Aim. Repeat revision surgery of total hip or knee replacement may lead to massive bone loss of the femur. If these defects exceed a critical amount a stable fixation of a proximal or distal femur replacement may not be possible. In these extraordinary cases a total femur replacement (TFR) may be used as an option for limb salvage. In this retrospective study we examined complications, revision free survival (RFS), amputation free survival (AFS) and risk factors for decreased RFS and AFS following a TRF in cases of revision arthroplasty with a special focus on periprosthetic joint infection (PJI). Method. We included all implantations of a TFR in revision surgery from 2006–2018. Patients with a primary implantation of a TFR for oncological indications were not included. Complications were classified using the Henderson Classification. Primary endpoints were revision of the TFR or disarticulation of the hip. The minimum follow up was 24 month. RFS and AFS were analyzed using Kaplan-Meier method, patients´ medical history was analyzed for possible risk factors for decreased RFS and AFS. Results. After applying the inclusion criteria 58 cases of a TFR in revision surgery were included with a median follow-up of 48.5 month. The median age at surgery was 68 years and the median amount of prior surgeries was 3. A soft tissue failure (Henderson Type I) appeared in 16 cases (28%) of which 13 (22%) needed revision surgery. A PJI of the TFR (Henderson Type IV) appeared in 32 cases (55%) resulting in 18 (31%) removals of the TFR and implantation of a total femur spacer. Disarticulation of the hip following a therapy resistant PJI was performed in 17 cases (29%). The overall 2-year RFS was 36% (95% confidence interval(CI) 24–48%). Patients with a Body mass Index (BMI) >30kg/m² had a decreased RFS after 24 month (>30kg/m² 11% (95%CI 0–25%) vs. <30kg/m² 50% (95%CI 34–66%)p<0.01). The overall AFS after 5 years was 68% (95%CI 54–83%). A PJI of the TFR and a BMI >30kg/m² was significantly correlated with a lower 5-year AFS (PJI 46% (95%CI 27–66%) vs no PJI 100%p<0.001) (BMI >30kg/m² 30% (95% KI 3–57%) vs. <30km/m² 85% (95% KI 73–98%)p<0.01). Conclusions. A TFR in revision arthroplasty is a valuable option for limb salvage but complications in need of further revision surgery are common. Patients with a BMI >30kg/m² should be informed regarding the increased risk for revision surgery and loss of extremity before operation

Abstract. Background. Reconstruction following resection of sarcomas of the upper extremity with methods described in the prevalent literature may not be possible in few selected cases. We describe Surgical Phocomelia or Phoco-reduction as a method of limb salvage in such cases of extensive sarcomas of the upper limb with its functional and oncological outcomes. Methods. Evaluation of functional and oncological outcomes was performed for 11 patients who underwent surgical phocomelia or phocoreduction for extensive sarcomas of the upper limb between 2010 and 2019. Results. Mean follow-up period in the study was27.8 months. Five patients required a segmental resection including the entire humerus while 6 patients underwent segmental resection around the elbow with a mean resection length of 21.5 cm. Mean MSTS 93 score was 22 depicting a good functional outcome. Mean hand grip strength on the operated side was 62% of the contralateral side with preservation of useful hand function. Mean time to humero-ulnar union was 6.7 months. Radial nerve palsy and implant failure occurred in 1 patient each. No patient developed local recurrence while 3 patients died of metastasis. Conclusion. Surgical phocomelia is a prudent alternative to severely incapacitating amputations in situations where other reconstruction methods are not feasible

