Introduction: The non-invasive growing prosthesis continues to be used successfully for the treatment of limb salvage operations in tumour patients. We report our continued experience in 17 skeletally immature patients with osteosarcoma of the distal femur.

Methods: Patients had a mean age of 10.2 years (range 6 to 15) at the time of surgery. The endoprosthesis was lengthened at appropriate intervals in outpatient clinics without anaesthesia using the principle of electromagnetic induction.

Results: The mean follow-up was 28 months (range 2 to 55). The prostheses were lengthened by a mean of 47.4 mm (range 0.5 to 208) and maintained a mean knee flexion of 110 degrees (range 90 to 120 degrees).

Complications developed in seven patients: two implants failed requiring revision, one peri-prosthetic fracture occurred, one developed a flexion deformity of 25 degrees at the knee joint, which was subsequently overcome and three died of disseminated disease.

Discussion: The medium term results from patients treated with this device have continued to show a promising outcome. Four patients successfully completed desired lengthening, six patients are continuing with ongoing lengthening. The implant avoids multiple surgical procedures, general anaesthesia and assists in maintaining leg-length equality.

Introduction: Pathological fractures commonly undergo biopsy to establish tissue diagnosis and plan definitive surgical management.

Methods: 129 patients undergoing image-guided needle biopsy of a pathological fracture between 1998 and 2007 were prospectively identified. Imaging was by CT, ultrasound or fluoroscopy. Biopsy was by Jamshedi, Temno or Trucut needle. The outcome measure was ability to make a tissue diagnosis by this method.

Results: The median age at diagnosis was 43 years. 59% were male, 41% female. The four most common sites of pathological fracture were the femur (35%), humerus (28%), tibia (12%) and pelvis (11%).

The five most common histopathological diagnoses were chondrosarcoma (9%), osteosarcoma (9%), meta-static renal carcinoma (8%), giant-cell tumour (6%), lymphoma (5%).

77% of biopsies yielded a tissue diagnosis. The remaining 23% underwent open biopsy, repeat image-guided needle biopsy or were not further investigated.

In the 30 cases (23%) of non-diagnostic biopsies 80% of these lesions had no extra-osseous component to them and the remaining 20% had a very small extra-osseous component.

Discussion: A tissue diagnosis of a pathological fracture can be obtained by primary image-guided needle biopsy in 77% of cases referred to a specialist bone tumour service. The majority (80%) of unsuccessful biopsies were of lesions with little or no extra-osseous component to the lesion.

This paper describes the preliminary results of a proximal tibial endoprosthesis which spares the knee joint and enables retention of the natural articulation by replacing part of the tibial metaphysis and diaphysis. In eight patients who had a primary malignant bone tumour of the proximal tibia, the distal stem, which had a hydroxyapatite-coated collar to improve fixation, was cemented into the medullary canal. The proximal end had hydroxyapatite-coated extracortical plates which were secured to the remaining proximal tibial metaphysis using cortical screws. The mean age of the patients at operation was 28.9 years (8 to 43) and the mean follow-up was for 35 months (4 to 48). The mean Musculoskeletal Tumour Society score was 79% (57% to 90%), the mean Oxford Knee score was 40 points of 48 (36 to 46) and the mean knee flexion was 112° (100° to 120°). In one patient, revision to a below-knee amputation through the prosthesis was required because of recurrence of the tumour. Another patient sustained a periprosthetic fracture which healed with a painful malunion. This was revised to a further endoprosthesis which replaced the knee.

In the remaining six patients the prosthesis allowed preservation of the knee joint with good function and no early evidence of loosening. Further follow-up is required to assess the longevity of these prostheses.

We retrospectively studied 67 patients who underwent proximal humeral replacement with the Bayley-Walker prosthesis, for tumour of the proximal humerus between 1997 and 2007. Of the 67 patients 10 were lost to follow up. Of the 41 surviving patients, function was assessed using the Musculoskeletal Tumour Society (MSTS) Score and the Toronto Extremity Salvage Score (TESS) questionnaire.

4 of the 41 patients received the new Bayley-Walker ‘captured’ proximal humeral replacement. The mean age was 46 years (7–87). The mean MSTS score at follow-up was 72.0 % and the mean TESS score was 77.2 %. The sub-group of 4 pts who received the new captured prosthesis had a mean MSTS score of 77.7 %. There was no mechanical failure of any prostheses in the follow up period.

Endoprosthetic replacement for tumour of the proximal humerus with the Bayley-Walker prosthesis, is a reliable operation yielding reasonable functional results and good long-term prosthesis survivorship. The performance of this prosthesis is expected to improve further with the new ‘captured’ prosthesis.

Introduction: Experimental studies in anatomic full size hip models indicate that larger femoral heads offer potential in providing greater hip range of motion and joint stability. We studied the effects of increasing head diameter from 28mm to 36 mm in total hip replacement (THR) on the range of flexion and abduction.

