Cite this article: Bone Joint J 2024;106-B(1):6–8.

Abstract

Aims

Most patients with advanced malignancy suffer bone metastases, which pose a significant challenge to orthopaedic services and burden to the health economy. This study aimed to assess adherence to the British Orthopaedic Oncology Society (BOOS)/British Orthopaedic Association (BOA) guidelines on patients with metastatic bone disease (MBD) in the UK.

Mirels’ score predicts the likelihood of sustaining pathological fractures using pain, lesion site, size and morphology. The aim is to investigate its reproducibility, reliability and accuracy in upper limb bony metastases and validate its use in pathological fracture prediction.

A retrospective cohort study of patients with upper limb metastases, referred to an Orthopaedic Trauma Centre (2013–18). Mirels’ was calculated in 32 patients; plain radiographs at presentation scored by 6 raters. Radiological aspects were scored twice by each rater, 2-weeks apart. Inter- and intra-observer reliability were calculated (Fleiss’ kappa test). Bland-Altman plots compared variances of individual score components &total Mirels’ score.

Mirels’ score of ≥9 did not accurately predict lesions that would fracture (11% 5/46 vs 65.2% Mirels’ score ≤8, p<0.0001). Sensitivity was 14.3% &specificity was 72.7%. When Mirels’ cut-off was lowered to ≥7, patients were more likely to fracture (48% 22/46 versus 28% 13/46, p=0.045). Sensitivity rose to 62.9%, specificity fell to 54.6%. Kappa values for interobserver variability were 0.358 (fair, 0.288–0.429) for lesion size, 0.107 (poor, 0.02–0.193) for radiological appearance and 0.274 (fair, 0.229–0.318) for total Mirels’ score. Values for intraobserver variability were 0.716 (good, 95% CI 0.432–0.999) for lesion size, 0.427 (moderate, 95% CI 0.195–0.768) for radiological appearance and 0.580 (moderate, 0.395–0.765) for total Mirels’ score.

We showed moderate to substantial agreement between &within raters using Mirels’ score on upper limb radiographs. Mirels’ has poor sensitivity &specificity predicting upper limb fractures - we recommend the cut-off score for prophylactic surgery should be lower than for lower limb lesions.

Aims

Malignancy and surgery are risk factors for venous thromboembolism (VTE). We undertook a systematic review of the literature concerning the prophylactic management of VTE in orthopaedic oncology patients.

Aims

Our rural orthopaedic service has undergone service restructure during the COVID-19 pandemic in order to sustain hip fracture care. All adult trauma care has been centralised to the Royal Shrewsbury Hospital for assessment and medical input, before transferring those requiring operative intervention to the Robert Jones and Agnes Hunt Orthopaedic Hospital. We aim to review the impact of COVID-19 on hip fracture workload and service changes upon management of hip fractures.

Aims

The purpose of this study was to identify prognostic indicators of outcome at presentation to the orthopaedic surgeon, in patients with metastatic prostate cancer. Our aim was to use this information in a pragmatic, clinic-based approach so that surgical decision making could be optimized to benefit the patient in their remaining lifetime.

Aims

The aim of this study was to validate the Mirels score in predicting pathological fractures in metastatic disease of the lower limb.

Aims

Dislocation rates are reportedly lower in patients requiring proximal femoral hemiarthroplasty than for patients undergoing hip arthroplasty for neoplasia. Without acetabular replacement, pain due to acetabular wear necessitating revision surgery has been described. We aimed to determine whether wear of the native acetabulum following hemiarthroplasty necessitates revision surgery with secondary replacement of the acetabulum after proximal femoral replacement (PFR) for tumour reconstruction.

Frozen section is a recognised technique to assist in the diagnosis of infection and there are standards for reporting. Our aim of this review was to assess the value of frozen section in the diagnosis of infection, as well as other variables.

