Aim. Squamous cell carcinoma (SCC) is a rare but often devastating complication of chronic osteomyelitis. Optimum diagnosis and management are not well established. This paper aimed to develop a definitive, evidence-based approach to its diagnosis and management. Method. A systematic review of relevant published studies available in English from 1999-present was conducted. Strict inclusion criteria ensured that the diagnoses of osteomyelitis and SCC were explicit and valid. Additional cases from our institution were included using the same eligibility criteria. Data regarding patient demographics, osteomyelitis diagnosis, SCC diagnosis and its management and patient outcomes were collected. Statistical significance was assessed by Fisher's exact test. Results. Nineteen publications involving 98 patients plus eight patients managed locally were included. Eighty percent of patients were male, diagnosed with SCC at an average age of 59 years old (24–82 years), 31 years after their osteomyelitis diagnosis (3–67 years). Multiple bones were affected: tibia or fibula (59%), femur (17%), pelvis and sacrum (8%), bones of the foot and ankle (8%) and upper limbs (6%). Malignant transformation was associated predominantly with sinus (82%), ulceration (61%) and discharge (41%). SCC was diagnosed by biopsy (77%) or incidentally (23%) following definitive management for osteomyelitis. Twenty-two percent of patients had a staging CT scan. Seventy-six percent of patients underwent amputation, 16% underwent limb-sparing wide local excision and the remaining patients were palliated. Incidental diagnosis of SCC was associated with poorer outcomes in terms of death or disease recurrence (one year, p=0.052, five years p=0.021, Fisher's exact test) as was metastatic disease at SCC diagnosis (one year, p=0.006, five years, p=0.032, Fisher's exact test) and pelvic or sacral disease (one year p<0.001, five years p=0.002, Fisher's exact test). All patients who were not actively treated died within one year of SCC diagnosis. Data was suggestive that more patients who underwent amputation (versus wide local excision) were disease free at one and five years, but this was not statistically significant (one year, p=0.058, five years, p= 0.152, Fisher's exact test). Conclusions. SCC should be suspected in all cases of chronic osteomyelitis with skin changes, particularly where changes exceed 3 years duration and involve the pelvis. Multiple biopsies for histology should be taken in all suspected cases, as well as routinely during surgical excision of osteomyelitis when chronic skin changes are present. Once SCC is identified, staging CT scan should be performed to guide management. Amputation, where possible, should be considered

Squamous Cell Carcinoma (SCC) is a rare complication of chronic osteomyelitis (OM), arising in a sinus tract (Marjolin's Ulcer). We routinely send samples for histological analysis for all longstanding sinus tracts in patients with chronic osteomyelitis. We reviewed the clinical features and outcomes of patients with SCC arising from chronic osteomyellitis. A retrospective study was performed of patients with osteomyelitis between January 2004 and December 2014 in a single tertiary referral centre. Clinical notes, microbiology and histo-pathological records were reviewed for patients who had squamous cell carcinoma associated with OM. We treated 9 patients with chronic osteomyelitis related squamous cell carcinoma. The mean age at time of diagnosis was 51 years (range 41–81 years) with 4 females and 5 males. The mean duration of osteomyelitis was 16.5 years (3–30 years) before diagnosis of SCC. SCC arose in osteomyelitis of the ischium in 5 patients, sacrum in 1 patient, femur in 1 patient and tibia in 2 patients. Osteomyelitis was due to pressure ulceration in 7 patients and post-traumatic infection in 2 patients. The histology showed well differentiated SCC in 4 cases and moderately differentiated SCC in 2 cases with invasion. Two patients had SCC with involvement of bone. One patient had metastatic SCC to bowel. All patients had polymicrobial or Gram-negative cultures from microbiology samples. Four patients (57%) in our series died as result of their cancer despite wide resection. The mean survival after diagnosis of SCC was 1.3 years and mean age at time of death was 44.7 years. Two of these patients had ischial disease and were treated with hip disarticulation, hemi-pelvectomy and iliac node clearance. Five patients remain disease free at a mean of 3.4 years (range 0.1 – 7yrs) after excision surgery. One patient in this group underwent a through-hip amputation, one underwent an above knee amputation and one underwent excision of ischium and surrounding sinuses. Of note, all these patients had clear staging scans at time of diagnosis. This case series demonstrates the consequences of an uncommon complication of osteomyelitis. In our series only 3 patients underwent biopsy for suspected SCC due to clinical appearances. The other cases were all identified incidentally after routine histological sampling, demonstrating the importance of this practice

