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The Bone & Joint Journal
Vol. 102-B, Issue 12 | Pages 1743 - 1751
1 Dec 2020
Lex JR Evans S Cool P Gregory J Ashford RU Rankin KS Cosker T Kumar A Gerrand C Stevenson J

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.

Methods

MEDLINE (PubMed), EMBASE (Ovid), Cochrane, and CINAHL databases were searched focusing on VTE, deep vein thrombosis (DVT), pulmonary embolism (PE), bleeding, or wound complication rates.


Bone & Joint Open
Vol. 1, Issue 9 | Pages 585 - 593
24 Sep 2020
Caterson J Williams MA McCarthy C Athanasou N Temple HT Cosker T Gibbons M

Aims

The aticularis genu (AG) is the least substantial and deepest muscle of the anterior compartment of the thigh and of uncertain significance. The aim of the study was to describe the anatomy of AG in cadaveric specimens, to characterize the relevance of AG in pathological distal femur specimens, and to correlate the anatomy and pathology with preoperative magnetic resonance imaging (MRI) of AG.

Methods

In 24 cadaveric specimens, AG was identified, photographed, measured, and dissected including neurovascular supply. In all, 35 resected distal femur specimens were examined. AG was photographed and measured and its utility as a surgical margin examined. Preoperative MRIs of these cases were retrospectively analyzed and assessed and its utility assessed as an anterior soft tissue margin in surgery. In all cadaveric specimens, AG was identified as a substantial structure, deep and separate to vastus itermedius (VI) and separated by a clear fascial plane with a discrete neurovascular supply. Mean length of AG was 16.1 cm ( ± 1.6 cm) origin anterior aspect distal third femur and insertion into suprapatellar bursa. In 32 of 35 pathological specimens, AG was identified (mean length 12.8 cm ( ± 0.6 cm)). Where AG was used as anterior cover in pathological specimens all surgical margins were clear of disease. Of these cases, preoperative MRI identified AG in 34 of 35 cases (mean length 8.8 cm ( ± 0.4 cm)).


The Bone & Joint Journal
Vol. 97-B, Issue 6 | Pages 853 - 861
1 Jun 2015
Hilven PH Bayliss L Cosker T Dijkstra PDS Jutte PC Lahoda LU Schaap GR Bramer JAM van Drunen GK Strackee SD van Vooren J Gibbons M Giele H van de Sande MAJ

Vascularised fibular grafts (VFGs ) are a valuable surgical technique in limb salvage after resection of a tumour. The primary objective of this multicentre study was to assess the risk factors for failure and complications for using a VFG after resection of a tumour.

The study involved 74 consecutive patients (45 men and 29 women with mean age of 23 years (1 to 64) from four tertiary centres for orthopaedic oncology who underwent reconstruction using a VFG after resection of a tumour between 1996 and 2011. There were 52 primary and 22 secondary reconstructions. The mean follow-up was 77 months (10 to 195).

In all, 69 patients (93%) had successful limb salvage; all of these united and 65 (88%) showed hypertrophy of the graft. The mean time to union differed between those involving the upper (28 weeks; 12 to 96) and lower limbs (44 weeks; 12 to 250). Fracture occurred in 11 (15%), and nonunion in 14 (19%) patients.

In 35 patients (47%) at least one complication arose, with a greater proportion in lower limb reconstructions, non-bridging osteosynthesis, and in children. These complications resulted in revision surgery in 26 patients (35%).

VFG is a successful and durable technique for reconstruction of a defect in bone after resection of a tumour, but is accompanied by a significant risk of complications, that often require revision surgery. Union was not markedly influenced by the need for chemo- or radiotherapy, but should not be expected during chemotherapy. Therefore, restricted weight-bearing within this period is advocated.

Cite this article: Bone Joint J 2015;97-B:853–61.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_18 | Pages 8 - 8
1 Apr 2013
Dunkerley S Cosker T Kitson J Bunker T Smith C
Full Access

The Delto-pectoral approach is the workhorse of the shoulder surgeon, but surprisingly the common variants of the cephalic vein and deltoid artery have not been documented. The vascular anatomy encountered during one hundred primary elective delto-pectoral approaches was documented and common variants described.

