Background

The cemented mobile bearing metal backed low contact stress patellofemoral arthroplasty (LCS PFA) is a newer design belonging to the second generation of inlay type implant, based on the more successful knee arthroplasty model. The advantage is the patella can articulate with the trochlear implant as well as the femoral component of a total knee replacement (TKR).

Introduction

The results of a prospective study of primary bone grafting in a selective group of patients with High energy open fractures (Grade III) of limbs with communition or bone loss are presented.

Background: The literature on description and management of advanced fungating soft tissue tumours (FSST) is limited because of the rarity of cases. Recent advances in diagnostic resources and an increased awareness of the disease has made early recognition easier. Manchester Royal Infirmary is a Regional Sarcoma Centre in the North West of England. We describe our experiences in managing patients with FSST of the extremities.

Patients and Methods: Between 1997 and 2007, 18 patients presented with FSST of the extremities (13 involving the lower limb, and 5 involving the upper limb), and 1 patient with a sarcoma involving the scapular region (limb girdle). The cohort included 14 males and 5 females with a mean average age of 68.5 ± 13.7 years. Follow-up ranged from a minimum of 6 months to 10 years from the initial referral.

Results: The histological diagnosis was sarcoma in 15 patients, subclassified into spindle cell sarcoma (4), fibrous histiocytoma (2), pleomorphic sarcoma (3), liposarcoma (2), leiomyosarcoma (2), fibrosarcoma (1) and round cell sarcoma (1). In the remaining 3 patients immunohistochemistry studies confirmed a metastatic squamous cell sarcoma, a metastatic malignant melanoma and a metastasis from a poorly differentiated upper gastrointestinal malignancy. Lung metastases were present at the time of referral in 6 patients and developed later during follow-up in 4 patients.

For patients where curative surgery was an option, primary wide local excision (15 patients) or primary amputation (2 patients) was performed. The remaining 2 patients presented with unresectable disease due to the location and localised spread; an embolisation was performed for palliation in both cases. Revision surgery was needed in 9 patients for either a positive resection margin confirmed by histology, or a recurrence; these included 3 secondary amputations. A histologically proven recurrence occurred in 6 patients after an average of 15.8 (4 to 41) months. Local adjuvant radiotherapy was administered to 7 patients and a combination of radio–and chemotherapy was used in 2 patients for metastases. Mortality was 53% (9 patients) by the end of 36 months follow-up period.

Conclusion: Fungation in soft tissue tumours is a rare phenomenon and often a sign of locally advanced disease with a high grade nature. Patients present with either systemic spread, or have a tendency to develop metastases despite good local disease control. Primary wide local excision is difficult with a high chance of a positive margin; hence primary amputation may be better for local clearance. Tumour recurrence and revision surgery, however, is common. We report a mortality rate of > 50% at the end of 3 years from presentation to treatment.

Introduction: Radical excision and amputation are the surgical options for advanced soft tissue tumours (STS) of the limbs. The sheer size of these advanced tumours in relation to the limb makes limb sparing surgery difficult. The rate of positive margins is high and further management options are quite limited.

Patients & Methods: We have identified 17 patients (13 males, 4 females) with sarcomas with skin changes at presentation, including recurrences and primary referrals. The average age was 67 (37–83) years. 11 patients had lower limb tumours and 6 had upper limb tumours. All patients were managed either with radical excision or amputation. Post op radiotherapy and chemotherapy was used s adjuvants when appropriate. All patients were followed up with regular clinical and radiological assessments for recurrences and metastases. The results of adequacy of clearance, recurrences, metastases and overall survival are presented.

Results: The follow-up was an average of 30 (7–120) months. Two patients had primary amputations and 15 had wide excision. Four patients had distant metastases at the time of referral. Positive margins were identified in 8 of the 17 patients after primary surgery. 5 patients had a single recurrence and 3 patients had two recurrences. Eight patients needed revision surgery (3 amputations/5 wider excisions) for a positive margin or a recurrence. A total of 8 patients had metastases by 1 year. Overall disease free survival in this cohort was 20 (3–41) months.

Conclusion: We encountered a very high rate of positive margins with high morbidity which seems quite common after limb sparing surgery in fungating STS. Amputation comparatively attains better local disease control but probably does not affect the overall survival.

Introduction: Anterior knee pain is a very common presenting symptom. Fat pad syndrome is an uncommon and a difficult condition to manage. The diagnosis is usually reached after a period of physiotherapy and investigation to rule out the more common aetiologies of anterior knee pain.

Patients & Methods: All patients who underwent excision of the infrapatellar fat pad following a diagnosis of Fat pad syndrome are included. Each patient was evaluated to exclude patellofemoral problems and intraarticular pathologies as the cause of anterior knee pain. Each patient underwent MR imaging and all the excised specimens were sent for histological analysis.

Results: The MR imaging provided with the provisional diagnosis in all patients. All the specimens were examined by a single senior histopathologist to correlate with the provisional diagnosis. The histology confirmed Hoffa’s syndrome in 5 patients and in the remaining 15 patients a spectrum of rare diagnoses as suspected by Magnetic Resonance imaging.

The more notable conditions were two synovial sarcomas, three haemangiomas and a Giant cell tumour of the tendon sheath. All patients were treated successfully with complete excision. No recurrences were recorded at the end of 3 year follow-up and all patients were symptom free.

Conclusion: The work up of a patient with suspected infrapatellar fat pad syndrome must include MR imaging and the exact underlying pathology should be confirmed with histological analysis of the excised fat pad as the rare causes include soft tissue malignancy.

Introduction: PVNS is a benign proliferative disorder of the synovium presenting as local or diffuse variants. The condition commonly involves the knee with a slow and indolent progress.

Case series:

Presented with anterior knee pain. Examination revealed supra-patellar fullness and tenderness. MRI scan showed a suspicious soft tissue tumour. Histology confirmed PVNS after excision biopsy.

Conclusion: This case series aims to highlight the complexities in diagnosing PVNS. It should be a differential diagnosis of any kind of soft tissue problem especially around the knee. Immunohistochemistry may be useful. Multiple recurrences is a problem; adjuvant therapy may be indicated in resistant cases.