Introduction

Following bone tumour resection, lower limb reconstruction results in leg-length discrepancy in skeletally immature patients. Previously, minimally invasive endoprostheses have been associated with a high risk of complications including joint stiffness, nerve injury, aseptic loosening and infection. The purpose of this study was to examine the outcome of the Stanmore non-invasive extendible endoprostheses used in our institution between 2002 and 2009 and compare them with implants used in the past.

Introduction

The proximity of the superior tibiofibular articulation to neurovascular structures makes the management of extraosseous tumours of the proximal fibula challenging in bone tumour surgery. The aim of study is to establish whether the recurrence rates are higher in this anatomical area compared to data that already exists in publication for bone tumours throughout the appendicular skeleton.

Introduction

Primary bone tumours of the distal radius are rare, while it remains the third commonest site for primary lesions and recurrences of Giant Cell Tumours (GCT). The functional demands on the hand make reconstruction of the wrist joint following the excision of distal radius, particularly challenging.

Sixty eight consecutive patients underwent proximal humeral replacement with a fixed fulcrum massive endoprosthesis for tumour between 1997 and 2007. The mean age was 46 years (7-87). Ten patients were lost to follow up and 16 patients died. The 42 surviving patients were assessed using the Musculoskeletal Tumour Society (MSTS) Score and the Toronto Extremity Salvage Score (TESS). The mean MSTS score was 72.3 % and the mean TESS was 77.2 %.

Four of 42 patients received a new constrained humeral liner to reduce the risk of dislocation. This sub group of 4 patients had a mean MSTS score of 77.7 % and a mean TESS of 80.0%.

Endoprosthetic replacement for tumour of the proximal humerus using this prosthesis is a reliable operation yielding good functional results without the documented problems of unconstrained prostheses. The performance of this prosthesis is expected to improve further with the new constrained humeral liner.

Non-invasive expandable prostheses for limb salvage tumour surgery were first used in 2002. These implants allow ongoing lengthening of the operated limb to maintain limb-length equality and function while avoiding unnecessary repeat surgeries and the phenomenon of anniversary operations.

A large series of skeletally immature patients have been treated with these implants at the two leading orthopaedic oncology centres in England (Royal National Orthopaedic Hospital, Stanmore, and Royal Orthopaedic Hospital, Birmingham).

An up to date review of these patients has been made, documenting the relevant diagnoses, sites of tumour and types of implant used. 87 patients were assessed, with an age range of 5 to 17 years and follow up range of up to 88 months.

Primary diagnosis was osteosarcoma, followed by Ewing's sarcoma. We implanted distal femoral, proximal femoral, total femoral and proximal tibial prostheses. All implants involving the knee joint used a rotating hinge knee. 6 implants reached maximum length and were revised. 8 implants had issues with lengthening but only 4 of these were identified as being due to failure of the lengthening mechanism and were revised successfully. Deep infection was limited to 5% of patients.

Overall satisfaction was high with the patients avoiding operative lengthening and tolerating the non-invasive lengthenings well. Combined with satisfactory survivorship and functional outcome, we commend its use in the immature population of long bone tumour cases.

