Metachronous multifocal osteosarcoma (MFOS) is a rare form of osteosarcoma manifested by one or more new tumors developing after the initial treatment of primary osteosarcoma. We present a 61 year old Asian male who was referred with 10 week history of pain and discomfort around his left shoulder and low back pain. In 1968, he received radiotherapy followed by disarticulation of left hip for an osteosarcoma of lower end of left femur complicated with pathological fracture. He did not show any clinical features suggestive of recurrence of disease since then until he presented again in February 2005. CT scan of left scapula has revealed extensive osteosarcoma of lower part of scapula, involving subscapularis and infraspinatus muscles. An MRI scan of whole spine has shown evidence of multiple lesions in sacrum, ilium and acetabulum. A core biopsy from scapula has confirmed the histological diagnosis as high grade osteoblastic osteosarcoma. Slides from 1968 were reviewed in the context of recent recurrence and were consistent with features of intermediate grade fibroblastic osteosarcoma. He is currently undergoing chemotherapy prior to planning definitive treatment as there is evidence in the literature that MFOS is a potentially curable condition.

Purpose: To identify the risk of metastases at the time of diagnosis in patients with soft tissue sarcomas and to estimate the cost effectiveness of identifying these.

Methods: A retrospective database review was used to identify all new soft tissue sarcoma patients referred to our unit and to find those identified to have metastases at diagnosis. Data of tumour size, depth, grade, age, type of tumours, Chest x-ray (CXR)/CT chest results were available in all patients. We estimated the efficacy of CXR in identifying metastases and the costs of various staging strategies.

Patients: 1170 with newly diagnosed STS in 7.5 years (1996–2004) were included.

Results: The incidence of metastases at diagnosis was 10% (116 patients), 8.25% (96 patients) had lung metastases and 20 had metastases elsewhere. The risk of having lung metastases at diagnosis was 11.8% in high grade tumours, 6.95% in intermediate grade and 1.2% in low grade tumours. The risk increased almost linearly with size at presentation and was higher in deep tumours and older patients. CXR alone detected 2/3 of all lung metastases. The positive predictive value of the CXR was 93.7%, the negative predictive value was 96.7%, the sensitivity 62.5% and the specificity 99.6%.

The accuracy was 96.9%. CT overestimated metastases in 4%.

Discussion: We recommend that all patients with a newly diagnosed STS should have a CXR and only those with an abnormality or who have large, deep high grade tumours should have a CT chest. This strategy will save £7500 per 100 new patients with STS and will detect 93% of all chest metastases, missing 1 patient with metastases per 166 patients.

Limb preserving surgery following segmental resection of the distal end of the radius and its articular surface presents a major challenge. We have studied 11 consecutive patients with aggressive tumours located in the distal radius that required segmental resection of the distal radius and its articular surface to evaluate the clinical and functional outcome of reconstruction of such defects.

The mean age at the time of diagnosis was 33 years (7–60). Follow up ranged from 12 to 306 months (median 56). Histological diagnosis was osteosarcoma in 4 patients, chondrosarcoma in 2, giant cell tumour in 5 and meta-static carcinoma in 1 patient. Four patients received chemotherapy. The length of excised bone ranged from 6 to 14cm. Reconstruction was performed with non-vascularised proximal fibula strut graft in 6 patients, ulna transposition in 3 and custom made endoprosthesis in 2 patients. The wrist joint was arthrodesed in 5 patients.

At the time of review 2 patients had died of disease, one was alive with disease and 8 were alive and free of disease. Non-union of the graft occurred in one patient, reflex sympathetic dystrophy in 2 and prosthetic dislocation in one. One patient had local recurrence. Four patients required further surgery including one patient who needed an amputation for severe reflex sympathetic dystrophy, one graft revision for non-union, one secondary wrist arthrodesis and one closed reduction of dislocated endoprosthesis. Patients without arthrodesis often had clinical and radiological signs of wrist instability. The majority of the patients achieved satisfactory function with little or no discomfort and ability to perform activities of daily living.

We conclude that limb salvage surgery is worthwhile in patients with resectable tumours of the distal radius.

