Aim: To investigate the effectiveness of silver coated titanium prostheses in preventing periprosthetic infection in a group of very high risk patients.

Methods: Periprosthetic infection is one of the main problems in limb salvage surgery, especially for tibial and pelvic prostheses or following revision surgery, particularly if it has been done for a previous infection. We have used silver coated prostheses in 21 cases on a named patient basis and have now assessed the results.

Results: Between July 2006 and June 2008 21 patients had a silver coated prosthesis inserted. 11 patients were having a second stage revision after a previous infection, 6 were having a pelvic prosthesis inserted, 3 were having a primary tibial replacement and one a one stage proximal tibial revision. Three patients developed a postoperative infection, two of the pelvic replacements and one infected revision (a total femur replacement). Of these only one patient required removal of the prosthesis (for overwhelming coliform infection in a pelvic replacement) whilst the other two infections both settled with antibiotics and washout.

Discussion: The anticipated risk of infection in this high risk group would have been around 20%. The actual infection rate was 14% but two of the infections completely resolved with relatively modest treatment. This suggests that the silver coating may not only have a role in preventing infection but also enhancing control of infection should it arise. There were no other side effects and we believe that these preliminary results are encouraging and should lead to a further evaluation of silver for preventing infection around prostheses.

Disappearing bone disease is also known as vanishing bone disease, phantom bone disease, massive osteolysis, Gorham’s disease or Gorham-Stout disease. Basically, it is characterised by osteolysis in (contiguous) bone segments, due to localised proliferation of thin-walled vascular channels in the bone and surrounding soft tissues.

The etiology and pathophysiology of this condition remain poorly understood and largely unclear, but there is increasing evidence that disordered lymphangiogenesis plays a role. It is an extremely rare cause of osteolysis, so all other differential diagnoses should be considered and ruled out before retaining the diagnosis of disappearing bone disease.

Treatment is fairly disappointing and no single treatment modality has proven effective in actually arresting the disease. Conservative treatment includes ant-resorptive agents (bisphosphonates), immunomodulating substances and radiation therapy, whereas surgical treatment options include resection and reconstruction with bone grafts and/or prostheses versus amputation.

We report on the only two cases that were identified in our database between 1984 and 2008, both affecting the lower limb (one tibia, one femur). In an attempt to limb salvage, these patients initially underwent endoprosthetic replacement of the affected bone segment, but due to disease progression both eventually ended up with a hip disarticulation.

Conclusion: Although benign, this condition can be very aggressive, necessitating amputation to achieve local control.

Aim: To estimate the risk of bone malignancy arising in premalignant conditions.

Methods: There are quite a number of possible premalignant conditions with considerable uncertainty about the actual risk of a bone sarcoma developing. The incidence of these malignant conditions was identified from a prospective database containing 3000 primary bone sarcomas.

Results: 178 of the 3000 patients with newly diagnosed bone sarcomas had a pre-exiting condition which in all probability led to the sarcoma. These included 50 with previous radiotherapy treatment and 47 with Paget’s disease. 31 patients developed malignancy in HME, 8 with neurofibromatosis and 7 each with Ollier’s disease and retinoblastoma. There were 4 malignancies in patients with Mafucci’s syndrome, 3 in patients with fibrous dysplasia, 3 in patients with synovial chondromatosis and 2 in patients with Rothmund-Thomson syndrome.

Given that the incidence of bone sarcomas is 9/million population per year, our 3000 patients represent 333 million population years. When the incidence of a condition is known in the population this allows an estimation of the risk of malignancy compared with the normal population. Retinoblastoma for instance is known to arise in 1 in 16000 births. The 7 malignancies we saw thus represents a risk to individuals with retinoblastoma of 336/million/yr – a figure 37 times the risk of the normal population. Approximate figures of risk have been calculated for other entities.

Conclusion: Data from a supra-regional register allows an approximate estimate of the increased risk of bone tumours in premalignant conditions.

Malignant tumours of the radius compose only 3% of all upper limb tumours. Owing to their rarity they are often difficult to manage satisfactorily. Of the options for fixation available, endoprosthetic replacements have been scarcely utilized despite their success in limb preservation with malignant tumours in other parts of the body. At our centre we have used these when biological solutions (eg fibula graft) were not indicated due to extensive disease or the need for radiotherapy.

