Introduction. Aneurysmal bone cysts commonly found in lower limbs are locally aggressive masses that can lead to bony erosion, instability and fractures. This has major implications in the lower limbs especially in paediatric patients, with potential growth disturbance and deformity. In this case series we describe radical aneurysmal bone cyst resection and lower limb reconstruction using cable transport and syndesmosis preservation. Materials & Methods. Case 1 - A 12-year-old boy presented with a two-week history of atraumatic right ankle pain. An X-ray demonstrated a distal tibia metaphyseal cyst confirmed on biopsy as an aneurysmal bone cyst. The cyst expanded on interval X-rays from 5.5cm to 8.5cm in 9 weeks. A wide-margin en-bloc resection was performed leaving a 13.8cm tibial defect. A cable transport hexapod frame and a proximal tibial osteotomy was performed, with syndesmosis screw fixation. The transport phase lasted 11 months. While in frame, the boy sustained a distal femur fracture from a fall. The femur and the docking site were plated at the same sitting and frame removed. At one-year post-frame removal he is pain-free, with full ankle dorsiflexion but plantarflexion limited to 25 degrees. He has begun graduated return to sport. Results. Case 2 - A 12-year-old girl was referred with a three-month history of lateral left ankle swelling. X-ray demonstrated an aneurysmal bone cyst in the distal fibula metaphysis. The cyst grew from 4.2 × 2.3cm to 5.2 × 3.32cm in 2 months. A distal fibula resection (6.2cm) with syndesmosis fixation and hexapod cable transport frame were undertaken. The frame was in situ for 13 weeks and during this time she required an additional osteotomy for premature consolidation and had one pin site infection. After 13 weeks a second syndesmosis screw was placed, frame removed, and a cast applied. 3 months later she had fibular plating, BMAC and autologous iliac crest bone graft for slow union. At 3 years post-operative she has no evidence of recurrence, is pain-free and has no functional limitation. Conclusions. We describe two cases of ankle syndesmosis preservation using cable transport for juxta-articular aneurysmal bone cysts. This allows wide resection to prevent recurrence while also preserving primary ankle stability and leg length in children. Both children had a minor complication, but both had an excellent final outcome. Cable bone transport and prophylactic syndesmosis stabilization allows treatment of challenging juxta-articular aneurysmal bone cysts about the ankle. These techniques are especially useful in large bone defects

Introduction. Hip arthrodiastasis for paediatric hip conditions such as Perthes disease is growing in popularity. Intended merits include halting the collapse of the femoral head and maintaining sphericity by minimising the joint reaction force. This can also be applied to protecting hip reconstruction following treatment of hip dysplasia. Our aim was to assess functional outcomes and complications in a cohort of paediatric patients. Materials and Methods. A retrospective single-surgeon cohort study was performed in a University teaching hospital from 2018–2021. Follow-up was performed via telephone interview and review of patient records. Complications, time in frame and functional scores using the WOMAC hip score were recorded. Results. Following review, 26 procedures were identified in 24 patients. Indications included 16 cases of Perthes disease, 4 following slipper upper femoral epiphysis, 3 avascular necrosis, and single cases following infection, dysplasia and a bone cyst. Pre-treatment WOMAC scores averaged 53.9, improving to 88.5 post-removal. Pin site infections were encountered in 11 patients, all treated with oral antibiotics. Two patients required early removal of frame due to pin loosening. Average time in frame was 3.9 months. Conclusions. This series displays how hip arthrodiastasis can be used to manage paediatric hip conditions. Complex reconstructions may be required in patients with severe deformity following perthes disease, DDH or SUFE. The use of arthrodiastasis in these patients aims to protect the reconstruction and potentially improve outcomes. A dedicated team of specialist nurses, physiotherapists and psychologists are crucial to the treatment program

