Purpose. The traditional management of pediatric aneurysmal bone cysts involves the application of intralesional resection principles that are used to treat benign aggressive tumors in general. Alternatively, some are treated by injections of sclerosing agents. The risks of these approaches include growth arrest, additional bony destruction necessitating the restoration of structural integrity, and soft tissue necrosis. We wished to evaluate the effectiveness of treating aneurysmal bone cysts in children by percutaneous
Benign aggressive tumors are common and can be debilitating for patients especially if they are in peri-articular regions or cause pathological fracture as is common for giant cell tumor of bone (GCT). Although GCT rarely metastasize, the literature reports many series with high rates of local recurrence, and evidence about which risk factors influence recurrence is lacking. This study aims to evaluate the recurrence rate and identify local recurrence risk factors by reviewing patient data from a single high-volume orthopedic oncology center. A retrospective analysis of all patients treated for GCT at a tertiary orthopedic oncology center was conducted. In total 413 patients were treated for GCT between 1989 and 2017. Multiple patient and tumour characteristics were analysed to determine if they influenced local recurrence including: age, gender, anatomical site, Campanacci stage, soft tissue extension, presence of metastasis, pathologic fractures, and prior local recurrence. Additional variables that were analysed included type of treatment (en bloc resection or aggressive intralesional curettage) and use of local adjuvants. The main outcome parameters were local recurrence- free survival, metastasis-free survival and complications. Patients treated with Denosumab were excluded from analysis given its recently documented association with high rates of local recurrence. “There were 63/413 local recurrences (15.3%) at a mean follow-up of 30.5 months. The metastatic rate was 2.2% at a mean 50.6 months follow-up and did not vary based on type of treatment. Overall complication rate of 14.3% was not related to treatment modality. Local recurrence was higher (p=0.019) following
Aim. Pin site infection (PSI) is a common complication of external fixators. PSI usually presents as a superficial infection which is treated conservatively. This study investigated those rare cases of PSI requiring surgery due to persistent osteomyelitis (OM), after pin removal. Method. In this retrospective cohort study we identified patients who required surgery for an OM after PSI (Checketts-Otterburn Classification Grade 6) between 2011 and 2021. We investigated patient demographics, aetiology of the OM, pathogen and histology, treatment strategies and complications. Infection was confirmed using the 2018 FRI Consensus Definition. Successful outcome was defined as an infection-free interval of at least 24 months following surgery, which was defined as minimum follow-up. Results. Twenty-seven patients were treated due to a pin site infection with an osteomyelitis (22 tibias, 2 humeri, 2 calcanei, 1 radius). 85% identified as male and the median age was 53.9 years. Eighteen infections followed external fixation of fractures, with 4 cases after Ilizarov deformity correction, 2 cases followed ankle fusion and 3 after traction pin insertion. Fifteen patients were classified as BACH Uncomplicated and 12 were BACH Complex. The median follow-up was 3.99 years (2.00–8.05 years). Staphylococci were the most common pathogens (16 MSSA, 2 MRSA, 2 CNS). Polymicrobial infections were present in 5 cases (19%). All surgery was performed in a single stage following the same protocol at one institution. This included deep sampling, debridement, implantation of local antibiotics, culture-specific systemic antibiotics and soft tissue closure. Seven patients required flap coverage (6 local, 1 free flap), which was performed in the same operation. 25 (93%) patients had a successful outcome after one surgery. Two had recurrence of infection which was successfully treated by repeat of the protocol. One patient suffered a fracture through the operated site after a fall. This healed without infection recurrence. Wound leakage after local antibiotic treatment was seen in 3/27 (11%) of cases. All resolved without treatment. After a minimum of 2 years follow up, all patients were infection free at the site of the former osteomyelitis. Conclusions. OM after PSI is uncommon but has major implications for the patient as 7 out of 27 patients needed flap coverage. This reinforces the need for careful pin placement and pin site care to prevent deep infection. These infections require appropriate surgery, not just
