Introduction

The regionalisation of major trauma in the UK has significantly improved outcomes for patients with severe, lower limb injuries. Chronic pain after complex lower limb injuries is well documented, but seems to remain a problem despite better clinical and radiological outcomes. We hypothesised that pain was mediated through the saphenous nerve, especially as most tibial injuries affected the soft tissues medially. As a proof of concept, we undertook adductor canal blocks to understand pain aetiology.

Purpose: Impending and pathologic fractures of the humerus, usually due to metastatic disease, are associated with significant pain, morbidity, loss of function, and diminished quality of life. Several methods of stabilization have been described. Here we report the outcome of fixation using intramedullary poly methyl methacrylate (bone cement) and non-locking plates.

Method: A retrospective review was undertaken which included all patients treated at a tertiary musculoskeletal oncology referral center from February, 1989 to October, 2009. Patients who underwent surgical management of an impending or pathologic fracture of the humerus were included. All patients were treated using the following technique: Vascular tumors were embolized pre-operatively. Following gross tumor removal through curettage, antibiotic bone cement was placed into the humeral canal and bone defect. If there was a fracture, the bone ends were held in place as the cement cured. The humerus was stabilized using non-locking plates fixed with screws inserted through the bone and hardened bone/cement composite. Ideally, plates spanned the osseous defect by at least 2 cortical diameters and often the entire length of the bone.

Results: Clinical records were available for 67 patients who underwent the above procedure. There were 44 males and 23 females with an average age of 62.2 years. In 76% of patients there was a pathologic fracture at presentation, while in 24% it was impending. The most common histology was myeloma (21%), followed by renal (20%) and lung adenocarcinoma (20%). Forty-nine patients (73%) had one plate, 16 (24%) had two plates, one patient had three plates, and one had four plates. Complications occurred in 14 (21%) cases, and eight (12%) required reoperation of the humerus. The most common cause for reoperation was disease progression (six of eight). There were two nerve palsies, one deep infection, and one hardware failure. Interestingly, the single hardware failure occurred in a patient whose pain relief and functional status improved to the point that he fractured his construct while hammering with the affected arm in a home improvement project.

Conclusion: Intralesional tumor resection and stabilization of impending and pathologic fractures of the humerus with the described technique has several attributes. Most importantly, it provides immediate, absolute rigidity of the upper extremity and enables early pain relief and return of function without the need for osseous union. Radiation has no negative effects on the construct. The patient’s local disease burden is reduced, thus helping to alleviate tumor-related pain and slow local disease progression. Finally, this technique is user-friendly and cost-effective as it does not require any special equipment or devices that are not available to community orthopaedic surgeons. This technique provides a durable option for the treatment of impending and pathologic humerus fractures.

A retrospective review of our prospectively collected database was undertaken and the functional and oncologic outcomes after Type One pelvic resections for bone tumours of the ilium and sacrum were analyzed. Seventeen patients were identified with a minimum followup after resection of twelve months. In seven patients the bone defect was reconstructed, with no reconstruction in the remaining ten patients. The functional/oncologic outcomes of the two groups are similar, however patients without reconstruction had fewer complications and less dependence on walking aids suggesting that reconstruction may not be justified.

Management of defects created by Type One pelvic resections of large iliac bone tumours remains controversial. We reviewed the functional/oncologic outcome following resection with and without reconstruction.

Similar functional/oncologic outcome was achieved in both groups suggesting that reconstruction is not justified.

A retrospective review of our prospectively collected database was undertaken analyzing functional/oncological outcome of seventeen patients with Type One pelvic resection. Minimum follow up was twelve months (12–96). Outcome data was available on 8/10 patients managed without reconstruction (WOR), with residual ilium collapsing back onto sacrum, and on 5/7 patients with bone graft reconstruction (WR).

Average age thirty-three years (WOR) and 48yrs (WR), (p=0.04), with average maximal tumour dimensions of 12cm and 9cm (p=0.1). The most frequent diagnosis was chondrosarcoma. The WOR group average TESS, MSTS 87 and MSTS 93 scores were respectively 73%, 18/35 and 58% at an average of 50 months (24–96) compared to 69%, 21/35 and 51% at an average of 37 months (12–60) for the WR group. 33% of WOR and 20% of WR patients did not require walking aids. Infection or wound necrosis occurred in 40% of WOR patients and 57% of WR patients. No local recurrences.

The perceived advantages of no reconstruction are shorter operating times, reduced incidence of complications and improved functional outcome due to medialization of the weightbearing axis in the absence of hip abductors. The oncologic/functional outcomes of both groups were similar but in those not reconstructed there was a lower incidence of complications and walking aids.

