We present a case report of postoperative pain following THR, which was initially diagnosed as infection. The salutary message is that the correct diagnosis was a secondary tumour.

A fifty three year old man had a primary right total hip replacement for osteoarthritis, using an uncemented CAD CAM (computer aided design, computer aided manufacture) prosthesis with a Trilogy cup. Postoperatively he recovered uneventfully, with a normal range of movement and good function; there were no radiographic abnormalities noted at the time. Two years after operation, he developed pain in the right thigh. His doctor referred him for investigation of his back, which was normal. He was then seen by an orthopaedic surgeon who diagnosed infection, based on an X-ray that revealed a destructive lesion of the upper femur. He was referred back to the senior author, who felt that the X-ray was more suggestive of tumour than infection; further investigation, with MRI and ultrasound confirmed the presence of a tumour; isotope bone scanning revealed it to be solitary. A needle biopsy showed follicular thyroid tumour to be present; this was confirmed by immunohistochemistry. His past medical history included a history of hemithyroidectomy eight years prior to the hip replacement – this was for what was believed to be a benign thyroid nodule. CT of his chest revealed multiple lung metastases.

Review of the X-ray taken six months post-operatively suggests, in retrospect, that the destructive process had already begun. He has been treated with a total thyroidectomy and radiotherapy to the right hip with encouraging early results. He is also having chemotherapy for the pulmonary metastases. Thyroid tumours metastasise by blood and commonly occur in bone; the proximal femur is a frequent site for metastasis. It is likely that the occurrence is coincidental.

Using serial CT scans, this project aims to develop a clinical research tool that analyzes changes in vertebral density in spines involved with metastatic disease. Tracking of total vertebral body and tumor volume alone was investigated. A program was developed to semi-automate the segmentation of the region of interest followed by image registration to superimpose the segmentation onto spatially aligned serial scans. Based on analysis of a simulated metastatic vertebra, generating a voxel distribution histogram from the vertebral body best quantified density in serial scans. This quantification method may improve clinical decision-making and treatment options for patients with vertebral metastases.

To develop a clinical research tool to serially track tumor involvement in vertebrae with metastatic disease by quantifying changes in CT attenuation.

Segmentation of the vertebral body and analysis of the voxel distribution within the region provides the most accurate method of quantifying changes in tumor involvement for the metastatic spine.

A quantitative method to assess the progression or regression of disease may improve clinical decision–making and treatment options for patients with spinal metastases.

The vertebral body segmentation was more accurate at tracking tumor involvement (voxel distribution histogram: 96.8% +/− 0.75% accuracy, mean density error: 4.7% +/− 0.8%) than segmenting the tumor volume alone (voxel distribution histogram: 86.1% +/− 3.6% accuracy, mean density error: 14.1% +/− 4.8%).

A program was developed to semi-automatically segment the total vertebral body and tumor volume alone from CT scans of metastatically involved vertebrae. Image registration through user-defined landmarks and surface matching was used to spatially align serial scans, and the initial segmentation was superimposed with the aligned scans. Changes within the segmentation between CT scans were tracked using mean density and a voxel distribution histogram. A cadaveric vertebra with a simulated tumor was scanned at five orientations with 20° offsets to determine the accuracy of the methods. Error primarily resulted from unavoidable re-sampling during alignment of the scans.

Aims

Frailty has been gathering attention as a factor to predict surgical outcomes. However, the association of frailty with postoperative complications remains controversial in spinal metastases surgery. We therefore designed a prospective study to elucidate risk factors for postoperative complications with a focus on frailty.