The appearance of a tumor as a result of chronic osteomyelitis is a relatively rare complication and of late-onset, with a low frequence in the modern world. For the majority of patients, the interval between the onset of primitive osteomyelitis and malignant degeneration is of several decades. We present our cases and the protocol of treatment used. From January 1977 to December 2014 we treated 36 patients (33M, 3F) suffering from squamous cell tumor out of a series of 247 tibial and 74 calcaneal osteomyelitis. 26 patients had chronic osteomyelitis of tibia, 10 of the calcaneus. Based on the functional needs of patients after resection of the tumor, in 18 we applied the Ilizarov apparatus, in 14 we opted for a two steps surgery, with the help of plastic surgeon; four required amputation. 29 patients healed. After 2-years of follow up 3 patients underwent to an amputation in the proximal third of the leg, 4 had a local recurrence. All patients were assessed by SF32 and the QoL test. Squamous cell tumor is the most common malignant tumor in chronic osteomyelitis. For the diagnosis of malignant transformation from a chronic ulcer there is a thorough process. Serial biposies must be performed, especially with the emergence of new clinical signs (increased pain, a bad smell, and changes in secretion by the wound). The definitive treatment is often amputation proximal to the tumor or wide local excision in combination with adjuvant chemotherapy and radiotherapy in selected patients. Early detection can sometimes allow limb salvage. However, the most effective treatment is prevention with the definitive treatment of osteomyelitis, including appropriate debridement, wide excision of the affected area, and early reconstruction

INTRODUCTION. There is historical evidence of increased incidence of transitional cell tumours of the renal tract in workers exposed to high levels of metal ions. This study was designed to establish any correlation between Metal on metal bearing hip arthroplasty and TCC. METHODS. A prospective North-East database of 2900 Urology/Oncology cases was compared with the Freeman Joint Registry, which is a prospective database of all Arthroplasty performed since 2001 to establish any correlation with TCC. After comparing the Urology database with the Freeman Joint Registry from 2001 to 2011, a group of patients was identified who underwent hip replacement and had TCC of bladder. The incidence of TCC was calculated in patients who had metal on metal hip replacement and those who had metal on poly hip replacement. On comparing both the groups no significant difference in incidence of TCC of bladder was recorded. RESULTS. No increase in the incidence of transitional cell carcinoma was observed in patients who had metal on metal hip replacements compared to the one who had metal on polyethylene hips

Advances in orthopaedic surgery have led to minimally invasive techniques to decrease patient morbidity by minimizing surgical exposure, but also limits direct visualization. This has led to the increased use of intraoperative fluoroscopy for fracture management. Unfortunately, these procedures require the operating surgeon to stay in close proximity to the patient, thus being exposed to radiation scatter. The current National Council on Radiation Protection recommends no more than 50 mSv of radiation exposure to avoid ill-effects. Risks associated with radiation exposure include cataracts, skin, breast and thyroid cancer, and leukemia. Despite radiation protection measures, there is overwhelming evidence of radiation-related diseases in orthopaedic surgeons. The risk of developing cancer (e.g. thyroid carcinoma and breast cancer) is approximately eight times higher than in unexposed workers. Despite this knowledge, there is a paucity of evidence on radiation exposure in orthopaedic surgery residents, therefore the goal of this study is to quantify radiation exposure in orthopaedic surgery residents. We hypothesize that orthopaedic surgery residents are exposed to a significant amount of radiation throughout their training. We specifically aim to: 1) quantify the amount of radiation exposure throughout a Canadian orthopaedic residency training program and 2) determine the variability in resident radiation exposure by rotation assignment and year of training. This ongoing prospective cohort study includes all local orthopaedic surgery residents who meet eligibility criteria. Inclusion criteria: 1) adult residents in an orthopaedic surgery residency program. Exclusion criteria: 1) female residents who are pregnant, and 2) residents in a non-surgical year (i.e. leave of absence, research, Masters/PhD). After completion of informed consent, each eligible resident will wear a dosimeter to measure radiation exposure in a standardized fashion. Dosimeters will be worn on standardized lanyards underneath lead protection in their left chest pocket during all surgeries that require radiation protection. Control dosimeters will be worn on the outside of each resident's scrub cap for comparison. Dosimeter readings will then be reported on a monthly and rotational basis. All data will be collected on a pre-developed case report form. All data will be de-identified and stored on a secure electronic database (REDCap). In addition to monthly and rotational dosimeter readings, residents will also report sex, height, level of training, parental status, and age for secondary subgroup analyses. Residents will also report if they have personalized lead or other protective equipment, including lead glasses. Resident compliance with dosimeter use will be measured by self report of >80% use on operative days. Interim analysis will be performed at the 6-month time point and data collection will conclude at the 1 year time point. Data collection began in July 2018 and interim 6-month results will be available for presentation at the CORA annual meeting in June 2019. This is the first prospective study quantifying radiation exposure in Canadian orthopaedic residents and the results will provide valuable information for all Canadian orthopaedic training programs