Myxoid liposarcoma (MLS) is an unusual type of soft tissue sarcoma as it tends to metastasize frequently to sites other than the lungs. This study was aimed to investigate the natural history of patients with MLS to try and identify prognostic factors which could help predict outcome and aid earlier detection of metastases.

Data was prospectively collected from patient notes and analysed retrospectively. Prognostic factors and metastatic pattern were examined using Kaplan-Meier curves. There were 124 patients with MLS, aged between 28 and 93, the median size of the tumours was 12cm and the most common site was the thigh. Following treatment with excision and radiotherapy the 5yr survival was 65%. Survival was related to younger age (p=0.010) and proximal site (p=0.003) and was also related to the % round cell component of the tumour but was not related to either size or depth of the tumour. Site and margins of excision were significant prognostic factors for local recurrence of disease. 32% of patients developed metastases, of whom 18 cases (46.2%) developed pulmonary metastases and 21 (53.8%) developed extra pulmonary metastases. The sites of these varied hugely and was not significantly related to the site or size of the primary tumour. There was no difference in time to develop metastases or in overall survival between the two groups. Median survival following metastases was 24 months.

Although MLS has an unusual pattern of metastases the site of metastases does not predict a better or worse outcome. Intensive follow up for extraskeletal metastases is probably not justified until they become symptomatic.

Purpose: The aim of this study was to understand the effect of endoprosthetic reconstruction in treatment of solitary bone plasmacytoma threatening structural integrity of bone.

Materials and methods: We retrospectively studied 11 patients who underwent endoprosthetic reconstruction for solitary bone plasmacytoma between 1988 and 2003 with more than 1 year follow up. Most had radiotherapy and those who sustained structural damage to a joint or thought to be salvageable were treated with endoprosthetic replacement.

Results: There were 7 males and 4 females, with M: F ratio of 1.75:1, the median age at diagnosis was 53.61years (35–74). Average duration of symptoms prior to presentation at oncology unit was 7.27 months. We had 4 proximal femoral, 2 pelvic, 4 humeral and one tibial Plasmacytomas that were treated with endoprosthetic replacements.8/11 had preoperative radiotherapy for at least 4weeks and 3 did not. Two had postoperative radiotherapy and one adjuvant chemotherapy. Average follow up is 5.45 years (range 1–16years). We had one death due to unrelated causes, one progression to Myeloma treated with adjuvant chemotherapy, two revisions and one dislocation which was reduced by open method. The cumulative overall survival for all patients was 91% at 5 years. The cumulative risk of failure of reconstruction including; infection, dislocation, local recurrence/progression to Myeloma was 27% at 5 years.

Conclusion: Literature review shows that nearly 53% of SBP progress despite radiotherapy to Myeloma at a median time of 1.8 years (2–4 years). But despite average follow up of 5.45 years, progression to Myeloma after endoprosthetic replacement at our unit is 9.09%. We concluded that the use of endoprostheses for reconstruction after excision of solitary bone plasmacytomas threatening structural integrity of bone combined with radiotherapy decreases the disease progression to Myeloma than radiotherapy alone and offers a reasonable but not absolute chance of cure.

Aim: The pelvis is a rare location for osteochondromas and differentiation from chondrosarcomas can be difficult. We aim to aid this differentiation using tends and demographics of treated cases.

Methods and Results: Patients referred to a supra-regional bone tumour centre with pelvic tumours, consequently diagnosed as osteochondromas were studied to determine the clinico-pathological features that differentiate them from chondrosarcoma. Treatment outcome was also reviewed.

30 patients were studied with a mean follow-up of 32 months. The mean age at diagnosis was 34yrs (range 19–79). The male to female ratio was 1:1. The most common location was the ilium (19 patients), with the pubis and ischium accounting for a third of patients. Only 1 patient had an acetabular osteochondroma. Median duration of symptoms prior to referral was 6 months (1–79). Pain without a lump was the main presenting symptom (16 patients), followed by lump with pain (6), and lump alone (6). Two patients presented with obstructive labour requiring emergency procedures. The lesions were solitary in 24 and associated with hereditary multiple exostosis (HME) in 6 patients. 1 patient had a radiation induced lesion.

