There is a paucity of data available for the use of Total Femoral Arthroplasty (TFA) for joint reconstruction in the non-oncological setting. The aim of this study was to evaluate TFA outcomes with minimum 5-year follow-up. This was a retrospective database study of TFAs performed at a UK tertiary referral revision arthroplasty unit. Inclusion criteria were patients undergoing TFA for non-oncological indications. We report demographics, indications for TFA, implant survivorship, clinical outcomes, and indications for re-operation. A total of 39 TFAs were performed in 38 patients between 2015–2018 (median age 68 years, IQR 17, range 46–86), with 5.3 years’ (IQR 1.2, 4.1–18.8) follow-up; 3 patients had died. The most common indication (30/39, 77%) for TFA was periprosthetic joint infection (PJI) or fracture-related infection (FRI); and 23/39 (59%) had a prior periprosthetic fracture (PPF). TFA was performed with dual-mobility or constrained cups in 31/39 (79%) patients. Within the cohort, 12 TFAs (31%) required subsequent revision surgery: infection (7 TFAs, 18%) and instability (5 TFAs, 13%) were the most common indications. 90% of patients were ambulatory post-TFA; 2 patients required disarticulation due to recurrent PJI. While 31/39 (79%) were infection free at last follow-up, the remainder required long-term suppressive antibiotics. This is the largest series of TFA for non-oncological indications. Though TFA has inherent risks of instability and infection, most patients are ambulant after surgery. Patients should be counselled on the risk of life-long antibiotics, or disarticulation when TFA fails.
The aim of this study was to determine the stability of a new
short femoral stem compared with a conventional femoral stem in
patients undergoing cementless total hip arthroplasty (THA), in
a prospective randomized controlled trial using radiostereometric
analysis (RSA). A total of 53 patients were randomized to receive cementless
THA with either a short femoral stem (MiniHip, 26 patients, mean
age: 52 years, nine male) or a conventional length femoral stem
(MetaFix, 23 patients, mean age: 53 years, 11 male). All patients
received the same cementless acetabular component. Two-year follow-up
was available on 38 patients. Stability was assessed through migration
and dynamically inducible micromotion. Radiographs for RSA were
taken postoperatively and at three, six, 12, 18, and 24 months.Aims
Patients and Methods
Short bone-conserving femoral stem implants were developed to achieve more physiological, proximal bone loading than conventional femoral stems. Concerns have arisen, however, that improved loading may be offset by lower primary stability because of the reduced potential area for bony contact. The aim of this study was to determine the primary stability of a novel short femoral stem compared with a conventional femoral stem following cementless total hip arthroplasty (THA), in a prospective, blinded, randomised, controlled trial using radiostereometric analysis.Background
Aims
Endoprosthetic replacement (EPR) is an available option for the management of massive bone loss around failed knee implants. The aim of this study was to determine the results of knee EPRs performed for non-tumour indications. Since 2007, 85 EPRs were performed for in a single tertiary centre by seven surgeons. Mean age at surgery was 73.5 years (range:35–95) with infection as the most common indication (49%), followed by aseptic loosening (18%), complex primary replacement (16%), fracture (15%) and mechanical failure (2%). Mean follow up was 4 years (range:1–9). Functional outcome was determined using the Oxford Knee Score (OKS). At follow-up, 21 patients were deceased and 2 lost to follow-up. Complication rate was 19%. Of the 7 infected cases, 6 were treated with DAIR (debridement, antibiotics, and implant retention) and one underwent above knee amputation. Four of the patients undergoing DAIR were cleared of infection and 2 are on long-term antibiotics. Accounting for implant revision, loss to follow-up and those on long-term antibiotics as failures, 5-year survival was 89% with an average OKS of 25 (SD=10). This mid-term study shows that distal femur EPR is a valuable option for the increasing burden of complex revision knee surgery
