Introduction

There are concerns that patient-reported outcome measures (PROMs) currently used for adults requiring, undergoing or after undergoing lower limb reconstruction (LLR) are not adequately capturing the range of experiences important to these patients. The ‘Patient-Reported Outcome Measure for Lower Limb Reconstruction’ (PROLLIT) study developed a conceptual framework of outcomes identified as important and relevant by adult LLR patients. This review explored whether existing PROMs address these outcomes, and exhibit content validity in this population.

Introduction

Knee arthrodesis is a useful limb salvage technique to maintain function in patients with complex and infected total knee arthroplasties (TKA). There are a number of commonly used external fixators, but no consensus on which of these are optimal.

The aim of this study was to synthesise the current literature to guide clinical decision making and improve patient outcomes. We systematically review the literature to compare outcomes of external fixators in arthrodesis following infected TKA.

Introduction

Schatzker V & VI tibial plateau fractures are serious life-changing injuries often resulting in significant complications including post-traumatic arthritis. Reported incidence of secondary TKA following ORIF of all tibial plateau fractures is 7.3% and 13% for Schatzker V & VI tibial. This study reports a 15-year single centre experience of CEF of Schatzker V & VI fractures including PROMs and incidence of secondary TKA. This study was approved by the local Institutional board.

Introduction

Circular external frames (CEF) are commonly used for a wide variety of indications, often when other devices are not appropriate. Circular frames are particularly associated with pin-site infection (PSI). Currently there is a gap in the available literature surrounding the risk of frame use with in-situ prosthetic joints. This retrospective study investigated the incidence of prosthetic joint infection (PJI) in a series of patients with in-situ arthroplasties treated with CEF.

Introduction

Intra articular distal tibia fractures can lead to post-traumatic osteoarthritis. Joint distraction has shown promise in elective cases. However, its application in acute fractures remains unexplored. This pilot study aims to fill this knowledge gap by investigating the benefits of joint distraction in acute fractures.

Introduction

Frame configuration for the management of complex tibial fractures is highly variable and is dependent not only on fracture pattern and soft tissue condition but also surgeon preference. The optimal number of rings to use when designing a frame remains uncertain. Traditionally, larger, stiffer constructs with multiple rings per segment were thought to offer optimal conditions for bone healing, however, the concept of reverse dynamisation questions this approach.

Aims

The standard of wide tumour-like resection for chronic osteomyelitis (COM) has been challenged recently by adequate debridement. This paper reviews the evolution of surgical debridement for long bone COM, and presents the outcome of adequate debridement in a tertiary bone infection unit.

Introduction

Circular frames for ankle fusion are usually reserved for complex clinical scenarios. Current literature is heterogenous and difficult to interpret. We aimed to study the indications and outcomes of this procedure in detail.

Introduction

Wide, tumor-like resection for chronic osteomyelitis (COM), a standard practice previously, has been challenged recently with adequate, local debridement. This paper reviews the evolution of surgical debridement for long bone osteomyelitis, and presents the outcome of adequate debridement in a tertiary bone infection unit.

Aims

Chronic osteomyelitis (COM) of the lower limb in adults can be surgically managed by either limb reconstruction or amputation. This scoping review aims to map the outcomes used in studies surgically managing COM in order to aid future development of a core outcome set.

Introduction

We undertook a qualitative study to explore what is important to people with lower limb conditions requiring reconstruction (LLR) and how it impacted their quality of life (QOL), in order to develop a conceptual framework for a new patient reported outcome measure (PROM). This builds on a previous qualitative evidence synthesis of existing research to develop a preliminary conceptual framework as part of the Patient Reported Outcomes for Lower Limb Reconstruction (PROLLIT) study.

Aims

Nearly 99,000 total knee arthroplasties (TKAs) are performed in UK annually. Despite plenty of research, the satisfaction rate of this surgery is around 80%. One of the important intraoperative factors affecting the outcome is alignment. The relationship between joint obliquity and functional outcomes is not well understood. Therefore, a study is required to investigate and compare the effects of two types of alignment (mechanical and kinematic) on functional outcomes and range of motion.

