Management of open tibial fractures remains controversial. We hypothesised that unreamed intramedullary nail offers inherent advantages of nail as well as external fixation. We undertook a prospective randomised study to compare the results of management of open tibial fractures with either an external fixator or an undreamed intramedullary nail until fracture union or failure.

Our study included 30 consecutive open tibial fractures (Gustilo I, II & IIIA) between 4 cm distal to knee and 4 cm proximal to ankle in skeletally mature adults, who presented to a level-1 trauma centre. Alternate patients were treated by either external fixation and unreamed nailing i.e. 15 in each group. Standard protocol for debridement and fixation was followed in all cases. All external fixators were removed at 6 weeks. All cases were followed up until fracture union, the main outcome measurement. 26 (87%) were males and 4 (13%) females; age range was 20-60 years (average 33.8).

All fractures in both groups united. Time to union averaged 7.9 months for both groups. Incidence of wound problems, infection, hardware failure and delayed union were comparable. However, there was higher incidence of angular deformities and stiffness of knee and ankle in external fixation group, although not statistically significant.

We found no statistically significant difference between unreamed intramedullary nailing and external fixation for the management of open tibial diaphyseal fractures, although ease of weight bearing as well as absence of angular deformities and joint stiffness were distinct advantages in the nail group. Therefore we recommend unreamed nail for Gustilo I, II and IIIA open tibial fractures.

Aim: To discuss the rationale, selection criteria, indications, and results of using large diameter ceramic heads in primary and revision hip arthroplasty.

Patients and Methods: We routinely use Biolox family of ceramic heads and acetabular liners in patients undergoing total hip replacements. We present our experience in using ceramic articular bearings over the last 20 years and the switch to larger diameter ceramic heads. We also present our rationale for using a large diameter ceramic head instead of a large metal head.

Results: We reviewed a total of 1189 arthroplasties over this time period and we report the outcome of large bearing couples with case examples in primary and revision scenarios. Furthermore we compared a subset of patients (110) with large diameter ceramic heads – Biolox Delta 36mm to patients who had metal on metal (large head 42 mm and above) bearing couples. The performance of the ceramic bearing couples will be discussed along with the functional outcome of these patients. We found no difference in the functional, clinical sports activities (UCLA and Tegner scores) between patients who had large metal bearing couples and large ceramic couples. Complication rate was less with the ceramic bearing arthroplasties, as was patient satisfaction

Conclusion: Ceramic bearing couples have stood the test of time and have demonstrated an excellent long term wear properties. The recent introduction of the large diameter couples proves to be an excellent alternative if not the first choice in young, complex primary and revision case scenarios

Aim: To report the clinical, functional and radiological outcome of consecutive primary hip arthroplasties using large diameter (36mm and above) ceramic bearing couples. We believe this to be one of the first reported series in the UK.

Methods: We prospectively reviewed 319 consecutive primary THA using fully HAC coated acetabular shell and fully HAC coated stem (JRI Ltd) in 302 patients, with minimum follow-up of 12 months. A Biolox-Delta ceramic liner with an 18 deg taper and Biolox-Delta ceramic head (36mm and 40mm) were used in all cases, which were performed in one institution by 3 surgeons. None were lost to follow-up. Clinical outcome was measured using Harris, Charnley Oxford, EuroQol EQ-5D scores. Radiographs were systematically analysed for implant position, loosening, migration, osteolysis. Return to sports and hobbies were recorded.

Results: Mean age was 64.9 yrs (11–82yrs). There were no dislocations. 50–62mm acetabular shells were used. 36 mm head was used in 96% of cases. No acetabular revisions were performed for aseptic loosening. Other re-operations were for infection (1), peri-prosthetic fractures (1). The mean Harris and Oxford scores were 95 (88–97) and 14.1 (12–33) respectively. The Charnley score was 5.7 (5–6) for pain, 5.8 (4–6) for movement and 5.9 (4–6) for mobility. There was a significant improvement in the range of movement of the hip. There was no migration of acetabular component. Acetabular radiolucencies were present around one shell. No acetabular liner wear was demonstrated in CT Scans. Mean inclination was 47.4deg(37–65). Mean EQ- 5D description scores and health thermometer scores were 0.84 (0.71–0.92) and 88 (66–96). With an end point of definite or probable loosening, the probability of survival was 100%. Overall survival with removal or repeat revision of either component for any reason as the end point was 99.1%.