Methods: 243 patients who underwent primary total hip replacement with S ROM prosthesis between July 1996 and June 2004 were studied. 151 patients (77 male and 74 female) underwent THR with 28 mm head and 92 patients (38 male and 54 female) underwent THR with 36 mm head. The range of flexion and abduction were studied and statistical analysis was performed using the Student t-test. We monitored the dislocation rate in both groups.

Results: The mean flexion is 87.0 for the 28 mm group and 89.6 for the 36 mm group. The mean abduction is 27.77 and 27.98 for 28mm and 36mm groups respectively. Even though there is a slight increase in the mean flexion and abduction from the 28mm to 36mm group, this increase in not found to be statistically significant. For flexion (2.6 (−0.85 to 3.2); p=0.377), and for abduction (0.02 (−2.37 to 1.94); p=0.847). Three hips dislocated in the 28mm group (2%) but none of the hips in 36mm group has dislocated.

Discussion: Even though experimental studies indicate improvement in range of motion with increasing head diameter in THR, this effect is not reflected in our clinical study. But there is improvement in the joint stability by using a prosthesis with larger head diameter as evidenced by a reduction in the dislocation rate.

Study Design: Prospective analysis of a cohort of patients who underwent a Spinal Fitness Exercise Program in a nurse led spinal assessment clinic in a University Hospital.

Objective: To determine if psychological status affects the outcome of a spinal fitness exercise program in patients with low back pain.

Background: Evidence for the effectiveness of exercise programs in the treatment of chronic mechanical low back pain is well documented. In this study, the effect of psychological status on the outcome of a self-help spinal fitness exercise programme was studied.

Methods: Patients who were referred by their primary care physicians to the nurse led spinal assessment clinic and met the inclusion criteria were given a spinal exercise booklet, which describes with the aid of diagrams how to perform a series of lumbar core stability exercises for them to practise at home. Back pain related disability was assessed before and 3 months after the exercise program using the Oswestry Disability Index (ODI). Psychological status was measured using the Distress and Risk Assessment Method (DRAM). This classifies patients into 4 groups based on the combination of scores from the Modified Somatic Perception Questionnaire (MSPQ, 13 questions, scored 0–13) and Modified Zung Questionnaire (23 questions scored 0–69): normal, at risk, distressed somatic and distressed depressive.

Results: Forty one patients were enrolled into the study (19 male, 22 female, mean age at treatment 45.8 years, age range 22–78 years). The DRAM scores showed that 9 had no psychological disturbance (normal), 17 were at risk, 4 were distressed somatic and 11 distressed depressive. Even though there was a statistically significant improvement in the mean ODI after the exercise program for all DRAM groups, the improvement in the ODI was not significantly different between the four groups (ANOVA, p = 0.596).

Conclusions: Our study suggests that the outcome of a spinal fitness exercise programme is not affected by the psychological status of the patient. We conclude that patients should not be excluded from spinal fitness exercise programs on the basis of psychological status.

We aimed to determine whether proximal femoral bone remodelling, as measured by DEXA scan for each Gruen Zone, differed for 3 different femoral stem designs. These were:

Group 1 – Triple taper polished (C-stem J& J DePuy)

Ethical Committee approval was obtained and all patients gave informed consent. All operations were performed by 3 surgeons using a standard lateral approach, third generation cementing technique and a standard post-operative regime.

Seventy-five patients were randomised prospectively using a stratified randomisation programme for known risk factors in bone density. The randomisation was stratified by age, sex, Charnley Group (A or B), BMI and femoral neck bone mineral density. There were 25 patients in each Group, 5 patients did not have complete data sets and were therefore withdrawn from evaluation.

The Groups were similar with regard to age, sex, BMI, BMD and Charnley Group. Patients were followed up at 3, 6, 12 and 24 months by Nurse Practitioners for clinical and radiological evaluation and DEXA scan at each time of follow-up. There were no catastrophic failures of sepsis or dislocation. All patients functioned well at 24 months by Harris Hip Score.

The bone remodelling pattern will be described for each stem design. Findings are summarised thus. In the lateral Gruen Zones the triple taper and collared stem design faired better and both behaved differently to the double taper design. In Gruen Zone 7, all stems demonstrated reduced bone density as compared to pre-operative scans but this was less with the triple taper design.

Purposes: To determine the effect of gravity on outcome in sacral epidurals injected in the prone compared to the lateral position in patients with unilateral back related leg pain.

Methods: A randomised controlled trial with 2 arms. This pilot study was conducted to determine the standard deviation (SD) of the primary outcome measure to allow calculation of a final sample size. Forty patients who met the inclusion/exclusion criteria were randomly allocated to prone or lateral sacral epidural injection. Twenty patients were allocated to the prone and 20 to the left or right lateral position dependent on their radicular back pain. The primary outcome measure of back and leg pain severity was assessed using a visual analogue scale (VAS) (0= none, 10 = worst imaginable). The Oswestry disability index, SF-36 and straight leg raise were also measured. Outcomes were assessed at baseline and at 6 and 12 week follow-up. A repeated measures analysis using mixed model methodology was used to determine statistical significance.

