The unusual phenomenon of histological grade change in locally recurrent soft tissue sarcomas is examined by retrospective review of a large sarcoma database. Increased histological grade was found to occur in 20% of recurrent tumours. Several possible factors predisposing to grade change were examined, and only the histologic diagnosis of myxoid malignant fibrous histiocytoma was found to be significant. Despite increased histologic grade, these tumours do not appear to have a worse prognosis in terms of developing systemic disease.

Soft tissue sarcomas (STS) have a reported local recurrence rate of between five and thirty percent. Recurrent tumours are often similar histologically to the initial tumour, however they are occasionally of higher histological grade than the original lesion. Factors that predispose to this change in grade are not known.

We sought to identify the frequency at which locally recurrent STS demonstrate a change in histological grade, and to investigate the possible factors leading to this change. We also investigate whether a change in grade is associated with a poorer prognosis.

We identified one hundred and seventy-three patients who developed locally recurrent STS, one hundred and twenty-four of which met inclusion criteria and who will form the basis of this study. Ninety-two patients (74%) had no change in histological grade, twenty-four (19%) demonstrated an increase in histological grade and eight (7%) a decreased histological grade. Univariate analysis of time to local recurrence, histological diagnosis and use of radiotherapy and chemotherapy did not reveal significant differences between the groups who did and did not undergo change in grade. When the diagnosis of myxoid MFH was looked at separately, there was a higher proportion in the group that developed increased histological grade. Development of a change in grade was not associated with a poorer survival rate.

Increase in histological grade occurs in approximately 20% of locally recurrent STS, but this phenomenon is not associated with a poorer prognosis than if the grade remains the same. A histological diagnosis of myxoid MFH predicts for an increase in histological grade.

Non-union of long bone fractures can be a challenging problem. There are several methods of treatment and they depend upon various patient factors, biology of non-union, and presence of infection. When faced with failure of treatment with biological reconstructive procedures patients have little choice. At our institute we have treated 10 such patients with radical excision and reconstruction using tumour endoprostheses as a last attempt to save the limb.

Median age of the patients was 71 years (25–85). 2 patients were male and 8 were female. Median follow-up was 49 months (8–229). 5 had infected non-union. Resection and massive endoprosthetic reconstruction involved the distal femur in 4 patients, proximal femur 3, distal humerus 2 and total Humerus in 1 patient. Time from diagnosis of non-union to treatment was 0 to 96 months (median 11 months) and patients had had 0 to 6 (median 3) previous operations 5 infected non-unions were operated as 2 stage procedures and received long term antibiotics. 4 out of 5 infected non-unions were salvaged. There were 5 complications, namely periprosthetic fracture, infection, a dislocated shoulder, radial nerve palsy, suture of bosing.

All the patients achieved immediate mobility and stability. Extendible prosthesis allowed partial correction of limb shortening.

Conclusion: Resection of established non-union and reconstruction with endoprostheses is a good salvage operation for elderly and low demand patients in whom time consuming biological reconstruction is not desirable.

Pathological fracture occurs in 5–10% of all primary malignant bone tumours. It is thought that they unfavourably influence survival, because the fracture haema-toma may contaminate adjacent tissues. Management is often more aggressive and one is less inclined to consider limb saving surgery.

Aim of this study was to determine whether the presence of pathological fracture had an effect on rate of limb salvage surgery, role of adjuvant treatment and survival.

A retrospective study was done on all patients with a pathological fracture through localised Ewing’s sarcoma, treated between 1979 and 2001. Of 289 patients with localised Ewing’s sarcoma, 27 had a pathological fracture. Eighteen presented with fracture, in 9 fracture occurred after biopsy. All were treated with chemotherapy according to protocol. Two fractures were already treated by osteosynthesis elsewhere, the rest healed with conservative treatment. After chemotherapy, 20 patients were treated surgically: 19 with limb saving surgery, 1 with amputation. Apart from chemotherapy, treatment was surgery alone in 15, surgery and radiotherapy in 5, and radiotherapy alone in 7 patients. Indications for radiotherapy were close margins, poor chemotherapy response, or pelvic tumours. Surgical margins were wide in 16 patients, marginal in 2, and intralesional in 1 patient. Local recurrence occurred in 2 patients, primarily treated with chemotherapy and radiotherapy alone. Five year survival was 60%, metastasis free survival 59%, both comparable with rates reported in literature.

