Aims

As the population ages, there is projected to be an increase in the level of demand for total knee arthroplasty (TKA) in octogenarians. We aimed to explore whether those aged ≥ 80 years achieved similar improvements in physical function to younger patients while also comparing the rates of length of stay (LOS), discharge to rehabilitation, postoperative complications, and mortality following TKA in older and younger patients.

The role of computer-assisted surgery in maintaining the level of the joint in primary knee joint replacement (TKR) has not been well defined. We undertook a blinded randomised controlled trial comparing joint-line maintenance, functional outcomes, and quality-of-life outcomes between patients undergoing computer-assisted and conventional TKR. A total of 115 patients were randomised (computer-assisted, n = 55; conventional, n = 60).

Two years post-operatively no significant correlation was found between computer-assisted and conventional surgery in terms of maintaining the joint line. Those TKRs where the joint line was depressed post-operatively improved the least in terms of functional scores. No difference was detected in terms of quality-of-life outcomes. Change in joint line was found to be related to change in alignment. Change in alignment significantly affects change in joint line and functional scores.

Internal hemipelvectomy is a standard treatment for malignant tumours of the pelvis. Reconstruction using a non-vascularised fibular graft is relatively straightforward compared to other techniques. We describe the surgical and functional outcomes for a series of ten patients who underwent an internal hemipelvectomy (type I or I/IV) with reconstruction by a non-vascularised fibular graft between 1996 and 2009. A key prerequisite for this procedure was a preserved sciatic notch, confirmed pre-operatively on MRI.

Graft-host union was achieved in all patients with a single fibular graft, and in the lower graft where two grafts had been used. The mean time to union was 7.3 months (3 to 12). The upper graft did not unite in four of six cases where two grafts had been used. Seven patients were eventually able to walk without a stick. The mean post-operative Musculoskeletal Tumour Society score was 75.4% (16.7 to 96.7). There were no cases of deep post-operative infection. The mean pelvic shortening was 0.9 cm (0.2 to 3.4). Recurrent tumour occurred in three cases, and death from tumour-related disease occured in one.

Patients who need an internal hemipelvectomy will do well if their pelvic ring is reconstructed with a non-vascularised fibular graft. The complication rate is low, and they attain a good functional outcome.

We welcome letters to the Editor concerning articles which have recently been published. Such letters will be subject to the usual stages of selection and editing; where appropriate the authors of the original article will be offered the opportunity to reply.

Letters should normally be under 300 words in length, double-spaced throughout, signed by all authors and fully referenced. The edited version will be returned for approval before publication.

Sarcoma is a malignancy of mesenchymal and neuroectodermal tissue, and as such, may arise in any location in the body. It is a rare tumour accounting for less than 1 in 1000 cancers and occurs with an incidence of 1.7–2 per 100000 head of population. Disease free survival following treatment of sarcoma has increased significantly over the last 20–30 years and five year survival for primary bone malignancies is approximately 75–80% and that for soft tissue sarcomas is approximately 70%.

Early attempts at limb sparing surgery was characterised by surgery with narrow margins, complicated incisions and substantial soft tissue bruising. Not surprisingly, the risk of local recurrence was high, but this was attributed to the nature of sarcoma rather than technique, and amputation became the treatment of choice for sarcoma.

In the mid 1970’s, the importance of surgical margins was recognised and guidelines were established for achieving oncologic surgical margins. Intralesional and marginal margins alone were regarded as inadequate, while wide and radical margins were acceptable for achieving local control of disease. The advent of magnetic resonance imaging improved the level of tumour delineation and allowed more accurate preoperative planning. This together with modern chemotherapy and radiotherapy increased the potential for limb sparing surgery.

Reconstruction following tumour resection is an exciting opportunity to protect the function of the limb and the mobility and independence of the patient. There have been a variety of techniques described and these involve either biological, prosthetic or a combination of these options. Reconstructions may be mobile or rigid. Mobile reconstructions frequently utilise prosthetic joints, but at other times pseudarthroses may function similarly, e.g. hip, shoulder. Osteoarticular allografts are also used to maintain joint function following tumour resection. Prosthetic joints incorporate advances in articulation and fixation to improve longevity as many of these devices are implanted into younger patients than normally anticipated for arthroplasty, and these joints are thus, exposed to an increased risk of wear and loosening. Osteoarticular allografts are prone to degenerative changes as well as graft disintegration and infection. Allograft prosthetic composites aim to reduce the articulation problems and may also assist in fixation of the construct. Biologic reconstructions using vascularised or non-vascularised bone are a useful technique for bridging defects and for replenishing bone stock. Adequate soft tissue coverage is vital following reconstruction.

The future of limb sparing surgery will depend on our ability to characterise the biological behaviour of the tumour because this will provide more information on the response of the tumour to treatment, the potential grade of the lesion and thus, its capacity to grown and spread. By understanding the process of tumour progression, we will be able to develop better strategies for treatment. Functional nuclear scanning using isotopes that are metabolised by tumours is a technique that is currently being evaluated as a complementary form of imaging. Chemotherapy has been the cornerstone in the treatment of bone sarcomas, but remains surprisingly disappointing when used for soft tissue sarcomas. Recent meta-analyses have demonstrated only a minimal improvement in disease–free survival with chemotherapy. Novel techniques or agents are required to improve the systemic role of chemotherapy. Patient selection is important and this may relate to their risk of developing systemic spread. Prognostic factors are therefore, important for identifying patients who may be candidates for novel or intensive chemotherapy. Molecular biology is providing an avenue for characterising these tumours but despite the identification of a multitude of distinctive chromosomal abnormalities with their associated gene products, only 2 abnormalities have been shown to be of prognostic significance (19p+ in MFH, and SSX/SYT in synovial sarcoma). Surgeon education is an area where significant advances may be made. Constant reiteration is required to ensure that the principles of proper diagnosis and referral are known. Successful treatment is dependent on knowledge of the criteria for and technique of biopsy, and the principle that the team that will be providing definitive treatment should perform the biopsy. Up to 30% of limbs are sacrificed each year because of inappropriate biopsy or surgery. This figure may be improved upon with greater understanding of the behaviour of sarcomas.

A regimented, multidisciplinary approach to the management of bone and soft tissue sarcomas is likely to improve the local and systemic control of this disease.