Conclusion: The results of this study show an excellent clinical and functional outcome and support the use of a fully coated prosthesis with ceramic bearing couples. We envisage to monitor and prospectively report the long-term outcome of this series of patients.

We aim to report the clinical, radiological outcome of consecutive primary hip arthroplasties using the JRI-Furlong Hydroxyapatite ceramic coated acetabular components. We reviewed 412 consecutive primary THA using fully coated acetabular shell in 392 patients, with minimum 12-year follow-up to 18 years, performed at two institutions. Twenty (22 THA) were lost prior to 12-year follow-up, leaving 372 patients (390 THA) available for study.

Fully HAC coated stems were used in all patients. Clinical outcome was measured using Harris, Charnley Oxford, EuroQol EQ-5D scores. Radiographs were systematically analysed for implant position, loosening, migration, osteolysis. Polythene wear was digitally measured.

Mean age was 74.4 yrs. Dislocation occurred in 10 patients (3 recurrent). Revision operations were performed in nine patients (1.9%). Four acetabular revisions were performed for aseptic loosening. Other re-operations were for infection (3), periprosthetic fractures (1), cup malposition (1), revision of worn liner (3). The mean Harris and Oxford scores were 87 (78–97) and 19.1 (12–33) respectively. The Charnley score was 5.6 (5–6) for pain, 5.2 (4–6) for movement and 5.3 (4–6) for mobility. Migration of acetabular component was seen in 4 hips. Acetabular radiolucencies were present in 54 hips (9.7%). The mean linear polythene wear was 0.06mm/year. Mean inclination was 48.4 deg(38–65). Mean EQ-5D description scores and health thermometer scores were 0.81 (0.71–0.89) and 86 (64–95). With an end point of definite or probable loosening, the probability of survival at 12 years was 96.1%. Overall survival at 12 years with removal or repeat revision of either component for any reason as the end point was 94.2%.

The results of this study support the continued use of a fully coated prosthesis and documents the durability of the HAC coated components. In our clinical experience, the Furlong prosthesis revealed encouraging radiographic stability over a long term period

It is generally accepted that urgent debridement and fixation of open tibial fractures minimizes the risk of infection. Traditionally surgeons follow the unwritten six hour rule. The purpose of this study was to determine the association between time to definite surgical management and rates of infection in open fractures of the tibia.

One hundred and twenty-seven patients with one hundred and twenty-eight open tibia fractures were retrospectively reviewed. Of these ninety patients with ninety-one one fractures were available for this study. All patients were followed up to clinical and radiological fracture union or until a definitive procedure for infection or non-union had been carried out.

The time from injury to surgery ranged from 2 hours 35 minutes to 12 hours with an average time of 5 hours 40 minutes. There were 24 Gustillo type I fractures (26.37%), 11 type II fractures (12.08%), 23 type IIIA fractures (25.27%) and 33 type IIIB fractures (36.26%). 5 patients (5.49%) in this study went onto develop a deep infection and there were 4(4.39%) non-unions. No infection occurred when the surgery was done within 2 hours. All the 5 infections in this study occurred in patients operated between 3 to 8 hours of the injury and were all in Gustillo Grade III fractures. The average time to treatment was not significantly different between the infected versus non infected group across all fracture types. There was no increase in infection rate in those treated after 6 hours compared to those treated within 6 hours.

The risk of developing an infection was not increased if the primary surgical management was delayed more than 6 hours after injury provided intravenous antibiotics were administered on presentation to the emergency department. The Gustillo grading of open fractures is a more accurate prognostic indicator for developing an infection.