The aim of this study is to investigate whether Metal-on-Metal (MoM) implants result in more chromosome aberrations and increased blood metal ions post-operatively when compared to Metal-on-Polyethylene (MoP) implants. Metal-on-metal arthroplasties are being inserted in increasing numbers of younger patients due to the increased durability and reduced requirement for revision in these implants. Recent studies have raised many concerns over possible genotoxicity of MoM implants. This is a prospective study of patients who have undergone elective total hip replacement, they were selected and then randomised into two groups. Group A received a MoP implant and group B received a MoM implant. Patients are reviewed pre-operatively (control group), at 3 months, 6 months, 1 year and 2 years post-operatively. On each occasion blood tests are taken to quantify metal ion levels (chromium, cobalt, titanium, nickel and vanadium) using HR-ICPMS method and chromosome aberrations in T lymphocytes using 24 colour fluorescent in situ hybridisation (FISH). 53 patients have been recruited to date. 24 of whom had MoP prosthesis and 29 a MoM. 37 of these have had their one year follow-up with blood analysis and 14 have had 2 year follow up. Cobalt and chromium concentration increased during the first 6 months in both MoM and MoP groups, in the MoM group the chromium levels were twice that of MoP group and 12x that of the preoperative samples. Chromosome aberrations occurred in both groups. At 6 months both the MoM and MoP groups showed increase frequency of aneuploidy aberrations with further increases after one year. Structural damage in the form of translocations occurred in the MoM group after one year, but not in the MoP group, by two years there was a profound increase in translocations Preliminary results of this study show that the levels of chromium and cobalt are significantly higher in the MoM group compared to the MoP group. This corresponds to increases in chromosome aberrations in the groups with increases in structural chromosome damage after two years.

Polymethyl methacrylate spacers are commonly used during staged revision knee arthroplasty for infection. In cases with extensive bone loss and ligament instability, such spacers may not preserve limb length, joint stability and motion.

We report a retrospective case series of 19 consecutive patients using a custom-made cobalt chrome hinged spacer with antibiotic-loaded cement. The “SMILES spacer” was used at first-stage revision knee arthroplasty for chronic infection associated with a significant bone loss due to failed revision total knee replacement in 11 patients (58%), tumour endoprosthesis in four patients (21%), primary knee replacement in two patients (11%) and infected metalwork following fracture or osteotomy in a further two patients (11%). Mean follow-up was 38 months (range 24–70). In 12 (63%) patients, infection was eradicated, three patients (16%) had persistent infection and four (21%) developed further infection after initially successful second-stage surgery. Above knee amputation for persistent infection was performed in two patients.

In this particularly difficult to treat population, the SMILES spacer two-stage technique has demonstrated encouraging results and presents an attractive alternative to arthrodesis or amputation.

When performing limb salvage operations for malignant bone tumours in skeletally immature patients, it is desirable to reconstruct the limb with a prosthesis that can be lengthened without surgery at appropriate intervals to keep pace with growth of the contra-lateral side. We have developed a prosthesis that can be lengthened non-invasively. The lengthening is achieved on the principle of electromagnetic induction.

The purpose of this study was to look at our early experience with the use of the Non Invasive Distal Femoral Expandable Endoprosthesis. A prospective study of 17 skeletally immature patients with osteosarcoma of the distal femur, implanted with the prosthesis, was performed at the Royal National Orthopaedic Hospital, Stanmore. The patients were aged between 9 and 15 years (mean 12.1 years) at the time of surgery. Patients were lengthened at appropriate intervals in outpatient clinics. Patients were functionally evaluated using the Musculoskeletal Tumour Society (MSTS) Scoring System and the Toronto Extremity Severity Score (TESS). Average time from the implantation to the last follow-up was 18.2 months (range 14-30 months). The patients have been lengthened by an average of 25mm (4.25-55mm). The mean amount of knee flexion is 125 degrees. The mean MSTS score is 77% (23/30; range 11-29) and the mean TESS score is 72%. There have been two complications: one patient developed a flexion deformity of 25 degrees at the knee joint and one patient died of disseminated metastatic malignancy.

The early results from patients treated using this device have been encouraging. Using this implant avoids multiple surgical procedures and general anaesthesia. This results in low morbidity, cost savings and reduced psychological trauma. We do need additional data regarding the long-term structural integrity of the prosthesis.

Background

Endoprosthetic reconstruction is an established method of treatment for primary bone tumours in children. Traditionally these were implanted with cemented intramedullary fixation. Hydroxyapatite collars at the shoulder of the implant are now standard on all extremity endoprostheses, but older cases were implanted without collars. Uncemented intramedullary fixation with hydroxyapatite collars has also been used in an attempt to reduce the incidence of problems such as aseptic loosening. Currently there are various indications that dictate which method is used.