Prior to the 1970s, almost all bone sarcomas were treated by amputation. The first distal femoral resection and reconstruction was performed in 1973 by Dr Kenneth C Francis at the Memorial Sloan-Kettering Cancer Centre in New York. Since that time, limb-sparing surgery for primary sarcoma has become the mainstay of sarcoma surgery throughout the world. Initially, the use of mega-prostheses of increasing complexity, involving all the major long bones and both pelvic and shoulder girdles, was popularised. In the early 1980s, wide use of massive allograft reconstructions became widespread in both Europe and in multiple centres in the USA and UK. Since that time, increasing complexity in the design of prostheses has allowed for increasing functional reconstructions to occur, but the use of allograft has become less popular due to the development of late graft failures of patients survive past ten years. Fracture rates approaching 50% at 10 years are reported, and thus, other forms of reconstruction are being sought. Techniques of leg lengthening, and bone docking procedures to replace segmental bone loss to tumour are now employed, but the use of biological vascularised reconstructions are becoming more common as patient survivorship increases with children surviving their disease. The use of vascularised fibular graft, composite grafts and re-implantation of extra-corporeally irradiated bone segments are becoming more popular. The improvement in survivorship brought about the use of chemotherapy is producing a population of patients with at least a 65% ten year survivorship, and as many of these patients are children, limb salvage procedures have to survive for many decades. The use of growing prostheses for children have been available for some 25 years, first commencing in Stanmore, UK, with mechanical lengthening prostheses. Non-invasive electro-magnetic induction coil mechanisms are now available to produce leg lengthening, with out the need for open surgery. Whilst many of these techniques have great success, the area of soft tissue attachment to metallic prostheses has not been solved, and reattachment of muscles is of great importance, of course, for return of function. There are great problems in the shoulder joints where sacrifice of rotator cuff muscles is necessary in obtaining adequate disease clearance at the time of primary resection, and a stable shoulder construct, with good movement, has yet to emerge. Similar areas of great difficultly remain the peri-acetabular and sacro-iliac resections in the pelvis. Perhaps the real future of the art of limb salvage will be in the reconstruction of failed major joint replacements where there is great loss of bone stock, and already massive tumour prostheses are providing a salvage pathway for failed standard joint replacement. The final future for limb salvage, however, may not rest with increasing surgical complexity and innovation, but with the development of molecular biology and specific targeted treatments, according to the cytogenetics of a particular tumour. We are on the threshold of yet another quantum change in the approach to cancer management; just as chemotherapy brought a tremendous change in the 1970s, molecular biology is the frontier to make much of the current limb salvage surgery that is performed redundant

To compare the costs of treatment and income received for treating patients with tibial osteomyelitis, comparing limb salvage with amputation. We derived direct hospital costs of care for ten consecutive patients treated with limb salvage procedures and five consecutive patients who underwent amputation, for tibial osteomyelitis. We recorded all factors which affect the cost of treatment. Financial data from the Patient-Level Information and Costing System (PLICS) allowed calculation of hospital costs and income received from payment under the UK National Tariff. Hospital payment is based on primary diagnosis, operation code, length of stay, patient co-morbidities and supplements for custom implants or external fixators. Our primary outcome measure was net income/loss for each in-patient episode. The mean age of patients undergoing limb salvage was 55 years (range 34–83 years) whereas for amputation this was 61 years (range 51–83 years). Both groups were similar in Cierny and Mader Staging, requirement for soft-tissue reconstruction, anaesthetic technique, diagnostics, drug administration and antibiotic therapy. In the limb salvage group, there were two infected non-unions requiring Ilizarov method and five free flaps. Mean hospital stay was 15 days (10–27). Mean direct cost of care was €16,718 and mean income was €9,105, resulting in an average net loss of €7,613 per patient. Patients undergoing segmental resection with Ilizarov bifocal reconstruction and those with the longest length of stay generated the greatest net loss. In the amputation group, there were 3 above knee and 2 below knee amputations for failed previous treatment of osteomyelitis or infected non-union. Mean hospital stay was 13 days (8–17). Mean direct cost of care was €18,441 and mean income was €15,707, resulting in an average net loss of €2,734 per patient. Length of stay was directly proportional to net loss. The UK National Tariff structure does not provide sufficient funding for treatment of osteomyelitis of the tibia by either reconstruction or amputation. Average income for a patient admitted for limb salvage is €6,602 less than that for amputation even though the surgery is frequently more technically demanding (often requiring complex bone reconstruction and free tissue transfer) and the length of hospital stay is longer. Although both are significantly loss-making, the net loss for limb salvage is more than double that for amputation. This makes treatment of tibial osteomyelitis in the UK National Health Service unsustainable in the long term