We performed a retrospective review of all frozen sections for suspected infection in 2016. Patient demographics, histological and microbiological investigations, laboratory and bedside tests were recorded and analysed using statistical software.

46 patients had 55 frozen sections; the majority were for lower limb arthroplasty. No sections were reported as polymorphonuclear neutrophils per high-power field. Three sections showed signs of infection and one without evidence had positive cultures. One uncertain section did not grow organisms. 10 patients had two-stage procedures, four of these were intended to be determined by frozen section but only two had evidence of infection on analysis.

Evidence of infection on frozen section does correlate with microbiological growth but does not relate to intention to stage procedures in half of patients. The effect of new tests such as Synovasure is highlighted by this review.

Frozen section analysis is reported subjectively but is a good predictor of infection. Clinical assessment is accurate in diagnosing infection. Histological, microbiological and additional investigations should be considered in relation to their cost-effectiveness.

Objectives

In this cross sectional study, the impact and the efficacy of a surveillance programme for sarcomas of the extremities was analysed.

Aims

The purpose of this study was to determine if clinical and radiological surveillance of cartilage tumours with low biological activity is appropriate.

Plots are an elegant and effective way to represent data. At their best they encourage the reader and promote comprehension. A graphical representation can give a far more intuitive feel to the pattern of results in the study than a list of numerical data, or the result of a statistical calculation.

The temptation to exaggerate differences or relationships between variables by using broken axes, overlaid axes, or inconsistent scaling between plots should be avoided.

A plot should be self-explanatory and not complicated. It should make good use of the available space. The axes should be scaled appropriately and labelled with an appropriate dimension.

Plots are recognised statistical methods of presenting data and usually require specialised statistical software to create them. The statistical analysis and methods to generate the plots are as important as the methodology of the study itself. The software, including dates and version numbers, as well as statistical tests should be appropriately referenced.

Following some of the guidance provided in this article will enhance a manuscript.

Cite this article: Bone Joint J 2015;97-B:1593–1603.

Patients who have limb amputation for musculoskeletal tumours are a rare group of cancer survivors. This was a prospective cross-sectional survey of patients from five specialist centres for sarcoma surgery in England. Physical function, pain and quality of life (QOL) outcomes were collected after lower extremity amputation for bone or soft-tissue tumours to evaluate the survivorship experience and inform service provision.

Of 250 patients, 105 (42%) responded between September 2012 and June 2013. From these, completed questionnaires were received from 100 patients with a mean age of 53.6 years (19 to 91). In total 60 (62%) were male and 37 (38%) were female (three not specified). The diagnosis was primary bone sarcoma in 63 and soft-tissue tumour in 37. A total of 20 tumours were located in the hip or pelvis, 31 above the knee, 32 between the knee and ankle and 17 in the ankle or foot. In total 22 had hemipelvectomy, nine hip disarticulation, 35 transfemoral amputation, one knee disarticulation, 30 transtibial amputation, two toe amputations and one rotationplasty. The Toronto Extremity Salvage Score (TESS) differed by amputation level, with poorer scores at higher levels (p < 0.001). Many reported significant pain. In addition, TESS was negatively associated with increasing age, and pain interference scores. QOL for Cancer Survivors was significantly correlated with TESS (p < 0.001). This relationship appeared driven by pain interference scores.

This unprecedented national survey confirms amputation level is linked to physical function, but not QOL or pain measures. Pain and physical function significantly impact on QOL. These results are helpful in managing the expectations of patients about treatment and addressing their complex needs.

Cite this article: Bone Joint J 2015;97-B:1284–90.