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 curettage as a means to avoid these risks. Method. A retrospective cohort study of pediatric, histologically proven aneurysmal bone cyst patients treated either by percutaneous curettage or by open intralesional resection with two years follow up was undertaken. Those cysts judged as uncontained and requiring restoration of structural bony integrity underwent open intralesional resection and reconstruction. Contained cysts judged as not requiring immediate structural restoration were treated percutaneously. This group was uniformly treated on an outpatient basis using angled curettes under image guidance followed by intralesional evacuation using a suction trap. None in this group had insertion of any substance into the cyst cavity. Short-term casting or immobilization was undertaken in most cases. The primary outcome evaluated was radiographic resolution, persistence or recurrence at two years according to the Neer/Cole classification. Complications were noted. Results. Twenty patients with a mean age of 11 (2–15) were evaluated, with ten in each group. In the open intralesional resection group, 9/10 achieved Neer/Cole grade I resolution; one case recurred and was successfully treated percutaneously. There was one case of valgus proximal tibial overgrowth deformity requiring hemiepiphysiodesis, and three cases requiring hardware removal for irritation. In the percutaneous group, 7/10 achieved Neer/Cole grade 1 resolution, one case exhibited radiographic persistence of nonexpansile, lytic change and two cases frankly recurred, necessitating repeat procedures. No fractures, growth arrests, or infections occurred in either group. Conclusion. Not all aneurysmal bone cysts require wide exposure for intralesional resection. Percutaneous curettage is a reasonable alternative for contained aneurysmal bone cysts. Children will readily restore bone stock in the absence of bone graft or bone substitute as long as the cyst is erradicated. Percutaneous curettage should be performed selectively and on an investigational basis for the time being

The primary goal of this study was to understand the subjective impact of a diagnosis of Simple Bone Cyst on children with regards to activity participation and psychosocial development. We aimed to explore the concepts of labeling, embodiment and activity participation to understand the impact of SBC. This was a qualitative study. Ten children between the ages of 4 and 17 years with SBC and their families participated in semi-structured interviews related to activity participation, social interactions and psychological impact of SBC. Interview questions were derived from psychology, sociology and philosophy literatures pertaining to illness and activity, sense of embodiment, self-concept and interactions with the social environment. Interviews were transcribed and analyzed using thematic analysis. First, children and families view SBC as an injury more than an illness and did not experience labeling or significant changes in embodiment. Second, SBCs cause anxiety in children related fear of fracture or pain, however normal function and activity participation were maintained. Third, there were significant shortcomings identified in the communication and the decision-making process between families and physicians regarding SBC management. SBC as a benign disease does not neatly fit into the category of illness or injury based on children's experiences. Children who previously perceived themselves as normal feel different and not normal following diagnosis with SBC. The experience of parents is largely one of anxiety, and much of that anxiety is derived from the uncertainty over the treatment plans for their child. The proposed framework of normality allows for the more temporary and fluid changes in perception experienced by the children in our study. The results of this study suggest that the current decision-making process in SBC is unsatisfactory leading to anxiety and worry. Parents felt pressure to make decisions regarding surgery without feeling that they sufficient information. Though understanding how children experience SBCs and how parents experience the treatment course of their child with SBC, we can shared decision-making as a potential way to reduce parents' anxiety and limit negative experience in children

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, curettage bone grafting and various other surgical procedures. The mean follow-up was 54 (22-90) months. Symptoms were relieved in all patients. 2 patients were lost to follow up. 18 (58%) of the 31 patients followed, had complete resolution of the lesion, 11 (35.5%) patients had partial healing (asymptomatic residual non progressive lytic areas). 2 (6.5%) patients showed recurrence in the proximal humerus during the follow-up. They are under follow-up but asymptomatic. 2 patients encountered more significant complications after the procedure. Ethibloc injection is a relatively simple, minimally invasive alternative procedure for the treatment of ABC, and makes open operation unnecessary by stopping the expansion of the cyst and inducing endosteal new bone formation. This technique may be used as the primary management of ABCs excluding spinal lesions as shown by this long-term follow-up study

A patient in his thirties developed synovitis with grade 4 chondrolysis and a stiff knee with a fixed flexion deformity between three and six years following PLC and PCL reconstruction using LARS (Ligament Augmentation and Reconstruction System, Corin). There was histologic evidence of foreign body reaction, the knee was painful, swollen and stiff. We did not use any further LARS ligaments for soft tissue reconstructions of the kneein our practice. We commenced a recall programme for all 83 patients patients who underwent a soft tissue knee reconstruction using LARS. Of those contacted, 41 replied (49%) and 16 patients had symptoms (19%) and were investigated further with XRay, MRI and arthroscopy as indicated. We discovered a total of five patients had histologically proven synovitis with foreign body reactions (6%), three of whom had life-changing symptomatic pain, swelling and stiffness with degenerate changes (3.6%). These patients had undergone various reconstructions, including a) PLC only, b) ACL and PCL, c) PCL and PLC and d) ACL, PCL and PLC. A further single case of massive bone cyst formation was noted, following PCL reconstruction using LARS (1.2%)

