Aims. This study aimed to explore the role of small colony variants (SCVs) of Staphylococcus aureus in intraosseous invasion and colonization in patients with periprosthetic joint infection (PJI). Methods. A PJI diagnosis was made according to the MusculoSkeletal Infection Society (MSIS) for PJI. Bone and tissue samples were collected intraoperatively and the intracellular invasion and intraosseous colonization were detected. Transcriptomics of PJI samples were analyzed and verified by polymerase chain reaction (PCR). Results. SCVs can be isolated from samples collected from chronic PJIs intraoperatively. Transmission electron microscopy (TEM) and immunofluorescence (IF) showed that there was more S. aureus in bone samples collected from chronic PJIs, but much less in bone samples from acute PJIs, providing a potential mechanism of PJI. Immunofluorescence results showed that SCVs of S. aureus were more likely to invade osteoblasts in vitro. Furthermore, TEM and IF also demonstrated that SCVs of S. aureus were more likely to invade and colonize in vivo. Cluster analysis and principal component analysis (PCA) showed that there were substantial differences in gene expression profiles between chronic and acute PJI. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis showed that these differentially expressed genes were enriched to chemokine-related signal pathways. PCR also verified these results. Conclusion. Our study has shown that the S. aureus SCVs have a greater ability to invade and colonize in bone, resulting in S. aureus remaining in bone tissues long-term, thus explaining the pathogenesis of chronic PJI. Cite this article: Bone Joint Res 2022;11(12):843–853

Background. Systemically administered vancomycin may provide insufficient target-site concentrations. Intraosseous vancomycin administration has the potential to overcome this concern by providing high target-site concentrations. Aim. To evaluate the local bone and tissue concentrations following tibial intraosseous vancomycin administration in a porcine model. Method. Eight female pigs were assigned to receive 500 mg diluted vancomycin (50 mg/mL) through an intraosseous cannula into the proximal tibial cancellous bone. Microdialysis was applied for sampling of vancomycin concentrations in tibial cancellous bone adjacent to the intraosseous cannula, in cortical bone, in the intramedullary canal of the diaphysis, in the synovial fluid of the knee joint, and in the subcutaneous tissue. Plasma samples were obtained. Samples were collected for 12 hours. Results. High vancomycin concentrations were found in the tibial cancellous bone with a mean peak drug concentration of 1,236 (range 28–5,295) µg/mL, which remained high throughout the sampling period with a mean end concentration of 278 (range 2.7–1,362.7) µg/mL after 690 min. The mean (standard derivation (SD)) peak drug concentration in plasma was 19 (2) µg/mL, which was obtained immediately after administration. For the intramedullary canal, in the synovial fluid of the knee joint, and subcutaneous tissue, comparable mean peak drug concentration and mean time to peak drug concentration were found in the range of 7.5–8.2 µg/mL and 45–70 min, respectively. Conclusions. Tibial intraosseous administration of vancomycin provided high mean concentrations in tibial cancellous bone throughout a 12-hour period, but with an immediate and high systemic absorption. The concentrations in cancellous bone had an unpredictable and wide range of peak concentration. Low mean concentrations were found in all the remaining compartments. Our findings suggest that intraosseous vancomycin administration in proximal tibial cancellous bone only is relevant as treatment in cases requiring high local concentrations nearby the intraosseous cannula

Tourniquet is widely used in orthopedic surgery to reduce intraoperative bleeding and improve visualization. We evaluated the effect of tourniquet application on both peri- and postoperative cefuroxime concentrations in subcutaneous tissue, skeletal muscle, calcaneal cancellous bone, and plasma. The primary endpoint was the time for which the free drug concentration of cefuroxime was maintained above the clinical breakpoint minimal inhibitory concentration (T>MIC) forStaphylococcus aureus (4 µg/mL).

