Study Design: A retrospective case-note study.

Objective: To evaluate causes of delayed admission for patients with spinal injuries.

Subjects: 432 patients admitted between March 1998 and March 2003.

Outcome Measures: Patients were analysed with respect to Injury Severity Score (ISS); date of injury, referral and admission independently and length of hospitalisation. The delays between injury and referral (> 3 days) and between referral and admission (> 7days) were correlated to the length of hospitalisation.

Results: There were 322 males (average age, 38.6 years) and 110 females (average age, 41.8 years), with 108 complete injuries, 115 incomplete and 209 intact. The average time between injury and referral was 5.5 days (range 0–94), and between referral and admission was 10.7 days (range 0–130). 161 patients (37%) experienced a delay between injury and referral, of whom 59 (37%) were subsequently also delayed to admission. The principal reason for delay was the treatment of concurrent injuries. Even patients with complete injuries (15/43) experienced delayed referral. 112 patients (26%) experienced a delay between referral and admission. Principal reasons included the provision of beds and stabilisation of concurrent injuries. We found the delay between referral and admission (p< 0.001), the ISS (p< 0.001) and increasing neurological severity of injury (p< 0.001) to be highly significant factors predisposing to longer hospitalisation.

Conclusions: Delayed admission for patients with spinal injuries is common. Provision of beds being the most common preventable reason for delay following referral. Early liason with a designated spinal injuries unit, especially for patients with cord injury remains vitally important.

Introduction and Aims: Several non-comparative studies for uni-compartmental knee replacement (UKR) and total knee replacement (TKR) have been published, but few provide a direct comparison in well-matched patients. The aim of this study was to assess five-year survivorship and the quality of outcome following UKR and TKR in pre-operatively matched patient groups.

Method: From a prospective database of over 600 patients undergoing knee replacement for osteoarthritis, 70 primary medial Oxford UKRs (62 patients) were matched pre-operatively with 70 primary Kinematic TKRs (68 patients) for age, sex, body mass index, active range of movement (ROM) and Knee Society Score (KSS). The two groups were assessed at six, 18, 36 and 60 months following knee replacement and compared for survivorship of the prosthesis (with failure defined as revision for any reason or ‘worst-case’ assuming all patients lost to follow-up are revised), quality of outcome based on the KSS (reported as separate knee and function score) and the ROM achieved.

Results: Three (4%) patients in the UKR group and two (3%) in the TKR group were unavailable for follow-up at five years. Five-year survivorship (Kaplan-Meier methodology) was significantly different for the two groups using revision for any reason as an endpoint – 90% for UKR, 100% for TKR (log-rank test, p=0.01). Assuming all patients lost to follow-up were revised, the ‘worst-case’ five-year survivorship was also significantly different for the two groups – 85% for UKR, 97% for TKR (log-rank test, p=0.02). Analysis of the KSS at six, 18, 36 and 60 months showed no significant difference between the two groups for the knee score (p=0.48) and the function score (p=0.1). The ROM achieved at five years was greater for the UKR group and the difference was statistically significant (UKR: Least square mean 105 degrees, standard error 1.2; TKR: Least square mean 98 degrees, standard error 1.2, p< 0.001).

Conclusion: In comparable patients with osteoarthritis of the knee, survivorship remains superior for TKR at five years. The ROM achieved is greater for UKR, but there is no difference in the overall quality of outcome following UKR or TKR. We believe that UKR should only be performed in carefully selected cases because mid-term functional outcome is similar following UKR or TKR and the complication rate may be higher for UKR.

Purpose: The purpose of this study was to determine whether the low rate of mechanical loosening of the SMILES rotating hinge distal femoral endoprosthesis relates to the hydroxyapatite (HA)-coated, grooved collar of the femoral component.

Methods and results: A database was used to identify two groups of cases of primary distal femoral replacement with a custom-designed and manufactured SMILES endoprosthesis at our unit; those with the collared femoral component (“collar group”), and those without a collar (“non-collar group”). From these two groups, patients were pair-matched for age and length of bone resection. We performed a retrospective review of serial biplanar pairs of radiographs of each patient, assessing radiolucent lines and extracortical bone pedicle. 11 matched pairs were identified, (14 females, 8 males), with a mean age of 36 years, (range 16–66). The pathology was primary bone tumour in 20 cases, (17 malignant, 3 benign), and metastatic disease in 2 cases. Mean length of follow-up was 85 months, (range 27–122). Radiolucent line score (RLS) progression over time was significantly lower in the collar group, (0.01 vs 0.73, p=0.001) (fig. 1 & 2), as was the mean final RLS, (2.72 vs 7.81, p=0.02). Mean RLS per radiographic quadrant was 0.56 in cases in which a bony pedicle was ingrown onto the prosthesis, (exclusively in the collared-group), 2.41 in cases in which the pedicle was not ingrown, (most prevalent in the non-collared group), and 1.02 in those cases without any pedicle formation, (ANOVA analysis, p=0.0002).

Conclusion: This study demonstrates that the HA-coated, grooved collar significantly reduces the progression of radiolucent lines, and consequently the overall RLS, explaining the reduced rate of mechanical loosening of the SMILES prosthesis. A bony pedicle that does not incorporate onto the prosthesis surface may be associated with an increase in radiographic loosening.

Purpose: To determine the mode of presentation of soft tissue sarcomas to a tertiary centre and the factors associated with a delay in diagnosis and referral.