Introduction

Deformity influences the weight bearing stresses on the knee joint. Correction of mechanical alignment is performed to offload the knee and slow the rate of degenerative change. Fixator assisted deformity correction facilitates accurate correction prior to internal fixation. We present our results with standard Ilizarov and UNYCO system assisted deformity correction of the lower limb.

Introduction

There are currently no quality of life Patient Reported Outcome Measures (PROMs) that have been validated for patients with conditions requiring lower limb reconstructive surgery. The extent to which current generic and lower limb specific PROMs address relevant dimensions for these patients is unclear.

Introduction

Patient reported outcome measures (PROMs) are used to understand the impact of lower limb reconstruction on patient's quality of life (QOL). Existing measures have not been developed to specifically capture patient experiences amongst adults with lower limb conditions that require reconstruction surgery. This systematic review of qualitative studies (qualitative evidence synthesis) aimed to identify what is important to these patients.

Introduction

Superficial pin site infection is a common problem associated with external fixation, which has been extensively reported. However, the incidence and risk factors with regards to deep infection is rarely reported in the literature. In this study, we investigate and explore the incidence and risk factors of deep infection following circular frame surgery. For the purpose of this study, deep infection was defined as: persistent discharge or collection for which surgical intervention was recommended.

Aims

A pilon fracture is a severe ankle joint injury caused by high-energy trauma, typically affecting men of working age. Although relatively uncommon (5% to 7% of all tibial fractures), this injury causes among the worst functional and health outcomes of any skeletal injury, with a high risk of serious complications and long-term disability, and with devastating consequences on patients’ quality of life and financial prospects. Robust evidence to guide treatment is currently lacking. This study aims to evaluate the clinical and cost-effectiveness of two surgical interventions that are most commonly used to treat pilon fractures.

Aims

Pin-site infection remains a significant problem for patients treated by external fixation. A randomized trial was undertaken to compare the weekly use of alcoholic chlorhexidine (CHX) for pin-site care with an emollient skin preparation in patients with a tibial fracture treated with a circular frame.

Aims

Bone demonstrates good healing capacity, with a variety of strategies being utilized to enhance this healing. One potential strategy that has been suggested is the use of stem cells to accelerate healing.

Aim

Despite advances in surgical and antibiotic therapies the treatment of chronic osteomyelitis remains complex and is often associated with a significant financial burden to the National Health Service. The aim of this review was to identify the different types of single-stage procedures being performed for this condition as well as to evaluate their effectiveness.

Introduction

Fracture and deformity after frame removal is a known risk in 9–14.5% of patients after circular frame treatment. The aims of this study were to assess the effectiveness of our staged protocol for frame removal and risk factors for the protocol failure.

The management of chronic osteomyelitis is fraught with difficulties; a multi-disciplinary team approach is recommended for optimum outcome. Thorough debridement, dead space management and organism targeted antibiotic therapy the gives best clinical results. Calcium sulphate beads impregnated with antibiotic is an absorbable option for prolonged local antibiotic elution and dead space management.

This study aims to analyse the early results of single stage management of osteomyelitis with antibiotic impregnated calcium sulphate beads. Following surgical debridement, calcium sulphate impregnated typically with tobramycin and/or vancomycin is inserted to obliterate the dead space. Intravenous antibiotics – typically teicoplanin and piperacillin-tazobactam – are administered until culture results permit rationalisation to narrow spectrum agents. Patients are followed up in Infectious Diseases and Orthopaedic clinics for a period of 12 months and discharged if quiescence is achieved.

We conducted a retrospective analysis of our prospective database to identify patients treated with our single stage protocol for chronic osteomyelitis. We excluded patients that had (1) less than 6 months of follow up, (2) incomplete metal-ware removal, (3) patients lost to follow up. Fourteen patients (9 men, 5 women) with mean age of 41 (16–73) years and mean follow up of 9 (6–12) months were included in study. Eleven patients had previous surgeries involving internal fixation; the rest were primary osteomyelitis. Seven patients had washouts and removal of metal-ware procedures for osteomyelitis prior to referral to the bone infection service. Clinical, radiographic, and laboratory (microbiological, biochemical and haematological) methods were used to monitor response to treatment.