The lesions showed increased uptake on bone scans and the cartilage cap was less than 10mm in all but 2 patients. Treatment was surgical excision in 21 patients and observation with serial radiographs in 9. Histological examination confirmed osteochondroma in all patients, however 1 patient with HME had areas of Grade I malignancy. Significant surgical complications occurred in 1 patient who developed pulmonary embolism.

Conclusion: We conclude that symptoms from osteochondromas of the pelvis are similar to those with chondrosarcomas and increased uptake on bone scans is seen in both. However, a tumour with a cartilage cap larger than 10mm or arising from the acetabulum is unlikely to be an osteochondroma.

Large benign lytic lesions of the proximal femur present a significant risk of pathological fractures. We report our experience of treating 9 consecutive patients with such defects treated with curettage and fibula strut grafting without supplementary osteosynthesis to evaluate the outcome of this type of reconstruction..

The mean age at the time of diagnosis was 13 years (8–21). Follow up ranged from 2 to 215 months (median 15). Histological diagnosis was fibrous dysplasia in 10 patients and unicameral cyst in 2. All the patients were at risk of pathological fracture. None of the patients developed pathological fracture after surgery and the lesions consolidated fully within one year. Local recurrence occurred in one patient (8%). Minor donor site complications occurred four patients.

All the patients were able to fully weight usually within 3 months of surgery.

At the time of review all but one patient were completely asymptomatic and fully weight bearing. The only symptomatic patient was the patient with local recurrence which has recently been treated.

We conclude that fibula strut graft is a good method of reconstruction of cystic defects in the proximal femut. It prevents pathological fracture, allows mechanical reinforcement of the lesion and delivers biological tissue allowing early consolidation of the defect.

We reviewed our experience with diaphyseal endoprostheses to determine the survival of this type of reconstruction and factors affecting that survival.

Method: We retrospectively studied 44 patients who underwent endoprostheticreconstruction of diaphyseal bone defects after excision of primary sarcomas between 1979 and 2002 with more than 2 years follow up.

Results: There were 27 males and 17 females, the median age at diagnosis was 25 years (8–75) and the median bone defect was 18cm (10–27.6).There were 33 femoral reconstructions, 6 tibial and 5 humeral. The cumulative overall survival for all patients was 67% at 10 years and prosthetic reconstruction using revision surgery as an end point was 62% at 10 years. The cumulative risk offailure of reconstruction including; infection, fracture, aseptic loosening, local recurrence and amputation was 45% at 10 years but for amputation only was 13% at 10 years. The patient age, the type of prosthesis ;whether cemented oruncemented, site of defect (femur, tibia, and humerus) and length of defect did not influence prosthetic survival.

Conclusion: We concluded that the use endoprostheses for reconstruction of diaphyseal bone defects remains a valuable method of reconstruction with predictable results and compares favourably with other forms of reconstruction of massive diaphyseal bone defects.

Purpose: To see if current guidelines for the early diagnosis of sarcomas can be improved.

Method: Data on 1100 patients referred to our unit with a lump suspicious of sarcoma was analyzed to try and identify clinical features more common in malignant than benign lumps. The following five items were analysed: size, history of increasing size, presence of pain, depth, age. For each of these items sensitivity, specificity, accuracy and weights of evidence were collected. ROC curves were used to identify the most sensitive cut off for continuous data.

Results: The best cut off predicting malignancy for size was 8cm and for age 53 years

The weights of evidence (WE) are logs of the likelihood ratios and can be added and a probability then calculated. e.g. a 36 yr old with a 10cm, deep, painless lump that is increasing in size scores −0.39 + 0.4 + 0.4 – 0.11 + 0.58 = 0.88. This equates to a risk of the lump being malignant of 70%.

Conclusion: This analysis shows that increase in size is the strongest predictor of malignancy/benignancy followed by age > 53 and size > 8cm. This data can help formulate strategies for earlier detection of soft tissue sarcomas.

Introduction: A ‘whoops’ procedure is when a lump, which subsequently turns out to be a soft tissue sarcoma (STS), is shelled out by a surgeon who is not aware of the diagnosis. In many cases residual tumour will be left behind necessitating further surgery. The significance of a whoops procedure in terms of survival and local control remains uncertain. This study has used case matched controls to compare outcome between two groups.