Many authors believe that size, histological grade and depth are the best predictors of outcome in soft tissue sarcoma. Enneking’s surgical staging system included compartmental status, and was intended to guide surgical intervention as well as provide prognostic information. Advances in surgical and radiotherapy techniques may mean that extracompartmental status is no longer a poor prognostic factor. We compared a group of popliteal fossa sarcomas with a group from the posterior thigh, and found that although the former group required more extensive surgery to obtain wide margins, their functional and survival outcomes were similar.

No single staging system has been generally accepted for extremity soft tissue sarcoma, although histologic grade, size and depth are widely accepted as prognostic indicators. Enneking outlined a surgical staging system which used compartmental status as a predictor of outcome. However, surgical reconstruction and adjuvant radiotherapy have advanced considerably. We wanted to know if a tumour arising in the popliteal fossa still had poorer survival or functional outcome in the light of these advances.

We identified twenty-three patients who had sarcomas of the popliteal fossa and forty-six patients who had sarcomas of the nearby posterior thigh compartment. Popliteal sarcomas were not of a different size or more likely to present with metastasis. Popliteal tumours more frequently required reconstructive techniques such as local or free tissue transfer and skin grafting than posterior thigh tumours (39.1% v 4.3% respectively). Popliteal tumours were also more likely to undergo a dissection or reconstruction of the major neurovascular structures of the lower limb (30.4% v 0% respectively). There was no difference in local or systemic recurrence rates between the groups. TESS and MSTS 1987 functional scores also showed no difference between the groups.

We conclude that popliteal fossa sarcomas require a greater level of surgical intervention to follow sound principles of sarcoma resection and achieve reconstruction of the ensuing soft tissue defect. However, if these principles are followed in a planned multidisciplinary setting, then survival and functional results similar to the posterior thigh can be expected.

A retrospective review of our prospectively collected database was undertaken to determine the functional and oncologic outcome following combined pelvic allograft and total hip arthroplasty (THA) reconstruction of large pelvic bone defects following tumour resection. There were twenty-four patients with a minimum followup of fifteen months. The complication rate following hemipel-vic allograft and THA reconstruction of resection Types I+II and I+II+III was high, but when successful this reconstruction resulted in reasonable functional outcome. In comparison, the functional outcome after allograft and THA reconstruction of isolated Type II acetabular resections was better and more predictable.

Resection of large pelvic bone tumours often results in segmental defects with pelvic discontinuity and loss of the acetabulum. We reviewed the functional and oncologic outcomes following pelvic allograft and total hip arthroplasty (THA) reconstruction.

Reconstruction of large pelvic defects including the acetabulum using hemipelvic allograft and THA is associated with high complication rates, however when successful provides reasonable function. In comparison, the outcomes of allograft and THA for acetabular defects alone are better and more predictable.

A retrospective review of our prospectively collected database was undertaken. Minimum followup was fifteen months (15–167). Nineteen patients were hemipel-vic resections (twelve Type I+II and seven Type I+II+III, eleven cases including partial sacral resection) reconstructed by hemipelvic allograft and THA. Five patients had Type II acetabular resections, reconstructed with structural allograft, roof ring and THA.

Osteosarcoma and chondrosarcoma were the most frequent tumours. All patients required walking aids. In the hemipelvic group there were two early deaths (peri-operative haemorrhage and aplastic anaemia). In seven patients (37%) the allograft remained intact without infection but three required revision THA for loosening. For these seven patients the functional outcome scores were TESS 64%, MSTS87 17/35 and MSTS93 of 45% (mean fifty-two months.). There were nine cases of deep infection (47%) with three patients maintaining a functional implant. The nineteenth patient was revised following allograft fracture.

In the Type II acetabular group, three patients had no complications, and two patients dislocated. The average scores were TESS 78%, MSTS87 21/35 and MSTS93 64% (mean fifty-five months).

The outcome of complex acetabular reconstruction was evaluated in twenty-one patients who were confined to a wheelchair or bed because of pain from acetabular metastases. Reconstruction rings were used where bone loss exceeded 50% of the acetabulum. Six roof reinforcement-rings, eight ilioischial-rings and eight Harrington reconstructions were performed. All but two patients(90%) became ambulatory without pain. Median survival was nine months. Two patients underwent acetabular revision for recurrence. These results support the role of acetabular reconstruction for palliation of pain in appropriate patients with acetabular metastases.

Metastatic disease of the acetabulum is painful and disabling. Operative intervention is indicated in certain patients with pathologic fractures, and non-responders to adjuvant treatment. The functional outcome of hip arthroplasty with reconstruction rings was evaluated in twenty-one patients with acetabular metastases between 1989 and 2001. Preoperatively all patients were confined to a wheelchair or bed and used significant narcotic medications. Preoperative radiotherapy was employed in eighteen cases (90%) and 30% had undergone chemotherapy.

