Quality outcomes from medical intervention are assumed by patients & the community. However such quality cannot be assured in every case. There are systems which can be developed which will make the safety of patients more assured. In any system of medical care, it is presumed that the practitioners who are taking care of the patient are qualified both in their basic qualification & also in their higher qualification. As well it is now accepted that appropriate credentialling occurs & that this is the purview of the hospital which will check the qualifications & currency of practice with the medical board & the higher degree & currency (participation in CPD) with the College concerned. They should also review the privileges which define the scope of practice.

In orthopaedic oncology it is now essential that a practitioner has completed a higher form of training such as a Fellowship. At the current time in this country there is no process of assurance of the quality of the education program but there is continuing development in this area. Peer review & audit remains problematic. The RACS demands that surgeons participate in an appropriate audit process yearly & that this reviews outcomes rather than just complications. The participation is however voluntary. Despite this, the participation rate is greater than 94% of all surgeons. Medical boards have been requested to make participation in a quality CPD program compulsory, but have not done so, & there are no sanctions for non participation – yet.

Most surgeons participate in regular morbidity & mortality meetings, but these are not truly audits of outcome. It would be wise for the Australian Sarcoma Group to develop outcome measures which could easily be collected. The desire to perform research should not be confused with audit which simply addresses quality at an appropriate expert level and which the community expects. Prospective collection & review of outcome measures will mean that trends in performance will be noted earlier. This is particularly important in adverse events.

These processes have been embraced by some branches of surgery more than others. Medical outcome reviews of performance have not been developed to such an extent in most disciplines for a variety of reasons, including the fact that surgical endpoints can be more easily identified. The same principles apply, however. It is important for the profession to participate in self audit or third parties will demand it, not necessarily in a way which we might prefer.

We evaluated the oncological and functional outcome of 27 patients who had limb salvage for a soft-tissue sarcoma of the foot or ankle between 1992 and 2007, with a mean follow-up of 7.5 years (1.05 to 16.2). There were 12 men and 15 women, with a mean age at presentation of 47 years (12 to 84). Referrals came from other hospitals for 16 patients who had previous biopsy or unplanned excision, and 11 presented de novo. There were 18 tumours located in the foot and nine around the ankle. Synovial sarcoma was the most frequent histological diagnosis. Excision was performed in all cases, with 16 patients requiring plastic surgical reconstruction with 13 free and three local flaps. Adjuvant treatment was undertaken in 20 patients, 18 with radiotherapy and two by chemotherapy. Limb salvage was successful in 26 of the 27 patients. There have been two local recurrences and two mesenchymal metastases. Four patients have died of their sarcoma and two of other causes.

Function was evaluated with the Toronto Extremity Salvage Score and a mean overall score of 89.40 (52.1 to 100) was obtained. A questionnaire revealed that all surviving patients are able to wear normal shoes and none require a walking aid.

Limb salvage can achieve good oncological and functional results with additional treatment.

Introduction and Aims: The aim of surgeons including patients with soft tissue sarcoma is to gain local control of the tumor, to avoid the risk of local recurrence, and to avoid the compromise of the patient’s potential survival. The aim of the investigation was to assess the significance of the extent of surgical margin on the chance of death, metastasis and local recurrence in soft tissue sarcoma.

Method: Three hundred and twenty-four patients were reviewed. Surgical margin data was unavailable for 21, and of the remaining 303 patients, 10 patients had no residual tumor, margins were not defined for 24 patients and nine patients had radical resections. Wide margins were achieved for the remaining 260 patients. Fifty-four percent had surgical margins of under five millimetres. Cox Proportional Hazards Regression modelling was used to consider the impact of surgical margin with an overall survival, disease-free survival and metastasis-free survival. Results were expressed as survival rate ratios and graphics represented as model-based survival curves. All associations that were statistically significant, as well as any associations for which the rate ratios were 2.0 or greater, were reported. Follow-up ranged from 53 days to 187 months, with a median of 40 months.

Results: Overall survival time for the 279 patients with complete information was 124 months. There was a significant association between overall survival and extent of the surgical margin (chi-squared test statistic = 14.7, 8df, p = 0.043). There was a significantly higher death rate in patients who had a wide contaminated margin or a radical resection – indicating a likely poorer prognostic group. There was however no difference between any margin less than 20mm. With respect to disease relapse, there were 27 local recurrences among 279 patients. There were no local recurrences in the 44 patients who had margins of 20mm or greater, no residual tumor, radical resection or for whom margins were not defined. Therefore to permit stable statistical analysis, 24 local recurrences among 213 patients were reviewed. There was a significant association between the extent of surgical margin and disease-free survival (chi-squared test statistic = 9.5, 4df, p = 0.051). However, with respect to metastasis, there was no relationship between surgical margin and the development of metastatic disease (chi-squared test statistic = 8.5, 8 df, p = 0.383).

