Talar body fractures are high energy intraarticular injuries that are best management by anatomical reduction and secure fixation to improve outcomes. The talus is relatively inaccessible surgically and requires extensive soft tissue dissection and/or osteotomies to gain adequate open visualisation. There are a small number of case reports on arthroscopic assisted fixation in the literature. This case series reports on the technique and early outcomes of six patients all of whom presented with significant intraarticular displacement and who were managed entirely arthroscopically. The fractures were of the main body of the talus involving the ankle and subtalar joints and all had preoperative CT scans. All six patients underwent posterior ankle and subtalar arthroscopy with cannulated screws used to stabilise the fractures after reduction. Visualisation of the fracture reduction was excellent. After 10 days in a backslab, the patients were protected in a boot and encouraged to actively move their ankles. Weight bearing was permitted once union appeared complete. There were no early complications of infection, avascular necrosis or VTE. There was one patient that had a non-clinically significant migration of a screw. Two patients were lost to follow up early due to being visitors. The mean length of follow up was 12 months in the remainder. The remaining four patients all returned to their preoperative level of activity. All had demonstrable subtalar stiffness. There was no early post-traumatic arthritis. This series represents the largest so far published. The main flaw in this report is the lack of long term follow up. While this report cannot state superiority over open techniques it is a safe, effective and acceptable technique that has significant conceptual benefits.
Vancomycin is commonly added to acrylic bone cement during revision
arthroplasty surgery. Proprietary cement preparations containing
vancomycin are available, but are significantly more expensive.
We investigated whether the elution of antibiotic from ‘home-made’
cement containing vancomycin was comparable with more expensive
commercially available vancomycin impregnated cement. A total of 18 cement discs containing either proprietary CopalG+V;
or ‘home-made’ CopalR+G with vancomycin added by hand, were made.
Each disc contained the same amount of antibiotic (0.5 g gentamycin,
2 g vancomycin) and was immersed in ammonium acetate buffer in a
sealed container. Fluid from each container was sampled at eight
time points over a two-week period. The concentrations of gentamicin
and vancomycin in the fluid were analysed using high performance
liquid chromatography mass spectrometry.Aims
Materials and Methods
The long term biological effects of wear products
following total hip arthroplasty (THA) are unclear. However, the indications
for THA are expanding, with increasingly younger patients undergoing
the procedure. This prospective, randomised study compared two groups of patients
undergoing THA after being randomised to receive one of two different
bearing surfaces: metal-on-polyethylene (MoP) n = 22 and metal-on-metal
(MoM) n = 23. We investigated the relationship between three variables:
bearing surface (MoP Our results demonstrated significantly higher mean cobalt and
chromium (Co and Cr) blood levels in the MoM group at all follow-up
points following surgery (p <
0.01), but there were no significant
differences in the chromosomal aberration indices between MoM and
MoP at two or five years (two years: p = 0.56, p = 0.08, p = 0.91, p
= 0.51 and five years: p = 0.086, p = 0.73, p = 0.06, p = 0.34)
for translocations, breaks, loss and gain of chromosomes respectively.
Regression analysis showed a strong linear relationship between
Cr levels and the total chromosomal aberration indices in the MoM
group (R2 = 0.90016), but this was not as strong for
Co (R2 = 0.68991). In the MoP group, the analysis revealed
a poor relationship between Cr levels and the total chromosomal
aberration indices (R2 = 0.23908) but a slightly stronger
relationship for Co (R2 = 0.64292). Across both groups,
Spearman’s correlation detected no overall association between Co and Cr
levels and each of the studied chromosomal aberrations. There remains
no clear indication which THA bearing couple is the most biocompatible,
especially in young active patients. While THA continues to be very
successful at alleviating pain and restoring function, the long-term
biological implications of the procedure still require further scrutiny. Cite this article:
We reviewed the outcome of 69 uncemented, custom-made,
distal femoral endoprosthetic replacements performed in 69 patients
between 1994 and 2006. There were 31 women and 38 men with a mean
age at implantation of 16.5 years (5 to 37). All procedures were
performed for primary malignant bone tumours of the distal femur.
At a mean follow-up of 124.2 months (4 to 212), 53 patients were
alive, with one patient lost to follow-up. All nine implants (13.0%)
were revised due to aseptic loosening at a mean of 52 months (8
to 91); three implants (4.3%) were revised due to fracture of the
shaft of the prosthesis and three patients (4.3%) had a peri-prosthetic
fracture. Bone remodelling associated with periosteal cortical thinning
adjacent to the uncemented intramedullary stem was seen in 24 patients
but this did not predispose to failure. All aseptically loose implants
in this series were diagnosed to be loose within the first five
years. The results from this study suggest that custom-made uncemented
distal femur replacements have a higher rate of aseptic loosening
compared to published results for this design when used with cemented
fixation. Loosening of uncemented replacements occurs early indicating
that initial fixation of the implant is crucial. Cite this article:
The National institute of Health and Clinical Excellence (NICE) guidelines for thromboprophylaxis following lower limb surgery and plastercast immobilisation recommend pharmacological prophylaxis be considered until the cast is removed. These guidelines have been extrapolated from data for hip and knee arthroplasty, and trauma studies. Recent studies have questioned the validity of these guidelines. At Portsmouth, low molecular weight heparin (LMWH) is prescribed for 14 days following surgery in high risk patients. The protocol predates the most recent NICE guidance. We set out to investigate whether this was a safe method of thromboprophylaxis following elective hindfoot surgery. A retrospective audit of all patients undergoing hindfoot surgery between 01/01/10 and 31/12/12 was performed. All patients were immobilised in a POP backslab and prescribed 14 days of LMWH. All patients were reviewed at 2 weeks and converted to a full cast or boot. Immobilisation was continued for between 6 and 12 weeks. A list of all patients who had undergone investigation for deep vein thrombosis at Queen Alexandra hospital from 01/01/10 to 28/03/13 was obtained from the VTE investigation department. The two lists were cross referenced to identify any DVTs occurring following hindfoot surgery and plastercast immobilisation.Introduction:
Methods:
Hallux valgus is a common condition often leading to significant symptoms. However, its correction has recently been suggested, to be a procedure of limited clinical value. Scarf osteotomy is one of the most commonly performed operations for hallux valgus correction. Although technically demanding, it is powerful in its capacity to correct the hallux valgus deformity and sufficiently robust with internal fixation to allow early weight bearing. We prospectively collected data for consecutive scarf osteotomies between 2008 and 2011. Preoperative and 6 week postoperative assessment was made using radiographic measurements HVA (hallux-valgus angle) and IMA (inter metatarsal angle). We evaluated 130 scarf osteotomies. The mean HVA improved from 29.5 pre-operatively to 12.6 post correction. The mean IMA improved from 12.4 pre-operatively to 8.1 post correction. The AOFAS hallux scores improved from an average of 55 pre op to 79 post operation. The results suggest that hallux valgus correction does have clinical value and that scarf osteotomy is a reproducible procedure, with a generally good to excellent results in the short term.
