The distal humerus represents 1% of all primary bone tumours. Endoprosthetic replacement can potentially improve function and provide good pain relief. We present out experience with the custom made Stanmore elbow endoprosthesis used after resection of malignant tumours of the distal humerus. Between 1970–2009 we carried out 19 endoprosthetic replacments for malignant tumours of the distal humerus. 10 were a result of metastasis and 9 were primary bone tumours. 7 patients had a pathological fracture as their first presentation and 3 had pathological fractures after the diagnosis was made. 11 patients died between 3 months to 16 year following surgery. The mean survival of the patient group was 7.1 years (range 3 months to 37 years). 4 patients underwent a revision EPR and one patient underwent two revision EPR's due to loosening. Two patients underwent maintenance procedures (rebushing) due to wear of the poly bushing. We have had no revisions since the design of hte implant was changed to a floppy hinge design. One patient underwent an above elbow amputation four years after surgery due to local recurrence. There were no early post operative infections. One patient developed a sinus requiring multiple wound explorations, one year after insertion of the endoprosthesis for a sarcoma. This patient was infection free till the time of death 3 years later. There were no nerve palsies, periprosthetic fractures or wound problems. The mean TES score was 72% (59–78%) in the surviving patients at review. As the majority of the patients were implanted for metastatic disease the initial reliablity and low complication rate of the procedure, in our series, confirms that this is a suitable reconstruction for patients in significant metastatic pain from a destructive lesion of the distal humerus, rapidly restoring function and relieving pain in a predictable manner

Introduction. Three-dimensional preoperative planning and bone tumour resection by navigation have been used in the past ten years. According to literature this workflow increases the surgical “accuracy”. However, there are a few and not completely clear reports describing accuracy in preoperative planning and navigation. The objective of this preliminary study was to determine the accuracy of osteotomies planned and guided by navigation in pelvis tumour resection. We assume that the surgical specimen scanned and 3D reconstructed is an acceptable method to determine the accuracy qualitatively and quantitatively of a virtual planning and navigation surgical workflow. Materials and Methods. A total of four patients were evaluated between May 2010 and February 2011, age range: 6–38, 17.4 mean; 2 males and 2 females. There were 4 malignant tumours: Malignant Schwannoma (1), Ewing's tumor (1) and Chondrosarcoma (2). All anatomic regions compromised by the tumour were preoperatively CT scanned (Mutislice 64, Aquilion, Toshiba Medical Systems, Otawara, Japan). Magnetic resonance images (MRI) of the corresponding region were acquired using a 1.5-T unit (Magnetom Avanto, Siemens Medical Solutions, Erlangen, Germany). Image fusion was applied to CT and MRI studies in order to determine the bone cortex and the intra-extraosseous soft tissues tumour extension. Once the fusion was obtained osteotomies were planned, taking into account the tumour extension in a three-dimensional virtual scenario. All patients were planned for two uniplanar osteotomies (intercalary resection). The minimal margin was determined in each plane by measuring the closest distance between malignant tumour and osteotomy plane. These studies allowed the visualisation of the tumour and the application of a virtual osteotomy. The simulation was carried out by using a computer-aided design (CAD) software, Mimics (Materialise, Leuven, Belgium). Three-dimensional preoperative planning was obtained in CAD format. Next, 3D models were exported to CT data sets in Digital Imaging and Communications in Medicine (DICOM) format and uploaded to the navigation system (3D OrthoMap navigation software v1.0, Stryker Navigator, Freiburg, Germany). Using the standard navigation tools (navigated pointer, camera and infrared tracker devices applied to the patient) the surgeon was able to establish a correspondence in a computer monitor between 3D images and real bone. Once osteotomies were performed, the tumour surgical specimen obtained was CT scanned and 3D reconstructed similarly to what was done previously to surgery to CT images acquired with the preoperative protocol in patients. Results. The correlation between the osteotomies preoperatively planned and the osteotomies achieved by navigation was in a global mean of 0.73 millimeters (SD: 3.14) in a total of 6 planes evaluated. Conclusion. According to clinical relevance, this work shows an acceptable accuracy in preoperative planning and navigation. Furthermore, we demonstrate the usefulness of three-dimensional models of surgical specimens when surgeons need to determine quantitative and qualitative accuracy of 3D planning and navigation procedures