Method: 794 patients of soft tissue sarcoma with minimum follow up of 5 years were found on our prospectively collected database. 113 were whoops cases, 96 had restaging and reexcision. An observer blinded to the outcome of patients matched the whoops cases with virgins by known prognostic factors i.e. grade, depth, patient age, site, size and diagnosis of the tumour. We have investigated outcome in terms of local control, metastatic disease and survival by known prognostic factors and by their status at presentation.

Results: 96 patients with a whoops procedure were compared with 96 referred directly to our unit. Despite attempts to match patients with as many variables as possible there was a tendency for the patients with whoops to have smaller tumours that were subcutaneous, they were however well matched for grade and stage at diagnosis. 64% of whoops patients had adequate final margin whereas only 44% of virgins had adequate margins. Overall 1.43 additional operations were needed to achieve final margins for whoops cases as against 0.21% for virgin cases. Overall 27% patients had amputation 20% for whoops and 34% for virgin cases nearly 60% were ray amputations of foot or hand. Overall 50% had radiotherapy and 25% had chemotherapy. There was no statistical difference in local recurrence or survival of patients between whoops and virgins at 5 years follow up. Inadequate margins and residual tumour were significant risk factors for local recurrence and high grade, size more than 5 cm, and age more than 50 years were significant prognostic factors for overall survival of the patients.

Conclusion: Inadvertent surgical excision of a STS is not desirable but does not seem to lead to an adverse outcome in this series in which wide re-excision of the area involved has been carried out.

The histological findings from the heads of femur or bone biopsy taken from 90 patients with suspected pathological fractures of the femoral neck were studied to determine the rates of significant abnormal pathological findings.The mean age at the time of fracture was 80.41 years (44–99). 29 patients were males and 71 females. The patients were divided into four groups. Group I: 34 patients with fracture without history of fall or trauma. Group II: 21 patients with suspicious radiology of pelvis. Group III: 27 patients with past history of malignancy without known bone metastases. Group IV: 8 patients with past history of malignancy and known bone metastases

None of the patients in groups I and II had significant abnormalities other than osteoporosis. 4 patients (15%) in group III had metastases and 6 patients (75%) in group IV had metastases on histological examination.

We conclude that the absence of history of fall or trauma or subtle radiographic findings in patients with fracture of the neck of the femur is usually not associated with sinister pathology and the cause of fracture in these patients is often osteoporosis. Patients with previous history of malignancy without known bone metastases have a 15% risk of finding of metastatic disease even in the absence of radiological abnormalities. Patients with fractured neck of femur with past history of malignancy and who are known to have bone metastases must be considered as having pathological fractures through metastatic disease until unless proven otherwise

Purpose; To show that Distal Femoral Endoprosthetic Replacement for metastatic disease can be performed with relatively few complications and allows good pain control and mobilisation for otherwise severely compromised patients.

Method; This is a retrospective study, using the oncology database, patient records and local correspondence, looking at 23 patients with distal femoral metastases who had limb salvage with a Distal Femoral Endoprosthesis (DF EPR).

Results; There were 10 males (43%) and 13 females (57%), mean age 65 (38–84). 13 (57%) had Renal, 6 (26%) Breast and 5 other primaries identified. Five had additional metastases. 8 (35%) had pathological fractures. The mean time for diagnosis of mets was 67 months ranging from 0 (i.e. at the time of primary tumour) to 30 years since the original diagnosis. 15 patients had surgery alone. 3 patients were lost to follow up. 15 patients have diseased at a mean of 26 months (4–58) post op. There was one intra-op and four post-op complications. The majority of the patients were satisfied post op with regards to pain and mobility.

The generally unfavourable prognosis and perceived risks have led surgeons to palliate, stabilise in situ or amputate for distal femoral metastases despite recognised morbidity and life style restrictions. We conclude that DF EPR should be considered as a limb salvage option in patients with distal femoral mets.

130 consecutive patients with metastatic tumours of the extremity bones treated with resection with or without major endoprosthetic reconstruction were studied retrospectively to determine the indication for surgery, complications, clinical outcome and oncological results of treatment.