The purpose of this study was to quantify the effect of BMP 7 and recombinant Human (rh) BMP 2 at stimulating bone formation and bone union in trauma and elective orthopaedic surgery. We retrospectively reviewed the use of BMP 7 and rhBMP 2 at the Queen Alexandra Hospital between 2005 and 2012. The minimum follow up was three months. Inclusion criteria consisted of all patients who had failed to achieve previous surgical bone union and then received either BMP 7 or rhBMP 2 in an attempt to achieve bone union (as part of revision surgery). Patients who have not completed a minimum of three months follow up were excluded. Bone union was defined clinically and radiographically. 17 patients were included (9 elective and 8 trauma patients). 9 patients received BMP2 (8 trauma and 1 elective) and 8 received rhBMP 2 (all elective). The average number of attempted fusions with autogenous bone graft prior to the use of BMP agent in the trauma and elective group was 2 and 3 respectively. The overall union rate following the use of BMP was 94.1%. 1 patient from the BMP 7 group (trauma patient) failed to unite. The union rate with BMP 7 and rhBMP 2 was 88.9% and 100% respectively. Following the use of BMP the average time to union was 117 days (BMP 7 124 days and rhBMP 2 112 days).Methods
Results
Local recurrence of tumours along the biopsy tract is a known complication of percutaneous closed needle biopsy. Correct surgical management requires preoperative identification and excision of the biopsy tract at time of surgery. These tracts become increasingly difficult to identify with time, leading to risk of inadequate excision of the biopsy tract and recurrence of the tumour at the biopsy site. In a prospective study conducted at our institution, 22 of the 45 patients with musculoskeletal tumours (49%) had unidentifiable biopsy sites, with a mean duration between biopsy and definite surgery being 98 days (range 13–164 days). We concluded that identification of the biopsy site was more difficult after 50 days. Radiotherapy related scar formation and the longer time duration between biopsy and definite surgery in patients requiring neoadjuvant therapy made identification more unlikely. Consequently, all patients received India ink skin tattoo to mark the biopsy site at the time of the needle biopsy. 56 patients were then prospectively reviewed on the day of surgery to identify the biopsy site.Introduction
Materials/Methods
Patients with skeletal dysplasia are prone to developing advanced degenerative knee disease requiring total knee replacement (TKR) at a younger age than the general population. TKR in this unique group of patients is a technically demanding procedure due to the bone deformity, flexion contracture, generalised hypotonia and ligamentous laxity. We set out to retrospectively review the outcome of 11 TKR's performed in eight patients with skeletal dysplasia at our institution using the SMILES custom-made rotating-hinge total knee system. There were 3 males and 5 females with mean age 57 years (range, 41–79 years), mean height 138 cm (range, 122–155 cm) and mean weight 56 kg (range, 40–102 kg). Preoperative diagnoses included achondroplasia, spondyloepiphyseal dysplasia, pseudoachondroplasia, multiple epiphyseal dysplasia, morquio syndrome, diastrophic dysplasia and Larson's Syndrome. Patients were followed clinically and radiographically for a mean of 7 years (range, 3–11.5 years). Knee pain and function improved in all 11 joints. Mean Knee Society clinical and function scores improved from 24 (range, 14–36) and 20 points (range, 5–40) preoperatively to 68 (range, 28–80) and 50 points (range, 22–74) respectively at final follow-up. Four complications were recorded (36%), including a patellar fracture following a fall, a tibial periprosthetic fracture, persistent anterior knee pain and a femoral component revision for aseptic loosening. Our results suggest that custom rotating-hinge TKR in patients with skeletal dysplasia is effective at relieving pain, optimising movement and improving function. It compensates for bony deformity and ligament deficiency and reduces the need for corrective osteotomy. Patellofemoral joint complications are frequent and functional outcome is worse than primary TKR in the general population. Submission endorsed by Mr Peter Calder, Consultant Orthopaedic Surgeon and Society member
Somatosensory evoked potential (SSEP) monitoring allows for assessment of the spinal cord and susceptible structures during complex spinal surgery. It is well validated for the detection of potential neurological injury but little is known of surgeon's responses to an abnormal trace and its effect on neurological outcome. We aimed to investigate this in spinal deformity patients who are particularly vulnerable during their corrective surgery. Our institutional neurophysiology database was analysed between 1st October 2005 and 31st March 2010. Monitoring was performed by a team of trained neurophysiology technicians who were separate from the surgical team. A significant trace was defined as a 50% reduction in trace amplitude or a 10% increase in signal latency. Patients suffering a significant trace event were examined post-operatively by a Consultant Neurologist who was separate from the surgical team.Introduction
Methods
Sixty eight consecutive patients underwent proximal humeral replacement with a fixed fulcrum massive endoprosthesis, for tumour, between 1997 and 2007. The mean age was 46 years, (7–87). Ten patients were lost to follow up and 16 patients died. The 42 surviving patients were assessed using the Musculoskeletal Tumour Society (MSTS) Score and the Toronto Extremity Salvage Score (TESS). The mean MSTS score was 72.3% and the mean TESS was 77.2%. Four of 42 patients received a new constrained humeral liner to reduce the risk of dislocation. This sub group of 4 patients had a mean MSTS score of 77.7% and a mean TESS of 80.0%. Endoprosthetic replacement for tumour of the proximal humerus using this prosthesis is a reliable operation yielding good functional results without the documented problems of unconstrained prostheses. The performance of this prosthesis is expected to improve further with the new constrained humeral liner.
Percutaneous biopsies can lead to seeding of tumour cells along the biopsy tract. Correct surgical management requires preoperative identification and excision of the biopsy tract at time of surgery. These tracts become increasingly difficult to identify with time, leading to risk of inadequate excision of the biopsy tract and recurrence of the tumour at the biopsy site. We conducted a prospective study involving 45 patients who had tissue biopsies for bone and soft tissue tumours between February and May 2008. All the biopsies were performed by consultant radiologist under ultrasound or CT guidance. Case note analysis, patient history and examination at the time of surgery were used to collect data. 23 of 45 patients had accurate identification of the biopsy tract by the surgeon at the time of excision. The mean time between biopsy and excision was 52 days (range 6–140). 22 of 45 patients had unidentifiable biopsy site, with the mean time between biopsy and excision being 98 days(range 13–164) p=0.0004(paired t test). All 4 patients who received post-biopsy radiotherapy had unidentifiable biopsy site tract (mean duration 104 days) and 11 of the 18 patients who underwent neoadjuvant chemotherapy had an unidentifiable biopsy tract (mean duration 108 days). We concluded that identification of biopsy site was more difficult after 50 days, especially in patients who underwent radiotherapy and chemotherapy. Following this study, all the patients who had biopsies of tumours had the site marked with India ink tattoo. We, then prospectively reviewed 36 patients between July and September 2010 who underwent excision of bone and soft tissue tumours and had their biopsy sites marked with India ink tattoo. After needle biopsy, one drop of the dye was applied at the site of the biopsy. This was taken up by capillary action beneath the dermis and remained present until the patient returned for their definitive surgery. The biopsy site was easily identifiable by the patients and the operating surgeon in all 36 patients. The mean time between biopsy and surgery was 77 days (range 10–299 days). Tattooing of the skin enabled the surgeon to accurately excise the biopsy tract along with the tumour. We recommend this technique of tattooing of the biopsy site with India ink, as it is safe, easily recognisable and permits accurate excision of the tract (including the tattoo), therefore preventing biopsy tract recurrence.
