The primary treatment goal for patients with femoroacetabular impingement syndrome, a common hip condition in athletes, is to improve pain and function. In selected patients, in the short term following intervention, arthroscopic hip surgery is superior to a pragmatic NHS- type physiotherapy programme. Here, we report the three-year follow-up results from the FemoroAcetabular Impingement Trial (FAIT), comparing arthroscopic hip surgery with physiotherapy in the management of patients with femoroacetabular impingement (FAI) syndrome.

Two-group parallel, assessor-blinded, pragmatic randomised controlled study across seven NHS England sites. 222 participants aged 18 to 60 years with FAI syndrome confirmed clinically and radiologically were randomised (1:1) to receive arthroscopic hip surgery (n = 112) or physiotherapy and activity modification (n = 110). We previously reported on the hip outcome score at eight months. The primary outcome measure of this study was minimum Joint Space Width (mJSW) on Anteroposterior Radiograph at 38 months post randomisation. Secondary outcome measures included the Hip Outcome Score and Scoring Hip Osteoarthritis with MRI (SHOMRI) score.

Minimum Joint Space Width data were available for 101 participants (45%) at 38 months post randomisation. Hip outcome score and MRI data were available for 77% and 62% of participants respectively. mJSW was higher in the arthroscopy group (mean (SD) 3.34mm (1.01)) compared to the physiotherapy group (2.99mm (1.33)) at 38 months, p=0.017, however this did not exceed the minimally clinically important difference of 0.48mm. SHOMRI score was significantly lower in the arthroscopy group (mean (SD) 9.22 (11.43)) compared to the physiotherapy group (22.76 (15.26)), p-value <0.001. Hip outcome score was higher in the arthroscopy group (mean (SD) 84.2 (17.4)) compared with the physiotherapy group (74.2 (21.9)), p-value < 0.001).

Patients with FAI syndrome treated surgically may experience slowing of osteoarthritisprogression and superior pain and function compared with patients treated non- operatively.

Background

Giant cell tumours of bone (GCT) are benign bone tumours with a locally aggressive character. Local recurrence is considered the main complication of surgical treatment and is described in up to 50% of patients. Intralesional curettage with the use of adjuvants like phenol or polymethylmetacrylate (PMMA) is recommended as initial treatment, significantly decreasing the risk of recurrence. However, risk factors for local recurrence in skeletal GCT have not yet been firmly established and a golden standard for local therapy remains controversial.

Introduction

Local recurrence of Giant cell tumours of bone (GCT) is considered the main complication of surgical treatment (50%). Intra-lesional curettage with adjuvants like phenol or polymethylmethacrylate (PMMA) is recommended as initial treatment, decreasing the risk of recurrence. However, risk factors for local recurrence in skeletal GCT have not yet been firmly established and a golden standard for treatment remains controversial.

Aim of this study is identification of risk factors for recurrence in GCT, specifically after intra-lesional curettage with or without adjuvants.

Aim

Multiple (hereditary) osteochondroma (MO) is a rare autosomal dominant disease. Previous reports show that the risk of a malignant degeneration varies between 5-25%, but these are often combined with data on other cartilaginous diseases. The aim of this study was to establish clinical and radiological parameters that could identify a group of MO patients who are at risk for peripheral chondrosarcoma.

Aim

To determine whether delayed diagnosis (lapse from initial symptoms to the beginning of treatment) has influence on the possibilities of crossing the physis by the tumour, and/or on the outcome in pediatric patients with high grade metaphyseal osteosarcoma.

Aim

The saddle prosthesis was originally developed for reconstruction of large acetabular defects in hip revision arthroplasty. Later on the saddle prosthesis was also used for hip reconstruction after resection of peri-acetabular tumours. In case of patient survival a long-term good hip function is required of the saddle prosthesis. The goal of this study is the measurement of long-term clinical results of saddle prosthesis after reconstruction of peri-acetabular tumours.