Conclusion: Chemotherapy allows fractures to consolidate with conservative treatment. Adequate surgical margins can be achieved in the majority of patients with limb saving surgery. Adjuvant radiotherapy does not seem necessary if margins are wide. Survival is not negatively influenced by pathological fracture. The survival rate following limb saving surgery in these patients is similar to that of patients in literature where amputation is done. Limb saving surgery seems a safe option.

We investigated whether our policy of routine re-excision of the tumour bed after an unplanned excision of a soft-tissue sarcoma was justified.

Between April 1982 and December 2005, 2201 patients were referred to our hospital with the diagnosis of soft-tissue sarcoma, of whom 402 (18%) had undergone an unplanned excision elsewhere. A total of 363 (16.5%) were included in this study. Each patient was routinely restaged and the original histology was reviewed. Re-excision was undertaken in 316 (87%). We analysed the patient, tumour and treatment factors in relation to local control, metastasis and overall survival.

Residual tumour was found in 188 patients (59%). There was thus no residual disease in 128 patients of whom 10% (13) went on to develop a local recurrence. In 149 patients (47%), the re-excision specimen contained residual tumour, but it had been widely excised. Local recurrence occurred in 30 of these patients (20%). In 39 patients (12%), residual tumour was present in a marginal resection specimen. Of these, 46% (18) developed a local recurrence. A final positive margin in a high-grade tumour had a 60% risk of local recurrence even with post-operative radiotherapy.

Metastases developed in 24% (86). The overall survival was 77% at five years. Survival was related to the grade of the tumour and the finding of residual tumour at the time of re-excision.

We concluded that our policy of routine re-excision after unplanned excision of soft-tissue sarcoma was justified in view of the high risk of finding residual tumour.

Pathological fractures due to metastasis with destruction of the acetabulum and central dislocation of the hip present a difficult surgical challenge. We describe a series using a single technique in which a stable and long-lasting reconstruction was obtained using standard primary hip replacement implants augmented by strong, fully-threaded steel rods with cement and steel mesh, where required.

Between 1997 and 2006, 19 patients with a mean age of 66 years (48 to 83) were treated using a modified Harrington technique. Acetabular destruction was graded as Harrington class II in six cases and class III in 13.

Reconstruction was achieved using three 6.5 mm rods inserted through a separate incision in the iliac crest followed by augmentation with cement and a conventional cemented Charnley or Exeter primary hip replacement. There were no peri-operative deaths. At the final follow-up (mean 25 months (5 to 110)) one rod had fractured and one construct required revision. Of the 18 patients who did not require revision, 13 had died. The mean time to death was 16 months (5 to 55). The mean follow-up of the five survivors was 31 months (18 to 47). There were no cases of dislocation, deep infection or injury to a nerve, the blood vessels or the bladder.

We have investigated whether improvements in design have altered the outcome for patients undergoing endoprosthetic replacement of the proximal tibia following resection of a tumour. Survival of the implant and ‘servicing’ procedures have been documented using a prospective database.

A total of 194 patients underwent a proximal tibial replacement, with 95 having a fixed-hinge design and 99 a rotating-hinge with a hydroxyapatite collar; their median age was 21.5 years (10 to 74). At a mean follow-up of 14.7 years (5 to 29), 115 patients remain alive. The risk of revision for any reason in the fixed-hinge group was 32% at five years, 61% at ten years and 75% at 15 and 20 years, and in the rotating-hinge group 12% at five years, 25% at ten years and 30% at 15 years. Aseptic loosening was the most common reason for revision in the fixed-hinge knees, fracture of the implant in the early design of rotating hinges and infection in the current version. The risk of revision for aseptic loosening in the fixed-hinge knees was 46% at ten years. This was reduced to 3% in the rotating-hinge knee with a hydroxyapatite collar. The cemented, rotating hinge design currently offers the best chance of long-term survival of the prosthesis.

Between 1966 and 2001, 1254 patients underwent excision of a bone tumour with endoprosthetic replacement. All patients who had radiotherapy were identified. Their clinical details were retrieved from their records.

A total of 63 patients (5%) had received adjunctive radiotherapy, 29 pre-operatively and 34 post-operatively. The mean post-operative Musculoskeletal Tumor Society scores of irradiated patients were significantly lower (log-rank test, p = 0.009). The infection rate in the group who had not been irradiated was 9.8% (117 of 1191), compared with 20.7% (6 of 29) in those who had pre-operative radiotherapy and 35.3% (12 of 34) in those who radiotherapy post-operatively. The infection-free survival rate at ten years was 85.5% for patients without radiotherapy, 74.1% for those who had pre-operative radiotherapy and 44.8% for those who had post-operative radiotherapy (log-rank test, p < 0.001). The ten-year limb salvage rate was 89% for those who did not have radiotherapy and 76% for those who did (log-rank test, p = 0.02).