We performed four endoprosthetic replacements of the distal radius in three males and one female with ages ranging from 19–66 years (average= 42.25 years of age). Two were performed for varieties of osteosarcoma (parosteal and osteoblastic osteosarcomas), one for a large destructive giant cell tumour (GCT) and one for destructive renal metastases. Three were right sided (75%) and one left sided (25%).

Medical records were evaluated for information on local recurrence, metastases, complications and functional outcome using the Toronto Extremity Salvage Score (TESS). Follow up ranged from 22 to 205 months (average= 116.5 months). The average TESS score was 58.1% (range= 44.6–74.5%). Neither case of osteosarcoma recurred. The GCT recurred twice and the patient with renal metastases had nodules removed from his affected wrist on two further occasions. There were no cases of infection, but the two earlier cases had problems with metacarpal stems cutting out and jointsubluxatinos. The two earlier cases have since died at 205 (parosteal osteosarcoma) and 189 months (GCT) respectively of other disease.

We conclude that although this is a very small series of endoprosthetic replacement of the distal radius, the technique is a useful addition to the surgical options, with acceptable postoperative functional results and complication rates when a biological solution or preservation of the wrist joint is not indicated.

Introduction: Limb salvage reconstruction evolved from the treatment of primary bone tumours. Endoprosthetic replacements (EPR) were originally designed for this purpose, but the versatility of these implants has resulted in an extension in the indications for their use. Severe bone loss, failed revision surgery and persistent deep infection present similar challenges and when a salvage procedure is required, EPR are occasionally used. The aim of our study was to assess the medium term survival and functional outcome of EPR.

Materials and Methods: 38 patients (23 females and 15 males), who underwent EPR for non-neoplastic conditions were identified from a prospectively kept database of all patient seen at the Royal Orthopaedic Hospital Oncology Service. The indications for replacement included failed joint replacement, fracture non-union, failed internal fixation and periprosthetic fractures.

The 38 procedures were identified from September 1995 to June 2007 and included 17 distal femoral replacements, 12 proximal femoral replacements, 4 proximal humeral replacements, 2 distal humeral replacements, 2 hemi-pelvic replacements and 1 total femoral replacement. EPR survivorship was calculated using a Kaplan-Meier survival curve. The quality of patients’ mobility and performance of activities of daily living was used to assess functional outcome.

Results: Patients had a mean age of 60 years (range 15–85 years) at surgery and had between 0 and 4 previous operations prior to EPR. Seven out of 38 patients had recorded deep infection prior to surgery (18%). The Kaplan-Meier implant survival was 91.3% at 5 years, 68.5% at 10 years and 45.7% at 20 years. The limb salvage survival for all reconstructions was 75% at 10 years.

87.4% of patients who underwent a lower limb EPR achieved a satisfactory or very satisfactory functional outcome. 100% of patients achieved a satisfactory or very satisfactory functional outcome in the upper limb EPR group.

3 implants failed, 2 as a result of infection and required staged revisions, 1 eventually requiring amputation, and 1 failed as a result of aseptic loosening. 2 patients dislocated their proximal femoral replacements, both were treated successfully by closed reduction. Despite the salvage surgery subsequent amputation was only required in one patient.

Conclusion: EPR appears to be effective and the medium term survival is encouraging. The aim of a pain free functional limb is achievable with this technique. The complication rates are acceptable considering the salvage nature of these patients. We recommend referral of complex cases to a tertiary centre with expertise in this type of surgery.

Introduction: Renal cell carcinoma often metastasizes to the skeleton and less frequently soft tissues, leading to the increased risk of fracture. Previous studies have show that the survival of patients with bone metastases is frequently prolonged and that early failure of surgical implants designed for fracture fixation is high. The aim of the study was to investigate the outcomes from surgical procedures undertaken at a tertiary referral bone tumour unit.

Methods: A retrospective review of consecutive patients presenting with a musculoskeletal metastasis to our unit from October 1976 to June 2007 was undertaken. There were 179 patients seen over this period, 89 with solitary and 90 with multiple mets. The mean age at presentation was 60.0 yrs. The mean follow up was 16.9 months. Kaplan-Meyer implant and patient survival analysis was undertaken.

