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 (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. The 9 had previously been treated as plantar fasciitis (3), tarsal tunnel (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 (mean16; 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 further with an MRI scan.

Introduction and Aims: There are more than 200,000 anterior cruciate ligament (ACL) ruptures each year in the United States. The replacements used for ACL repair do not fully recreate the ACL’s function and histological appearance. Therefore, a novel tissue-engineered ligament was designed and evaluated after ACL reconstruction in a rabbit model.

Method: Rabbits received tissue-engineered ligaments or tissue-engineered ligaments seeded with primary rabbit ACL cells. The tissue-engineered ligaments were composed of multifilament poly-L-lactide yarn (70 denier) fabricated into novel 24 yarn 3-D braids. Scaffolds were designed to be easily handled and fixed by the surgeon in ACL reconstructions using the suture over the button technique. A continuous scaffold design accommodated the flexibility of intra-articular loads and the rigours of the bone tunnels. The contralateral legs were used as controls. A key parameter for tissue ingrowth was scaffold porosity at 58 ± 9% and mode pore diameter of 183 ± 83 μm.

Results: Histological evaluations showed slow collagen tissue infiltration at the surface of the replacement at the four-week time point for both the tissue-engineered ligament and cell-seeded tissue-engineered ligament. At the 12-week time point, both replacements showed collagen ingrowth and remodelling across the entire implant occurred with a thin fibrous capsule. The cell-seeded tissue-engineered ligament demonstrated greater levels of mature collagen ingrowth and healing compared to the non-cell seeded tissue-engineered ligament. The initial tensile strength properties of the scaffold were 332 ± 20 N and 354 ± 68 MPa, which compared well to the rabbit ACL control (314 ± 66 N). The tensile properties of the tissue-engineered ligament and seeded tissue-engineered ligament at four weeks were 67% and 76%, respectively of control. The tensile properties of the biodegradable implant decreased with time for the tissue-engineered and cell seeded tissue-engineered ligament and by 12 weeks was 9% and 30% respectively, as compared to the rabbit ACL control. The 30% strength retention for the tissue-engineered ligament replacements at 12 weeks was greater than reported by others using poly(lactic acid) and polypropylene ligament augmentation devices (LAD) at 12 weeks, with values of 13% and 16% of control strength retention, respectively.

Conclusion: The results of this study demonstrate the promise of a novel cell seeded tissue-engineered ligament for anterior cruciate ligament regeneration.

Study Design: A prospective cohort study of patients undergoing surgery for prolapsed intervertebral disc.

Objective: To assess a patient’s ability to recall information discussed pre-operatively at the time of informed consent six weeks following surgery.

Subjects: Sixty-one consecutive patients undergoing discectomy for prolapsed intervertebral disc with follow up six weeks after surgery.

Outcome measures: Patients were assessed, using a pre-prepared questionnaire, to establish their understanding of disc surgery prior to signing a consent form. All information on the questionnaire had previously been given to the patient at the time of being put on the waiting list via a copy of the clinic letter to the general practitioner. If patients were unable to complete the questionnaire, they were then tutored using visual aids such as posters and models until they were able to answer the questions correctly. The consent form was then signed. Six weeks following surgery, patients were then asked the same questionnaire to establish their ability to recall the information discussed pre-operatively about disc surgery.

Results: Prior to tutoring, 20 % of patients were unable to recall that their symptoms were due to disc pathology and that surgery to remove the disc would relieve their symptoms. They were also unable to recall the success rate of surgery. Following surgery, only half of this group of patients could recall these facts. Only 32% of patients were able to recall two or more risk factors of surgery prior to tutoring. This improved to 45% following surgery. Pre- and post-operative questionnaire scores were analysed using a paired t-test. There was no statistical improvement in questionnaire scores long term following tutoring.

Conclusion: In this group of patients, extensive tutoring with the use of visual aids as an adjunct, does not statistically improve their ability to recall important information about surgery for prolapsed intervertebral disc and the risks associated with it.

Introduction and Aims: The aim of this study is to identify specific risk factors for developing haemophilia-related orthopaedic complications and to provide a qualitative and quantitative analysis of the orthopaedic management of haemophilia complications.