Methods and Results Between 2000 and 2002, we identified 120 patients with primary soft tissue sarcomas histologically verified at our institution. We reviewed the case histories, referral letters and the histology reports in all cases. The mean age of the study group was 54.5 (range 10 to 91 years). Pathological diagnoses included 32 liposarcomas, 20 malignant fibrous histiocytomas, 19 synovial sarcomas, 12 leiomyosarcomas, 9 fibrosarcomas, 7 spindle cell sarcomas, 4 pleomorphic sarcomas, 3 identified only as high grade soft tissue sarcomas, 3 epithelioid sarcomas, 2 extraosseous Ewing’s sarcomas, 2 malignant round cell tumours and one each of neurofibroma, malignant peripheral nerve sheath tumour, angiosarcoma, alveolar cell sarcoma, extraosseous chondrosarcoma, extraosseous osteosarcoma and clear cell sarcoma of tendon sheath.

Presenting features included a discrete lump or diffuse swelling in 115 patients (95.8%). Pain was not a feature in 69 patients. 3 patients (2.5%) presented with pain alone and 2 patients (1.7%) with varicosities. 116 patients (96.7%) were referred to our unit as a possible soft tissue sarcoma. 4 patients were referred as suspected benign lesions requiring specialist assessment owing to size and location. 46 patients (38.3%) ignored their swelling, resulting in a delay to presentation to their local units. In only 13 patients was pain a feature. These were not considered to be true delayed referrals. 24 patients (20%) experienced a delayed referral to our unit. An alternative diagnosis was suggested in 7 patients by preliminary imaging investigations. A ‘Whoops procedure’ was performed in 14 patients. 3 patients were initially misdiagnosed as muscular injuries, with consequent conservative management resulting in delay.

Conclusion: Soft tissue sarcomas are relatively rare when considered alongside benign soft-tissue lesions. Pain is an infrequent feature, which may result in patients undervaluing their significance and delay their initial presentation to a doctor. Delayed referral is relatively common, although may not always be avoidable. Clinicians should maintain a high level of suspicion when dealing with soft-tissue lesions, with referral to a specialist centre whenever concern exists as to the nature of the lesion.

Purpose: The purpose of this study was to evaluate the results of custom-made endoprosthetic reconstruction for both tumourous and non-tumourous conditions around the elbow joint.

Methods and Results: 28 consecutive cases of endoprosthetic elbow reconstruction, performed between 1989 and 2003, were identified using the unit database. There were 12 males and 16 females, with a mean age of 48.9 years, (range 14–84). There were 16 cases of malignant tumour (10 primary, 6 secondary), 3 cases of benign tumour (one each of giant cell tumour, osteoblastoma and pigmented villonodular synovitis) and 10 non-oncological cases, (5 cases of fracture, 3 failed total elbow replacements and 1 infected synostosis). A distal humeral prosthesis was used in 16 patients, distal humeral and proximal ulna in 10 patients, proximal ulna with a humeral component in one patient and proximal radial replacement in one patient. Clinical and radiographic review of all available patients, including a functional assessment with The Toronto Extremity Salvage (TES) score was undertaken. The average follow-up was 54.9 months (range 5–144). 5 patients with malignancy died of their disease. One patient required amputation for local recurrence at 5 months. There were two revisions at 4 and 7 years for aseptic loosening of the humeral component. Six patients developed deep prosthetic infection at an average of 21 months (range 6–31), necessitating two-stage revision, of which one patient required subsequent excision arthroplasty. There were no cases of permanent nerve palsy. 18 patients (64.3%) were available for functional follow-up. Average flexion deformity was 33 degrees (7–80) and average flexion was 85 degrees (30–133). The mean TES score was 67.8 (range 36.6–96.6). The mean TES score following two-stage revision for infection, (available in 4/5 patients) was 73.9 (range 54.8–91.6).

Conclusion: Custom-made endoprosthetic reconstruction around the elbow joint is effective in a wide range of pathologies, allowing in most cases a reasonable level of function, even following two-stage revision for infection.

Purpose: Dedifferentiated chordomas are a rare and aggressive variant of chordoma. They usually occur in recurrences or following radiotherapy. We describe the rare occurrence of three cases arising de novo within conventional chordoma.

Methods and Results: 29 cases of histopathologically verified chordoma were identified from our unit database. From these, we identified three cases of primary dedifferentiated chordoma. The study group included three men, with an average age of 58.3 years (range 57–61). Presenting features were comparable and included lower back pain and rectal discomfort, with a mass palpable per rectum. A needle biopsy was undertaken in one patient, which demonstrated evidence of a pleomorphic spindle cell tumour without evidence of chordoma. Surgical management involved subtotal sacrectomy, with complete excision achieved in two cases. Histopathological examination confirmed dedifferentiated chordoma with varying amounts of sarcomatous elements in each case. Post-operative radiotherapy was administered in two patients and chemotherapy in one patient. Two patients died at 7 and 10 months following presentation with pulmonary metastases. The third patient remains well and alive at two years follow-up. This patient had a complete excision with post-operative radiotherapy, however histopathological examination revealed only a small focus of the dedifferentiated component.

Conclusions: Dedifferentiated chordoma is a fatal tumour, with metastases and death the likely outcome. Most cases in the literature and the two cases reported in this series, uphold this ominous prognosis. However this may not always hold true. Small areas of dedifferentiation within the chordoma tumour may carry a more favourable prognosis.