National Institute of Clinical Excellence guidelines on Metastatic Spinal Cord Compression recommend urgent consideration of patients with spinal metastases and imaging evidence of structural spinal failure with spinal instability for surgery to stabilise the spine and prevent Metastatic Spinal Cord Compression. We aimed to compare neurological outcomes of patients managed operatively and non-operatively. Prospective collection of 397 patients' data over a 4-year period. Males represented 59.2% of patients. Median age was 69 years. Non-operative intervention in 62.2% of patients. Prostate, lung, Breast, Myeloma, Renal Cell Carcinoma and Lymphoma accounted for over 75% of all primary tumours (n=305). Median Length of hospital stay was longer in the operative group of 15 days compared to 10 days in the non-operative group (p<0.0001). Patients who were ambulating on presentation maintained their ambulation in 70.2% of cases in the operative group compared to 90.9% in the non-operative group (p<0.0001). However, upon discharge 41% of patients managed operatively were ambulatory compared to the non-operative group rate of 36.5% (p<0.0001). In Prostate, Breast, Myeloma, RCC and Lymphoma 100% of patients managed non-operatively maintained ambulation. Lung primaries managed operatively had an 80% chance of maintaining ambulation compared to 76.9% in the non-operative group (p<0.05). A higher proportion of patients managed non-operatively maintained ambulation than those managed operatively. With operative intervention, more patients regained ambulatory status. Whilst we have mainly focused on ambulatory status in this paper there are other factors to consider including pain relief and spinal stability which may be an indication for surgical intervention

The rate of fracture and subsequent nonunion after radiation therapy for soft-tissue sarcomas and bone tumors has been demonstrated to quite high. There is a paucity of data describing the optimal treatment for these nonunions. Free vascularized fibular grafts (FVFG) have been used successfully in the treatment of large segmental bone defects in the axial and appendicular skeleton, however, their efficacy with respect to treatment of radiated nonunions remains unclear. The purpose of the study was to assess the 1) union rate, 2) clinical outcomes, and 3) complications following FVFG for radiation-induced femoral fracture nonunions. We identified 24 patients who underwent FVFG for the treatment of radiation-induced femoral fracture nonunion between 1991 and 2015. Medical records were reviewed in order to determine oncologic diagnosis, total preoperative radiation dose, type of surgical treatment for the nonunion, clinical outcomes, and postoperative complications. There were 11 males and 13 females, with a mean age of 59 years (range, 29 – 78) and a mean follow-up duration of 61 months (range, 10 – 183 months). Three patients had a history of diabetes mellitus and three were current tobacco users at the time of FVFG. No patient was receiving chemotherapy during recovery from FVFG. Oncologic diagnoses included unspecified soft tissue sarcomas (n = 5), undifferentiated pleomorphic sarcoma (UPS) (n = 3), myxofibrosarcoma (n = 3), liposarcoma (n = 2), Ewing's sarcoma (n = 2), lymphoma (n = 2), hemangiopericytoma, leiomyosarcoma, multiple myeloma, myxoid chondrosarcoma, myxoid liposarcoma, neurofibrosarcoma, and renal cell carcinoma. Mean total radiation dose was 56.3 Gy (range, 39 – 72.5), given at a mean of 10.2 years prior to FVFG. The average FVFG length was 16.4 cm. In addition to FVFG, 13 patients underwent simultaneous autogenous iliac crest bone grafting, nine had other cancellous autografting, one received cancellous allograft, and three were treated with synthetic graft products. The FVFG was fixed as an onlay graft using lag screws in all cases, additional fixation was obtained with an intramedullary nail (n = 19), dynamic compression plate (n = 2), blade plate (n = 2), or lateral locking plate (n = 1). Nineteen (79%) fractures went on to union at a mean of 13.1 months (range, 4.8 – 28.1 months). Musculoskeletal Tumor Society scores improved from eight preoperatively to 22 at latest follow-up (p < 0.0001). Among the five fractures that failed to unite, two were converted to proximal femoral replacements (PFR), two remained stable pseudarthroses, and one was converted to a total hip arthroplasty. A 6th case did unite initially, however, subsequent failure lead to PFR. Seven patients (29%) required a second operative grafting. There were five additional complications including three infections, one wound dehiscence, and one screw fracture. No patient required amputation. Free vascularized fibular grafts are a reliable treatment option for radiation-induced pathologic femoral fracture nonunions, providing a union rate of 79%. Surgeons should remain cognizant, however, of the elevated rate of infectious complications and need for additional operative grafting procedures