Introduction. The Two Week Waiting Time Standard, which requires that patients with suspected cancer referred by general practitioners should be seen within 2 weeks, was introduced in 2000. We reviewed the performance of this standard with regards to proportion of patients seen and tumour detection rates. Methods and results. We reviewed all the referrals sent under the ‘two week’ rule from January 2004 to December 2005, to our bone and soft tissue sarcoma service. These referrals were evaluated for:. Whether or not the referral met established referral guidelines for bone and soft tissue tumours. The proportion of patients seen within two weeks. The proportion of patients referred under the guidelines that had malignant tumours. This was compared with the total number of referrals to the unit and their tumour detection rates. A total of 40 patients were referred under the ‘two week’ rule. 95% of these were seen within two weeks of referral. Of the 40 patients, three patients had soft tissue metastasis from a primary tumour elsewhere, and six had primary malignant soft tissue tumours. 13 had a benign bone/ soft tissue tumour. 18 (45%) patients had a non neoplastic pathology (6 Muscle tear/ herniation; 4 ganglion/bursa; 2 lumps that disappeared) During the same period a total of 507 patients were referred by other routes. Conclusion. Only 10 of 40 patients referred under the 2-week rule had malignant tumours. The majority of referrals to our service do not fall under this rule. Significant numbers of referral under the rule are not in line with the referral guidelines. It is our impression that the 2-week rule, whilst highlighting the need of these patients to be seen urgently, may distort clinical priorities and disadvantage patients referred from other sources

The use of peritumoral oedema on magnetic resonance (MR) imaging to predict soft tissue tumour grade is controversial. The clinical significance of oedema visualised on MR scans is poorly defined in the literature. We undertook this study to ascertain a diagnostic relationship between peritumoral oedema surrounding soft tissue sarcomas and the histological grade of the tumour. One hundred and ten consecutive soft tissue tumours were extracted from the New Zealand Bone and Soft Tissue Tumour Registry. Key inclusion criteria were tumours deep to fascia, measuring more than 5cm in any dimension. Both benign and malignant sarcomas were included. MR scans and histology were reviewed, separately and in random order by a single author. Histology was graded as benign, low or high grade (based on the American Joint Committee on Cancer grading system). Peritumoral oedema was defined as the increased signal intensity, on T2 or STIR images, immediately surrounding a discrete lesion. It was measured on two or more planes with the largest value used in diagnostic calculations. Oedema greater than or equal to 20mm was defined as a positive test result. Twenty five random scans were double read to ensure inter-observer reliability. Data was obtained for 83 tumours, 36 benign and 47 malignant (34 high grade and 13 low grade). The tumours in all groups were matched for size. The mean peritumoral oedema was 10.5mm for benign tumours, 20.6mm for low grade sarcomas (p<0.1), 28.1mm for high grade tumours (p<0.01) and 26.1mm if all malignant tumours were included as a single group (p<0.01). Using peritumoral oedema as a diagnostic test for tumour grade resulted in a specificity of 72%. The highest diagnostic ability was found when comparing benign to high grade tumours which yielded sensitivity of 59% and a positive likelihood ratio of 2.1. This data suggests a high false negative rate and that the test adds little to the diagnostic process. To our knowledge this is the first study which assesses the diagnostic accuracy of peritumoral oedema to predict the histological grade of soft tissue sarcomas. Our results show a statistically significant difference, in surrounding peritumoral oedema, exists when comparing benign to high grade sarcomas and to all malignant tumours. This relationship is not apparent for low grade tumours. As a diagnostic test, using only peritumoral oedema to predict histological grade is unreliable

