We believe this technique provides good oncological and functional results and recommend this treatment option is considered in young active patients required distal fibula excisions for sarcoma.
We report on a group of 20 metal-on-metal resurfaced hips (17 patients) presenting with a soft tissue mass associated with various symptoms. We describe these masses as pseudotumours. All patients underwent plain radiography and fuller investigation with CT, MRI and ultrasound. Where samples were available, histology was performed. All patients in this series were female. Presentation was variable; the most common symptom was pain or discomfort in the hip region. Other symptoms included spontaneous dislocation, nerve palsy, an enlarging mass or a rash. The common histological features were extensive necrosis and lymphocytic infiltration. Fourteen of the 20 cases (70%) have so far required revision to a conventional hip replacement and their symptoms have either settled completely or improved substantially since the revision surgery. Two of the three bilateral cases have asymptomatic pseudotumours on the opposite side. We estimate that about 1% of patients develop a pseudotumour in the first five postoperative years after a hip resurfacing. The cause of these pseudotumours is unknown and is probably multi-factorial, further work is required to define this; they may be manifestations of a metal sensitivity response. We are concerned that with time the incidence of these pseudotumours will increase.
Young active patients with malignant tumours arising in the distal fibula, requiring excision, present a challenge to the treating surgeon. Wide local excision is advocated, to achieve clearance, however, disruption of the ankle mortise results and fusion is often required to restore stability. The loss of movement is poorly tolerated in the younger patient and leads to progressive degenerative changes in surrounding joints. Excision of the distal fibula lesion followed by harvesting of the proximal fibula and using this graft to recreate the ankle mortise restores ankle stability and retains ankle movement. Between 1998 and 2007, we have performed this technique on 4 patients. Diagnoses were Ewing’s sarcoma, chondrosarcoma, parosteal osteosarcoma and osteofibrous dysplasia. To date there has been no evidence of distant or local recurrence. One case was complicated by infection, which resolved with radical debridement and antibiotics; the other three fibula grafts survived. Good to excellent results were achieved. We will present the technical aspects of this procedure, with particular reference to the most recent case, performed on a young female patient with parosteal osteosarcoma. We believe this technique provides good oncological and functional results and recommend this treatment option is considered in young active patients requiring distal fibula excisions for sarcoma. Correspondence should be addressed to Major M Butler RAMC, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, Devon.
Proprioception protects joints against injurious movements and is critical for joint stability maintenance under dynamic conditions. Knee replacement effect on proprioception in general remains elusive. This study aimed to evaluate the changes in proprioceptive performance after knee replacement; comparing Total (TKA) to Unicompartmental Knee Arthroplasty (UKA). Thirty-four patients with osteoarthritis were recruited; 15 patients underwent TKA using the AGC prosthesis and 19patients underwent UKA using the Oxford prosthesis. Both cruciate ligaments were preserved in the UKA group, while only the PCL was preserved in TKA patients. Patients’ age was similar in both groups.>
Joint Position Sense (JPS) and postural sway were used as measures of proprioception. Both groups were assessed pre- and 6 months post-operatively in both limbs. JPS was measured as the error in actively and passively reproducing five randomly ordered knee flexion angles between 30 and 70°using an isokinetic dynamometer. Postural sway (area and path) was measured during single leg stance using a Balance Performance Monitor. Functional outcome was assessed using the Oxford Knee Score (OKS). Pre-operatively, no differences in JPS or sway were found between limbs in either group. No differences existed between the two groups. Post-operatively, both groups had significant improvement of JPS in the operated limb (UKA mean4.64°, SD1.44° and TKA mean5.18°, SD1.35°). No changes in JPS were seen in the control side. A significant improvement (P<
0.0001) in sway area and path was found in the UKA group only in both limbs. No significant changes in sway occurred in either limb of TKA patients. The OKS improved from 21.4 to 35.5 for TKA patients and from 23.9 to 38for UKA patients. Both UKA and TKA improve proprioception as assessed by JPS. However, UKA alone improves postural sway in both limbs. This may impart explain why UKA patients function better than TKA patients