Introduction: Authors aim to present an interesting series of calcaneal tumors accrued from Scottish Bone Tumor Registry. The available literature is largely limited to the case reports. Bony tumors of the foot account for approximately 3% of all osseous tumors (1), of which Calcaneal location is the second most common site after the metatarsals in the foot. This study describes tumors of varying aetiology with regard to epidemiology, clinical features, diagnostic findings, treatment modalities and outcome.

Material and Methods: This study is a retrospective review of the medical records and imaging modalities of forty patients with calcaneal tumors which were accrued from Scottish Bone Tumor Registry between January 1954 and December 2006. Patient demographics including presentation characteristics, and delay in the presentation from the onset of symptoms were noted. Plain radiographs followed by further imaging with CT, MR and Bone scanning were reviewed. Size, location and spread of the tumors were noted based on imaging modalities. The type of biopsy, histological diagnosis, type of resection and adjuvant therapy was noted. All patients were followed-up clinically and radiologically for a minimum of 2 yrs or until death

Results: There were 28 primary benign, 11 primary malignant and 1 secondary malignant tumors. In the cohot of 40 patients 26 were male and 14 females with mean age of 27 years. Pain (37/40), swelling (27/40) and restriction of movements (25/40) were the main presenting features. Pathological fractures were found in 4 patients. Mean duration of symptoms was 12 months. Histological diagnoses included Osteoid Osteoma (4/40), PVNS (4/40), Chondroblastoma (3/40), Simple bone cyst (3/40), ABC (3/40), GCT (3/40), Osteochondroma (2/40), Chondroblastoma, Enchondroma, Fibrous Histiocytoma and Glomus tumour (1 case each). Chondrosarcoma, Ewing’s and Paget’s sarcoma (2 cases each), Osteosarcoma, Spindle cell and Pleomorphic Sarcoma (1 case each). Thirty eight patients underwent operative management.

Summary: Current study is one of the largest reported series of calcaneal tumors. A wide variety of lesions seem to involve patients from different age groups and either sex. Presentation features include mainly pain and swelling aggravated by walking. Radiological features may differ than those reported for common locations for the given tumor type. The recurrence rate for benign bone forming as well as cartilage tumors seem to be low provided adequate curettage or excision has been carried out. Whereas most benign lesions can be managed with limb salvage, below knee amputation sees to be a standard operation for primary malignant tumors. Metastatic lesions have poor survival prognosis.

Introduction: It is generally accepted that urgent debride-ment and fixation minimizes the risk of infection. Traditionally surgeons follow the unwritten six hour rule. The purpose of this study was to determine the association between time to definite surgical management and rates of infection in open fractures of the tibia.

Methods: One hundred and twenty-seven patients with one hundred and twenty-eight open tibia fractures were retrospectively reviewed. Of these sixty patients with sixty fractures were available for this study. All patients were followed up to clinical and radiological fracture union or until a definitive procedure for infection or non-union had been carried out.

Results: The time from injury to surgery ranged from 2 hours 35 minutes to 12 hours with an average time of 5 hours 40 minutes. There were 23 type IIIA fractures (38%) and 37 type IIIB fractures (62%). 5 patients (5.49%) in this study went onto develop a deep infection and there were 4(4.39%) non-unions. No infection occurred when the surgery was done within 2 hours. All the 5 infections in this study occurred in patients operated between 3 to 8 hours of the injury. The average time to treatment was not significantly different between the infected versus non infected group across all fracture types. There was no increase in infection rate in those treated after 6 hours compared to those treated within 6 hours.

Conclusions: The risk of developing an infection was not increased if the primary surgical management was delayed more than 6 hours after injury provided intravenous antibiotics were administered on presentation to the emergency department. The Gustillo grading of open fractures is a more accurate prognostic indicator for developing an infection.

Introduction: Distal radius locking plates are increasingly being used to treat distal radius fractures.

The purpose of our study was to determine the medium term clinical and radiological outcome of comminuted, displaced fractures of the distal radius. We present our experience in using the Aculoc (Acumed) volar fixed angle plate to treat 100 consecutive fractures of the distal radius.