Background

It is common practice nowadays to treat patients with metastatic epidural spinal cord compression (MESCC) surgically. Extend and type of surgery should be in proper relation to the expected survival time of the patient. It is still difficult to predict patient's survival time and different scoring systems are used. Reliable prediction of survival is mandatory, in that way adjustable surgical treatment can be established.

Background and Purpose: Retrospective evaluation of short-term (8 weeks) and long-term (54 weeks) radiologic follow-up of vertebral wedge angle and anterior, center and posterior vertebral heights after Percutaneous VertebroPlasty (PVP) in type II Osteoporotic Vertebral Compression Fractures (OVCF).

Methods: Between September 2002 and August 2007 47 PVP’s were performed in 25 consecutive patients (5 male, 20 female (age 70 ± 9,5 yrs) with OVCF’s type II (mean fracture age: 35.0 weeks (range: 10.0 – 136.7)). With pre-vertebroplasty conventional radiographs and MRI’s, post-vertebroplasty CT’s and conventional radiographs follow-up of the vertebral compression fractures were analyzed.

Analysis of vertebral morphometrics with emphasis of the vertebral wedge angle and height of the vertebral body at the anterior, center and posterior border. Determining the loss and gain of height of the vertebra with OVCF pre- and post-PVP up to one year, using pre-PVP estimated heights.

Results: A mean wedge angle reduction of 2.9° and anterior- and center heigth gain of 4.4% and 5.6% directly post-PVP, posterior height remained stable. The parameters at short- and long-term follow-up compared to the pre-PVP parameters showed no significant differences accept for anterior height.

Conclusion: Besides alleviating the refractory back pain in patients a limited decrease in wedge angle and increase of anterior and center height is possible in type II OVCF. Although the long-term follow-up depicts a slight anterior height loss, the wedge angle and restored center height were stable.

Giant cell tumour of bone (GCT) is a primary osteolytic neoplasm, histopathologically characterized by osteoclast-like giant cells and clinically characterized by local bone destruction and high recurrence rates. There is a need to identify risk factors for recurrence. In order to reduce the recurrence rate we initiated an international, multicenter, randomised phase II trial with adjuvantzoledronic acid as compared to standard care for high risk GCT patients.

One hundred and sixteen GCT patients, treated at the LUMC from 1971 to 2006, with a minimal follow-up of a year, were retrospectively analysed for the following risk factors for local recurrence: GCT grade III and tumour involvement into soft tissue caused by ingrowth or fracture. Resection was used as treatment in 21 patients (group A), intralesional surgery with cement or adjuvant in 24 (group B) and intralesional surgery with cementation and adjuvant in 71 patients (group C).

GCT recurred in 5% (1/21) in group A. Risk factors were found in 90% of patients without recurrence (18/20). Group B shows a recurrence of 25% (6/24). Risk factors were found in 83% (5/6) of recurring GCTs, compared with 28% in patients without recurrence. In group C, a recurrence rate of 23% (16/71) was found. Risk factors were present in 94% (15/16) of recurrences, compared to 36% (20/55) in patients without recurrence.

Soft tissue involvement and GCT grade 3 and up are risk factors for recurrence in GCT. Recurrence rates are lowest when resection is used. Risk factors may influence the choice of treatment. High risk patients may benefit from resection or systemic treatment with adjuvant therapy.

Synovial sarcoma (SS) is rare but increasingly diagnosed and associated with poor prognosis. Primary surgical resection with wide margins and adjuvant radiation-therapy is considered gold standard in treatment of primary SS. Although (Neo)adjuvant chemo- and radiationtherapy are used in the primary treatment of SS, they are not advocated outside a clinical trial setting. In patients with primary SS and pulmonary metastases, (neo)adjuvant chemotherapy is often added to the treatment protocol but it’s effect on overall survival seems limited.