Introduction. Blunt trauma of the lower limb can lead to vascular injury causing devastating outcomes, including loss of limb and even loss of life. The primary aim of this study was to determine the limb salvage rate of patients sustaining such injuries when treated at Leeds General Infirmary (LGI) since becoming a Major Trauma Centre (MTC). Secondary aims included establishing the patient complications and outcomes. Materials and Methods. Retrospective analysis found that from 2013–18, 30 patients, comprising of 32 injured limbs, were treated for blunt trauma to the lower limb associated with vascular injury. Long-term functional outcomes were determined using postal and telephone questionnaires. Results. Twenty-four patients were male and 6 were female, their mean ages were 32 and 49 respectively. Of the 32 limbs, 27 (84%) were salvaged. Three limbs were deemed unsalvageable and underwent primary amputation; of the remaining 29 potentially salvageable limbs, 27 (93%) were saved. Eleven limbs had prophylactic fasciotomies, 3 limbs developed compartment syndrome – all successfully treated, and three contracted deep infections – one of which necessitated amputation. All but 1 patient survived their injuries and were discharged from hospital. Of the 15 questionnaire responses, self-reported limb function was understandably worse post-injury with patients experiencing mild pain on average. In addition, there was a long-standing psychological impact and the injuries altered many patients’ normal lives significantly, 10 experiencing financial difficulties and 6 having changed or lost jobs post-injury. Conclusions. Fortunately, 27 (84%) limbs were salvaged and nearly all patients survived these injuries when treated at an MTC. Whilst the number of complications was low, the future challenges these patients face are wide-ranging and significant

Foreword. Silver coatings, used in many surgical devices, have demonstrated good antimicrobial activity and low toxicity. Oncological musculoskeletal surgery have an high risk of infection, so in the last decades, silver coated mega-prostheses have been introduced and are becoming increasingly widespread. Material and methods. We performed a retrospective analysis of 158 cases of bone tumors, primary or metastatic, treated between 2002–2014 with wide margins resection and reconstruction with tumoral implants. The average age was 59 years (range 11–78 years), all patients were treated by the same surgeon, with antibiotic prophylaxis according to a standard protocol. In 58.5% of patients were implanted silver-coated prostheses, in the remaining part, standard tumor prosthesis. Patients were re-evaluated annually and were recorded complications, with particular attention to infectious diseases. Results. The mean follow-up was 39.5 months. 23.4% of patients died at a median time of 34.9 months after surgery. 18.4% develop complications that required a new surgery, in 12.6% of cases due to infectious problems. Patients treated with silver-coated implants developed early infection in 2.2% of cases against the 10.7% of the patients treated with standard tumor prosthesis. This different among the two groups was statistically significant, while the percentage of late infections, occurred from 6 months after surgery, was similar between groups. Assuming a reduction of antimicrobial silver activity in the time, it was carried out a microscopic analyses [Fig. 1] of silver-coated prostheses explanted 82 months and 27 months after surgery. It confirmed an important degradation of the coating surface with almost complete absence of silver. Silver blood level, taken in a sample of patients, at different time after surgery, always showed values well below the threshold of toxicity, and no patient has never shown any sign of local or general toxicity secondary to silver [Fig. 2]. Discussion. Our study demonstrates that tumor silver-coated implants have a rate of early infection significantly less than traditional implants, while there were no differences in the rate of late infections, as described also in the literature. This likely is related to wear of the silver coating, which occurs on average around 2 years after implantation. Conclusion. We recommend to use silver–coated prosthesis as primary implants for limb salvage surgery, in primary or metastatic bone tumors, considering the absence of signs of toxicity and the lower rate of early infection

