Aim

To review the first 50 cases, looking at survivorship of the irradiated autograft, complications and functional outcomes in a wide range of bony malignancies and anatomical locations.

The aim was to investigate whether or not the pre-operative injection of cortico-steroids into the knee influences the infection rate of a subsequent total knee replacement.

This was a case controlled study, in which it was calculated that 152 controls and 38 infected cases would give sufficient power to the study. The infection group had to have had a delay in wound healing or have had a revision for infection.

A total of 32.8% had had an injection at some time pre-operatively. The average number of injections was 2.23, with a range of 1–15. 37% were performed by a G.P., 35% by an orthopaedic surgeon, and 22% by a rheumatologist.79% had the injection within 12 months of surgery. The rate of injection was the same in the two groups. There was no significant difference in the infection rate between the two groups (OR 1.38; 95%CI 0.55–3.31)

Despite recent literature indicating that there is a 10% increase in infection in patients having steroid injections into the hip prior to THR this study does not confirm this risk in patients undergoing TKR.

Aim: To clinically and radiologically review our first 50 cases of treatment of malignant bone tumours by extra-corporeal irradiation (ECI) and re-implantation and review the world literature’s other 100 such cases.

Methods: We have treated 50 patients with bony malignancy by en bloc resection, ECI with 50Gy and reimplantation of the bone segment as a method of limb salvage. Mean survivor follow-up is 38 months (12–92).

Results: 42 patients remain alive without disease. 4 recurrences occurred. Functional results were generally good: Mankin grades 17 excellent, 13 good, 9 fair, 3 failures; MSTS mean 77 (20–100); TESS mean 81 (40–100). Solid bony union was the norm, however bone resorption was seen in some cases.

Discussion: The dose of radiation is theoretically lethal to all cells and produces a dead autogenous bone graft of perfect fit. ECI is a useful technique of limb salvage where there is a reasonable residual bone stock. It allows effective re-attachment of muscle tendons, and produces a lasting biological reconstruction. The risk from the re-implanted bone of both local recurrence and of late radiotherapy induced malignancy should be nil.

We have treated 50 patients with bony malignancy by en bloc resection, extracorporeal irradiation (ECI) with 50Gy and re-implantation of the bone segment as a method of limb salvage. Mean survivor follow-up is 38 months (12–92). 42 patients remain alive without disease. 4 recurrences occurred. Functional results were generally good: Mankin grades 17 excellent, 13 good, 9 fair, 3 failures; MSTS mean 77 (20–100); TESS mean 81 (40–100). Solid bony union was the norm, however bone resorption was seen in some cases. The dose of radiation is theoretically lethal to all cells and produces a dead autogenous bone graft of perfect fit. ECI is a useful technique of limb salvage where there is a reasonable residual bone stock. It allows effective re-attachment of muscle tendons, and produces a lasting biological reconstruction. The risk from the re-implanted bone of both local recurrence and of late radiotherapy induced malignancy should be nil.

Introduction and Aims: To assess and compare treatment of pelvic Ewing’s sarcoma, particularly extracorporeal irradiation (ECI) and re-implantation of bone segments.

Method: We reviewed all patients presenting to the New South Wales Bone Tumor Service with Ewing’s sarcoma of the pelvis from 1995 until 2003. All received chemotherapy. There were 17 patients. Resection was performed in 14 cases: 12 were reconstructed by ECI and re-implantation of the bone segment; one with autograft and THR; one with allograft and THR. Three patients with sacral lesions had chemotherapy and radiotherapy only. All margins were clear. All patients were clinically and radiologically reviewed. Three scoring systems were used: The Musculoskeletal Tumor Society score (MSTS), the Toronto Extremity Salvage Score (TESS), and the Harris Hip Score (HHS).

Results: The average age at presentation was 18 years (range six to 35). There were seven males and 10 females. One patient presented with metastatic disease. Survivor follow-up ranged from 25 to 105 months (mean 55). In those who developed metastases these were detected at a mean of 27 months (range one to 79). Deaths occurred at a mean 31 months (range eight to 65). Fourteen underwent surgery. Seven had THR as part of their reconstruction. There have been no local recurrences after surgery. Six patients have died, 11 patients are alive (65%), one with metastatic disease. Overall disease-free survival is 59%. The disease-free survival in those who underwent ECI and re-implantation is 75% (minimum two-year follow-up). Functional outcome is good. The TESS mean was 83 (range 60–100). The MSTS score mean 85 (range 60–97). The HHS mean 92 (range 67–100). Radiologically solid bony union at the osteotomy sites was the norm. Lysis existed at two periacetabular osteotomies, around the posterior iliac crest of one osteotomy, and a fibrous union occurred at one sacro-iliac joint with breakage of the sacro-iliac screws. There have been no graft fractures.

Conclusion: The best surgical management for these difficult cases is extracorporeal irradiation and re-implantation of bone segments.