Endoprosthetic replacement of the proximal femur may be required to treat primary bone tumours or destructive metastases either with impending or established pathological fracture. Modular prostheses are available off the shelf and can be adapted to most reconstructive situations for this purpose. We have assessed the clinical and functional outcome of using the METS (Stanmore Implants Worldwide) modular tumour prosthesis to reconstruct the proximal femur in 100 consecutive patients between 2001 and 2006. We compared the results with the published series for patients managed with modular and custom-made endoprosthetic replacements for the same conditions. There were 52 males and 48 females with a mean age of 56.3 years (16 to 84) and a mean follow-up of 24.6 months (0 to 60). In 65 patients the procedure was undertaken for metastases, in 25 for a primary bone tumour, and in ten for other malignant conditions. A total of 46 patients presented with a pathological fracture, and 19 presented with failed fixation of a previous pathological fracture. The overall patient survival was 63.6% at one year and 23.1% at five years, and was significantly better for patients with a primary bone tumour than for those with metastatic tumour (82.3% vs 53.3%, respectively at one year (p = 0.003)). There were six early dislocations of which five could be treated by closed reduction. No patient needed revision surgery for dislocation. Revision surgery was required by six (6%) patients, five for pain caused by acetabular wear and one for tumour progression. Amputation was needed in four patients for local recurrence or infection. The estimated five-year implant survival with revision as the endpoint was 90.7%. The mean Toronto Extremity Salvage score was 61% (51% to 95%). The implant survival and complications resulting from the use of the modular system were comparable to the published series of both custom-made and other modular proximal femoral implants. We conclude that at intermediate follow-up the modular tumour prosthesis for proximal femur replacement provides versatility, a low incidence of implant-related complications and acceptable function for patients with metastatic tumours, pathological fractures and failed fixation of the proximal femur. It also functions as well as a custom-made endoprosthetic replacement

Introduction: Modular tumour prosthetic replacement is especially useful in the region of proximal femur following pathological fractures and failed fixation. The aim of the study was to assess the clinical and functional outcomes following modular tumour prosthesis reconstruction of the proximal femur in 100 consecutive patients with metastatic tumours and to assess its cost effectiveness. Methods: The study was a retrospective review of 100 consecutive patients who underwent modular tumour prosthetic reconstruction of the proximal femur using the METS prosthesis [Stanmore Implants Worldwide] for metastatic tumours from 2001 to 2008. Results and conclusion: There were 45 male and 55 female patients. The mean age was 60.2 years. The indications were metastasis [23renal ca, 28 breast ca, 11 ca bronchus, 5 ca prostate and 31 others]. 75 patients presented with pathological fracture or with failed fixation and 25 patients were at a high risk of developing fracture. The mean follow up was 24.6 months [range0–74]. Three patients died within 2 weeks following surgery. Of the 60 patients who were dead 58 did not need revision surgery indicating that the implant provided single definitive treatment which outlived the patient. 1 patient had revision surgery. There were 2 dislocations. 6 patients had deep infections. The implant survival was 98% with revision or amputation as end point. The hospital cost of an endoprosthetic replacement is estimated to be £12,000. This procedure becomes cost effective when compared with no treatment if the patients’ life expectancy is more than 40 days and when compared with internal fixation if the patients’ life expectancy is more than 2 years. We conclude that METS modular tumour prosthesis for proximal femur provides versatility; low implant related complications and acceptable function lasting the lifetime of the patients with metastatic tumours of the proximal femur providing a cost effective solution

Residual tumor cells left in the bone defect after malignant bone tumor resection can result in local tumor recurrence and high mortality. Therefore, ideal bone filling materials should not only aid bone reconstruction or regeneration, but also exert local chemotherapeutic efficacy. However, common bone substitutes used in clinics are barely studied in research for local delivery of chemotherapeutic drugs. Here, we aimed to use facile manufacturing methods to render polymethylmethacrylate (PMMA) cement and ceramic granules suitable for local delivery of cisplatin to limit bone tumor recurrence. Porosity was introduced into PMMA cement by adding 1-4% carboxymethylcellulose (CMC) containing cisplatin, and chemotherapeutic activity was rendered to two types of granules via adsorption. Then, mechanical properties, porosity, morphology, drug release kinetics, ex vivo reconstructive properties of porous PMMA and in vitro anti-cancer efficacy against osteosarcoma cells were assessed. Morphologies, molecular structures, drug release profiles and in vitro cytostatic effects of two different drug-loaded granules on the proliferation of metastatic bone tumor cells were investigated. The mechanical strengths of PMMA-based cements were sufficient for tibia reconstruction at CMC contents lower than 4% (≤3%). The concentrations of released cisplatin (12.1% and 16.6% from PMMA with 3% and 4% CMC, respectively) were sufficient for killing of osteosarcoma cells, and the fraction of dead cells increased to 91.3% within 7 days. Functionalized xenogeneic granules released 29.5% of cisplatin, but synthetic CaP granules only released 1.4% of cisplatin over 28 days. The immobilized and released cisplatin retained its anti-cancer efficacy and showed dose-dependent cytostatic effects on the viability of metastatic bone tumor cells. Bone substitutes can be rendered therapeutically active for anticancer efficacy by functionalization with cisplatin. As such, our data suggest that multi-functional PMMA-based cements and cisplatin-loaded granules represent viable treatment options for filling bone defects after bone tumor resection

