Introduction

Osteonecrosis of the knee encompasses three conditions; spontaneous osteonecrosis of the knee, secondary osteonecrosis (ON) and post-arthroscopic ON. Early stage lesions can be managed by non-operative measures that include protected weight-bearing and analgesia. The aim of this study was to report the experience of the authors in managing early stages of knee ON by analysing the functional outcome and need for surgical intervention.

Study Design: An analysis of patients admitted with cervical trauma, comparing: those managed with rigid collars until definitive management; rigid collar usage overnight; and no rigid collar usage from outset.

Objectives: To determine the safety of omitting a rigid collar following cervical trauma, whilst awaiting definitive management.

Summary of Background Data: The use of a rigid collar can result in pain, occipital sores, as well as raised intracranial pressure in head injured patients.

Subjects: Fifty one patients with proven cervical fractures were analysed. Three groups of patients were identified with respect to their initial management after admission to the ward until definitive management: 1) Hard collar, sandbags and bed rest 2) Hard collar in situ overnight and then sandbags and bed rest. 3) Sandbags and bed rest. All patients had full spinal care and precautions, with rigid collars used for any transfers. The spectrum of injury severity was similar throughout all 3 groups.

Outcome measures: Loss of alignment, neurological compromise and complications related to the rigid collar.

Results: There was no loss of reduction or progression of neurological deficit in any group. There were compliance issues in the rigid collar group. Two patients developed occipital skin problems following rigid collar use. All groups proceeded to definitive management successfully.

Conclusion: No significant adverse events were noted in any group. Management without a rigid collar depends on good nursing care. It is more comfortable for the patient and avoids the potential problems encountered with rigid collar use. In compliant patients not requiring immediate definitive management the omission of the rigid collar did not result in loss of reduction or neurological compromise. We feel such collars should be for transport and extrication only.

The Kramer osteotomy for hallux valgus deformity was described in 1990 and has been performed by the senior author in our unit since 1999. The procedure involves a wedge excision of bone and lateral displacement of the first metatarsal head. The osteotomy is splinted by a K-wire passed medially to the phalanges and metatarsal head into the metatarsal diaphysis.

During the period October 1999 to December 2001 this procedure was performed on 26 feet in 24 patients. Case notes were reviewed retrospectively to assess the subjective outcome following the operation. Patients were invited to attend a follow up clinic to assess the outcome using the Hallux Metatarsal-Interphalangeal Scale (HMIS) of the American Orthopaedic Foot and Ankle Society and weight bearing radiographs of the foot. Twelve patients (13 feet) were seen at this follow up.

Discharge from hospital was on the day following surgery in 20/24 patients with three days maximum stay. K-wires and plaster boots were left in situ for 41 days on average (30–50 days range). From the case notes, using absence of hallux pain, deformity, hallux stiffness and footwear problems as outcome measures, 20 feet (77%) had a good outcome, five feet (19%) had a fair outcome and one foot (4%) had a poor outcome. At the follow up clinic at a mean time from operation of 134 weeks (range 56–153 weeks), the average HMIS score was 86/100 (Range 60–100) with 77% scoring 85 or more out of 100. Average postoperative intermetatarsal, hallux valgus and distal metatarsal articular angles were 6.9, 15.8 and 11 degrees respectively. Other than six cases of minor infection of skin, treated empirically with antibiotics, no other complications were seen. All patients were happy they had received this treatment.

In conclusion the Kramer osteotomy is a technically simple operation which gives good results with few complications.

To assess whether primary spindle cell sarcomas of bone behave like other primary bone sarcomas.

185 patients with primary spindle cell sarcomas of bone, that is non-osteosarcoma, non-chondrosarcoma and non-Ewings sarcoma of bone, were identified from the patient database of the Orthopaedic Oncology Service in Birmingham, UK. This database contains information on over 10, 000 patients treated in Birmingham since 1970 and collected prospectively since 1986.

Spindle cell sarcomas of bone are primary bone tumours which share the histological spindle shaped cells. They are a heterogeneous group including the cytological diagnoses of malignant fibrous histiocytoma (MFH), spindle cell sarcoma, leiomyosarcoma, fibrosarcoma, angiosarcoma and secondary sarcoma.

119 (64%) of the patients were male. The mean age was 47 years with 116 (63%) older than 40 years. Only 6 patients were low grade and 34 had metastases at presentation. 12 patients developed tumours secondarily to other pathology such as Pagets or radiotherapy. The patient’s limb was affected in 155 (84%) of cases with the distal femur being the most common site.

Treatment was with chemotherapy and surgery where indicated. Chemotherapy was with adriamycin and cis-platin most commonly and was neoadjuvant in 75% of those who had it. Of the 150 patients who had surgery, 113 (75%) had limb salvage.

Overall five year survival was 52 %. Survival in patients who had high grade limb tumours, with no metastases at presentation and which weren’t secondary tumours had a five year survival of 60 %. These results are comparable to previous studies looking at similar tumour groups. Good prognostic factors included treatment since 1980, good response (> 90% necrosis) to neo-adjuvant chemotherapy, limb tumours, age < 40 and local control. 73% of patients with local recurrence died with a mean survival of 11 months. There was no difference in outcome or behaviour between the different diagnoses although prognosis was slightly better than those of aged matched patients with osteosarcoma.

Spindle cell sarcomas of bone respond in a similar way to, if not better than, osteosarcoma when treated in the same way with chemotherapy and surgery. Consequently this should be the preferred method of management.