Endoprosthetic replacement of the proximal femur may be required to treat primary bone tumours or destructive metastases either with impending or established pathological fracture. Modular prostheses are available off the shelf and can be adapted to most reconstructive situations for this purpose. We have assessed the clinical and functional outcome of using the METS (Stanmore Implants Worldwide) modular tumour prosthesis to reconstruct the proximal femur in 100 consecutive patients between 2001 and 2006. We compared the results with the published series for patients managed with modular and custom-made endoprosthetic replacements for the same conditions.

There were 52 males and 48 females with a mean age of 56.3 years (16 to 84) and a mean follow-up of 24.6 months (0 to 60). In 65 patients the procedure was undertaken for metastases, in 25 for a primary bone tumour, and in ten for other malignant conditions. A total of 46 patients presented with a pathological fracture, and 19 presented with failed fixation of a previous pathological fracture. The overall patient survival was 63.6% at one year and 23.1% at five years, and was significantly better for patients with a primary bone tumour than for those with metastatic tumour (82.3% vs 53.3%, respectively at one year (p = 0.003)). There were six early dislocations of which five could be treated by closed reduction. No patient needed revision surgery for dislocation. Revision surgery was required by six (6%) patients, five for pain caused by acetabular wear and one for tumour progression. Amputation was needed in four patients for local recurrence or infection.

The estimated five-year implant survival with revision as the endpoint was 90.7%. The mean Toronto Extremity Salvage score was 61% (51% to 95%). The implant survival and complications resulting from the use of the modular system were comparable to the published series of both custom-made and other modular proximal femoral implants.

We conclude that at intermediate follow-up the modular tumour prosthesis for proximal femur replacement provides versatility, a low incidence of implant-related complications and acceptable function for patients with metastatic tumours, pathological fractures and failed fixation of the proximal femur. It also functions as well as a custom-made endoprosthetic replacement.

We treated 98 patients with peri-acetabular tumours by resection and reconstruction with a custom-made pelvic endoprosthesis. The overall survival of the patients was 67% at five years, 54% at ten years and 51% at 30 years. One or more complications occurred in 58.1% of patients (54), of which infection was the most common, affecting 30% (28 patients). The rate of local recurrence was 31% (29 patients) after a mean follow-up of 71 months (11 to 147). Dislocation occurred in 20% of patients (19). Before 1996 the rate was 40.5% (17 patients) but this was reduced to 3.9% (two patients) with the introduction of a larger femoral head. There were six cases of palsy of the femoral nerve with recovery in only two. Revision or excision arthroplasty was performed in 23.7% of patients (22), principally for uncontrolled infection or aseptic loosening. Higher rates of death, infection and revision occurred in men.

This method of treatment is still associated with high morbidity. Patients should be carefully selected and informed of this pre-operatively.

Analysis of the outcome of neurovascular island flap developed to reconstruct volar-oblique fingertip amputations. A comparison of results with the initial study.

Patients were contact telephonically and recalled for review. A subjective questionnaire was filled in and objective clinical measurements taken. The parameters of the original study were reproduced in order to compare results.

We have 12 cases since 2004. 5 Cases were lost to follow up with only clinic notes available. 7 Cases were reviewed. Mean age 20y (4–65y). Good subjective results with regard to cold intolerance, hypersensitivity, numbness, pain and stiffness. Good cosmesis and patient satisfaction. Objective measurements of IPJ stiffness were insignificantly different from the contra lateral side and 2 point discrimination < =5mm. A single flap failure due to sepsis.

It was concluded that this was a safe and reliable method of reconstruction, with a number of advantages over previous methods.

Aim: To identify tumour and treatment factors significant for both local control and survival for patients with chondrosarcoma of the pelvis.

Method: The features of all patients with non metastatic chondrosarcoma of the pelvis treated at a tertiary treatment centre between 1971 and 2001 with more than 2 years of follow-up were analyzed.