Radiotherapy increased the risk of revision (log-rank test, p = 0.015). A total of ten amputations were necessary to control infection, of which nine were successful. Radiotherapy may be necessary for the treatment of a bone sarcoma but increases the risk of deep infection for which amputation may be the only solution.

We identified 42 patients who presented to our unit over a 27-year period with a secondary radiation-induced sarcoma of bone. We reviewed patient, tumour and treatment factors to identify those that affected outcome. The mean age of the patients at presentation was 45.6 years (10 to 84) and the mean latent interval between radiotherapy and diagnosis of the sarcoma was 17 years (4 to 50). The median dose of radiotherapy given was estimated at 50 Gy (mean 49; 20 to 66). There was no correlation between radiation dose and the time to development of a sarcoma. The pelvis was the most commonly affected site (14 patients (33%)). Breast cancer was the most common primary tumour (eight patients; 19%). Metastases were present at diagnosis of the sarcoma in nine patients (21.4%). Osteosarcoma was the most common diagnosis and occurred in 30 cases (71.4%). Treatment was by surgery and chemotherapy when indicated: 30 patients (71.4%) were treated with the intention to cure. The survival rate was 41% at five years for those treated with the intention to cure but in those treated palliatively the mean survival was only 8.8 months (2 to 22), and all had died by two years. The only factor found to be significant for survival was the ability to completely resect the tumour. Limb sarcomas had a better prognosis (66% survival at five years) than central ones (12% survival at five years) (p = 0.009).

Radiation-induced sarcoma is a rare complication of radiotherapy. Both surgical and oncological treatment is likely to be compromised by the treatment received previously by the patient.

We investigated whether improvements in design have altered the outcome for patients undergoing endoprosthetic replacement of the distal femur after resection of a tumour. Survival of the implant and ‘servicing’ procedures have been documented using a prospective database, review of the design of the implant and case records. In total, 335 patients underwent a distal femoral replacement, 162 having a fixed-hinge design and 173 a rotating-hinge. The median age of the patients was 24 years (interquartile range 17 to 48).

A total of 192 patients remained alive with a mean follow-up of 12 years (5 to 30). The risk of revision for any reason was 17% at five years, 33% at ten years and 58% at 20 years. Aseptic loosening was the main reason for revision of the fixed-hinge knees while infection and fracture of the stem were the most common for the rotating-hinge implant. The risk of revision for aseptic loosening was 35% at ten years with the fixed-hinge knee, which has, however, been replaced by the rotating-hinge knee with a hydroxyapatite collar. The overall risk of revision for any reason fell by 52% when the rotating-hinge implant was used.

Improvements in the design of distal femoral endoprostheses have significantly decreased the need for revision operations, but infection remains a serious problem. We believe that a cemented, rotating-hinge prosthesis with a hydroxyapatite collar offers the best chance of long-term survival of the prosthesis.

Introduction: The anterior drawer test for anterior cruciate ligament (ACL) deficiency, requires a subjective assessment of joint movement, as the tibia is pulled forward. The aim of this study was to objectively quantify this movement using a magnetic tracking device.

Materials and Methods: Ten patients aged 24 to 44 years were assessed as having unilateral ACL deficiency with conventional clinical tests. These patients were then re-assessed using a magnetic tracking device (Polhemus Fastrak). Patients had magnetic sensors attached around their femurs and tibias using elasticated Velcro straps. The Anterior Drawer test was then performed with the patient lying within range of the system’s magnetic source. The test was performed three times on the normal and injured knees of each patient, using a spring balance to apply a standard 20 lb (=89 N) force. During the tests, sensor position and orientation data was collected with an accuracy better than 1 mm and 1 degree, respectively. The data was sampled at 10Hz and stored on a computer for post-test analysis. This analysis deduced the tibial displacement resulting from each anterior drawer.

Results: During the anterior drawer test the supine patient’s knee is in 90 degrees flexion, with the foot planted on the examination couch. As the tibia is pulled anteriorly, it rotates upwards from the foot and the femur experiences a corresponding rotation from the hip. These complex coupled movements are best quantified in terms of absolute displacement of the tibia from the femur. In the normal knees, the mean displacement of the tibia from the femur was 4.2 mm (SD=1.6). In comparison the ACL deficient knees had a mean displacement of 6.3 mm (SD=2.9). This is 50 % more. A paired t test of this data showed a highly significant difference, with P = 0.005.