When performing limb salvage operations for malignant bone tumours in skeletally immature patients, it is desirable to reconstruct the limb with a prosthesis that can be lengthened without surgery at appropriate intervals to keep pace with growth of the contra-lateral side. We have developed a prosthesis that can be lengthened non-invasively. The lengthening is achieved on the principle of electromagnetic induction. The purpose of this study was to look at our early experience with the use of the Non Invasive Distal Femoral Expandable Endoprosthesis. A prospective study of 17 skeletally immature patients with osteosarcoma of the distal femur, implanted with the prosthesis, was performed at the Royal National Orthopaedic Hospital, Stanmore. The patients were aged between 9 and 15 years (mean 12.1 years) at the time of surgery. Patients were lengthened at appropriate intervals in outpatient clinics. Patients were functionally evaluated using the Musculoskeletal Tumour Society (MSTS) Scoring System and the Toronto Extremity Severity Score (TESS). Average time from the implantation to the last follow-up was 18.2 months (range 14-30 months). The patients have been lengthened by an average of 25mm (4.25-55mm). The mean amount of knee flexion is 125 degrees. The mean MSTS score is 77% (23/30; range 11-29) and the mean TESS score is 72%. There have been two complications: one patient developed a flexion deformity of 25 degrees at the knee joint and one patient died of disseminated metastatic malignancy. The early results from patients treated using this device have been encouraging. Using this implant avoids multiple surgical procedures and general anaesthesia. This results in low morbidity, cost savings and reduced psychological trauma. We do need additional data regarding the long-term structural integrity of the prosthesis

Segmental excision of long-bone sarcomas can require complex reconstruction, often resulting in the use of prosthetic replacements at a young age. The use of vascularised free fibula grafting (VFFG) is well established as a reconstruction modality in sarcoma surgery. Aims. To analyse the experience of two European sarcoma centres and their use of vascularised free fibula grafting as a primary and revision procedure in limb salvage for diaphyseal long-bone defects in sarcoma surgery. Methods. A retrospective analysis was carried out of 70 consecutive patients undergoing VFFG between 1996 and 2009 under the Oxford Sarcoma Service (Nuffield Orthopaedic Centre) and the Dutch Orthopaedic Tumour Society (Leiden University Hospital). Clinical and radiological assessments were made and functional outcome scores collected. Results. 70 patients, 42 male, with a mean age of 20 years (3–61) received a VFFG (a primary procedure in 76%) and underwent mean follow up of 82 months (11–181). 83% of grafts were located in the lower extremity with 71% resulting from reconstruction of malignant tumours. VFFGs with a mean length of 17.4 cm (6–25) were used to reconstruct defects with a mean length of 13.5 cm (8–21). 92% of VFFGs achieved union at mean of 59 weeks (16–250). Predictors for non-union included defects greater than 12cm, malignant disease processes and an immature skeleton. 65% of patients had at least one complication with 51% requiring at least one revision procedure, although only 3 required removal of the graft (2 endoprosthetic replacements and 1 amputation). Mean MSTS score at final follow-up was 26.7 (20–30). Conclusion. The vascularised free fibula graft has been proven to provide a stable reconstruction of bony defects after tumor resection and results in a functional extremity, however it is accompanied by a high risk of complications and revision surgery

Introduction. Around the knee high-energy fractures/dislocation may present with vascular injuries. Ischaemia time i.e. the time interval from injury to reperfusion surgery is the only variable that the surgeon can influence. It has been traditionally taught that 6-8 hours is revascularisation acceptable. There are only limited case series that have documented the time-dependent lower limb salvage rate (LSR) or the lower limb amputation rate (LAR). We have conducted a meta-analysis to look at LSR and LAR to inform clinical standard setting and for medicolegal purposes. Methods. Two authors conducted an independent literature search using PubMed, Ovid, and Embase. In addition the past 5 years issues of Journal of Trauma, Injury and Journal of Vascular surgery were manually scrutinised. Papers included those in the English language that discussed limb injuries around the knee, and time to limb salvage or amputation surgery. The Oxman and Guyatt index was used to score each paper. Results. 21 retrospective case series articles were identified from 8 different journals. A total of 1575 patients were compiled, 92 patients were lost or died. 263 lower limbs underwent amputation and 1220 limbs were salvaged. 984 lower limbs were salvaged within the 8 hours. The LAR increased with time from 3% with reperfusion surgery in less than 4 hours to 13% at 6 hours and 32% at 8 hours. A lower LAR of 20% for patients presenting after 12 hours was seen