We retrospectively reviewed 71 histopathologically-confirmed bone and soft-tissue metastases of unknown origin at presentation. In order to identify the site of the primary tumour all 71 cases were examined with conventional procedures, including CT, serum tumour markers, a plain radiograph, ultrasound examination and endoscopic examinations, and 24 of the 71 cases underwent 2-deoxy-2-[F-18] fluoro-D-glucose positron emission tomography (FDG-PET). This detected multiple bone metastases in nine patients and the primary site in 12 of the 24 cases; conventional studies revealed 16 primary tumours. There was no significant difference in sensitivity between FDG-PET and conventional studies. The mean maximal standardised uptake value of the metastatic tumours was significantly higher than that of the primary tumours, which is likely to explain why FDG-PET did not provide better results. It was not superior to conventional procedures in the search for the primary site of bone and soft-tissue metastases; however, it seemed to be useful in the staging of malignancy

We present two cases of metastatic lung cancer which occurred at the site of a previously united tibial fracture. Both patients were treated with a locked intramedullary nail. The patients presented with metastases at the site of their initial fracture approximately 16 and 13 months after injury respectively. We discuss this unusual presentation and review the relevant literature. We are unaware of any previous reports of a metastatic tumour occurring at the site of an orthopaedic implant used to stabilise a non-pathological fracture. These cases demonstrate the similar clinical presentation of infection and malignancy: a diagnosis which should always be considered in such patients

To present our experience and evaluate functional results on endoprostethic reconstruction of extremities with bone tumors after tumor resection. 47 patients (15 females, 32 males; mean age 55 years; range 13–85 years) who underwent tumor resection and cemented endoprosthetic replacement using the TMTS (Turkish Musculoskeletal Tumor Society) prosthesis for bone tumors of the extremities were analysed. Thirty patients (63.8%; mean age 63 years) had metastatic, 17 patients (36.1%; mean age 53 years) had primary tumors. The femur (70%) was the most frequent tumor location site. Functional assesments of the patients were made using the Musculoskeletal Tumor Society (MSTS) scoring system on the follow-up period. The mean follow-up period was 18 months, being 36.3 months for primary, and 7.3 months for metastatic tumors. Postoperative complications were seen in 9 patients (19.1%). 22 patients died due to tumoral causes during follow-up period, distant metastases exists in 4 patients, and 21 patients are tumor-free. Survival rates found significantly better in patients with primary tumors. All the patients were able to walk without crutches in the postoperative period. The mean MSTS score was 58.7% in survivors, which was 71% for primary tumors, and 53.1% for metastatic tumors. Reconstruction with cemented modular endoprostheses is an appropriate surgical alternative in the treatment of extremity tumors, with satisfactory functional results particularly in primary tumors

We evaluated the possible induction of a systemic immune response to increase anti-tumour activity by the re-implantation of destructive tumour tissue treated by liquid nitrogen in a murine osteosarcoma (LM8) model. The tumours were randomised to treatment by excision alone or by cryotreatment after excision. Tissue from the tumour was frozen in liquid nitrogen, thawed in distilled water and then re-implanted in the same animal. In addition, some mice received an immunological response modifier of OK-432 after treatment. We measured the levels of interferon-gamma and interleukin-12 cytokines and the cytotoxicity activity of splenocytes against murine LM8 osteosarcoma cells. The number of lung and the size of abdominal metastases were also measured. Re-implantation of tumour tissue after cryotreatment activated immune responses and inhibited metastatic tumour growth. OK-432 synergistically enhanced the anti-tumour effect. Our results suggest that the treatment of malignant bone tumours by reconstruction using autografts containing tumours which have been treated by liquid nitrogen may be of clinical value