Ten patients scheduled for hallux valgus or hallux rigidus surgery were included. Microdialysis catheters were placed for sampling of cefuroxime concentrations bilaterally in subcutaneous tissue, skeletal muscle, and calcaneal cancellous bone. A tourniquet was applied on the thigh of the leg scheduled for surgery. Cefuroxime (1.5 g) was administered intravenously as a bolus 15 minutes prior to tourniquet inflation, followed by a second dose 6 hours later. The mean tourniquet duration (range) was 65 (58; 77) minutes. Dialysates and venous blood samples were collected for 12 hours.

For cefuroxime the T>MIC (4 μg/mL) ranged between 4.8–5.4 hours across compartments, with similar results for the tourniquet and non-tourniquet leg. Comparable T>MIC and penetration ratios were found for the first and second dosing intervals.

We concluded that administration of cefuroxime (1.5 g) 15 minutes prior to tourniquet inflation is safe in order to achieve tissue concentrations above 4 µg/mL throughout surgery. A tourniquet application time of approximately 1 hour did not affect the cefuroxime tissue penetration in the following dosing interval.

The course of secondary fracture healing typically consists of four major phases including inflammation, soft and hard callus formation, and bone remodeling. Callus formation is promoted by mechanical stimulation, yet little is known about the healing tissue response to strain stimuli over shorter timeframes on hourly and daily basis. The aim of this study was to explore the hourly, daily and weekly variations in bone healing progression and to analyze the short-term response of the repair tissue to well-controlled mechanical stimulation.

A system for continuous monitoring of fracture healing was designed for implantation in sheep tibia. The experimental model was adapted from Tufekci et al. 2018 and consisted of 3 mm transverse osteotomy and 30 mm bone defect resulting in an intermediate mobile bone fragment in the tibial shaft. Whereas the distal and proximal parts of the tibia were fixed with external fixator, the mobile fragment was connected to the proximal part via a second, active fixator. A linear actuator embedded in the active fixator moved the mobile fragment axially, thus stimulating mechanically the tissue in the osteotomy gap via well-controlled displacement being independent from the sheep's functional weightbearing. A load sensor was integrated in the active fixation to measure the force acting in the osteotomy gap. During each stimulation cycle the displacement and force magnitudes were recorded to determine in vivo fracture stiffness. Following approval of the local ethics committee, experiments were conducted on four skeletally mature sheep. Starting from the first day after surgery, the daily stimulation protocols consisted of 1000 loading events equally distributed over 12 hours from 9:00 to 21:00 resulting in a single loading event every 44 seconds. No stimulation was performed overnight.

One animal had to be excluded due to inconsistencies in the load sensor data. The onset of tissue stiffening was detected around the eleventh day post-op. However, on a daily basis, the stiffness was not steadily increasing, but instead, an abrupt drop was observed in the beginning of the daily stimulations. Following this initial drop, the stiffness increased until the last stimulation cycle of the day.

The continuous measurements enabled resolving the tissue response to strain stimuli over hours and days. The presented data contributes to the understanding of the influence of patient activity on daily variations in tissue stiffness and can serve to optimize rehabilitation protocols post fractures.

The formation of biomimetic environments using scaffolds containing cell recognition sequence and osteo-inductive factors in combination with bone cells offers tremendous potential for bone and cartilage regeneration. In tissues, collagen forms the scaffold by mediating the flux of chemical and mechanical stimuli. Recently, a synthetic 15-residue peptide P-15, related biologically to the active domain of type I collagen, has been found to promote attachment and the osteoblast phenotype of human dermal fibroblasts and periodontal ligament fibroblasts on particulate anorganic bone mineral (ABM). The aim of this study was to exam the ability of the collagen peptide, P-15, to promote human osteoprogenitor attachment, proliferation and differentiation on cell culture surfaces and 3-D scaffolds.