Results: The 2 groups were comparable in gender and age. The prone group had a mean improvement in VAS back pain score at 6 weeks follow-up of 0.5 compared to 1.6 in the lateral group. At 12 weeks follow-up there was a negative response of 0.1 compared to baseline in the prone group and 1.4 improvement in the lateral group. Repeated measures analysis showed no significant difference in back pain scores between the groups at the 5% level (F2,38 = 3.24; P = 0.0797). Similarly mean improvement in VAS leg pain scores at 6 weeks follow-up were 1.4 in the prone group and 1.7 in the lateral group. At 12 weeks follow-up the scores were 1.1 for the prone and 2.4 for the lateral group. Repeated measures analysis showed no significant difference in leg pain scores between the groups (F1,38= 0.76; P = 0.3898). A post-hoc power calculation using the sample VAS SD showed we had reached only 65% power.

Conclusion: This pilot study has shown that sacral epidural injection for sciatica in the lateral position gives superior pain relief compared to the prone position but the difference is not statistically significant. More patients will now be recruited in order to minimise a type II error that may have occurred.

Introduction: Pain after total hip arthroplasty (THA) can be caused by infection, aseptic loosening, heterotopic ossification, and referred pain. Psoas tendonitis is a rare cause of groin pain after THA and resurfacing arthroplasty. It is believed to be caused by psoas tendon impingement against a malpositioned acetabular component due to defective anteversion or centring and the use of oversized cups. We report 4 cases of psoas tendonitis following resurfacing arthroplasty and hybrid surface arthroplasty.

Methods: Between April 2004 and June 2005, we diagnosed 4 cases (3 female and 1 male) of psoas tendonitis among 152 cases of resurfacing arthroplasty and hybrid surface arthroplasty (2.6%). 116 patients had a hip resurfacing with ASR prosthesis (2 cases, 1.7%) and 36 patients had hybrid surface arthroplasty with ASR unipolar head on S ROM stem (2 cases, 5.6%). All these patients presented 2–5 months postoperatively with severe groin pain which was exaggerated when moving from the sitting position to the upright position and when going up stairs. Common causes of pain after hip arthroplasty, infection and loosening were ruled out. Radiological and ultrasound examination were performed.

Results: Ultrasound examination revealed thickening of psoas tendon in all cases and fluid collection around the tendon in one case. All cases were treated with corticosteroid injection under ultrasound guidance. Significant but temporary symptomatic relief was achieved in all cases.

Discussion: Psoas tendonitis should be considered in the differential diagnosis of groin pain after hip resurfacing procedures. Ultrasound examination is the initial investigation of choice and corticosteroid injection around the tendon is initial method of treatment. Computerized tomography and surgical options of management should be considered in resistant cases.

Aims: The main purpose of this study was to evaluate hemiplevis replacements in patients with periacetabular tumours in terms of the functional results and implant survivorship of the prosthesis. The second aim was to evaluate the complications and how they might be prevented in the future.

Methods: Case notes, hospital databases and radiographs were reviewed in 51 patients treated in a 16 year period with a custom made hemipelvis replacement (Stanmore Implants Worldwide). There were 13 deaths and 4 were lost to follow up. Of the remaining 34 patients there were 18 males and 16 females with a mean age of 48.6 (range 14 – 71).

Results: At a mean follow-up of 78 months (range 7 – 204), 70% of patients were still alive and the most common diagnosis was chondrosarcoma (17 cases). There were 2 cases of prosthesis failure and 22 of the 34 patients had one or more complications (12 cases of infection (8 deep and 4 superficial), 4 nerve palsies, 2 dislocations and 7 others). 13 patients had to have a second operation. The mean MSTS score was 63.8% and the TESS score was 59.8%

Conclusion: Infection was the most common complication and was the most significant reason for reoperation. This method of reconstruction is associated with a high morbidity rate and should be performed only at specialist centres, but the functional and oncological outcomes are satisfactory.

Introduction: Experimental studies in anatomic full size hip models indicate that larger femoral heads offer potential in providing greater hip range of motion and joint stability. We studied the effects of increasing head diameter from 28mm to 36 mm in total hip replacement (THR) on the range of flexion and abduction.

Methods: 243 patients who underwent primary total hip replacement with S ROM prosthesis between July 1996 and June 2004 were studied. 151 patients (77 male and 74 female) underwent THR with 28 mm head and 92 patients (38 male and 54 female) underwent THR with 36 mm head. The range of flexion and abduction were studied and statistical analysis was performed using the Student t-test. We monitored the dislocation rate in both groups.

Results: The mean flexion is 87.0 for the 28 mm group and 89.6 for the 36 mm group. The mean abduction is 27.77 and 27.98 for 28mm and 36mm groups respectively. Even though there is a slight increase in the mean flexion and abduction from the 28mm to 36mm group, this increase in not found to be statistically significant. For flexion (2.6 (−0.85 to 3.2); p=0.377), and for abduction (0.02 (−2.37 to 1.94); p=0.847). Three hips dislocated in the 28mm group (2%) but none of the hips in 36mm group has dislocated.

