Revision arthroplasty poses many challenges including extensile exposure and difficulty in safe removal of cemented/uncemented femoral component and/or distal cement particularly from a poor bone stock. Extended trochanteric osteotomies are associated with complications including non-union, proximal migration of the trochanter or osteotomised segment, wire breakage and difficulties associated with reattachment of the fragment. We present a technique of trochanter sparing extended anterior femoral osteotomy (AFO) through a modified Hardinge approach in reducing the difficulties associated in conventional and ETO. We assessed the performance of this technique in 23 patients with a maximum follow-up of 10 years. No trochanteric escape or fractures seen in any cases. No proximal migration, subsidence or failure of femoral component seen. Union was seen in all cases. Mean time for union was 3 months. 1 patient developed recurrent dislocations that required constrained liner.

Improvement in Harris Hip scores was noted from 13 (pain) and 9 (function) pre-operatively to 39 (pain) and 22 (function) (p<0.05). Extended trochanter sparing AFO allows extensive exposure similar to traditional ETO. It heals reliably without the use of vertical wires, trochanteric plates or grips. The avoidance of abductor mechanism and osteotomy through weakest anterior non weight bearing area of the proximal femur may be a significant advantage.

Introduction

Local recurrence of tumours along the biopsy tract is a known complication of percutaneous closed needle biopsy. Correct surgical management requires preoperative identification and excision of the biopsy tract at time of surgery. These tracts become increasingly difficult to identify with time, leading to risk of inadequate excision of the biopsy tract and recurrence of the tumour at the biopsy site.

Local recurrence along the biopsy track is a known complication of percutaneous needle biopsy of malignant musculoskeletal tumours. In order to completely excise the track with the tumour its identification is essential, but this becomes increasingly difficult over time. In an initial prospective study, 22 of 45 patients (48.8%) identified over a three-month period, treated by resection of a musculoskeletal tumour, had an unidentifiable biopsy site at operation, with identification statistically more difficult after 50 days. We therefore introduced the practice of marking the biopsy site with India ink. In all 55 patients undergoing this procedure, the biopsy track was identified pre-operatively (100%); this difference was statistically significant. We recommend this technique as a safe, easy and accurate means of ensuring adequate excision of the biopsy track.

Cite this article: Bone Joint J 2013;95-B:250–3.

Percutaneous biopsies can lead to seeding of tumour cells along the biopsy tract.

Correct surgical management requires preoperative identification and excision of the biopsy tract at time of surgery. These tracts become increasingly difficult to identify with time, leading to risk of inadequate excision of the biopsy tract and recurrence of the tumour at the biopsy site. We conducted a prospective study involving 45 patients who had tissue biopsies for bone and soft tissue tumours between February and May 2008. All the biopsies were performed by consultant radiologist under ultrasound or CT guidance. Case note analysis, patient history and examination at the time of surgery were used to collect data. 23 of 45 patients had accurate identification of the biopsy tract by the surgeon at the time of excision. The mean time between biopsy and excision was 52 days (range 6–140). 22 of 45 patients had unidentifiable biopsy site, with the mean time between biopsy and excision being 98 days(range 13–164) p=0.0004(paired t test). All 4 patients who received post-biopsy radiotherapy had unidentifiable biopsy site tract (mean duration 104 days) and 11 of the 18 patients who underwent neoadjuvant chemotherapy had an unidentifiable biopsy tract (mean duration 108 days). We concluded that identification of biopsy site was more difficult after 50 days, especially in patients who underwent radiotherapy and chemotherapy.

Following this study, all the patients who had biopsies of tumours had the site marked with India ink tattoo. We, then prospectively reviewed 36 patients between July and September 2010 who underwent excision of bone and soft tissue tumours and had their biopsy sites marked with India ink tattoo. After needle biopsy, one drop of the dye was applied at the site of the biopsy. This was taken up by capillary action beneath the dermis and remained present until the patient returned for their definitive surgery. The biopsy site was easily identifiable by the patients and the operating surgeon in all 36 patients. The mean time between biopsy and surgery was 77 days (range 10–299 days). Tattooing of the skin enabled the surgeon to accurately excise the biopsy tract along with the tumour. We recommend this technique of tattooing of the biopsy site with India ink, as it is safe, easily recognisable and permits accurate excision of the tract (including the tattoo), therefore preventing biopsy tract recurrence.

Bizarre parosteal osteochondromatous proliferation (BPOP), or Nora's lesion, is a rare condition characterised by the formation of surface-based osteocartilaginous lesions typically affecting the hands and feet. 22 cases were identified from the records of a regional bone tumour unit, dating from 1985 to 2009. Of 22 cases, 9 lesions involved the long bones of the hand, 7 the long bones of the feet, 1 case originated from a sesamoid bone of the foot and 5 from long bones (radius, ulna, femur [2] and tibia). Age ranged from 6 to 66 (mean: 31.8) and male to female ratio was 1.8:1. Diagnosis was based on combined radiological and histological features, and initial surgical treatment was excision in 21 cases, and 1 amputation. Follow-up ranged from 12–162 months (mean 32). Recurrence occurred in 6 patients (27%), with mean time to recurrence 49 months (range 10–120). 2 of 8 patients with complete resection margins developed recurrence (25%), versus 4 of 14 with marginal or incomplete resection (28%). Given the potential surgical morbidity inherent in resection, our data suggest that there may be a role for a relatively tissue-conserving approach to the excision of these lesions.

Sacral tumours are rare and can present difficult diagnostic and therapeutic challenges even at an early diagnosis. Surgical resection margins have a reported prognostic role in local recurrence and improved survival. Successful management is achieved within a specialist multidisciplinary service and involves combination chemotherapy, radiotherapy and surgery. We present our experience of patients with sacral tumours referred to our unit, who underwent total and subtotal sacrectomy procedures.