Fibular Hemimelia is not just a fibular anomaly but there is entire limb involvement with varied expression in each segment. Factors which we have considered in treatment are the amount of fibula present, percentage of shortening, tibial and leg deformity and foot deformity. Residual or recurrent foot deformity is the prime reason for unsatisfactory results, so we have used Paley's classification which takes into consideration foot deformity. Our series is of 29 cases, Paley type I-7, Type II-6, Type III-16 and none of type IV. Tibial lengthening (+/−) bow correction was performed in 28 cases. Supramalleolar osteotomy was done in 4 cases. In foot, soft tissue release only was done in 6 cases and soft tissue release with osteotomy (subtalar or calcaneal) was done in 14 cases. Amputation was done in 2 cases. Age ranged from 11 months to 16 years. Mean follow up was 4.2 years. Mean lengthening was 3.5 cm. Desires lengthening was achieved in 21/29 cases and plantigrade foot was achieved in 16/29 cases. Complications faced were recurrence of foot deformity, knee valgus, knee fixed flexion deformity, knee subluxation and pin tract problems. Less than 3 rays and more than 25 cm of limb length discrepancy were poor prognostic factors. We had 7 excellent, 16 good and 6 poor results. To conclude, it is difficult to achieve the aim of plantigrade foot and limb length equality in all cases but radical surgery with foot correction and tibial lengthening can give good results.

Introduction and Purposes

Custom made acetabular prosthesis are a valid option for the reconstruction after the resection of pelvic tumors. They should guarantee a stable and reliable reconstruction for the expected survival of the patient. Nevertheless in many cases periacetabular metastatic lesions have been compared to high grade (IIIA-B) Paprosky defects, but treated with low or intermediate longevity implants. Some complex post-traumatic scenarios or total hip arthroplasty (THA) multiple failures need a reconstruction according to oncologic criteria to fill in the huge defect and to obtain an acceptable function. The aim of the study is to compare 3D custom-made implants for tumors and for THA failures.

It has become standard practice in our unit to treat large giant cell tumours with intralesional curettage, burring, a locking plate and adjuvant liquid nitrogen & PMMA cementation. 24 patients have been treated in this fashion over the past 7 years. We have had 2 recurrences to date, both recent.

These 2 cases of large Campanacci type 2 & 3 giant cell tumour of the distal femur & proximal tibia, successfully treated with megaprosthetic replacement are reported. One patient had lung metastases, which appeared stable and were being closely monitored for progress. Histopathology had been reviewed and giant-cell rich osteosarcoma definitely excluded. Osteoclastic inhibitory chemotherapy was instituted 6 weeks post-op.

Aim. Mega-endoprosthesis over the last two decades have played a significant role in management of non-neoplastic cases for limb salvage for a variety of indications involving bone loss, infection, fracture and failed revision surgery. This is a retrospective case control study comparing outcomes of Mega-Endoprosthesis (MEP) in non-neoplastic cases with periprosthetic joint infections (PJI), with previous history of PJI and aseptic revision. Failure was defined as persistence/recurrence of infection, all cause revision, and antibiotic suppression during the follow up period. Secondary aims were identification of causative organisms, resistance profile and causative factors for revision surgery. Method. A total of 122 patients undergoing 133 MEPs were identified between January 2012 and December 2020. 60 procedures were categorised as group 1 (infection; 50%), 20 as group 2 (previous history of infection; 16.7%), and 53 controls (no infection; 44.2%). Mean age of the cohort was 70.97 years (37.16–94.17), with a mean follow-up of 44.5 months (0.2–179) including patients lost to follow up. Results. Overall failure rate was 71/133 53.3% (group 1 39/60 (55.56%), group 2 12/20 (60%) and controls 20/53 (37.7%)). Thirteen patients died in the first 2 years (five in group 1, one in group 2 & seven in controls). The most common postoperative infection was polymicrobial followed by Coagulase Negative Staphylococcus Species (CoNS) and Methicillin Sensitive Staphylococcus aureus (MSSA). Nineteen patients had polymicrobial PJI (Eighteen in group 1 and one in control). CoNS led to postoperative infection in Fifteen patients (six in group 1, five in group 2 and four in control group). MSSA was the pathogen in four patients (three in group-1 and one in the control group). The same organisms were responsible for recurrent infection in fourteen patients in group 1 and one patient in group 2. Limb salvage was achieved in 96.2% overall (95% group 1, 90% group 2, 100% control group). Conclusions. MEPs in the context of PJI have a significant risk of failure however they play an important role in limb salvage. Patients should be counselled appropriately prior to surgery