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

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

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

Introduction. Pulmonary emboli (PE) after total hip and knee arthroplasties is an uncommon event. However, once it happens, it may results in sudden death. Thus, the prophylaxis of venous thromboembolism (VTE), including symptomatic deep vein thrombosis (DVT) and PE, is one of the challenging trials for Orthopaedic surgeons. Many procedures have been developed, e.g. early mobilization, compression stocking, intermittent pneumatic compression (IPC) devices, and anticoagulation agents. However, the most effective treatment for prophylaxis against VTE after the arthroplasties remains undecided. Recently, many low molecular weight heparin (LMWH) agents are developing, and these are strongly effective for anticoagulation. However, these agents sometimes lead to bleeding complications, and result in uncontrolled critical bleeding. We are introducing our protocol with conventional aspirin as VTE prophylaxis after the arithroplasties. Patients and methods. All patients prior to the surgeries are evaluated laboratory and duplex venous ultrasonography examinations to exclude thrombophilic or hemophilic conditions, and existence of DVT. Then, the thrombophilic, and also prolonged immobility, obesity, malignant tumors, cardiovascular dysfunction and DVT patients are regarded as high risk for VTE. These are offered a prophylaxis consisting of a removable inferior vena cava (IVC) filter, together with anticoagulant medication. Usually, the filter is removed three months after the surgery. In other patients, the arthroplasties are carried out under the spinal or epidural anesthesia with IPC on both feet. IPC is also applied, except for the periods of ambulation, usually two to three days of hospitalization after surgery. Full weight bearing ambulation with a walker is allowed on post-op day one. Patients receive aspirin (acetylsalicylic acid) 325 mg daily for six weeks starting the night of surgery. Pain is controlled with celecoxib (COX-2 selective nonsteroidal anti-inflammatory drug) 400 mg daily, and oral narcotics for break through pain. Before discharge, usually within three days post surgery, all patients are evaluated DVT by duplex venous ultrasonography. The incidence of blood loss, wound complications, and subcutaneous ecchymosis are recorded. Results and discussion. Although the incidence rate of all DVT (symptomatic and asymptomatic) after the arthroplasties was 2–3%, there was no patient readmitted or reoperated with critical bleeding, wound complications, nor fatal DVT/PE in this time period. The cost for the preoperative screening examinations, i.e. blood test and duplex venous ultrasonography, is approximately 200 US dollars. This is much less expensive than the cost associated with more aggressive anticoagulation agents and our procedures provided an acceptable level of outcomes with minimal risk of severe complications. Conclusions. The efficacy and safety of multimodal prophylaxis which employs aspirin against symptomatic PE in selected patients with hip and knee arthroplasties was demonstrated. Thus our protocol is recommended as a first choice for VTE prophylaxis