Method: A postal survey was sent to 48 patients on the Wellington region haemophilia database. The questionnaire covered both qualitative and quantitative questions covering the participants’ current condition and treatment, past and present orthopaedic and non-orthopaedic management, support, education, employment and leisure activities.

Results: Twenty-five patients returned the questionnaire, a response rate of 52%. Most of the participants (68%; 17/25) felt that their education had been compromised as a result of haemophilia complications. Of those participants that were 16 years or older, 68.4% (13/19) felt that their working opportunities had been compromised as a result of haemophilia complications. Despite patients less than 18 years of age receiving prophylactic Factor VIII replacement (n=7) and all patients having Factor VIII available on demand, 18 patients had significant bleeds in the previous six months. Most bleeds were into joints, 13 knees, 13 ankles, 12 elbows, six shoulders and three hips, but a significant number of intra-muscular bleeds (n=22) also occurred. There were 62 painful joints reported by 19 patients, the ankle being most common (n=21), followed by hip (n=13), elbow (n=12), and knee (n=8). Twenty-five orthopaedic operations were described by eight patients, mainly knee (n=11) and hip (n=5) replacements, and synovectomies (n=9). In the last year, two patients who have factor VIII inhibitor had been successfully operated on, one for a large pseudotumor of the thigh, and the other for contralateral hip and knee joint replacement.

Conclusion: Despite good medical management, recurrent joint bleeds are a major problem in haemophilia. Many study patients commented that orthopaedic procedures were not performed readily enough, and that by the time they received their operation, their function had deteriorated significantly.

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

Method: Over 11, 000 patients have been treated in our unit over 35 years. Information collected prospectively on a database, includes demographic data, diagnosis, treatment (including adjuvant), complications, and outcomes. Data was analysed to identify any infection in EPRs, its management and outcome. Factors such as operating time, blood loss, adjuvant therapy, type of prosthesis were investigated. Outcomes of treatment options were evaluated.

Results: Data was analysed on 1265 patients undergoing EPR over 34 years. Giving a total follow-up time of over 6500 patient years. One hundred and thirty-seven (10.8%) patients had deep infection (defined by a positive culture [n=128] or a clinically infected prosthesis with pus in the EPR cavity [n=9]). Forty-nine (34%) required amputations for uncontrollable infection. The commonest organisms were Coagulase Negative Staphylococcus, Staphylococcus aureus and Group D Streptococci. The only satisfactory limb salvaging operation was two-stage revision, with a 71% success in curing infection. Systemic antibiotics, antibiotic cement or beads and surgical debridement had little chance of curing infection. Infection rates were highest in tibial (23.1%) and pelvic (22.9%) EPRs (p< 0.0001). Patients who had pre- or post-operative radiotherapy had significantly higher rates of infection (p< 0.0001), as did patients with extendable EPRs (p=0.007). Patients who had subsequently undergone patella resurfacing and rebushing also had a higher rate of infection (p= 0.019 & p=0.052).

Conclusion: Infection is a serious complication of EPRs. Treatment is difficult and prolonged. Two-stage revision is the only reliable method for limb salvage following deep infection. Prevention must be the key to reducing the incidence of this serious complication.

Introduction and Aims: An important prognostic factor in neonatal brachial plexus injury is the timing of biceps recovery. Although the natural history is not clear, biceps recovery after three months has been used to predict universally poor long-term shoulder function. The absence of biceps function at three months has been adopted as an indication for early microsurgery, in an attempt to improve upper limb function. e

Method: Between 1980 and 1992, 170 patients with neonatal brachial plexus injury were entered into a prospective study, which recorded details of the birth and serial examinations. Patients were grouped according to the level of injury and timing of biceps return. Twenty-nine patients were observed to have absent biceps at three months. Twenty-eight of 29 patients were available for long-term review at an average of 11 years and one month (range 5yrs 7mths–16 years). At follow-up, patients answered a questionnaire, underwent muscle strength testing, sensory evaluation, and had their shoulder function graded according to Gilbert’s modification of the Mallet score. The level of injury and time of biceps return were compared to the final outcomes.