AAOS classification of the acetabular lesion revealed: six-type II, seven-type III and eight-type IV deficiencies. All cases required a reconstruction ring due to bone loss exceeding 50% of the acetabular dome. Six roof reinforcement rings, eight ilioischial rings and eight Harrington reconstructions with rings were performed in this group. Determination of the reconstructive technique was based on preoperative computerized tomography and intraoperative examination of the acetabular deficiency.

All but two patients (90%) became ambulatory without significant pain. Eleven patients used a walker or two canes and nine walked with one or no canes. Median survival was nine months and patients with visceral involvement had a shorter duration. Eight early post-operative complications developed in six patients (29%). In two patients the acetabular construct failed with cup migration due to locally recurrent disease; both were successfully revised.

The results of complex acetabular reconstruction for metastatic disease validate its role for palliation of pain and to improve ambulatory status. Preoperative planning with computerized tomography can assist in classifying acetabular bone loss and determining optimal reconstruction technique.

Two hundred and forty-one patients with extremity osteosarcoma presented to our institution between 1989 and August 2002, thirty-six of whom had a pathologic fracture. There were twenty-five limb salvage surgeries and ten primary amputations, with three limb salvage surgeries requiring secondary amputations. One patient had an unresectable tumor and was treated palliatively. At mean follow-up of 96.9 months there was one local recurrence and eighteen patients were alive without disease in the pathologic fracture group. There was no survival difference between the pathologic fracture group with no metastases at presentation and the non-pathologic fracture group with no metastases (119.4 months vs 134.3 months, log rank 0.83, p=0.36).

To examine the outcome of osteosarcoma patients that present with a pathologic fracture as compared to those patients without a pathologic fracture.

There was no significant difference in the rate of amputation vs limb salvage surgery in osteosarcoma patients that presented with a pathologic fracture as compared to those without. There was no difference in the two groups’ disease-free and overall survival, for those patients that presented without metastatic disease.

Presentation with a pathologic fracture in osteosarcoma does not preclude limb salvage surgery and is not a prognostic indicator for decreased survival.

Retrospective review of all patients presenting to our institution with extremity osteosarcoma between 1989 and August 2002.

There were two hundred and forty-one patients with extremity osteosarcoma, thirty-six of whom presented with a pathologic fracture. In the pathologic fracture group, there were nineteen males and seventeen females. Twenty-five were treated with limb salvage surgery, ten required a primary amputation and one was unre-sectable. Three limb salvage surgery patients required a secondary amputation. Sevenpatients presented with metastatic disease. Twenty-eight of the thirty-six patients received (neo) adjuvant chemotherapy. At last follow-up, eighteen patients were alive no evidence of disease (51.4%), three were alive with disease, eleven were dead of disease and three were deceased from other causes. There was one local recurrence (2.8%). Mean overall survival was 119.4 months (0–147.1) for patients with a pathologic fracture and no metastasis at presentation and 134.3 months (0–172.5) for patients with no pathologic fracture and no metastasis (log rank 0.83, p=0.36).

As patients live longer following treatment for soft tissue sarcomas, complications from treatment will continue to emerge. Predicting which patients are at risk allows for improved preoperative planning, treatment, and surveillance. The data presented here suggests that females greater than fifty-five years of age treated with high dose, postoperative radiotherapy in combination with limb salvage surgery for soft tissue sarcomas are at an increased risk of post irradiation fractures. Unlike previous reports, a significantly higher rate of fracture occurred in patients who received higher doses (60 or 66Gy) of radiation versus lower doses (50 Gy).

This retrospective study was performed to determine if the timing and dosage of radiotherapy are related to the risk of post radiation pathologic fracture following combined therapy for lower extremity soft tissue sarcomas. Three hundred sixty-four patients with sarcomas treated with external beam radiation therapy and limb salvage surgery were evaluated. High dose radiation was defined as 60 Gy or 66 Gy; low dose as 50Gy. Radiation timing schedules were preoperative, postoperative, or preoperative with a postoperative boost. Univariate and multivariate analysis was used to determine which factors were associated with fracture risk. Twenty- seven pathologic fractures occurred in twenty-three patients. Twenty- four fractures occurred in twenty patients who were treated with high dose radiation. Sixteen of these patients had postoperative radiation (fourteen patients received 66Gy, two received 60Gy), and four had pre-operative radiation with a postoperative boost (total dose = 66Gy). Three fractures occurred in three patients who received low dose preoperative radiation (50Gy). Both high dose radiation (versus low dose) (p=.001) and preoperative radiation (versus postoperative) (p =0.002) were associated with a risk of fracture. Findings in this study were consistent with previous reports in that females over fifty-five years of age who undergo removal of a thigh sarcoma combined with radiation therapy are at a higher risk of a pathologic fracture, and differs in that there was a significantly higher rate of fracture in patients who received higher doses (60 or 66Gy) of radiation versus lower doses (50 Gy), and when radiation therapy was given postoperatively versus preoperatively.