Introduction. Charcot neuroarthropathy is a limb threatening condition and the optimal surgical strategy for limb salvage in gross foot deformity remains unclear. We present our experience of using fine wire frames to correct severe midfoot deformity, followed by internal beaming to maintain the correction. Materials and Methods. Nine patients underwent this treatment between 2020–2023. Initial deformity correction by Ilizarov or hexapod butt frame was followed by internal beaming with a mean follow up of 11 months. A retrospective analysis of radiographs and electronic records was performed. Meary's angle, calcaneal pitch, cuboid height, hindfoot midfoot angle and AP Meary's angle were compared throughout treatment. Complications, length of stay and the number of operations are also described. Results. Mean age was 53 years (range:40–59). Mean frame duration was 3.3 months before conversion to beaming. Prior frame-assisted deformity correction resulted in consistently improved radiological parameters. Varying degrees of subsequent collapse were universal, but 5 patients still regained mobility and a stable, plantargrade, ulcer-free foot. Complications were common, including hardware migration (N=6,66%), breakage (N=2,22%), loosening (N=3,33%), infection (N=4,44%), 1 amputation and an unscheduled reoperation rate of 55%. Mean cumulative length of stay was 42 days. Conclusions. Aggressive deformity correction and internal fixation for Charcot arthropathy requires strategic and individualised care plans. Complications are expected for each patient. Patients must understand this is a limb salvage scenario. This management strategy is resource heavy and requires timely interventions at each stage with a well-structured MDT delivering care. The departmental learning points are to be discussed

Introduction. Management of open fractures is challenging and requires a multidisciplinary team approach. Gustilo Anderson Type IIIB fractures reportedly have a higher infection rate (up to 52%) and up to 16% amputation rate. This study aims to evaluate outcomes of using Adjuvant Local Antibiotic Hydroxyapatite Bio-Composite in management of Open Gustilo-Anderson IIIB fractures. Materials and Methods. We reviewed a prospective data of 80 patients who presented with Gustilo Anderson Type IIIB Open Fracture to a single ortho-plastic centre. Only patients who were managed with single-stage “Fix and Flap” along with intra-operative Adjuvant Local Antibiotic Bio-Composite were included. Results. Mean follow-up time was 22 months. The mean time from injury until definitive surgery was 7.73 days (1–30 days). Primary union achieved in 88.3% within 32 weeks on average. The delayed union reported in 7.8% of patients, for the bone healing stimulated by injecting the fracture site with Autologous Bone Marrow Aspirate Concentrate. Subsequent follow-up showed signs of successful fracture healing at 60 weeks post-injury. Three patients (3.9%) had non-union. Limb salvage rate was 96.25%, and only 1.25% deep infection rate. Conclusions. Our results highlight that low infection rates, high limb salvage rates and high union rates can be achieved in these complex injuries with a combined OrthoPlastic approach, MDT input, meticulous technique and the use of adjuvant local antibiotic bio-composite. Delay in definitive surgery, gentamicin resistance and smoking were not associated with any increased deep infection or non-union in our series. At 22 months of follow-up, deep infection rate was 1.25%, limbs salvage rate was 96.25%, fracture union rate was 96.1%, and reoperation rate 18.75%