Discussion: Even though experimental studies indicate improvement in range of motion with increasing head diameter in THR, this effect is not reflected in our clinical study. But there is improvement in the joint stability by using a prosthesis with larger head diameter as evidenced by a reduction in the dislocation rate.

Background: Advances in adjuvant and neoadjuvant therapies have rendered many tumours that previously necessitated amputation amenable to limb salvage procedures. However, a significant proportion of tumours are still treated by hindquarter amputation in an attempt to cure the patient, or to reduce the tumour load. This tends to be lengthy, mutilating and is associated with high morbidity and poor survivorship.

Aims: To review the survivorship, quality of life and functional assessment following hindquarter amputations performed in this centre in the last 10 years.

Methods: This was a retrospective study of 51 consecutive patients who had hindquarter amputations for tumours between 1996 to 2006. Available patients were evaluated using contemporary functional outcome assessments (Musculoskeletal Society Tumour Score, Toronto Extremity Salvage Score, SF36).

Results: Fifty-one patients (31 males, 20 females) had palliative(8) or curative hindquarter amputations(43) for Chondrosarcoma(18), Malignant Fibrous Histiocytoma(6), Osteosarcoma(4) and other sarcoma sub-types(23). The mean age was 50.7 years (range 24–78). The mean duration of symptoms until referral was 5.2 months, the mean time from referral to tissue diagnosis was 16.2 days (range 2–80) and the time from confirmed histological diagnosis to surgery was 39.2 days (range 2–190) on average. Significant complications included phantom limb pain(15), wound problems(24), urinary problems(6), cardiopulmonary events(5) and erectile dysfunction(3). 33 of the 51 patients have passed away, with a mean survival postoperatively of 10.7 months (range 2–43), with carcinomatosis the main cause of death. The mean cumulative survival following hindquarter amputation in this hospital is 17.3 months.

Conclusions: Patients with no metastasis and clear margins at amputation had a better cumulative survival rate. Therefore the decision to proceed for hindquarter amputation to achieve a curative resection is justified but has to be weighed up against the associated significant complications, morbidity and functional deterioration.

Aim: To study the remodelling of cortical bone around the passive growing component of an expandable endoprosthesis.

Introduction: When inserting the passive component of an expandable prosthesis a polyethylene sleeve is commonly used. The sleeve migrates towards the lateral cortex and causes a cortical reaction and hence the use of the sleeve has been discarded recently. This study quantifies the amount of cortical reaction and degree of cortical drift in patients that had sleeves and those that did not.

Material And Methods: We reviewed X-rays and case notes of all patients that had an expandable endoprosthesis in a 20 year period. The thickness of medial and lateral cortices of the tibial diaphysis was measured at 6 months and on the last follow up radiograph. The distance from the edge of the sleeve (or prosthesis) from the cortical edge was also compared. Retrieved components also had their histology reviewed.

Results: The sleeve shifted laterally on average by 2mm (range 0.5 – 3mm) and touched the cortex. This was associated with an increase in lateral cortical thickness by 2.27mm (range 1 – 3mm). When the sleeve was used the prosthesis was inserted in the mid-line. When the sleeve was not used the tibial component tended to be inserted in valgus.

Conclusions: The presence of a sleeve is associated with a cortical reaction and the sleeve tends to migrate laterally. The clinical implications of this and the evolution of the design will be discussed in the meeting.

Purpose: We report a series of 58 patients with metastatic bone disease treated with resection and endoprosthetic reconstruction over a 5 year period at our institution.

Introduction: The recent advances in adjuvant and neo-adjuvant therapy in cancer treatment has resulted in improved prognosis of patients with bone metastases. Most patients who have an actual or impending pathological fracture should have operative stabilisation or reconstruction. According to BOA guidelines patients should undergo a single procedure which allows early full weight bearing and lasts the expected lifespan of the patient. The use of modern modular endoprostheses allows these criteria to be met.

Methods and Results: We retrospectively identified all patients diagnosed with metastatic disease to bone between 1999 to 2003. 171 patients were diagnosed with bone metastases. Metastatic breast and renal cancer accounted for 47% of the lesions. 58 patients with bone metastasis to the appendicular skeleton had an endo-prosthetic reconstruction. There were 28 males and 30 females. 11 patients had lesions in the upper extremity and 47 patients had lesions in the lower extremity. Mean age at presentation was 62 years (24 to 88 years). 19 patients are still alive, 34 patients had died and 5 were lost to follow-up. Patients died of disease at a mean of 22 months (2 to 51 months) from surgery. Mean follow-up was 55 months (24 to 78 months). There were 5 wound infections, 1 aseptic loosening, 3 dislocations, 1 subluxation and 1 prosthesis rotated requiring open repositioning. Patients were followed up and evaluated using the Musculoskeletal Society Tumour Score (MSTS) and the Toronto Extremity Salvage Score. The mean MSTS score was 73% (57 to 90%) and TESS was 71% (84 to 95%).