Forty-six patients with an uncemented proximal tibial endoprosthesis were reviewed following resection of a proximal tibial tumor. The mean age was thirty-four years and the majority were male. The most common malignant diagnosis was osteosarcoma. Oncologic and functional analysis was performed on these cases. At latest follow-up thirty of the patients remain alive with no evidence of disease and eleven had died. The most common complication was deep infection (7/46). Only six patients had mechanical prosthesis related complications. At latest follow up the average TESS score was 76.3 and MSTS score 75.5 with an average extensor lag of 6.5o.

To review the oncologic and functional results of a series of forty-six uncemented proximal tibia tumour replacements.

A retrospective review of our prospectively collected database revealed forty-six patients with an uncemented proximal tibial replacement following tumour excision. The data was analysed with respect to patient demographics, operative and prosthetic complications. Oncologic diagnosis and results and functional results were also reviewed.

The average age of the forty-six patients was thirty-four years (14–73) with thirty-three males and thirteen females. The most common diagnosis was osteosarcoma. There were four cases of benign GCT. At an average follow-up of 85.8 months (11–170), thirty were alive with no evidence of disease while eleven patients had died of their disease. Four patients were alive with evidence of disease at latest follow-up and one patient had died of unrelated causes.

The most common operative complication was infection (9/46) with seven of these being deep infections requiring prosthesis removal, followed by mechanical problems including stem fracture (3/46) and bushing failure (3/46) also requiring operative intervention.

Functional assessment revealed an average extensor lag of 6.5o with an average ROM of 83.6o, average TESS scores of 76.3 and MSTS 93 scores of 75.5.

Large series of uncemented proximal tibial endoprostheses are uncommon in the literature. In our series there is a low rate of aseptic loosening at an average seven year follow-up, but this is offset by problems including infection and prosthetic fracture. Overall the functional and oncologic results remain satisfactory.

Purpose: To determine the outcome of patients 80 years old and greater that were diagnosed with a primary soft tissue sarcoma and if these patients should be treated as aggressively as younger patients.

Methods: One-hundred two patients were retrospectively reviewed.Well differentiated liposarcoma and der-matofibrosarcoma were excluded.

Results: There were 52 males. Average age was 84 years (80–94). Malignant fibrous histiocytoma was most common (36 patients) followed by leiomyosarcoma (22 pts) and liposarcoma (17 pts). Tumors were superficial in 25 patients and deep in 75. The lower extremity was most frequent site(70 patients), 27 patients had upper extremity involvement and 9 had a back lesion. MSTS stages were IA 6 patients, IB 22 patients, IIA 55 patients, IIB 9 patients, III 1 patient, and was unknown for 9 cases. Lesions were larger than 5cm in 80%. Four patients had no surgery, 89 patients had limb salvage, and 8 patients underwent amputation. Thirty-two patients had pre-operative radiotherapy, 30 patients had post-operative radiation, and 3 patients received both. No patients were given chemotherapy. The average follow up was 24 months (0–107months). Seventeen patients experienced local recurrence. Thirty-one patients developed metastatic disease. At latest follow-up 49 patients were alive without disease, 21 patients were alive with disease, 22 patients died of their disease, 8 patients died of another cause and the final status was unknown for 2 patients.. The MSTS functional score pre-treatment was 24 (11–72) and 31 (20–77) one year following treatment.

Conclusions: Elderly patients with soft tissue sarcoma have a poor outcome. Taking into account their associated medical condition, this group should likely be managed as younger patients although chemotherapy has no role according to our experience Funding: Other Education Grant Funding Parties: CIHR,|Stryker Canada

Purpose: Endoprosthetic reconstruction of the distal femur is the preferred approach for patients undergoing resection of bone sarcomas. The traditional How-medica Modular Resection System, using a press-fit stem (HMRS or Kotz prosthesis, Stryker Orthopaedics, Mahwah, New Jersey, USA) has shown good long-term clinical success, but has also been known to incur complications such as stem fracture. The Restoration stem, as a part of the new Global Modular Resection System (GMRS, Stryker Orthopaedics, Mahwah, NJ, USA), is currently proposed for this same application. This stem has a different geometry and provides the advantage of decreased risk of fracture of the component. The goal of this study was to compare the HMRS and Restoration press-fit stems in terms of initial mechanical stability.