It is important to be able to identify patients with an increased risk of venous thromboembolism (VTE) in order to minimise the risk of an event. We investigated the incidence and risk factors for post-operative VTE in 168 consecutive patients with a malignancy of the lower limb. The period of study included ten months before and 12 months after the introduction of chemical thromboprophylaxis. All data about the potential risk factors were identified and classified into three groups (patient-, surgery- and tumour-related). The outcome measure was a thromboembolic event within 90 days of surgery. Of the 168 patients, eight (4.8%) had a confirmed symptomatic deep-vein thrombosis and one (0.6%) a fatal pulmonary embolism. Of the 28 variables tested, age > 60 years, higher American Society of Anesthesiologists grade and metastatic tumour were independent risk factors for VTE. The overall rate of symptomatic VTE was not significantly different between patients who received chemical thromboprophylaxis and those who did not. Knowledge of these risk factors may be of value in improving the surgical outcome of patients with a malignancy of the lower limb. Cite this article: Bone Joint J 2013;95-B:558–62

Aims. The aims of this study were to determine the incidence and factors for developing periprosthetic joint infection (PJI) following hemiarthroplasty (HA) for hip fracture, and to evaluate treatment outcome and identify factors associated with treatment outcome. Methods. A retrospective review was performed of consecutive patients treated for HA PJI at a tertiary referral centre with a mean 4.5 years’ follow-up (1.6 weeks to 12.9 years). Surgeries performed included debridement, antibiotics, and implant retention (DAIR) and single-stage revision. The effect of different factors on developing infection and treatment outcome was determined. Results. A total of 1,984 HAs were performed during the study period, and 44 sustained a PJI (2.2%). Multiple logistic regression analysis revealed that a higher CCI score (odds ratio (OR) 1.56 (95% confidence interval (CI) 1.117 to 2.187); p = 0.003), peripheral vascular disease (OR 11.34 (95% CI 1.897 to 67.810); p = 0.008), cerebrovascular disease (OR 65.32 (95% CI 22.783 to 187.278); p < 0.001), diabetes (OR 4.82 (95% CI 1.903 to 12.218); p < 0.001), moderate-to-severe renal disease (OR 5.84 (95% CI 1.116 to 30.589); p = 0.037), cancer without metastasis (OR 6.42 (95% CI 1.643 to 25.006); p = 0.007), and metastatic solid tumour (OR 15.64 (95% CI 1.499 to 163.087); p = 0.022) were associated with increasing PJI risk. Upon final follow-up, 17 patients (38.6%) failed initial treatment and required further surgery for HA PJI. One-year mortality was 22.7%. Factors associated with treatment outcome included lower preoperative Hgb level (97.9 g/l (SD 11.4) vs 107.0 g/l (SD 16.1); p = 0.009), elevated CRP level (99.1 mg/l (SD 63.4) vs 56.6 mg/l (SD 47.1); p = 0.030), and type of surgery. There was lower chance of success with DAIR (42.3%) compared to revision HA (66.7%) or revision with conversion to total hip arthroplasty (100%). Early-onset PJI (≤ six weeks) was associated with a higher likelihood of treatment failure (OR 3.5 (95% CI 1.2 to 10.6); p = 0.007) along with patients treated by a non-arthroplasty surgeon (OR 2.5 (95% CI 1.2 to 5.3); p = 0.014). Conclusion. HA PJI initially treated with DAIR is associated with poor chances of success and its value is limited. We strongly recommend consideration of a single-stage revision arthroplasty with cemented components. Cite this article: Bone Jt Open 2022;3(12):924–932