Cierney-Mader classification determined that 8 patients were classed as type A (normal hosts); 4 as BS (systemically compromised); 2 as BLS (locally and systemically compromised). Anatomic analysis suggested 7 were Type 1 (medullary osteomyelitis); the remaining 7 were type 3 (localised disease). Five patients were staged IA; three each staged IIIA and IIIBS; and one each staged IBs, IBLS, IIIBLS.

Staphylococcus Aureus was the commonest causative organism.

Follow up radiograph monitoring indicated absorption of the beads by 3 months.

There has been no evidence of recurrence based on clinical, radiographic and blood based parameters in all patients.

Short-term results of single stage osteomyelitis treatment with calcium sulphate beads impregnated with antibiotics are promising.

Open fractures of the long bones of the limbs are associated with an increased risk of osteomyelitis and few studies investigate this complication in circular frames. We reviewed the incidence of and contributory factors toward infection-related outcomes in Grade 3 open fractures, managed with a circular frame, at a single centre.

We performed a retrospective study of consecutive adult patients presenting with a Grade 3 open fracture, who required a circular frame for definitive skeletal fixation from 2005 to 2014. Patient case notes, microbiology results and radiological studies were reviewed for demographic details and surgical management. Infection-related outcomes were classified as ‘possible’ and ‘definitive’, based on clinical findings, microbiology and imaging features at follow-up at 6 and 12 months.

74 patients were identified with an average age of 43 years. There were 70 unilateral and 4 bilateral limb injuries. Most treated limbs had a tibial fracture (97%). There were 24 Gustillo-Anderson grade 3A, 37 grade 3B, 4 grade 3C and 9 not sub-classified. 33% of patients were debrided on the day of injury. Average time to circular frame installation was 14 days. 27 Ilizarov, 44 Taylor spatial and 3 other circular frames were used. A variety of plastic surgery reconstruction was used to provide wound coverage: skin grafts, local and free flaps. Circular frames were in place for 259 days on average. 10 patients (1 bilateral limb fracture) still have their frames in-situ. Additional bone grafting to the fracture site was carried out in 13 patients and 15 limbs (1 patient had 2 episodes of bone grafting to the same limb). 8 limbs in 8 patients were excluded from infection-related outcome analysis: 4 patients lost to follow-up, 2 patients who went on to below knee amputation and 2 patients had <6 months’ follow-up. 13 patients (14 limbs) had only 6 months’ follow-up and 53 patients (56 limbs) had 12 months’ follow-up. There were 5 patients (5 limbs) with ‘possible’ infection (7%): 1 screw infection and 4 soft tissue infections. 1 patient (1 limb) had a tissue-confirmed ‘definitive’ infected non-union (1.4%).

Patients managed with circular frames typically have complex fracture configurations less amenable to other methods of definitive fixation. Our patient cohort has a limb salvage rate (97%) and a soft tissue infection rate (‘possible’ infection) comparable to other reported series. We report a low rate of osteomyelitis (‘definitive’ infection) in consecutive patients managed using our protocol.

Chronic osteomyelitis is a challenging problem and a growing burden for the National Health Service. Conventional method of treatment is 2 stage surgery, with debridement and prolonged courses of antibiotics. Recently single stage treatment of chronic osteomyelitis is gaining popularity due decreased patient morbidity and cost effectiveness. Dead space management in single stage treatment is accomplished by either a muscle / myocutaneous or antibiotic loaded calcium sulphate beads.

We analysed the cost effectiveness of two dead space management strategies in single stage treatment of osteomyelitis. Study is designed to analyse the health economics at 2 time points; 45 days post surgery and 2 years post surgery. We report preliminary results at 45 days post surgery.

Setting – Level 1 trauma centre and university hospital

Approval – Ethics committee approved study

10 patients in each group were retrospectively analysed through patient records. Each group was identified for standard demographics, duration of procedure, hospital stay, type and duration of postoperative antibiotics, number of out patient visits in first 45 days and recurrence of infection.

Table attached details the results of both groups

In health technology assessment four quadrant model, CSB appears in quadrant II suggesting that it is more cost effective.

Based on small data set and on assessment only evaluating cost, at 45 days assessment, antibiotic calcium sulphate beads from a Health Economic Cost Effectiveness Analysis offers a better economic outcome. This is holding constant the morbidity of the patients and effectiveness, assuming both treatments are standards of care, which is best evaluated at 24 months.