The primary objective of this study was to determine if paediatric proximal humerus fractures undergo significant displacement resulting in change in management. A retrospective analysis was performed on children who presented with proximal humeral fractures to our institution between 2009 and 2014. Patients were included if they were diagnosed with a fracture of the proximal humerus in the absence of an underlying bone cyst or pathological condition. Patients with open fractures, multiple fractures, neurologic, or vascular injuries were excluded. The primary endpoint was conversion to operative treatment after initial non-operative management. Secondary endpoints were a healed fracture with acceptable alignment at the final radiographic evaluation, as well as the number of follow-up radiographs obtained after the initiation of non-operative management. A decision to manage the fracture operatively at the initial presentation was made in 14 out of 239 patients. Of the 225 patients that were initially managed non-operatively, only 1 patient underwent subsequent surgical management. In this series, no non-unions, re-fractures, nor fracture-dislocations were identified. These data support that the majority of management decisions for paediatric proximal humeral fractures are made at the initial presentation. Once non-operative management is chosen, routine follow-up imaging rarely leads to any change in treatment

Introduction:. Sinus histiocytosis with massive lymphadenopathy (SHML) also known as Rosai – Dorfman disease is a disease of bone marrow stem cell origin. It affects lymph nodes primarily. Solitary bone lesions are very rare and can cause diagnostic difficulty. Aim:. To increase the awareness of SHML as a cause of cystic bone lesions. Materials and methods:. A 2 year old presented with 4 months history of pain and swelling of the distal forearm. There was no history of tuberculosis or HIV disease. The swelling was 4 × 3 cm firm, non-fluctuant and slightly tender. There were no lymph nodes. Radiographs showed an oval cystic lesion expanding with a well-defined margin. The ulnar cortex was deficient. CT scan confirmed a cystic lesion with contents of granulation tissue. The Hb and WCC were normal, ESR 20 was, CRP<5 and mantoux was negative. At surgery the lesion was curretted. The contents resembled tuberculous granulation but there was no caseation. The borders were well formed, the ulnar cortex was deficient. Results:. The histology revealed granulation tissue with numerous large histiocytes and immuno chemistry confirmed Rosai Dorfman disease. Healing with sclerosis was seen at 6 months. Discussion:. Rosai Dorfman disease is a systemic disease of bone marrow stem cells and lymphadenopathy is the prominent manifestation. Only ±8% of cases have been reported with bone involvement and 4% of these had no lymphadenopathy. The lesions are cystic and medullary but cortical involvement can occur. Solitary ossseous lesions characterized by a background of histocytes without eosinophils can mimic Langerhans histocytosis, localized osteomyelitis, fibrous dysplasia, tuberculosis, simple or aneurysmal bone cysts and metastatic deposits. Conclusion:. Lesions of haematopoetic origin should be considered in the diagnosis of lucent bone lesions in children

Introduction. The femoral neck in children is a common site for bone lesions. The majority are benign. However these lesions can cause diagnostic problems. Aim. To present a spectrum of chronic lesions of the femoral neck in children and emphasize the importance of tissue diagnosis. Materials and methods. Thirty two children with isolated chronic bone lesions in the femoral neck treated between 1994 and 2013were retrospectively reviewed. The ages ranged between 1–13 years. Clinical features were pain and limp. Routine blood tests, x-rays and CT scans were done in all and MRI scans in 5 cases. All diagnoses were confirmed histologically. Results. Three radiological patterns were seen: lucent or cystic in 22, infiltrative (permeative)in 2, and localized densities with nidus in 8 cases. Histologically the lesions were subacute osteomyelitis in 4, tuberculosis in 9, simple bone cyst in 7, osteoid osteoma in 7, chondroblastoma in 1, monostotic fibrous dysplasia in 2 and eosinophilic granuloma in 2 cases. Two tuberculous lesions were associated with subluxation of the hip and involvement of the head occurred in 2 others. Treatment and outcome. All lesions were curetted. Bone grafting was done in 10. Immobilisation was by internal fixation in 1, traction in 2 and spica cast in 29 cases. Follow up was 9 months to 11 years. Healing occurred in the majority. Recurrence occurred in 2 cases. Coxa vara developed in 6, and growth disturbance with shortening in 9 patients. Discussion. Femoral neck lesions are mainly benign, present diagnostic difficulty and treatment is challenging. There are problems with immobilization and of purchase with fixation devices due to poor bone stock on the neck of femur. The spica cast is a reliable method of immobilization in children under 10years. Growth disturbance and coxa vara can result after healing. CT scan is useful in assessing the architecture of the bone. NO DISCLOSURES