Aims. Proximal femoral endoprosthetic replacements (PFEPRs) are the most common reconstruction option for osseous defects following primary and metastatic tumour resection. This study aimed to compare the rate of implant failure between PFEPRs with monopolar and bipolar hemiarthroplasties and acetabular arthroplasties, and determine the optimum articulation for revision PFEPRs. Methods. This is a retrospective review of 233 patients who underwent PFEPR. The mean age was 54.7 years (SD 18.2), and 99 (42.5%) were male. There were 90 patients with primary bone tumours (38.6%), 122 with metastatic bone disease (52.4%), and 21 with haematological malignancy (9.0%). A total of 128 patients had monopolar (54.9%), 74 had bipolar hemiarthroplasty heads (31.8%), and 31 underwent acetabular arthroplasty (13.3%). Results. At a mean 74.4 months follow-up, the overall revision rate was 15.0%. Primary malignancy (p < 0.001) and age < 50 years (p < 0.001) were risk factors for revision. The risks of death and implant failure were similar in patients with primary disease (p = 0.872), but the risk of death was significantly greater for patients who had metastatic bone disease (p < 0.001). Acetabular-related implant failures comprised 74.3% of revisions; however, no difference between hemiarthroplasty or arthroplasty groups (p = 0.209), or between monopolar or bipolar hemiarthroplasties (p = 0.307), was observed. There was greater radiological wear in patients with longer follow-up and primary bone malignancy. Re-revision rates following a revision PFEPR was 34.3%, with dual-mobility bearings having the lowest rate of instability and re-revision (15.4%). Conclusion. Hemiarthroplasty and arthroplasty PFEPRs carry the same risk of revision in the medium term, and is primarily due to acetabular complications. There is no difference in revision rates or erosion between monopolar and bipolar hemiarthroplasties. The main causes of failure were acetabular wear in the hemiarthroplasty group and instability in the arthroplasty group. These risks should be balanced and patient prognosis considered when contemplating the bearing choice. Dual-mobility, constrained bearings, or large diameter heads (> 32 mm) are recommended in all revision PFEPRs. Cite this article: Bone Joint J 2021;103-B(10):1633–1640

Purpose: Pluridisciplinary therapeutic management is well defined for metastatic long bones. There are few prognostic criteria enabling an evidence-based choice between palliative surgery or abstention. We report a series of 24 metastatic femurs treated by palliative surgery and evaluated with the Tokuyashi score. Material and methods: Sixteen women and eight men, mean age 71 years (5!-89) underwent centromedullary nailing of a metastatic femur (13/16 breast cancer in women, 20.24 other metastases. The Toskuhashi score was > 6 for 16/24 patients with pain unresponsive to morphine. Thirteen patients had fractured femurs and eleven had frail femurs due to the metastasis. Mean time to surgery was six days (1–15). Results: A solid nail was used for four patients and a reconstruction nail for twenty. Operative time was 93 minutes (57–123). Blood loss was 200 l (150–350). There no intraoperative complications (fat embolus) excepting one tulip femur. Hospital stay was 23 days (8–55). Survival was 148 days (8–510) in patients with a frail metastatic tumour. Eight deaths occurred in patients with a fractured metastatic tumour (six within the first three postoperative weeks), two after preventive nailing. Weight bearing in living patients with a fractured femur was possible at 57 days (30–90). Only six patients required morphine in the early postoperative period. For the femurs with an isolated metastasis, the antalgesic effect of centromedullary nailing was significant (p< 0.05). There was a significant correlation between thee Tokuyashi score and mean survival. Mean survival in patients with a score < 3 was 2.1 months. Mean survival in patients with a score > 6 was 17 months. Conclusion: Centromedullary nailing of the femur for metastatic fracture or fragilisation remains the treatment of choice for patients with short life expectancy. This technique limits pain while preserving independence as long as possible. The Tokuyashi score is correlated with patient survival. If this easy to establish score is too low (< 3), the survival can be expected to be insufficient for any surgical benefit