Methods: Six matching pairs fresh frozen adult femora were obtained and prepared using a flexible canal reamer and fitted with either a Restoration or HMRS press-fit stem distally. All constructs were mechanically tested in axial compression, lateral bending, and torsion to obtain mechanical stiffness. Torque-to-failure was finally performed to determine the offset force required to clinically fail the specimen by either incurring damage to the femur, the stem, or the femur-stem interface.

Results: Restoration press-fit stems results were: axial stiffness (average=1871.1 N/mm, SD=431.2), lateral stiffness (average=508.0 N/mm, SD=179.6), and torsional stiffness (average=262.3 N/mm, SD=53.2). HMRS stems achieved comparable levels: axial stiffness (average=1867.9 N/mm, SD=392.0), lateral bending stiffness (average=468.5 N/mm, SD=115.3), and torsional stiffness (average=234.9 N/mm, SD=62.4). For torque-to-failure, the applied offset forces on Restoration (average=876.3 N, SD=449.6) and HMRS (aver-age=690.5 N, SD=142.0) stems were similar. There were no statistical differences in performance between the two stem types regarding axial compression (p=0.97), lateral bending (p=0.45), or torsional stiffnesses (p=0.07). Moreover, no differences were detected between the groups when tested in torque-to-failure (p=0.37). The mechanism of torsional failure for all specimens was “spinning” (i.e. surface sliding) at the femur-stem interface. No significant damage was detected to any bones or stem devices.

Conclusions: These results suggest that the Restoration and HMRS press-fit stems may be equivalent clinically in the immediate post-operative situation. Funding: Commerical funding Funding Parties: Stryker Orthopaedics

In this paper, a retrospective review was undertaken of a large musculoskeletal tumour database to identify patients who presented with tumours of the foot and ankle. Soft tissue tumours occurred more frequently than bone tumours, and were also more frequently malignant than bone tumours. In contrast to the more recent trend towards limb-preserving surgery in other anatomic areas, malignant tumours of the foot and ankle were frequently unresectable and were treated with amputation.

Although the majority of extremity tumours that present to the orthopaedic surgeon are found in the proximal limbs or around the knee, tumours of the ankle and foot are also relatively common. The purpose of this study is to identify the frequency with which benign and malignant bone and soft tissue tumours occur in the foot and ankle and the oncologic and surgical outcomes of these patients.

A retrospective review of a large musculoskeletal tumor database in a tertiary referral center from the years 1986–2002 was undertaken. For oncologic outcomes, a minimum two-year follow up was considered.

A total of one hundred and sixteen bone and one hundred and seventy-one soft tissue tumours were identified. Seventy-seven bone tumours were benign and thirty-nine were malignant. Sixty-six soft tissue tumours were benign and one hundred and five were malignant. The most common benign bone tumour was giant cell tumour and osteosarcoma was the most common malignancy. Malignant fibrous histiocytoma was common in the distal leg but synovial sarcoma and clear cell sarcoma were more common in the foot. Twenty patients with bone malignancies (51%) and twenty-four with soft tissue sarcomas (23%) had amputation as definitive surgical management. Death from metastases occurred in 25% of patients with bone malignancies and 10% of soft tissue sarcomas.

At this center, the majority of bone tumours treated are benign but the majority of soft tissue tumours are malignant. Limb salvage is often not possible and amputation for local tumour control is necessary far more often than in other anatomic sites.

Lymph node metastasis in soft tissue sarcoma is considered to be a rare event (1.6–8.2%), From 1986 to 2001 1066 patients with extremity soft tissue sarcoma were treated surgically (+/− adjuvant therapy) at our institution.

Thirty-nine patients (3.6%) were identified with lymph node metastasis, most common histological subtypes were: Epitheliod sarcoma (3/15), rhabdomyosarcoma (4/21), clear cell sarcoma (2/18), and angiosarcoma (2/18).

Comparing expected five- year survivorship, we found that surprisingly in this study, extremity soft tissue sarcoma patients initially presenting with lymph node metastases had survival comparable to patients with high grade soft tissue sarcoma and no metastases.

To determine the outcome in patients with soft tissue sarcoma (STS) of the limbs that presented with lymph node metastasis (LNM) at diagnosis or developed them after it, comparing to all STS of limbs population that was treated at our center.

LNM in soft tissue sarcoma is considered to be a rare event (1.6–8.2%) with a devastating effect on the outcome,our study represent one of the largest reported cohorts, and suggest that agressive approach to LNM might contribute to survivorship.

Thirty-nine patients (3.6%) were identified with LNM along their course of disease

Thirteen patients presented with both lymphatic and systemic disease while twenty-six had isolated LNM at time of diagnosis. The mean follow-up from diagnosis of the primary tumor was 46.3 months (range zero to one hundred and forty-eight), and from diagnosis of lymph node involvement was 29.9 months (range zero to one hundred and twenty).