Methods: All one hundred patients were prospectively (clinically and radiologically) assessed between 2003 –2007, with a minimum follow up of one year. Fractures were radiologically classified using the Frykman classification Clinical outcome was measured using the Mayo score, DASH questionnaire, SF36 and Range of Wrist Movement and pinch and grasp power. The post operative x rays were assessed for fracture union, alignment and displacement.

Conclusion: Our study demonstrates that volar fixation of distal radius fractures, using a fixed angle, locking accumed plate provides satisfactory treatment for fractures of the distal radius. Angular stability of the implant provides mechanical stability and aids early rehabilitation which results in good functional outcomes.

Introduction: Giant cell tumours are locally highly aggressive and extremely unpredictable bone tumours. Treatment of spinal GCTs remains controversial. We report our experience of 11 Giant cell tumours of the spine identified from the Scottish Bone Tumour Registry.

Materials and Methods: Details of 11 cases of histologically confirmed Giant cell tumours of the spine (9 benign and 2 malignant) between 1960 and 2004, were extracted from the Scottish Bone Tumour Registry. The casenotes and radiographs were retrospectively reviewed.

Results: There was a slight feminine predominance of 7 cases. Mean age was 34 years (range, 16 to 61 years). The sacrum (5) was most common location, followed by lumbar (3), thoracic (2) and rarely in cervical (1). Operative intervention was carried out in 5 (curettage-1; excision-5). Three also received supplemented bone grafts. Radiotherapy (including some of the operative cases) was administered in 9 patients. There were 5 recurrences (45.4%). There were 7 survivors 2 of whom still had evidence of persistent primary disease. Two died with unrelated illnesses and two from local recurrences.

Conclusions: Axial GCTs behave aggressively with a high recurrence rate (45%). Radiotherapy is useful in the management of GCTs of the spine and conservative surgery with local radiotherapy is a viable treatment option in some selected patients.

Introduction: A retrospective analysis was performed to determine the oncological outcome of patients with Ewing’s sarcoma of the spine treated with combined chemotherapy and radiotherapy for definitive local control.

Materials and Methods: Fifteen patients were identified from the Scottish Bone Tumour Registry with a histologically confirmed Ewing’s sarcoma affecting the axial skeleton. All case notes and imaging were retrospectively reviewed.

Results: Primary vertebral Ewing’s sarcoma accounted for 8.3% of all malignant spinal lesions in our registry. The mean age was 17.8 years (between 4 and 39 years). There was a male predilection with 9 male and 6 female patients. Site was evenly distributed between cervical (4), dorsal (5) and lumbosacral (6) regions. Progressively worsening back pain was the first symptom in all the patients. Satisfactory imaging studies were available in all with plain radiographs (15), bone scan (11), CT-scan (12) and MR Scan (9) patients.

Biopsy was performed in 11 patients and surgical treatment was carried out in 3 patients including curettage (2) and excision with bone grafting (1). All patients were treated with adjuvant radiotherapy while 87% also received adjuvant chemotherapy. Seven patients were alive with no evidence of disease at a mean 6 year follow-up. Six patients died of metastatic disease, one due to local recurrence and one with persistent primary disease. The mean follow-up time was 65 months (median 28 months; ranging from 12 to 218 months).

Conclusions: Primary vertebral Ewing’s sarcoma comprised 8.3% of our National Registry’s primary malignant spinal lesions. Progressive vertebral pain in the late second decade and male gender should raise the suspicion of Ewing’s sarcoma. Ewing’s sarcoma of the spine treated with combined chemotherapy and radiotherapy for definitive local control achieved a 45% five year survival.

The aim of the paper is to provide an independent single surgeon experience with BHR after a seven-year follow-up.