Background:

Potential injury to the common peroneal nerve at the level of the fibula head/neck junction during fine wire insertion in stabilization of proximal fibula, is a recognised complication. This study aims to relate the course of the common peroneal nerve to fibula head transfixion wire.

Methods:

Total radiation exposure accumulated during circular frame treatment of distal tibial fractures was quantified in 47 patients treated by a single surgeon from March 2011 until Nov 2014. The radiation exposures for all relevant radiology procedures for the distal tibial injury were included to estimate the radiation risk to the patient.

Background:

Septic arthritis following intra-capsular penetration of the knee by external fixation devices is a complication of traction/fixation devices. This study aimed to demonstrate the capsular attachments and reflections of the distal femur to determine safe placements of wires.

Theatre efficiency is an increasingly important factor as the health service is faced with an ever greater number of patients, but tighter fiscal restrictions. We carried out an audit was to utilise data collected routinely on the Opera Surgical Management System (CHCA, Canada) to look at the efficiency of orthopaedic theatre usage, and to look for potential areas of improvement. The data related to all elective procedures carried out by a single Orthopaedic Consultant in a city hospital, over a one year period.

We found that lists frequently started late, with the first patient of the day entering the anaesthetic room after 9 am on over 50% of occasions. The reasons for this were not regularly recorded. There was a wide variability in the length of time taken to anaesthetise and position the patients. Although there was a weak association with the underlying health of the patients (ASA score), the seniority of the anaesthetist was not available for correlation. The turnaround time between cases was variable, with a tendency for it to take longer over the lunchtime hours. Almost a third of lists finished before 4.30 pm, mainly due to patient cancellations, however nearly a third of lists finished after 5.30 pm.

We found that data routinely collected on our theatre management system provides useful information that could potentially be used to fine-tune our peri-operative processes, however greater detail about specific timings and delays affecting the patient journey would be required before any recommendations could be made to improve theatre efficiency.

Both conservative and operative forms of treatment have been recommended for patients with a ‘floating shoulder’. We compared the results of conservative and operative treatment in 25 patients with this injury and investigated the use of the glenopolar angle (GPA) as an indicator of the functional outcome. A total of 13 patients (ten male and three female; mean age 32.5 years (24.7 to 40.4)) were treated conservatively and 12 patients (ten male and two female; mean age 33.67 years (24.6 to 42.7)) were treated operatively by fixation of the clavicular fracture alone. Outcome was assessed using the Herscovici score, which was also related to changes in the GPA at one year post-operatively.

The mean Herscovici score was significantly better three months and two years after the injury in the operative group (p < 0.001 and p = 0.003, respectively). There was a negative correlation between the change in GPA and the Herscovici score at two years follow-up in both the conservative and operative groups, but neither were statistically significant (r = -0.295 and r = -0.19, respectively). There was a significant difference between the pre- and post-operative GPA in the operative group (p = 0.017).

When compared with conservative treatment, fixation of the clavicle alone gives better results in the treatment of patients with a floating shoulder. The GPA changes significantly with fixation of clavicle alone but there is no significant correlation between the pre-injury GPA and the final clinical outcome in these patients.

Cite this article: Bone Joint J 2013;95-B:815–19.

Abstract

We present here the results of a prospective follow-up study of radiological and functional outcome in 43 patients treated using the Taylor Spatial Frame (TSF) for definitive management of tibial fractures.

Introduction

The optimal treatment of high-energy tibia fractures remains controversial. The role of external fixators has been shown to be crucial. This study aimed to compare the effectiveness of using either Taylor Spatial Frame (TSF) or Ilizarov frames in treatment of high-energy tibia fractures in a tertiary trauma referral centre.

Introduction

The Ilizarov (IF) and Taylor Spatial (TSF) external fixator frames are commonly used to manage complex fractures and bone deformities and a dedicated Frame Service Team at our unit supports patients during pre- and post-operative period. Few studies have assessed the satisfaction of patients who have been treated with Circular frames.

AIM

To study the incidence of thromboembolism among patients treated with ring fixators in lower limb injuries and their risk factor association.