Evidence suggests that intra-operative spinal cord monitoring is sensitive and specific for detecting potential neurological injury. However, little is known about surgeons' responses to trace changes and the resultant neurological outcome. To examine the role of intra-operative somatosensory evoked potential (SSEP) monitoring in the prevention of neurological injury, specifically sensitivity and specificity, and whether the abnormalities were reversible.Introduction
Objective
Extendable proximal femoral replacements(PFR) are used in children with bone tumours in proximity to the proximal femoral physis, previously treated by hip disarticulation. Long-axis growth is preserved, allowing limb salvage. Since 1986, survival outcomes after limb salvage and amputation have been known to be equal. Retrospective review of all patients <16years undergoing extendable PFR at Royal National Orthopaedic Hospital (UK) between 04/1996 and 01/2006, recording complications, failures, procedures undertaken and patient outcomes.Background
Method
Extendable partial femoral replacements (EPFR) permit limb salvage in children with bone tumours in proximity to the physis. Older designs were extended through large incisions or minimally invasive surgery. Modern EPFR are lengthened non-invasively. Lengthening improves functional score (Futani, 2006) but has been associated with complications including infection (Jeys, 2005). This study is the first to look specifically at the relationship between EPFR lengthening and complications. Retrospective review of 51 paediatric (<16 years) oncology patients undergoing primary (1 °) EPFR (minimally/noninvasive) between 06/1994 and 01/2006. Exclusions: 1 patient with 5cm extension without medical intervention and 5 patients with incomplete data.Background
Method
The development of extendable prostheses has permitted limb salvage surgery in paediatric patients with bone tumours in proximity to the physis. Prostheses are extended to offset limb length discrepancy as the child grows. Aseptic loosening (AL) is a recognised complication. The implant stem must fit the narrow paediatric medullary canal and remain fixed while withstanding growth and increasing physical demands. Novel designs incorporate a hydroxyapatite (HA) coated collar that manufacturers claim improves bony ongrowth and stability, providing even stress distribution in stem and shoulder regions and providing a bone-implant seal, resulting in decreased AL and prolonged survival. This study aims to assess whether there is a relationship between bony ongrowth onto a HA collar and AL. Hypothesis: Bone ongrowth onto the HA collar of extendable prostheses is associated with more stable fixation and less AL despite patient growth. Retrospective review of 51 primary partial femoral extendable prostheses implanted over 12 years from 1994–2006 (followed up to death at a mean of 2.5±2.2 years or last clinical encounter at a mean of 8.6 years) and 24 subsequent revisions, to ascertain failure rate and mode, together with a cohort study reviewing bony ongrowth onto the HA coated collar in 10 loose and 13 well fixed partial femoral, humeral and tibial implants. Patient growth was measured as a change in bone:implant-width ratio.Background/Aims
Methods
The surgical treatment of bone tumours can result in large perioperative blood loss due to their large sizes and hypervascularity. Preoperative embolisation has been successfully used to downgrade vascularity, thus reducing perioperative blood loss and its associated complications. Prior to embolization era, blood loss as high as 18,500mL have been reported peri-opratively. Twenty-six patients with a variety of bone tumours (average size 10.5×7.5×5.5cm), who underwent pre-operative embolisation between 2005 and 2009, were retrospectively studied. The group comprised of 17 females and 9 males. Their mean age was 38 years old. All patients underwent surgical resection within 48 hours of embolization. Mean blood loss was 796mL and required on average 1.1units of blood. We experienced no complications. Pre-operative arterial embolisation of large, richly vascular bone tumours in anatomically difficult positions, is a safe and effective method of downstaging vascularity and reducing blood loss.
Sacral tumours are rare and can present difficult diagnostic and therapeutic challenges even at an early diagnosis. Surgical resection margins have a reported prognostic role in local recurrence and improved survival. Successful management is achieved within a specialist multidisciplinary service and involves combination chemotherapy, radiotherapy and surgery. We present our experience of patients with sacral tumours referred to our unit, who underwent total and subtotal sacrectomy procedures. Between 1995 and 2010, we identified twenty-six patients who underwent a total or subtotal sacrectomy operation. Patients were referred from around the United Kingdom to our services. We reviewed all case notes, operative records, radiological investigations and histopathology, resection margins, post operative complications, functional outcomes and we recorded long-term survival outcomes. Patients who were discharged to local services for continued follow up or further oncological treatment were identified and information was obtained from their general practitioner or oncologist. We reviewed the literature available on total sacrectomy case series, functional outcomes and soft tissue reconstruction. We reviewed 26 patients, 16 male and 10 female, with a mean age at presentation of 53.4 years (range 11–80 years). Duration of symptoms ranged from 2 weeks to 6 years; lower back pain and sciatica were amongst the most common presenting features. Histological diagnoses included chordoma, Ewing's, malignant peripheral nerve sheath tumour, chondromyxoid fibroma, spindle cell sarcoma, synovial sarcoma, chondrosarcoma. A combined approach was used in two-thirds of patients and most of these patients had a soft tissue reconstruction with pedicled vertical rectus myocutaneous flap. Complications were categorised into major and minor and subdivided into wound, bladder and bowel symptoms. Wound complications and need for further intervention were more common amongst the patient group who did not have simultaneous soft tissue reconstruction at operation. All patients had a degree of bladder dysfunction in the early postoperative period. We present survivorship curves including recurrence and development of metastases.Materials and Methods
Results
The aim of this study is to investigate whether MoM implants result in more chromosome aberrations and increased blood metal ions postoperatively whe compared to MoP implants. MoM arthroplasties are being inserted in increasing numbers of younger patients due to the increased durability and reduced requirements for revision in these implants. Recent studies have raised many concerns over possible genotoxicity of MoM implants. This is a prospective study of patients who have undergone elective total hip replacement, they were selected and then randomised into two groups. Group A received a MoP implant and group B received a MoM implant. Patients are reviewed pre-operatively (control group), at 3 months, 6 months, 1 year and 2 years post-operatively. On each occasion blood tests are taken to quantify metal ion levels (chromium, cobalt, titanium, nickel and vanadium) using HR-ICPMS method and chromosome aberrations in T lymphocytes using 24 colour fluorescent in situ hydridisation (FISH). 51 patients have been recruited to date, 23 of whom had MoP prosthesis and 28 a MoM. 47 of these had their 1 year follow-up with blood analysis and 38 have had 2 year follow up. There appeared to be a bedding period for both MoM and MoP groups, with an increase in metal ion release. The blood concentration of chromium, cobalt and titanium rise significantly in the MoM group at the 2 year stage. Chromosome aberrations occurred in both groups. Both the MoM and MoP groups showed increase frequency of aneuploidy aberrations and structural damage. The greatest increase in metal ion levels occurred at the 1 to 2 year interval corresponding to significant rise in chromosome aberrations. Preliminary results of this study show that the levels of chromium, cobalt and titanium are significantly higher in the MoM group compared to the MoP group. This corresponds to increases in chromosome aberrations in the groups with increases in structural chromosome damage after two years.