A cohort of 117 hips in 101 consecutive patients operated by the senior author between Jan 1998 and Dec 2002 were assessed to note their clinical, radiological and functional outcome after a mean follow-up of 7 years (5–9.4 years). Primary osteoarthritis was seen in 73 hips and secondary in 44 hips. Their mean age at surgery was 54 years (range 20–74years). At latest follow-up their mean flexion was 100°and their mean functional outcome scores were respectively: Oxford hip score of 21.5 (12–52, mode 12); Harris hip score of 84.8 (25–100, mode 97), Charnley modification of Merle d’ Aubigné and Postel scores were 4.8 for pain, 4.3 for walking and 5.4 for movement; and SF-36 (physical component 43.9 and mental component 51.45). Failure in the study was defined as revision for any reason. Revision was undertaken in 8 hips (6.8%), five within the first year for periprosthetic fracture neck of femur and 3 hips after the end of 5-year follow-up (2 for advance collapse of the femoral component in patients’ with avascular necrosis of the femoral head and 1 hip for sepsis).

The Kaplan-Meier survival with revision as end point at minimum 5-years of follow-up was 95.7% (95% CI 92–99%) and overall survival at an average 7-years was 91.7% (95% CI 86–97.6%). All the failures were due to the femoral component. However, the reported survival with the use of traditional uncemented and cemented femoral stems is beyond 99% at similar period of follow-up. Patient selection particularly in patients with secondary osteoarthritis is therefore a critical factor when choosing BHR components.

Introduction: Benign bone-forming tumours are common in children and adolescents. Careful radiographical and histological study is necessary to distinguish slow growing from more aggressive bone forming tumours. We reviewed 25 cases of primary benign bone forming tumours of the spine to investigate whether there were any obvious differences in their biological behaviour in adults compared to children.

Materials and Methods: Twenty five cases of primary benign bone forming tumours of the spine were identified from the Scottish Bone Tumour Registry: this data is collected prospectively. A retrospective review of this data was performed. There were 9 osteoid osteomas, 15 osteoblastomas and 1 aggressive osteoblastoma. These cases were divided into group A (children) and group B (adults).

Results: There were 16 patients in group A (6-osteoid osteoma, 9-osteoblastoma, 1-aggressive osteoblastoma), 10 boys and 6 girls. The mean age was 12.1 years (range, 6–16 years). There were 2 cervical, 4 thoracic, 8 lumbar and 2 sacral tumours. There were 9 patients in Group B (3-osteoid osteoma, 6-osteoblastoma), 7 boys and 2 girls. The mean age was 26.6 years (range, 18–53 years). There were 1 cervical, 6 thoracic, 2 lumbar and none sacral tumours.

Twenty two tumours were excised and 3 had curettage performed (1 child and 2 adults). There were 2 recurrences (one osteoid osteoma, one osteoblastoma), one from the excision group and one who had curettage, both in adults. These were successfully treated with re-excision. Mean follow-up was 8 years and all were alive at the time of final follow-up.

Conclusions: Benign bone forming tumours of the spine are extremely uncommon. In children they occur more commonly in lumbar spine, while thoracic involvement predominates in adult patients. Good outcomes are obtained with surgical treatment. Recurrence occurred only in the adult group: both of these patients had successful outcomes following further treatment.

Introduction: Obtaining adequate images can be difficult in ring fixator patients during outpatient follow-up. Following a recent publication, we introduced the spirit level technique as an effective method to ensure better quality images for interpretation, reduce unnecessary x-ray exposure, and improve clinic efficiency.

Method: A comparison was made of radiograph quality, patient inconvenience and x-ray exposure between standard X-ray techniques and those with a frame mounted spirit-level in all patients attending the senior author’s outpatient clinic for routine follow up following Ilizarov and Taylor-Spatial frames.

Prospective data was collected using a paper proforma in frame clinic. Information was gathered on all patients sent for plain radiographs. Radiographers collected data regarding time taken in the X-ray Department and total number of radiographs taken to gain the images required. The senior author recorded if these images were satisfactory and if returned to the department for further imaging. The radiation dose was retrieved from the Radiology computer.

The control group consisted of patients from clinics prior to implementation of the spirit-level device. Following a period of familiarization, data was collected from the study group using the spirit-level.