Cartilage lesions vary in the spectrum from benign enchondromas to highly malignant dedifferentiated chondrosarcomas. From the treatment perspective, enchondromas are observed, Grade 1 chondrosarcomas are curetted like aggressive benign tumors, and rest are resected like other sarcomas. Although biopsy for tissue diagnosis is the gold standard for diagnosis and grade determination in chondrosarcoma, tumor heterogeneity limits the grading in patients following a biopsy. In the absence of definite pre-treatment grading, a surgeon is therefore often in a dilemma when deciding the best treatment option. Radiology has identified aggressive features and aggressiveness scores have been used to try and grade these tumors based on the imaging characteristics but there have been very few published reports with a uniform group and large number of cases to derive a consistent scoring and correlation. The authors asked these study questions :(1) Does Radiology Aggressiveness and its Score correlate with the grade of chondrosarcoma? (2) Can a cut off Radiology Agressiveness Score value be used to guide the clinician and add value to needle biopsy information in offering histological grade dependent management?. A retrospective analysis of patients with long bone extremity intraosseous primary chondrosarcomas were correlated with the final histology grade for the operated patients and Radiological parameters with 9 parameters identified a priori and from published literature (radiology aggressiveness scores - RAS) were evaluated and tabulated. 137 patients were identified and 2 patients were eliminated for prior surgical intervention. All patients had tissue diagnosis available and pre-treatment local radiology investigations (radiographs and/or CT scans and MRI scans) to define the RAS parameters. Spearman correlation has indicated that there was a significant positive association between RAS and final histology grading of long bone primary intraosseous chondrosarcomas. We expect higher RAS values will provide grading information in patients with inconclusive pre-surgery biopsy to tumor grades and aid in correct grade dependant surgical management of the lesion. Prediction of dedifferentiated chondrosarcoma from higher RAS will be attempted and a correlation to obtain a RAS cut off, although this may be challenging to achieve due to the overlap of features across the intermediate grade, high grade and dedifferentiated grades. Radiology Aggressiveness correlates with the histologic grade in long bone extremity primary chondrosarcomas and the correlation of radiology and biopsy can aid in treatment planning by guiding us towards a low-grade neoplasm which may be dealt with intralesional extended
Introduction. Fibrous dysplasia is a pathological condition, where normal medullary bone is replaced by fibrous tissue and small, woven specules of bone. Fibrous dysplasia can occur in epiphysis, metaphysis or diaphysis. Occationally, biopsy is necessary to establish the diagnosis. We present a review of operative treatment using the Ilizarov technique. The management of tibial fibrous dysplasia in children are
Sarcomas generally metastasize to the lung, while extra-pulmonary metastases are rare. However, they may occur more frequently in certain histological sub-types. Bone metastases from bone and soft tissue sarcomas account for a significant number of extra-pulmonary disease. Resection of lung metastases is widely accepted as therapeutic option to improve the survival of oligometastatic patients but there is currently no literature supporting curative surgical management of sarcoma bone metastases. Most are treated on a case-by-case basis, following multidisciplinary tumour boards recommendations. One study reported some success in controlling bone metastases using radiofrequency ablation. Our goal was to assess the impact of curative resection of bone metastases from soft tissue and bone sarcomas on oncologic outcomes. Extensive review of literature was done to evaluate epidemiological and outcomes of bone metastases in sarcoma. We examined our prospective database for all cases of bone metastases from sarcoma treated with surgical resection between 1990 and 2016. Epidemiology, pathology, metastatic status upon diagnosis, type of secondary relapses and their treatments were recorded. Overall survival and disease-free survival were calculated and compared to literature. Thirty-five patients were included (18 men, 17 women) with a mean age of 46 years. Fifteen were soft tissue (STS) and 20 were bone (BS) sarcomas. Most STS were fibrosarcomas, leiomyosarcomas or UPS while chondrosarcomas and osteosarcomas were the most frequent BS. Nine (60%) STS were grade 3, 4 (27%) grade 2 and one grade 1 (3%). Eight (23%) were metastatic upon diagnosis (6 lungs, 3 bone). Treatment of the primary tumour included wide excision with reconstruction and (neo)-adjuvant therapies as required. Margins were negative in 32 cases and micro-positive in 3 cases. Amputation occurred in 6 (17%) cases. Primary lung metastases were treated by thoracotomy and primary bone metastases by wide excision. First relapse occurred in bone in 19 cases (54%), lungs and bone in 7 cases, 5 in lungs and 4 in soft-tissues. Lung metastases were treated by thoracotomy and chemotherapy in 3 cases, chemotherapy alone in the remaining cases. Bone metastases were treated by wide resection-reconstruction in 24 cases, extensive
Chondroblastomas arise in the epiphyseal area of bones. In the femoral head this can cause considerable difficulty in obtaining access as the epiphysis is entirely intra-articular. We have reviewed management and outcome of 10 patients with chondroblastoma of the femoral head to identify outcome and complications. The mean age was 14 years and all presented with pain (frequently in the knee) and a limp. All were diagnosed on plain Xray and MRI. Five younger children were treated by