Results: The mean patient survival was 22 months (range 1 month to 16 years). The 1yr, 3yr and 10yr patient survival was 77 %, 44 % and 11 % respectively. The types of surgical treatment undertaken included EPR in 119 patients, conventional arthroplasty in 15 patients, fracture fixation in 14 patients, excision only in 12 patients, amputation in 9 patients, curettage and cementation in 9 patients, decompression stabilization of spine in 1 patient. Two femoral EPRs failed due to infection, requiring hindquarter amputations. Failure of fixation to the humerous lead to a forequarter amputation, two hip dislocations. Failure of curettage and cementation in the acetabulum and proximal tibia were treated with THR and EPR respectively.

Discussion: Patients with renal cell carcinoma metastases can survive for prolonged periods. Any surgical intervention for bone metastases has to outlive the patient and EPRs are reliable with a low rate of failure or complication. We would recommend resection and reconstruction with endoprostheses for solitary renal metastases in a tertiary referral unit.

Aim: To review treatment outcomes in patients with sacral chordoma treated at our centre over the past 20 years.

Methods: Retrospective review of prospectively kept data. Previously treated patients were excluded. The surgical objective was to obtain clear margins. If sacrifice of S2,3,4 was necessary, this was usually combined with colostomy.

Results: 30 patients were treated (20 males, 10 females), median age 63.5 (28 to 94). Median duration of symptoms before presentation was 79 weeks (3–260), mean tumour size 11 cm. Most had neurological symptoms. Eight tumours involved the S2 roots, 1 the entire sacrum. Treatment was palliative in 7 patients, resection in 23. Operation time averaged 4.5 hours (1.5 to 8). Margins were wide in 7, marginal in 12, and intralesional in 4 patients. There was a high rate of postoperative complications, mostly wound problems (61% of patients). In 1 case this resulted in septicaemia and post-operative death. Average operative blood loss was 1600ml (0–3500). 65% of patients were incontinent of urine and/or faeces. Local recurrence (LR) occurred in 52% of operated patients at a median of 32 months (4–134). Incidence of LR was 60% after intralesional, 57% after marginal and 25% after wide surgery (p=0.49). LR was treated with re-excision, radiofrequency ablation, radio- and occasionally chemotherapy. Overall survival (Kaplan-Meier) of all patients was 57% at 5, and 40% at 10 years. Of operated patients this was 67% and 47%. There was a trend for better survival after wide resection margin. Metastatic disease only occurred in 3 patients.

Conclusion: Chordoma of the sacrum is frequently diagnosed late. Resection is associated with a high complication rate. Local recurrence is the most common cause of death. Early referral to a specialist centre is recommended to optimize treatment. The role of adjuvant therapy remains unclear.

Introduction: The aim of this study was to identify the pattern of symptoms in patients presenting with synovial sarcoma, examine how these corresponded to the symptoms outlined by the NICE guidelines on the rapid referral of patients with a suspected sarcoma and spot factors that led to long delays in diagnosis.

Methods: Early symptoms and the results of clinical and radiological investigation were reviewed along with the presumed diagnoses that had been made for 35 children. The total duration of symptoms was separated into patient delay and doctor delay.

Results: Using the four clinical findings suggestive of sarcoma according to the NICE guidance, only half of the patients had one or more of them at the time of initial symptoms. The most common presentation was a painless mass (n=16), and in 10 children there was no mass identified. Seven patients had an inexplicable joint contracture, many having been extensively investigated unsuccessfully. The mean duration of symptoms before the diagnosis was made was 98 weeks (range 2 to 364). The mean number of doctors seen prior to referral was 3 (range 1–6) and for 15 patients the diagnosis was obtained after inadvertent excision. The factors associated with long duration of symptoms before diagnosis were knee and elbow location (p=0.0047) or periarticular location (p=0.01), absence of lump (p=0.016) or painful mass as early symptom (p=0.04), the presence of calcifications on x-rays (p=0.01) and a fixed joint contracture (p=0.0003).

We could not show that delay in diagnosis led to a worse prognosis.

Discussion: This paper highlights the sometimes bizarre symptoms associated with synovial sarcoma and hopefully this will increase awareness of the condition among relevant sections of the medical profession and help to reduce the delay in diagnosing these cases.

Introduction: Chondrosarcoma has always been treated with respect by oncology surgeons, given that it is relatively resistant to chemotherapy and radiotherapy. The importance of the adequacy of surgical resection margins has been previously reported, however, the aim of the study was to study the outcomes of surgery for Chondrosarcoma and determine the role of initial surgical margins and local recurrence on final outcome.