Results: (Table deleted)

Conclusion: The implementation of a simple frame mounted spirit-level as a guide for the radiographers in the outpatient clinic improves x ray quality, to assess healing, and significantly reduces the number of suboptimal images. The data does not support a significant impact on patient inconvenience.

Aim: We present the outcome of Birmingham Hip Resurfacing Arthroplasty performed by a single surgeon after at least five years follow up.

Patients and Methods: One hundred hips in 84 patients were studied with a mean follow-up of 6.4 years (5–8.3 years), performed by a single surgeon. Three patients died of unrelated causes and 2 patients were lost to follow-up, hence the study group comprised of 79 patients with 95 hips. Birmingham resurfacing femoral and acetabular components were used in all patients.

The clinical outcome was measured using Harris, Charnley, Oxford hip scores and quality of life using SF-36. Radiographs were systematically analysed for implant position, fixation, and loosening.

Results: The mean age was 54 years (20–74years) and BMI of 28 (19–35). Primary osteoarthritis was seen in 69 hips. Six patients (6.1%) underwent revision of the femoral component (3 for peri-prosthetic fractures of the neck of femur, 2 for deep infection and 1 for collapse due to AVN). None of the patients had evidence of loosening around the acetabular component and femoral components in 28 patients. Type 1 pedestal sign was seen in 61 hips and Type 2 in 2 hips.

The clinical scores were respectively, Harris 85 (25–100), Oxford 21.5 (12–52), mean Charnley score 4.8 for pain, 5.3 for movement and 4.3 for mobility; the mean SF-36 score were 44 (12–58) for the physical and 51.4 (19–71) for the mental component. With an end point of definite or probable aseptic loosening, the probability of survival at 5 years was 100% and 97.3% (95% CI = 2.9) for acetabular and femoral components respectively. Overall survival at 5years with removal or repeat revision of either component for any reason as the end point was 91% (95% CI: 82 to 97%).

Conclusion: The results of this study support the continued use of Birmingham Hip Resurfacing Arthroplasty in young active individuals. As loosening can occur as a late phenomenon, a longer follow up is needed to determine longevity, durability of this prosthesis.

Introduction: We aim to report the clinical and radiological outcome of consecutive primary hip arthroplasties using the JRI-Furlong Hydroxyapatite ceramic (HAC) coated acetabular components.

Methods: We reviewed 412 consecutive cementless primary THA using fully coated acetabular shell in 392 patients, with a minimum 12-year follow-up to 18 years, performed at two institutions between 1986 and 1994. Twenty (22 THA) were lost prior to 12-year follow-up, leaving 372 patients (390 THA) available for study. Fully HAC coated stems were used in all patients. The clinical outcome was measured using Harris, Charnley and Oxford hip scores. Quality of life using EuroQol EQ-5D. Radiographs were systematically analysed for implant position, loosening, migration, osteolysis. Polythene wear was digitally measured. The radiographic stability of the acetabular component was determined by Enghs criteria

Results: The mean age was 74.4 yrs. Dislocation occurred in 10 patients (3 recurrent). Re operations were performed in 9 patients (1.9%). Four acetabular revisions were performed for aseptic loosening. Other re-operations were for infection (3), periprosthetic fractures (1), cup malposition (1), revision of worn liner (3). The mean Harris and Oxford scores were 87 (78–97) and 19.1 (12–33) respectively. The Charnley score was 5.6 (5–6) for pain, 5.2 (4–6) for movement and 5.3 (4–6) for mobility. Migration of acetabular component was seen in 4 hips. Acetabular radiolucencies were present in 54 hips (9.7%). The mean linear polythene wear was 0.06mm/year. Mean inclination was 48.4deg(38–65). Radiolucencies were present around 37 (6.6%) stems. Mean EQ–5D description scores and health thermometer scores were 0.81 (0.71–0.89) and 86 (64–95). With an end point of definite or probable loosening, the probability of survival at 12 years was 96.1% for acetabular Overall survival at 12 years with removal or repeat revision of either component for any reason as the end point was 94.2%.