Aim. The reconstruction of bone critical size defects of the tibia is one of the most complex therapeutic challenges in the orthopedic field. This study aims to describe and evaluate our three-staged surgical protocol of reconstruction of infected defects of the tibia emphasizing in limb salvage rate, resolution of infection, functional outcome and patient satisfaction. Method. A retrospective review was performed in all cases of complex infected tibia fracture with combined soft and bone tissue loss treated in a specialized limb reconstruction center between 2010 and 2018. In all cases, a three-stage protocol was performed: 1) Infected-limb damage control with radical debridement, 2) Soft tissue coverage with vascularized or local flap 3) Bone reconstruction procedure. The minimum follow-up required was 12 months after external fixator removal. Results. Twenty-eight patients with a mean age of 42 years were included. The mean soft tissue defect was 91.7 cm2 and the mean bone defect was 5.8 cm. 67.85% of the cases were classified as a type IV B-local osteomyelitis. The median global treatment time was 456 days. The External Fixator Time (EFT) was 419, 284, 235 for bone transport, shortening-lengthening and acute shortening groups respectively. The median Bone Healing Index (BHI) was 1.82 months/cm in bone transport group and 2.15 months/cm in shortening-lengthening group. The limb salvage rate was 92.85%. Infection resolution rate was 96,42%. We achieved bone union in 92,85% of the cases. Regarding ASAMI bone score, 92.8% of the cases were “good-or-excellent”. Two patients underwent a delayed amputation. Eight cases of non-progressive Docking Site (DS) healing were observed. Nineteen non-expected reinterventions were performed. Functional data: the mean VAS score was 1.0. The mean LEFS score was 55.88 (55.88/80). Regarding ASAMI functional score, 78,6% of the cases were “good-or-excellent”. More than 80% of the patients could return to work. 100% of the patients were “very satisfied” or “moderately satisfied” (75% and 25% respectively). Conclusions. Our results demonstrate that our three-stage surgical approach in infected tibial bone defects with soft tissue damage can result in high infection resolution, good functional outcome, good patient satisfaction and an acceptable limb salvage rate despite the large time of treatment and unexpected reinterventions

The Australia and New Zealand Sarcoma Association established the Sarcoma Guidelines Working Party to develop national guidelines for the management of Sarcoma. We asked whether surgery at a specialised centre improves outcomes. A systematic review was performed of all available evidence pertaining to paediatric or adult patients treated for bone or soft tissue sarcoma at a specialised centre compared with non-specialised centres. Outcomes assessed included local control, limb salvage rate, 30-day and 90-day surgical mortality, and overall survival. Definitive surgical management at a specialised sarcoma centre improves local control as defined by margin negative surgery, local or locoregional recurrence, and local recurrence free survival. Limb conservation rates are higher at specialised centres, due in part to the depth of surgical experience and immediate availability of multidisciplinary and multimodal therapy. A statistically significant correlation did not exist for 30-day and 90-day mortality between specialised centres and non-specialised centres. The literature is consistent with improved survival when definitive surgical treatment is performed at a specialised sarcoma centre. Evidence-based recommendation: Patients with suspected sarcoma to be referred to a specialised sarcoma centre for surgical management to reduce the risk of local recurrence, surgical complication, and to improve limb conservation and survival. Practice point: Patients with suspected sarcoma should be referred to a specialised sarcoma centre early for management including planned biopsy

