Introduction. Stryde® lengthening nail has been recently withdrawn because of concerns about osteolysis and other bone lesions that have been observed early after implantation. The present study analyses the incidence and features of these bone lesions in our patients. Materials and Methods. This is a retrospective review of a series of patients from two centres specializing in limb reconstruction. Inclusion criteria was a history of surgery with Stryde® lengthening nail with more than one year follow-up available. All postoperative x-rays were and clinical notes were reviewed. Results. 36 patients with 75 bone segments were included. 11 (30.5%) patients and 32 (42.6%) bone segments were without any lesion. In 3 (8.3%) patients and 3 (4%) segments, osteolytic lesions only were noticed. 11(30.5%) patients and 14 (18.6%) segments had combined lytic lesions and periosteal reaction or cortical thickening. 12 (33.3%) patients and 26 (34.6%) segments developed only periosteal reaction or cortical thickening. 54.8% of patients with bilateral nailing had bilateral lesions. 52% of the patients with bone lesions reported late onset of pain after the completion of the lengthening. The average earliest interval that any of the lesions was noticed was 10.2 months post-surgery. Conclusions. Patients with Stryde® nails should be monitored clinically and radiologically at regular intervals until removal. The early failure and withdrawal of Precise Stryde® nail, is a significant event in the field of limb reconstruction; this study adds useful data to the growing pool of published data related to the this event

Aim. To study the antimicrobial effect of a gentamicin loaded bio-composite bone void filler in relation to a limited or extensive debridement of osteomyelitis lesions, respectively. Methods. Nine pigs were inoculated into the right proximal tibial bone with a high virulent gentamicin sensitive strain of Staphylococcus aureus (10. 4. CFU). Seven days after inoculation, Group A pigs (n=3) were exposed to a limited debridement of the bone lesion, whereas Group B pigs (n=3) were exposed to an extensive debridement. The bone defects of Groups A and B were filled with (2–5 ml) of an absorbable gentamicin (175 mg/10 mL) loaded bio-composite. The animals of Group A and B were euthanized 12 days after revision surgery. Group C animals did not undergo revision surgery and were euthanized seven (n=1) or nineteen (n=2) days post inoculation in order to follow the development of the untreated infection. None of the animals were treated with systemic antimicrobials. All bones were exposed to a post mortem CT scan and rigours pathological examinations. The surrounding bone tissue and the bio-composite were sampled for microbiology. Results. All animals developed a substantial purulent bone infection in the inoculated leg prior to revision surgery. In the cases of limited debridement, the bone lesions surrounding the bio-composite bone void filler had clearly expanded since revision surgery, and contained extensive amounts of pus, necrotic bone tissue and oedematous fibrotic tissue. In the cases of extensive debridement, the bio-composite bone void filler was surrounded by only a few mm of fibrosis and sclerotic bone tissue i.e. the bone lesions were not expanding. However, in one pig the bio-composite bone void filler was communicating with a small purulent osteolytic lesion without a sclerotic border indicating appearance after revision surgery. In all pigs, S. aureus bacteria were post mortem cultured from the adjacent bone tissue and the bio-composite surface. Conclusions. The gentamicin concentrations within the bio-composite could not eradicate the residual infection after debridement. However, extensive debridement and filling of the bone void with gentamicin loaded bio-composite contained the lesion formed by revision surgery, which are important complementing roles as adjuvant to systemic antimicrobial therapy and the immune system in eradication of the infection. The present study emphasizes that extensive debridement is fundamental for successful treatment of bone infections and that antimicrobial loaded bone void fillers or bone substitutes should not be used as an alternative to extensive debridement