Following bone tumour resection, lower limb reconstruction results in leg-length discrepancy in skeletally immature patients. Previously, minimally invasive endoprostheses have been associated with a high risk of complications including joint stiffness, nerve injury, aseptic loosening and infection. The purpose of this study was to examine the outcome of the Stanmore non-invasive extendible endoprostheses used in our institution between 2002 and 2009 and compare them with implants used in the past. Fifty-five children with a mean age of 11.4 years (5 to 16) underwent limb reconstruction with thirty-three distal femoral, two total femoral, eight proximal femoral and twelve proximal tibial implants. Forty-six endoprostheses were lengthened in clinic without anaesthesia using the principle of electromagnetic induction. Patients were assessed using the Musculoskeletal Tumour Society Score (MSTS) and the Toronto Extremity Salvage Score (TESS).Introduction
Methods
The proximity of the superior tibiofibular articulation to neurovascular structures makes the management of extraosseous tumours of the proximal fibula challenging in bone tumour surgery. The aim of study is to establish whether the recurrence rates are higher in this anatomical area compared to data that already exists in publication for bone tumours throughout the appendicular skeleton. A retrospective study of all patients treated for Ewing's tumours and osteosarcoma at a regional bone tumour unit between January 1995 and December 2009 was conducted.Introduction
Method
Primary bone tumours of the distal radius are rare, while it remains the third commonest site for primary lesions and recurrences of Giant Cell Tumours (GCT). The functional demands on the hand make reconstruction of the wrist joint following the excision of distal radius, particularly challenging. A single-centre retrospective study, reporting the functional and oncological outcomes of six patients (4 males, 2 females - mean age of 53 (22 to 79)) who underwent a custom-made endoprosthetic replacement of the distal radius with arthrodesis at our institution, during 1999 - 2010. Five patients were diagnosed with primary bone sarcoma of the distal radius (4 GCTs, 1 osteosarcoma) and another had a metastatic lesion from a primary renal cell carcinoma. The diagnosis was confirmed by needle biopsy in all cases. We assessed the patients' functional outcomes using the Musculoskeletal Tumour Society scoring system (MSTS) and the Toronto Extremity Salvage Score (TESS).Introduction
Methods
Sixty eight consecutive patients underwent proximal humeral replacement with a fixed fulcrum massive endoprosthesis for tumour between 1997 and 2007. The mean age was 46 years (7-87). Ten patients were lost to follow up and 16 patients died. The 42 surviving patients were assessed using the Musculoskeletal Tumour Society (MSTS) Score and the Toronto Extremity Salvage Score (TESS). The mean MSTS score was 72.3 % and the mean TESS was 77.2 %. Four of 42 patients received a new constrained humeral liner to reduce the risk of dislocation. This sub group of 4 patients had a mean MSTS score of 77.7 % and a mean TESS of 80.0%. Endoprosthetic replacement for tumour of the proximal humerus using this prosthesis is a reliable operation yielding good functional results without the documented problems of unconstrained prostheses. The performance of this prosthesis is expected to improve further with the new constrained humeral liner.
Primary Care Trusts across the country are being encouraged to ration service provision due to austerity measures. Obesity has been suggested as a rationing tool with poor clinical outcomes sited as justification. There is, however, a lack of evidence in the literature pertaining to clinical outcomes post elective foot and ankle surgery in patients with an increased Body Mass Index (BMI). All patients undergoing elective foot and ankle surgery at Queen Alexandra Hospital, Portsmouth are entered into a prospective database, which includes their BMI at time of assessment in clinic. From this, we analysed the notes of all patients with a BMI ≥30, excluding any not operated on between July 2007 and August 2009 or with a BMI of <30 at time of surgery, to determine whether there was an increased incidence of peri- or post-operative complications. Included in the study were 109 patients with a mean age of 54 (range 21 - 79). Female patients accounted for 63% of those notes reviewed and the mean BMI was 34 (range 30 - 50). A mixture of hindfoot and forefoot procedures were carried out (20 different procedures). Median length of stay was 0 nights (range 0 – 15 days). The causes for excessive length of stays (>4 nights) included a pre operative Lower Respiratory Tract Infection missed prior to intubation and the initiation of CPAP post operatively in a patient with known Obstructive Sleep Apnoea. We found 3 cases of post operative Venous Thrombo-embolism within 3 months of surgery and 1 proven wound infection in a non-insulin dependent diabetic patient. Also noted were 3 non-unions, all requiring further surgery. Based on our historical evidence of infective and thrombo-embolic complications in patients with a BMI <30, we conclude that peri- and post-operative complications in obese patients occur no more frequently than in a patient population with a BMI <30.
There is very limited literature available on the use of prosthetic replacement in the treatment of primary and secondary tumours of the radius. In the past these were treated with vascularised and non-vascularised autografts which had associated donor site morbidity, problems of non union, graft or junctional fractures and delayed return to function. Our study is a mid to long term follow-up of implant survivorship and the functional outcome of metal prosthetic replacement used for primary and metastatic lesions of radius. We had 15 patients (8 males:7 females) with a mean age of 53 years. 8 patients underwent proximal radial replacement, 2 with mid-shaft radial replacement and 6 patients had distal radial replacements with wrist arthrodesis. The indications for replacement included metastatic lesions from renal cell carcinoma, primary giant cell tumours, ewings' sarcoma, chondroblastoma, radio-ulnar synostosis and benign fibrous histiocytoma. The average follow up was 5 years and 6 months (range 3 months - 18 years). Four patients died as a result of dissemination of renal cell carcinoma and two patients were lost to follow-up. There were no complications with the prosthesis or infection. Clinically and radiographically there was no loosening demonstrated at 18 years with secure fixation of implants. Two patients developed interossoeus nerve palsies which partially recovered. Functional outcomes of the elbow were assessed using the Mayo performance score with patients achieving a mean score of 85 postoperatively (range 65-95). All but one patient had full range of motion of the elbow. The patient with radio-ulnar synostosis had a 25 degree fixed flexion pot-operatively. Although the distal radial replacements had decreased range of movements of the wrist due to arthrodesis, they had excellent functional outcomes. Only one patient required revision surgery due to post-traumatic loosening of the implant. Our results of the use of endoprosthetic replacement of radius in the treatment of tumours are encouraging with regards to survivorship of the implant and functional outcome. This type of treatment results in an early return to daily routine activties, good functional outcome and patient satisfaction.