Results: There were 106 patients with a median age of 44. There were equal numbers of male and female patients in the group. The median size of the tumours was 12cm. 47 tumours were grade 1, 37 were grade 2 and 22 were grade 3. Treatment involved hindquarter amputation in 33 and excision with or without reconstruction in 73. Clear margins (wide or better) were achieved in 34 cases. The excision was marginal in 30 cases and intralesional or contaminated in 37. Local recurrence arose in 39 patients and was related to adequate margins of excision (p=0.03) and grade (p=0.01). Overall survival was 72% at 5 years, 56% at 10 years and 46% at 15 years. Survival was strongly related to grade (p=0.08) but survival beyond 5 years was most strongly related to the adequacy of the excision margins.

Conclusion: Tumour grade is the most important prognostic factor for chondrosarcoma of the pelvis but the ability to obtain clear margins of excision influences both local control and the prospects for long term survival.

Introduction: The population of the UK is getting older. Patients over the age of 80 (the older old) are increasingly presenting with musculoskeletal tumours that require major surgery. We have investigated the success or otherwise of endoprosthetic replacements after tumour excision in this population.

Methods: We looked at an oncological database to identify patients over the age of 80 who had an endprosthetic replacement after tumour excision. We reviewed the records of all patients over the age of 80 who had an endoprosthetic replacement to assess the oncological and functional outcomes of the procedure.

Results: 17 patients over the age of 80 had an endoprosthesis over the past 10 years. The main indication was for metastatic disease (9 patients) but 6 had primary malignant bone tumours. The most common site was the distal femur in 9 followed by the proximal femur in 5. Most of the patients had associated co-morbidity (12 were ASA 2 or 3). There were no perioperative deaths but 2 patients had early complications with one having a paralytic ileus and one a chest infection. The median survival of the patients was 2 years with death being due to progressive metastases in most. 3 had late complications to do with the prosthesis including one infection in a proximal tibial replacement and a late dislocation at 2 years in a proximal femoral replacement. Two patients developed local recurrence treated by local excision and radiotherapy. There were no amputations or revisions.

Conclusions: Endoprosthetic replacements have a useful role to play in the surgical management of elderly patients. Although they have significant comorbidity most do well. Functional results are less good than in the younger population but most patients regain their independence and are free of pain.

Introduction: This study is a prospective series using a porous-coated cobalt-chromium alloy cup augmented with screw fixation for acetabular revisions.

Methods: Between August 1997 and December 2001, eighty-five consecutive cementless acetabular revisions (81 patients) were performed. The mean age at operation was 64 years. Using the AAOS classification of acetabular defects there was one type I defect, 25 type two defects and 59 type III defects. Eighty-three cases were available for review (98%) with an average follow up of 6 years 6 months (range 3 months – 110 months). Clinical outcome was measured using the Charnley Hip Score and radiological assessment by plain radiographic measurement.

Results: The Charnley Hip Score had improved from a pre-operative average of 7.52 (range 4–11) to the latest score of 14.84 (range 8 – 18). Significant cup migration occurred in only one case, which did not require revision. Sixteen cases demonstrated non-progressive radiolucent lines in one or two Delee and Charnley zones but none extended to all three zones. There were no cases of significant osteolysis. There were five dislocations none requiring re-operation; one revision was carried out for deep infection and one liner exchange at time of stem revision for subsidence. The results of Kaplan-Meier survival analysis using revision for all causes as the endpoint was 98.8% (95% confidence limits 0.964 to 1) at seventy-three months.

Discussion: This press fit porous-coated cobalt-chromium alloy cup augmented with screw fixation for acetabular revision surgery produced excellent midterm results. Changes in cup design and material should only be undertaken with consideration of such results.