Conclusions: We conclude that endoprosthetic replacement for the treatment of bone metastases in selected cases achieves the aims of restoring function, allowing early weight bearing and alleviating pain. The complication rate is low.

Introduction: Since 1975, 6 types of extendable endo-prostheses have been developed at Biomedical Engineering, UCL, and Stanmore Implants Worldwide in conjunction with the surgeons at this centre.

Aims: To establish whether developments in design have had the desired effect of improving both implant survivorship and functional outcome.

Methods: This was a retrospective study using case notes, hospital databases and a radiological review, combined with contemporary functional outcome assessments (MSTS, TESS, SF36).

Results: 161 consecutive prostheses in 138 paediatric patients, between the years of 1983 – 2005, were implanted for primary bone tumours. Mean age was 10.3 (3 – 18), 81 were males and 57 females. There were 136 primary procedures and 25 revisions.

6 prostheses that used ball bearings to achieve length (designed in 1981) were implanted, 3 (50 %) were revised due to mechanical failure.

19 prostheses that utilised external C-washes (1998) to achieve length were implanted, 6 (32 %) were revised, half of these for mechanical failure.

Of the 98 minimally invasive prostheses (1992) that utilized an Allan key and screw-jack mechanism to lengthen, 14 (14 %) were revised, half of these for infection.

17 non-invasive extendable endoprostheses (2001) that are lengthened by electromagnetic coupling have been implanted so far. There has only been 1 (6 %) revision. This was due to full extension being reached.

Conclusions: Design improvements in growing endoprostheses since 1983 have led to improved survivorship. Initially this led to a reduction in mechanical failure and latterly to a reduction in infection, as indications for revision.

Key Words: Bone tumour, children, endoprosthesis, survivorship.

Purpose: We report a series of patients with malignant tumours of the pelvis that had a tissue expander inserted in the pelvis to facilitate radical radiotherapy, and report functional outcomes following treatment.

Introduction: Surgery for malignant tumours affecting the pelvis is challenging. Some tumours are suitable for internal hemipelvectomy and reconstruction, some require hindquarter amputation and some are inoperable. Overall prognosis is poor with high morbidity and mortality rates. There may be a place for alternative treatment with the insertion of pelvic spacers to facilitate radical radiotherapy. This is indicated in patients who have an inoperable tumour, who decline amputation, or who had an internal hemipelvectomy with close margins and high risk of local recurrence.

Methods & Results: We performed a retrospective review of all patients who presented with a malignant tumour of the pelvis and who underwent an insertion of a pelvic spacer followed by local high dose radiotherapy. Available patients were followed up and evaluated using the Musculoskeletal Society Tumour Score (MSTS) and the Toronto Extremity Salvage Score (TESS). There were ten patients; 5 had Ewing’s sarcoma, 3 had osteosarcoma, 1 had spindle cell sarcoma and 1 had alveolar soft part sarcoma. 4 patients had metastases on presentation. The average age was 30 years (14 to 56 years), and average follow-up was 15 months (12 to 24 months). 4 patients died and 6 are still alive. There were no surgical complications. The average length of hospital stay was 6 days (2 to 10 days). Patients averaged an MSTS score of 63% and a TESS of 67%.

Conclusion: Radical radiotherapy after spacer insertion offers an alternative to morbid surgery and is associated with good functional outcomes.

Background: Extra-compartmental limb soft tissue sarcomas are notoriously difficult to treat. These tumours can exhibit macro or microscopic spread beyond the confines of normal anatomical barriers and require radical resection, often necessitating excision of bone as well as soft tissue. This will inevitably affect the patient’s functional outcome. The primary operations for these aggressive sarcomas include wide local excision of soft tissue and adjacent involved bone, radical resection with endoprosthetic reconstruction and amputation.

Methods: 85 patients who underwent such an operation between 1995 to 2000 were reviewed and categorised according to whether they received wide local excision, endoprosthesis reconstruction or amputation. Patient demographics, sarcoma details, recurrence and survival rates were identified and compared between the three groups. Functional outcomes in the 45 patients still alive were assessed using TESS and MSTS scores.

Results: Mean age was 61 years (range 8 to 92). There were 51 males and 34 females. Anatomical distribution was as follows: arm 26, leg 47, pelvis 8 and other 4. The commonest histology subtypes were MFH, leiomyosarcoma and undifferentiated soft tissue sarcoma. 17 had wide local excision of bone and soft tissue, 32 underwent endoprosthesis reconstruction and 36 underwent primary amputation. Recurrence rates were highest in the endoprosthesis group at 19%. Five year survival was worst in the amputation group at 49%. Functional outcomes were highest in the wide local excision group, and similar in the other two surgical groups.