Expected five year survival in patients initially presenting with LNM was comparable to patients with high grade soft tissue sarcoma and no metastases.

From Jan’ 1986 to Dec’ 2001 1066 patients with extremity STS were treated at our institution.

Fifteen patients presented with LNM at time of first diagnosis, and twenty-four subsequently developed LNM after it.

Linear regression analysis and Kaplan-meier curves were used to compare expected survivorship in all patients with STS of limbs.

Comparing expected five- year survivorship, we found that Surprisingly in this study, extremity STS patients initially presenting with LNM had survival comparable to patients with high grade soft tissue sarcoma and no metastases.

Twenty-three patients with scapular chondrosarcomas presented to our institution between 1989 and 2003. Twenty-two were treated surgically while one presented with metastases and was treated palliatively. Fourteen patients underwent partial scapulectomy and eight had a Tikhoff-Linberg procedure. There were no local recurrences and only two patients have suffered a systemic recurrence at mean follow-up of fifty-two months. Mean functional scores were: TESS – 88, MSTS 1987 – 27 and MSTS 1993 – 84. Overall, the oncologic and functional outcome for these patients was excellent.

To examine the oncologic and functional outcome of patients treated for chondrosarcoma of the scapula.

Rates of local recurrence and metastasis for adequately treated chondrosarcomas of the scapula were very low and patient function was quite good.

Unlike previous reports in the literature, we found that scapular chondrosarcomas are highly amenable to limb salvage surgery and the oncologic and functional outcomes are excellent.

Retrospective review of our prospectively collected database for all patients treated surgically at our institution for scapular chondrosarcoma between 1989 and 2003.

Twenty-three patients presented with scapular chondrosarcoma, but one had spine metastases and was treated palliatively. Thus twenty-two patients were treated with limb salvage surgery. There were fourteen males and eight females. One patient presented as a local recurrence. Four tumors were grade one, sixteen grade two and two grade three. Eight were secondary to a primary benign primary tumor of bone. There were fourteen partial scapulectomies and eight Tikhoff-Linberg procedures. Surgical margins were positive in three cases. two patients received post-operative radiation and no patients received adjuvant chemotherapy. At last follow-up, twenty patients were alive with no evidence of disease (90.9%), one was alive with disease and one was dead of disease. There were two systemic recurrences and no local recurrences at an average follow-up of fifty-two months (range 12–113). Mean functional scores were: TESS – 88, MSTS – 1987 27 and MSTS 1993 – 84.

Introduction and Aims: Resection of large pelvic bone tumors often results in segmental defects with pelvic discontinuity and loss of the acetabulum. We reviewed the functional and oncologic outcomes following pelvic allograft and total hip arthroplasty (THA) reconstruction.

Method: A retrospective review of our prospectively collected database was undertaken. Minimum follow-up was 15 months (range 15–167 months). Nineteen patients were hemipelvic resections (12 Type I+II and seven Type I+II+III, 11 of these cases included partial sacral resection) reconstructed by hemipelvic allograft and THA. In comparison, five patients had Type II acetabular resections, reconstructed with structural allograft, roof ring and THA. Functional outcome was assessed by the Toronto Extremity Salvage score (TESS) and the Musculoskeletal Tumor Society scores (MSTS87 and MSTS93).

Results: Osteosarcoma and chondrosarcoma were the most frequent tumors. All patients required walking aids. In the hemipelvic group there were two early deaths (peri-operative haemorrhage and aplastic anaemia). In seven patients (37%), the allograft remained intact without infection but three required revision THA for component loosening. For these seven patients, the functional outcome scores were TESS 64%, MSTS87 17/35 and MSTS93 45% (mean follow-up 52 months). There were nine cases of deep infection (47%) with three patients maintaining a functional implant with antibiotic suppression. Of the remaining six patients with infection, four patients required hindquarter amputation, one patient required allograft removal and the allograft fragmented in the remaining patient. The 19th patient was revised following allograft fracture. Five patients sustained at least one allograft fracture.

In the Type II acetabular group, three patients had no complications, and two patients sustained dislocations. The average scores were TESS 78%, MSTS87 21/35 and MSTS93 64% (mean follow-up 55 months).

Conclusion: Reconstruction of large pelvic defects including the acetabulum using hemipelvic allograft and THA is associated with high complication rates, however when successful provides reasonable function. In comparison, the functional outcome after allograft and THA reconstruction of isolated Type II acetabular resections was better and more predictable.