Between 1985 and 2004 33 patients with primary SS were treated in our clinic. Seventeen patients were diagnosed with pulmonary metastases at presentation (9) or during postoperative follow-up (8). Wide resection or focally marginal resection followed by radiotherapy was used as primary treatment for all patients. All primary metastasized patients were treated with adjuvant multi-agent chemotherapy including Isofosfamide. Average survival in this group was 32 months (5 year OS 50%), compared to 60 months in the late metastasized patient-group (2 and 5 year OS 50 and 11%). Wide resection was not related to improved overall survival when compared to marginal margins and additional radiation therapy. In the early metastasized group combined chemo-radiaton therapy provided no significant improvement in overall survival over adjuvant chemotherapy or radiation therapy alone. However additional chemotherapy in the late metastasized group was slightly associated with increased overall survival (5 year OS 0% vs 66%).

Treatment of early pulmonary metastasized SS remains highly dependent of the individual preference of patient and physician. In contrast to the reported prolonged disease free/overall survival of Enneking stage IIA and IIB SS patients, aggressive surgical and chemo-radiation therapy has not yet been associated with improvement of disease free/overall survival in stage III disease. Patients presenting with late pulmonary metastasis might benefit from adjuvant multi-agent chemotherapy treatment.

Sacrococcygeal chordoma is a slow growing, malignant tumour with a clinical poor outcome due to a high local recurrence (LR) rate. Several studies emphasize that margin-free tumour resection is the most important predictor of survival and LR in patients with sacrococcygeal chordoma. However, a high recurrence rate still remains. The purpose of this report is to define the role of postoperative radiotherapy (RT).

15 patients (7 females and 8 males) underwent surgical treatment for sacrococcygeal chordoma between 1981 and 2003. The mean age at surgery was 54 (range 31–70) years. The mean follow up was 8.5 (range 4 – 20) years. Most patients suffered from local swelling and pain; only one patient had a mild urinary continence being the only pre- and postoperative neurological deficit. Mean time of preoperative complaints was 4.5 (range 0.8 – 8) years. In 9 patients an en bloc resection was performed, in 6 patients a subtotal resection was achieved. Most patients with a subtotal resection received RT (5/6 patients) following surgery, patients with en bloc resection only received RT (> 50Gray) after LR (6/9 patients).

After en bloc resection (no initial RT) all patients had local recurrence of the tumour with a mean time to recurrence of 3 (range 0.8 – 13) yrs. Only two patients in the group with subtotal resection had LR after 11 yrs. Six of 9 patients with LR after en bloc surgery received RT after recurrence and had a survival of at least 9 (range 5 – 20) years. There were no major complications. The time to recurrence was significantly longer in the group that received immediate RT after surgery, even after resection with irradical margins. There was no difference in survival between both surgical groups.

Our results suggest that postoperative RT is more important in the prevention of local recurrence than margin-free tumour resection. This supports the strategy to add radiotherapy as a standard adjuvant therapy to tumour resection in patients with sacrococcygeal chordoma.

Giant cell tumors (GCT) of the sacrum have a high recurrence rate, up to 33%. Treatment of Giant Cell Tumors (GCT) of the sacrum has many options. Although curettage is more often performed than partial sacral resection the indications are not well described. Large resection in the sacral area is limited, and adequate local adjuvant therapy potentially damages the nervous system. Therefore the type of surgical treatment of sacral GCT is still under debate.

The purpose of this study was to compare clinical outcome after surgical treatment in GCT of the sacrum using two different surgical techniques: curettage and Extended Cortical Excision (ECE).

Pre-operative embolisation was routinely performed, followed by curettage or PSR followed by reconstruction if indicated. Between 1994–2005 11 patients were treated for GCT of the sacrum. Eight were female, 3 men. The median age was 43.5 (14–66) years. The median follow-up period was 60 (6–156) months. Five patients were eventually treated by ECE. The other patients were operated on using different techniques, mainly curettage and/or adjuvant therapy.

Two patients died disease-related 42 and 6 months after primary treatment, both metastasized. All other patients are alive and currently disease-free. Six patients had a recurrence, after 33 (4–140) months. Three patients had a recurrence twice. Three patients received radiotherapy, 1 as palliative treatment and 2 as (adjuvant) therapy for recurrence. No recurrences were seen after ECE compared to 86% (6/7) after curettage only, and 50% (2/4) after curettage with adjuvant therapy.