Aim. The osteolytic process of osteomyelitis is, according to textbooks, caused by increased osteoclast activity due to RANKL production by osteoblasts. However, recent findings contradict this theory. Therefore, the aim was to investigate, in a porcine osteomyelitis model, how osteolysis is affected by massive inflammation and RANKL blocking, respectively. In parallel, patients with chronic osteomyelitis, diabetes, foot osteomyelitis, and fracture related infections (FRI) were included for advanced histological analysis of osteolysis. Methods. In pigs, a tibial implant cavity was created and inoculated with 10. 4. CFU of Staphylococcus aureus: Group A (n=7). Group B (n=7); + 1cm. 3. spongostan into the cavity. Group C (n=4); + systemic Denosumab treatment. Spongostan was used as an avascular material to support bacterial growth and thus increase the inflammatory response. Denosumab treatment was administrated to suppress osteoclast activity by RANKL inhibition (as in osteoporotic patients). The volume of osteolysis was accessed by CT scans. Immunohistochemistry with antibodies towards Cathepsin K was used to identify osteoclasts within the bone lesions. Briefly, the number of Cathepsin K positive cells, i.e., both precursors and bone resorbing osteoclasts, respectively, were counted in 10 high power fields (400x). In total, 50 bone infection patients were included (Herlev Hospital). From each patient five parried samples were taken for histology and microbiology, respectively. Histopathology, CT osteolysis volume estimation, and molecular expression of osteoclasts and inflammatory markers are ongoing. One FRI patient was osteoporotic and treated with Denosumab for 6 years. Results. All pigs were confirmed infected in the implant cavity. The volume (2.41 ± 1.29cm. 3. ) of osteolysis was significantly increased in the spongostan group in comparison to Group A (1.24 ± 0.59 cm. 3. ) (p=0.04). Thereby, the spongostan group had bacteria deeper into the bone from the inoculation point. Sufficient Denosumab treatment, i.e. reduced serum Ca was seen in 3 pigs. None of the Denosumab treated pigs showed reduced osteolysis in comparison to Group A (1.42 ± 0.63 cm. 3. ). The Cathepsin K score of Group C was 17 (15-23 IQR) of precursor osteoclasts and 2 (0-2 IQR) of osteoclasts in Howship lacunae. The Denosumab treated patient showed substantial osteolysis and histological analysis confirmed acute inflammatory. Conclusions. Application of spongostan, i.e., bacterial host optimization and massive inflammation promotes osteolysis and local bacterial dissemination. Osteoclast blocking with Denosumab showed no impact on osteolysis. Elucidation of the pathophysiology causing bone loss in osteomyelitis is fundamental. However, the widely accepted osteoclast-based theory might not be the only relevant

The presence of metastatic bone disease (MBD) often necessitates major orthopaedic surgery. Patients will enter surgical care either through emergent or electively scheduled care pathways. Patients in a pain crisis or with an acute fracture are generally admitted via emergent care pathways whereas patients with identified high-risk bone lesions are often booked for urgent yet scheduled elective procedures. The purpose of this study is to compare the post-operative outcomes of patients who present through emergent or electively scheduled care pathways in patients in a Canadian health care system. We have conducted a retrospective, multicenter cohort study of all patients presenting for surgery for MBD of the femur, humerus, tibia or pelvis in southern Alberta between 2006 and 2021. Patients were identified by a search query of all patients with a diagnosis of metastatic cancer who underwent surgery for an impending or actual pathologic fracture in the Calgary, South and Central Alberta Zones. Subsequent chart reviews were performed. Emergent surgeries were defined by patients admitted to hospital via urgent care mechanisms and managed via unscheduled surgical bookings (“on call list”). Elective surgeries were defined by patients seen by an orthopaedic surgeon at least once prior to surgery, and booked for a scheduled urgent, yet elective procedure. Outcomes include overall survival from the time of surgery, hospital length of stay, and 30-day hospital readmission rate. We have identified 402 patients to date for inclusion. 273 patients (67.9%) underwent surgery through emergent pathways and 129 patients (32.1%) were treated through urgent, electively scheduled pathways. Lung, prostate, renal cell, and breast cancer were the most common primary malignancies and there was no significant difference in these primaries amongst the groups (p=0.06). Not surprisingly, emergent patients were more likely to be treated for a pathologic fracture (p<0.001) whereas elective patients were more likely to be treated for an impending fracture (p<0.001). Overall survival was significantly shorter in the emergent group (5.0 months, 95%CI: 4.0-6.1) compared to the elective group (14.9 months 95%CI: 10.4-24.6) [p<0.001]. Hospital length of stay was significantly longer in the emergent group (13 days, 95%CI: 12-16 versus 5 days, 95%CI: 5-7 days). There was a significantly greater rate of 30-day hospital readmission in the emergent group (13.3% versus 7.8%) [p=0.01]. Electively managed MBD has multiple benefits including longer post-operative survival, shorter length of hospital stay, and a lower rate of 30-day hospital readmission. These findings from a Canadian healthcare system demonstrate clinical value in providing elective orthopaedic care when possible for patients with MBD. Furthermore, care delivery interventions capable of decreasing the footprint of emergent surgery through enhanced screening or follow-up of patients with MBD has the potential to significantly improve clinical outcomes in this population. This is an ongoing study that will justify refinements to the current surgical care pathways for MBD in order to identify patients prior to emergent presentation. Future directions will evaluate the costs associated with each care delivery method to provide opportunity for health economic efficiencies