Recurrence of back or leg pain after discectomy is a well-recognised problem with an incidence of up to 28%. Once conservative measures have failed, several surgical options are available and have been tried with varying degrees of success. In this study, 42 patients with recurrent symptoms after discectomy underwent less invasive posterior lumbar interbody fusion (LI-PLIF). Clinical outcome was measured using the Oswestry Disability Index (ODI), Short Form 36 (SF-36) questionnaires and visual analogue scales for back (VAS-BP) and leg pain (VAS-LP). There was a statistically significant improvement in all outcome measures (p < 0.001). The debate around which procedure is the most effective for these patients remains controversial.

Our results show that LI-PLIF is as effective as any other surgical procedure. However, given that it is less invasive, we feel that it should be considered as the preferred option.

Metal-on-metal arthroplasties are being inserted in increasing numbers of younger patients due to the increased durability and reduced requirement for revision in these implants. Recent studies have raised many concerns over possible genotoxicity of MoM implants. This is a prospective study of patients who have undergone elective total hip replacement, they were selected and then randomised into two groups. Group A received a MoP implant and group B received a MoM implant. Patients are reviewed pre-operatively (control group), at 3 months, 6 months, 1 year and 2 years post-operatively. On each occasion blood tests are taken to quantify metal ion levels (chromium, cobalt, titanium, nickel and vanadium) using HR-ICPMS method and chromosome aberrations in T lymphocytes using 24 colour fluorescent in situ hybridisation (FISH).

Fiffty three patients have been recruited to date, 24 of whom had MoP prosthesis and 29 a MoM. 25 of these have had their one-year follow-up with blood analysis. Cobalt and chromium concentration increased during the first 6 months in both MoM and MoP groups, in the MoM group the chromium levels were twice that of MoP group and 12x that of the preoperative samples. There was no difference with the levels of titanium, nickel and vanadium. Chromosome aberrations occurred in both groups. At 6 months both the MoM and MoP groups showed increase frequency of aneuploidy aberrations with further increases after one year. Structural damage in the form of translocations occurred in the MoM group after one year, but not in the MoP group.

Preliminary results of this study show that the levels of chromium and cobalt are significantly higher in the MoM group compared to the MoP group. This corresponds to increases in chromosome aberrations between the groups particularly in translocations present in the MoM group at 1 year.

Non-invasive expandable prostheses for limb salvage tumour surgery were first used in 2002. These implants allow ongoing lengthening of the operated limb to maintain limb-length equality and function while avoiding unnecessary repeat surgeries and the phenomenon of anniversary operations.

A large series of skeletally immature patients have been treated with these implants at the two leading orthopaedic oncology centres in England (Royal National Orthopaedic Hospital, Stanmore, and Royal Orthopaedic Hospital, Birmingham).

An up to date review of these patients has been made, documenting the relevant diagnoses, sites of tumour and types of implant used. 74 patients were assessed, with an age range of 7 – 16 years and follow up range of 4 – 88 months.

We identified five problems with lengthening. One was due to soft tissue restriction which resolved following excision of the hindering tissue. Another was due to autoclaving of the prosthesis prior to insertion and this patient, along with two others, all had successful further surgery to replace the gearbox. Another six patients required mechanism revision when the prosthesis had reached its maximal length. Complications included one fracture of the prosthesis that was revised successfully and six cases of metalwork infection (two of which were present prior to insertion of the implant and three of which were treated successfully with silver-coated implants). There were no cases of aseptic loosening.

Overall satisfaction was high with the patients avoiding operative lengthening and tolerating the non-invasive lengthenings well. Combined with satisfactory survivorship and functional outcome, we commend its use in the immature population of long bone tumour cases.