Selected human bone marrow cells were cultured on particulate microporous anorganic bone mineral (‘pure ‘ hydroxyapatite based on x-ray diffraction standard JCPDS9-432) phase and polygalactin vicryl mesh adsorbed with or without P-15 in basal or osteogenic conditions. Cell adhesion, spreading and patterning were examined by light and confocal microscopy following incorporation of cell tracker green and ethidium homodimer fluorescent labels. Osteoprogenitor proliferation and differentiation was assessed by DNA content and alkaline phosphatase specific activity. Growth and differentiation on 3-D ABM structures were examined by confocal and scanning electron microscopy (SEM).

P-15 promoted human osteoprogenitor cell attachment and patterning on particulate bovine anorganic bone mineral phase and polygalactin vicryl mesh over 5–24 hours compared to culture on ABM and vicryl mesh alone as observed by photomicroscopy. Increased alkaline phosphatase specific activity was enhanced following culture on P-15 adsorbed matrices as recognized by enhanced expression of alkaline phosphatase, type I collagen, osteocalcin and cfba-1. The presence of mineralised bone matrix and extensive cell ingrowth and cellular bridging between 3-D ABM matrices and polygalactin vicryl mesh adsorbed with P-15 was observed by confocal microscopy and alizarin red staining. SEM confirmed the 3-D structure of newly formed cell constructs and cellular ingrowth on and between the P-15 modified inorganic bone mineral materials. Negligible cell growth was observed on ABM alone or polygalactin vicryl mesh alone.

These observations demonstrate that the synthetic 15-residue collagen peptide, P-15, when adsorbed to ABM or polygalactin vicryl mesh, can stimulate human osteoprogenitor attachment and spreading. They also demonstrated that P-15 coupled 3-D matrices stimulate human osteoprogenitor differentiation and materialisation. The studies indicate that a synthetic analogue of collagen provides a biomimetic environment supportive for cell differentiation and tissue regeneration and indicate a potential for the use of extracellular matrix cue in the development of biomimetic environments for bone tissue engineering.

There has been significant advancement in the principles and practices of Tissue Banking in Australia over the last two years. Those advances relate to scientific development, regulatory modulation and inter-relationships between both Federal and State governments. Licencing issues

The Therapeutic Goods Administration of the Federal Department of Health and Aged Care

Aims. Flucloxacillin is commonly administered intravenously for perioperative antimicrobial prophylaxis, while oral administration is typical for prophylaxis following smaller traumatic wounds. We assessed the time, for which the free flucloxacillin concentration was maintained above the minimum inhibitory concentration (fT > MIC) for methicillin-susceptible Staphylococcus aureus in soft and bone tissue, after intravenous and oral administration, using microdialysis in a porcine model. Methods. A total of 16 pigs were randomly allocated to either intravenous (Group IV) or oral (Group PO) flucloxacillin 1 g every six hours during a 24-hour period. Microdialysis was used for sampling in cancellous and cortical bone, subcutaneous tissue, and the knee joint. In addition, plasma was sampled. The flucloxacillin fT > MIC was evaluated using a low MIC target (0.5 μg/ml) and a high MIC target (2.0 μg/ml). Results. Intravenous administration resulted in longer fT > MIC (0.5 μg/ml) compared to oral administration, except for cortical bone. In Group IV, all pigs reached a concentration of 0.5 μg/ml in all compartments. The mean fT > MIC (0.5 μg/ml) was 149 minutes (95% confidence interval (CI) 119 to 179; range 68 to 323) in subcutaneous tissue and 61 minutes (95% CI 29 to 94; range 0 to 121) to 106 minutes (95% CI 76 to 136; range 71 to 154) in bone tissue. In Group PO, 0/8 pigs reached a concentration of 0.5 μg/ml in all compartments. For the high MIC target (2.0 μg/ml), fT > MIC was close to zero minutes in both groups across compartments. Conclusion. Although intravenous administration of flucloxacillin 1 g provided higher fT > MIC for the low MIC target compared to oral administration, concentrations were surprisingly low, particularly for bone tissue. Achievement of sufficient bone and soft tissue flucloxacillin concentrations may require a dose increase or continuous administration. Cite this article: Bone Joint Res 2021;10(1):60–67