Pigmented villonodular synovitis (PVNS) is a rare benign disease of the synovium of joints and tendon sheaths, which may be locally aggressive. We present 18 patients with diffuse-type PVNS of the foot and ankle followed for a mean of 5.1 years (2 to 11.8). There were seven men and 11 women, with a mean age of 42 years (18 to 73). A total of 13 patients underwent open or arthroscopic synovectomy, without post-operative radiotherapy. One had surgery at the referring unit before presentation with residual tibiotalar PVNS. The four patients who were managed non-operatively remain symptomatically controlled and under clinical and radiological surveillance. At final follow-up the mean Musculoskeletal Tumour Society score was 93.8% (95% confidence interval (CI) 85 to 100), the mean Toronto Extremity Salvage Score was 92 (95% CI 82 to 100) and the mean American Academy of Orthopaedic Surgeons foot and ankle score was 89 (95% CI 79 to 100). The lesion in the patient with residual PVNS resolved radiologically without further intervention six years after surgery. Targeted synovectomy without adjuvant radiotherapy can result in excellent outcomes, without recurrence. Asymptomatic patients can be successfully managed non-operatively. This is the first series to report clinical outcome scores for patients with diffuse-type PVNS of the foot and ankle.

Cite this article: Bone Joint J 2013;95-B:384–90.

Introduction

Chondroblastomas are rare bone tumours accounting for approximately 1% of all benign bone lesions. They occur in children and adolescents and are more frequent in males.

The conventional treatment for chondroblastomas is surgery, however, this can be difficult and disabling due to the apo- or epiphyseal location. Surgery is curative in most cases, but recurrence rates of 10%–35% have been reported in the literature. Radiofrequency ablation is well established in the treatment of osteoid osteomas and painful bone metastases. We report our experience with the use of radiofrequency ablation in the treatment of chondroblastomas.

Simple bone cysts are relatively common in children. When they present to a musculoskeletal oncology unit, they are usually treated by a variety of methods that range from observations following fracture to surgically curettage. The outcome is usually good.

Very little is written in the literature regarding adults with a cystic bone lesion.

We present 10 consecutive skeletally mature patients who presented with a benign cystic bone lesion. The mean age at diagnosis was 38 years (20–60 years). Three patients has a cyst in the foot, three in the hip, two in the knee, one in the pelvis and the remainder in the shoulder. Full work up, including biopsy, was performed in all cases. All hip lesions required internal fixation for actual or impending fractures. The average follow up was 1.5 years. The surgical outcome was good in all cases.

The histological features are similar in all cases. Cementum, as found in Unicameral Bone Cysts, is not seen. This may present a new entity that is not described in the literature.

Objective

To evaluate the rise in impedance during percutaneous radiofrequency thermo coagulation (PRFTC) of osteoid osteomas as a predictor of local recurrence.

Introduction

Enchondromas located in the phalangeal bones may be more cellular than non-digital locations necessitating clinical and radiological correlation to determine diagnosis. Atypical enchondromas have increased cellularity and atypia relative to simple enchondromas but no evidence of permeation. Chondrosarcomas of the phalanges are thought to have a more indolent course than chondrosarcomas in other locations. The aim of the study was to determine the outcome of atypical enchondromas and grade 1 chondrosarcomas of the phalanges treated surgically.

Periarticular metastasis may be treated with endoprosthetic reconstruction. The extensive surgery required may not, however, be appropriate for all patients. Our aim was to establish if the outcome of locking plate fixation in selected patients with periarticular metastases.

Prospective data collection was performed. Twenty one patients underwent surgery for periarticular metastatic tumours. The median duration of follow-up for surviving patients was one year. There have been no cases of implant failure and no requirement for revision surgery. Pain relief was excellent or good in the majority of patients. Patients who had sustained a fracture prior to fixation had restoration of their WHO performance status. All patients had a dramatic improvement in their MSTS scores. The median pre-operative score was 15% (0%-37%) improving to a median score of 80% (75% -96%) post operatively.

Locking plates provide reliable fixation and excellent functional restoration in selected patients suffering from periarticular metastatic bone disease.

Background: There are no evidence based guidelines on the surveillance of cemented total hip arthroplasty. We reviewed the outcomes of those patients undergoing this procedure in 1996 & 1997.