Methods: Electronic patient records were retrieved on all patients seen at a tertiary referral musculoskeletal oncology centre with Chondrosarcoma of bone with a minimum of 2 years follow up. A total of 532 patients were seen with Chondrosarcoma between 1970 and 1/1/2006. Patients were excluded if they had initial treatment in another unit (20 patients), a subdiagnosis of dedifferentiated Chondrosarcoma (due to very poor prognosis, 43 patients), metastases at presentation (6 patients) and if they presented with disseminated metastases prior to local recurrence (12 patients). This left 451 patients in the study group and the clinicopathological records were reviewed on these patients.

Results: Of the 451 patients, the mean age was 48 years old at diagnosis (range 6–89 years) with the most commonly sites of presentation being in the pelvis in 132 patients (29%), proximal femur in 81 patients (18%), distal femur in 40 patients (9%) and proximal humerus in 40 patients (9%). Grade at presentation was grade 1 in 44%, grade 2 in 44% and grade 3 in 12%. Surgical margins were wide in 45%, marginal in 28% and incisional (including curettage procedures) in 27%. Local recurrence occurred in 88 patients (19.5%). Local recurrence rates were significantly different for surgical margins on Fisher exact testing (p=0.003), which held true even when stratified by presenting grade of tumour. Local recurrence occurred at a mean of 2.8 years, however, 12.5% occurred more than 5 years from diagnosis. There was a significant difference in survival compared between those patients with local recurrent disease and those without on Kaplan Meier analysis; 10 year survival for those without recurrence was 73.1% compared to 41% for those with local recurrence(p< 0.0001, Logrank). On cox regression analysis significant factors affecting survival were pelvic location (p=0.004), local recurrence (p=0.007), age at presentation (p=0.01), marginal margins (p=0.04) and initial tumour grade (p=0.043). There was no significant difference between survival and initial surgical margin when stratified by grade of tumour, possibly as further surgery to improve adequacy of margins. Further sub-analysis is being performed.

Conclusions: There is a complex relationship between surgical margins, local recurrence and margins. It appears that long term survival is possible in approximately 1/3 patients who have local recurrence in intermediate and high grade chondrosarcomas and therefore ever effort should be made to regain local control following local recurrence.

Introduction: The aim of this study was to investigate the results of a series of cases from a single institution with respect to local disease control and patient survival to determine prognostic factors.

Methods: Electronic patient records were reviewed on all patients with STS between February 1963 and January 2007. 2445 patients had over 30 types of STS. 1639 (67%) had not received any treatment prior to presentation, however, 770 patients (32%) had undergone a previous attempted excision. Survival analyses were done using Kaplan Meier and Cox regression analyses, however, for prognostic factor analysis, only patients presenting without prior treatment were included.

Results: Common diagnoses were liposarcoma (292 patients, 12%), synovial sarcoma (242 patients, 10%) and leiomyosarcoma (239 patients, 10%). Most presented in the thigh (950 patients, 39%), arm (325 patients, 13%) or lower leg (275 patients, 11%) and most were deep to fascia (1581 patients, 74%). The mean size was 10.2cm.

Overall cumulative patient survival was 58% at 5 years and 44% at 10 years. Locally recurrent disease occurred in 350 patients (14%), 204 patients (8%) presented with and 720 patients (30%) subsequently developed metastatic disease.

Prognostic factors for locally recurrent disease were arm tumours (p=0.003, HR=0.3), hip tumours (p=0.01, HR=0.31), thigh tumours (p=0.002, HR=0.52), intralesional margins (p< 0.0001, HR=3.7), high grade tumours (p=0.03, HR=1.8), tumour size 3–6cm (p=0.04, HR=0.54) and tumour size 6–10cm (p=0.03, HR=0.63).

Prognostic factors for patient survival were deep location (p=0.02, HR=1.6), high grade tumours (p< 0.0001, HR=4.7), intermediate grade tumours (p< 0.0001, HR=3.4), surgical margins (p=0.04), age at diagnosis (p< 0.0001, HR=1.02), size of tumour < 3cms (p=0.04, HR=0.29), 3–6cms (p< 0.0001, HR=0.41), 6–10cms (p=0.007, HR=0.63), no locally recurrent disease (p=0.0001, HR=0.59).

Conclusions: Significant prognostic factors have been proven for STS, and marginal margins have not been proven to alter the risk of locally recurrent disease or patient survival.