Extended cortical excision may improve the recurrence rate in sacral GCT.

Current 5-year survival after complete resection of pulmonary metastases is ≈ 30%, and many patients develop pulmonary recurrences. Obviously new treatment options are needed for this indication. Isolated lung perfusion (ILuP) is an experimental technique to deliver high-dose chemotherapy to the lung without systemic exposure. Recently, a phase I trial of ILuP combining 45 mg melphalan followed by pulmonary metastasectomy for resectable lung metastases proved to be feasible and safe.

The current 3-center phase II study (including University Hospital Antwerp/P. van Schil and Anthonius Hospital Nieuwegein/F. Schramel) allows patients with resectable lung metastases from colorectal cancer, soft tissue- and osteosarcoma to be treated with ILuP prior to metastasecomy.

At Leiden University Medical Center we treated 8 patients: 4 with colorectal cancer (age 54–59 y), 2 osteosarcoma (19–20 y), 1 sarcoma NOS of bone (38 y) and 1 sarcoma NOS (56 y) of soft tissue. The number of metastases was 1–2 and one patient had resection of 9 metastases. The procedure was uncomplicated in 7 cases and 1 patient had reversible pulmonary edema. Hospital admission duration was 6–8 days in the uncomplicated group and 14 days in the one patient with a complication. No long term toxicity was observed with extensive follow-up including lung function tests. With a median follow-up of 7 months (range 2–16), only the patient with 9 metastases had a recurrence and died of disease.

Our single center prelimininary data show that ILuP is feasible and does not lead to irreversible or severe toxicity. Compared to retrospective data with metastasectomy alone, perfusion did not add toxicity. Follow-up is too short to draw any conclusions on efficacy.

A retrospective study focusing on long-term follow up of 28 patients with a malignant bone tumour in the distal femur was conducted. Patients with a mean age of 50 (18–90) were clinically and radiologically followed-up for a mean period of 64 months (7–144). Osteosarcoma was the most common primary bone tumour, occurring in 15 patients. The 5-year survival for all patients was 80,9%. At final follow-up, 19 patients were still alive and had a mean follow up of 74,6 months (7–137).

Clinical evaluation was done with the MSTS questionnaire (mean score: 70,0 (26,7–93,3)) and the use of the TESS (mean score: 82,5 (45–99,2) and SF-36 (mean Physical Component Score (PCS): 46,6 (27,1–56,5), mean Mental Component Score (MCS): 53,7 (range 37,0–62,1) was introduced

There were 12 complications: 5 aseptic loosenings, two deep prosthetic infections, two luxations, one prosthetic fracture and two fissures. Six failures were re-operated. An overall prosthetic survival at 5-years of 77,0 % was found. A total of eight (29%) prostheses were considered to have failed after a mean follow up of 27,4 months (0–97). Risk factors in failure of the prosthetics were: non HA-coated stem and top stem-ratio > 1.2. Not length of the endoprosthesis and base stem-ratio. The top-ratio had a mean value of 1,14 (1,00–1,52) and for the four patients with an aseptic loosening the mean top-ratio was 1,23 (1,12–1,51) which was significantly different (p< 0,05 Mann-Whitney U test).

Our results suggest that of the MUTARS endoprosthesis has a good 5-year survival.

The use with a HA coating is preferable. The use of a stem-cortex ratio (> 1.2) at the top of the prosthetic stem can be predictor for aseptic loosening. The addition of the TESS and SF-36 scores give more insight information in how patients undergo their disease: half do not feel disabled.

Limb-sparing surgery has become the preferred surgical treatment of malignant bone tumours of the knee. In patients with intra-articular extension of their tumour, extra-articular limb sparing surgery can prevent the knee from amputation. In a retrospective study between January 1985 and December 2007, we performed 34 extra-articular tumour resections of the knee-joint for a bone- or soft tissue tumour in the distal femur or proximal tibia with (suspect) intra-articular tumour extension into the knee on MRI. Contra-indications were extension of the tumour into the extensor mechanism and/or tumour involvement of the neurovascular bundle. Osteosarcoma (23/34) was the most common primary malignancy. Mean age was 36 years (17–70) and the mean follow up was 9 years (1–19).