Aim. The incidence of orthopaedic methicillin-resistant staphylococcus aureus infections is increasing. Vancomycin may therefore play an increasingly important role in orthopaedic perioperative antimicrobial prophylaxis. Adequate antimicrobial concentrations at target site is essential for prevention of orthopaedic infections. Current studies investigating perioperative bone and soft tissue concentrations of vancomycin are sparse and challenged by a lack of appropriate methods. The aim of this study was therefore to assess the concentration of vancomycin in plasma, subcutaneous tissue and bone after single dose administration using microdialysis (MD) in patients undergoing total knee replacement. Method. 1,000 mg of vancomycin was postoperatively administered intravenously over 100 minutes to 10 male patients undergoing primary total knee replacement. Vancomycin concentrations in plasma, subcutaneous tissue (SCT), cancellous and cortical bone were measured the following 8 hours. MD was applied for sampling in solid tissues. The vancomycin concentration in MD-samples was determined using ultra-high performance liquid chromatography, whilst the free plasma concentration was determined using a chemistry analyzer*. Results. For all extravascular tissue, an impaired penetration was demonstrated, with lower area under the concentration-time curve (AUC) compared to free plasma. The lowest AUC was found in cortical bone. For all tissues, tissue penetration expressed as the ratio of the area under the concentration–time curve from 0 to the last measured value (AUC0-last tissue/AUC0-last plasma) were below 0.5. The time to a mean clinically relevant minimal inhibitory concentration (MIC) of 2 mg/L were 3, 36, 27 and 110 min for plasma, SCT, cancellous and cortical bone, respectively. As opposed to the other compartments, a mean MIC of 4 mg/L was not reached in cortical bone. The AUC0-last and peak drug concentrations (Cmax) for SCT, cancellous and cortical bone were lower than those of free plasma. The time to Cmax was higher for all tissues compared with free plasma. Conclusions. Penetration of vancomycin to bone and SCT was found to be impaired and delayed in male patients undergoing total knee replacement surgery. Adequate perioperative vancomycin concentrations may not be reached at target site using standard prophylactic dosage. *Cobas c501

Purpose: The purpose of this study was to determine the rate of clinically detected deep venous thrombosis and pulmonary embolism in patients with trunk or extremity bone or soft tissue sarcomas. Patients and methods: The clinical records of patients with a confirmed diagnosis of primary bone or soft tissue sarcoma presenting between 1998 and 2003 were reviewed. Data relating to clinical features, risk factors for thromboembolism and clinical thromboembolic events were retrieved. Results: 252 patients were identified. 94 had a diagnosis of primary bone sarcoma and 158 a diagnosis of primary soft tissue sarcoma. The mean age was 53 (range 15 to 94); 137 (54%) were male. 37 patients were suspected clinically of having a deep venous thrombosis, 10 of which were confirmed radiologically, giving a rate of 4%. Nine patients had a suspected pulmonary embolism, 2 of which were confirmed radiologically and one of whom died of pulmonary embolism, giving an overall rate of fatal pulmonary embolism of 0.4%. All patients with thromboembolic events had lower extremity tumours and all were surgical patients. However, the majority of thromboembolic events (6 of 10 deep venous thromboses and 2 of 3 pulmonary embolisms) occurred prior to surgery. Discussion: The risk of a clinically apparent thromboembolic event in patients with bone or soft tissue sarcomas is comparable to that in other orthopaedic patients. Risk factors for venous thromboembolism include lower extremity sarcomas and mechanical obstruction of the venous system. Consideration should be given to excluding deep venous thrombosis before surgery