Discusssion and conclusion: The results of this study support the continued use of a fully coated prosthesis and documents the durability of the HAC coated components. In our clinical experience, the Furlong prosthesis revealed encouraging radiographic stability over a long term period.

Introduction: Benign bone-forming tumours are common in children and adolescents. Careful radiographical and histological study is necessary to distinguish slow growing from more aggressive bone forming tumours. We reviewed 25 cases of primary benign bone forming tumours of the spine to investigate whether there were any obvious differences in the biological behaviour of such tumours in adults compared to children.

Materials and Methods: Twenty five cases of primary benign bone forming tumours of the spine were identified from the Scottish Bone Tumour Registry: this data is collected prospectively. A retrospective review of this data was performed. There were 9 osteoid osteomas,15 osteoblastomas and 1 aggressive osteoblastoma. These cases were divided into group A (children) and group B (adults).

Results: There were 16 patients in group A (6-osteoid osteoma, 9-osteoblastoma, 1-aggressive osteoblastoma), 10 boys and 6 girls. The mean age was 12.1 years (range, 6–16 years). There were 2 cervical, 4 thoracic, 8 lumbar and 2 sacral tumours. There were 9 patients in Group B (3-osteoid osteoma, 6-osteoblastoma), 7 boys and 2 girls. The mean age was 26.6 years (range, 18–53 years). There were 1 cervical, 6 thoracic, 2 lumbar and none sacral tumours.

Twenty two tumours were excised and 3 had curettage performed (1 child and 2 adults). There were 2 recurrences (one osteoid osteoma, one osteoblastoma), one from the excision group and one who had curettage, both in adults. These were successfully treated with re-excision. Mean follow-up was 8 years and all were alive at the time of final follow-up.

Conclusions: Benign bone forming tumours of the spine are extremely uncommon. In children they occur more commonly in lumbar spine, while thoracic involvement predominates in adult patients. Good outcomes are obtained with surgical treatment. Recurrence occurred only in the adult group: both of these patients had successful outcomes following further treatment.

Introduction: Only 4–13 % of all spine tumours are primary bone tumours. We report on 180 cases of primary malignant bone tumours of the spine from the Scottish Bone Tumour Registry. The aim of the study was to analyse the incidence, demography, pathology and survival patterns of primary malignant bone tumours of the vertebral column.

Materials and Methods: All of the data in the Scottish Bone Tumour Registry is compiled prospectively. This report is based on a retrospective review of all the data from 180 cases of primary malignant bone tumours (excluding metastatic lesions).

Results: Of 4,301 registry cases 4.1% were primary malignant lesions (n=180). Seventy two percent of all spinal tumours were primary malignant neoplasms. There were 22 cervical, 72 thoracic, 45 lumbar and 41 sacrococcygeal lesions. There was a male preponderance (103 males & 77 females). The mean age at presentation was 54 years (range, 4–86 years). The top two ranked tumours were myeloma (42) and chordoma (41). Ewing’ sarcoma (15), Leukaemik-Lymphomatous lesions (13), conventional osteosarcoma (10) and Paget’s sarcoma (9) followed thereafter.

The predominant presenting symptom was pain. Pathological fracture occurred in 7 patients. The operative treatment consisted of curettage (21), excision (51) and resection (9) with supplemented bone grafting (13). Adjuvant chemo (=61) and radiotherapy (=131) was also used in selective cases. Thirty patients were alive with no evidence of disease at a mean 5 year follow-up. Six were alive with persistent primary disease and/or local recurrence and/or metastases at the time of review. Eighty four patients died with persistent primary disease, 30 patients died of metastatic disease, 9 due to local recurrence and 17 of unrelated causes.

Conclusions: Only 4.1% of the musculoskeletal tumours were spinal: 40% involved the thoracic spine. Mean age at presentation was 54 years. Myeloma, chordoma, chondrosarcoma and Ewing’ sarcoma were the most common pathologies. Myeloma predominated: osteosarcoma was much less common in our series compared to previous reports. Early diagnoses resulted into improved outcome.