Introduction: This study aimed to analyse immunohis-tochemically the proteolysis of Amyloid Precursor Protein (APP) using Caspase-3-mediated APP proteolytic peptide (CMAP), beta-Amyloid (Aβ) and Active Caspase-3 in post-mortem human specimens in acute and chronic compressive myelopathy. Compressive myelopathy, occurring through traumatic fracture/dislocation of vertebrae, iatrogenic injury, cervical spondylotic myelopathy (CSM), or metastatic tumour, causes much socio-economic and emotional disability for patients as well as physical consequences. In such conditions, APP is recognised as an early and specifi c marker of axonal injury. The proteolysis of APP in both acute and chronic compressive myelopathy has not yet been described. Studies analysing axonal injury after brain trauma suggest a role for Caspase-3 in the cleavage of APP. 1. In addition, Caspase-3-mediated cleavage of APP has been found to be associated with the formation of Aβ, a neurotoxic protein thought to contribute to cell death in Alzheimer’s disease. 2. Furthermore, A? may subsequently encourage activation of Caspases −2, −3, and −6, the major effector molecules in apoptosis. 2. The current study addressed two hypotheses; that APP provides a substrate for the Caspase-3 enzyme, and, that this event is associated with Aβ production in the compressed spinal cord. Methods: Spinal cord material from 17 patients with documented SCI was analysed. The spatial distribution of cellular immunoreactivity was qualitatively assessed in injury due to trauma (n=5), iatrogenic event (n=1), CSM (n=6) and metastatic tumour (n=5). Morphological, immunohistochemical and immunofl uorescent techniques were used to investigate APP proteolysis. Results: Caspase-3, APP, CMAP and Aβ were present in anterior horn cells of the grey matter and axons of the white matter. An association was found between neuronal immunoreactivity and that of axons in motor tracts. Dual-immunolabelling revealed axonal co-localisation of CMAP with Aβ and Caspase-3 with Aβ. Although CMAP was present in axons which were immunoposi-tive for APP, an inverse relationship was found as each marker was limited to its own, distinct region, consistent with the theory that CMAP actively cleaves APP. In neurons, co-localisation occurred between Caspase-3 and Aβ, and CMAP with Aβ. No neuronal co-localisation was shown between CMAP and APP in the acute and chronic state. Discussion: Caspase-3 appears likely to contribute to the proteolytic cleavage of APP in compressive myelop-athy. CMAP was associated with the production of Aβ as demonstrated using single and dual immunolabelling. Furthermore, evidence is given for the association of Caspase-3 itself with the neurotoxic peptide, Aβ. It is possible that activation of Caspase-3 via these secondary mechanisms may trigger the advancement of the apoptotic cascade with the subsequent demise of the cell

Introduction: Apoptosis, or secondary cell death, has been demonstrated in a number of neurological conditions, including Alzheimer’s disease, Parkinson’s disease, amyotrophic lateral sclerosis and brain ischaemia. It is well established from studies of acute spinal cord injury that apoptosis seems an important factor in secondary cell death and irreversible neurological deficit. It is only recently that studies have emerged analysing secondary cell death in chronic injury to the cord. In this study, the spatial and temporal expression of apoptotic cells was analysed in acute traumatic spinal cord injury (SCI) (n=6) and chronic myelopathies due to metastatic tumour (n=5), degenerative spondylosis (n=6) and syringomyelia (n=4). The study aimed to demonstrate apoptosis in compressive spinal cord injury and to analyse the spatial and temporal distribution of apoptosis in acute and chronic myelopathy. Method: Archival material from 21 spinal cords of patients with documented myelopathy during life and definitive evidence on post mortem examination were available for study. The spatial and temporal expression of apoptotic cells was analysed in acute traumatic spinal cord injury (SCI) (n=6) and chronic myelopathy due to metastatic tumour (n=5), degenerative spondylosis (n=6) and syringomyelia (n=4). Immunohistochemical analysis of each specimen was conducted using markers of apoptosis, as well as the biochemical apoptotic marker TUNEL. A total of 1800 histopathological slides were analysed. Specimens were also analysed using confocal microscopy to identify the immunopositive cell type. A combination of morphological, immunohistochemical and in situ end-labelling techniques were used to investigate the mechanism of cell death in this experiment. The analytical techniques employed were aimed at showing firstly the presence of apoptosis and secondly the size and position of the damaged regions. Results: Positivity for active Caspase-3, DNA-PKCS, PARP, TUNEL and active Caspase-9 was found in glia (oligodendrocytes and microglia) axons and neurons in both acute and chronic compression above, below and at the site of compression. In chronic compression, the severity of positivity for apoptotic immunological markers was positively correlated with the severity of white matter damage, as measured by APP immunostaining for axonal injury, and Wallerian degeneration. There was no correlation between the duration of chronic compression and immunopositivity for apoptotic markers. In acute SCI, axonal swellings were consistently positive for Caspases −9 and -3, suggesting mitochondrial activation of apoptotic pathways. Conclusion: Apoptosis occurs in both acute and chronic spinal cord injury. In acute compression, axonal injury is associated with apoptotic immunopositivity of glia and neurons. In chronic compression, apoptosis of oligodendrocytes and microglia correlates with demyelination of axons within the white matter