Between 1997 and 2007, 68 consecutive patients underwent replacement of the proximal humerus for tumour using a fixed-fulcrum massive endoprosthesis. Their mean age was 46 years (7 to 87). Ten patients were lost to follow-up and 16 patients died. The 42 surviving patients were assessed using the Musculoskeletal Tumor Society (MSTS) Score and the Toronto Extremity Salvage Score (TESS) at a mean follow-up of five years and 11 months (one year to ten years and nine months). The mean MSTS score was 72.3% (53.3% to 100%) and the mean TESS was 77.2% (58.6% to 100%).

Four of 42 patients received a new constrained humeral liner to reduce the risk of dislocation. This subgroup had a mean MSTS score of 77.7% and a mean TESS of 80.0%. The dislocation rate for the original prosthesis was 25.9; none of the patients with the new liner had a dislocation at a mean of 14.5 months (12 to 18).

Endoprosthetic replacement for tumours of the proximal humerus using this prosthesis is a reliable operation yielding good results without the documented problems of unconstrained prostheses. The performance of this prosthesis is expected to improve further with a new constrained humeral liner, which reduces the risk of dislocation.

Failed Back Surgery Syndrome (FBSS) refers to having persistent back and/or leg pain after one or more surgical procedures aimed at correcting lumbosacral disease. Different modalities including Epidural injections, Spinal cord stimulation, Anterior/Posterior Lumbar Interbody Fusion (ALIF, PLIF) have been described in the literature with varying outcome. Our aim was to review the functional outcome of patients treated with Posterior Lumbar Interbody Fusion for FBSS since June 2000 to December 2006.

This is a retrospective study of prospectively collected data of 25 patients diagnosed with FBSS and treated with PLIF at University Hospital of North Tees. All patients were requested to fill in the Oswestry Disability Index(ODI), Numerical Rating Scale for Back Pain (NRSBP), Numerical Rating Scale for Leg Pain (NRSLP), SF36 pre and post operatively. The scores were analysed using SPSS software for statistical significance.

There were 12 men and 13 women. Mean age was 47.8 years (range 31–76 years). Mean follow up was 24.8 months (range 4 – 63 months). Four of the 25 patients had Post discectomy syndrome while the rest had post laminectomy syndrome. Most common level of surgery was L5/S1 either as a single level or in combination with other levels above. ODI decreased from a pre-op mean of 55.6(range 20–74.1) to 20.6(range 2–54) while VASBP decreased from 6.9 (range 1–9) to 2.2(range 0–6) (p< 0.05) and VASLP decreased from 6.4 (range 3–10) to 2.2 (range 0–7) (p< 0.05). SF36BP scores improved from a mean 26.7 (range 12–37.1) before the surgery to 45 (range 31–62) (p< 0.05) after surgery. 84% of the patients felt that the outcome of the surgery met their expectation and were satisfied with result.

Our results show that PLIF can be offered as a safe and effective for treatment of FBSS.

Non-bacterial osteitis (NBO), a term referring to sterile bone lesions with non-specific histopathological features of inflammation, may be either uni- or multifocal, acute (6 months) or chronic, and recurrent. Only when the condition is chronic, recurrent and multifocal is it appropriate to use the term chronic recurrent multifocal osteomyelitis (CRMO).

We present our clinical experience as the largest reported series of children with NBO to date. Of 41 children (2–16 years) diagnosed with NBO in our institution over the last 6 years, 21 (51%) had recurrent disease and 18 of 41 (44%) had multifocal disease. The most common bones affected were the clavicle, femur and tibia (in order of decreasing prevalence) accounting for 44 (63%) of a total of 70 lesions. Only one individual had SAPHO syndrome and no other patients had evidence of bowel or skin disease. In the absence of evidence for an infective aetiology, we recommend non-steroidal anti-inflammatory agents as first line therapy, and bisphosphonates only in cases of resistant disease.