Background. There are some critical points of Cruciate retaining (CR) TKA. We recognized that it is one of the most important issue how to manage for release of PCL contracture. PCL contracture would lead to poor ROM, stiff or painful knee after CR TKA. PCL release at insertion of femoral / tibial side or cut in PCL itself, “pie craft” were reported. However, for retaining of PCL function after TKA, peeling off PCL itself would be not desirable. Therefore, we proposed to perform V shape-osteotomy at PCL insertion of tibia with osteotome (Fig.1,2) and cancellous bone graft at osteotomy site to get bony union (V-shape osteotomy with cancellous bone graft: VOCG). We would present how to perform VOCG at CR TKA and clinical results. Patients and Methods. 188 knees in 126 patients were received NRG CR TKA (Stryker) at Nagano Matsushiro General Hospital between February 2008 and August 2009. Mean age at operation was 75.1±5.9 years old. The indications for VOCG were positive of POLO test positive, inadequate soft tissue balance because of PCL contracture, or poor pre-operative ROM et al. All patients were reviewed with clinical and radiographic assessments. Clinical evaluation was carried out using the Knee Society Score (knee score and functional score). The range of motion (ROM) was pre- and post-operatively. In order to evaluate the effect of VOCG, clinical outcomes were compared between two groups (with VOCG vs without VOCG). Results. Of 126 patients (188 knees), 4 (6 knees) died in cardiac disease or malignant tumor within 1 year. 3 (5 knees) suffered from some comorbidities. Therefore, 177 knees in 119 patients available for review at a minimum 1 year (one to six). There were no revision cases. No patients had PCL dysfunction, infection or deep vein thrombosis in current study. 21 knees (11.8%) received VOCG. The reasons for VOCG: lift off positive:11 knees, inadequate soft tissue balance: 8 knees, flexion contracture: 1 knee There were no significant difference in FTA before TKA and KS between with VOCG and without VOCG cases. In pre-oprerative varus knee group (n=133), there was significant difference in pre-oprerative ROM between with VOCG group (94.4°±25.5°) and without VOCG group (106.0°±25.5°) (p<0.05). In addition, post operatively ROM of without VOCG group (125.6°±17.3°) was significantly better than with VOCG group(112.8°±13.5°)(p<0.05). However, there was no significant difference in improvement rate of ROM between two groups. In radiographic evaluation, no cases revealed non-union at osteotomy site. Conclusions. In current series, no cases revealed PCL dysfunction after CR TKA in two groups. Our clinical results suggested that VOCG would provide reasonable PCL release and remain PCL function in CR TKA

Introduction. The purpose of this study was to introduce our perioperative prophylaxis method for infection and clarify surgical site infection rate in our patients performed total hip arthroplasty (THA). Method. Two hundred and eighty four THA (including revision 18 cases) performed by single surgeon between Oct. 2007 and Jan. 2013 were evaluated. The mean age of patients was 65.7 years old. The male to female ratio was 46 to 238. BMI was 23.6. Ninety patients (32%) were compromised host suffering from diabetes mellitus, rheumatoid arthritis, autoimmune disease, history of malignant tumor, hemodialysis or skin disease at surgical site respectively. At preoperative period, we checked decayed tooth, alveolar pyorrhea, hemorrhoids, and leg skin condition. In addition, we examined culture of nasal cavity. At the day of surgery, patient took a shower just before entering surgical room. All of THA was performed in clean room NASA class 100. Surgeons and assistant nurse put on nonwoven fabric gown, space suit and double rubber gloves. We wiped surgical site leg by gauze impregnated by 0.5% chlorhexidine alchohol to eliminate skin bacteria twice just before surgeons scrubbing hands. Surgical site was covered by povidone iodine containing drape. Surgeons or nurse changed gloves when glove was broken at each time. We cleaned surgical field by pulse washer whenever necessary. We did not use drain except for 5 revision THAs. Regarding to prophylactic antibiotics usage, we administered cefcapene pivoxil orally the day before surgery. Drip infusion antibiotics (PIPC: until Oct. 2008, CEZ: after Oct. 2008) was administered at the period of 30 min. before surgery and 4 hours after surgery in case of prolonged surgical time (4 hours >). Skin closure was performed by staple and covered by gauze until May 2010. After that, we used surgical tape and transparent water proof sheet. After finishing surgery, antibiotic was administered 8 hours interval at surgery day and 12 hours interval for additional two days. In case multi-drug resistant bacteria (MRSA, MRSE) was positive in nasal culture, we applied mupirocin ointment to nasal cavity for 3 days before surgery and administered vancomycin (from Aug. 2011) or linezolid (from 2012) for prophylactic antibiotics in perioperative period. Results. Multi-drug resistant bacteria was detected from nasal cavity in 23 patients (8%). The mean operation time was 194 min (due to education for young surgeon). Intraoperative bleeding was 598g. Length of skin incision was 13.6 cm. Intraoperative wash volume was 4500 ml. The infection rate were 0 % in early period and 0.7 % (two case) in late period respectively. One infected case was 75 years old female. Deep infection was occurred 3 years after surgery. She was administered steroid and immunosuppressive drug due to metal allergy after total knee arthroplasty. The other case was 64 years old female. Superficial infection happened 3 months after THA. The patient was suffered from collagen disease and diabetes. Conclusion. Our prophylaxis method for surgical site infection of THA achieved 0 % in early infection and 0.7% late chronic infection respectively