Aims. To evaluate the incidence, patient demographics, primary tumour characteristics and treatment modalities of patients with radiation induced soft tissue sarcoma (RISTS) presenting to the East Midlands Sarcoma Service at Nottingham City Hospital. Methods. All consecutive patients with histologically proven RISTS were identified from our pathology database. Case notes were retrospectively reviewed to identify patient demographics, oncological features and treatment outcome. Results. From 1998 to 2011, 24 patients were identified to have RISTS. 17 were female, 7 male. The mean age at time of diagnosis is 67 years (range 40–85 years). The average latency period is 12.8 years (range 1–50). The most common primary oncological diagnosis were breast carcinoma 11 (11, 45.8%) and endometrial carcinoma and testicular tumours (both 3, 12.5%). The sarcoma subtypes were 9 angiosarcomas (37.5%), 6 pleomorphic sarcomas (29.1%), 3 leiomyosarcomas (12.5%), 2 myofibroblastic sarcomas (8.4%), 1 MPNST (4.2%) 1 soft-tissue osteosarcoma (4.2%) 1 dedifferentiated liposarcoma (4.2%) and 1 myxoid liposarcoma (4.2%). At the time of this study, 8 patients died of disease, 13 were alive and disease free, 1 alive with disease, 1 discharged from follow-up disease free and 1 lost to follow-up. Discussion. RISTS are rare sarcomas with poor prognosis. An aggressive surgical approach with multi-disciplinary team involvement is of paramount importance

Soft tissue sarcomas (STS) have not demonstrated favourable clinical responses to emerging immunotherapies such as checkpoint inhibitors. Studies in carcinomas and melanoma have demonstrated that tumours lacking T-cell infiltrates are associated with poor responses to immunotherapies. It is postulated that STS lack tumour asscoiated lymphocytes which renders these tumours insensitive to checkpoint inhibitors. Our objective was to develop a novel syngeneic mouse model of STS and characterize the immune phenotype of these tumours. Additionally, we sought to evaluate the therapeutic responses of these sarcomas to checkpoint inhibitors and a Type I interferon agonist. K-ras mutagenesis and p53 deletion was induced using a Lenti-Cre-recombinase injection into the hindlimb of 3 week old C57BL/6 mice. Tumours were harvested and characterized using standard histopathology techniques and whole trascriptome sequencing (RNAseq). Full body necrospy and histopathology was performed to identify metastases. Flow cytometry and immunohistochemistry was used to evaluate tumour immune phenotypes. Tumours were implanted into syngeneic C57BL/6 mice and the therapeutic responses to anti-CTLA4, anti-PD1 and DMXAA (Type I interferon agonist) were performed. Tumour responses were evaluated using bioluminescent imaging and caliper measurements. Soft tissue sarcomas developed in mice within 2–3 months of Lenti-Cre injection with 90% penetrance. Histologic analyses of tumours was consistent with a high-grade myogenic sarcoma characterized by smooth muscle actin, Desmin and Myogenin D positive immunostaining. Using crossplatform normalization protocols, geneexpression signatures of the mouse tumours most closely correlated with human undifferentiated pleomorphic sarcoma (UPS). Collectively, gene expression signatures of this murine sarcoma correlated with all muscle-derived human sarcomas (ERMS, ARMS, Synovial sarcoma, UPS). No lung or other visceral metastases were observed in all mice who developed spontaneous tumours. Immune phenotyping demonstrated a paucity of tumour-infiltrating lymphocytes (TILs, (TAMs). 50% of identified TILs in these murine sarcomas expressed PD-1, yet tumours were not responsive to anti-PD1 therapy or anti-CTLA4 therapy. A single intra tumoural (i.t.) injection of the Type I interferon agonist, DMXAA resulted in 80–90% tumour necrosis 72 hrs post-injection, decreased tumour viability up to 2 weeks post-injection and a marked infiltration of CD8+ T-cells and anitgen presenting dendritic cells and macrophages. Additional longitudinal experiments demonstrate a sustained and progressive anti-tumour effect in 83% (5/6) mice up to 6weeks following a single i.t. injection of DMXAA. All control treated mice (6/6) reached humane endpoint within 14 days. At 3 months post-DMXAA treatment, 4/6 mice were free of disease. We re-injected UPS tumours into these mice and tumours did not grow, suggesting abscopal effects after DMXAA treatment of primary tumours. We have characterized a new orthotopic and syngeneic mouse model of a myogenic soft tissue sarcoma. Like most human STS sub-types, these tumours have an immune inert tumour microenvironment and are not sensitive to checkpoint inhibitors. This model, syngeneic to C56BL/6 mice will enable future opportunities to investigate how various branches of the immune system can be targetted or manipulated to unearth new immunotherapeutic strategies for sarcoma. Using this model we have demonstrated that a single, intra-tumoural injection of a Type I interferon agonist can result in anti-tumour effects, recruit cytotoxic lymphocytes and antigen presenting cells with into the the tumour microenvironment. Abscopal tumour rejection after DMXAA treatement suggest adaptive T-cell responses against UPS are active in this model. Future work is needed to determine if upregulation of Type I inferferon pathways can be used as a therapeutic strategy for sarcoma or as a sensitization strategy for checkpoint inhibitors