Functional outcomes are commonly reported in studies of musculoskeletal oncology patients undergoing limb salvage surgery; however, interpretation requires knowledge of the smallest amount of improvement that is important to patients – the minimally important difference (MID). We established the MIDs for the Musculoskeletal Tumor Society Rating Scale (MSTS) and Toronto Extremity Salvage Score (TESS) in patients with bone tumors undergoing lower limb salvage surgery. This study was a secondary analysis of the recently completed PARITY (Prophylactic Antibiotic Regimens in Tumor Surgery) study. This data was used to calculate: (1) the anchor-based MIDs using an overall function scale and a receiver operating curve analysis, and (2) the distribution-based MIDs based on one-half of the standard deviation of the change scores from baseline to 12-month follow-up, for both the MSTS and TESS. There were 591 patients available for analysis. The Pearson correlation coefficients for the association between changes in MSTS and TESS scores and changes in the external anchor scores were 0.71 and 0.57, indicating “high” and “moderate” correlation. Anchor-based MIDs were 12 points and 11 points for the MSTS and TESS, respectively. Distribution-based calculations yielded MIDs of 16-17 points for the MSTS and 14 points for the TESS. The current study proposes MID scores for both the MSTS and TESS outcome measures based on 591 patients with bone tumors undergoing lower extremity endoprosthetic reconstruction. These thresholds will optimize interpretation of the magnitude of treatment effects, which will enable shared decision-making with patients in trading off desirable and undesirable outcomes of alternative management strategies. We recommend anchor-based MIDs as they are grounded in changes in functional status that are meaningful to patients

Introduction. Open tibial fractures typically occur as a consequence of high energy trauma in patients of working age resulting in high rates of deep infection and poor functional outcome. Whilst improved rates of limb salvage, avoidance of infection and better ultimate function have been attributed to improved centralisation of care in orthoplastic units, there remains no universally accepted method of definitive management of these injuries. The aim of this study is to the report the experience of a major trauma centre utilising circular frames as definitive fixation in patients sustaining Gustilo-Anderson (GA) 3B open fractures. Materials & Methods. A prospectively maintained database was interrogated to identify all patients. Case notes and radiographs were reviewed to collate patient demographics and injury factors . The primary outcome of interest was deep infection rate with secondary outcomes including time to union and secondary interventions. Results. 247 open tibial fractures with a soft tissue manipulation in order to achieve skin cover, of which 203 had a minimum follow up of 2 years. Mean age was 43.2 years old, with 72% males, 34% smokers and 3% diabetics. Total duration of frame management averaged 6.4 months (SD 7.7). Nine (4.4%) patients developed a deep infection and 41 (20%) exhibited signs of a pin site infection. Seventy-five (37%) of patients had a secondary intervention of which; 8 comprised debridement of deep infection, 1 amputation for deep infection and the remainder adjustments of frames. Conclusions. Orthoplastic care including circular frame fixation for GA 3B fractures of the tibia results in a low rate of deep infection, around a quarter of contemporary literature for internal fixation

Abstract. Background. Extracorporeal radiation therapy (ECRT) has been reported as an oncologically safe and effective reconstruction technique for limb salvage in diaphyseal sarcomas with promising functional results. Factors affecting the ECRT graft-host bone incorporation have not been fully investigated. Methods. In our series of 51 patients of primary bone tumors treated with ECRT, we improvised this technique by using a modified V-shaped osteotomy, additional plates and intra-medullary fibula across the diaphyseal osteotomy in an attempt to increase the stability of fixation, augment graft strength and enhance union at the osteotomy sites. We analyzed our patients for various factors that affected union time and union rate at the osteotomy sites. Results. On univariate analysis, age <20 years, metaphyseal osteotomy site, V-shaped diaphyseal osteotomy, extramedullary plate fixation and use of additional plate at diaphyseal ostetomy had a significantly faster time to union while gender, tumor type, resection length, chemotherapy and use of intra-medullary fibula did not influence union time. In multivariate analysis, metaphyseal ostoeotomy, V-shaped diaphyseal osteotomy and use of additional plate at diaphyseal ostetomy were the independent factors with favourable time to union. Although the rate of union was higher with V-shaped diaphyseal osteotomy and use of additional plate and intra-medullary fibula at diaphyseal ostetomy, this difference could not be established statistically. None of the analyzed factors apparently affected the union rate in univariate analysis. Conclusion. Judicious choice of osteosynthesis and augmentation of ECRT graft can enhance incorporation with reduced complications and good functional outcome