Introduction: Local recurrence of tumour following definitive treatment of bone or soft tissue sarcoma is a predictor of increased morbidity. Early detection of local recurrence may affect outcome. The role of magnetic resonance imaging (MRI) screening following definitive treatment is controversial. This study investigates the experience of one treatment centre with routine surveillance MRI following treatment of sarcoma. Methods: Patients were identified from the records of the Regional Sarcoma Group. With Local Ethics Committee approval the casenotes, MRI and histology reports for sixty-five patients who had routine surveillance MRI scans following definitive treatment of sarcoma in a single treatment centre were reviewed. The minimum follow up period was 24 months. The primary outcome was the presence of local tumour recurrence and whether this was identified on surveillance or interval scanning. Results: There were sixty-four patients identified with a bone or soft tissue sarcoma. All had undergone surveillance scanning biannually for the first year then annually. Six patients with Ewing’s sarcoma were excluded because they had not had surgical excision. Fifty-eight patients (59% men) with a bone or soft tissue sarcoma without metastasis between 1996 and 2003 were available for study. The median age at diagnosis was 53 years (range 6–78 years). Eighty three percent had a diagnosis of soft tissue sarcoma. Ten patients had a primary bone tumour. Fourteen patients had local recurrence (24%). Six were identified on surveillance scan, and the remaining eight required interval scans because of clinical suspicion of tumour recurrence. There were no statistical differences in gender, age, or tumour characteristics between those identified on surveillance or interval scans. All those detected on surveillance had intra-lesional or marginal resections. Conclusions: Surveillance scanning has a role in the early detection of local recurrence of bone and soft tissue sarcoma. Whether this results improvements in prognosis require longer-term follow up studies

The aims of the treatment of tibial infected nonunions with bone and soft tissue loss (generally consequent to open fractures) are: the healing of infection, the bone consolidation with preservation of lower limb length and the reconstruction of soft tissue loss. The epider-mato-fascio-osteoplasty according to Umiarov (a modification of bifocal or multifocal compression-distraction osteosynthesis) enables to treat wide areas of bone and soft tissue loss without a preventive sterilization of the infection neither soft tissues closure and without bone and skin grafts. An important point of the treatment is the prevention of complications such as: persistence of infection (due to an insufficient debridement), trouble in formation of bone regenerate and /or callus at the docking site (due to inadequate configuration of the external fixator, imperfect management of the phases of treatment, obstacles on bone transport), defect of skin coverage (due to an improper rate of bone and soft tissue transport), complications at the site of application of the device (inflammation or infection, breaking of the fixation elements), functional impairment (knee and ankle stiffness). In the 54 patients treated the anatomical and functional results have been particularly favourable, thanks to an accurate preoperative planning and a careful postoperative management, diminishing the risks of complications

This study investigates the experience of one treatment centre with routine surveillance MRI following excision of sarcoma. Casenotes, MRI and histology reports for fifty-nine patients were reviewed. The primary outcome was the presence of local tumour recurrence and whether this was identified on surveillance or interval scanning. Forty-eight patients had a diagnosis of soft tissue sarcoma, the remaining 11 a primary bone tumour. Fifteen patients had local recurrence (25%). Eight were identified on surveillance scan, and the remaining 7 required interval scans. Surveillance scanning has a role in the early detection of local recurrence of bone and soft tissue sarcoma