We are presenting the outcome of a young adult with extensive epithelioid hemangioendothelioma of the femur treated with wide excision and vascularised fibular graft. An 18-year-old builder was referred with an aggressive primary bone tumor of the right femur. Initial staging showed no evidence of distant disease but tumor confined to a 26.5cm diaphyseal segment of the femoral shaft. The patient’s pre-operative Oxford knee score was 28 and the AKSS scores were 74 (observational) and 65 (functional). True cut open biopsy confirmed low grade angiosarcoma. The patient underwent a wide excision of the lesion through a lateral approach leaving a generous cuff of bone and muscle tissue around the tumor. Clear resection margins were assessed intraoperatively. Histologically, the tumor was found to be epithelioid hemangioendothelioma. The 29.5cm defect was filled with a vascularised bone graft of the ipsilateral fibula. The graft was secured with a 22-hole DCS bridging plate and screws at both ends. Intraoperative knee range of motion was from 0 to 125 degrees without recurvatum and graft movement. The patient had an unremarkable recovery. At the latest follow-up, one year after his operation, the patient had made an excellent functional recovery with non-symptomatic full weight bearing and had also returned to his work as a builder. He demonstrated a knee range of motion of 0 to 115 with a slight genu varum. The patient’s post-operative Oxford knee score was 40 and the AKSS scores were 70 (observational) and 90 (functional). Radiographs showed excellent union at the distal aspect of the graft and a healing stress fracture of the fibula graft at the proximal aspect. Vascularized fibular graft with plating is a safe reconstruction limb salvage option for defects of long bones after tumor resection.
The identified patients had their notes reviewed, and were contacted by post to complete a Toronto Extremity Severity Score (TESS) questionnaire to assess lower limb function in day-to-day life. Details of their presenting features, oncological work-up, surgical intervention and adjuvant therapy was established and correlated to the TESS score.
Between 1972 and 2002 74 patients were treated under the combined care of the orthopaedic oncology service and lymphoma clinic with primary bone lymphoma. We reviewed the seventeen cases affecting the upper limb (23%). Of the seventeen patients nine remain alive. Assessment of the patient’s clinical presentation, histopathological definition, treatment and function outcome was made. The nine survivors were assessed clinically and with the Oxford shoulder score and the Toronto extremity salvage score. Average time from first presentation to diagnosis was 7 months. All seventeen were diagnosed as a B –cell non-Hodgkin’s lymphoma, fifteen cases were high grade and two cases were low grade. The scapula was involved in six, humerus eight and clavicle three cases. Seven patients sustained pathological fractures three of which were at presentation; of these two were treated surgically. Eight patients have subsequently died of their disease. Functional outcome in surviving patients after medical treatment was very good with average TESS score of 79% (52%–99%) and OSS of 27 (12–52). The presentation of lymphoma of the shoulder girdle may mimic benign shoulder conditions and lead to a delay in radiological and histopathological diagnosis. Pathological fracture is a common presentation and complication of treatment, however these fractures have a high chance of healing with medical treatment alone. Although shoulder stiffness remains a problem following medical treatment, overall upper limb function is good. There is little evidence that these patients require surgery in the short to medium term.
Over a five year period 50 patients required combined orthoplastic care out of 987 patients presenting with bone and soft tissue tumours. Thirty men, mean age 51 years, had their treatment reviewed at a mean follow up of 23 months (3–54 months) post surgery. All surviving patients completed the Toronto Extremity Salvage Score. There were 23 bone and 27 soft tissue sarcomas, 4 were Enneking stage I, 41 stage II and 5 stage III. All tumours were removed by wide resection to achieve microscopically clear margins in 49. 9 endoprostheses were inserted. Soft tissue reconstruction involved 9 local flaps, 13 distant flaps (mainly muscle) and 8 free flaps (including 3 composite osseous flaps). 20 patients received adjuvant radiotherapy and 14 patients received chemotherapy. Two endoprosthetic replacements required surgery for infection, one distant lap and one free flap required further surgery (6%). The mean disease free interval was 29 months (2–49 months). There were 6 deaths and pulmonary metastases occurred in a further 8 patients. Within this study period there was one episode of local recurrence, but no local recurrence in the group that had radiotherapy. 77% of surviving patients completed the Toronto Extremity Salvage Score and good to excellent function was seen in most cases. Combined orthoplastic approach facilitates limb sparing surgery and early adjuvant radiotherapy.