Purpose of the study. To review the primary bone tumours of the spine treated at our unit. Description of methods. Retrospective review of folders and x-rays of all the patients with primary bone tumours of the spine treated at our unit between 2005 and 2012. All haematological tumours were excluded. Summary of results. We treated 15 cases during this period. The median age at presentation was 36 years (8–65). There was a significant delay from onset of symptoms to diagnosis in most cases (median 7 months). Histological diagnoses included:. -Benign tumours.  Active. Hemangioma. 3. Osteoid osteoma. 1. Eosinophilic granuloma. 1.  Aggressive. Osteoblastoma. 1. Giant cell tumours. 2. Aneurysmal bone cysts. 4. -Malignant tumours.  Osteosarcomas. 2.  Leiomyosarcoma of bone. 1. A variety of definitive surgical methods were utilised. Seven patients had a debulking or intralesional resection of the tumour. Eight patients had an attempted marginal excision. This was achieved through anterior surgery only in 1 case, posterior only surgery in 6 cases and combination anterior and posterior surgery in 8 cases. The anterior and posterior surgery was performed in a single sitting in 5 cases and in a staged fashion in 3 cases. Adjuvant radiotherapy and chemotherapy were used where indicated. Three cases presented with significant neurological impairment. Of these 2 made a significant recovery. There were no cases of neurological deterioration following surgery. All 3 patients with malignant tumours died in the follow up period. We had 1 case of hardware failure due to chronic sepsis. Conclusion. Primary bone tumours of the spine are associated with a significant delay in diagnosis. Surgical treatment options and adjuvant therapy should be tailor made for each case depending on the diagnosis. Acceptable results with minimal complications can be achieved with this approach

Introduction. Bony tumours of the foot account for approximately 3% of all osseous tumours. However, literature regarding os calcis and talar tumours comprises individual case reports, short case series or literature reviews with no recent large series. Methods. We retrospectively reviewed the medical notes and imaging for all patients with calcaneal or talar tumours recorded in the Scottish Bone Tumour Registry since the 1940's. Demographics, presentation, investigation, histology, management and outcome were reviewed. Results. 34 calcaneal tumours and 23 talar tumours were identified. Calcaneal tumours. 2:1 male prevalence, mean age at presentation 30, average length of symptoms 9 months. 4 cases presented with pathological fracture. 21 benign tumours including 6 unicameral bone cysts, 3 chondroblastoma, and a wide variety of individual lesions. 13 malignant tumours comprising 6 osteosarcoma, 5 chondrosarcoma and 2 Ewings sarcoma. Talar Tumours. male to female ratio 3:1, mean age at presentation 28, average length of symptoms 5 months. 20 benign cases including 7 osteoid osteoma, 4 chondroblastoma, and several individual lesions. 3 malignant lesions comprising 2 chondrosarcoma, 1 osteosarcoma. Discussion. Tumours of the hindfoot frequently are delayed in diagnosis due to their rarity and lack of clinician familiarity. They are more common in men, especially talar tumours, which are most commonly benign osteoid osteoma or chondroblastoma. Calcaneal tumours have 1 in 3 risk of malignancy and cover a wider variety of lesions. Osteosarcoma of the foot tends to present later than other anatomical regions. Outcome is dependant on early diagnosis, timely surgery and most importantly neo-adjuvant chemotherapy. Diagnosis is often made on plain radiograph but MRI is the gold standard. Despite their rarity clinicians should maintain a high index of suspicion as accurate and timely diagnosis is important to management and outcome

Objective. To evaluate functional and oncological outcomes following sacral resection. Methods. A retrospective review was conducted of 97 sacral tumours referred to tertiary referral spinal or oncology unit between 2004 and 2009. Results. The study included Chordoma 26; Metastases 17; Chondrosarcoma 9; Osteosarcoma 8; Lymphoma 7; Ewing's Sarcoma 6; Giant Cell Tumours 5; Other Sarcomas 5; Aneurysmal Bone Cyst 4; Myeloma 4; Others 7. There were 61 males, 37 females with an average age of 47 (range 3-82). The average duration of pre-diagnosis symptoms was 13 months. In 17 cases the diagnosis was metastatic disease and these were excluded from further discussion. Of the remainder 36/81(44%) underwent surgery: 21 excision, 9 excision and instrumented stabilisation, and 6 curettage. Thirteen (16%) patients were inoperable: 8 advanced disease, 3 unable to establish local control and 2 cases of recurrence. Colostomy was performed in 11/21 (52%) patients who underwent excision. Deep wound infections in 6/21 (29%). No difference in infection rates between definitive surgery with or without colostomy – 3/11 (27%) vs 3/10 (30%). In the instrumented group, no colostomies were performed due to concerns about deep infection and none resulted (0/9). Radiological failure of stabilisation was noted in 7/9(78%). However, functionally, 3/9 (33%) were mobilising independently, 3/9 (33%) with crutches, 2/9 (22%) able to transfer and 1/9 (11%) undocumented. Mean follow-up was 25 months (range 0-70). Local recurrence in 9/36 (25%) of operated patients. Metastasis occurred in 4/36 (11%) and mortality 8/36 (22%) although follow-up period was noted to be short. Conclusions. Results are comparable with current literature. Mechanical stabilisation for extensive sacral lesions is challenging. Despite radiological failure in 7/9 instrumented stabilisations, patients were relatively asymptomatic and only 1/9 required revision stabilisation surgery. By design none had colostomies and there were no deep infections