Methods: The patients were identified from theatre log books. The follow up date was then retrieved from the electronic patient record system used at our institution. From these we recorded the age, sex, side of procedure, evidence of radiological loosening & time of revision surgery. The data with regards to radiological evidence of loosening & revision surgery were then analysed using a ® statistical software package. From this we were able to plot Kaplan-Meier survival & hazard plots.

Results: We identified 425 primary total hip arthroplasties. Using radiological evidence of loosening as the end point we found that there was an initial peak and a peak at 8 years. There was a 10 year survival rate of 85.8%. Using revision surgery as the end point we found that there was, again, an initial peak & a peak at 8 years. There was a 10 year survival rate of 91.5%.

Conclusions: Once the patient has made it through the first post operative year they do not need to be followed up again until 8 years assuming they remain asymptomatic.

Background: There are no evidence based guidelines on the surveillance of cemented total hip arthroplasty. We reviewed the outcomes of those patients undergoing this procedure in 1996 & 1997.

Methods: The patients were identified from theatre log books. The follow up date was then retrieved from the electronic patient record system used at our institution. From these we recorded the age, sex, side of procedure, evidence of radiological loosening & time of revision surgery. The data with regards to radiological evidence of loosening & revision surgery were then analysed using a XXX statistical software package. From this we were able to plot Kaplan-Meier survival & hazard plots.

Results: We identified 425 primary total hip arthroplasties. Using radiological evidence of loosening as the end point we found that there was a peak initially and a peak at 8 years. There was a 10 year survival rate of 85.8%. Using revision surgery as the end point we found that there was, again, an initial peak & a peak at 8 years. There was a 10 year survival rate of 91.5%.

Conclusions: Once the patient has made it through the first post operative year they do not need to be followed up again until 8 years assuming they remain asymptomatic.

Tension band wire fixation continues to be the most popular method of fixation for displaced olecranon fractures despite several biomechanical studies questioning the validity of the tension band concept. Our aim was to compare the outcome of the tension band wire (TBW) method with plate fixation. 58 consecutive olecranon fractures underwent internal fixation in 58 patients between September 2000 and December 2004. There were 30 male and 28 female with a mean age at the time of surgery of 52.5 years for the TBW group (range 19 to 88) and 46.1 for the plate group (range 19 to 72). Patients were excluded if they were less than 16 years of age. Choice of fixation was based on surgeon preference, fracture pattern and presence of associated injuries. 43 patients were managed with the AO tension band technique and 15 with plate fixation. Clinical assessment and functional analysis was performed using Helm’s scoring system. Radiographic assessment was performed to assess the quality of reduction. All fractures were displaced and classified according to Colton’s classification. Mean follow up was 13 months (range 6 to 18) and similar for the two groups. For the TBW group 41 (95 %) had a fair or good result. 27 (62.8%) patients had symptomatic metal prominence requiring implant removal. In the plate fixation group 14 (94%) had a fair or good functional result despite having more complex fractures. Only 2 (18%) patients required implant removal for symptomatic metalwork, including one failure due to a technical problem. Similar functional results were seen with plating and tension band wiring of displaced olecranon fractures. Despite meticulous technique, tension band wire fixation still has an unacceptably high complication rate with symptomatic metal prominence requiring further surgery. To avoid this problem, we recommend plating, even for the more simple olecranon fractures.

Purpose: Chondroblastomas are a lesion of immature cartilage found in a typically epiphyseal location. The peak incidence is in teenagers. Current surgical treatment is a balance between complete excision, with potential for physeal and articular cartilage damage, and local recurrence. A minimally invasive technique with a low complication rate providing effective treatment may be provided by radiofrequency (RF) thermocoagulation. Already the treatment of choice for Osteoid Osteoma – another lesion that can occur in the epiphysis.1,2,3 Literature to date on clinical use of RF thermocoagulation in chondroblastoma is scarce.4 The high water content of chondroblastoma should ensure its sensitivity to RF ablation. Our units experience in osteoid osteoma has been extended to RF thermocoagulation of chondroblastoma.