On the basis of our findings we propose a patient questionnaire and protocol for investigating and managing patients who present to orthopaedic surgeons with NBO. We predict that this will benefit patients with this disorder by providing valuable information about the pathogenesis, clinical outcome and response to treatment. In the future, clarification of the pathogenesis of this disease will undoubtedly help rationalise the therapeutic approach improving both quality of life and outcome for these patients.

Introduction: The aim of this study is to investigate whether MoM implants result in more chromosome aberrations and increased blood metal ions post-operatively when compared to MoP implants.

Large head metal-on-metal articulating surfaces of the hip are being used in increasing numbers of patients for oncological purposes due to the increased stability and reduced dislocation rate. Recent studies have raised many concerns over possible genotoxicity of MoM implants.

Methods: This is a prospective study of patients who have undergone elective total hip replacement. Patients were randomised into two groups (MoP and MoM). Patients are reviewed pre-operatively (control group), at 3 months, 6 months, 1 year and 2 years post-operatively. On each occasion blood tests are taken to quantify metal ion levels (chromium, cobalt, titanium, nickel and vanadium) using HR-ICPMS and chromosome aberrations in T lymphocytes using 24 colour fluorescent in situ hybridisation (FISH).

Results: 24 patients had MoP prosthesis and 29 a MoM. Cobalt and chromium concentration increased during the first 6 months in both MoM and MoP groups, in the MoM group the chromium levels were twice that of MoP group and 12x that of the preoperative samples. There was no difference with the levels of titanium, nickel and vanadium. Chromosome aberrations occurred in both groups. At 6 months both the MoM and MoP groups showed increase frequency of aneuploidy aberrations with further increases after one year. Structural damage in the form of translocations occurred in the MoM group after one year, but not in the MoP group.

Discussion: Results of this study show that the levels of chromium and cobalt are significantly higher in the MoM group compared to the MoP group. This corresponds to increases in chromosome aberrations between the groups particularly in aneuploidy and translocations present in the MoM group at 1 year.

Introduction: Within a study group of 102 consecutive patients diagnosed with chondrosarcoma of the femur, tibia or humerus, an association with previously treated breast cancer was noted. We researched this proposed relationship.

Methods: We retrospectively reviewed the records of all patients diagnosed histologically with chondrosarcoma of the femur, tibia or humerus over a six-year period at a supra-regional bone tumour unit. We identified those patients who had previously been treated for breast cancer.

Results: There were 58 female and 44 male patients. The study group contained six females (10%, mean age 53 years) who had previously been treated for breast cancer, a higher proportion than would be expected. They were referred following identification of a solitary area of increased activity on routine screening with isotope bone scan, presumed to be a solitary bony metastasis. Most (86%) of this breast carcinoma sub-group had developed low-grade bone chondrosarcoma (Trojani grade 0.5-I) and only one case (14%) had developed high-grade chondrosarcoma (Trojani grade II–III).

Discussion: A suspicious long bone lesion on bone scan in a patient with a past medical history of breast cancer must, therefore, not be assumed to be a metastasis without further investigation; the possibility of a chondral lesion should be considered. It is important that patients receive a full multidisciplinary team investigation prior to treatment in order to obtain the correct tissue diagnosis, as the management of these conditions is often different. Our study suggests there may be a relationship between patients previously treated for breast cancer and the development of subsequent chondrosarcoma.

Introduction: Low-grade fibromyxoid sarcoma (LGFMS) is a rare soft tissue neoplasm most commonly presenting in young to middle-aged adults. LGFMS is an indolent tumour with a deceptively benign histological appearance. Local recurrences are not uncommon and tumours can metastasise. The FUS-CREB3L2 gene translocation has been shown to occur commonly in cases of LGFMS. The literature suggests that the FUS-CREB3L2 fusion-gene is a specific marker for LGFMS.

Methods: We report the cytogenetic analysis of 29 LGFMS cases, and clinical outcomes of 21 patients treated surgically between 1998 and 2008 at our regional bone and soft-tissue tumour centre.

