Aims

Most patients with advanced malignancy suffer bone metastases, which pose a significant challenge to orthopaedic services and burden to the health economy. This study aimed to assess adherence to the British Orthopaedic Oncology Society (BOOS)/British Orthopaedic Association (BOA) guidelines on patients with metastatic bone disease (MBD) in the UK.

Aims

Malignancy and surgery are risk factors for venous thromboembolism (VTE). We undertook a systematic review of the literature concerning the prophylactic management of VTE in orthopaedic oncology patients.

Background

Highly porous acetabular components are widely used in revision hip surgery. The purpose of this study is to compare the mid-term survivorship, clinical and radiological outcomes of a hemispherical cup (Stryker Tritanium Revision component) and a peripherally expanded cup (Zimmer TM modular component) in revision hip surgery.

Objectives

All Polyethylene Tibial components in Total Knee Arthroplasty have been in use for some years, studies showing equivalent results to Total Knee Arthroplasty (TKA) with metal-backed Tibial components at 10 years have shown no significant difference between the two on radiostereometric analysis and revision rates[1].

Post operative patient outcome data using standard metal-backed Tibial components is widely reported in the literature. This study is looking at patient outcomes following All-polyethylene tibial component TKA. We hypothesize that using standard patient outcome measures, an improvement comparable with that expected for metal-backed tibial component TKA will be shown with All-polyethylene tibial component TKA.

Introduction: Metastases in multiple myeloma are typically lytic and when non-union occurs it is usually atrophic

Methods: We report a lady of 67 years who was diagnosed with myeloma 9 years previously. She presented with a sudden onset of pain in her right forearm. Plain radiographs demonstrated a lytic lesion typical of multiple myeloma with an undisplaced pathological fracture in her right ulna. The fracture was treated in a short arm cast for 6 weeks and then by mobilisation. The underlying bone deposit was treated subsequently by external beam irradiation.

Results: Nine months later she was re-referred to the orthopaedic oncology service with marked forearm pain particularly on rotation. Radiographs demonstrated a hypertrophic non-union of the pathological fracture with a typical elephant’s hoof appearance. The fracture was stabilised using a Foresight ulnar nail (Smith and Nephew, Warwick, UK).

Discussion: Whilst non-unions in metastatic malignancy are typically atrophic, just occasionally hypertrophic non-unions can occur. Management principles remain the same with stabilisation of the entire bone and early mobilisation being appropriate.

Introduction: Despite the lack of good clinical evidence post operative radiotherapy is standard practice following non radical surgical treatment of skeletal metastases in long bones There is little in the literature about the size of radiation field and whether the whole bone, the nail or just the area of the metastatic deposit should be covered.

Methods: We present two cases where the metastases were treated by intramedullary nailing and were subsequently irradiated. In each case the tip of the intramedullary nail was outside the radiotherapy field.

Results: Subsequent second metastasis formation occurred at the tip of the nail compounded by pathological fracture. Salvage surgery was achieved in one case with a total femoral replacement and in the other by bi-columnar plating of the humerus with cement augmentation.

Discussion: Intramedullary nailing of a metastasis will seed the tumour to the tip of the nail. It is therefore essential that the tip of the nail be included in the radiotherapy field post-operatively as salvage surgery for subsequent pathological fracture is technically demanding. The aim of any surgery for skeletal metastases is that the reconstruction should outlast the patient. Communication between surgeon and radiation oncologist is essential.

Objectives: It is common for breast surgeons to excise impalpable tumours and fine-wire localisation is commonly deployed by breast radiologists to facilitate such surgery. Pre-operative localisation can be achieved using conventional ultrasound but this necessitates co-ordination with the radiology department.

Methods: We have utilised the SonoSite (SonoSite Inc, Bothell, WA) portable ultrasound system available widely in operating theatres for insertion of vascular lines and perineural catheters, for localisation of deep impalpable tumours.