Conclusions: Unsurprisingly survival is poorest in the primary amputee group because of the highly aggressive nature of these sarcomas, despite having the most radical treatment. The similar functional outcomes shown between endoprosthesis reconstruction and primary amputation may be influential when considering cases in which this decision is unclear and function is the main issue at stake.

Purpose: We report the clinical and functional outcome of limb salvage surgery and endoprosthetic reconstruction of the distal tibia and ankle joint in 5 patients.

Introduction: The distal tibia is an uncommon site for primary malignant bone tumours and the treatment of choice for most patients is a below knee amputation. Patients who decline an amputation may be offered an endoprosthetic replacement. This is a technically challenging operation and may be associated with high morbidity.

Methods and Results: Over 25 years at our centre, 5 patients underwent distal tibial replacements for bone or soft tissue sarcomas. Two had osteosarcoma, one had a recurrence of Ewing’s sarcoma, one had malignant fibrous histiocytoma, and one had an adamantinoma. The mean age was 37 years (13 to 69 years). There were no tumour recurrences. Four patients developed complications with wound infection. Two of these resulted in below knee amputations. Average follow-up was 31 months (19 to 55 months) with 1 patient lost to follow-up. Patients were evaluated using the Toronto Extremity Salvage Score (TESS) and the Musculoskeletal Tumour Society (MSTS) score. The mean MSTS score was 88% and the mean TESS was 88.5%. Two patients who later had a below knee amputation and who were using a prosthesis averaged an MSTS score of 86.3% and a TESS of 89.3%.

Conclusion: For those patients who are unwilling to undergo an amputation for malignant tumours of the distal tibia, endoprosthetic reconstruction is an alternative, but at the cost of increased risk of significant complications, functional deterioration and morbidity. There was little difference between functional scores for patients who proceeded to have a below knee amputation compared to patients who still had their endoprosthesis

Four patients who developed malignant synovial tumours are described; one with chondromatosis developed a synovial chondrosarcoma and three with pigmented villonodular synovitis developed malignant change. The relevant literature is discussed.

We used a knee-sparing distal femoral endoprosthesis in young patients with malignant bone tumours of the distal femur in whom it was possible to resect the tumour and to preserve the distal femoral condyles. The proximal shaft of the endoprosthesis had a coated hydroxyapatite collar, while the distal end had hydroxyapatite-coated extracortical plates to secure it to the small residual femoral condylar fragment. We reviewed the preliminary results of this endoprosthesis in eight patients with primary bone tumours of the distal femur. Their mean age at surgery was 17.years (14 to 21). The mean follow-up was 24 months (20 to 31). At final follow-up the mean flexion at the knee was 102° (20° to 120°) and the mean Musculoskeletal Tumour Society score was 80% (57% to 96.7%).

There was excellent osteointegration at the prosthesis-proximal bone interface with formation of new bone around the hydroxyapatite collar. The prosthesis allowed preservation of the knee and achieved a good functional result. Formation of new bone and remodelling at the interface make the implant more secure. Further follow-up is required to determine the long-term structural integrity of the prosthesis.

We report our early experience with the use of a non-invasive distal femoral expandable endoprosthesis in seven skeletally immature patients with osteosarcoma of the distal femur. The patients had a mean age of 12.1 years (9 to 15) at the time of surgery. The prosthesis was lengthened at appropriate intervals in outpatient clinics, without anaesthesia, using the principle of electromagnetic induction. The patients were functionally evaluated using the Musculoskeletal Tumour Society scoring system. The mean follow-up was 20.2 months (14 to 30). The prostheses were lengthened by a mean of 25 mm (4.25 to 55) and maintained a mean knee flexion of 110° (100° to 120°). The mean Musculoskeletal Tumour Society score was 68% (11 to 29). Complications developed in two patients; one developed a flexion deformity of 25° at the knee joint, which was subsequently overcome and one died of disseminated disease. The early results from patients treated with this device have been encouraging. The implant avoids multiple surgical procedures, general anaesthesia and assists in maintaining leg-length equality.

Background/Aims: Biopsy of musculo-skeletal tumours is hazardous and, when poorly performed, may compromise limb salvage surgery and patient survival. The aim of this paper is to examine the early management of such patients referred to our unit with particular reference to the biopsy.

Methods: We conducted a prospective audit of all patients referred to our musculo-skeletal tumour service during 2002. Inclusion criteria were patients with primary tumours of the musculo-skeletal system. Patients with metastases were excluded. We compared the outcome of patients biopsied prior to referral with that of patients biopsied in a recognised treatment centre. Statistical analysis was performed using the chi-squared test and accepting a p value of 0.05 as significant.

