In 2004 the Scottish Sarcoma Network (SSN) was established with the aim of optimising management of patients with sarcoma. Clinical, radiological, oncological and pathological details of all bone and soft tissue sarcomas presenting in Scotland are registered and cases discussed in a multi-centre, tele-link multidisciplinary team (MDT) forum.

The aim of this study was to establish any difference in referral patterns, time to specialist review, preoperative MRI scanning and appropriate biopsy before and after establishment of the Scottish Sarcoma Network in Grampian.

A database was established of all patients presenting with sarcomas of the trunk or extremity in Grampian between 1991 and 2010. One hundred and fifty eight patients were randomly selected, 79 (50%) presenting prior to the establishment of the Scottish Sarcoma Network.

Since the initiation of the Scottish sarcoma network we found that the median time of referral to review by the sarcoma service has improved from 19.5 days to 10 days (P=0.016). There has been an increase in the number of patients referred from other specialities while the number of general practice has remained fairly constant. This has resulted in a slight increase in the median total patient journey from 35 days to 41 days, this does not reach statistical significance.

A greater number of patients are undergoing pre biopsy MRI scan, 53 (67%) before 2004 and 68 (86%) after (P=0.009). More patients are also undergoing appropriate biopsy 45(57%) before the network and 62(79%) after.

The creation of the Scottish Sarcoma Network has had a positive impact on the care of sarcoma patients presenting in Grampian.

Despite advances in Locking Plate (LP) design, distal femoral fractures remain challenging injuries to treat especially in the elderly where approximately 15–30% develop nonunions secondary to failure of fixation.

Aim: To establish the mechanisms of nonunion in our patient population using two different LP systems.

Methods: Between December 2002-May 2008, we prospectively collected data on all 67 patients with distal femoral fractures who were treated using a suitable distal femoral LP (LISS, 35 cases, or Periloc, 32 cases). 72% of the patients were female; ages ranged from 25–94 years (ave. 67 years). Many of our patients had a number of significant co-morbidities.

Results: The presence of significant co-morbities e.g. Rheumatoid arthritis, long term systemic steroid use, cerebrovascular accidents resulting in ambulatory problems, previous major joint arthroplasty including ipsilateral knee replacements, paralysis, and severe dementia, did not appear to influence fracture union significantly. However, old age was strongly correlated with nonunion with all failed cases (7 patients - 10% of the study group) presenting with failure of fixation. 2 of the LP system failures resulted in malunion and the 5 other cases required revision surgery. Of note, all 7 patients were elderly, 6 being over 80 years of age. The mechanism of fixation failure was specific to each of the LP systems. All 4 of the failures treated with LISS, resulted from poor proximal stability as a consequence of unicortical screw fixation. Two patients required to have the proximal fixation revised through the insertion of bicortical screws which subsequently resulted in successful union. The other two patients were treated in long leg casts as the varus deformities were considered acceptable given each patient’s needs. All 3 of the failures who had been treated with a Periloc LP, resulted from fracturing of the plate at the metaphyseo-diaphyseal junction at the level of the main extra-articular component of the fracture. The plates all fractured through the unfilled screw holes, and all 3 patients required revision of fixation to bring about union.

Discussion: The LISS failures can all be attributed to poor proximal fixation that is associated with the use of unicortical screws in osteoporotic bone and confirms the need for bicortical screw fixation. However, modern LP systems manufactured from stainless steel offer increased implant stability that may in turn stress any fracture bridging segments of the LP.

Conclusion: Although we are aware of the importance of bicortical screws in osteoporotic patients, it is also seems likely that excessive plate rigidity should be avoided, by using long plates with well spaced out screws.

Aim: The use of volar plates in the management of distal radius fractures has increased dramatically over the last decade. Our aim was to ascertain if long term outcome could be predicted at clinical review four months following operation.

Patients and Methods: Between January 2003 and January 2005, all patients presenting with unilateral distal radius fractures and treated with volar locking plate fixation (Synthes) were invited to participate in long-term follow up. The decision to use a volar plate and the operative procedure itself was undertaken by the on-call consultant and his team. Patients who agreed to enter the study were evaluated at 4, 6 and 12 months following operation. Patient demographics, hand dominance and fracture type were recorded. Assessment of grip strength and wrist movements were undertaken and expressed as a percentage of the contralateral, uninjured side.

Results: A total of 76 out of 100 eligible patients agreed to participate in the study. Of those patients, 23 (30%) failed to attend all their follow-up appointments, leaving a dataset of 53 patients (70%) available for analysis. There were 28 females (53%) and the mean patient age was 55 years (range 28–83).

Grip strength, pinch grip, wrist flexion, wrist extension, radial deviation, ulnar deviation, pronation and supination all showed graded improvement in the year following fracture, achieving a mean range of 73% to 95% of function compared to the contralateral side at 12 months. Wrist flexion and ulnar deviation showed near maximum improvement by 6 months, whereas the other variables continued to show significant improvement between 6 and 12 months.

Logistic regression analysis suggested that improvement in wrist extension at four months was the best predictor of a good outcome at one year.

Discussion: Use of volar plate fixation is an increasingly common method of managing distal radius fractures. Our study suggests that good functional results can be achieved by this method of treatment. Failure to regain reasonable wrist extension by four months appears to predict higher risk of poor outcome and therefore patients in this group should be followed up more closely.