Aim. The liver is the major source of acute phase proteins (APPs) and serum concentrations of several APPs are widely used as markers of inflammation and infection. The aim of the present study was to explore if a local extra hepatic osseous acute phase response occurs during osteomyelitis. Method. The systemic (liver tissue and serum) and local (bone tissue) expression of several APPs during osteomyelitis was investigated with qPCR and ELISA in a porcine model of implant associated osteomyelitis (IAO) at 5, 10 and 15 days after inoculation with S. aureus or saline, respectively. Additionally, samples were also collected from normal heathy pigs and pigs with spontaneous, chronic, haematogenous osteomyelitis. Afterwards, immunohistochemistry towards different upregulated APPs was performed on the porcine osteomyelitis lesions and on bone biopsies from human patients with chronic osteomyelitis. Results. All infected porcine bone lesions (apart from Day 5 in the IAO model) were made up by necrosis, pus, and various degree of fibrotic encapsulation. A local, highly significant upregulation of Serum Amyloid A (SAA, up to 4000-fold upregulation), Complement component C3 (C3), and Inter-Alpha-Trypsin Inhibitor Heavy Chain 4 (ITIH4) were present in infected pigs compared to sterile controls. For the experimental IAO animals, the upregulation of C3 and ITIH4 increased over time, i.e., the highest expression was seen on day 15 after bacterial inoculation. In the liver, only C-reactive protein (CRP) and ITIH4 (not SAA or C3) were slightly upregulated in infected pigs. Serum concentrations of CRP, SAA and haptoglobin were only upregulated at day 5 in IAO infected animals. Immunohistochemically, comparable numbers of APP positive cells (leucocytes and bone cells) were found in human and porcine bone samples with chronic osteomyelitis. Conclusions. This is to our knowledge the first description of local APP up-regulation during chronic bone infection. Only small changes in the expression of APPs were found in the liver and serum samples. Thus, the presence of an osseous upregulation of APPs appears to be part of a predominantly local response that will be difficult to measure systemically. The importance of a local immune response in bone infections seems logical as the blood supply is severely impaired during osteomyelitis. There is a real need for supportive diagnostic bone infection criteria which should be based on a comprehensive understanding of the local inflammatory response. As seen from the present study, staining for SAA or C3 could potentially improve the diagnostic performance of histopathology

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

Aims. Bone is a common site of metastatic disease. Skeletal complications include disabling pain and pathological fractures. Palliative surgery for incurable metastatic bone lesions aims to preserve quality of life and function by providing pain relief and stable mobility with fixation or replacement. Current literature has few treatment studies. We present a 5 year longitudinal cohort study of surgery for metastatic bone disease at our large teaching hospital reviewing our complication and mortality rates. Methods. Patients that underwent palliative surgery for metastatic bone lesions were identified from operative records. Demographics, clinical details and outcomes were recorded. Kaplan-Meier analysis was used to calculate survivorship. Results. 43 patients were treated for 44 bone metastases (34 IM Nails, 9 prosthetic replacements, 1 plate). The median age at primary diagnosis was 66 (33–92). Lung cancer was the most common primary. 56% presented with complete fractures and 44% with impending fractures (median Mirel score of 10). Pertrochanteric bone lesions were the most common (74%). Two out of 43 patients died within one day of surgery. 30 day mortality was 12% and 45% at 1 year. In those surviving the 30 day perioperative period, we report a complication rate of 14%. One patient had a dislocated prosthesis. Two patients had delayed or non union and two patients had failure of metalwork. No patient required re operation. Conclusion. Our series observed a 5% fixation failure rate and significant perioperative mortality. Whilst surgery may offer benefit in the non moribund patient with pathological fracture the decision to offer prophylactic surgery is more difficult in light of the high perioperative mortality seen in our study. Indeed, the patients in our study who died within 24 hours of surgery had prophylactic fixations. We conclude that surgical intervention must be carefully considered with realistic expectations of outcomes