Results: The mean age was 45.4 years and mean follow-up 30.1 months. The most common tumour location was the lower limb. There were no cases of local recurrence or metastasis. Fifteen patients (52.2%) were FUS-CREB3L2 translocation-positive, suggesting either that translocation incidence in our series is lower than other studies, or that reverse-transcriptase polymerase chain reaction (PCR) is less sensitive than the literature suggests. Patients testing positive presented at a younger age (38.2 years, compared to 45.6 years), and had larger tumours than their negative counterparts (mean diameter 97.6mm, compared to 65.2mm), although there was no difference in clinical outcome.

Discussion: We conclude that PCR testing for the FUS-CREB3L2 translocation is a useful tool for confirming the diagnosis of LGFMS, but has no role in predicting short-term clinical outcome. It is not necessary to perform wide excision, and marginal margins are adequate. Longer-term follow-up is required to elucidate differences in the long-term clinical outcome between translocation-positive and negative patients.

Introduction: The aim of the study was to review the long-term survival and outcome of 49 consecutive endoprosthetic lower limb diaphyseal replacements undertaken for neoplastic conditions.

Methods: A retrospective review of all femoral and tibial diaphyseal replacements performed between 1990 and 2009 at our specialist bone and soft tissue tumour unit was performed. Minimum follow-up was one year. Joint sparing prostheses were excluded.

Results: 49 femoral (31) and tibial (18) diaphyseal replacements were implanted into 46 patients (31 male, 15 female). Mean age at surgery was 47 years (range 9–79). Surgery was performed for malignancy in 46 cases (97%), of which 41 (89%) were primary bone and soft tissue sarcomas. The predominant pathologies were osteosarcoma (24%), malignant fibrous histiocytoma (14%) and chondrosarcoma (14%). Mean follow-up was 81 months (range 12–221 months). Survival within the follow-up group was 96% at 1 year, 79% at 5 years, and 69% at 10 years. In surviving patients, using revision, recurrence and amputation as endpoints, prosthesis survival was 91% at 1 year, 58% at 5 years, and 33% at 10 years. In total, 13 prostheses underwent revision surgery and there were 3 amputations following diaphyseal replacement. Of these 16 cases, 75% were for aseptic loosening or prosthetic failure, 13% for tumour recurrence, and 13% for infection.

Discussion: Lower limb diaphyseal endoprosthetic replacements are a useful surgical treatment method for patients with malignant neoplastic diaphyseal bone lesions requiring excision and reconstruction. This is both limb salvage and joint-sparing reconstructive surgery.

Introduction: Chondrosarcoma is the second most common primary malignant bone tumour. Distinguishing between grades is not necessarily straightforward and may alter the management of the disease. We evaluated the correlation between the pre-operative needle biopsy and excision biopsy histological grading of chondrosarcoma of the femur, tibia and humerus.

Methods: A consecutive retrospective series of 100 patients with a histological diagnosis of chondrosarcoma made at a supra-regional bone tumour unit was reviewed. Twenty-one patients were excluded because 20 had only excision biopsy, due to radiological confidence in the diagnosis, and one had only the pre-operative biopsy on record, thus this series included 79 available cases. The remaining patients underwent a pre-operative needle biopsy.

Results: In 11 instances, there was a discrepancy in histological grade. Therefore, there was an 86% (68 out of 79) accuracy rate for pre-operative histological grading of chondrosarcoma, based on needle biopsy. However, the accuracy of the diagnostic biopsy to distinguish low-grade from high-grade was 90% (71 out of 79).

Discussion: From this series we conclude that accurate image-guided biopsy is a very useful adjunct in determining histological grade of chondrosarcoma and the subsequent treatment plan. At present, a multidisciplinary approach, comprising experienced Orthopaedic Surgeons, Radiologists and Pathologists offers the most reliable means of accurately diagnosing and grading chondrosarcoma of long bones.