Introduction: Hip resurfacing is a popular alternative to total hip arthroplasty. It aims to provide more physiological loading of the proximal femur, avoiding stress shielding and associated bone resorption. However, finite element analysis of hip resurfacing systems suggests stress shielding occurs in the femoral neck below the prosthesis and theoretically may lead to femoral neck fracture. Nevertheless, recent DEXA studies indicate femoral bone stock preservation with no evidence of stress shielding. It is not yet known what actually occurs in clinical practice. The aim of this study was to assess whether femoral neck resorption occurs in one particular type of hip resurfacing post operatively and quantify the degree of narrowing.

Methods: Femoral neck resorption of the Cormet 2000 metal-on-metal resurfacing prosthesis (Corin, UK) was assessed by measuring the prosthesis-neck ratio on postoperative radiographs. 39 prostheses (35 patients) were measured on plain AP pelvis radiographs taken immediately and mean 2 years post-operatively. Subsequent follow up radiographs were measured up to maximum 7 years follow up, mean 4.75 years.

Results: There was evidence of neck atrophy in 35/39 hips at an average of 2 years post operation, with the overall average neck narrowing from a ratio of 0.86 to 0.81 at 2 years. Average neck ratios were calculated up to 7 years post resurfacing; 25 hips measured at 3 years average ratio of 0.81, 20 at 4 years ratio 0.8, 25 at 5 years ratio 0.8, 9 at 6 years ratio 0.8, 1 at 7 years ratio 0.81.

Discussion: A degree neck resorption occurs with this resurfacing prosthesis by 2 years, however no further resorption appears to occur beyond this, to a maximum follow up of 7 years. This may indicate that early narrowing is more likely to be due to harmless bone adaption then a progressive absorption jeopardising the femoral neck.

We reviewed the treatment and clinical outcome of 32 consecutive patients with Ewing’s sarcoma who presented with or developed pathological fracture after biopsy between 1984 and 2004. The minimum follow-up was 18 months. The mean age at diagnosis was 20 years (5 – 51). There were 18 males and 14 females. All patients were newly diagnosed and had localized disease at the time of diagnosis. 21 patients presented with pathological fracture while 11 patients developed fracture during the course of chemotherapy. The femur was the most common location in 15 patients.

All the patients had chemotherapy according to the protocol current at the time of treatment. 7 patients had radiotherapy alone while 25 patients underwent surgical excision and reconstruction. Of the patients who had surgery, 7 patients had adjuvant radiotherapy. Fracture healing was the norm after pre-operative chemotherapy. Surgical margins were wide in 17 patients, marginal in 4 and intralesional in 3 patients.

Local recurrence developed in one patient (3%). Metastases occurred in 12 patients (37%). At the time of review 16 patients were free of disease, 3 were alive with disease and 13 patients had died of disease. The cumulative 5 year metastases free and overall survival in all the patients was 58% and 61 % respectively and similar to patients with Ewing’s sarcoma without fracture treated at our centre. The prognosis of patients who presented with fracture was exactly similar to those who developed fracture in the course of treatment.

We conclude that limb preserving surgery is perfectly safe in patients with Ewing’s sarcoma who have associated pathological fracture and survival is not in any way compromised. Survival of patients who present with fracture is similar to those who develop fracture in the course of treatment. The exact role of adjuvant radiotherapy in these patients needs to be clarified.

Synovial sarcoma is a morphologically well-defined neoplasm that most commonly occurs in soft tissue accounting for 5% to 10 % of all soft tissue sarcomas. We reviewed 156 patients with synovial sarcoma of soft tissues treated at a supra-regional centre to determine survival and prognostic factors.

There were 77men and 79 women with mean age at presentation of 38 years (3 to 84). Follow-up periods ranged from 3 to 494 months (median 43 months). Tumor was located in lower extremities in 111patients, upper extremities in 34 patients, and trunk and pelvis in 11 patients. Overall survival was 66% at 5 years and 48% at 10 years. The 5 and 10 year survival for the 23 patients who had metastases at the time of diagnosis was 13% and 0% respectively compared to 75% and 54% for those without metastases at diagnosis. Local recurrence occurred in 18 patients (13%). The significant prognostic factors for survival included presence of metastases at diagnosis and development of local recurrence. Tumour size and depth, age of patients and use of chemotherapy did not significantly influence survival.