Aim: To identify the clinical features of patients who present with soft tissue metastases (from a cancer elsewhere) and to identify the source of the cancer.

Method: In a database containing details of 7242 patients referred to our unit for investigation of a soft tissue lump, only 100 of these patients were found to have a soft tissue metastasis (1.4%). We analysed their presenting features and identified the site of the primary malignancy.

Results: The most common presentation of soft tissue metastases was a painless lump The lumps ranging from 2 to 35 cm (mean 8.3cm) with 78% of the lumps located deep to the fascia. The mean age at presentation was 62 and there were equal males and females. 53 had a past history of malignancy. Of these 53, 52 had metastases from the same primary (lung 11, melanoma 10, kidney 9, GI tract 4, breast 6, bladder 4 and others in 9). The other 47 patients had no past history of malignancy and the metastasis was the first presentation of malignancy. The primary sites in these cases were: lung in 19, GI tract 4, kidney 2, melanoma 9, other 3 and unknown (despite investigations) in 10. There was no correlation of the site of the metastases with the primary tumour.

Of the 7242 patients with soft tissue lumps, 476 had a past history of malignancy. Of these patients, only 12% actually had a soft tissue metastasis while 28% had a benign diagnosis, 55% a soft tissue sarcoma and 5% other malignancy.

Conclusion: Patients with a past medical history of malignancy and a new soft tissue lump have a 12% chance of it being a soft tissue metastasis. If a lump proves to be a soft tissue metasasis, the lung is the most common primary site.

We identified eight patients of 2900 with a primary malignant bone tumour who had coexisting neurofibromatosis type 1. This was a much higher incidence than would be expected by chance. The patients had a mean age of 22.4 years (9 to 54): five were male. Two patients subsequently developed a second bone sarcoma, one of which was radiation induced. Four of the primary tumours were osteosarcomas, four were spindle-cell sarcomas and one a Ewing’s sarcoma. All the patients were treated with chemotherapy and surgery: six of the eight appear to be cured.

This study suggests a possible relationship between neurofibromatosis type 1 and the development of a bone sarcoma, the increased risk being estimated at eight times that of the normal population. We recommend that further research into this possible link should be considered.

In our database of 7935 patients referred for investigation of a soft-tissue mass, only 100 were found to have a soft-tissue metastasis (1.3%). Our aim was to define the clinical features of such patients and to identify the site of their primary tumour.

The most common presentation was a painful lump, deep to the fascia, ranging between 2 cm and 35 cm (mean 8.3 cm) with 78% of the lumps located deep to the fascia. The mean age of the patients at presentation was 64 years (22 to 84) and there were almost equal numbers of men and women. Of 53 patients with a history of malignancy, 52 had metastases from the same primary (lung in 12, melanoma in ten, kidney in nine, gastrointestinal track in four, breast in five, bladder in four, and others in eight). The other 47 had no history of malignancy and the metastasis was the first presentation. The primary sites in these cases were the lung in 19, gastro-intestinal track in four, kidney in two, melanoma in nine, other in three, and unknown (despite investigations) in ten. There was no correlation between the site of the metastases and the primary tumour.

Of the 7935 patients, 516 had a history of malignancy. Of these, only 10% had a soft-tissue metastasis, 29% had a benign diagnosis, 55% a soft-tissue sarcoma and 6% another malignancy. Patients with soft-tissue metastases have similar clinical features to those with soft-tissue sarcomas and should be considered for assessment at appropriate diagnostic centres for patients with suspicious soft-tissue lumps.

We have analysed the pattern of symptoms in patients presenting with synovial sarcoma to identify factors which led to long delays in diagnosis. In 35 children, the early symptoms and the results of clinical and radiological investigation were reviewed, along with the presumed diagnoses. The duration of symptoms was separated into patient delay and doctor delay.

Only half of the patients had one or more of the four clinical findings suggestive of sarcoma according to the guidance of the National Institute for Clinical Excellence at the onset of symptoms. Of the 33 children for whom data were available, 16 (48.5%) presented with a painless mass and in ten (30.3%) no mass was identified. Seven (21.2%) had an unexplained joint contracture. Many had been extensively investigated unsuccessfully. The mean duration of symptoms was 98 weeks (2 to 364), the mean patient delay was 43 weeks (0 to 156) and the mean doctor delay was 50 weeks (0 to 362). The mean number of doctors seen before referral was three (1 to 6) and for 15 patients the diagnosis was obtained after unplanned excision. Tumours around the knee and elbow were associated with a longer duration of symptoms and longer doctor delay compared with those at other sites. Delays did not improve significantly over the period of our study of 21 years, and we were unable to show that delay in diagnosis led to a worse prognosis.