Patients: Four patients were treated with RF thermocoagulation for a chondroblastoma. Minimum follow up one year.

Methods: A RITA Starburst probe thermocoagulates the lesion for at least 5 minutes at 90 degrees centigrade. Overnight stay and outpatient follow up until skeletal mature, or two years following treatment.

Results: Two chondroblastomas were in the proximal tibia, one in the distal femur and one in the proximal humerus. One patient had surgery previously and one patient presented with collapse of the proximal tibial plateau. All patients were treated successfully and are pain free. All patients, accepting the one with pre-existing collapse, have a full range of movement. There has been no local recurrence at one year.

Conclusion & Discussion: Our experience suggests that radiofrequency thermocoagulation is a safe and effective treatment method for patients with chondroblastoma.

To assess the efficacy of the current surveillance programme for patients with sarcoma we undertook a prospective analysis of all patients with sarcoma treated between 1990 and 1995. The patients routinely enter a surveillance programme which consists of regular clinical evaluation, CXR and radiological imaging.

We reviewed 643 cases of sarcoma with mean follow up 8. 4 years (range 6. 2–11. 3). Local recurrence occurred in 14% of cases and 34% developed metastases. The cumulative survival at 10 years was 59%. 46% of the deaths were directly attributable to metastases.

For the soft tissue sarcomas 15% of the local recurrences were picked up at surveillance appointment and 70% were picked up early by the patient. For the sarcomas of bony origin 36% were picked up at surveillance and 57% were picked up early by the patient.

Pulmonary metastasis was by far the common metastasis with 82% developing these. 78% were identified by surveillance CXR of which 83% were asymptomatic and 34% went on to thoracotomy and metastectomy. Of the other metastases a third were picked up during surveillance and all were symptomatic.

Surveillance programmes have a role in the management of patients with sarcoma, allowing the earlier identification of local recurrence and metastasis. Clinical evaluation and CXR were found to be, in particular, valuable tools, but patient education and open access to clinics is also important.

Due to advances in the assessment and treatment of patients with metastatic bone disease, the survival has improved in recent years.

It was the aim of this met-analysis to assess the outcome of patients with metastatic bone disease across Europe.

Five major bone tumour treatment centres participated in the met-analyses. Data had been collected prospectively and was retrieved from the databases for the purpose of this study. All patients were referred to the bone tumour centre for assessment and possible surgical treatment.

The data of almost 2500 patients were analysed. The average age at diagnosis was 60 years and the male to female ratio was 1:1.07.

The overall 5-year survival was 35%, but this was significantly better in metastatic disease of the thyroid and breast as well as multiple myeloma.

The number and site of metastases or the presence of a pathological fracture were not prognostic factors in terms of survival. Patients who were female or younger than 50 years of age at time of diagnosis had a better outcome.

This registry will be expanded and more information analysed to try and provide useful information about prognostic factors and outcome for patients with meta-static bone disease.

Limb salvage is now customary in the treatment of primary bone tumours. The proximal tibia is a frequent site for these neoplasms but reconstruction, especially in children, is a formidable challenge. We reviewed 20 children with extendible replacements of the proximal tibia, all with a minimum follow-up of five years. Five died from their disease and, of the remaining 15, four had above-knee amputations for complications. Infection occurred in seven patients; in five it was related to the lengthening procedure. Aseptic loosening is inevitable in the younger children and only two have avoided a revision, amputation or other major complication; both were aged 12 years at the time of the initial surgery. Despite this, 11 children are alive with a functioning leg and a mean Musculoskeletal Tumour Society functional score of 83%. The lengthening mechanisms used in our series required extensive open operations. We are now using a simpler, minimally invasive, technique which we hope will decrease the incidence of complications. At present, the use of extendible prostheses of the proximal tibia remains an experimental procedure.