Introduction

Restoration of mechanical axis is one of the main aims during Total Knee Arthroplasty (TKA) surgery. Treatment of osteoarthritis (OA) of the knee with extra-articular deformity either in femur or in tibia poses a technical challenge in achieving this aim. Insufficient correction of axis is associated with poor clinical outcome of total knee arthroplasty (TKA). Extra-articular deformity can either be addressed with compensatory intra-articular bone resection at the time of TKA or correctional osteotomy prior to or at the time of TKA.

Purpose of study

The aim of this study is to evaluate the role of low intensity pulsed ultrasound, Exogen in the treatment of delayed and non unions. Methodology: We conducted a retrospective study of 292 patients who has had Exogen treatment for delayed and non union from 2005 to 2009. Patient's age, sex, associated co morbidities, smoking history, medications, type of fractures (open/closed), infection and site of fractures were sought for. 271 patients' data (228 delayed and 43 non unions) were available during the study with mean age of 53.5 yrs.

Exogen therapy was initiated at 3–4 months for delayed unions and 6–12 months for non unions in 61 tibia (15 open); 31 femur (2 open); 20 scaphoid; 38 5th metatarsal; 31 ankle (2 open); 17 ulna (1 open); 15 radius (3 open); 29 humerus (2 open); 16 clavicles; 6 olecranon; 4 pilon (2 open) and 2 metacarpal fractures.

Introduction

There are controversies in the literature about thoracoplasty and its effect on lung function changes. The aim of the study was to evaluate the effect and outcome of thoracoplasty in conjunction with pedicle screw construct in the treatment of thoracic adolescent idiopathic scoliosis on lung functions.

Introduction

Open tibial fractures are associated with increased risk of complications, particularly a higher risk of infections and decreased functional outcome.

Background

Complex tibial fractures are difficult to treat. The costs associated with hospitalization can be substantial, yet it is unknown how these vary depending upon the type of implant used. There have been multiple studies on economics of tibial fractures but none of these studies actually focussed on costing of illizarov and taylor spatial frames. We discuss the cost analysis of 200 tibial fractures treated with illizarov or taylor spatial frames. The purpose of this study was to compare the cost of treatment of complex tibial fractures with reimbursement given to the hospital in treating such injuries.

The present study was conducted to evaluate the cost of physiotherapy both for inpatient and outpatient services. Significant physiotherapy resources are required to rehabilitate patients with an Ilizarov or Taylor Spatial Frame (TSF). Within Hull and East Yorkshire Hospitals NHS Trust Physiotherapy department the average number of outpatient treatment sessions per routine patient is 6. In comparison, the average number of treatment sessions required for a patient with an ilizarov (or TSF) is 24 for a trauma patient and 33 for a patient undergoing an elective procedure.

Seventy three (73) patients received physiotherapy treatment with an Ilizarov frame or a Taylor spatial frame between April 2008 and April 2010. Physiotherapy input was recorded (in minutes) for the patients identified. This included treatment received as an inpatient as well as an outpatient (if the patient received their treatment within Hull and East Yorkshire NHS trust).

Data collection was divided into either trauma or elective procedure for analytical purposes. The average cost of physiotherapy treatment to Hull and East Yorkshire Hospitals NHS Trust for an inpatient with an ilizarov frame is £121.82 per case (trauma) and £133.15 per case (elective).

The average cost of physiotherapy treatment to Hull and East Yorkshire Hospitals NHS Trust for an outpatient for a trauma case was calculated as £404.65 and £521.41for an average elective case. This is in comparison to a routine patient costing the service £60.29 (when treated by a Band 7 physiotherapist). The present study gives valuable data for future business planning and assistance with the setting of local or national tariffs for the treatment of this patient group.

Aim

Chronic osteomyelitis still remains challenging and expensive to treat in spite of advances in antibiotics and operative techniques. We present our experience with free muscle flap after radical debridement of chronic osteomyelitis, performed as a single stage procedure.

Introduction

Spinal infections constitute a spectrum of disease comprising pyogenic, tuberculous, nonpyogenic-nontuberculous and postoperative spinal infections. The aim of this study was to review the epidemiology, diagnostic yield of first and second biopsy procedures and microbiology trends from Sheffield Spinal Infection Database along with analysing prognostic predictors in spinal infections.