Our findings highlight the variety of symptoms associated with synovial sarcoma and encourage greater awareness of this tumour as a potential diagnosis in childhood.

To identify the incidence of a cortical breech on the initial presentation X-rays of patients with distal femoral GCTs, and whether this lead to a higher rate of local recurrence of tumour, a prospective database is kept of all patients seen in the unit. Initial presentation X-rays on 54 patients with distal femroal GCTs were reviewed. The size of the tumour was estimated by measuring the largest dimensions of the tumour (depth, breadth & height). The volume of the distal femur was estimated using the same X-ray and computer programme. The X-rays were then carefully studied for evidence of a cortical breach. The records were also checked for evidence of subsequent locally recurrent disease and subsequent surgery.

X-rays were reviewed on 54 patients (29 male, 25 female), range of 18–72 years. All patients had a biopsy-proven GCT of the distal femur, X-rays (prior to biopsy) were reviewed. 34 (63%) patients with a cortical breech on X-ray. The mean tumour volume: distal femoral volumes (TV:DFV) was statistically greater between those patients with a cortical breach and those without, using ANOVA (p< 0.0001). There were 13 patients with local recurrent disease but no statistical difference in subsequent local recurrence rates between the two patient groups. There was also no statistical differences between the number of operations for those who presented with a cortical breach or without. There was no evidence that more radical surgery was required if a patient presented with a cortical breach.

The risk of cortical breech in patients with GCTs of the distal femur is dependant upon the tumour volume to distal femur volume ratio. If the ratio is above 54% then present with a cortical breech on X-ray is likely (95% confidence interval).There is no evidence those patients with a cortical breach have a higher rate of local recurrence, an increased number of operations or more radical surgery.

Conclusion: The risk of cortical breech in patients with GCTs of the distal femur is dependent upon the tumour volume to distal femur volume ratio.

Introduction and Aims: Endoprosthetic replacement (EPR) following Bone Tumor excision is common. A major complication is infection with serious consequences. The aim is to investigate the cause of infection, management and sequalae.

Method: Over 11, 000 patients have been treated in our unit over 35 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 were investigated. Outcomes of treatment options were evaluated.

Results: Data was analysed on 1265 patients undergoing EPR over 34 years. Giving a total follow-up time of over 6500 patient years. One hundred and thirty-seven (10.8%) patients had deep infection (defined by a positive culture [n=128] or a clinically infected prosthesis with pus in the EPR cavity [n=9]). Forty-nine (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 two-stage revision, with a 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 tibial (23.1%) and 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 & p=0.052).

Conclusion: Infection is a serious complication of EPRs. Treatment is difficult and prolonged. Two-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.

We undertook this retrospective study to determine the rate of recurrence and functional outcome after intralesional curettage for chondroblastoma of bone. The factors associated with aggressive behaviour of the tumour were also analysed. We reviewed 53 patients with histologically-proven chondroblastoma who were treated by intralesional curettage in our unit between 1974 and 2000. They were followed up for at least two years to a maximum of 27 years.

Seven (13.2%) had a histologically-proven local recurrence. Three underwent a second intralesional curettage and had no further recurrence. Two had endoprosthetic replacement of the proximal humerus and two underwent below-knee amputation after aggressive local recurrence. One patient had the rare malignant metastatic chondroblastoma and eventually died. The mean Musculoskeletal Tumour Society functional score of the survivors was 94.2%.

We conclude that meticulous intralesional curettage alone can achieve low rates of local recurrence and excellent long-term function.

The use of distal femoral centralising devices has been advocated in order to achieve an even cement mantle. This has been shown to improve femoral component survival but it is recognised that the presence of voids in the mantle has a deleterious effect on the mechanical strength of cement at laboratory testing and in terms of implant survival. The effect of centralising devices on the mantle in relation to the timing of stem insertion has not previously been investigated.

The purpose of this study is to assess the quality of the cement mantle in artificial bone using a polished taper stem with centralisation inserted at different stages of cement cure time and using different cements.

