Contrary to NICE guidance there remains a role for Austin-Moore hemiarthroplasty (AM) for patients with significant pre-existing comorbidities who are at higher risk of death and complications following cemented hemiarthroplasty.

We analysed prospectively-collected data comparing uncemented AM hemiarthroplasty in frail, poorly-mobile patients, and cemented hemiarthroplasty. We analysed age, pre-operative morbidity, duration of operation, death rate and complication rate.

AM patients were significantly older with significantly higher ASA grades. It took significantly longer to optimise them before surgery. AM was significantly shorter to perform. There was no significant difference in complications requiring re-operation. Twice as many AM patients developed post-operative pneumonia despite absence of cement. Twice as many AM patients died after surgery and a significant proportion died within the first month despite no increased risk of repeat operation, shorter operating time and no risk of cement-disease. We infer that these patients would likely have fared badly had they undergone a longer, cemented procedure. A modern cemented prosthesis costs £691 more than AM.

There exists a subset of patients within the neck of femur cohort who are significantly more unwell. Contrary to guidelines, we suggest that the cheaper, user-friendly Austin-Moore can be a reasonable prosthesis to use for this cohort.

Aim

To investigate any intra-operative alteration in management in those patients who had a pre-operative echocardiogram, a retrospective study for one year (March 2004 to February 2005) was carried out at West Middlesex University Hospital.

We attempted to investigate the incidence, the treatment modalities used and the outcome of Osteosarcoma (OS) patients treated at the two major Pediatric Oncology Hospitals in Singapore. A comprehensive list of patients with OS treated at the National University Hospital and KK Women’s and Children’s Hospital Singapore between April 1980 and May 2006 was generated. During the study interval, patients received neoadjuvant chemotherapy followed by definitive surgery consisting of either limb salvage or amputation followed by adjuvant chemotherapy. Chemotherapy was as per the European Osteosarcoma Intergroup (EOI) and as per the Memorial Sloan-Kettering Cancer Center’s (MSKCC) T12 protocols. Treatment of subsequent relapses consisted of various combinations of Methotrexate, ifosfamide, etoposide, other, and/or surgery.

Of the total 49 patients with OS, 30% presented with metastatic OS. Median age of diagnosis of OS was 12.4 years. For the cohort, two and five-year overall survival were 71% and 55% respectively. The two-year overall survival was 73% for patients who were treated as per the MSKCC protocol. At last follow-up, median 4.3 years (range, 0.3 – 21.6 years), 25 were alive with no evidence of disease and 16 were dead of disease.

Survival from OS in Singapore appears to be improving. Rarity and complexity of OS makes it crucial for patients to seek a centralized multi-disciplinary Musculoskeletal Oncology team involving surgeons and Pediatric Oncologists dedicated to the care of these young patients with the intent to cure.

Childhood long-term survivors now experience significant late effects from the primary cancer itself or from therapy. Cisplatin, an alkylating agent used in treatment for osteosarcoma, has been associated with irreversible high-frequency sensorineural hearing loss. There were 27 osteosarcoma patients treated at Department of Pediatrics, National University Hospital from 1997 to 2005. Twelve of these were long-term survivors, i.e. survived more than 2 years from initial diagnosis.

Pre-chemotherapy audiogram was performed in 50% (n=6) of patients and the audiogram results were not available in the remainder (n=6, 50%) as it was either not done or records were not available. Prior to year 2003, Cisplatin was administered at a dose of 100mg/ m2/course (EOI regimen) in 50% of cases, and after year 2003, 120mg/m2/course (T12 regimen) in 45%. Median cumulative dose of cisplatin was 550mg/m2 (cumulative dose range, 240 – 800 mg/m2). Out of 12 patients, 7 patients (58%) experienced cisplatin induced ototoxicity. According to NCI Toxicity Criteria, Grade I ototoxicty was observed in two cases (30%), grade 2 toxicity in five cases (70%), and bilateral sensorineural hearing loss was noted in six of the survivors. One long term survivor required a hearing aid. Six of them had and renal tubulopathy (NCI Toxicity Grade 2) was noted simultaneously in 35% of cases (n=4).

The incidence of cisplatin induced ototoxicity is high in our small series of long-term survivors of osteosarcoma. Baseline pre-chemotherapy testing, close monitoring during treatment and further follow-up are essential for this subset of patients receiving high doses of cisplatin.

The study was funded by Singapore Cancer Syndicate (POU-097)

Childhood cancer survival has increased dramatically over the last 30 years. Childhood Cancer Survivor Study- SG was established to evaluate the outcome and toxicities experienced by long term childhood cancer survivors in Singapore. There were 429 cases of hematological malignancies (HM) and 342 cases of solid tumors (ST) diagnosed and treated at National University Hospital (NUH) Singapore from May 1981 to December 2007.