The burden of peri-prosthetic joint infection (PJI) following hip and knee surgery is increasing. Endoprosthetic replacement (EPR) is an option for management of massive bone loss resulting from infection around failed lower limb implants. To determine clinical outcome of EPRs for treatment of PJI around the hip and knee joint.Introduction
Aims
A possible solution for the management of proximal femoral bone
loss is a modular femoral endoprosthesis (EPR). Although the outcome
of EPRs in tumour surgery has been well described, the outcome of
their use in revision hip surgery has received less attention. The
aim of this study was to describe the outcome of using EPR for non-neoplastic
indications. A retrospective review of 79 patients who underwent 80 EPRs for
non-neoplastic indications was performed, including the rates of
complication and survival and the mean Oxford Hip Scores (OHS),
at a mean of five years post-operatively. The mean age at the time
of surgery was 69 years (28 to 93) and the mean number of previous operations
on the hip was 2.4 (0 to 17). The most common indications for EPR
implantation were periprosthetic joint infection (PJI) (n = 40),
periprosthetic fracture (n = 12) and failed osteosynthesis of a
proximal femoral fracture or complex trauma (n = 11).Objectives
Methods
The management of proximal femoral bone loss is a significant challenge in revision hip arthroplasty. A possible solution is the use of a modular proximal femur endoprosthesis (EPR). Although the survivorship and functional outcome of megaprostheses used in tumour surgery has been well described, outcome of EPRs used in revision hip surgery has received less attention. The aim of this study was to determine the 5-year outcome following proximal femur EPR and determine factors that influence it. This was a retrospective consecutive case series of all EPRs (n=80) performed for non-neoplastic indications, by 6 surgeons, in our tertiary referral centre, between 2005–2014. Patient demographics and relevant clinical details were determined from notes. The most common indications for the use of EPRs included infection (n=40), peri-prosthetic fracture (n=12) and failed osteosynthesis of proximal femoral fractures/complex trauma (n=11). Outcome measures included complication and re-operation rates, implant survival and assessment of functional outcome using the Oxford-Hip-Score (OHS). The mean age at surgery was 69 years and mean follow-up was 4 (0 – 11) years. The mean number of previous hip operations was 2.4 (range: 0 – 17). Twenty-five patients sustained a complication (31%), the most common being infection (n=9) and dislocation (n=4). By follow-up, further surgery was required in 18 (22%) hips, 9 of which were EPR revisions. 5-yr implant survivorship was 87% (95%CI: 76 – 98%). Mean OHS was 28 (range: 4 – 48). Inferior survival and outcome were seen in EPRs performed for the treatment of infection. Infection eradication was achieved in 34/41 with the index EPR procedure and in 40/41 hips by follow-up. Limb salvage was achieved in all cases and acceptable complication- and re-operation rates were seen. EPRs for periprosthetic fractures and failed osteosynthesis had best outcome. We recommend the continued use of proximal femur EPR in complex revision surgery.
Guidelines for the management of patients with metastatic bone
disease (MBD) have been available to the orthopaedic community for
more than a decade, with little improvement in service provision
to this increasingly large patient group. Improvements in adjuvant
and neo-adjuvant treatments have increased both the number and overall
survival of patients living with MBD. As a consequence the incidence
of complications of MBD presenting to surgeons has increased and
is set to increase further. The British Orthopaedic Oncology Society
(BOOS) are to publish more revised detailed guidelines on what represents
‘best practice’ in managing patients with MBD. This article is designed
to coincide with and publicise new BOOS guidelines and once again
champion the cause of patients with MBD. A series of short cases highlight common errors frequently being
made in managing patients with MBD despite the availability of guidelines.Objectives
Methods
In May 2012, in airports across the globe, seven
orthopaedic surgeons bravely said goodbye to their loved ones, and
slowly turned towards their respective aircraft. Filled with expectation
and mild trepidation they stepped into the unknown… the ABC fellowship
of 2012.