Background. Resection of sacral chordoma remains challenging because complex anatomy and important nerves in the sacrum make it difficult to achieve wide surgical margins. Computer-assisted navigation has shown promise in aiding in optimal preoperative planning and in providing accurate and precise tumour resection during surgery. Purpose. To evaluate the benefit of using computer-assisted navigation in precise resection of sacral chordoma. Methods. From 2007 to 2012, we performed sacral chordoma resections with computer-assisted navigation in 19 consecutive patients, of which 15 were primary and 4 were recurrent. There were 11 male and 8 female patients with a mean age of 53.5 years (range, 36–81 years). Eighteen lesions had their upper extent above S3 and the remaining one was below S3. Reconstructed three-dimensional images were used to plan the bone resection before operation. Five patients were treated with CT-based navigation system. 14 cases got ISO-C scanned during operation and CT and MR images were fused using the navigation software. Results. The mean intra-operative blood loss was 2821 mL and the mean operating time was 300 minutes. The mean deviation of registration during operation was 1.5 mm. Wide margins and marginal margins proved by specimen evaluation were achieved in 3 patients and 14 patients, respectively. Two patients received extensive
Background. Treatment of aggressive benign bone lesions with
Introduction. the aim of this study was to analyse the long-term radiological changes following tsa in order to better understand the mechanisms responsible for loosening. Material and methods. between 1991 and 2003, in 10 European centers, 611 shoulder arthroplasties were performed for primary osteoarthritis using a third generation anatomic prosthesis with a cemented all-polyethylene keeled glenoid component. Full radiographic and clinical follow-up greater than 5 years was available for 518 shoulders. Kaplan-meier survivorship analysis was performed with glenoid revision for loosening and radiological loosening as end points; clinical outcome was assessed with the constant score, patient satisfaction score, subjective shoulder value and range of movement. Results. after a mean follow-up of 103,6 months (61-209 months),the constant score improved significantly(p<0,0001) from 30,1 points pre-operatively to 65,2 points at latest follow-up. the active anterior elevation increased from 91,5 to 138,1 degrees (p<0,0001),and active external rotation increased from 7,9 to 33,2 degrees (p<0,0001). 90,3% of patients were either very satisfied or satisfied with their outcome and the average ssv was 77,1%. radiological loosening was found in 166 cases(32%).three pattern of glenoid component migation were observed in 136 cases: superior tilting (10%), posterior tilting(6,3%), and a subsidence (7,9%) of the glenoid component. different risk factors were statistically associated with the migration of the glenoid component(p<0,001):proximal migration of the humeral head, excessive reaming of the glenoid, type of glenoid preparation for the keel (i.e.
Introduction. Metal on metal hip resurfacing (MoM HR) is attractive for young active patients. Patients with osteonecrosis of the femoral head (ONFH) are relatively young. HR can be an option of treatment, however, long-term stability of the femoral component is a concern because of the necrotic lesion in the femoral head. There is also a concern of ARMD for MoM implants. The purpose of this study is review a 10 year outcome of a consecutive patients with ONFH who underwent MoM HR. Methods. The subjects of this study were 30 hips of 26 patients with ONFH who underwent HR between 1998 and 2004. There were 21 hips of 18 males and 9 hips of 8 females. The average age at operation was 40 years (range, 20–63 years). 19 ONFHs were induced by steroid and 11 ONFHs were alcohol related. According to the Japanese Investigation Committee classification, there were 8 hips with Type C1 and 22 hips with Type C2. There were 16 hips in stage 3A, 7 hips in Stage 3B, and 7 hips in Stage 4. Operation was performed through a posterior approach. A fragile necrotic bone was
Primary tuberculous bursitis was a relatively frequent manifestation of the disease before the antituberculosis drug era. Nowadays, it is considered a rare condition; it accounts for 1–2% of all musculoskeletal tuberculosis. The diagnosis and treatment of tuberculous bursitis may be delayed because the paucity of symptoms, its indolent clinical course and a low clinical suspicion. A 50-year-old patient with tuberculous trochanteric bursitis is reported. A 50-year-old woman was referred to our department to investigate a persistent pain in her left hip with 6 months duration. She was afebrile. The examination revealed a diffuse swelling from the buttock through the thigh, notable over the trochanter, but no sign of acute inflammation such as heat and redness. Her past medical and family histories revealed no previous tuberculosis. Plain films of the left hip showed a partial destruction of the margin of the greater trochanter, lytic foci in the underlying bone and a small focus of calcification in the adjacent soft tissues. A computed tomogram showed a soft tissue mass and demonstrated the relationship with the trochanter. We performed a needle biopsy which revealed granulomatous tissue. The patient underwent complete excision of the bursa and