There were seven long term survivors for Osteosarcoma (OS) out of 26 patients seen during the study period. Median age at diagnosis was 13.8 (range, 6.4–15.8 years) and median follow-up was 7.9 (range, 2.6 – 13.2 years). Cumulative doses of chemotherapy received included: cisplatin (240 – 800 mg/m2); doxorubicin 150 – 450 mg/m2); methotrexate (16 – 144 Grams/m2); ifosfamide (27–80 mg/m2); and etoposide (1000 – 3300 mg/ m2). According to the NCI Criteria for Toxicity (CTC version 2.0), three patients experiences grade 2 sensorineural hearing loss; three cases of grade 1 cardiomyopathy; three cases of grade 1 renal tubulopathy; and six cases of post surgical complications (infection-3, length discrepancy-3, poor fitting prosthesis-2).

Many of the patients did not have baseline pre-treatment evaluations such as audiograms, renal function, echocardiograms and similar proportion were not adequately followed-up post treatment. This is the first analysis and report in the country on treatment related outcome and toxicity in long-term survivors of childhood cancers such as osteosarcoma and other solid tumors. Authors recommend that future treatment protocols for childhood cancer in Singapore should incorporate pre- and post-treatment evaluations and close follow-up of young survivors with establishment of a multi-disciplinary late effects clinic.

Introduction: Ankle fractures are one of the most common injuries treated by the orthopaedic surgeon. The general recommendation is if surgical treatment is not carried out within the first 24 hours from injury, then it should be delayed for about 5–7 days to reduce the risk of wound complications associated with limb swelling. The aim of our study was to see whether timing of surgery affects the relative risk of skin complications following internal fixation of ankle fractures.

Method: We analysed medical records of 102 patients with closed ankle fractures admitted to the orthopaedic department at our hospital between May 2003 and May 2005. The fractures were classified according to the Weber-AO classification. Open reduction and internal fixation was performed according to the techniques of the AO Group.

Results: The mean age of patients was 43 years(range 13–87). According to the AO classification, 3 were type A(A1–3), 77 were type B(B1-16, B2-42, B3-16), 17 were type C(C1-2, C2-11, C3-4), 4 were isolated medial malleolus and 1 was Salter-Harris type 2 fractures. The mean delay before surgery was 3(0–18) days. The mean length of hospital stay was 6(1–44) days. Out of 102 patients, 53 of the patients were operated within 24 hours, 22 were operated from 24–72 hours, 15 within 4 to 7 days and the rest were operated within 7–18 days. The main reasons for delay were either failed initial conservative management or late presentation.

There was one case of superficial wound infection, deep vein thrombosis, neuroma and delayed union of medial malleolus each.

Conclusion: We conclude that for ankle fractures that are not operated on within the initial 24 hours from the injury, delayed treatment could be instituted as soon as patient and limb factors permit and rigid adherence to waiting times of 5–7 days is not necessary.

Introduction: (OCD) is characterized by bone necrosis and softening of the overlying cartilage, which may separate and displace. It is thought to be secondary to trauma, ischaemia or abnormal epiphyseal ossification. Management remains controversial during the early stages of the disease. Surgery for advanced chondral lesions with loose bodies however remains a challenge. Options that include periosteal graft and autologous chondrocyte transplantation have been used with variable degrees of success. This study investigates the efficacy of these techniques and the use of mesenchymal stem cells to treat advanced chondral lesions found in OCD in animal models.

Materials and Methods: A full thickness articular cartilage defect (6mm long, 3mm wide and 1mm deep) was created in the weight-bearing surface of medial femoral condyle in 22-week old NZW rabbits. A total of 90 knees were randomly divided into 3 groups as follows: 1) Transfer of cultured chondrocytes 2) Transfer of cultured periosteum-derived MSCs and 3) Repair by periosteal graft with their contralateral knees as control. The rabbits were allowed to move freely in their cages. The rabbits were sacrificed at 2, 6, 12, 24 and 36 weeks post-operatively. The healing of the defects was assessed by gross examination and histological grading and subjected biomechanical testing.

Results: Gross and histological examination at 36 weeks post operation (Wakitani et al grading), the mean score for Group 1 is 2.5, Group 2 is 2.3 and Group 3 is 4.5 with control group of 8.9 in terms of cell morphology, matrix staining, surface regularity, thickness of repaired cartilage and integration of cartilage to adjacent host. Biomechanically by indentation test, Group1 had value of 0.22 MPa, Group 2 0.20 MPa, Group 3 0.16 MPa and Control group of 0.12 MPa.

Conclusion: The findings suggested that cultured chondrocytes and mesenchymal stem cells had comparable enhancing effect of the repair of chondral defect in advanced OCD