We conclude that the clinical factors which influence survival of patients with synovial sarcoma are different from those of soft tissue sarcomas in general. Biological factors may better predict prognostic survival than the usual clinical factors.

Aim: To identify patient, tumour or treatment factors that influence outcome in patients with radiation induced sarcoma of bone.

Method: A retrospective review of an oncology database supplemented by referral back to original records.

Results: We identified 42 patients who presented to our Unit over a 25 year period with a new sarcoma of bone following previous radiotherapy. The age of the patients at presentation ranged from 10 to 84 years of age (mean: 17 years) and the time interval from previous radiotherapy ranged from 4 to 50 years (median: 14 yrs; mean: 17 years). The median dose of radiotherapy given had been 50 Gy but there was no correlation of radiation dose with time to development of sarcoma. The pelvis was the most common site for development of sarcoma (14 cases) but breast cancer was the most common primary tumour (8 cases). 9 of the patients had metastases at the time of diagnosis of the sarcoma. Osteosacoma was the most common diagnosis (30). Treatment was by surgery and chemotherapy when indicated and 30 of the patients had treatment with curative intent. The survival rate was 41% at 5 years for those treated with curative intent but in those treated palliatively median survival was only 6 months and all had died by one year. The only factor found to be significant for survival was the ability to completely resect the tumour, thus limb sarcomas had a better prognosis (66% survival at 5 years) than central ones (12%)(p=0.009).

Conclusion: Radiation induced sarcoma is a rare complication of radiotherapy. Both surgical and oncological treatment is likely to be compromised by previous treatment the patient has received. Despite this 40% of patients will survive more than 5 years with aggressive modern treatment.

Purpose: To study the results of treatment of symptomatic non-union with endoprosthesis at the Royal Orthopaedic Hospital

Methods: Between 1987 & 2005, 17patients were treated with massive endoprosthesis for non-union. We performed a retrospective review of these case notes

Results: Mean age at diagnosis was 63years (range 36–86). Location of non-union was distal femur in 9, proximal femur in 4, proximal humerus in 2, proximal tibia in 1, distal humerus in 1. The majority of the patients had received prior multiple operations before endoprosthetic surgery.

Four patients had obvious infection confirmed by histology and/or microbiology prior to surgery. Endoprosthetic Reconstruction was performed as a 1 stage procedure in 13 and as a 2 stage in 4.

Complications occurred in 5 patients. These included recurrence of infection in 1, persistent pain in 1, aseptic loosening in 1, periprosthetic fracture in 1 and a non ST myocardial infarction in 1. At the last follow-up, (mean 5years, range 1–18years) majority of patients achieved good range of motion and good mobility.

Conclusion: We conclude that endoprosthetic replacement is a reasonable option for treatment of end-stage non-union in carefully selected patients. Adequate mobility and function can be achieved in majority of patients following such treatment

Purpose of the study: To analyze survival and prognostic factors in a series of patients treated for chondrosarcoma of the pelvis.

Material and methods: The series included 106 patients (53 women and 53 men) treated for non-metastatic chondrosarcoma of the pelvis. Minimum follow-up was two years. Mean age at diagnosis was 44 years. Tumors were grade 1 (n=47), grade 2 (n=37), grade 3 (n=22). Conservative surgery was performed in 73 patients (resection with or without reconstruction) and interilio-abdominal disarticulation for 33.

Results: Resection margins were sufficient for 34 patients (wide or radical resection), marginal for 35, and intratumoral or malignant for 37. Local recurrence was noted in 39 patients (37%). Prognostic factors affecting local recurrence were: quality of resection (p=0.03), grade (p=0.01). Overall survival at 5, 10 and 15 years were 72, 56, and 46% respectively. Survival was strongly correlated with grade (p=0.08) and survival after five years was also correlated with resection margins.