The aim of this study was to establish the ability of an invasive fibre-optic probe to measure intra-muscular pH, pCO2, pO2, HCO3-−, ambient temperature, base excess and O2 saturation. The secondary aim was to determine the effect of elevation of the limb on these parameters. Fibre-optic probes were introduced into the anterior compartment muscle of the leg in five volunteers via 16G cannulae. After equilibration the limb was monitored for 11min with the volunteer supine on an examination couch. The limb was elevated to 22cm (Braun frame) and then 44cm for the same time. Subsequently the leg was returned to 22cm and supine. All volunteers followed this set protocol. Continuous recording of all indices was made throughout. Data was stored to a personal computer for analysis. Similar trends were observed across all subjects for all parameters. The mean pO2 when lying flat was 27mmHg (S.D.7.4). Elevation to 22cm increased muscle pO2 to 33 mmHg (S.D. 5.8). Further elevation to 44 cm resulted in a reduction in muscle pO2 to a level below that measured when supine. When the limb was returned to 22cm the pO2 trend reversed, the level improving. Returning to the supine position the pO2 returned to the level seen at the start of monitoring. This novel probe gives reproducible measures of pH, pCO2, pO2, HCO3−, ambient temperature, base excess and O2 saturation. Results indicate that elevation to 22cm improves muscle oxygenation; a height of 44cm seems detrimental. This technique may be applicable in surveillance for compartment syndromes and muscle ischaemia.
Giant Cell Tumour of the Tendon Sheath is a benign tumour of synovial origin most frequently affecting the upper limb. Up to 11% exhibit radiographic evidence of cortical erosion and intra-osseous expansion. In the upper limb recurrence rates of between 10–50% following excision have been reported. However, GCT-TS is rarely described in the foot and ankle and its behaviour is ill understood. 17 cases of this rarely described tumour in the foot and ankle are presented, describing their clinical presentation, histopathology, treatment and outcome. Analysis of all cases of histopathologically proven GCT-TS of the foot and ankle from the Oxford Tumour Registry, was conducted between the periods of January 1984 to December 1999. 22 cases were identified of which 17 cases had adequate records to allow analysis of patient demographics, duration of symptoms, preoperative investigations, presumed diagnosis, precise site of origin, post operative complications and recurrence rates The mean age of presentation was 28 (8–53). 10 cases were female and 7 male. 76% cases occurred in the foot, all of which arose adjacent to the phalanges or heads of the metatarsals. 14% occurred in relation to the ankle or sub-talar joint. 82% presented with a painless swelling. The duration of symptoms ranged from 6 months to 8 years. Only one patient complained of sensory symptoms. Pre-operative investigations included radiographs in 64% with 3 cases having an additional MRI scan. The MRI scans of GCT-TS have characteristic changes on T1 and T2 images. The presumed preoperative diagnosis was incorrect in 82%. 36% of radiographs taken showed changes including cortical erosion and speckled calcification. A local excision was performed in 15 cases, an amputation in one and a wide local excision in one case only. There have been no recurrences during the follow up period of between 1–12 years. GCT-TS of foot and ankle is rare and is commonly misdiagnosed. Despite only a local excision being performed in more than 80% of this series there were no recurrences. Plain radiographs may show cortical erosion or speckled calcification in up to 36% and MRI is helpful in further defining the anatomy of the lesion, allowing planned excision and reducing the risk of recurrence.
We analysed the histological findings in 1146 osteoarthritic femoral heads which would have been considered suitable for bone-bank donation to determine whether pathological lesions, other than osteoarthritis, were present. We found that 91 femoral heads (8%) showed evidence of disease. The most common conditions noted were chondrocalcinosis (63 cases), avascular necrosis (13), osteomas (6) and malignant tumours (one case of low-grade chondrosarcoma and two of well-differentiated lymphocytic lymphoma). There were two with metabolic bone disease (Paget’s disease and hyperparathyroid bone disease) and four with inflammatory (rheumatoid-like) arthritis. Our findings indicate that occult pathological conditions are common and it is recommended that histological examination of this regularly used source of bone allograft should be included as part of the screening protocol for bone-bank collection.