The purpose of this study was to profile the mRNA expression for the 23 known matrix metalloproteinases (MMPs), 4 tissue inhibitor of metalloproteinases (TIMPs) and 19 ADAMTSs (a disintegrin and metalloproteinase with thrombospontin motif) in Dupuytren's Disease and normal palmar fascia. Dupuytren's Disease (DD) is a fibroproliferative disorder affecting the palmar fascia, leading to contractures. The MMPs and ADAMTSs are related enzymes collectively responsible for turnover of the extracellular matrix. The balance between the proteolytic action of the MMPs and ADAMTSs and their inhibition by the TIMPs underpins many pathological processes. Deviation in favour of proteolysis is seen in e.g. invasive carcinomata, whereas an imbalance towards inhibition causes e.g. fibrosis. A group of patients with end-stage gastric carcinoma was treated with a broad spectrum MMP inhibitor in an attempt to reduce the rate of carcinoma advancement; a proportion developed a ‘musculoskeletal syndrome’ resembling DD. Tissue samples were obtained from patients undergoing surgery to correct contractures caused by DD and from healthy controls undergoing carpal tunnel decompression. The DD tissue was separated macroscopically into cord and nodule. Total RNA was extracted and mRNA expression analysed by quantitative real-time reverse transcriptase polymerase chain reaction (qRT-PCR), normalised to 18S rRNA. Comparing across all genes, the DD nodule, DD cord and normal palmar fascia samples each had a distinct mRNA expression profile. Statistically significant (p<0.05) differences in mRNA expression included: higher MMP-2, -7 and ADAMTS-3 levels in both cord and nodule; higher MMP-1, -14, TIMP-1 and ADAMTS-4 and -5 in nodule alone, lower MMP-3 in nodule and cord and lower TIMP-2, -3 and -4 and ADAMTS-1 and -8 levels in nodule alone. The distinct mRNA profile of each group suggests differences in extracellular proteolytic activity which may underlie the process of fascial remodelling in DD

There is very limited literature available on the use of prosthetic replacement in the treatment of primary and secondary tumours of the radius. In the past these were treated with vascularised and non-vascularised autografts which had associated donor site morbidity, problems of non union, graft or junctional fractures and delayed return to function. Our study is a mid to long term follow-up of implant survivorship and the functional outcome of metal prosthetic replacement used for primary and metastatic lesions of radius. We had 15 patients (8 males:7 females) with a mean age of 53 years. 8 patients underwent proximal radial replacement, 2 with mid-shaft radial replacement and 6 patients had distal radial replacements with wrist arthrodesis. The indications for replacement included metastatic lesions from renal cell carcinoma, primary giant cell tumours, ewings' sarcoma, chondroblastoma, radio-ulnar synostosis and benign fibrous histiocytoma. The average follow up was 5 years and 6 months (range 3 months - 18 years). Four patients died as a result of dissemination of renal cell carcinoma and two patients were lost to follow-up. There were no complications with the prosthesis or infection. Clinically and radiographically there was no loosening demonstrated at 18 years with secure fixation of implants. Two patients developed interossoeus nerve palsies which partially recovered. Functional outcomes of the elbow were assessed using the Mayo performance score with patients achieving a mean score of 85 postoperatively (range 65-95). All but one patient had full range of motion of the elbow. The patient with radio-ulnar synostosis had a 25 degree fixed flexion pot-operatively. Although the distal radial replacements had decreased range of movements of the wrist due to arthrodesis, they had excellent functional outcomes. Only one patient required revision surgery due to post-traumatic loosening of the implant. Our results of the use of endoprosthetic replacement of radius in the treatment of tumours are encouraging with regards to survivorship of the implant and functional outcome. This type of treatment results in an early return to daily routine activties, good functional outcome and patient satisfaction