Abstract: Dealing with peri-articular pathology in the skeletally immature is challenging. Where the process is benign the emphasis rests on preservation of the joint while minimising the risk of recurrence. However when dealing with lesions of the femoral head this may lead to avascular necrosis (AVN), negating the effects of conservative surgery, and potentially subjecting a child to a prolonged period of fruitless treatment, increased hospital stay, reduced mobility and significant time out of education and social interaction. Case & Method: A 13 year-old Caucasian female presented with a six-month history of pain in her right hip, initially in the groin, and a limp necessitating the use of crutches. Radiographs revealed a lytic lesion in the femoral head with a thinned but intact articular surface. This was biopsied, and a diagnosis of chondroblastoma reached. The operative alternatives of arthrodesis and arthroplasty were discarded in preference for hip salvage. An anterior approach to the hip, with dislocation of the femoral head allowed identification of the fragile cortical margin of the chondroblastoma. This was opened with a scalpel and curetted. Corticocancellous strips of bone graft were placed into the defect as struts around cancellous graft. An autogenous fascia lata graft was sutured over the articular defect in the femoral head. The capsule was repaired. Results: One year post-operatively she is pain free and has returned to normal activities. Radiographs show good incorporation of the bone graft. Conclusion: Femoral head preservation is effective with benefits outweighing the risk of AVN.

Aim: To review an uncommon deformity arising in four patients. Method: A clinical and radiological review. Abstract: We describe four cases of distal radial epiphyseal dysplasia associated with a localised area of cutis aplasia congenita (CAC) over the dorsum of the distal forearm. The cutis aplasia was diagnosed at birth in all cases, but the radial dysplasia was not recognised until presentation to our orthopaedic department between the ages of 5 and 10 years. Radial dysplasia describes a spectrum of osseous, musculotendinous, and neurovascular dysplasias of the pre-axial border of the upper limb, and is the most common form of longitudinal deþ ciency. Cutis aplasia congenita involves an ulcerated area lacking in normal skin formation, present at birth. The most common site is on the scalp, but it has been described on the extremities, and overlying embryological malformations. This association, the long-term implications and the requirement for follow-up until skeletal maturity have not previously been described. We emphasise the importance of continued monitoring of these patients as the effects of radial dysplasia did not become obvious for several years, and the potential beneþt from achieving early skin cover with grafting rather than allowing healing by secondary intention is discussed. It is important to increase awareness of this condition so that early orthopaedic and plastic surgical opinions can be sought, in order to reduce the disabling effect on the underlying radius. Conclusions: Heightened awareness and early treatment with monitoring is required.

Hip pain in cerebral palsy is regarded to be underreported. Management of these patients at home is difficult as the patients mature. In the ‘non walker’ category, the aims of surgery are to relieve pain and to allow sitting and transfer.

Neuromuscular hips may have variable acetabular deficiencies ie) anterior /posterior / lateral. Many forms of surgical management, of varying complexity, have been described to address these problems.

To describe a new technique with multidirectional coverage that achieves pain free hips, 15 patients were reviewed over a 4 year period.

Inclusion criteria :- 1 Subluxated / dislocated hips with hip pain. 2 Patients who have failed conservative management. 3. Those not suitable for redirectional osteotomies.

A standardised technique was performed by one surgeon, at one institution.

In summary, the technique involves initially a standard derotation varus osteotomy. Via an anterior approach, a lateral iliac unicortical graft and strips of cancellous graft are harvested. The cancellous graft is laid on top of the intact capsule, in the areas of deficiency. The cancellous graft is held by the unicortical graft with a single screw.

15 patients were reviewed. Patients were categorised as ‘walkers’ (3) and ‘non- walkers’ (12.) The mean age was 13.2 years.

All patients were pain free after recovery. This was defined as not requiring analgesia and parental satisfaction.

The radiological appearances showed that all the shelves had incorporated, with satisfactory cover of the femoral head.

This technique addresses multidirectional cover of femoral head. The technique is relatively easy to perform. All the patients have achieved a pain free outcome to date.

We clinically and radiologically reviewed 79 uncemented PFC acetabular components inserted by our unit during a seven-year period, June 1991 to June 1998. Of these, 50 (63.3%) were primary and 29 (26.7%) were revision arthroplasties. The mean follow-up was five years (60 months), with a range of 12 to 95 months. Sixteen (20%) were excluded from the study, leaving 63 (26.7%) for review. Three (4.7%) cases were deemed to have failed (at 63, 69, 79 months), all of which were primary arthroplasties. One of them was found to be loose at revision and the other two cups had 2 mm of periacetabular radiolucency in only one zone, but had no definite evidence of loosening.

The remaining 60 (95.3%) cases showed no radiological evidence of migration of any cups, and no hip had a radiolucent line in all three zones of the acetabulum. Clinical review gave a mean Harris hip score of 96.5. Fifty (79.4%) reported no pain from the hip. One case (1.6%) had undergone recent revision of the stem, at which time the cup was found to be stable. Three (4.7%) reported slight, occasional pain. Another three (4.7%) described mild pain that did not compromise their average activities and was relieved by simple analgesia. Two cases (3.2%) complained of moderate pain that placed some limitations on their activities and required regular analgesia, and one elderly patient who had an ankylosed contralateral hip and ipsilateral sciatic nerve palsy described marked pain (1.6%), and these were considered poor outcomes. In all of these cases the cups were clinically and radiologically stable.

In conclusion, 81% of outcomes were excellent, painfree THRs. A further 4.75% had good and 4.75% fair results. 4.75% had poor outcomes and 4.75% of cases failed. We conclude that the PFC cup merits continued use and follow-up, and together with other uncemented cup designs, may produce benefits in the form of quality and longevity of results in total hip arthroplasty.