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

Background. Treatment of aggressive benign bone lesions with curettage, burring, cementation and plate augmentation is a widely accepted treatment. We have used the above method using a locked plate (rather than conventional), facilitating stability and early mobilisation. We hypothesise that this is an alternative to megaprosthetic joint replacement, and provides acceptable functional outcomes at follow-up. Methods. Patients with peri-articular aggressive benign bone lesions of the lower limb were treated with marginal excision, intra-lesional curettage, burring and cementation. This was augmented with a locked plate of varying designs. Where feasible, liquid nitrogen was used as an adjunctive treatment. Functional outcome was evaluated at follow-up using the Musculoskeletal Tumour Society Score (MSTS). Routine X-rays were performed at follow up to determine if there was any radiographic evidence of recurrence or any complications. Results. 13 patients with aggressive benign tumours of the lower limb were treated between 2005 and 2009. All tumours were aggressive benign peri-articular tumours with extension to the articular surface. Several of the tumours had fractured the articular cartilage and extended into the joint. Several pathological fractures were noted. The patients were treated in the manner described. The average MSTS score was 89%. Average follow-up time is 35 months. Patients were discharged 2 weeks post-operatively, a prerequisite being the ability to achieve 90° of knee flexion. To date there have been no complications or evidence of radiological recurrence. Conclusion. Our early results in a small series make us cautiously optimistic that this may be an alternative to immediate megaprosthetic reconstruction in patients with relative joint preservation and form an intermediate step in the treatment of aggressive benign peri-articular bone tumours. These may be amenable to arthroplastic reconstruction at a later stage, if necessary

INTRODUCTION. Recently, as the number of total knee arthroplasty (TKA) is increasing, the number of revision TKA due to loosening or osteolysis is rapidly increasing. Large bone defect is one of the most critical issues during revision TKA. Therefore, early detection of bone loss around the TKA prosthesis before bone loss has been enlarged is very important. However, it is difficult to detect the loosening or ostolysis at the early stage around the femoral component even using fluoroscopically guided plain radiograph. A novel technique of tomography (Tomosynthesis; Shimazu Corporation, Kyoto, Japan) was introduced to detect the small bone loss. The purpose of this study was to examine, in a pig model of radiolucent line and osteolysis around TKA, the sensitivity and specificity of detection of radiolucent line and osteolysis using fluoroscopically guided plain radiographs and a novel technique of tomography. METHODS. Six cemented femoral components (PFC Sigma; DePuy, Warsaw, IN, USA) were implanted in pig knees. Two components were implanted with standard cement technique (Standard model). Two components were implanted with 2 mm-thick defect between the cement and bone (Radiolucent line model). Two components were implanted with cystic defects (mean size = 0.7 cm. 3. ) in femoral condyles (Osteolysis model). The simulated bone lesions were filled with agarose to simulate granuloma tissue and to reduce the air artifact around the bone lesions, which can interfere with imaging techniques (Figure 1). Fluoroscopically guided plain radiographs (63 kV, 360 mA, 50 msec) were taken in 4 postures (antero-posterior, lateral, and +/−45 degrees oblique views) for each specimen (Figure 2). For Tomosynthesis, 74 frames were acquired in the rate 30 frames/sec with fixed X-ray condition (65 kV 1.25 mAs) and were reconstructed (Figure 3). Seven blinded assessors experienced in clinical radiographic analysis examined. The sensitivities, specificities and accuracy of the two imaging techniques were compared. RESULTS. The mean sensitivity and specificity of Tomosynthesis were 85.4% and 87.2% (Table 1). Any bone defects (radiolucent lines or osteolysis) were not detected using fluoroscopically guided plain radiographs, because metal box for post-cam mechanism hinder the bone defect around the femoral condyles. DISCUSSION. This study demonstrates the uselessness of fluoroscopically guided plain radiographs for small bone defect around the femoral component. Tomosynthesis, a novel technique of tomography, showed much higher efficacy comparing to conventional fluoroscopically guided plain radiographs. Although the size of bone defect in this study (0.7 cm. 3. ) was much smaller than previous report (1.4 cm. 3. ) using CT (Solomon L, et al., J Arthroplasty in press), sensitivity of this study was higher than that of previous study using CT (75%). Tomosynthesis will be useful method for early detection of small periprosthetic bone defects around femoral component of TKA