Introduction: The ‘Two Week Wait’ (2ww) process has been in force since the year 2000, with the subsequent implementation of 32-day diagnosis and 62-day treatment ‘rules’ in 2005. The aims of this study were to compile a definitive diagnostic profile of 2ww referrals, establish whether a histological biopsy was required for diagnosis and consider the current 2ww impact on services in our centre. Materials and Methods: Two hundred and nine patients were referred under 2ww to the North of England Bone and Soft Tissue Tumour service and prospectively recorded on a computerised multidisciplinary tumour database from 2006–8. The data was reviewed and verified using pathology, radiology reports and patient records. Results: Malignancy was diagnosed in 41(20%) patients. This comprised 21 soft tissue sarcomas (10%), 11 primary bone tumours (5%), and 9 metastatic bone tumours (4%). 63 (30%) benign bone or soft tissue neoplasia and 80 (38%) non-neoplastic conditions were diagnosed. No mass lesion was identifiable in 25 patients (12%). A diagnostic or therapeutic biopsy was required in 108 (52%) patients. Discussion and Conclusion: 15% of 2ww referrals to our centre have a primary bone or soft tissue sarcoma but over half of all 2ww patients require biopsy for diagnosis creating additional strains on resources under the 32- and 62-day rule. Emphasis is placed on obtaining a rapid diagnosis, to ease pressure on time to treatment, utilising a ‘one-stop clinic’ approach for biopsies of accessible tumours where applicable. The availability of timely radiological resources, facilitated by an MDT involving a designated coordinator (‘patient-tracker’), is key to ensure treatment is not delayed for any cancer patient regardless of referral route. Our centre is 100% compliant for waiting times for sarcoma according to the Department of Health 2008 data

Introduction: The ‘Two Week Wait’ (2ww) process has been in force since the year 2000, with the subsequent implementation of 32-day diagnosis and 62-day treatment ‘rules’, as part of reforms to NHS cancer services. The aims of this study were to compile a definitive diagnostic profile of 2ww referrals, establish whether a histological diagnosis was required and consider the current 2ww impact on services in our centre. Methods: Two hundred and nine patients were referred to the North of England Bone and Soft Tissue Tumour service and prospectively recorded on a computerised multidisciplinary tumour database from 2006–8. The data was reviewed and verified using pathology, radiology reports and patient records. Results: Malignancy was diagnosed in 41(20%) patients (n=209). This comprised 21 soft tissue sarcomas (10%), 11 primary bone tumours (5%), and 9 metastatic bone tumours (4%). 63 (30%) benign bone or soft tissue neoplasia and 80 (38%) non-neoplastic conditions were diagnosed. No mass lesion was identifiable in 25 patients (12%). A diagnostic or therapeutic biopsy was undertaken in 108 (52%) patients. Discussion: Fifteen percent of 2ww referrals to our centre have a primary bone or soft tissue malignancy. The 2ww caseload has increased significantly in recent years and non-malignant conditions (80%) must still be diagnosed within the 31 day rule. We utilise a ‘one-stop clinic’ approach, with access to ultrasound guided biopsy, and a weekly multidisciplinary meeting to facilitate timely investigation and treatment of all patients regardless of referral route

Introduction. The reduction of intraoperative blood loss during total knee arthroplasty (TKA) and total hip arthroplasty (THA) and even organ resection is an important factor for surgeons as well as the patient. In order to cauterize blood vessels to stop bleeding diathermy is commonly used and involves the use of high frequency and induces localized tissue damage and burning. Saline-coupled bipolar sealing RFE technology however has been shown to reduce tissue carbonization, however the dosage effects of RFE are not well known for both bone and soft tissue. This study examined sealing progression of blood vessels using a range of energy levels of saline-coupled bipolar RFE on bone and various soft tissues in a non-survival animal study. Materials and Methods. Following institutional ethical approval, three mature sheep were used to examine the cancellous bone of the femoral trochlear groove and soft tissue (liver, kidney, lung, pancreas and mesentry peritoneum) subjected to the following treatment regime varying by watts and time: (1) untreated control, (2) 50 W for 1 sec, 2 sec, 3 sec and 5 sec, (3) 140 W for 1 sec, 2 sec, 3 sec and 5 sec and (4) 170 W for 1 sec, 2 sec, 3 sec and 5 sec. The Aquamantys™ System Generator and hand piece (Salient Surgical Technologies, Inc, Portsmouth, NH) coupled to a saline (0.9% NaCl) drip was used to apply RFE to the various tissues. Two clinical diathermy settings were used as controls. Tissues were immediately harvested, fixed in 10% buffered formalin and prepared for routine paraffin histology. Stained sections were evaluated in a blinded fashion for the acute in vivo response. Result. Soft tissue histology treated with the Aquamantys System revealed varying degrees of coagulation and blood vessel sealing. Initial observations were indicative of hemostasis. Once RFE and saline were applied to the tissues, the blood vessels constricted and platelets were observed along the blood vessels to provide a seal to cover the break in the vessel wall. No smoke or char formation was evident when this system was placed in contact with the tissues. Higher frequency revealed an increased cluster of platelets along the vessel wall. Saline-coupled bipolar RFE application on bone demonstrated blood vessel sealing and clumping of bone marrow. With increased frequency and time red blood cells clumped together however the most significant observation was that the surrounding bone remained normal and no damage was evident. Diathermy however demonstrated a complete disruption of the collagen fibres. Conclusions. Saline-coupled bipolar RFE can provide many clinical benefits not just during orthopaedic reconstruction but also during spine surgery and clinical oncology. The use of high frequencies for longer periods of time enables complete sealing of blood vessels without damage to the tissue or bone