Results: The level of injury was C5/6 in 13/28 (46%), C5/6/7 in 5/28 (18%) and pan-plexus in 10/28 (36%), with a Horner’s syndrome in four patients. Of the 28 patients with absent biceps function at three months, biceps contraction was observed in 20 patients (71%) by six months. 13/13 C-5,6 patients, 3/5 C-5,6,7 patients, and 4/9 pan-plexus patients (0/4 of those with a Horner’s syndrome) regained biceps by six months. Twenty-two patients did not have plexus surgery, nine of these had subsequent shoulder surgery. At follow-up, 27 of 28 patients had at least anti-gravity biceps function. Patients who regained biceps function between three and six month had better scores for abduction (p=0.04), hand to neck (p=0.05) and hand to back (p< 0.001) than patients who regained biceps after six months. Patients with C-5, 6 lesions had better scores for external rotation (p=0.04), hand to neck (p=0.05), hand to mouth (p< 0.01) and hand to back (p< 0.001) than patients with pan-plexus lesions. Twelve of the 22 (55%) patients who did not have plexus surgery had Mallet class IV shoulders (good function). Of the C-5, 6 patients who did not have plexus surgery, 8/12 had class IV shoulders.

Conclusion: This study supports the associations between prolonged neurological recovery, more extensive level of injury and worse long-term shoulder function. In patients with C-5, 6 injuries and absent biceps function at three months, good shoulder function is common in the long-term without plexus surgery. This finding is important in considering the indications for and the results of early microsurgical intervention.

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

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

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

Purpose: The purpose of this work was to analyse follow-up and prognostic factors in a series of patients treated for soft tissue tumours as a function of the type of facility providing initial care: a supra-regional referral centre (Royal Orthopaedic Hospital, Birmingham), and 38 regional hospitals in the referral area.

Material and methods: This series included 260 patients (111 women and 149 men) treated between 1994 and 1996. Mean age at diagnosis was 61 years. Primary care was given to 96 patients (37%) in the referral centre and 164 (63%) in other centres. Minimum follow-up was five years. The risk of local recurrence and survival prognosis were studied by risk factor: grade, localisation (supra versus infra aponeurotic), tumour size, quality of resection margins.

Results: High-grade tumours were found in 73% of patients with a supra-aponeurotic localisation in 59%. Mean tumour size was 8.6 cm. Tumours in patients treated in the referral centre were larger (10.3 cm versus 7.5 cm) (p< 0.05). Frequency of local recurrence was 20% for the referral centre versus 37% for the other centres. Overall five-year survival rate was 58% and was correlated with grade, tumour size, and localisation (p< à.05). Overall survival of patients given primary care in the referral centre was not statistically different from those treated in the other centres, but for high-grade tumours (UICC grade III), five-year survival was 41% for the referral centre and 14% for the other centres (p< 0.05).

Discussion: Soft tissue sarcomas are rare tumours. For high-grade sarcomas, the rate of recurrence after treatment and the survival rate were better for patients given primary care in the referral centre. The question of centralising patients with this type of disease in referral centres is raised.

Introduction: Referrals for Low Back Pain (LBP) are common and many patients appear to see more than one specialist. In one acute trust, a dedicated Spinal Assessment Clinic (SAC) run by nurse practitioners was developed.

Objective: To determine patterns of referral for LBP from primary to secondary care.

Method: All new referrals to the hospital for LBP in an index period June–November 1998 were included. Consultations for these patients in the preceding six months and the subsequent two years were studied.

Results: A total of 801 patients were referred in the audit period. The patients were seen in the SAC 75%, orthopaedics 5.5%, rheumatology 4.5%, neurosurgery 12% and the pain clinic 4%. Onward referrals made after the initial appointment from the SAC 4.9%, from orthopaedics 26.7%, from rheumatology 8.6%, from neurosurgery 33.7% and from the pain clinic 10.3%. Subsequent repeat referrals made by the GP occurred in 3.7%of patients initially seen in the SAC, 11.1% from orthopaedics, 2.9% from Rheumatology, 3.2% from Neurosurgery and 17.2% from the pain clinic. The average wait in days for a first appointment was SAC 42, orthopaedics 103, Rheumatology 82, Neurosurgery 78 and pain clinic 77.