Conclusion: There is significant statistical evidence to suggest improved overall survival and also improved local recurrence survival with increasing width of surgical margins. There is however the confounding information that the rate of metastasis does not depend on the width of the surgical margin. The question of whether success in obtaining local control is significant in terms of overall metastasis and death remains unresolved in terms of our study.

Introduction The aim of the investigation was to assess the significance of the extent of surgical margin on the chance of death, metastasis and local recurrence in soft tissue sarcoma.

Methods The review consisted of 324 patients. Surgical margin data was unavailable for 21, and of the remaining 303 patients, 10 patients had no residual tumour, margins were not defined for 24 patients and nine patients had radical resections. Wide margins were achieved for the remaining 260 patients. Fifty-four percent had surgical margins of under five millimetres. Cox Proportional Hazards Regression modelling was used to consider the impact of surgical margin with an overall survival, disease-free survival and metastasis-free survival. Results were expressed as survival rate ratios and graphics represented as model based survival curves. All associations that were statistically significant as well as any associations for which the rate ratios were 2.0 or greater were reported. Follow-up ranged from 53 days to 187 months, with a median of 40 months.

Results Overall survival time for the 279 patients with complete information was 124 months. There was a significant association between overall survival and extent of the surgical margin (chi-squared test statistics = 14.7, 8df, p = 0.043). There was a significantly higher death rate in patients who had a wide contaminated margin or a radical resection indicating likely poorer prognostic groups. There was however no difference between any margin from one to 20 mm. With respect to disease relapse, there were 27 local recurrences among 279 patients, and for statistical reasons, 24 local recurrences among 213 patients were reviewed. There was a significant association between the extent of surgical margin and disease-free survival (chi-squared test statistics = 9.5, 4df, p = 0.051). With relation to metastasis, 68 of 257 patients were reviewed, there being no statistical association between metastasis-free survival and margin extent.

Conclusions There is significant statistical evidence to suggest overall and disease-free survival increase with increasing width of surgical margin. The evidence is not convincing in our assessment of metastasis-free survival

In relation to the conduct of this study, one or more of the authors is in receipt of a research grant from a non-commercial source.

Introduction Structure, position, strength, function and durability are critical following reconstruction after treatment of bone tumours. We aimed to assess performance and make recommendations in relation to shoulder reconstruction.

Methods Shoulder reconstruction following resection of bone tumours of the shoulder girdle was evaluated for thirty-two patients treated from 1987 to 2002. Several kinds of reconstructive procedures were performed and classified according to the system of the Musculoskeletal Tumour Society. Fourteen patients had an osteosarcoma, ten patients had a chondrosarcoma, four patients had an Ewings sarcoma and four had an extensive giant-cell tumour. The choice of reconstruction depended on the type of resection and the needs of the patient. The functional results were assessed and graded quantitatively according to the functional rating system of the Musculoskeletal Tumor Society. The average duration of follow-up was 75 months for the 23 patients who were still alive at the time of the latest follow-up examination.

Results Nine patients died of malignancy (four patients with surgical stage III disease and one with Paget’s osteosarcoma); these patients had an average 18 months follow-up post-operatively. The resection was classified as wide in 27 of 32 patients and as marginal in five. Two patients had local recurrence. Functional results were related to the type of resection and the method of shoulder reconstruction. In patients where the deltoid and rotator cuff could be preserved, allograft-prosthetic composite had better function than prosthesis alone after intra-articular resection of the humerus because reconstruction of the deltoid and the rotator cuff could be performed incorporating the allograft. After intra-articular resection of the proximal humerus with loss of the abductor mechanism, arthrodesis resulted in good function and more strength than was found after reconstruction with prosthesis or allograft-prosthetic composite. A secondary arthrodesis was performed in two patients with symptomatic instability following failed reconstruction with an allograft-prosthetic composite or an osteoarticular allograft. Insertion of an allograft, a vascularized fibular graft, a rotational latissimus dorsi flap and cancellous autograft bone was the preferred arthrodesis technique to achieve fusion as well as to reduce complications. There was one fracture and one infection in 10 patients. After extra-articular resection of the glenoid cavity and the proximal humerus with abductor mechanism, reconstruction with a functional spacer frequently resulted in superior subluxation of the implant and only fair function of the shoulder. With two teen-aged patients, a free fibular graft inserted after intra-articular resection of the proximal humerus led to fair function, to be followed by secondary arthrodesis when growth is complete. After resection of the acromion-glenoid cavity complex in one patient and the entire scapula in a child, no reconstruction resulted in good function of the shoulder.

Conclusions Indications for the method of reconstruction depend on type of resection, age, gender, occupation, the expected functional level and restriction of activity. After resection of the abductor mechanism, arthrodesis resulted in more strength and capacity to position the arm in space. It was suitable for the young. Allograft-prosthetic composite showed better function when the abductor mechanism had been reconstructed. Prostheses should be used in old patients or for palliative surgical treatment after resection the abductor mechanism. The most durable and functional reconstruction was arthrodesis.