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

Chondrosarcoma is a malignant tumour and accounts for approximately 20% of bone sarcomas. The pelvis is one of the commonest sites. Chondrosarcoma of the pelvis lends itself to surgical excision and is relatively resistant to irradiation and chemotherapy. A long term survival analysis of this challenging condition is rarely reported in literature. We review and evaluate the oncological and functional results of all the patients operated at our centre and we analyse the survival analysis of these patients with special focus on the prognostic factors. Fifty-four consecutive patients with chondrosarcoma of the pelvis who were treated at the Royal National Orthopaedic Hospital, Stanmore, UK between 1987 and 2001 were included in the study. Demographic data, case notes, histopathological results and follow-up data were obtained and statistically analysed. There were 38 males and 16 females with a mean age of 48.4 years [18-77]. The chondrosarcomas were primary [n=38], secondary [n-7] or recurrences [n=9]. The anatomical sites in the pelvis were in the epicentre I [n=24], II [n=20] and III [n=10]. The surgical procedures performed were local resection [n=28], local resection and hip arthroplasty [n=6], hemipelvectomy (+endoprothesis) [n=16], hemipelvectomy [+fibular strut graf] [n=2] and hinquarter amputation [n=2]. The histological grade was Gr [n=27], Gr 2[n=20] and Gr 3 [n=7]. The complication rate was 24%:wound revision [9%], dislocation [8%] and infection [7%]. There was a 5, 10 and 15 year cumulative survival rate of 74%, 65% and 40%. The overall recurrence rate was 24%. The factors associated with a worse prognosis were high histologic tumour grade, increasing patient age, anatomical location in site I and III, primary surgery outside of tumour centre, inadequate surgical margins, and those treated by local extension. Aggressive surgical approach significantly improves the prognosis of the patients with chondrosarcoma of the pelvis

We performed a retrospective review of 98 patients with malignant tumours of the periacetabular region, treated by resection and endoprosthetic reconstruction between 1971 and 2005 at the Royal National Orthopaedic Hospital, Stanmore and The Royal Orthopaedic Hospital, Birmingham. The mean age of the patients was 43.6 years (10 to 76). 53 patients (54%) were male. The age distribution demonstrated peaks in the 2nd and 6th decades. The mean follow up was 65 months (2 to 405. The overall 10-year survival rate was 56% (determined by the Kaplan-Meier method). 54 patients (58.1%) had one or more complications. Infection was the most common (30%) with the majority occurring in the first 2 years. Dislocation occurred in 19 (20%) of our patients all in the first year following surgery. All were recurrent with a mean of 2.9 (2 to 6) episodes. Operations performed before 1994 were associated with a dislocation rate of 40.5% and after 1996 the rate was only 3.9% (p < 0.001). Function was assessed according the Toronto Extremity Salvage Sore (TESS). The overall TESS was 59.4. In patients that had a major complication the TESS was 37.1 but in the group that did not the TESS was 70.3 (p < 0.001). Men experienced higher rates of death, infection and revision than women (p < 0.05). The local recurrence rate was 31% with high grade tumours associated with higher recurrence rates (p < 0.05). Tumour resection in the ilium is associated with higher rates of infection than tumours located in the periacetabular region alone (p < 0.05). This method of reconstruction is still associated with high complication rates. Function is good if a major complication can be avoided. The lower dislocation rate more recently is probably the result of improved surgical technique and the use of larger femoral heads