The aim of this study is to investigate whether Metal-on-Metal (MoM) implants result in more chromosome aberrations and increased blood metal ions post-operatively when compared to Metal-on-Polyethylene (MoP) implants. Metal-on-metal arthroplasties are being inserted in increasing numbers of younger patients due to the increased durability and reduced requirement for revision in these implants. Recent studies have raised many concerns over possible genotoxicity of MoM implants. This is a prospective study of patients who have undergone elective total hip replacement, they were selected and then randomised into two groups. Group A received a MoP implant and group B received a MoM implant. Patients are reviewed pre-operatively (control group), at 3 months, 6 months, 1 year and 2 years post-operatively. On each occasion blood tests are taken to quantify metal ion levels (chromium, cobalt, titanium, nickel and vanadium) using HR-ICPMS method and chromosome aberrations in T lymphocytes using 24 colour fluorescent in situ hybridisation (FISH). 53 patients have been recruited to date. 24 of whom had MoP prosthesis and 29 a MoM. 37 of these have had their one year follow-up with blood analysis and 14 have had 2 year follow up. Cobalt and chromium concentration increased during the first 6 months in both MoM and MoP groups, in the MoM group the chromium levels were twice that of MoP group and 12x that of the preoperative samples. Chromosome aberrations occurred in both groups. At 6 months both the MoM and MoP groups showed increase frequency of aneuploidy aberrations with further increases after one year. Structural damage in the form of translocations occurred in the MoM group after one year, but not in the MoP group, by two years there was a profound increase in translocations Preliminary results of this study show that the levels of chromium and cobalt are significantly higher in the MoM group compared to the MoP group. This corresponds to increases in chromosome aberrations in the groups with increases in structural chromosome damage after two years.
Infected mega-endoprostheses are difficult to treat with systemic antibiotics due to encapsulation of the implant by fibrous tissue, formation of biofilms and antibiotic resistant bacteria. Modifying the implant surface by incorporating a bactericidal agent may reduce infection. Infection rates are typically in the range of 8% to 30%. This study describes a novel process method of “stitching-in” ionic silver into the implant surface, A novel process has been developed to “stitch in” ionic silver into the upper surface of titanium alloy (Ti6Al4V). The process produces a modification by anodisation of the titanium alloy in dilute phosphoric acid, followed by absorption of silver from an aqueous solution. The engineered surface modification is therefore integral with the substrate and loaded with silver by an ion exchange reaction. Using this technique the maximum inventory of silver for typical a mega-prosthesis is 6mg and this is greater than 300 times lower than the No Observable Adverse Affects Level (NOAEL). Scanning electron microscopy revealed that the silver was concentrated in pits and forming reservoirs of ionic silver exposed to the body tissues. Laboratory-based studies focusing on the safety and efficacy of silver as a bactericidal agent have included investigation into cytotoxicity using fibroblast and osteoblast cell lines, the impact of silver in reducing corrosion and laboratory testing to establish if the modified surface has an effect on the wear and mechanical characteristics. A range of fatigue, static, tensile pull off tests were performed. The silver elution profiles for both silver loaded and HA coated over a silver loaded surface have been examined. Histological studies were also performed to examine the impact of the silver on osseointegration. The To date (May 10) 147 silver treated mega-prostheses have been implanted since March 2006. The majority of implants were distal femoral (29%), proximal tibial (23%) or hemiplevic (10%). The most common indication was revision of a failed limb salvage reconstruction (58%), with the dominant cause of failure being infection. The next most common indication was bone tumour (31%) and the large majority were used in the high risk skeletal locations of the tibia (44%) and the pelvis (27%). Early clinical results are encouraging indicating a significant reduction in the incidence of infection. Three implants have been retrieved. An analysis of a proximal humeral replacement that had been This novel process of “stitching-in” silver appears to be a safe and effective surface treatment in helping to control infections of mega-prostheses. This technology has the potential to be transferred to other arthroplasty joints.
Polymethyl methacrylate spacers are commonly used during staged revision knee arthroplasty for infection. In cases with extensive bone loss and ligament instability, such spacers may not preserve limb length, joint stability and motion. We report a retrospective case series of 19 consecutive patients using a custom-made cobalt chrome hinged spacer with antibiotic-loaded cement. The “SMILES spacer” was used at first-stage revision knee arthroplasty for chronic infection associated with a significant bone loss due to failed revision total knee replacement in 11 patients (58%), tumour endoprosthesis in four patients (21%), primary knee replacement in two patients (11%) and infected metalwork following fracture or osteotomy in a further two patients (11%). Mean follow-up was 38 months (range 24–70). In 12 (63%) patients, infection was eradicated, three patients (16%) had persistent infection and four (21%) developed further infection after initially successful second-stage surgery. Above knee amputation for persistent infection was performed in two patients. In this particularly difficult to treat population, the SMILES spacer two-stage technique has demonstrated encouraging results and presents an attractive alternative to arthrodesis or amputation.
We discuss the use of the SMILES (Stanmore Modular Individualised Lower Extremity System) in salvage revision knee surgery and review the medium-long term results of 42 cases. This is a prospective, single-centre study. The SMILES prosthesis is a custom-made implant incorporating a rotating hinge knee joint. 42 prostheses were used in 40 patients as salvage revision procedures between September 1991 and September 1999. Patients undergoing surgery for tumours were excluded. The minimum follow-up was seven years with a mean follow-up of ten years and six months. Patients were independently assessed using the Knee Society Rating Score. The age of the patients ranged from 36-85 years (mean 68 years and 6 months). 23 of the patients were male. The original pathology was osteoarthritis in 32 patients and rheumatoid arthritis in 8 patients. The number of previous arthroplasties ranged from 1-4. The main indications for a SMILES prosthesis were aseptic loosening, periprosthetic fracture and infection in the presence of bone loss and ligamentous laxity.Introduction
Methods
In skeletally immature patients, resection of
bone tumours and reconstruction of the lower limb often results
in leg-length discrepancy. The Stanmore non-invasive extendible
endoprosthesis, which uses electromagnetic induction, allows post-operative
lengthening without anaesthesia. Between 2002 and 2009, 55 children
with a mean age of 11.4 years (5 to 16) underwent reconstruction
with this prosthesis; ten patients (18.2%) died of disseminated
disease and one child underwent amputation due to infection. We
reviewed 44 patients after a mean follow-up of 41.2 months (22 to
104). The mean Musculoskeletal Tumor Society score was 24.7 (8 to
30) and the Toronto Extremity Salvage score was 92.3% (55.2% to
99.0%). There was no local recurrence of tumour. Complications developed
in 16 patients (29.1%) and ten (18.2%) underwent revision. The mean length gained per patient was 38.6 mm (3.5 to 161.5),
requiring a mean of 11.3 extensions (1 to 40), and ten component
exchanges were performed in nine patients (16.4%) after attaining
the maximum lengthening capacity of the implant. There were 11 patients
(20%) who were skeletally mature at follow-up, ten of whom had equal
leg lengths and nine had a full range of movement of the hip and
knee. This is the largest reported series using non-invasive extendible
endoprostheses after excision of primary bone tumours in skeletally
immature patients. The technique produces a good functional outcome,
with prevention of limb-length discrepancy at skeletal maturity.