Pathologic fractures about the hip are an uncommon, but increasingly prevalent, clinical scenario encountered by orthopaedic surgeons. These fractures about the hip usually necessitate operative management. Life expectancy must be taken into account in management, but if survivorship is greater than 1 month, operative intervention is indicated. Determination must be made prior to operative management if the lesion is a solitary or metastatic lesion. Imaging of the entire femur is necessary to determine if there are other lesions present. Bone lesions that have a large size, permeative appearance, soft tissue mass, and rapid growth are all characteristics that suggest an aggressive lesion. Biopsy of the lesion in coordination with the operative surgeon should be conducted if the primary tumor is unknown. Metastatic disease is much more common than primary tumors in the adult population. Many metastatic fractures in the intertrochanteric region, and all fractures in the femoral neck and head are an indication for hemiarthroplasty or total hip arthroplasty. Cemented femoral implants are generally indicated. This allows immediate weight bearing in a bone with compromised bone stock, thus reducing the risk of peri-operative fractures. Additionally, patients are often treated with radiation and/or chemotherapy, which may prevent proper osseointegration of an ingrowth femoral component. Highly porous ingrowth shells have been shown to provide reliable and durable fixation even in these situations. Management of a periacetabular pathologic fracture, particularly resulting in a pelvic discontinuity is a particularly challenging situation. Use of a highly porous acetabular component combined with an acetabular cage, a custom acetabular component, a cemented Harrington technique, or a primary acetabular reconstruction cage may be utilised. Patients with neoplastic disease are often at risk for infection and thromboembolic disease both from the disease and treatment. Pre-operative evaluation of nutrition status by measuring albumin and pre-albumin will give the surgeon insight. Additionally, dehydration is commonly seen in cancer patients, and adequate pre-operative optimization of fluids and electrolytes may reduce peri-operative complications from other organ systems

Introduction:. Skeletal involvement in non-Hodgkin lymphoma in HIV/AIDS is rarely reported. The bone lesions can have a spectrum of radiological features. Aims:. The aim of the study was to review the radiological features of non-Hodgkin lymphoma (NHL) involving the bone in HIV positive patients. Methodology:. All cases of NHL involving bone in HIV positive patients diagnosed histopathologically were recorded retrospectively between September 2002 and December 2013. Clinical manifestations, radiological features and haematological investigations were analysed from the patients' records. Histopathological subtypes were analysed from slides. Results:. 105 Cases of lymphoma involving bone were recorded. Of these, 46 patients met the criteria of being HIV positive and diagnosed with NHL involving bone. The male to female ratio was equal, the age ranged from 14 to 51 years (average 35 years), the absolute CD 4 count ranged from 17 to 307 (average 100). The sites of involvement were:- vertebrae (22), ribs (8), pelvis (6), femur (3), mandible (3), humerus (2), sternum (1) and clavicle (1). Vertebral involvement was multifocal with a large extradural soft tissue mass in 17 cases and solitary in 5 cases. Pathological fractures were seen in 4 cases of long bone involvement. Most patients presented with a high grade large B cell non-Hodgkin lymphoma with CD20 immunopositivity. Conclusion:. Primary bone lymphoma is a rare disease, accounting for approximately 3% of all primary bone malignancies and 4% to 7% of all extranodal lymphomas in the general population. The prevalence of primary and secondary bone lymphoma is very high in HIV positive patients. The disease is very aggressive, presenting in patients with low CD 4 count and the prognosis is poor. The radiologic patterns can be lytic, blastic or subtle changes, solitary or multifocal. The diagnosis of skeletal NHL is made on histopathology