Introduction. Despite the advances in adjuvant chemotherapy and surgical techniques, the diagnosis of a bone tumour still carries with it a significant risk of mortality. This study investigates factors affecting survival, in patients treated for malignant tumours of bone using Endoprosthetic replacement (EPR). Methods. Our tertiary referral musculoskeletal tumour unit has taken referrals over 40 years. Electronic patient records have been prospectively kept on all patients seen since 1986 and data has been entered retrospectively for patients seen between 1966 and 1986. A consecutive series of 1264 patients underwent endoprosthetic reconstruction; after 158 patients were excluded, 1106 patients were left in the study group. Factors including diagnosis, size of tumour, surgical margins, percentage tumour necrosis following chemotherapy, tumour site, local recurrence, decade of reconstruction, fracture and post-operative deep infection were analysed. Results. Overall population survival was 58.4% at 5 years, 50.5% at 10 years and 44.6% at 20 years. Significant prognostic factors on cox-regression analysis included locally recurrent disease (p<0.001), metastatic disease (p<0.001), chemotherapy (p<0.001), percentage tumour necrosis after chemotherapy (p=0.001), tumour size (p<0.001), post-operative surgical margin (p<0.001), fracture (p<0.001) and post-operative deep infection (p=0.05). Univariate analysis showed proximal femoral site (p=0.01) and EPRs after 1991 (p=0.05) were significant factors. Patients diagnosed with a deep infection within 2.5 years from implantation had 63.2% 10 year survival, compared to 49.4% in the non infected group. When stratified by diagnosis this was significant in patients with myeloma (p=0.01) and a showed strong trend in those with osteosarcoma (p=0.1). Trends towards better survival with Staphylococcal infections (p=0.2) were not demonstrated with other organisms. Discussion and conclusion. Several known prognostic factors were demonstrated for malignant bone tumours but there was evidence for increased survival after deep post-operative infection. The authors feel the results of this study and other recent evidence warrant further investigation

STS are rare malignant tumours of mesenchymal origin giving a wide array of histological types and behaviour. Common sites of involvement include the extremities which are of most relevance to orthopaedic surgeons. Like almost all other malignancies, STS become more common with increasing age with median age of 65 years. All patients aged 65 and over with STS of the extremities referred to the NZ Tumour Registry at Middlemore Hospital between 1967 and 2010 were included in the study. Data collected include baseline demographics (age, sex), diagnosis, site, time of referral, definitive treatment, adjuvant therapy, surgical margins (if applicable), local recurrence, survival, and cause of death. Each patient was staged according to AJCC (1997, 5th edition) and Enneking's staging systems. Primary outcomes were measured in terms of 5-year survival alongside with cause of death. A total of 116 patients. 21 upper extremities, 95 lower extremities. Average age of 74 with a 1.2:1 female to male ratio. Stage 1 disease was uncommon, accounting for only 5 cases (4%). 3 patients died within 5 years (1 due to metastatic disease and 2 from non-sarcoma related disease). 2 patients were still alive in 2010 with 1 of them surviving >5yrs. Stage 2 disease was found in 41 patients (35%). Common histologies included malignant fibrous histiocytoma (MFH), liposarcomas, or leiomyosarcomas (LMS). 44% (n=18) had greater than 5-year survival. 20% (n=8) died within 5 years succumbing to metastatic disease. 11 were under 5-yr follow up. Stage 3 disease was found in 48 patients (41%). MFH was by far the most common diagnosis accounting for 63% of patients. 5-year survival 25% (n=12). 5-year mortality 56% (n=27) mainly from advanced disease and metastases. Rest (n=9) are still within 5-yr follow up. Distant metastases at presentation were seen in about 10% of all patients (12 cases) with the most common site of involvement being the lung. 9/13 died of metastatic disease within 5 yrs while others are still within the 5 yr follow up period. STS are most commonly observed in the elderly and prognosis depends on several factors. Management should ideally be carried in a specialised centre with early referral and combined multidisciplinary approach to optimise patient outcome