Patients with skeletal dysplasia are prone to
developing advanced osteoarthritis of the knee requiring total knee replacement
(TKR) at a younger age than the general population. TKR in this
unique group of patients is a technically demanding procedure owing
to the deformity, flexion contracture, generalised hypotonia and ligamentous
laxity. We retrospectively reviewed the outcome of 11 TKRs performed
in eight patients with skeletal dysplasia at our institution using
the Stanmore Modular Individualised Lower Extremity System (SMILES)
custom-made rotating-hinge TKR. There were three men and five women
with mean age of 57 years (41 to 79). Patients were followed clinically
and radiologically for a mean of seven years (3 to 11.5). The mean
Knee Society clinical and function scores improved from 24 (14 to
36) and 20 (5 to 40) pre-operatively, respectively, to 68 (28 to
80) and 50 (22 to 74), respectively, at final follow-up. Four complications
were recorded, including a patellar fracture following a fall, a
tibial peri-prosthetic fracture, persistent anterior knee pain,
and aseptic loosening of a femoral component requiring revision.
Our results demonstrate that custom primary rotating-hinge TKR in
patients with skeletal dysplasia is effective at relieving pain,
with a satisfactory range of movement and improved function. It compensates
for bony deformity and ligament deficiency and reduces the likelihood
of corrective osteotomy. Patellofemoral joint complications are
frequent and functional outcome is worse than with primary TKR in
the general population.
We performed a retrospective review of 98 patients with malignant tumours of the periacetabular region, treated by resection and endoprosthetic reconstruction between 1971 and 2005 at the Royal National Orthopaedic Hospital, Stanmore and The Royal Orthopaedic Hospital, Birmingham. The mean age of the patients was 43.6 years (10 to 76). 53 patients (54%) were male. The age distribution demonstrated peaks in the 2nd and 6th decades. The mean follow up was 65 months (2 to 405. The overall 10-year survival rate was 56% (determined by the Kaplan-Meier method). 54 patients (58.1%) had one or more complications. Infection was the most common (30%) with the majority occurring in the first 2 years. Dislocation occurred in 19 (20%) of our patients all in the first year following surgery. All were recurrent with a mean of 2.9 (2 to 6) episodes. Operations performed before 1994 were associated with a dislocation rate of 40.5% and after 1996 the rate was only 3.9% (p < 0.001). Function was assessed according the Toronto Extremity Salvage Sore (TESS). The overall TESS was 59.4. In patients that had a major complication the TESS was 37.1 but in the group that did not the TESS was 70.3 (p < 0.001). Men experienced higher rates of death, infection and revision than women (p < 0.05). The local recurrence rate was 31% with high grade tumours associated with higher recurrence rates (p < 0.05). Tumour resection in the ilium is associated with higher rates of infection than tumours located in the periacetabular region alone (p < 0.05). This method of reconstruction is still associated with high complication rates. Function is good if a major complication can be avoided. The lower dislocation rate more recently is probably the result of improved surgical technique and the use of larger femoral heads.
Metal-on-Metal (MoM) hip bearings are being implanted in ever-increasing numbers and into ever-younger patients. The consequence of chronic exposure to metal ions is a cause for concern. Therefore, using cytogenetic biomarkers, we investigated a group of patients who have had MoM bearings in situ for in excess of 30 years. Whole blood specimens were obtained from an historical group of patients who have had MoM bearings in situ for in excess of 30 years. Blood was also obtained from an age and sex matched control group and from patients with Metal-on-Polyethylene (MoP) components of the same era. The whole blood was cultured with Pb-Max karyotyping medium and harvested for cytogenetics after 72 hrs. The 24 colour FISH (Fluorescent In Situ Hybridisation) chromosome painting technique was performed on the freshly prepared slides, allowing chromosomal mapping. Each slide was evaluated for chromosomal aberrations (deletions, fragments and translocations) against the normal 46 (22 pairs and two sex) chromosomes. At least 20 metaphases per sample were scored and the number of aberrations per cell calculated.Purpose
Method
Chondrosarcoma is a malignant tumour and accounts for approximately 20% of bone sarcomas. The pelvis is one of the commonest sites. Chondrosarcoma of the pelvis lends itself to surgical excision and is relatively resistant to irradiation and chemotherapy. A long term survival analysis of this challenging condition is rarely reported in literature. We review and evaluate the oncological and functional results of all the patients operated at our centre and we analyse the survival analysis of these patients with special focus on the prognostic factors. Fifty-four consecutive patients with chondrosarcoma of the pelvis who were treated at the Royal National Orthopaedic Hospital, Stanmore, UK between 1987 and 2001 were included in the study. Demographic data, case notes, histopathological results and follow-up data were obtained and statistically analysed. There were 38 males and 16 females with a mean age of 48.4 years [18-77]. The chondrosarcomas were primary [n=38], secondary [n-7] or recurrences [n=9]. The anatomical sites in the pelvis were in the epicentre I [n=24], II [n=20] and III [n=10]. The surgical procedures performed were local resection [n=28], local resection and hip arthroplasty [n=6], hemipelvectomy (+endoprothesis) [n=16], hemipelvectomy [+fibular strut graf] [n=2] and hinquarter amputation [n=2]. The histological grade was Gr [n=27], Gr 2[n=20] and Gr 3 [n=7]. The complication rate was 24%:wound revision [9%], dislocation [8%] and infection [7%]. There was a 5, 10 and 15 year cumulative survival rate of 74%, 65% and 40%. The overall recurrence rate was 24%. The factors associated with a worse prognosis were high histologic tumour grade, increasing patient age, anatomical location in site I and III, primary surgery outside of tumour centre, inadequate surgical margins, and those treated by local extension. Aggressive surgical approach significantly improves the prognosis of the patients with chondrosarcoma of the pelvis.