Hip arthroscopy is a relatively new procedure and evidence to support its use remains limited. Well-designed prospective clinical trials with long-term outcomes are required, but study design requires an understanding of current practice. Our aim was to determine temporal trends in the uptake of non-arthroplasty hip surgery in England between 2001 and 2011. Using procedure and diagnosis codes, we interrogated the Hospital Episode Statistics (HES) Database for all hip procedures performed between 2001 and 2011, excluding those relating to arthroplasty, tumour or infection. Osteotomy procedures were also excluded.Introduction
Methods
Segmental excision of long-bone sarcomas can require complex reconstruction, often resulting in the use of prosthetic replacements at a young age. The use of vascularised free fibula grafting (VFFG) is well established as a reconstruction modality in sarcoma surgery. To analyse the experience of two European sarcoma centres and their use of vascularised free fibula grafting as a primary and revision procedure in limb salvage for diaphyseal long-bone defects in sarcoma surgery. A retrospective analysis was carried out of 70 consecutive patients undergoing VFFG between 1996 and 2009 under the Oxford Sarcoma Service (Nuffield Orthopaedic Centre) and the Dutch Orthopaedic Tumour Society (Leiden University Hospital). Clinical and radiological assessments were made and functional outcome scores collected.Aims
Methods
Delays to diagnosis and management of soft tissue sarcomas are preventable but still occur. The introduction of a referral proforma to the Thames Valley Cancer Network in 2005 and National guidelines in 2006 aimed to decrease the incidence of partially and inadequately managed soft tissue sarcomas. This study aims to assess referrals for partially or inadequately managed soft tissue sarcomas and their subsequent management. A prospective analysis of all patients referred to the Oxford Sarcoma Service following inadvertent excision of a soft tissue sarcoma between January 2010 and August 2011 was carried out. Pre-operative investigation and subsequent secondary managements were recorded. Patients with a diagnosis of dermatofibrosarcoma protuberans were excluded.Aims
Methods
Since the introduction of 3rd generation Metal-on-Metal-Hip-Resurfacing-Arthroplasty (MoMHRA), thousands of such prostheses have been implanted worldwide in younger patients with end-stage hip osteoarthritis. However, no independent centre has reported their medium-to-long term outcome. The aim of this study is to report the ten year survival and outcome of the Birmingham Hip Resurfacing (BHR), the most commonly used MoMHRA worldwide. Since 1999, 648 BHRs were implanted in 555 patients, the majority of which were male (326). The mean age at surgery was 52.1years (range: 17–82), with primary OA as most common indication (85%). Mean follow up was 7.1years (range: 1–11). The Oxford Hip Score (OHS) and UCLA questionnaires were sent to all patients. Implant survival was established, with revision as the end point. Sub-analysis was performed by gender, femoral component size (small: <45mm, standard: 46–52, large: >53mm) and age at surgery (young:<50yrs, old:>50yrs).Introduction
Methods
Tissue diagnosis is essential to direct the definitive management of a suspected soft tissue or bone sarcoma tissue. Knowledge of both the diagnostic yield and accuracy of core needle biopsies is therefore important to give the investigating team information on the likelihood of their initial investigations achieving a diagnosis. This is a retrospective study of patients referred to a specialist orthopaedic centre for investigation of a suspected soft tissue or bone sarcoma. Details of all core needle biopsies performed in a 13-month period were obtained from the hospital database. We defined a diagnostic biopsy as either a specific tissue diagnosis or a biopsy that decided the definitive management of the patient, specifically if malignancy was excluded and no further intervention was required, to calculate the diagnostic yield. Diagnostic accuracy was established by comparing histological diagnosis at biopsy to that at final excision.Introduction
Methods