Aim. Periprosthetic joint infection (PJI) is a major complication of prosthetic implantation and needs a combined surgical and antimicrobial treatment. One-stage revision results usually in similar cure rate than two-stage (around 85–92%), but antibiotic therapy duration is not well established. The aim of study was to evaluate the efficacy of a short six-weeks antibiotic course in hip and knee PJIs after one-stage replacement arthroplasty (RA). Method. This was a retrospective, observational study conducted at Orthopaedic Department of Cochin Hospital, Paris, between 1stJanuary 2010 and 31 December 2015. Inclusion criteria were: age>18 years; clinical/microbiological diagnosis of PJI; one-stage RA; 6-weeks course of antibiotics; follow-up of at least one year. PJIs were classified depending on the delay of infection from implantation as: early(<3 months), delayed(3–24 months), late(>24 months). Pearson's-χ2 and t-tests were used to compare categorical and continuous variables. Results. Fifty patients with PJIs treated with one-stage hip/knee replacement arthroplasty (HRA/KRA) were included, 42 HRA, 8KRA. Median age was 69.3 years (IQR 24.5–97.4), 31 were males. Comorbidities included tumours(18%), polyarthritis(12%), chronic kidney disease (CKD), HIV infection. ASA score was ≥3 in 15(30%) cases. PJIs occurred after a mean of 36 months:9 early, 9 delayed, 32 late. Bone biopsy and synovial fluid cultures were positive for methicillin-susceptible coagulase-negative Staphylococci (MSCNS) in 19(65%) cases, methicillin-resistant CNS (MRCNS) in 5(17%), methicillin-susceptible S. aureus (MSSA) in 5(17%), P. acnes in 20(40%), Enterobacteriacae in 6(12%), Streptococcus spp. in 4(8%), E. faecium and Listeria spp.(2%). Twelve PJIs (24%) were polymicrobial. Intravenous antibiotics were administered for 11 days (IQR 4–45). Daptomycin was used in 22(44%) cases. Forty-six 46(92%) patients were switched to oral antibiotics: fluoroquinolones in 25(54%) cases, clindamycin in 19(41%), beta-lactams in 17(37%), rifampicin in 12(26%). One patient died due to a carcinoma, while others reached at least one year evaluation (IQR 12–60). Overall, the remission rate was 90%(HRA=90%, KRA=88%). Failures included 4 relapses and one reinfection: HRA in 80%, ASA score ≥3 in 40%. Infections recurred after 6 months (IQR 4–12); bacteria involved were: MSCNS(n=2), MSSA, P. acnes and ESBL-producing K. pneumoniae. Univariate analysis, performed for demographical and PJI parameters, showed no differences between success and failures, except for radiotherapy, HIV infection and CKD associated to worst prognosis (p=0.05, OR=10.7; remission rate=50%). The lowest rate of failures was observed with rifampicin use, but it was not significant(p=0.14). Conclusions. six-weeks course of antibiotics in knee and hip PJIs treated with one stage revision, seems sufficient with a satisfactory remission rate

The insidious and occult characteristics of psoas abscess and clinical features similar to conditions like lumbar strain, abdominal/urologic disorders sometimes cause diagnostic delays; resulting in considerably high morbidity and mortality. Chronic inflammatory conditions of the digestive tract and tuberculosis of spine are the commonest source of secondary abscess in the developed and developing countries, respectively [1]. We report a case of an 86 year with a psoas abscess secondary to mucinous adenocarcinoma of colon. 86 year old female presented with right thigh pain in February 2014. CT scan confirmed the clinical suspicion of right psoas abscess which was drained surgically. Intraoperatively, we found pus mixed with mucinous material coming from a small opening in a rounded structure lateral to psoas which could not be identified. The abscess recurred within 2 days. Culture grew Pseudomonas aerugenosa and streptococcus viridans and histopathology showed metastatsis of mucin secreting adenocarcinoma infiltrating the muscle with pyogenic abscess. Repeat CT scan showed abscess communicating with tumor in the colon(Fig 1). Abscess was drained, but tumor was not addressed considering patients age. The infection resolved with 6 weeks of oral linezolid, however the patient expired after 8 months. Cultures in secondary psoas abscess are often mixed, with E. coli and Bacteroides spp predominating. One must rule out gastrointestinal/genitourinary pathology in cases where the CT/ USG guided culture reports are suggestive of gram negative infection. The fact that carcinoma of the colon could be a cause of psoas abscess should be considered when an unexplained psoas abscess is diagnosed [2]. Acknowledgements. None of the authors received payments or services, either directly or indirectly from a third party in support of any aspect of this work that could be perceived to influence what is written