It has become standard practice in our unit to treat large giant cell tumours with intralesional
Salmonella osteomyelitis occurs infrequently in children without a sickle cell disease, and its subacute form is rare. Diagnosis is often delayed because its slow onset, intermittent pain and it can be confused with bone tumors. An otherwise healthy 13-year-old boy was admitted from another center in order to discard bone tumor in proximal tibia, with compatible radiologic findings. There was no history of trauma or previous illness. Twenty days ago, he had flu symptoms and myalgia. On the physical examination the child was feverless, showed increased heat over his left knee, considerable effusion and painful restriction of movement. Inflammatory laboratory results revealed erythrocyte sedimentation rate 46mm/h and C-Reactive protein, 11,2 mg/L. Radiographs revealed a lytic lesion localized in the proximal metaphysis and epiphysis. The MRI showed an area of edema around the lytic lesion and surrounding soft tissues. Images supported the diagnosis of subacute osteomyelitis, (Brodie abscess). Empirically, intravenous cefuroxime was started. Forty-eight hours post admission, the patient underwent abscess surgical debridement, washout and cavity
The aim of this study is to assess the long-term results of Ethibloc (Ethnor Laboratories/ Ethicon, Norderstedt, Germany) injection in aneurysmal bone cysts (ABC). 33 patients with aneurysmal bone cysts were treated with computed tomographic (C.T) guided percutaneous injection of Ethibloc into the cyst cavity. 22 patients had Ethibloc injection as primary treatment and 11 patients had presented to us with recurrence following previous procedures including steroid injection, bone marrow injection,
Introduction. Pathologic humerus fractures secondary to metastases are associated with significant pain, morbidity, loss of function, and diminished quality of life. Here we report our experience with stabilisation using intramedullary polymethylmethacrylate (PMMA) cement and non-locking plates. Methods. A retrospective review was undertaken of patients treated at a tertiary musculoskeletal oncology centre from 1989 to 2009. Patients who underwent surgery for an impending or completed pathologic humerus fracture with a diagnosis of metastatic disease or myeloma were included. All patients underwent intralesional
Introduction. Objective was to assess clinical results of treatment of Infected Non Union (INU) of long bones, using Antibiotic Cement Impregnated Nail (ACIN), a single or two staged approach, Stage 1 - Debridement, eradication of infection, primary stabilization with (ACIN). 2nd Stage - Definitive stabilization and early rehabilitation. Methods. 185 cases of infected non-union of long bones from Jan 2002 to Jan 2009 were treated in this hospital. 46 females and 139 males, age varied from 17–65 years (Avg. 40). Tibia was the commonest bone to be affected, followed by femur & humerus. The control of infection was by debridement, antibiotic cement impregnated K-nail (ACIN) insertion with or without Ilizarov ring fixator application, second stage treatment by definitive internal fixation and bone grafting was done if required. Average duration of follow up, was 26 months (14–58 months). Main outcome measurements were assessment of bone healing, functional outcome, healing time and complications. Results. Out of the 185 cases treated in our institute 174 (93.7%) patients achieved union at an average of 8 months. 2 limbs with non union tibia fractures were amputed on demand by patients, 2 limbs developed severe edema, 7 patients did not achieve union, inspite of repeated procedures. Infection was controlled early especially in Type 1 non unions. 5 patients had persistent infection though mild inspite of 2 or 3 surgeries of exploration and
The aim of this study was to examine the progression of osteolytic lesions following liner exchange surgery and relate this to the size of the lesion prior to surgery, and whether the defect underwent
In response to the COVID-19 pandemic, there was a rapidly implemented restructuring of UK healthcare services. The The Royal National Orthopaedic Hospital, Stanmore, became a central hub for the provision of trauma services for North Central/East London (NCEL) while providing a musculoskeletal tumour service for the south of England, the Midlands, and Wales and an urgent spinal service for London. This study reviews our paediatric practice over this period in order to share our experience and lessons learned. Our hospital admission pathways are described and the safety of surgical and interventional radiological procedures performed under general anaesthesia (GA) with regards to COVID-19 in a paediatric population are evaluated. All paediatric patients (≤ 16 years) treated in our institution during the six-week peak period of the pandemic were included. Prospective data for all paediatric trauma and urgent elective admissions and retrospective data for all sarcoma admissions were collected. Telephone interviews were conducted with all patients and families to assess COVID-19 related morbidity at 14 days post-discharge.Introduction
Methods
Hydatid disease of bone is rare. It probably represents between 0.5% and 4% of all human shydatid disease and, in about 60% of patients, affects the spine or pelvis. Between 1986 and 1998, we treated 15 cases of bone hydatidosis.