Patient survival rates at 5 years and 10 years are 78% and 58% respectively, mean patient survival was 47 months (8–211). In 12 (35%) patients, the primary implanted prosthesis failed during follow up. Prosthetic survival rates including minor revision surgery were 63% at 5 years and 36% at 10 years. Six (18%) patients had local recurrence of their malignancy, 5 of them in the popliteal fossa. Local recurrence was significantly correlated with marginal margins (P< 0.05). Fifteen patients had major complications (44%) mainly deep infection in proximal tibia resections and aseptic loosening in distal femur resections. Aseptic loosening was significantly correlated with non HA-coated stems (P< 0.05). Functional outcome scores according to MSTS (mean 81, (65–93)) and TESS (mean 85, (56–98)) of survivors are good.

Our results suggest that extra-articular tumour resections of the knee-joint can provide a functional endoprosthesis and can be an alternative for primary amputation. However it is a technical demanding procedure with acceptable local recurrence and high complication rates in patients with, in general, poor survival.

A rotationplasty is a unique surgical procedure used to reconstruct after resection of a tumor of the leg or a congenital defect. This procedure avoids phantom pain, limb length discrepancy and infections or implant related complications. The outcome is unusual for cosmesis but very functional.

Background: Borggreve first described a rotationplasty in Germany in 1930 for a 12 year old patient whose knee was destroyed by tuberculosis. In 1950 Van Nes modified the procedure. Kotz and Saltzer described in 1982 the use of a modified version of a rotationplasty to treat malignant tumors of the distal femur.

Case studies of two such patients will be presented.

A 27 year old man had a non-metastic osteosarcoma of his distal femur at the age of five. He underwent chemotherapy and a rotationplasty. Six years after his operation a correction osteotomy was done. He is doing very well physically and mentally. He graduated business studies, went yearly on Alpine skiing on two legs, likes jogging and perceives no limitations in his life (MSTS, TESS, SF-36).

Although is said that rotationplasty had a poor cosmesis and poor psychosocial acceptance, this is not our experience.

Purpose: Surgery is the only treatment option for chondrosarcoma grade I. Because this cartilage tumour is found by coincidence, patients feel unsafe, are anxious and very emotional. The purpose of this study was to evaluate the psychological and social impact of a chondrosarcoma grade I and to optimize the care of these patients.

Patients and methods: Eighty-two patients with a mean age of 50 years (22 – 80), who underwent surgery because of a chondrosarcoma grade I between 1990 and 2007, participated in this retrospective multi-method study. Assessment followed using, the Short Form-36, the MSTS and a special developed semi-structured questionnaire. The mean follow-up time was 4,8 year. 66 patients had a curettage, fenolisation and bonegraft. Sixteen patients had a resection. Five of them underwent a reconstruction with an allograft and another five a reconstruction with prosthesis.

Results: The majority of the patients (77%) were satisfied with our information. For mortgage and life/health insurance there were consequences in 18% of the patients. The SF-36 displayed slight lower scores in all domains except for mental health. Satisfaction with the operation is connected to emotional acceptance.

Conclusions: For patients afflicted by chondrosarcoma grade I the psychological impact is enormous. Three-quarter of the patients think often about the diagnosis and 40% was concerned about the waiting time before operation. To a lesser extent, patients were concerned about the impact of the chondrosarcoma on their lives. Within both domains, psychological as well social, there is a task for the nurse practitioner or a social worker in improving care of these patients. The extent of the surgical procedure does not influence patient satisfaction. The emotional acceptance of the disease decides the level of patient satisfaction.

Study design. Cross sectional.

Objectives. In literature it has been suggested that a strong relationship exists between psychosocial factors and disability in patients with chronic low back pain (CLBP). However, most studies only focus on self reported disability. This study was performed to analyze the relationship between psychological factors and performance based and self-reported disability, as measured with and Functional Capacity Evaluation (FCE) and the Roland Morris Disability Questionnaire (RMDQ), in patients with CLBP.