Spinal stenosis and disc herniation are the two most frequent causes of lumbosacral nerve root compression. This can result in muscle weakness and present with or without pain. The difficulty when managing patients with these conditions is knowing when surgery is better than non-operative treatment: the evidence is controversial. Younger patients with a lesser degree of weakness for a shorter period of time have been shown to respond better to surgical treatment than older patients with greater weakness for longer. However, they also constitute a group that fares better without surgery. The main indication for surgical treatment in the management of patients with lumbosacral nerve root compression should be pain rather than weakness.

Purpose

Shoulder dislocations account for 50 % of all dislocations, of which 98% are anterior dislocations. Different techniques have been described in literature with variable success, which depends upon type of dislocation, technique used and muscle relaxation.

AIM

Chronic osteomyelitis still remains challenging and expensive to treat inspite of advances in antibiotics and operative techniques.

We present our experience with free muscle flap after radical debridement of chronic osteomyelitis, performed as a single stage procedure.

Introduction

Viscosupplementation is used widely to provide symptomatic relief to patients with knee OA. This study aimed to compare the efficacy and safety of the standard (3×2ml) and single (1×6ml) dosing regimens of hylan G-F 20

Introduction

Viscosupplementation is used widely to provide symptomatic relief to patients with knee OA. This study aimed to compare the efficacy and safety of the standard (3×2ml) and single (1×6ml) dosing regimens of hylan G-F 20.

Introduction

The policy of treating open fractures within 6 hrs can result in complex operations being performed under sub optimal conditions. The purpose of this study was to determine the association between time to initial debridement and rate of infection in high energy (Grade III) open fractures of Tibia.

Plasma levels of cobalt and chromium ions and Metal Artefact Reduction Sequence (MARS)-MRI scans were performed on patients with 209 consecutive, unilateral, symptomatic metal-on-metal (MoM) hip arthroplasties. There was wide variation in plasma cobalt and chromium levels, and MARS-MRI scans were positive for adverse reaction to metal debris (ARMD) in 84 hips (40%). There was a significant difference in the median plasma cobalt and chromium levels between those with positive and negative MARS-MRI scans (p < 0.001). Compared with MARS-MRI as the potential reference standard for the diagnosis of ARMD, the sensitivity of metal ion analysis for cobalt or chromium with a cut-off of > 7 µg/l was 57%. The specificity was 65%, positive predictive value was 52% and the negative predictive value was 69% in symptomatic patients. A lowered threshold of > 3.5 µg/l for cobalt and chromium ion levels improved the sensitivity and negative predictive value to 86% and 74% but at the expense of specificity (27%) and positive predictive value (44%).

Metal ion analysis is not recommended as a sole indirect screening test in the surveillance of symptomatic patients with a MoM arthroplasty. The investigating clinicians should have a low threshold for obtaining cross-sectional imaging in these patients, even in the presence of low plasma metal ion levels.

Introduction

Spinal infections constitute a spectrum of disease comprising pyogenic, tuberculous, nonpyogenic-nontuberculous and postoperative spinal infections. The aim of this study was to review the epidemiology, diagnostic yield of first and second biopsy procedures and microbiology trends from Sheffield Spinal Infection Database along with analysing prognostic predictors in spinal infections.

Introduction

Spinal osteosarcomas are quite rare and the optimal treatment strategy is unknown. We report a series of 9 cases of osteosarcoma of the spine treated with intralesional resection and adjuvant combination therapy in order to evaluate their clinico-pathological correlation, recurrence rate and survival.

Introduction

Aneurysmal bone cysts are uncommon benign lesions affecting the spinal column. They mostly occur in the lumbar spine and have a propensity to affect adjacent vertebrae. We describe 14 aneurysmal bone cysts affecting the spinal column from the Scottish Bone Tumour Registry with regard to assess the incidence, demography, biological behaviour and recurrence rate.

Introduction

Medical Exposure Directive of the European Commission, 97/43/Euratom recommended setting-up local national diagnostic reference levels (DRLs) for the most common radiological examinations in order to comply with the law and to maintain safe clinical practice. There are no guidelines for spinal diagnostic and therapeutic procedures. The aims of this study were to evaluate local radiation doses & screening times for diagnostic spinal blocks, to look at PACS image intensifier films for diagnostic representation and to assess the accuracy of data in IR(ME) document.