General Practitioners will be confronted with a sarcoma rarely in their working lives. Most will never see a bone sarcoma although most will see at least one soft tissue sarcoma. Guidelines designed to lead to earlier diagnosis of the most common cancers were introduced by NICE in 2000 and were updated in 2005, containing basic guidance on the earlier diagnosis of bone and soft tissue tumours. Referral criteria include: masses greater than 5cm in diameter, masses deep to fascia, masses which are fixed or immobile, masses which are painful, those which are increasing in size and recurrence after previous excision We examined 350 General Practitioner referrals over the past 3 years to our service and examined the correlation between the above criteria and the likelihood of malignancy.Introduction
Methods
Primary soft tissue sarcomas of the extremities are uncommon. Many such lesions will present to specialists in other clinics such as specialist Hand or Foot and Ankle clinics. Many are of a small size at presentation and may appear to be alternate, more common pathology. We collected data from all those patients with acral soft tissues sarcomas and referred to the Oxford Sarcoma Service, Nuffield Orthopaedic Centre, Oxford over a thirteen year period from 1997 – 2010. Data were collected regarding the primary suspected diagnosis, the final diagnosis, the referral route and whether patients had undergone previous inadvertent excision.Introduction
Methods
A GP may only encounter one sarcoma in their professional career. Early diagnosis and treatment will improve the outcomes of this rare and malignant disease. Guidelines designed to lead to earlier diagnosis of the most common cancers were introduced by NICE in 2000 and were updated in 2005. These advise and assist in the early referral of potential bone and soft tissue sarcoma. Prior to 2000 only ~10% of GP referrals were proven to be malignant. In a referral region of ∼3m, we reviewed the referral patterns of suspected sarcoma by General Practitioners since 2005 in an effort to determine whether the published NICE guidelines had influenced an improvement in the diagnosis and management of malignant disease.Introduction
Methods
Our Unit has been treating large volume soft tissue sarcomas involving the sciatic nerve with epineurectomy for over a decade. The aim of this study was to quantify the functional outcome of patients who were known to have sciatic nerve involvement pre-operatively and went on to have nerve preserving surgery utilising a planned marginal excision with epineurectomy. 20 patients with soft tissue sarcomas involving the sciatic nerve were studied treated between 1997 and 2010. Nineteen underwent surgery with extended epineurectomy of the sciatic nerve and planned marginal excision. All patients underwent staging and follow up at our Sarcoma Clinic with functional assessment and TESS evaluation.Introduction
Methods
A case series with functional and radiographic outcomes, of modular endoprosthetic distal femoral replacement in complex cases of periprosthetic fracture. Sixteen cases were identified of endoprosthetic replacement (EPR) from the bone and soft tissue cancer implant registry. A retrospective review was undertaken.Aim
Method
Metal on metal hip resurfacing (MMHR) is a popular procedure for the treatment of osteoarthritis in young patients. Several centres have observed masses, arising from around these devices, we call these inflammatory pseudotumours. They are locally invasive and may cause massive soft tissue destruction. The aim of this study was to determine the incidence and risk factors for pseudotumours that are serious enough to require revision surgery. In out unit, 1,419 MMHRs were performed between June 1999 and November 2008. All revisions were identified, including all cases revised for pseudotumour. Pseudotumour diagnosis was made by histological examination of samples from revision. A Kaplan-Meier survival analysis was performed, Cox regression analysis was used to estimate the independent effects of different factors. The revision rate for pseudotumour increased with time and was 4% (95% CI: 2.2% to 5.8%) at eight years. Female gender was a strong risk factor: at eight years the revision rate for pseudotumours in men was 0.5% (95% CI 0% to 1.1%), in women over 40 it was 6% (95% CI 2.3% to 10.1%) and in women under 40 it was 25% (95% CI 7.3% to 42.9%) (p<
0.001). Other factors associated with an increase in revision rate were, small components (p=0.003) and dysplasia (p=0.019), whereas implant type was not (p=0.156). We recommend that resurfacings are undertaken with caution in women, especially those younger than 40 years of age, but they remain a good option in men. Further work is required to understand the patho-aetiology of pseudotumours so that this severe complication can be avoided.