Results: One hundred and forty two patients were included. There were 72 men and 70 women with a mean age of 40 years (6–88). The referring surgeon performed biopsies in 29 cases of which 20 were malignant lesions. The senior author biopsied the remaining 113 cases of which 57 were malignant. In 38% of patients biopsied by the referring surgeon definitive treatment was hindered by a badly performed biopsy. In 25 % the definitive treatment had to be changed either to a more radical procedure than would have originally been necessary or to palliative rather than curative intent. Three patients underwent unnecessary amputation. Patients biopsied elsewhere were more likely to a non-diagnostic biopsy (p< 0.0001), more likely to have an incomplete excision (p< 0.0001), more likely to require amputation (p< 0.03) and more likely to require adjuvant radiotherapy (p< 0.05) than those biopsied in our unit.

Conclusions: There is a high complication rate when patients with musculo-skeletal tumours are biopsied by surgeons inexperienced in the management of such lesions. These patients are best served by early referral to a specialist centre where the biopsy can be performed quickly, safely and accurately and definitive treatment can be administered.

Clear cell sarcoma of soft tissues is a rare, poorly understood tumour with little written about it in peer reviewed literature. The aim of this paper is to present a consecutive series of patients treated at our institution.

All patients were staged using the system of the musculo-skeletal tumour society (MSTS). The aim of surgery was to achieve a wide excision. Adjuvant chemotherapy or radiotherapy was used in some patients depending on the margins, age and general health of the patient. Follow-up comprised clinical examination, magnetic resonance imaging (MRI) of the tumour bed and chest x-rays. Patients were seen 3 monthly for the first 2 years and then 6 monthly.

Between 1997 and 2003 14 patients were included. There were 5 males and 9 females with a mean age of 49 years (21–82). Mean follow-up was 42 months (1–84). Seven tumours occurred in the upper limb and 7 in the lower limb. Four patients were lymph node positive at presentation. The mean maximum diameter of the tumour was 5.6 cm (2–8). Ten patients were referred prior to excision but 4 patients had already undergone inadvertent excision biopsy elsewhere. Four patients developed local recurrence and 3 patients developed metastases. Seven patients remain disease free, 2 have no active disease, 1 is alive with disease and 4 have died of the disease.

The 2 year survival in this series is 71%. Poor prognostic factors include positive lymph nodes at diagnosis, maximum diameter of the tumour greater than 5cm and incomplete initial excision. It is important that these patients are treated early and that wide excision is achieved. We recommend early referral to a recognised musculo-skeletal tumour centre.

Introduction Patients with musculo-skeletal tumours require appropriate staging investigations followed by prompt treatment. Biopsy of these lesions is hazardous and, when poorly performed, may compromise limb salvage surgery and patient survival. We examine the early management of such patients referred to our unit with particular reference to the biopsy.

Methods We conducted a prospective audit of all patients referred to our musculo-skeletal tumour service during 2002. Inclusion criteria were patients with a tumour of the musculo-skeletal system of unknown tissue diagnosis at presentation. Biopsies were performed either by the referring surgeon or the senior author. Patient demographics were recorded as well as details of the histological diagnosis, the site of the tumour and its stage. We recorded who performed the biopsy, the type of biopsy, the choice of biopsy site, whether or not adequate material was obtained and whether or not a poorly performed biopsy compromised the definitive treatment. We saw 162 patients (83 men and 79 women) with a mean age of 41 years (6 to 85). There were 81 primary bone tumours of which 40 were malignant, 58 primary soft tissue tumours of which 29 were malignant, 15 metastases from unknown primary tumours and eight haematological malignancies. One hundred and thirty-nine tumours were in the extremities, 12 pelvic, six trunk and six spinal. We saw patients at a mean of 11 days after receiving the referral letter. Of the 69 primary malignant tumours we saw 60 (87%) within two weeks and 67 (97%) within four weeks. The referring surgeon had performed biopsies in 29 cases.

Results Of the tumours biopsied by other surgeons, adequate diagnostic material was obtained in 75% compared to 99% in those biopsied by us. The biopsy site was suboptimal in 11/29 (38%). Fine needle aspiration (FNA) had been performed in 7/29 with only two (29%) providing diagnostic material. Poorly performed biopsy changed our definitive treatment in 5/29 (17%). Of those four had amputations and one patient received radiotherapy instead of further surgery. Twelve of 29 (41%) patients required re-excision of an incompletely excised tumour.

Conclusions Biopsies taken from sub-optimal sites may contaminate surrounding tissues, are frequently non-diagnostic and may compromise limb salvage surgery. FNA is particularly unreliable. We conclude that these patients are best served by early referral to a specialist centre where the biopsy can be performed quickly, safely and accurately.

Introduction 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.

Methods 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 nine men with a mean age of 26 years (6 to 52). Mean follow-up was 51 months (12 to 106). There were 19 malignant tumours, all stage 2b, and five giant cell tumours. The mean length of graft was 12.5 cm (4.5 to25). Sixteen grafts were used in the upper limb and eight in the lower limb. Arthrodesis was performed in eight cases and intercalary reconstruction in 16 cases. Fixation of grafts was achieved with a plate and screws in 21, a blade plate in two and an IM nail in one. In six cases the resected tumour bone was reinserted as autograft after extracorporeal irradiation.