Introduction and Aims: The management of bone defects created by Type 1 pelvic resections of large iliac bone tumors remains controversial. We reviewed the functional and oncologic outcome following Type I resection with and without bone reconstruction.

Method: A retrospective review of our prospectively collected database was undertaken analysing functional and oncological outcome of 16 patients with Type I pelvic resections. Minimum follow-up was 12 months (range 12–96 months). Outcome data was available on eight of 10 patients managed without reconstruction (WOR), with the residual ilium allowed to collapse back onto the sacrum, and on five of six patients with bone graft reconstruction (WR). Functional outcome was assessed by the Toronto Extremity Salvage score (TESS) and the Musculoskeletal Tumor Society scores (MSTS87 and MSTS93).

Results: Average age at surgery was 33 years (WOR) and 48 years (WR), (p=0.04), with average maximal tumor dimensions of 12cm and 9cm respectively (p=0.1). The most frequent diagnosis was chondrosarcoma. The WOR group average TESS, MSTS 87 and MSTS 93 scores were respectively 73%, 18/35 and 58% at an average of 50 months (range 24–96 months) compared to 69%, 21/35 and 51% at an average of 37 months (range 12–60 months) for the WR group. Thirty-three percent of WOR and 20% of WR patients did not require walking aids. Infection or wound necrosis occurred in 40% of WOR patients and 50% of WR patients. No local recurrences were identified.

Conclusion: Similar functional and oncologic outcome was achieved in both groups suggesting that bone reconstruction is not justified following Type I pelvic resection.

Aim: To explore the relationship between anatomical location in lower extremity soft tissue sarcoma and function as measured by the Musculoskeletal Tumour Society (MSTS 93) rating and Toronto Extremity Salvage Score (TESS).

Methods: 207 patients of median age 54 years (15 to 89) were reviewed. 58 tumours were superficial and 149 deep. Deep tumours were allocated to one of 9 locations based on anatomical compartments.

Results: Treatment of superficial tumours did not lead to significant changes in MSTS (mean 90.6% vs 93.0%, p=0.566) or TESS (mean 86.4% vs 90.9%, p=0.059). Treatment of deep tumours lead to significant reductions in MSTS and TESS (mean 86.9% vs. 83.0%, p=0.001. mean 83.0% vs. 79.4%, p=0.015). There were no significant differences in MSTS and TESS when overall scores were compared by anatomical location. Exploratory analysis of MSTS subscales showed groin tumours were more painful than others, and posterior calf tumours had the lowest scores for gait. TESS subscales analysis suggested groin and buttock tumours were associated with difficulty sitting, and groin tumours were associated with difficulty dressing. Further exploratory analysis suggested “conservative” surgical excision of low-grade liposarcomas in all locations was associated with a significant decrease in functional scores.

Conclusion: There is significant variation in MSTS and TESS subscale scores when anatomical locations are compared. The “conservative” surgery used in the treatment of low-grade fatty tumours in all locations has a significant impact on functional scores.

Introduction A literature review, supplemented by a small personal series of fractures in osteosarcoma, treated with internal fixation is presented.

Methods In a cooperative effort of the Musculoskeletal Tumor Society (2), retrospective data was gathered on fifty-two patients with osteosarcoma who had a pathologic fracture and on fifty-five matched patients with osteosarcoma who had not had a pathologic fracture.

Results From the literature review. Abudu et al (1) reviewed the Birmingham experience in 40 patients with pathological fractures from localised osteosarcoma of the long bones to determine the outcome of limb salvage in their management. All had had adjuvant chemotherapy. The authors undertook limb salvage in 27 patients and amputation in 13. The margins of resection were radical in five patients, wide in 26, marginal in six, and contaminated in three cases. Local recurrence developed in 19% of those treated by limb salvage and in none of those who had an amputation. The cumulative five-year survival of all the patients was 57% and in those treated by limb salvage or amputation it was 64% and 47%, respectively (p > 0.05). The authors concluded that limb-sparing surgery with adequate margins of excision can be achieved in many patients with pathological fractures from primary osteosarcoma without compromising survival, but the risk of local recurrence is significant.

From our retrospective study. The five-year estimated survival rates were 55% for the group with a pathologic fracture and 77% for the group without a fracture (p = 0.02). Eleven (37%) of the 30 patients with a fracture who were managed with limb salvage and 10 (45%) of the 22 patients with a fracture who were managed with an amputation died of the disease (p = 0.50). The performance of a limb-salvage procedure in patients with pathologic fracture did not seem to significantly increase the risk of local recurrence or death.

Conclusions Factors predictive of improved outcome, such as the response to chemotherapy and union of the fracture, should be taken into account when limb salvage is being considered. The limited Toronto experience with fracture fixation prior to chemotherapy and limb salvage will be discussed.