For the whole cohort, there was no significant difference in ion levels (Cr: p=0.092. Co=0.075) between cups positioned within Z3 (n=58) versus those outside (n=46 mean). Male patients with cups within Z3 (n=27) had lower ion levels in comparison to those outside Z3, which were significantly lower for Co (p=0.049) but not Cr (p=0.084). Female patients had similar levels within and out of Z3 for both ions (Cr: p=0.83, Co: p=0.84). However, patients with cups within Z1 (n=13) had significantly lower Co (p=0.005) and Cr (p=0.001) than those outside Z1 (n=95). Interestingly, Co levels were significantly lower in Z1 (n=13) in comparison to Z2 (n=33) (p=0.048) but Cr levels were not different (p=0.06).
Although originally designed to aid the management of primary malignant bone tumours, the indications for modular endoprosthetic replacement (EPR) have expanded to include complex periprosthetic fractures and failed internal fixation. The incidence of these challenging cases is increasing with an aged population. We reviewed retrospectively our experience with the use of EPR in patients who had undergone limb salvage following complex trauma presentations. Between 2003 and 2008 twenty one patients underwent EPR following referral to the Oxford Sarcoma Service following lower limb trauma. The average age was 71 years (44–87). The average number of previous surgical procedures was 3 (range 0–11). The mean Harris Hip Score was 89.5 (range 64–85). The mean American Knee Society Score was 82 (range 62–100) and the mean functional score was 62 (range 30–75). Complications included two cases of deep infection; one resulted in a two stage revision procedure, while the other retained the EPR following a washout. EPR is an effective salvage procedure for failed trauma fixation and periprosthetic fractures. Immediate weight bearing and a good functional outcome can be expected in this difficult group of patients.
to determine the prevalence of asymptomatic pseudotumours after MoMHRA; and to measure Co and Cr ion levels as well as lymphocyte proliferation responses to Ni, Co and Cr (the principal elements in the CoCr alloy used in MoMHRA) in MoMHRA patients with and without asymptomatic pseudotumours.
Metal Ion Levels – The presence of pseudotumour was associated with significantly higher median serum cobalt levels (9.2mg/L vs. 1.9mg/L, p<
0.001), chromium levels (12.0mg/L vs. 2.1mg/L, p<
0.001), hip aspirate cobalt levels (1182 mg/L vs. 86.2mg/L, p=0.003), and aspirate chromium levels (883mg/L vs. 114.8mg/ L, p=0.006), as well as with inferior functional scores (OHS 41 vs. 47 p<
0.001). There was no significant difference in acetabular cup inclination angle (p=0.51). Lymphocyte Reactivity: A higher incidence and level of enhanced lymphocyte reactivity to Ni (p=0.001), but not to Co or Cr (the principal elements in the CoCr alloy used in metal-on-metal hip resurfacing implants), was found in patients with MoMHRA compared to the patients without MoM implants. However, lymphocyte reactivity to Co, Cr and Ni did not significantly differ in patients with pseudotumours compared to those patients without pseudotumours. Conclusion: The prevalence of asymptomatic pseudotumours in females was high, especially in females with bilateral MoMHRA implants (30%). The patients with ‘asymptomatic’ pseudotumours were in fact mildly symptomatic. Lymphocyte reactivity to Co, Cr and Ni did not differ in patients with pseudotumour compared to those patients without pseudotumours, suggesting that systemic hypersensitivity type IV reactions, mediated by lymphocyte reactivity to these metals, is not the dominant mechanism in pathogenesis of the soft tissue pseudotumours. Furthermore, pseudotumours were not detected in those patients who had normal levels of cobalt and chromium ions. This suggests that pseudotumours do not occur if MoM articulations are well functioning. Therefore, pseudotumours are likely to be a biological consequence of the large amount of metal debris generated in vivo due to excessive wear.