Conclusion: This study has quantified the movement produced during the Anterior Draw test for ACL deficiency. The tracker’s lightweight sensors caused minimal disturbance to the established clinical test. The system therefore provides objective measurement data to augment the clinicians subjective assessment.

Peri- and sub-prosthetic fractures, or pathological fractures below an existing well-fixed femoral component, with or without an ipsilateral knee replacement, present a difficult surgical challenge.

We describe a simple solution, in which a custom-made prosthesis with a cylindrical design is cemented proximally to the stem of an existing, well-fixed femoral component. This effectively treats the fracture without sacrificing the good hip. We describe five patients with a mean age of 73 years (60 to 81) and a mean follow-up of 47 months (6 to 108).

The mean overlap of the prosthesis over the femoral component was 7.5 cm (5.5 to 10). There have been no mechanical failures, no new infections and no re-operations. We suggest that in highly selected cases, in which conventional fixation is not feasible, this technique offers a durable option and avoids the morbidity of a total femoral replacement.

Aim: To identify prognostic for patients who develop local recurrence after initial attempted curative treatment for a soft tissue sarcoma (STS).

Method: All patients who developed a local recurrence (LR) after initial primary treatment of a STS were identified from a prospective database. Their management and outcome were analysed to find prognostic factors.

Results: 178 patients were identified. They had a median age at original diagnosis of 53 and 102 of the patients had high grade tumours, 50 intermediate grade and 23 low grade. The median time to LR was 14 months but extended up to 11.5 years. 47 of the patients developed metastases either before or synchronously with the LR. In these patients the median survival was 20 months with only 4% surviving to 5 years. In the 131 patients who did not have identifiable metastases at the time of diagnosis, 74 subsequently developed metastases at a median time of 12 months following the development of LR.

The median survival for patients without metastases at the time of LR was 3 years with a 31% survival at 10 years. The most important prognostic factor in this group was grade with low grade tumours having a much better outlook (70% survival at 10 years) than intermediate or high grade tumours (24% at 10 years). Complete control of the first local recurrence could not be shown to be a prognostic factor.

Conclusion: Local recurrence has a poor prognosis but this is because it frequently arises in patients who have other bad prognostic factors. Whilst obtaining local control is important, overall survival is poor, but not as bad for those patients who develop metastases.

Aims: To establish the frequency and demographics of soft tissue sarcomas (STS) presenting in the lower limb.

Methods: Patients presenting to a tertiary referral orthopaedic oncology unit over a 10-year period were prospectively entered into a computerised database. The site of primary STS and demographic details were also recorded.

Results: 1519 STS in all body regions were treated. 1067 (70.2%) within the lower limb. 57.0% thigh, 13.0% calf, 8.2% foot and ankle, 7.7% buttock, 5.7% knee, 4.6% pelvis and 3.8% in the groin. There was a male predominance (56.2%). M:F ratio was 2.5:1 for the groin and 1.3:1 for the thigh with the other body regions approximately equal.

Conclusion: The majority of STS are found in the lower limb. In this large series there was a male predominance most marked in groin presentations.

Aims: Soft tissue sarcomas (STS) of the foot and ankle are rare tumours. The aims of this study were to examine the presenting features and highlight those associated with a delay in diagnosis.

Methods: Patients presenting during a 10-year period were identified using a computerised database within the Orthopaedic Oncology Unit at the Royal Orthopaedic Hospital, Birmingham, UK. Additional information was obtained from a systematic case note review.

Results: 1519 patients were treated for STS of which 87 (8.2%) had tumours sited in the foot and ankle. Of these, 75 (86.2%) had presented with a discrete lump (42 (56%) of them having an inadvertent “whoops” excision biopsy), 3 (3.4%) with ulceration and the remaining 9 (10.3%) with symptoms more commonly associated with other benign foot and ankle pathology. Within the group of 9 patients they had previously been treated as plantar fasciitis (3), tarsal tunnel syndrome (2), Morton’s neuroma (1) and none specific hind foot pain (3). Median delay from onset of symptoms to diagnosis as STS was 26 months for this group (mean 50; range 6–180 months) compared to 12 months (mean 32; range 3–240) for the “whoops” biopsy group and 10 months (mean 16; range 2–60 months) for the unbiopsied discrete lump group.

Conclusion: Soft tissue sarcoma in the foot and ankle may present insidiously and with symptoms of other benign pathologies. Failure to respond to initial treatment of suspected common benign pathology should be promptly investigated with further imaging e.g. MRI scan or high resolution ultrasound, or with specialist consultation.

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.

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.