Two common variants are described. A type I (71%), whereby the deltoid artery crosses the interval and inserts directly in to the deltoid musculature. In this variant the surgeon is unlikely to encounter any vessels crossing the interval apart from the deltoid artery itself. In a type II pattern (21%) the deltoid artery runs parallel to the cephalic vein on the deltoid surface and is highly likely to give off medial branches (95%) that cross the interval, as well as medial tributaries to the cephalic vein (38%).

Knowledge of the two common variants will aid the surgeon when dissecting the delto-pectoral approach and highlights that these vessels crossing the interval are likely to be arterial, rather than venous. This study allows the surgeon to recognize these variations and reproduce bloodless, safe and efficient surgery.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXX | Pages 23 - 23
1 Jul 2012
Porter C Cosker T Gibbons M Sharpley F
Full Access

Introduction

The diagnosis and subsequent management of sarcoma often requires multiple separate attendances to Hospital and often a prolonged inpatient stay post surgery. Previous research has focused on the physical and emotional aspects of a diagnosis of cancer, but little has been discussed regarding the financial costs incurred by patients and their families.

Methods

40 patients treated at our Unit were contacted and were questioned about the financial costs relating to their diagnosis and treatment. The questionnaire included distance travelled to the Unit, mode of transport, who patients were accompanied by, costs whilst at the Hospital e.g. car parking, days off work and impact on employment and career progression.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXX | Pages 24 - 24
1 Jul 2012
Cosker T Whitwell D Sharpley F Porter C Gibbons M
Full Access

Introduction

General Practitioners will be confronted with a sarcoma rarely in their working lives. Most will never see a bone sarcoma although most will see at least one soft tissue sarcoma. Guidelines designed to lead to earlier diagnosis of the most common cancers were introduced by NICE in 2000 and were updated in 2005, containing basic guidance on the earlier diagnosis of bone and soft tissue tumours. Referral criteria include: masses greater than 5cm in diameter, masses deep to fascia, masses which are fixed or immobile, masses which are painful, those which are increasing in size and recurrence after previous excision

Methods

We examined 350 General Practitioner referrals over the past 3 years to our service and examined the correlation between the above criteria and the likelihood of malignancy.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXX | Pages 32 - 32
1 Jul 2012
Cosker T White HB James A Athanisou N Whitwell D Gibbons M
Full Access

Introduction

Primary soft tissue sarcomas of the extremities are uncommon. Many such lesions will present to specialists in other clinics such as specialist Hand or Foot and Ankle clinics. Many are of a small size at presentation and may appear to be alternate, more common pathology.

Methods

We collected data from all those patients with acral soft tissues sarcomas and referred to the Oxford Sarcoma Service, Nuffield Orthopaedic Centre, Oxford over a thirteen year period from 1997 – 2010. Data were collected regarding the primary suspected diagnosis, the final diagnosis, the referral route and whether patients had undergone previous inadvertent excision.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXX | Pages 33 - 33
1 Jul 2012
Cosker T Whitwell D James A Reynolds E Porter C Gibbons M
Full Access

Introduction

A GP may only encounter one sarcoma in their professional career. Early diagnosis and treatment will improve the outcomes of this rare and malignant disease. Guidelines designed to lead to earlier diagnosis of the most common cancers were introduced by NICE in 2000 and were updated in 2005. These advise and assist in the early referral of potential bone and soft tissue sarcoma. Prior to 2000 only ~10% of GP referrals were proven to be malignant.

Methods

In a referral region of ∼3m, we reviewed the referral patterns of suspected sarcoma by General Practitioners since 2005 in an effort to determine whether the published NICE guidelines had influenced an improvement in the diagnosis and management of malignant disease.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXX | Pages 11 - 11
1 Jul 2012
Cosker T MacDonnell S Critchley P Whitwell D Giele H Athanasou N Gibbons M
Full Access

Introduction

Our Unit has been treating large volume soft tissue sarcomas involving the sciatic nerve with epineurectomy for over a decade. The aim of this study was to quantify the functional outcome of patients who were known to have sciatic nerve involvement pre-operatively and went on to have nerve preserving surgery utilising a planned marginal excision with epineurectomy.