Conclusion: The SAC offers a shorter wait for patients and an extremely low “churn” rate, implying high rates of satisfaction in patients and GP’s. The wait for other specialities is longer, and in orthopaedics and neurosurgery the re-referral rate is almost one third. Referral procedures to secondary care might need to be streamlined for more efficiency.

Purpose: Hand localisations predominate in Ollier disease. There have however been few studies devoted to this topic and the one report available only presented a few cases. Treatment of multiple enchondromatosis is sometimes discussed with the treatment of solitary enchondromas despite different recurrence behaviour and aggressiveness. A specific approach is indicated.

Material and methods: We present a retrospective series of 22 children treated for multiple enchondromatosis of the hand. One hand was involved in 11 and both hands in 11. We thus identified 246 enchondromas on 33 hands. One girl with Maffucci syndrome died at the age of six years due to angiosarcomatous degeneration of the leg.

Results: At diagnosis, mean age was six years nine months. Pain and pathological fractures were exceptional, observed in three patients. Overall hand function remained satisfactory. We performed surgery for 14 patients (mean age 8 yr 8 mo) due to increasing symptoms and tumour volume. Five patients required two operations and one a third. We thus performed 18 interventions on 37 hand bones (51 surgical procedures). Simple curettage was performed in 21 cases, combined with autologous cancellous grafting in 30 others. One finger had to be amputated due to aggressive recurrence. Radio-lucent residual lesions were found in 62% of the children at mean 19 months follow-up.

Discussion: Hand function remained satisfactory despite a worrisome radiographic aspect. The decision for surgery was basically made to improve the aesthetic aspect of the hand. Many surgical techniques have been proposed. In our experience, it is difficult to eradicate a treated lesion but grafting appears to be more effective than simple curettage.

Conclusion: Function remains good during growth, fractures are exceptional. Lesions stabilise at the end of growth. We have not observed any case of chondrosarcomatous degeneration in our series of paediatric patients. There is however a risk of malignant degeneration which should be suspected in the event of pain, increased tumour volume or pathological fracture.

Aims: Tumours of the distal humerus are rare but a challenge to treat. Options for treatment are excision and flail elbow, arthrodesis with considerable shortening, allograft replacement or endoprosthetic replacement (EPR). A retrospective analysis of 10 cases of EPR distal humerus was done to assess their success in treating tumours.

Methods: A retrospective analysis of 10 distal humeral tumours operated between 1970 and 2001 was done by retrieving data from notes. No patient was lost to follow up. The Toronto Extremity Salvage Score (TESS) was used to assess function in patients still alive.

Results: There were 4 male and 6 female patients, with ages ranging from 15 to 76 years. The period of follow up ranged from 5 months to 31 years. 8 patients had primary tumours and 2 had secondary tumours. 4 out of 10 patients died of metastatic disease 12 to 71 months after operation. None of the 10 patients had local recurrence, infection, amputation or permanent nerve palsy. There were 3 revisions at 48, 56 and 366 months for aseptic loosening. There were 3 rebushings of the plastic inserts at 62,78 and 113 months. Two of the three rebushings were done after revision of the humeral component at 6 months and 30 months. The average TESS Score for these patients was 72.91 out of 100 (29.2 to 93.33).

Conclusion: Custom-made EPR for distal humeral tumours are an effective way of replacing the diseased bone leading to a reasonable level of function and an acceptable failure rate.

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.

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.

The purpose of this paper is to present the rare occurrence of clear cell chondrosarcoma in a patient suffering from Niemann-Pick disease (NPD).