Three cement types were studied, 45‘saw bone’ models were used. The cementation was carried out in an operating theatre at constant temperature of 23.2Ê°C. The cement was mixed according to the manufacturers instructions and pressurised. Early, intermediate and late stem insertion times were determined for each cement type. The late group included stems with and without centralisers. Video recordings of the stem cement interface were made with a 4 mm endoscope after stem removal. Large cement mantle defects were noted in the ‘with centraliser’ group in 7 out of 15 late insertion times and all had small defects in the mantle. None of the ‘without centraliser’ group had cement mantle defects.

Based on our results we advise surgeons to be very aware of the timing of stem insertion when using centralisers.

Endoprosthetic Replacements are one of the most commonly used types of limb salvage following surgical excision of bone tumours. The advantages of Endoprosthetic Replacements are their initial reliability and the rapid restoration of function along with their ready availability. The problems with Endoprosthetic Replacements are the long term problems of wear, loosening, infection and mechanical failure. Increasing and insolvable problems may lead to the necessity for amputation. This paper assesses the risk of amputation following Endoprosthetic Replacement.

A total of 1262 patients have undergone Endoprosthetic Replacement surgery at our centre in the past 34 years. They have a total of 6507 patient years of follow up. A total of 112 patients have had subsequent amputation (8. 9%). The reasons for amputation were local recurrence in 71(64. 4%), infection in 38(33. 9%), mechanical failure in 2(1. 8%) and continued pain in 1 case (0. 8%). The risk of amputation was greatest in the proximal tibia 15. 5% (n=38/246), followed by pelvis 10. 2%(5/49), and femur 7. 4% (n=58/784), whilst the risk of amputation was least in the humerus at 6. 4% (n= 1l/182). The time to amputation varied from 2 days to 16. 3 7 years, with a mean of 31 months. The risk of amputation decreased with time although 10% of the amputations took place more than 5 years after implantation.

The greatest risk of amputation is in the first 5 years and is due to local recurrence, whilst infection poses the next greatest threat. The risk decreases with time. Attempts to control both local recurrence and infection will decrease the need for amputation. Late failure of the endoprosthetic replacements, even in young patients does not seen to be a major cause of amputation thus far.

To investigate the fears of female patients of child bearing age, who required surgical stabilisation for pelvic fractures, and to assess the outcomes of subsequent pregnancy. Between 1990 & 2002 from a prospectively kept database in our institution, patients sustaining pelvic fractures requiring surgery who were women under 35 years of age at the time of injury were identified and included in this study. Patient’s medical records and radiographs (birth canal status) were reviewed and data collected.

All the patients were attempted to be contacted by telephone and a questionnaire completed recording the type of pelvic injury, previous obstetric history, fears regarding future pregnancy, pregnancy outcomes, Euroqol pain scores pre & post fracture and painkiller usage. Those who were unable to be contacted by telephone, were followed up by a postal questionnaire. The mean time of follow up from injury was 4.2 years (range 1 to 12 years). Out of 554 patients, 197 (36%) were women and of these, 54 (27%) patients were less than 35 years old at the time of injury. A telephone questionnaire was completed on 31 patients [57 % (study group)], results from the postal questionnaire are being collated. The mean age of the study group at injury was 23.3 years (range 6 to 34 years). There were 14 (45 %) isolated ace-tabular fractures and 17 (55 %) pelvic ring fractures. 11 (36 %) had previously had children prior to the injury, and 22 (71 %) had planned to have children in the future, prior to fracture. 23 (74 %) had expressed fears related to their future ability to have children.

Out of 8 (26 %) patients who had subsequent pregnancies, only 1 (12.5%) had a normal vaginal delivery. Out of the rest, 3 (37.5%) patients had investigations for pelvic disproportion; 2 (20%) went on to elective caesarean section for disproportion; 1 patient requested an elective section after concerns regarding delivery; 1 patient had a ventouse assisted delivery for delayed second stage; 1 patient had an ectopic pregnancy; 1 patient had a miscarriage at 18 weeks gestation and 1 patient had infertility problems. 4 out of 31 (13%) patients were advised against future pregnancy and one patient underwent a tubal ligation following this advice. Pelvic fractures represent a serious group of injuries; after initial recovery, many female patients have serious concerns regarding future pregnancy. A number will go on to have further pregnancies, and many will suffer the risk of complications following their pelvic injury.