Results 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 to 78). Graft hypertrophy was seen in 7/29 cases (24%). Complications included two wound breakdowns, three stress fractures, one muscle contracture, one malunion and one painful plate. Overall eight patients (33%) required second operation. Two patients died of recurrent disease and one has metastases. The mean MSTS functional score was 87% (80 to 93).

Conclusions 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.

Introduction: The aim of this study is to compare the efficacy of the AO Universal Spine System (AO USS) with Harrington-Luque instrumentation for the treatment of King type II idiopathic scoliosis.

Methods/Results: A retrospective analysis was performed on two groups of patients with King II adolescent idiopathic scoliosis. The first group consisted of 40 consecutive patients treated with Harrington-Luque instrumentation between 1990 and 1993. The second group consisted of 25 consecutive patients treated with AO USS instrumentation between 1994 and 1996. The groups were well matched with respect to age, sex and curve severity. Inclusion criteria were patients over the age of 12 years with a King II curve pattern and a Cobb angle of greater than 40°. Half of the patients in each group underwent anterior release prior to posterior fusion. All patients were followed up six monthly for 18 months. The thoracic curve, lumbar curve, kyphosis and lordosis were measured using the Cobb method.

The mean pre-operative thoracic and lumbar curves were 62° and 43.9° respectively in the Harrington group and 57.5° and 35.9° in the AO USS group. On average 11.4 levels were fused in the Harrington group compared to 10.9 levels in the AO USS group. The mean post-operative correction of the thoracic curve in the AO USS group of 64% was significantly greater than the 51% achieved in the Harrington group (p< 0.005). At 18 months there was a 7% loss of correction in the Harrington group and 9% in the AO USS group. The correction of lumbar curve of 41% in the Harrington group and 46% in the AO USS group at 18 months was not significantly different. In the sagittal plane the AO USS group had significantly better preservation of the lumbar lordosis but there was no difference in kyphosis correction. Blood loss was similar in both groups. Mean operative time of 132 minutes in the AO USS group was shorter than the mean time of 153 minutes in the Harrington group (p< 0.05). Two hooks in the Harrington group became dislodged and two in the AO group. There were no neurological complications in either group. All the patients in both groups achieved a solid fusion.

Conclusion: AO USS is a safe and effective instrumentation system for the treatment of King type II adolescent idiopathic scoliosis. Correction of the thoracic curve is superior to that achieved with Harrington-Luque instrumentation and operative time is shorter. AO USS enables better preservation of the lumbar lordosis than Harrington-Luque. There is no difference in blood loss, complication rate and fusion rates between the two techniques. It has become our instrumentation system of choice for this group of patients.

A prospective study on total knee replacement in patients with Juvenile Idiopathic Arthritis was carried out. There were 31 knee replacements in 17 patients; 12 were female. Bilateral procedures were performed in 11 patients; 10 staged during a single admission and 1 performed in a single procedure. The mean age was 19 years (range, 14–26), and the mean follow-up was 23 months (range, 6–44). The surgery was complicated in 9 cases by a previous distal femoral osteotomy. The results were assessed using the Hospital for Special Surgery (HSS) scoring system. A cruciate sacrificing implant was used in all cases, and the patella was resurfaced in 25/31.

The pre-operative mean arc of motion was 62° (range 10°–90° ) and this averaged 89° (range, 20° –115°) at latest follow-up. The pre-operative mean fixed flexion 17° (range, 0° –15° ). The mean pre-operative HSS score was 36 (range, 8–59), and the mean at latest follow-up was 81 (range, 67–95). There has been no sign of aseptic loosening on serial radiographs over the follow-up period. One patient developed a deep infection at 20 months requiring a 2-stage revision and one patient developed a perforated duodenal ulcer postoperatively.

The clinical results are very satisfactory, allowing patients to regain their mobility and independence. The early radiographic results are very encouraging despite the poor bone quality and severe deformities that require correction.

The aim of this study is to evaluate the early results of gleno-humeral reconstruction after tumour excision with a new design of endoprosthesis.

The prosthesis is a fixed fulcrum gleno-humeral replacement consisting of a hydroxyapatite (HA) coated glenoid component with a polyethylene liner and a cemented stem with HA coated collar. Between 1997 and 2000 we inserted the prosthesis into 15 patients with primary bone tumours of the proximal humerus. There were nine males and six females with a mean age of 38 years (range: 8–71 years). Twelve stems were cemented and three uncemented. Two skeletally immature patients had an extendible stem inserted, one subsequently having a successful lengthening procedure. The mean follow-up was 28 months (range: 12–41 years). Functional outcome was assessed using the Musculoskeletal Tumour Society (MTS) scoring system.

There were two early dislocations and one superficial wound infection. Three patients died of their disease and one underwent forequarter amputation for local recurrence. The remaining eleven had satisfactory functional outcomes with a mean MTS score of 81%. Radiologically there has been no evidence of early loosening. Microscopic analysis of the components in the amputated arm showed excellent osseointegration around the HA coated components.