindquarter amputation for uncontrolled infection. In these five patients we performed an average of 10. 2 operative procedures per patient (range of 3–17 procedures) including 5 lengthening procedures (range of 1–8 procedures) and a mean total extension of 69. 7 mm per patient. Acetabular loosening and hip dislocations were the most frequent complications. Only two patients have not had a revision or a major complication. Despite this, 4 children are alive with a functioning lower limb and a mean Musculoskeletal Tumour Society functional score of 77. 6%. The limb length discrepancy was less than 1 0 mm in three of these patients. The remaining patient has a discrepancy of 50 mm and is awaiting further limb equalization procedures.

Extendible endoprostheses of the proximal femur in selected children is a viable reconstructive procedure. It allows for equalization of limb length and the ability to walk without the use of mobility aids.

Endoprosthetic replacement (EPR) following Bone Tumour excision is common. A major complication of EPRs is infection, which can have disastrous consequences.

This paper investigates the cause of infection, management and sequelae.

Over 10, 000 patients have been treated in our unit over 34 years. Information collected prospectively on a database includes demographic data, diagnosis, treatment (including adjuvant), complications, and outcomes. Data was analysed to identify any infection in EPRs, its management and outcome. Factors such as operating time, blood loss, adjuvant therapy, type of prosthesis (extendable or standard) were investigated. Outcomes of treatment options were evaluated. Data was analysed on 1265 patients undergoing EPR over 34 years, giving a total follow up time of over 6500 patient years.

137 (10.8%) patients have been diagnosed with deep infection (defined by a positive culture [n=128] or a clinically infected prosthesis with pus in the EPR cavity [n=9]). Of these 49 (34%) required amputations for uncontrollable infection. The commonest organisms were Coagulase Negative Staphylococcus, Staphylococcus aureus and Group D Streptococci. The only satisfactory limb salvaging operation was 2 stage revision, which had 71% success in curing infection. Systemic antibiotics, antibiotic cement or beads and surgical debridement had little chance of curing infection. Infection rates were highest in the Tibial (23.1%) & Pelvic (22.9%) EPRs (p< 0.0001). Patients who had pre or post-operative radiotherapy had significantly higher rates of infection (p< 0.0001), as did patients with extendable EPRs (p=0.007).

Patients who had subsequently undergone patella resurfacing and rebushing also had a higher rate of infection (p=0.019 and p=0.052). Infection is a serious complication of EPRs. Treatment is difficult and prolonged. 2 stage revision is the only reliable method for limb salvage following deep infection. Prevention must be the key to reducing the incidence of this serious complication.

34 two-stage revision procedures were carried out between 1989 and 1998 for controlling deep infection following resection of bone tumours and reconstruction with endoprostheses. In 4 cases the procedure failed with early recurrent infection. In six others infection reappeared after further operative procedures. Six of these ten patients required amputation. The success of the procedure in controlling infection was 75% at 5 years. Two stage revision procedures have proved effective in controlling infection in massive endoprostheses but the risk of re-infection appears to be much greater in patients requiring further surgery for any cause.