Methods

20 patients with soft tissue sarcomas involving the sciatic nerve were studied treated between 1997 and 2010. Nineteen underwent surgery with extended epineurectomy of the sciatic nerve and planned marginal excision. All patients underwent staging and follow up at our Sarcoma Clinic with functional assessment and TESS evaluation.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_II | Pages 25 - 25
1 Feb 2012
Cosker T Ghandour A Elsayed S Visvakumar K Butchart E Routledge P Chatterji S
Full Access

There is currently wide variation in the management of patients who are anticoagulated with Warfarin and require urgent orthopaedic surgery. These form an important and significant group of patients, in terms of real numbers (at least 5,600 per annum in the UK).

A study was initiated with an audit of 34 patients presenting to the West Wales unit who were warfarinised at admission and required trauma surgery. Observations were recorded about their pre-operative management and the delay this caused in taking the patient to theatre. 6 months later, a similar group of patients were re-audited.

The mean delay to surgery in those patients in whom the INR was left to fall spontaneously was 5.5 days. Following administration of 1mg i.v. Vitamin K in those patients without cardiac valves, re-audit showed the mean delay reduced to 2.2 days.

Representations from at least 6 major specialties were considered and a consensus statement was derived. Standardised protocols, which hinge on whether or not the patient has or does not have a cardiac valve were devised. Vitamin K should not be given to those patients with a cardiac valve and early consultation with cardiology and anaesthetics is recommended, with consideration of referral to a specialist cardiothoracic unit. For those patients without a cardiac valve, 1mg of Vitamin K may be administered, repeated as necessary until the INR is less than 1.8. Intravenous Heparin should be provided in the interim whilst the patient is waiting for surgery. This is discontinued the morning of surgery and subcutaneous Heparin reinstated post-operatively. These recommendations have been trialled in the two units involved in the study and have been relatively safe and easy to implement.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_III | Pages 458 - 458
1 Aug 2008
Cosker T Jacobs J Ghandour A Basu K James N Chatterji S
Full Access

Purpose of study: This study assessed the current availability of “out of hours” MRI scans for patients who present with symptoms suggestive of cauda equina syndrome to trauma units across the United Kingdom (UK).

Methods: 98 trauma units in 212 hospitals across the UK were identified. Senior house officers and registrars were questioned about the availability of emergency MRI scans after 5pm and midnight and at weekends. All units responded to the survey.

Results: 88 of 98 units had an on-site MRI scanner. In 32 hospitals, an MRI scan could be obtained after 5pm. In only 27 hospitals was this possible after midnight. In 58 units (65%) of cases, consultant to consultant contact was required to arrange the scan. 67 units found it “very difficult” or “impossible” to obtain an MRI scan at the weekend producing a potential delay of 64 hours from presentation at 5pm on a Friday night to 9am on a Monday morning.

Conclusions: The availability of urgent MRI scans in cases of suspected cauda equina syndrome currently represents a “postcode lottery” across the UK. This may mean that patients requiring urgent surgical decompression face a significant delay in diagnosis. Delayed or missed cases of cauda equina syndrome have huge personal, social and economic impact. On-site MRI facilities, which are available 24 hours a day for such cases are recommended in all units receiving an acute trauma on call.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_I | Pages 1 - 1
1 Mar 2008
Gupta S Cosker T Tayton K
Full Access

A study of 50 consecutive osteoporotic pelvic rami fractures has been carried out to investigate the full extent of injury following low energy falls.