Introduction Morbidity associated with wound complications may translate into disability and quality-of-life disadvantages for patients treated with radiotherapy (RT) for soft tissue sarcoma (STS) of the extremities. Functional outcome and health status of extremity STS patients randomized in a phase III trial comparing pre-operative versus post-operative RT is described.

Methods One hundred and ninety patients with extremity STS were randomized after stratification by tumor size dichotomized at 10 cm. Function and quality of life were measured by the Musculoskeletal Tumor Society Rating Scale (MSTS), the Toronto Extremity Salvage Score (TESS), and the Short Form-36 (SF-36) at randomization, six weeks, and three, six, 12, and 24 months after surgery. One hundred and eighty-five patients had function data.

Results Patients treated with post-operative RT had better function with higher MSTS (25.8 v 21.3, P < .01), TESS (69.8 v 60.6, P =.01), and SF-36 bodily pain (67.7 v 58.5, P =.03) scores at six weeks after surgery. There were no differences at later time points. Scores on the physical function, role-physical, and general health sub-scales of the SF-36 were significantly lower than Canadian normative data at all time points. After treatment arm was controlled for, MSTS change scores were predicted by a lower-extremity tumor, a large resection specimen, and motor nerve sacrifice; TESS change scores were predicted by lower-extremity tumor and prior incomplete excision. When wound complication was included in the model, patients with complications had lower MSTS and TESS scores in the first two years after treatment.

Conclusions The timing of RT has minimal impact on the function of STS patients in the first year after surgery. Tumor characteristics and wound complications have a detrimental effect on patient function.

Introduciton In our experience, amputation is rarely indicated in osteosarcoma. Amputation is more frequently required in soft tissue sarcoma for the following reasons: 1) recurrent tumour in previously radiated field; 2) composite tissue involvement of soft tissue, bone, vessels and nerves; 3) size of lesion. We have measured functional outcome in bone and soft tissue sarcoma using a combination of clinimetric measures describing impairment and patient determined measures assessing disability (1,2).

Methods In a matched case-control study (3), 12 patients with amputation were matched with 24 patients treated by limb-sparing surgery on the following variables: age, gender, length of follow-up, bone versus soft-tissue tumor, anatomic site, and treatment with adjuvant chemotherapy. End points included the Toronto Extremity Salvage Score (TESS), a measure of physical disability; the Shortform-36 (SF-36), a generic health status measure; and the Reintegration to Normal Living (RNL), a measure of handicap.

Results Mean TESS score for the patients with amputations was 74.5 versus 85.1 for the limb-sparing patients. (p = .15). Only the physical function subscale of the SF-36 showed statistically significant differences, with means of 45 and 71.1 for the amputation versus limb-sparing groups, respectively (p = .03). The RNL for the amputation group was 84.4 versus 97 for the limb-sparing group (p = .05). Seven of the 12 patients with amputations experienced ongoing difficulty with the soft tissues overlying their stumps. There was a trend toward increased disability for those in the amputation group versus those in the limb-sparing group, with the amputation group showing significantly higher levels of handicap.

Conclusions These data suggest that the differences in disability between amputation and limb-sparing patients are smaller than anticipated. The differences may be more notable in measuring handicap.

Introduction Localised Langerhans-cell histiocytosis of bone (eosinophilic granuloma) is a benign tumour-like condition with a variable clinical course. Different forms of treatment have been reported to give satisfactory results. However, previous series all contain patients with a wide age range. Our aim was to investigate the effect of skeletal maturity on the rate of recurrence of isolated eosinophilic granuloma of bone excluding those arising in the spine.

Methods We followed-up 32 patients with an isolated eosinophilic granuloma for a mean of five years; 17 were skeletally immature.

Results No recurrences were noted in the skeletally immature group even after biopsy alone. By contrast, four of 13 skeletally mature patients had a recurrence and required further surgery.

Conclusions This suggests that eosinophilic granuloma has a low rate of recurrence in skeletally immature patients.

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

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

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

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

Localised Langerhans-cell histiocytosis of bone (eosinophilic granuloma) is a benign tumour-like condition with a variable clinical course. Different forms of treatment have been reported to give satisfactory results. However, previous series all contain patients with a wide age range. Our aim was to investigate the effect of skeletal maturity on the rate of recurrence of isolated eosinophilic granuloma of bone excluding those arising in the spine.

We followed up 32 patients with an isolated eosinophilic granuloma for a mean of five years; 17 were skeletally immature. No recurrences were noted in the skeletally immature group even after biopsy alone. By contrast, four of 13 skeletally mature patients had a recurrence and required further surgery. This suggests that eosinophilic granuloma has a low rate of recurrence in skeletally immature patients.