Introduction:. Over the last several decades, life expectancy following solid organ transplant (i.e. kidney, liver, heart, lung, and pancreas) has increased significantly, largely due to improvements in surgical technique, immunosuppressive regimens, patient selection, and postoperative care. As this population ages, many of these transplant patients become candidates for total knee arthroplasty (TKA). However, these patients may be at greater risk of complications following TKA due to immunosuppression and metabolic derangements secondary to organ dysfunction. The purpose of this study was to use a large, nationally representative database to compare morbidity, mortality, length of stay (LOS), and charges for TKA patients with and without a history of solid organ transplant. Methods:. This retrospective study was a review of the Nationwide Inpatient Sample (NIS; the largest all-payer inpatient care United States database representing a 20% stratified sample) from 1998 to 2010. Patients who had a primary TKA (ICD-9-CM 81.54) were included (n = 5,706,675, weighted national frequency). A total of 763,924 cases were excluded for the following: age <18 years, pathologic fracture of lower extremity, malignant neoplasm and/or metastatic cancer, previous and/or bilateral arthroplasty, admission type other than “elective”. The remaining 4,942,751 patients were categorized as transplant (n = 5,245; included only liver, kidney, heart, lung and/or pancreas transplant) or non-transplant group (n = 4,931,017; no history of any transplant including solid organ or tissue). A multivariable regression model was used to identify any association(s) between a history of solid organ transplant and morbidity, mortality, LOS and hospital charges, while adjusting for patient and hospital characteristics. Results:. Between 1998 and 2010, the volume of TKA increased among transplant patients at a rate of 382%, which was significantly higher than that of the non-transplant group (197%; p < 0.01). Patients with a history of transplant had a significantly higher prevalence of renal failure (+69.3%), liver disease (+22.9%), uncomplicated diabetes (+9.0%), hypertension (+8.9%), deficiency anemia (+8.9%) (p < 0.001). Transplant patients suffered 1 or more complication at a rate of 7.3%, which was significantly higher than that of the non-transplant group (5.7%; p < 0.001). A 0.1% mortality rate was observed in the non-transplant group, while no deaths were reported in the transplant group. Unadjusted trends for mean LOS (Figure 1) show that transplant patients have a longer LOS (4.2 days) than non-transplant patients (3.7 days; p < 0.001), although LOS decreased for both groups. Overall mean charges per admission (USD) were significantly higher for the transplant cohort ($ 40,999) than the non-transplant group ($ 35,686; p < 0.001), and both increased over time (Figure 2). After adjusting for patient demographics, hospital characteristics, and comorbidity, transplant patients stayed 0.46 days longer in the hospital (p < 0.01) and had $ 3,480 increased charges (p < 0.01). There was no statistically significant increase in hospital complications (adjusted odds ratio = 1.20; p = 0.13). Conclusions:. While the annual number of TKAs performed in the United States on patients with a history of solid organ transplant is relatively low, the rate is increasing at nearly twice that of non-transplant patients undergoing TKA. Transplant patients have a significantly higher number of comorbidities, longer LOS, and greater charges than patients with no transplant history