It is advised that lumps which are greater than 5cm should be referred to a sarcoma centre for management and that small lesions cause less harm with unplanned excision.
Of the hand patients 7 of the 10 patients had wide excision of the lesion with 3 an amputation. 5 of the cases were for inadequate previous excision (50%). 7 of the 17 in the foot and ankle group underwent amputation (41%) the rest wide excision. 29% of cases were for second time surgery due to inadequate previous excision.
Tribological studies of hip arthroplasty suggest that larger diameter metal-on-metal (MOM) articulations would produce less wear than smaller diameter articulations. Other advantages using these large femoral heads implants include better stability with lower dislocation rates and improved range of motion. The aim of the present study was to compare chromium (Cr), cobalt (Co) and titanium (Ti) ion concentrations up to 1-year after implantation of different large diameter MOM total hip arthroplasty (THA).
Statistical group comparison revealed significant difference for Cr (p=0.006), Co (p=0.047) and Ti (p=<
0.001). With Biomet implants presenting the best results for Cr and Co and Zimmer the highest Ti level.
Metal on Metal Hip Resurfacing Arthroplasty (MoMHRA) has gained popularity due to its perceived advantages of bone conservation and relative ease of revision to a conventional THR if it fails. Known MoMHRA-associated complications include femoral neck fracture, avascular necrosis/collapse of the femoral head/neck, aseptic loosening and soft tissue responses such as ALVAL and pseudotumours. This study’s aim was to assess the functional outcome of failed MoMHRA revised to THR and compare it with a matched cohort of primary THRs.
Pseudotumours are a rare complication of hip resurfacing. They are thought to be a response to metal debris which may be caused by edge loading due to poor orientation of the acetabular component. Our aim was to determine the optimal acetabular orientation to minimise the risk of pseudotumour formation. We matched 31 hip resurfacings revised for pseudotumour formation with 58 controls who had a satisfactory outcome from this procedure. The radiographic inclination and anteversion angles of the acetabular component were measured on anteroposterior radiographs of the pelvis using Einzel-Bild-Roentgen-Analyse software. The mean inclination angle (47°, 10° to 81°) and anteversion angle (14°, 4° to 34°) of the pseudotumour cases were the same (p = 0.8, p = 0.2) as the controls, 46° (29° to 60°) and 16° (4° to 30°) respectively, but the variation was greater. Assuming an accuracy of implantation of ± 10° about a target position, the optimal radiographic position was found to be approximately 45° of inclination and 20° of anteversion. The incidence of pseudotumours inside the zone was four times lower (p = 0.007) than outside the zone. In order to minimise the risk of pseudotumour formation we recommend that surgeons implant the acetabular component at an inclination of 45° (± 10) and anteversion of 20° (± 10) on post-operative radiographs. Because of differences between the radiographic and the operative angles, this may be best achieved by aiming for an inclination of 40° and an anteversion of 25°.
The treatment of acetabular metastases with total hip arthroplasty is technically challenging often with significant loss of structural continuity in the medial wall and roof of the acetabulum, as described by Harrington in 1981 as class III defects. Traditionally the acetabular component is stabilised with Harrington rods but the risk of post-operative complications, especially bleeding is significant. We performed 10 consecutive total hip arthroplasties in patients with metastases involving the acetabulum with Harrington class III defects. The first three patients had acetabular reconstruction with a Kerboull cage, (Stryker Howmedica.) The cage was secured using a combination of screw fixation to the ileum and PMMA cement filling voids behind the cage. A polyethylene acetabular cup is then cemented into the cage. There was concern about the superior fixation using this implant and so the remaining 7 patients were treated using the Graft Augmentation Prosthesis (GAP II), (Stryker How-medica.) This is a titanium reconstruction cage with two superior flanges allowing extensive screw fixation onto the ileum. Two patients had very large defects where there was not sufficient support to use this cage alone, so the technique was augmented with Harrington rods. No implants have failed to date. One patient, an 83 year old female, died 23 days post-operatively after suffering a stroke. Two patients died of their disease 95 and 115 days after surgery. The remaining patients continue to have good pain and mobility following surgery as demonstrated by the Oxford hip score. We conclude that in suitable patients with extensive metastatic involvement of the acetabulum, a flanged acetabular reconstruction cage prosthesis is much improved way of providing support for a total hip replacement. This procedure can greatly improve quality of life, and to date we have had no mechanical failures of fixation using this technique.