Introduction:. 25% of patients with an unknown primary tumour present to the orthopaedic surgeon with skeletal metastases. The onus is on the orthopaedic surgeon to establish the diagnosis, not only to decrease the patient's anxiety but also because the median survival increases from 6–9 months to 23 months when the primary is identified and allows for specific cancer treatment. The diagnostic work up of an unknown primary includes a multitude of special investigations. Since PET/CT has high sensitivity and specificity for detecting the primary tumours, we asked the question: Can you diagnose the unknown primary in patients with skeletal metastases with a PET/CT?. Method:. We included all PET/CT scans done in our institution between 2010 and 2013 for patients with malignancies known to metastasize to bone (melanoma, breast, lung, head and neck, GIT, other) and all scans done in patients with unknown primaries. After reviewing 686 PET/CT scans, 492 showed metastatic disease, with 78 of these having either spinal or skeletal metastases. Results:. Of these 78 patients, 68 primaries could be detected on the PET/CT scan. Thus the PET/CT detected the primary in 87% of cases. This number could possibly be higher as some were melanoma and breast cancer patients who had already undergone surgical resection. The most common primary detected was lung, followed by a group of other and unknown primaries which included cervical, kidney and thyroid carcinoma. Conclusion:. PET/CT scan is a good modality to use when looking for a primary malignancy in patients who present to the orthopaedic surgeon with bone metastases. We postulate that this might be a possible first line investigation when looking for the primary

Introduction:. Skeletal TB has a paucibacillary nature. It is often found in poorly accessible areas for biopsy purposes. Retrieved samples may have a poor representation of the underlying disease process. Additionally, patients have normally commenced anti-tubercular medication that further decreases the number of bacilli. This has resulted in poor sensitivity and specificity outcomes for the tests that are traditionally done. The polymerase chain reaction (PCR) has been proven to be a useful test for the demonstration of extrapulmonary TB. It has a high specificity and sensitivity. Objective:. The study measures the sensitivity and specificity of PCR done on fresh biopsies from patients suspected of a tuberculous spinal infection. Method and Results:. A retrospective review of results was done of spinal tissue biopsies. A total of 30 consecutive patients were identified. There were 15 males (mean age = 40,3 yrs) and 15 females (mean age = 45,8 yrs). 18 of the patients were HIV positive. Acid fast bacilli were demonstrated in 4 (13,33%) patients by staining. Culture was positive in 10 (33,33%), in which 2 had commenced antitubercular therapy. Histology reported features in keeping with tuberculosis in 9 (30%) patients. Furthermore, multiple myeloma, adenocarcinoma, osteomyelitis and thyroid carcinoma was reported. PCR was positive in 12 (40%) patients. Sensitivity of PCR was calculated as 85,7% whilst specificity was 72,7% (the amount correctly classified was 77,8%). Only 4 patients had positive tests for all 4 methods used for diagnosing tuberculosis. Conclusion:. Tuberculosis should always be considered in spinal lesions. PCR provides a quick and effective means of identifying it. This allows early commencement of anti-tubercular treatment

Management of periprosthetic femoral fractures above a Total Knee Arthroplasty remains a challenge. The different treatment options available include casting for undisplaced fractures, ORIF for a displaced fracture with a well-fixed implant or revision arthroplasty for a very distal fracture and for a fracture with a loose implant. We describe our experience in treating a very distal displaced supracondylar fracture above a well-fixed femoral component in a 68-year-old woman who was recently diagnosed with breast carcinoma and awaiting mastectomy. There was no evidence of metastatic disease. The knee replacement was done 4 years before and the patient did not have any symptoms in the knee prior to the fall. Conventional ORIF with IM nailing or plate osteosynthesis was not possible due to the very distal site of the fracture. We used a custom modified 95 degree angled blade plate in which a slot was cut in the middle of the blade halfway along its length to accommodate the pegs of the femoral component in the distal fragment. The fracture was reduced and fixed with the angled blade plate restoring length, alignment, and providing coronal stability. The patient had a satisfactory union at 3 months without deformity giving a good range of pain free movement in the knee. DCS and 95 degree angled blade plate have been used in the past with mixed results. The lag screw or the blade has to be inserted more proximally to avoid the femoral component and so the distal fixation is often sub optimal. In our case modification of the blade allowed more distal placement providing optimal fixation and avoiding complex revision surgery