Introduction:. Solid organ transplant patients are living longer than in past decades, largely due to improvements in surgical technique, immunosuppressive regimens, patient selection, and postoperative care. As these patients grow older, many of them present for total hip arthroplasty (THA). However, life-long immunosuppressive therapy, metabolic disorders, and post-transplant medications may place transplant patients at higher risk for complications following THA. The objective of this study was to use a national administrative database to compare morbidity, acute complications, in-hospital mortality, length of stay (LOS), and admission costs for THA patients with and without solid organ transplant history. Methods:. The Nationwide Inpatient Sample (NIS), the largest all-payer inpatient care database representing a 20% stratified sample of United States hospitals, was retrospectively queried for primary THA (ICD-9-CM 81.51) patients from 1998 to 2009 (n = 2,567,930; weighted national frequency). Cases were excluded (n = 324,837) for the following: age <18 years, pathologic fracture of lower extremity, malignant neoplasm and/or metastatic cancer, primary diagnosis of femoral neck fracture, admission type other than “elective,” previous and/or bilateral arthroplasty. The remaining 2,243,093 THA patients were assigned to transplant (n = 6,319; liver, kidney, heart, lung and/or pancreas transplant history) or non-transplant groups (n = 2,231,446; no history of any transplant including solid organ or tissue). Acute complications included a variety of organ-specific and procedure-related complications (i.e. mechanical implant failure, dislocation, hematoma, infection, pulmonary embolism, venous thrombosis). Multivariable regression and general estimating equations were developed to study the effect of transplant history on outcomes, adjusting for patient/hospital characteristics and comorbidity. Results:. Between 1998 and 2009, the volume of THA among patients with a history of solid organ transplant grew approximately 40% (444 to 620 cases/year), which was lower than that among non-transplant patients (+102%). Transplant THA patients were significantly sicker than their non-transplant peers, with an elevated Elixhauser comorbidity index (7.69 vs. 1.21; p < 0.001). Transplant and non-transplant patients had similar rates of 1+ inpatient complication(s) following THA (transplant 23.6% vs. non-transplant 24.3%; p = 0.60). There were no in-hospital deaths in the transplant group, while 0.1% (n = 2,855) of non-transplant patients died after THA. Unadjusted trends show that transplant patients have a longer mean LOS (4.5 days) than non-transplant patients (3.9 days; p < 0.001) after THA, although LOS decreased for both groups over time (Figure 1). Also, overall unadjusted mean costs per THA admission were significantly higher for the transplant cohort ($15,518) than the non-transplant group ($14,474; p < 0.001), and both increased over time (Figure 2). After adjusting for confounders, transplant patients had an 8% increase in LOS (0.38 days) compared to non-transplant patients (p < 0.001); however, there were no statistically significant increases in admission costs (p = 0.13) or complications (p = 0.19). Conclusions:. While the annual volume of THA performed in the United States on patients with a history of solid organ transplant is increasing, the rate is less than half that of non-transplant patients undergoing THA. Transplant patients have a significantly higher number of comorbidities and longer LOS after THA compared to non-transplant patients. Admission costs and acute complications are comparable among these populations, after adjusting for patient and hospital characteristics

During the pandemic of COVID-19, some patients with COVID-19 may need emergency surgeries. As spine surgeons, it is our responsibility to ensure appropriate treatment to the patients with COVID-19 and spinal diseases. A protocol for spinal surgery and related management on patients with COVID-19 has been reviewed. Patient preparation for emergency surgeries, indications, and contraindications of emergency surgeries, operating room preparation, infection control precautions and personal protective equipments (PPE), anesthesia management, intraoperative procedures, postoperative management, medical waste disposal, and surveillance of healthcare workers were reviewed. It should be safe for surgeons with PPE of protection level 2 to perform spinal surgeries on patients with COVID-19. Standardized and careful surgical procedures should be necessary to reduce the exposure to COVID-19.

We reviewed 234 benign solitary schwannomas treated between 1984 and 2004. The mean age of the patients was 45.2 years (11 to 82). There were 170 tumours (73%) in the upper limb, of which 94 (40%) arose from the brachial plexus or other nerves within the posterior triangle of the neck. Six (2.6%) were located within muscle or bone. Four patients (1.7%) presented with tetraparesis due to an intraspinal extension.

There were 198 primary referrals (19 of whom had a needle biopsy in the referring unit) and in these patients the tumour was excised. After having surgery or an open biopsy at another hospital, a further 36 patients were seen because of increased neurological deficit, pain or incomplete excision. In these, a nerve repair was performed in 18 and treatment for pain or paralysis was offered to another 14.

A tender mass was found in 194 (98%) of the primary referrals. A Tinel-like sign was recorded in 155 (81%). Persistent spontaneous pain occurred in 60 (31%) of the 194 with tender mass, impairment of cutaneous sensibility in 39 (20%), and muscle weakness in 24 (12%).

After apparently adequate excision, two tumours recurred. No case of malignant transformation was seen.