Patients with osteochondrodysplasia frequently require Total Hip Arthroplasty at a younger age, as a result of early degenerative disease of the hip joint. The outcome of Modular Total Hip Arthroplasty in this group of patients has been reported previously. In this retrospective study we evaluated the outcome of custom made (CADCAM) Total Hip Arthroplasty in patients with osteochondrodysplasia.

Between 1974 and 2009, twenty one CADCAM Total Hip Arthroplasty procedures were performed in fourteen patients in our institution. There were eight female and six male patients, with the mean age at time of surgery of 40.95 years (20 to 78). The patients were followed up clinically and with the Harris hip score for a mean of 7.12 years (0.5 to 17 years).

Four of the twenty-one hips (23.8%) required revision surgery at a mean of 11.54 years (6.5 to 17 years); one required it for aseptic loosening of the femoral component; one required complete revision of the acetabular component; one required exchange of acetabular liner; and one was for symptomatic non-union of a lesser trochanter avulsion.

This study shows encouraging clinical outcomes of custom made (CADCAM) Total Hip Arthroplasty in patients with osteochondrodysplasia,

There is very limited literature available on the use of prosthetic replacement in the treatment of primary and secondary tumours of the radius. In the past these were treated with vascularised and non-vascularised autografts which had associated donor site morbidity, problems of non union, graft or junctional fractures and delayed return to function. Our study is a mid to long term follow-up of implant survivorship and the functional outcome of metal prosthetic replacement used for primary and metastatic lesions of radius. We had 15 patients (8 males:7 females) with a mean age of 53 years. 8 patients underwent proximal radial replacement, 2 with mid-shaft radial replacement and 6 patients had distal radial replacements with wrist arthrodesis. The indications for replacement included metastatic lesions from renal cell carcinoma, primary giant cell tumours, ewings' sarcoma, chondroblastoma, radio-ulnar synostosis and benign fibrous histiocytoma. The average follow up was 5 years and 6 months (range 3 months - 18 years). Four patients died as a result of dissemination of renal cell carcinoma and two patients were lost to follow-up. There were no complications with the prosthesis or infection. Clinically and radiographically there was no loosening demonstrated at 18 years with secure fixation of implants. Two patients developed interossoeus nerve palsies which partially recovered. Functional outcomes of the elbow were assessed using the Mayo performance score with patients achieving a mean score of 85 postoperatively (range 65-95). All but one patient had full range of motion of the elbow. The patient with radio-ulnar synostosis had a 25 degree fixed flexion pot-operatively. Although the distal radial replacements had decreased range of movements of the wrist due to arthrodesis, they had excellent functional outcomes. Only one patient required revision surgery due to post-traumatic loosening of the implant. Our results of the use of endoprosthetic replacement of radius in the treatment of tumours are encouraging with regards to survivorship of the implant and functional outcome. This type of treatment results in an early return to daily routine activties, good functional outcome and patient satisfaction.

Giant cell tumours of tendon sheaths have been given multiple denominations due to the uncertain pathologic nature of this lesion. Various contributory factors have been accounted for a wide variation in their recurrence rates. Owing to their high recurrence rates ranging from 9% to 44%, these tumours continue to present with treatment dilemma. There is a lack of consensus regarding how to best manage the balance between extensive dissection and preservation of normal tissues for normal function and recovery versus the risk of recurrence. The authors studied 46 patients with histopathologically confirmed Giant cell tumours over a period of 9 years between 1997 and 2006. The average follow-up in this case series was 35 months. This study aims to analyse the distribution of giant cell tumours of tendon sheaths in hand and our experience with their resection in a District General Hospital with possible predictors associated with recurrence. The referral letters, radiographs, operative and histology records were reviewed. The data was carefully analysed including patients' age and sex at the time of presentation and surgery, presenting symptoms, any associated trauma and the anatomical location of the tumour. A telephonic questionnaire was conducted and the patients with any complications or recurrence were reviewed. Our recurrence rate of 8.6% (4 patients) is lower than previously reported in the literature when the patients did not receive post-operative radiotherapy. Recurrence was seen to be statistically higher in cases where the tumours were excised piecemeal as opposed to removed in one piece and in patients with osseous erosions which were confirmed radiologically and intra-operatively. No atypical mitosis was reported on histology. None of our patients received radiotherapy post-operatively. Other factors including age, size, degenerative joint disease and location within the digit were not confirmed as risk factors in our study. We recommend meticulous surgical technique by an experienced hand surgeon and warning patients of the risk of recurrence if any risk factors were identified.

We describe 22 cases of bizarre parosteal osteochondromatous proliferation, or Nora’s lesion. These are surface-based osteocartilaginous lesions typically affecting the hands and feet. All patients were identified from the records of a regional bone tumour unit and were treated between 1985 and 2009. Nine lesions involved the metacarpals, seven the metatarsals, one originated from a sesamoid bone of the foot and five from long bones (radius, ulna, tibia, and femur in two). The mean age of the patients was 31.8 years (6 to 66), with 14 men and eight women. Diagnosis was based on the radiological and histological features. The initial surgical treatment was excision in 21 cases and amputation of a toe in one. The mean follow-up was for 32 months (12 to 162). Recurrence occurred in six patients (27.3%), with a mean time to recurrence of 49 months (10 to 120). Two of the eight patients with complete resection margins developed a recurrence (25.0%), compared with four of 14 with a marginal or incomplete resection (28.6%).

Given the potential surgical morbidity inherent in resection, our data suggest that there may be a role for a relatively tissue-conserving approach to the excision of these lesions.