Conclusions: In this series, tumor grade was the most important prognostic factor for patients with chondrosarcoma of the pelvis but achieving satisfactory resection with wide margins also has a significant effect on prognosis for local recurrence and long-term survival.

Background: Limb preserving surgery in patients with tumours involving the whole femur present a formidable challenge.

Results: We present our experience of treating such patients with total femur endoprostheses over the last 30 years (1975 to 2005). There were twenty six consecutive patients including 14 males and 12 females. Average age was 40 years (14 – 82 years) at the time of surgery. Eleven patients were still alive of which nine were free of disease at the time of review. The mean follow-up was 57 months (3 to 348). Using Kaplan Meier estimates, the long-term patient survival at 10 years was 37%. The survival of patients with primary localised tumour was 50% at 10 years.

Revision of the prostheses was necessary in two patients at 110 and 274 months after surgery because of recurrent dislocation in one and aseptic loosening of the acetabular cup and tibial stem in the other. Amputation was necessary in two patients, one due to deep infection and the other due to local recurrence. The long-term limb survival being 92% at 10 years. Nine patients who were alive with no evidence of disease were assessed for function of the salvaged limbs using the musculoskeletal tumour society (MSTS) rating system. The mean functional score was 72%.

Conclusion: We conclude that total femur endoprosthetic replacement offers an excellent method of limb reconstruction following excision of the whole femur either for primary or metastatic tumours. However, patients survival after such operation is poor due to disease related factors.

We have investigated whether improvements in design have altered outcome for patients undergoing endoprosthetic replacement of the distal femur following tumour resection.

Survival of the implant and ‘servicing’ procedures has been documented using a prospective database and review of the implant design records and case records.

A total of 335 patients underwent a distal femoral replacement with 162 having a fixed hinge design and 173 a rotating hinge. The median age of the patients was 24 years (range 13–82yrs). With a minimum follow up of 5 years and a maximum of 30 years, 192 patients remain alive with a median follow up of 11 years. The risk of revision for any reason was 17% at 5 years, 34% at 10 years and 58% at 20 years. Aseptic loosening was the most common reason for revision in the fixed hinge knees whilst infection and stem fracture were the most common reason in the rotating hinges. The risk of revision for aseptic loosening in the fixed hinges was 32% at ten years compared with 4% for rotating hinge knees with a hydroxyapatite collar. The overall risk of revision for any reason was halved by use of the rotating hinge.

Conclusion: Improvements in design of distal femoral replacements have significantly decreased the risk of revision surgery. Infection remains a serious problem for these patients.

Aim: To investigate the outcome of prosthetic pelvic replacements., analyzing complications and suggesting ways of avoiding these

Method: We reviewed the records of all 52 patients undergoing custom made hemipelvic replacement of the pelvis at our centre over the past 30 years.

Results: The mean age of the patients was 40 (range 13 to 75) and the most common diagnosis was chondrosarcoma followed by Ewing’s sarcoma. 4 patients had metastases at the time if diagnosis. All tumours involved the acetabulum (P2) and 9 had a significant extension up into the ilium with 28 involving the pubis. There was a very high incidence of complications – local recurrence arose in 40% and infection in 32% at 5rs, there was a 10% risk of amputation (all for local recurrence). The overall survival of the patients was 69% at 5yrs and 59% at 10 yrs and the survival of the prosthesis without a major complication (infection or local recurrence) was only 40% at 5 and 10 yrs. Local recurrence was related to effectiveness of chemotherapy and margins whilst infection was increased by tumours involving the pubic area.

Discussion: Although a successful hemipelvic replacement can produce a good functional outcome, the incidence of complications is very high. Steps to reduce these risks should be carefully considered including the use of wider margins and the use of silver coated prostheses as well as greater use of local or free flaps in selected cases.

99 patients with new diagnosed soft tissue sarcomas involving the pelvic region were studied to determine the outcome and prognostic factors for survival and local recurrence.