We reviewed 20 patients who had undergone a Coonrad-Morrey total elbow arthroplasty after resection of a primary or metastatic tumour from the elbow or distal humerus between 1980 and 2002. Eighteen patients underwent reconstruction for palliative treatment with restoration of function after intralesional surgery and two after excision of a primary bone tumour. The mean follow-up was 30 months (1 to 192). Five patients (25%) were alive at the final follow-up; 14 (70%) had died of their disease and one of unrelated causes. Local control was achieved in 15 patients (75%). The mean Mayo Elbow Performance Score improved from 22 (5 to 45) to 75 points (55 to 95). Four reconstructions (20%) failed and required revision. Seven patients (35%) had early complications, the most frequent being nerve injury (25%). There were no infections or wound complications although 18 patients (90%) had radiotherapy, chemotherapy or both. The Coonrad-Morrey total elbow arthroplasty provides good relief from pain and a good functional outcome after resection of tumours of the elbow. The rates of complications involving local recurrence of tumour (25%) and nerve injury (25%) are of concern

Purpose: To analyze the cases with metastatic humeral tumors and to discuss treatment methods for humeral metastasis. Methods: Forty-two cases (46 bones) with metastatic humeral tumors were reviewed. There were 23 males and 19 females and the average age was 57.4 (range 37 to 88). The common origins were lung, liver, and kidney(25/42 cases) and the common metastatic site was proximal one third of the humerus (28/46 bones). Seventeen cases were solitary humeral metastasis at the first examination and 21 cases sufferred from pathological fractures. All cases were treated for humeral lesions. The cases were divided into two groups :surgical treatment group (SG, 24 cases) and conservative treatment group (CG, 18 cases). The two group were compared. Results: Surgical treatments included tumor resection with replacement of the endoprosthesis, tumor resection and internal fixation, and palliative medullary nailing. The plates and screws or medullary nails were used for internal fixation and the bone cement was also used. Conservative treatments included chemotherapy, radio-therapy, and brace or splint. One year survival rate of SG was 36.4% and CG was 6%. All cases of SG and 6/18 cases showed pain relief or decrease, and 22/24 cases of SG showed improvement of ADL, although only three cases of CG obtained improvement of ADL. Discussion: The results showed surgical treatments for humeral metastasis obtained improvement of QOL. The survival rate of SG higher than CG, but the reason seemed that the surgeryies were performed for the cases with reratively good general conditions. Internal fixation with the bone cement seemed to be effective for rigid fixation. Conclusion: Surgical treatment should be performed as possible for metastatic humeral tumors, and rigid fixation with or without tumor resection seemed important

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

Concomitant tumour resistance (CTR) is a unique phenomenon in which animals harbouring large primary tumours are resistant to the growth of smaller metastatic tumours by systemic angiogenic suppression. To examine this clinically, in ten patients with osteosarcoma, we investigated the effects of removal of the primary tumour on the development of pulmonary metastases, the systemic angiogenesis-inducing ability and the serum levels of several angiogenesis modulators. We found that removal of the primary tumour significantly elevated systemic angiogenesis-inducing ability in five patients who had post-operative recurrence of the tumour. Post-operative elevation of the angiogenesis-induced ability was suppressed by the addition of an angiogenic inhibitor, endostatin. Also, primary removal of the tumour decreased the serum levels of vascular endothelial growth factor and endostatin. These findings suggest, for the first time, the presence of CTR in patients with osteosarcoma for whom postoperative antiangiogenic therapy may be used to prevent the post-operative progression of micrometastases