Results: Two patients who had undergone mid-forearm amputations for synovial sarcoma are presented. The first presented with axillary recurrence of his tumour. MRI scanning of his stump revealed two lesions suspicious of recurrence. Both were impalpable initially. The lesions were identified using the SonoSite and excision biopsy performed. Histologically the lesions were neuromata. The second patient had imaging in keeping with neuromata and again the Sonosite was utilised to detect the lesions and facilitate removal.

Discussion: Sonosite portable ultrasound machines are readily available in the operating theatre and may be utilised to aid removal of tumours. They do not replace other imaging but can make surgery less traumatic in that smaller incisions may be used.

The most appropriate protocol for the biopsy of musculoskeletal tumours is controversial, with some authors advocating CT-guided core biopsy. At our hospital the initial biopsies of most musculoskeletal tumours has been by operative core biopsy with evaluation by frozen section which determines whether diagnostic tissue has been obtained and, if possible, gives the definitive diagnosis. In order to determine the accuracy and cost-effectiveness of this protocol we have undertaken a retrospective audit of biopsies of musculoskeletal tumours performed over a period of two years.

A total of 104 patients had biopsies according to this regime. All gave the diagnosis apart from one minor error which did not alter the management of the patient. There was no requirement for re-biopsy. This protocol was more labour-intensive and 38% more costly than CT-guided core biopsy (AU$1804 vs AU$1308). However, the accuracy and avoidance of the anxiety associated with repeat biopsy outweighed these disadvantages.

Bone tumours are not common in the bones of the feet. We reviewed 10 years of referrals to the Leeds regional bone tumour registry between 1990 and 1999 which revealed twenty such tumours accounting for 5% of the total number of 341 bone tumours.

The mean age of the patients was 32 years (range 2 yrs to 80 yrs).

Men were affected more commonly than women (60% versus 40%).

40% affected the tarsal bones, 25% affected the hind foot, and 35 % affected the small tubular bones of the foot.

80% of tumours were benign. Malignant tumours accounted for only 20 % of all foot tumours and of these, 95% were primary tumours and only 5 % were metastases. Malignant tumours were found more frequently in the older population mean age (50 years).

Bone tumour registries offer a reliable source of data to study rare neoplasms in a large population group.

Longer hip axis length (HAL) has been shown to be associated with the risk of hip fracture. We examined whether HAL is associated with hip fracture risk in elderly community dwelling women in England, unselected for osteoporosis.

We undertook a case-controlled study of women aged ≥ 75 years enrolled to a large, randomised controlled study looking at the effect of a bisphosphonate, clodronate, in the prevention of hip fractures. Cases comprised those women who sustained a radiologically verified hip fracture during follow-up (median 3. 1 years). Two age, height and weight-matched controls were selected for each case. Baseline total hip bone mineral density (BMD) was measured using a Hologic 4500 QDR and the HAL was measured using the densitometer’s automated software.

92 of 4347 women (2. 1%) sustained a hip fracture, but two women had not received a baseline BMD assessment and were excluded, leaving 90 women with hip fractures and 180 matched controls.

The mean age of the cases and controls was 81. 9 ± 4. 9 years. The mean hip BMD was significantly lower (0. 65 ± 0. 31 vs 0. 72 ± 0. 13, P< 0. 001) and the mean HAL was significantly longer in the hip fracture women than the controls (11. 1 ± 0. 6 vs 10. 9 ± 0. 6, P=0. 03).

The increase in the HAL was significantly associated with the risk of hip fracture (Odds Ratio (OR) per 1 standard deviation increase was 1. 33, 95% CI 1. 02–1. 72; p=0. 03) remaining significant after adjustment for hip BMD (OR 1. 32, 95% CI 1. 01–1. 71; p=0. 04).

An increase in hip axis length is associated with an increased risk of hip fracture in elderly English women independent of hip BMD, although the odds ratio appears somewhat lower than that reported in other studies.