Introduction: Management of surgical failures of 1st MTP joint is complex. We present a series of 9 patients treated with bone block arthrodesis of the 1st MTP joint.

Materials and Methods: 9 patients who underwent bone block arthrodesis of the hallux MTP joint over a three year period were retrospectively identified. Most of the patients had failed fusions and kellers arthroplasty. All 9 patients had pain and deformity of the hallux, 8 patients had limitation of mobility and 6 patients had gait and shoe wear problems. All patients underwent 1st MTP arthrodesis with interpositional tricortical bone blocks, to restore 1st ray length, with additional cancellous bone graft used in three patients. The construct was held with K-wires which were buried under the skin. 3 patients were put in plaster postoperatively.

Results: The average age of the patients was 59 years with average follow up of 15 months. The hallux MTP score postoperatively was 78 out of the possible 90. The 1st MTP joint angle improved from 29.17 to 15.33. All the nine patients were satisfied (four rated it excellent and five rated it good) with their outcome, of which six would readily undergo similar operation and three would undergo the operation if there was no other option. Postoperative complications were mostly metalware related with 8 patients having shoe wear problems for which they underwent K-wire removal (usually under a local anaesthetic in the clinic). 4 patients had minor paraesthesia, 3 patients had superficial infection treated with antibiotics and 1 patient had persistent non-union (but was pain free).

Conclusion: The results with bone block arthrodesis are satisfactory and have added advantage of restoring the length of the 1st ray.

Objective: To do assess changes in patients’ symptoms and the operative plan.

Materials and methods: 147 patients on a spinal surgery waiting list were assessed at a mean wait of 15.8 ± 1.3 months. 89 (61%) were male and 58 (39%) were female at a mean age of 49.7 yrs (16–78). 123 patients had a degenerative condition (20 cervical; 03 lumbar); 20 patients were seen for scoliosis; 2 with a post-traumatic kyphosis and 1 each with ankylosing spondylitis and a psudarthrosis.

Outcomes assessed: Changes in patients symptoms; changes from the initial operative plan when listed; requirement for re-imaging due to the wait.

Results: 31 patients reported improved symptoms at the re-assessment, while 96 were worse off and 20 were unchanged. 137 had axial pain when listed which changed to 116 at review (p=0.0018). 130 had radicular pain when listed which improved to 80 on re-assessment (p< 0.0001). However 19 reported an increase in the axial and 17 in the radicular symptoms. 71 patients (48.3%) required to be re-imaged at the re-assessment due to changes in the clinical picture. 42 patients received the procedure as originally listed. 30 patients were taken off the list, 24 received a different operation, and 38 had an interim or a definitive needling procedure while 13 await a re-assessment.

Conclusions: On the basis of the observations on our cohort, 1 in 5 operations were cancelled; 65% had an increased severity of the symptoms and just 1 in 3 patients were operated as planned while 48% required re-imaging. A long wait inevitably leads to changed symptoms and a review of these patients is mandatory. The review and the re-imaging adds to the burden on the already over-loaded system.

Purpose: To evaluate the effectiveness of the Ponseti method of the treatment i late presentation of clubfeet.

Method: Prospective study comprising 91 patients(141 feet) between August 2003 and September 2005. Age range was from 7 dats to 20 months. Majority of patients belonged to Dimeglio grade 3 (75%) and Pirani grade 4(43%) at presentation. All were treated by Ponseti method of serial casting with or wothout tendo-achillis lengthening. Tendon lengthening was required in 79% of patients. The average duration of follow up was 1.5 years.

Results: Recurrence of deformity was seen in patients who presented late and had severe deformity at time of presentation. The Ponseti technique failed to achieve correction in 4 patients. Follow up at 2 years showed overall correction rate of 95%. In develpoing countries, delayed presentation could signifucantly affect the final outcomes as the joint deformities progressively become fixed. Our study showed that number of corrective casts, recurrence of deformity and the nned for tendoachillis lengthening was inversly related to the time of presentation. This technique can be relable used to correct clubfeet even in delayed present.