Methods. The study was performed in an outpatient rehabilitation setting. The study sample consisted of 92 patients with CLBP admitted for multidisciplinary treatment. Prior to treatment, all patients completed questionnaires to measure psychological factors (distress, depression, self efficacy, fear avoidance, pain cognitions and coping style) and self-reported disability, and performed a standardized set of tests in FCE.

Relationships among the variables were measured by means of Pearson correlation coefficients.

Results. Out of 28 relations analyzed, correlations were either non-significant or weak. Correlations between psychosocial factors and FCE were all non-significant, except for one. Results of subgroups will be presented.

Conclusion. The suggested strong relationship between psychological factors and performance based and self-reported disability measures could not be confirmed in this study. This may implicate that the relationship between psychological factors and disability may not be as unambiguous as suggested for patients with CLBP.

Background Context. In the assessment and treatment of patients with chronic low back pain (CLBP) the bio- psycho-social model is used world wide. Psychological distress has been reported to have a strong relationship with self reported disability. The relationship between psychosocial distress measured with the SCL-90-R and self reported disability measured with the RMDQ has not been investigated.

Purpose. To analyze the relationship between psychosocial distress measured with the Symptom Checklist-90-Revised (SCL-90-R) and self reported disability measured with the Roland Morris Disability Questionnaire (RMDQ) in patients with CLBP.

Study design/Setting. This cross sectional study was performed in an outpatient pain rehabilitation setting.

Patient sample. The study sample consisted of 152 patients with CLBP.

Outcome measures. Scores on SCL-90-R and the RMDQ.

Methods. All patients admitted for multidisciplinary treatment completed the SCL-90-R and RMDQ prior to treatment. Pearson’s correlation coefficients between SCL-90-R (Global Severity Index and subscales) and RMDQ were calculated.

Results. Correlation coefficients between SCL-90-R (Global Severity Index and subscales) and RMDQ ranged from 0.18 to 0.31 (p< 0.05).

Conclusion. The relationship between psychosocial distress measured with the SCL-90-R and self reported disability measured with the RMDQ in CLBP patients is weak. For clinical practice it is important to unravel the components and their suggested relationships in the bio-psycho-social model. This research has demonstrated that these relationships cannot be confirmed with the combined use of the SCL-90-R and the RMDQ. Further research is needed to determine which combination of instruments is most suitable to use in clinical practice, and to confirm or refute the suggested impact of psychosocial distress on self reported disability.

Introduction: Pain related fear and pain intensity have been identified as factors that potentially negatively influence Functional Capacity Evaluation (FCE) performances in patients with chronic low back pain (CLBP). Conflicting results have been reported in the literature. The objective of this study was to analyze the relationships between pain intensity and pain-related fear on the one hand, and performances during an FCE on the other hand in two samples of patients with CLBP.

Methods: Two cross sectional observation studies were performed with two samples of patients with CLBP (study 1: n=79; study 2: n=58). Pain related fears were operationally defined as the score on the Tampa Scale of Kinesiophobia in study 1, and the Fear Avoidance Beliefs Questionnaire (FABQ) in study 2. Pain intensity was measured with a Numeric Rating Scale in both studies. Avoidance behavior observed during FCE was in both studies operationally defined as the unwillingness to engage in high intensity performance levels of three different functional activities: high intensity lifting, prolonged standing in a forward bend position, and fast repetitive bending at the waist.

Results: A total of 25 correlations between pain and pain related fear, and performance variables were calculated, out of which 7 were significant (p< 0.05). The strength of these significant correlations ranged from r=−0.23 to r=−0.50. Multivariate linear regression analyses revealed non-significant relationships in most instances. Pain and pain related fear contributed little if any to these models.

Conclusions: The relation between pain and pain related fear and FCE performance is weak or non-existent in these samples of patients with CLBP. The hypothesis that pain and pain related fear are important factors in FCE performance was not supported in this study. Possible explanations will be discussed during the presentation.