We report on a group of 20 metal-on-metal resurfaced hips (17 patients) presenting with a soft tissue mass associated with various symptoms. We describe these masses as pseudotumours. All patients underwent plain radiography and fuller investigation with CT, MRI and ultrasound. Where samples were available, histology was performed. All patients in this series were female. Presentation was variable; the most common symptom was pain or discomfort in the hip region. Other symptoms included spontaneous dislocation, nerve palsy, an enlarging mass or a rash. The common histological features were extensive necrosis and lymphocytic infiltration. Fourteen of the 20 cases (70%) have so far required revision to a conventional hip replacement and their symptoms have either settled completely or improved substantially since the revision surgery. Two of the three bilateral cases have asymptomatic pseudotumours on the opposite side. We estimate that about 1% of patients develop a pseudotumour in the first five postoperative years after a hip resurfacing. The cause of these pseudotumours is unknown and is probably multi-factorial, further work is required to define this; they may be manifestations of a metal sensitivity response. We are concerned that with time the incidence of these pseudotumours will increase.
We report 17 patients (20 hips) in whom metal-on-metal resurfacing had been performed and who presented with various symptoms and a soft-tissue mass which we termed a pseudotumour. Each patient underwent plain radiography and in some, CT, MRI and ultrasonography were also performed. In addition, histological examination of available samples was undertaken. All the patients were women and their presentation was variable. The most common symptom was discomfort in the region of the hip. Other symptoms included spontaneous dislocation, nerve palsy, a noticeable mass or a rash. The common histological features were extensive necrosis and lymphocytic infiltration. To date, 13 of the 20 hips have required revision to a conventional hip replacement. Two are awaiting revision. We estimate that approximately 1% of patients who have a metal-on-metal resurfacing develop a pseudotumour within five years. The cause is unknown and is probably multifactorial. There may be a toxic reaction to an excess of particulate metal wear debris or a hypersensitivity reaction to a normal amount of metal debris. We are concerned that with time the incidence of these pseudotumours may increase. Further investigation is required to define their cause.
We report the clinical, radiographic and histologic features of these cases.
There were no infections in this series. Three subjects required revision surgery.
This study suggests that resurfacing arthoplasty can also induce a local hypersensitivity reaction in response to metal wear debris. It therefore raises new concerns regarding the long-term safety of this procedure.
The identified patients had their notes reviewed, and were contacted by post to complete a Toronto Extremity Severity Score (TESS) questionnaire to assess lower limb function in day-to-day life. Details of their presenting features, oncological work-up, surgical intervention and adjuvant therapy was established and correlated to the TESS score.
The ipsilateral and contralateral fibulae have been used as a vascularised bone graft for loss of tibial bone usually by methods which have involved specialised microvascular techniques to preserve or re-establish the blood supply. We have developed a method of tibialisation of the fibula using the Ilizarov fixator system, ipsilateral vascularised fibular transport (IVFT), and have used it in five patients with massive loss of tibial bone after treatment of an open fracture, infected nonunion or chronic osteomyelitis. All had successful transport, proximal and distal union, and hypertrophy of the graft without fracture. One developed a squamous-cell carcinoma which ultimately required amputation of the limb. The advantage of IVFT is that the fibular segment retains its vascularity without the need for microvascular dissection or anastomoses. Superiosteal formation of new bone occurs if the tibial periosteal bed is retained. Other procedures such as corticotomy and lengthening can be carried out concurrently.