The purpose of this study is to provide a systematic review of the literature and assess outcome of our experience of Ilizarov Bone Transport in reconstruction for primary malignant tumours of bone (PMTB). A systematic review of the literature for reported cases of primary reconstruction of PMTB using distraction osteogenesis was performed. All cases of distraction osteogenesis for primary reconstruction of PMTB in our institution were reviewed. Outcome was determined from retrospective review of case notes and radiology. Patients were contacted to define final status. There are few cases of primary reconstruction of PMTB using Ilizarov method in the literature. Most reports relate to benign tumours or reconstruction of secondary deformities or non-union after tumour resection. At our institution we have treated 7 patients with bone defects resulting from excision of a PMTB. Mean age was 42.1 years (23–48). Tumours occurred in the tibia in 4 cases and the femur in 3 cases. Histologic diagnosis was chondrosarcoma in 3, malignant fibrous histiocytoma in 2, adamantinoma in 1 and malignant intraosseous nerve sheath tumour in 1. All patients were assessed through the hospital sarcoma board and shown to have isolated bone lesions without metastases. Mean bone defect after resection was 13.1 cm (10–17). Mean frame time was 13.6 months (5–23). Mean follow-up was 46 months (15–137). Complications included pin infection, docking site non-union, premature fusion of corticotomy, soft tissue infection and minor varus deformity. There was one local recurrence of tumour at five months after resection, resulting in a through hip disarticulation. The other cases remain tumour-free with united, well-aligned bones and acceptable long-term function. PMTB is rare and poses a major reconstructive dilemma. Distraction osteogenesis provides an effective method of biologic reconstruction in selected cases, and good outcomes can be achieved

Background. It has been suggested that routine follow-up of primary THR patients could be performed by GPs in primary care, rather than by orthopaedic specialists. Essential radiographic follow-up would likely be based on radiographic reports, rather than on inspection of the radiographs themselves. Aim. To look at the quality of the radiographic reports to determine their usefulness as a method of radiographic follow-up of THRs. Methods. The immediate pre-revision radiographs of a consecutive series of 50 patients, who had undergone revision surgery in 2 hospitals, were examined by a senior orthopaedic registrar, supervised by a Consultant with a revision THR practice, and compared to the findings of the corresponding radiologist report. Signs of failure were categorised into loosening, bone lysis and polyethylene wear. Results. Comparison to previous radiographs, essential in assessing THRs, was only performed by radiologists in 42% of cases. Fixation type (cemented/uncemented) was mentioned in only 2 cases and was correct in 1 case. With regard to loosening, acetabular component loosening was missed by radiologists in 10% of cases and femoral component loosening in 12%. Radiologists missed osteolysis on the acetabular side in 28% of cases and on the femoral side in 26%. Polyethylene wear was reported by surgeons in 30% of cases, but radiologists failed to report this in 28% of cases. Discussion. The radiographs reviewed contained definite evidence of failure, being pre-revision radiographs. Despite this, a significant amount of important information was lacking in the radiologists' reports. Primary care doctors would have been reassured that all was well with the prosthesis in a significant number of cases and hence specialist referral would have not taken place, unless the patient was symptomatic. We cannot support the radiographic component of GP follow-up of primary THRs using radiological reports on the basis of this study