When performing limb salvage operations for malignant bone tumours in skeletally immature patients, it is desirable to reconstruct the limb with a prosthesis that can be lengthened without surgery at appropriate intervals to keep pace with growth of the contra-lateral side. We have developed a prosthesis that can be lengthened non-invasively. The lengthening is achieved on the principle of electromagnetic induction. The purpose of this study was to look at our early experience with the use of the Non Invasive Distal Femoral Expandable Endoprosthesis. A prospective study of 17 skeletally immature patients with osteosarcoma of the distal femur, implanted with the prosthesis, was performed at the Royal National Orthopaedic Hospital, Stanmore. The patients were aged between 9 and 15 years (mean 12.1 years) at the time of surgery. Patients were lengthened at appropriate intervals in outpatient clinics. Patients were functionally evaluated using the Musculoskeletal Tumour Society (MSTS) Scoring System and the Toronto Extremity Severity Score (TESS). Average time from the implantation to the last follow-up was 18.2 months (range 14-30 months). The patients have been lengthened by an average of 25mm (4.25-55mm). The mean amount of knee flexion is 125 degrees. The mean MSTS score is 77% (23/30; range 11-29) and the mean TESS score is 72%. There have been two complications: one patient developed a flexion deformity of 25 degrees at the knee joint and one patient died of disseminated metastatic malignancy. The early results from patients treated using this device have been encouraging. Using this implant avoids multiple surgical procedures and general anaesthesia. This results in low morbidity, cost savings and reduced psychological trauma. We do need additional data regarding the long-term structural integrity of the prosthesis.
Patient warming significantly decreases the risk
of surgical site infection. Recently there have been concerns that forced
air warming may interfere with unidirectional airflow, potentially
posing an increased risk of infection. Our null hypothesis was that
forced air and radiant warming devices do not increase the temperature
and the number of particles over the surgical site when compared
with no warming device. A forced air warming device was compared with
a radiant warming device and no warming device as a control. The
temperature and number of particles were measured over the surgical
site. The theatre was prepared as for a routine lower-limb arthroplasty
operation, and the same volunteer was used throughout the study. Forced air warming resulted in a significant mean increase in
the temperature (1.1°C
Performance evaluation in specialist orthopaedic hospitals was reviewed in comparison to district general hospitals (DGHs) using a variety of outcome measures, including surgical activity, length of stay and infection rates. Data regarding admission rates, operations performed or cancelled, outpatient activity and waiting times were obtained from the Hospital Episode Statistics department of the Department of Health. Surgical site infection (SSI) and MRSA infection rates from the Royal National Orthopaedic Hospital (RNOH) are compared to national data supplied by the Health Protection Agency. In comparison with DGHs, specialist orthopaedic hospitals admit fewer patients, with fewer emergencies; have a higher ratio of waiting list patients to number of patients admitted; have longer waiting list times on average; perform more primary joint arthroplasty surgery; undertake more revision procedures; discharge patients home following joint arthroplasty surgery on average one day earlier; have a lower total hip arthroplasty SSI rate (0.8%) compared with 2.3% in 146 DGHs and from RNOH data, provide a service with a lower surgical site infection and MRSA rate. Specialist orthopaedic hospitals in England provide a unique, efficient and effective service compared to DGHs. However, short-term performance measures, though simpler to collate, may not be as valuable as longer-term outcome measures, thus making direct comparisons between DGHs, specialist orthopaedic hospitals and independent treatment centres difficult.
Endoprosthetic reconstruction is an established method of treatment for primary bone tumours in children. Traditionally these were implanted with cemented intramedullary fixation. Hydroxyapatite collars at the shoulder of the implant are now standard on all extremity endoprostheses, but older cases were implanted without collars. Uncemented intramedullary fixation with hydroxyapatite collars has also been used in an attempt to reduce the incidence of problems such as aseptic loosening. Currently there are various indications that dictate which method is used. To establish long term survivorship of cemented versus uncemented endoprosthesis in paediatric patients with primary bone tumours.Background
Aims
There is limited literature available on the use of metal prosthetic replacements for the treatment of non-traumatic lesions of the proximal radius. This study discusses the implant survivorship and the functional outcome of the elbow following insertion of metal proximal radius endoprostheses performed at the Royal National Orthopaedic Hospital. We present a series of six patients treated with endoprosthetic reconstruction of the proximal radius following resection of non-traumatic pathologies. The patients included four females and two males, with a mean age of 39 years at the time of surgery. Their diagnoses included Ewing’s sarcoma, chondroblastoma, benign fibrous histiocytoma, radio-ulna synostosis and renal carcinoma metastases in two patients. Follow-up extended to 192 months with a mean of 76 months. During this time there were no complications with the prostheses, the most recent radiographs demonstrated secure fixation of the implants and none required revision. One patient developed posterior interosseuous nerve neuropraxia following surgery, which partially recovered, and another patient passed away as a result of disseminated metastatic renal cell carcinoma which was present preoperatively. The patient with radio-ulna synostosis had a 25° fixed flexion deformity of the elbow post-operatively but good flexion, supination and pronation. All other patients had full ranges of movement at the elbow. Functional scores were assessed using the Mayo Elbow Performance Score with patients achieving a mean score of 86 out of 100. The results of the use of proximal radial endoprostheses for treatment of non-traumatic lesions are encouraging with regards to survivorship of the implant and functional outcome of the elbow.
The best method of reconstruction after resection of malignant tumours of the tibial diaphysis is unknown. In the absence of any long-term studies analysing the results of intercalary endoprosthetic replacement, we present a retrospective review of 18 patients who underwent limb salvage using a tibial diaphyseal endoprosthetic replacement following excision of a malignant bone tumour. There were ten men and eight women with a mean age of 42.5 years (16 to 76). Mean follow-up was 58.5 months (20 to 141) for all patients and 69.3 months (20 to 141) for the 12 patients still alive. Cumulative patient survival was 59% (95% confidence interval (CI) 32 to 84) at five years. Implant survival was 63% (95% CI 35 to 90) at ten years. Four patients required revision to a proximal tibial replacement at a mean follow-up of 29 months (10 to 54). Complications included metastases in five patients, aseptic loosening in four, peri-prosthetic fracture in two, infection in one and local recurrence in one. The mean Musculoskeletal Tumor Society score and the mean Toronto Extremity Salvage Score were 23 (17 to 28) and 74% (53 to 91), respectively. Although rates of complication and revision were high, custom-made tibial diaphyseal replacement following resection of malignant bone tumours enables early return to function and provides an attractive alternative to other surgical options, without apparent compromise of patient survival.