Bone preserving hip arthroplasty devices are appealingfor use in young patients because their high-demand activities and extended lifetimes makes the prospect of multiple revisions a reality. Therefore prostheses which ensure a straightforward revision with a low complication rate and good clinical outcome are favourable for young and active patients. Modern hip resurfacing serves these conditions and shows very good mid-term and now longer term (10 and 13 years) results especially in osteoarthritis. With other diagnoses like avascular necrosis, deformities of the femoral head in m. Perthes or slipped femoral epiphysis (SUFE), or in large bone cysts and erosive arthritis the bone stock of the femoral head gives insufficient support to the femoral component. In these conditions the alternative to a resurfacing procedure had been a stemmed total hip arthroplasty (THA). The Birmingham Mid Head Resection device (BMHR; Smith&Nephew Orthopaedics) is an alternative to resurfacing and to a stemmed THA. The BMHR device consists of an uncemented short stem made of titanium alloy and a large diameter cobalt-chrome head. The stem does not enter the femoral canal thus facilitating future revisions. The metal-on-metal bearing is the same as in resurfacing. The instrumentation allows switching from a planned BHR to the BMHR. The BMHR uses the unique anatomy of the head neck junction to prepare internally a cone that matches the frustoconical section of the BMHR stem. Thus a cement free press fit can be achieved. This maintains anatomical load transmission and avoids osteopenia of the proximal fenur. Since 2006 we have performed 662 BMHR implantations. The indications were osteoarthritis in about 70%, dysplasia in 20%, AVN 5,5%, posttraumatic OA in 3%, SUFE and m. Perthes in 1%. Complications occured in 3,2%. Fractures of the femoral neck occured in 8 patients, 4 of them caused by technical errors in the beginning, 3 because of higher risk indication. All revisions were performed successfully and the cup was retained. Low grade infections in 2 cases with one stage revision and 3 unstable cups needed to be reinserted. All revisions were successful. One early dislocation was treated by closed reduction, another remained unstable and was treated by THA. In conclusion we continue to use the BMHR to bridge the gap between resurfacing and stemmed THA because the complications we experienced are not inevitable and had become very rare with our growing experience

Hydatid disease of the bone and soft tissue of the musculoskeletal system is uncommon. The dissemination mode leads to local malignancy with severe prognosis. Tunisia is an endemic area of the disease. Therefore we treated many patients affected the disease. We retrosectivelly reviwed 6 cases of bone hydatid cyst from 1990 to 2010. There were 3 males and 3 females. The mean age was 13 years. The localisation were 03 spinal, 2 in the proximal tibia and & localisation in trochanter. The diagnosis were histoligical in all patient. the mean delay for the diagnosis was 3 years. One patient with spinal localisation had neurological complication paraplegia. All the patient had surgical excision of the hydatid cyst. Ther ewere 3 cases with local recurrence. Because of the poor results with medical treatment, osseous hydatidosis must be treated by a radical operation with wide excision, adapted to each localization. In the main, the prognosis of osseous hydatidosis remains poor, especially with spinal and pelvic localizations, which are the most frequent ones. The prognosis and treatment of osseous hydatidosis belong in the same category as a locally malignant lesion

Introduction

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.

Aims

The Precice intramedullary limb-lengthening system has demonstrated significant benefits over external fixation lengthening methods, leading to a paradigm shift in limb lengthening. This study compares outcomes following antegrade and retrograde femoral lengthening in both adolescent and adult patients.

This article presents an overview of mycetoma and offers guidelines for orthopaedic surgeons who may be involved in the care of patients with this condition.

Cite this article: Bone Joint J 2014;96-B:420–5.