Purpose:. To assess the outcomes of osteosarcoma cases managed between January 2006 & December 2010 in a tertiary centre. Methods:. A retrospective review of patient records. Results. Twenty eight consecutive cases of osteosarcoma managed over 5 years were reviewed retrospectively. 16 patients were male, and ages ranged from 11 to 69 years, with 20 patients in their 2nd decade. The distal femur was involved in 17 cases and the proximal tibia in 4. Histologically 13 cases were osteoblastic, 4 chondroblastic and the rest other forms of osteosarcoma. Tumour size varied from 6 to 35 cm, with only 6 less than 10 cm in size. Metastases were present on admission in 14 cases, and 2 more developed metastases within 2 months. One patient was Enneking Stage IIA, 13 Stage IIB and 14 Stage III at presentation. 3 patients refused any treatment. 4 cases were considered inoperable and died within days. Chemotherapy was started in 17 patients, and 4 additional patients who were considered for chemotherapy defaulted. 17 patients were treated by amputation, achieving local control in all cases at last follow up. A single patient had a wide tumour resection and prosthetic reconstruction. 5 patients are disease free at average 16 months survival, while 3 have survived an average of 13 months with metastases. 9 patients were lost to follow up, 7 are known and 4 are presumed to be dead. Conclusion:. These results show the problems of managing osteosarcoma in the public sector. Patients are referred far too late, tumours are so large that most require amputation, half the patients have metastases at presentation and some are preterminal. Many patients refuse amputation or default from chemotherapy. Results of treatment of osteosarcoma in the public sector are discouraging mostly due to late referral. Education of medical personnel to refer suspicious bone lesions without delay is the only way to improve outcomes

Cementoplasty, like vertebroplasty, is a technique whereby Polymetylmethacrylate is placed into a bone lesion either percutaneouly or by surgery under image intensifier guidance. Although there have been few studies with regard to cementoplasty percutaneously, there is no series in the literature to support the open surgical technique as a palliative procedure. In our series we describe four patients (1male and 3 females, age range 63-83) with metastatic bone cancer who have benefited from an open surgical procedure. The four patients presented to our hospital between January 2004 and December 2006. They all had gradually worsening hip pain at the time of presentation and pelvic radiographs revealed osteolytic lesions in the acetabulum. A 5 centimetre longitudinal incision proximal to the greater trochanter was made and the malignant lesion identified using the image intensifier. The malignant tissue was curetted and sent for microscopy, culture, sensitivity and histopathology and the remaining void filled with bone cement (via a gun or by hand) under x-ray control. Radiographs were taken in all patients post-operatively and were referred for adjuvant radiotherapy. All patients had immediate relief of pain and were able to mobilise within 48 hours. Two patients died within 6 weeks post-operatively due to complications from their primary malignancy (lung). One patient died at three months due to unknown primary. One patient remained pain free and fully ambulatory at one and a half years post surgery (breast primary). This procedure can be recommended for patients with metastatic bone disease as it provides adequate pain control and improves the quality of life in this group of patients. These patients need a multi-disciplinary approach to their care, but as orthopaedic surgeons, we can make a significant impact to such patients and their families

In February 2004, our institute began to perform routine cervical CT scans in addition to head CT examinations on patients with blunt head trauma who had received high energy injuries. We present the findings of 108 patients who underwent a routine cervical CT within the last year and the usefulness of routine cervical CT examinations is discussed. The present report is, to our knowledge, the only prospective study to examine the utility of routine cervical CT examinations. Among the patients admitted to the emergency room of our institute after receiving high energy injuries, 108 patients had blunt head trauma and underwent a routine cervical CT examination in addition to the head CT examination specified by our original protocol for cervical clearance. The mechanism of injury and the presence of cervical bone lesions were noted in each case. 76 males and 32 females ranging in age from 13 to 77 years (average, 41.0 years) were included in the study. Among these 108 cases, cervical fractures or subluxation were visible in 5 cases on plain films. Although no fractures were seen on the plain films taken in the remaining 103 cases, the additional cervical CT examinations demonstrated 14 cervical fractures in 13 (12.6%) of these cases. For patients with blunt head trauma, a cervical CT examination is not usually performed if no evidence of a cervical fracture is found on plain films and no neurological deficits are present. Nevertheless, the present findings suggest that many cervical fractures may have been missed on plain films in the past, and the routine inclusion of a cervical CT examination in addition to a head CT examination might be appropriate in the evaluation of patients with blunt head trauma who have been involved in a high energy injury