Aims: Surgical treatment big defect of long bone and soft tissue of extremities is one of more difþcult surgical problems in orthopedics and traumatology. Methods: A hundred and twenty patient with big defect of bone and soft tissue wounded during the war in Bosnia and Herzegovina ware treated in Cantons Hospital Zenica. Only twenty patient treated with primary shortening and secondary lengthening, with Illizarov technique and Ilizarov external þxation. Results: Defects of bone ware from 3 Ð 32 cm, the middling defect was 12 cm. The middling time of treatment by every patient was about one year. There were not any plastic operation, amputation, pseudarthrosis and osteomyelitis. Conclusions: Our experience said us that the primary shortening Ð secondary lengthening is the best of choice for treatment big defect of long bone and soft tissue of extremities

Purpose: Management of extensive tibial loss raises the question of indications for vascularised grafts. These techniques depend on the number of functional vascular trunks available. We developed a modified technique which allows using this type of graft without sacrificing the tibial pedicle, making it usable when only one trunk remains functional. We use the fibular arterial supply to bridge the remaining axis. The purpose of this work was to detail the modalities of this technique and provide early results. Material and method: Since 2000, we have reserved this technique for infected nonunion with loss of tibial tissue extending over 5 cm in patients who decline amputation. Four patients (four men, mean age 30 years) underwent the procedure. The initial trauma resulted from a motorcycle (n=3) or firearm (n=1) accident. The patients were referred to our unit within three months on the average. Prior treatments (cancellous graft in an open or intrafocal procedure) had failed in all patients who presented persistent infection. Antibiotics were administered until bone healing in all patients. Mean length of the gap was 10 cm (7 – 15 cm). The composite graft (skin and fibula with a vascularised fibular bundle) was raised from the contralateral limb and cross-leg anastomosed proximally and distally on the receiver anterior tibial bundle (all four cases). Results: All fractures consolidated between six and twelve months after initiating management of this technique. Bone and soft tissue losses healed without shortening. There were not repeated fractures after mean follow-up of twelve months (range eight months to two years). No complementary bone graft was necessary. Infection resolved in all patients. Discussion and conclusion: As for classical vascularised fibula grafts, this technique enables controlling bone and soft tissue problems together (composite graft). The graft is vascularised favouring antibiotic diffusion. The mechanical quality is better than with a pure cancellous graft but longer follow-up would be required to determine the rate of repeated fractures. This technique broadens indications for vascularised fibula grafts which can be used in unfavourable vascular contexts where only one or two leg trunks persist