NPD is a rare autosomal recessive inborn error of metabolism. It is a lysosomal storage disorder affecting children and adolescents often causing death in early childhood although in milder form patient may survive up to adulthood. Although chondrosarcoma is a relatively common malignant bone lesion, these lesions rarely affect patients suffering from Niemann-Pick disease. This article presents the case of a 50-year-old man with a chondrosarcoma in the olecranon of the left ulna who also suffered from milder form of Niemann-Pick disease. Radiography and MRI showed cortical disruption and an expansile lesion. Histologically, the tumour was classified as grade 2 clear cell chondrosarcoma with classical differentiation according to the American Joint Committee of Cancer pathologic staging system. Amputation of an above elbow type was performed to obtain clear surgical margins. A case report and discussion of this rare association of a patient suffering from milder form of NPD who developed a clear cell chondrosarcoma is presented here. NPD and clear cell chondrosarcoma are rare diseases and together their occurrence was not found reported in the literature. NPD patients rarely live to the age of 50 years. This raises a possibility that if Niemann-Pick patients survived long enough they might develop chondrosarcoma. Alternatively this could just be coincidental. More research is needed to clarify this possibility.

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.

Two collagen type IX gene polymorphisms that introduce a tryptophan residue into the protein’s triple-helical domain have been linked to an increased risk of lumbar disc disease. To determine whether a particular subset of symptomatic lumbar disease is specifically associated with these polymorphisms, we performed a prospective case-control study of 107 patients who underwent surgery of the lumbar spine. Patients were assigned to one of five clinical categories (fracture, disc degeneration, disc herniation, spinal stenosis without spondylolisthesis and spinal stenosis with spondylolisthesis) based on history, imaging results, and findings during surgery. Of the 11 tryptophan-positive patients, eight had spinal stenosis with spondylolisthesis and three had disc herniation. The presence of the tryptophan allele was significantly associated with African-American or Asian designation for race (odds ratio 4.61, 95% CI 0.63 to 25.35) and with the diagnosis of spinal stenosis with spondylolisthesis (odds ratio 6.81, 95% CI 1.47 to 41.95).

Our findings indicate that tryptophan polymorphisms predispose carriers to the development of symptomatic spinal stenosis associated with spondylolisthesis which requires surgery.

Aims: Tumours of the distal humerus are rare but a challenge to treat. Options for treatment are excision and ßail elbow, arthrodesis with considerable shortening, allograft replacement or endoprosthetic replacement (EPR). A retrospective analysis of 10 cases of EPR distal humerus was done to assess their success in treating tumours.

Methods: A retrospective analysis of 10 distal humeral tumours operated between 1970 and 2001 was done by retrieving data from notes. No patient was lost to follow up. The Toronto Extremity Salvage Score (TESS) was used to assess function in patients still alive.

Results: There were 4 male and 6 female patients, with ages ranging from 15 to 76 years. The period of follow up ranged from 5 months to 31 years. 8 patients had primary tumours and 2 had secondary tumours. 4 out of 10 patients died of metastatic disease 12 to 71 months after operation. None of the 10 patients had local recurrence, infection, amputation or nerve palsy. There were 3 revisions at 48, 56 and 366 months for aseptic loosening. There were 3 rebushings of the plastic inserts at 62,78 and 113 months. Two of the three rebushings were done after revision of the humeral component at 6 months and 30 months. The average TESS Score for these patients was 72.91 out of 100 (29.2 to 93.33).

Conclusion: Custom-made EPR for distal humeral tumours are an effective way of replacing the diseased bone leading to a reasonable level of function and an acceptable failure rate.

Aim: To investigate the versatility of ßexible intramedullary nails (FIN) in the surgical treatment of forearm fractures in children. Methods: 28 children were treated using FIN for displaced forearm fractures over a period of 5 years. There were 18 boys and 10 girls. The mean age was 11.5 years and the mean follow up were 7.9 months. Two nails were used one each for radius and ulna. 12 children were operated for unstable displaced fractures, 14 were operated after failed initial reduction and 2 were operated for open fractures. 16 were nailed by closed method, 12 had mini open technique in cases of failed initial closed reduction. The nails were removed on an average of 6–8 months. Results: All the children achieved bony union in excellent position. The average time for union was 5.6 weeks. All but 2 patients had full range of movements and none had any functional difþculty. 3 children had transient hypo aesthesia in the area of superþcial radial nerve distribution and one child developed compartment syndrome which needed fasciotomy. There were no long term sequel. Conclusions: Use of FINs in paediatric forearm fractures should be encouraged when surgical intervention is needed. They are axially and rotationally stable. They are safe to introduce and remove at a later date. Their ßexibility allows remodelling of the fracture and growth of the long bones.