50 consecutive elderly patients with fresh fractures of the pelvis were each investigated with an MRI scan of the pelvis in order to assess the competency of the pelvic ring. The 50 patients consisted of 45 female and 5 males with a mean age of 77.7 years. 44 patients had unilateral pubic rami fractures. The mechanism of injury in all cases was a simple fall in the home environment. On admission 96% of the patients complained of sacral pain and were tender in the sacral or posterior pelvic region. On MRI, 90% of patients had a sacral fracture associated with the pubic rami fractures and in all but 4 of these the posterior pelvic pain was directly related to the sacral fracture site. At 6 month follow-up, 82% still complained of posterior pelvic tenderness. Areas of tenderness corresponded to the sites of the fractures. Before the injury, 38 of the final 44 reviewed were reasonably independently mobile, whilst at review 39 were significantly disabled.

Conclusion: The study shows that the apparently benign traumatic pelvic rami fracture in the elderly has a high association with sacral fractures. After discharge from hospital, attention should be paid to treatment of the on-going anterior and posterior pelvic pain.


Orthopaedic Proceedings
Vol. 88-B, Issue SUPP_I | Pages 43 - 43
1 Mar 2006
Mittal M Cosker T Ghandour A Roy S Gupta A Johnson S
Full Access

Introduction: Fractures of the neck of femur has a considaerable impact on the NHS and due to the elderly group of population it involves morbidity can be very costly. We assesed the outcome of trauma patients with these fractures after providing orthogeriatric care in our hospital.

Aim: 179 patients had been studied who had been managed in our hospital over a period of 18 months with hemiarthroplasty for displaced intracapsular fracture of the neck of femur. 104 patients had routine orthopaedic care and 75 patients had regular orthogeriatric care. All the complication were noted, analysed and compared with the national averages.

Methodology: This was a retrospective study-clincal notes of all patients who had hemiarthroplasty during the 18 month period were reviewed and a performa was completed.

Result: Total sample size was 179 patients(104 before and 75 after the introduction of orthogeriatric service) who had hemiartroplasty for the displaced intracapsular fracture of the neck of femur. The median length of stay being 16.5 days before and 20 days after. The medical complications before and after the introduction of this service were-Cardiac complication 4% before and 1% after, Chest infection 2% before and 1% after, DVT 2% before and 1% after. The Overall complication rate has been reduced from 41% to 18% and the one year mortality reduced from 16.34% to 12 with the introduction of orthogeriatric service.

Conclusion: We believe that the weekly ward round and a continued supervision by the orthogeriatric team is one of the factors in improving the outcome of geriatric trauma patients in terms of reduced morbidity and mortality.


Orthopaedic Proceedings
Vol. 88-B, Issue SUPP_I | Pages 23 - 23
1 Mar 2006
Mendonca A Cosker T Makwana N
Full Access

Aims: The aims of this study were to 1) determine if vacuum assisted closure therapy (VAC) helps assist closure in diabetic foot ulcers and wounds secondary to peripheral vascular disease, 2) if it helps debride wounds and 3) if it prevents the need for further surgery

Materials and Methods: 15 patients were reviewed, average age 49.3yrs at an average of 6.3 months (1–18months). Ten patients had diabetes (8 IDDM) with 5 patients having grade 3 ulcers (Wagner-Meggitt). All wounds were surgically debrided prior to the application of the VAC therapy. The VAC therapy was applied according to the manufacturers instrucrtions. The main outcome measures were 1) time to satisfactory wound closure 2) change in the wound surface area and 3) need for further surgery

Results: Satisfactory healing was achieved in 11 patients (73.3%). 10 were diabetic, 5 patients had peripheral vascular disease and 5 patients had both. The time to satisfactory healing was 2.5 months, average 1–6 months. The average size of the wound ulcer was 7.41cm2 (2–10cm2) prior to treatment and 1.58cm2 (0–2cm2) following treatment in an average of 2.5 months. VAC therapy helped debride all non healing wounds following surgical debridement. In 10 patients, the need for further radical surgery, namely amputation, was avoided.

Conclusion: VAC therapy is a useful adjunct to the standard treatment of chronic wound /ulcers in patients with diabetes with or without periphearl vascular disease. Its use in foot and ankle surgery leads to a quick wound closure and in some cases avoids the need for further surgery with a potential for limb salvage.