Introduction. The Western Infirmary/Gartnavel General Hospital orthopaedic department is geographically located next to the Beatson Oncology Centre, a specialist regional oncology unit. Pathological femoral fractures are the commonest reason for surgical intervention in patients referred from the Beatson and we have used them as a model to establish the demographic data, referral patterns, treatment results, and survival characteristics in such a group of patients. Methods. We have collected prospective data for the last 4 years on referrals from patients under the care of oncology services. Results. 52 patients with 53 pathological fractures and 2 impending pathological fractures of the femur during a 4 year period have been treated with a surgical intervention. The surgery included locked reconstruction femoral nailing, long stem hemiarthroplasty with distal locking and proximal femoral replacement with or without acetabular augmentation/reconstruction. 34 patients were female, 18 were male reflecting the most common primary diagnosis of breast carcinoma (30 patients). The mean age was 64 years (range 31 to 82). Post-operative complications include one death at 48 hours, 4 pulmonary emboli, a symptomatic DVT and one sciatic nerve palsy. No dislocations have occurred and there have been no implant failures at a mean of 1.2 years (range 2-26 months). We present survival characteristics based on primary tumour type and indicators of poor prognosis. Discussion. The benefits of timely orthopaedic intervention in patients with pathological fractures is well established and this study provides further insight to aid informed decisions and provides information on surgical provision required

Introduction. Pathologic humerus fractures secondary to metastases are associated with significant pain, morbidity, loss of function, and diminished quality of life. Here we report our experience with stabilisation using intramedullary polymethylmethacrylate (PMMA) cement and non-locking plates. Methods. A retrospective review was undertaken of patients treated at a tertiary musculoskeletal oncology centre from 1989 to 2009. Patients who underwent surgery for an impending or completed pathologic humerus fracture with a diagnosis of metastatic disease or myeloma were included. All patients underwent intralesional curettage of the tumour followed by fixation with intramedullary PMMA and plating. Results. Clinical records were available for 63 patients who underwent the above procedure. There were 43 males and 20 females. In 48 (76%) there was a pathologic fracture at presentation, while in 15 (24%) it was impending. The most common histology was myeloma (22%) followed by lung and renal carcinoma which were 21% each. Complications occurred in 14 (22%) cases, and 7 (11%) required re-operation. The most common cause for re-operation was disease progression (5 of 7). At latest follow-up, 85% had no or mild pain and 80% required no or minimal assistance with activities of daily life (ADLs). Conclusion. Intralesional tumour resection and stabilisation of pathologic humerus fractures with the described technique has several attributes. It provides immediate, absolute rigidity and enables early pain relief and return of function without the need for osseous union. The patient's local disease burden is reduced, which alleviates tumour-related pain and slows disease progression. Finally, this technique is user-friendly and cost-effective as it does not require equipment or devices that are unavailable to community orthopaedic surgeons. The cemented plate technique provides a durable option for the treatment of impending and completed pathologic humerus fractures

Previous studies have shown improved outcome following surgery for spinal cord compression due to metastatic disease. Further papers have shown that many patients with metastatic disease are not referred for orthopaedic opinion. The aims of this paper are to study the survival and morbidity of patients with spinal metastatic disease who receive radiotherapy. Do patients develop instability and progressive neurological compromise? Can we predict which patients will benefit from surgery?. Retrospective review of patients receiving radiotherapy for pain relief or cord compression as a result of metastatic disease. Patients were scored with regards to Tomita and Tokuhashi, survival and for deterioration in neurology or spinal instability. 94 patients reviewed. All patients were followed up for a minimum of 1 year or until deceased. Majority of patients had a primary diagnosis of lung, prostate or breast carcinoma. Mean Tomita score of 6, Tokuhashi score 7, and mean survival following radiotherapy of 8 months. 11:94 patients referred for surgical opinion. Poor correlation with Tomita scores (-0.25) & Tokuhashi scores (0.24) to predict survival. Four patients developed progressive neurology on follow-up. One patient developed spinal instability. The remainder of the patients did not deteriorate in neurology and did not develop spinal instability. All patients with normal neurology at time of radiotherapy did not develop spinal cord compression or cauda equina at a later date. This study suggests that the vast majority of patients with spinal metastatic disease do not progress to spinal instability or cord compression, and that prophylactic surgery would not be of benefit. The predictive scoring systems remain unreliable making it difficult to select those patients who would benefit. The referral rate to spinal surgeons remains low as few patients under the care of the oncologists develop spinal complications

The ipsilateral and contralateral fibulae have been used as a vascularised bone graft for loss of tibial bone usually by methods which have involved specialised microvascular techniques to preserve or re-establish the blood supply. We have developed a method of tibialisation of the fibula using the Ilizarov fixator system, ipsilateral vascularised fibular transport (IVFT), and have used it in five patients with massive loss of tibial bone after treatment of an open fracture, infected nonunion or chronic osteomyelitis. All had successful transport, proximal and distal union, and hypertrophy of the graft without fracture. One developed a squamous-cell carcinoma which ultimately required amputation of the limb. The advantage of IVFT is that the fibular segment retains its vascularity without the need for microvascular dissection or anastomoses. Superiosteal formation of new bone occurs if the tibial periosteal bed is retained. Other procedures such as corticotomy and lengthening can be carried out concurrently