The aim of this study was to compare accuracy of an image guided percutaneous core needle biopsy (PCNB), using ultrasound or computed tomography, to PCNB without image guidance in the diagnosis of palpable soft tissue tumors. One hundred forty patients with a suspected soft tissue sarcoma underwent a percutaneous core needle biopsy with or without image guidance. One hundred eleven patients had subsequent surgical excision. The accuracy of guided PCNB and blind PCNB was calculated by comparing the histological results of the needle biopsy to the surgical specimen. The diagnostic accuracy of blind percutaneous core needle biopsy was 78% (36 of 46 biopsies) and significantly lower (p ≤ 0.025) in comparison to image guided percutaneous core needle biopsy which was 95% (62 of 65 biopsies). We suggest that image guidance improves the diagnostic accuracy of PCNB especially for small size deep sited suspected soft tissue tumours.
Metal-on-metal arthroplasties are being inserted in increasing numbers of younger patients due to the increased durability and reduced requirement for revision in these implants. Recent studies have raised many concerns over possible genotoxicity of MoM implants. This is a prospective study of patients who have undergone elective total hip replacement, they were selected and then randomised into two groups. Group A received a MoP implant and group B received a MoM implant. Patients are reviewed pre-operatively (control group), at 3 months, 6 months, 1 year and 2 years post-operatively. On each occasion blood tests are taken to quantify metal ion levels (chromium, cobalt, titanium, nickel and vanadium) using HR-ICPMS method and chromosome aberrations in T lymphocytes using 24 colour fluorescent in situ hybridisation (FISH). Fiffty three patients have been recruited to date, 24 of whom had MoP prosthesis and 29 a MoM. 25 of these have had their one-year follow-up with blood analysis. Cobalt and chromium concentration increased during the first 6 months in both MoM and MoP groups, in the MoM group the chromium levels were twice that of MoP group and 12x that of the preoperative samples. There was no difference with the levels of titanium, nickel and vanadium. Chromosome aberrations occurred in both groups. At 6 months both the MoM and MoP groups showed increase frequency of aneuploidy aberrations with further increases after one year. Structural damage in the form of translocations occurred in the MoM group after one year, but not in the MoP group. Preliminary results of this study show that the levels of chromium and cobalt are significantly higher in the MoM group compared to the MoP group. This corresponds to increases in chromosome aberrations between the groups particularly in translocations present in the MoM group at 1 year.
The use of massive endoprostheses following bone tumour resection is well recognised. Where possible, joint salvage rather than joint replacement is usually attempted. However cases arise where there may be insufficient bone stock following tumour resection to allow fixation of a joint sparing prosthesis. We report a series of 4 patients (age4–12) treated between 1994 and 2008, in which irradiated autologous bone has been combined with a diaphyseal or distal femoral replacement in order to preserve the native hip joint. There were 3 cases of osteosarcoma and 1 cases of Ewings sarcoma. After a mean follow up of 53 months (range 9–168) all patients had survived without evidence of local recurrence or metastases. One implant was revised after 14 years following fracture of the extending component of the growing endoprosthesis. There have been no cases of loosening or peri-prosthetic fracture. This is the first report of irradiated autologous bone with joint sparing endoprostheses in the skeletally immature patient.
Non-invasive expandable prostheses for limb salvage tumour surgery were first used in 2002. These implants allow ongoing lengthening of the operated limb to maintain limb-length equality and function while avoiding unnecessary repeat surgeries and the phenomenon of anniversary operations. A large series of skeletally immature patients have been treated with these implants at the two leading orthopaedic oncology centres in England (Royal National Orthopaedic Hospital, Stanmore, and Royal Orthopaedic Hospital, Birmingham). An up to date review of these patients has been made, documenting the relevant diagnoses, sites of tumour and types of implant used. 74 patients were assessed, with an age range of 7 – 16 years and follow up range of 4 – 88 months. We identified five problems with lengthening. One was due to soft tissue restriction which resolved following excision of the hindering tissue. Another was due to autoclaving of the prosthesis prior to insertion and this patient, along with two others, all had successful further surgery to replace the gearbox. Another six patients required mechanism revision when the prosthesis had reached its maximal length. Complications included one fracture of the prosthesis that was revised successfully and six cases of metalwork infection (two of which were present prior to insertion of the implant and three of which were treated successfully with silver-coated implants). There were no cases of aseptic loosening. Overall satisfaction was high with the patients avoiding operative lengthening and tolerating the non-invasive lengthenings well. Combined with satisfactory survivorship and functional outcome, we commend its use in the immature population of long bone tumour cases.
Between 1997 and 2007, 68 consecutive patients underwent replacement of the proximal humerus for tumour using a fixed-fulcrum massive endoprosthesis. Their mean age was 46 years (7 to 87). Ten patients were lost to follow-up and 16 patients died. The 42 surviving patients were assessed using the Musculoskeletal Tumor Society (MSTS) Score and the Toronto Extremity Salvage Score (TESS) at a mean follow-up of five years and 11 months (one year to ten years and nine months). The mean MSTS score was 72.3% (53.3% to 100%) and the mean TESS was 77.2% (58.6% to 100%). Four of 42 patients received a new constrained humeral liner to reduce the risk of dislocation. This subgroup had a mean MSTS score of 77.7% and a mean TESS of 80.0%. The dislocation rate for the original prosthesis was 25.9; none of the patients with the new liner had a dislocation at a mean of 14.5 months (12 to 18). Endoprosthetic replacement for tumours of the proximal humerus using this prosthesis is a reliable operation yielding good results without the documented problems of unconstrained prostheses. The performance of this prosthesis is expected to improve further with a new constrained humeral liner, which reduces the risk of dislocation.
Non-bacterial osteitis (NBO), a term referring to sterile bone lesions with non-specific histopathological features of inflammation, may be either uni- or multifocal, acute (6 months) or chronic, and recurrent. Only when the condition is chronic, recurrent and multifocal is it appropriate to use the term chronic recurrent multifocal osteomyelitis (CRMO). We present our clinical experience as the largest reported series of children with NBO to date. Of 41 children (2–16 years) diagnosed with NBO in our institution over the last 6 years, 21 (51%) had recurrent disease and 18 of 41 (44%) had multifocal disease. The most common bones affected were the clavicle, femur and tibia (in order of decreasing prevalence) accounting for 44 (63%) of a total of 70 lesions. Only one individual had SAPHO syndrome and no other patients had evidence of bowel or skin disease. In the absence of evidence for an infective aetiology, we recommend non-steroidal anti-inflammatory agents as first line therapy, and bisphosphonates only in cases of resistant disease. On the basis of our findings we propose a patient questionnaire and protocol for investigating and managing patients who present to orthopaedic surgeons with NBO. We predict that this will benefit patients with this disorder by providing valuable information about the pathogenesis, clinical outcome and response to treatment. In the future, clarification of the pathogenesis of this disease will undoubtedly help rationalise the therapeutic approach improving both quality of life and outcome for these patients.
Large head metal-on-metal articulating surfaces of the hip are being used in increasing numbers of patients for oncological purposes due to the increased stability and reduced dislocation rate. Recent studies have raised many concerns over possible genotoxicity of MoM implants.