The mean age at diagnosis was 61 (22 – 84). The tumours originated from a variety of organs. Lower extremity was involved in 104 and upper extremity in 26. Metastatic disease was solitary in 55 patients and multiple in 75 at the time of surgery. The median follow-up possible from the time of operation to review was 18 months (0–103)

The indication for surgery was radical treatment of solitary metastases with curative intent in 33, pathological fracture in 46, impending fracture in 27, failure of prior fixation devices in 17, painful swelling or extremity in 37. Surgical treatment included excision of expendable bones without reconstruction in 20 patients and resection with endoprosthetic reconstruction in 110 patients. 7 patients received adjuvant chemotherapy and the majority received adjuvant radiotherapy.

At the time of review, 58 patients had died at a mean time of 23 months (0–90) from surgery (53 from progressive metastatic disease and 5 from other causes). 72 were alive at mean follow-up of 22 months (1–103) from surgery. 36 patients (28%) were alive at 2 years post-surgery and 8 (6%) at 5 years. One patient died intra-operatively. Post-operative complications occurred in 32 patients (25%). 18 patients required further surgical procedures for dislocation, infection haematoma, stiff joint, plastic surgical procedures. All the patients had control of pain and 90% achieved desired mobility.

There was no difference in the survival of patients who presented with solitary and multiple metastases, renal and non-renal metastases, and upper or lower limb metastases.

We conclude that selected patients with bone metastases can benefit from resection and major bone reconstruction with acceptable morbidity. We have not identified predictable prognostic factors in these selected patients.

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

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

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

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

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

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

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

113 consecutive patients with soft tissue sarcoma treated by excision and reconstructive flaps were studied to assess the risk of complications and to compare local tumour control with those in whom primary wound closure was possible.

Minimum follow-up was 24 months and mean age was 55 years (16–95). The sarcoma was located in the lower extremity in 83 and upper extremity 30 patients. Significant wound complications developed in 37 patients (33%). The most common complications were wound infections or partial necrosis occurring in 16% (18/113) and 13% (15/113) respectively. Complete flap necrosis requiring flap removal occurred in 6 patients (5%). Three patients (2.3%) required amputation as a result of complications. Significant risk factors for development of wound complications include location of tumour in the lower limb compared to upper limb (relative risk 2.3, p=0.02) and use of pre-operative radiotherapy compared to no or post-operative radiotherapy (relative risk 2.05, p=0.02). There was no difference in rates of complications in patients with free or pedicled flaps, tumours < or > 5cm, distal or proximal location of tumour.

The rates of negative excision margins (80%) and wound complications in patients who required reconstructive flaps were not different from that for the other patients treated at our centre who did not require reconstructive flaps.

The use of soft tissue reconstructive flaps did not reduce the risk of positive excision margins or the rates of wound complications. The risk of amputation secondary to flap complication or failure is low.

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

No increased risk of thromboembolic complications or mortality was found.

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

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

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

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

Deep prosthetic infections are a significant cause of failure after arthroplastic surgery. Superficial wound infections are a risk factor for deep infections. We aimed to quantify the risk of deep infection after superficial wound infections, and analyse the microbiology of organisms grown.

We defused Superficial Infection according to the definition used by the Centre for Disease Control, and Deep Infection according to the Swedish Hip Register. We retrospectively analysed the results of 6782 THR and TKRs performed consecutively from 1988–1998. We analysed patient records, radiology and microbiological data. The latter collected prospectively by our infection control team.

We identified 81 (1. 2%) superficial wound infections, however we had to exclude 3 due to poor follow-up. Of the 78 patients studied, mean age was 71 (23–89), 50 were female, 28 male, 41 THR, 37 TKR and follow-up was a mean 49 months (12–130). The majority (81%) of organisms grown in the superficial wound infections were gram positive Staphylococci. These organisms were most frequently sensitive to Erythromycin or Flucloxacillin. All the superficial infections were treated with antibiotics, 66% settled with less than 6 weeks therapy. Deep prosthetic infections occurred in 10% of superficial infections in both THR and TKR. In 80% of cases the organism in the superficial infection caused the deep infection. Wound dehiscence, haematoma, post-op pyrexia and patient risk factors had no affect on onset of deep infection. However patients who had a wound discharge with positive microbiology and those patients in whom there was clinical doubt about the diagnosis of deep infection and thus had antibiotic therapy for more than six weeks had increased risk of deep sepsis.