The mean age at diagnosis was 57 years. There were 55 males and 44 females. The mean tumor size was 12cm. The tumor was deep in 79 patients and superficial in 20. Surgical treatment was excision in 93 patients and hindquarter amputation in 6 patients. Histological grade was low grade in 23 and high grade in 75 patients. 7% of the patients had metastases at presentation.

The 5 year overall survival was 57% and local recurrence occurred in 22% of the patients. The risk of inadequate surgical margins in patients with tumors within the pelvic brim was 50% compared to 18% for those with tumors located outside the pelvic brim. The significant predictors of local recurrence were inadequate margins and location of the tumor within the pelvic brim. Tumor size, grade and depth did not influence development of local recurrence. Significant predictors of survival included metastases at presentation, tumor grade and depth. The cumulative 5 year survival for patients with deep high grade tumors, deep low grade tumors, superficial high grade and superficial low grade tumors were 45%, 74%, 63% and 100% respectively (p=0.01). The 5-year overall survival was 66% in those patients without local recurrence compared to 37% in those who develop local recurrence (p=0.005). Multivariate analysis revealed that development of local recurrence was the most important determinant of overall and metastases free survival.

We conclude that patients with pelvic soft tissue sarcoma who develop local recurrence have an extremely poor prognosis. Patients with high grade and inadequate surgical margins represent a particular group with very high risk of metastases and death even with radiotherapy and perhaps should be considered for other adjuvant treatment.

We report our experience of treating 17 patients with benign lesions of the proximal femur with non-vascularised, autologous fibular strut grafts, without osteosynthesis. The mean age of the patients at presentation was 16.5 years (5 to 33) and they were followed up for a mean of 2.9 years (0.4 to 19.5). Histological diagnoses included simple bone cyst, fibrous dysplasia, aneurysmal bone cysts and giant cell tumour. Local recurrence occurred in two patients (11.7%) and superficial wound infection, chronic hip pain and deep venous thrombosis occurred in three. Pathological fracture did not occur in any patient following the procedure.

We conclude that non-vascularised fibular strut grafts are a safe and satisfactory method of treating benign lesions of the proximal femur.

130 consecutive patients with metastastic 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 48 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.

Conclusion: 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.

Only 1% of all primary bone tumours are situated in the distal humerus. Destruction of the distal humerus by tumour is rare and reconstruction of the distal humerus is challenging. Because of the amount of bone loss following tumour excision, excision arthroplasty or arthrodesis is impossible and hence some form of reconstruction is usually required. Allograft reconstruction and hemiarthroplasty are uncommon and lead to an unpredictable outcome.

Ten patients underwent endoprosthetic replacement of the distal humerus for bone tumours over a thirty one-year period. There were 8 primary and 2 secondary tumours and male to female ratio was 2:3. Average age of the patients was 47.5 years (15–76 years). Mean follow up was 8 years (9 months - 31 years). Four patients required further surgery, three having revision for asceptic loosening and two of these and one other later needing a rebushing. There were no permanent nerve palsies, infections, local recurrences or mechanical failures of the implant. Four patients died of their disease between 12 and 71 months after operation, all with their prosthesis working normally.

Average flexion deformity was 15 degrees (0–35) and average flexion of these patients was 115 degrees (110–135). The average TES Score for these patients was 73% (29% to 93%). The activities which the patients found to be no problem (TES score more than 4.5 out of 5) were: brushing hair, drinking from a glass, putting on make up or shaving, picking up small items, turning a key in a lock, doing light household chores and socialising with friends, whilst activities that proved difficult (TES score less than 3 out of 5) were: gardening and lifting a box to an overhead shelf. Pain was not a problem and only 1 of the surviving patients reported ever having to use regular analgesics.

Conclusions: Endoprosthetic replacement of the distal humerus and elbow joint is a satisfactory method of dealing with these unusual tumours in the long term.

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.