Tibial fractures complicated by bone and/or soft tissue loss present a great challenge. Traditional methods of limb reconstruction are lengthy and may not yield satisfactory functional results. Despite its tremendous contribution to the management of this condition, the Ilizarov technique of bone transport has several problems and difficulties. The present study was carried out between 1997 and 2002 and included 21 patients with tibial fractures complicated by bone and soft tissue defects as a result of open fractures or surgical debridement of infected non-unions. The bone loss ranged from three to eleven cm. (average 4.7 cm.). Ages ranged from 12 to 54 years (average 28.8 years). The follow-up ranged from 24 to 75 months. The procedure included resection of all devitalised tissues, acute limb shortening to close the defect, application of the external fixator and metaphyseal osteotomy for re-lengthening. In all patients the fractures united with well aligned limbs. Acute limb shortening of up to six cm. was done in the lower third of the leg. Limb lengthening was done in all cases and ranged from 3 to 9.5 cm. (average 4 cm.). An Ilizarov external fixator was used in nine cases (41%) and a monolateral fixator in 13 cases (59%) with a total of 22 applications. Residual leg length discrepancy of more than 3cm. occurred in four cases (19%). Complications included one refracture, one transient peroneal nerve palsy and one equinus contracture of ten degrees. Satisfactory results were obtained in 93% of cases. Acute limb shortening and re-lengthening converts a complicated limb reconstruction into a relatively simpler one of linear limb lengthening, without the difficulties of traditional Ilizarov techniques and eliminated the need for soft tissue flaps. It is better instituted early in the management of these cases to ensure better functional results and shorter treatment time

Disease-free survival and local relapse rates in patients with malignant bone tumors are similar following limb salvage and amputation. However, while there has been considerable interest in comparative function after surgery, as assessed by clinicians, there is less information on patient-reported outcomes (PROs). Interest in PROs has evolved from recognizing the usefulness of measures of (health-related) quality of life (HRQL) and the acceptance that the “gold standard” in such assessments is provided by the individual reporting on his/her own health status. In the context of cancer and cancer-treatment, the importance of PROs is firmly embedded in the conduct of clinical trials, as documented by the Cancer Outcomes Working Group of the National Cancer Institute (NCI) in the USA. The NCI has promoted the development of appropriate instruments for eliciting and evaluating PROs through the Patient Reported Outcomes Measurement Information System (PROMIS). Similar initiatives have been undertaken in Canada, the United Kingdom, Western Europe and elsewhere. This topic was the subject of a series of reviews in a recent issue of the Journal of Clinical Oncology. Large studies in the United States and Canada revealed that, among survivors of cancer in childhood and adolescence, those who had had brain or bone tumors experienced the greatest compromise in physical performance, psychosocial outcomes and HRQL. Inclusion of PROs and measures of HRQL are still not routine in the design and conduct of clinical trials, and these are seldom used in regular day-to-day practice by clinical oncologists who have yet to be sufficiently persuaded of the added value provided by such determinations. However, the orthopedic community lead the way more than 25 years ago with an assessment of HRQL following treatment of sarcomas of the extremities (at that time refuting the commonly held belief that any therapy, no matter how “aggressive”, was better than limb amputation). That study enrolled only a small number of patients and the therapeutic (especially surgical) options have changed substantially in a generation, but a “marker” was established and the challenge to provide current evidence remains. Measures of HRQL that focus on orthopedic problems have been developed and subjected to recent rigorous review. But assessments are subject to many confounding factors such as age, gender, diagnosticdetails (tumor type, size and location), prior (neo-adjuvant) and subsequent therapy, the era of treatment and the time elapsed since surgical intervention. Sample sizes will need to be very large to address these variables. Despite the almost consistent problem of small samples, some common findings emerge. Females experience poorer outcomes than males; there can be improvement over time; and, insofar as they are comparable (candidates for amputation are seldom candidates for limb salvage surgery), the differences in HRQL among amputees, patients who had rotationplasties, and those who underwent limb salvage (with endoprostheses or bone grafts) are small. Measures of functional outcome and HRQL are neither fully inter-changeable nor mutually exclusive, and much remains to be learned from the measurement of PROs in patients with bone and soft tissue sarcomas