Introduction

There is no consensus among scoliosis surgeons on which surface topography method and parameters may be used as an alternative to serial radiography to monitor scoliosis progression. The aim of this study was to evaluate the inter-correlation among surface rotation (4-D formetric II) with 3-D Quantec scan and 2-D cobb's angle measurements for assessing torso asymmetry in adolescent idiopathic scoliosis (AIS).

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

We reviewed 412 consecutive cementless primary THA using fully coated acetabular shell in 392 patients—with a minimum 12 to 18 year follow-up—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 and the 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.

The mean age was 74.4 years. 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 four hips. Acetabular radiolucencies were present in 54 hips (9.7%). The mean linear polythene wear was 0.06mm/year. Mean inclination was 48.4° (38–65).

Radiolucencies were present around 37 (6.6%) stems. Dislocation occurred in 10 patients (three recurrent). Re-operations were performed in nine patients (1.9%). Four acetabular revisions were performed for aseptic loosening. Other re-operations were for infection (three), periprosthetic fractures (one), cup malposition (one) and revision of worn liner (three). 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 97.1% for acetabular component. Overall survival at 12 years with removal or repeat revision of either component for any reason as the end point was 96.2%.

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.

Chordomas are slowly growing, locally aggressive primary malignant neoplasms derived from primitive notochordal cells. They tend to occur at the extreme of ages and at the two ends of the spinal column. The purpose of this study was to evaluate the presentation, morphology and behaviour of 20 non-clival, non-sacral chordoma cases.

Details of 20 cases of histologically confirmed Chordomas of the mobile spine (Cervical-7, Thoracic-7, Lumbar-6) between 1967 and 2006, were extracted from the Scottish Bone Tumour Registry. The casenotes and radiographs were retrospectively reviewed.

Non-sacral chordomas comprised 48.7% (20/41 cases) of total chordomas registered. There was a slight feminine predominance (11/20 cases). Mean age was 58.1 years (range, 12 to 82 years). Progressively worsening back pain was the first symptom in all the patients. Seven had intra-lesional (five recurred), six marginal (1 recurred) and 2 wide resections (none recurred). Eleven of the twenty-one patients were treated with adjuvant radiation therapy. In five patients, the chordoma was inoperable and all but one were treated with radiotherapy. There were 2 recurrences in the group of patients treated without adjuvant radiotherapy.

Six patients (40%) developed local recurrences and 3 patients (15%) developed metastases. There were 4 survivors including one with local recurrence. Sixteen patients died including 3 with metastases, 7 with persistent primary disease, 1 with local recurrence and 5 with no evidence of disease or died of unrelated causes. Median survival was 19 months (mean-30.2 months), with 5- and 10-year survival rates 10% and 0.0% respectively.

We found that non-sacral/non-clival chordomas had a much poorer prognosis than published in the literature. Local recurrences occurred in 40%. Intra-lesional resection should be avoided as it is associated with 71.4% local recurrence in our series.

Following the implementation of the Ionising Radiations (Medical Exposure) Regulations Act 2000 and recommendation from International Commission on Radiological Protection (ICRP), the establishment of diagnostic reference levels (DRLs) for all radiological examinations became mandatory. There are no recommended or published standards or national dosage guidelines in the UK of diagnostic reference levels available for fluoroscopy-guided diagnostic and therapeutic spinal procedures. The aim of this study is to establish reference dose area product (DAP) levels for the diagnostic spinal procedures requiring fluoroscopy as a basis for setting DRLs.

All patient data consisted of diagnostic spinal procedures done in 2009 at Newcastle General Hospital under care of 4 spinal surgeons. Radiation data were collected on specific type of the procedure, DAP and screening time. Nerve root blocks, facet joint blocks and facet joint rhizolysis were included for data collection and analysis for this study. The third-quartile values were used to establish the DRLs.

There were 387 nerve root blocks with a mean exposure per injection 171.3 cGycm² (range, 3.0 to 2029.1; third quartile 209.4). Facet joint injections were 669 at a mean radiation dose 41.3 cGycm² (range, 1.9 to 541.0; third quartile 48.9). In a total 430 facet joint rhizolysis, the mean exposure was 44.4 cGycm² (range, 7.7 to 154.5; third quartile 58.4). The mean screening times were 36.7s (range, 0.4-281s; third quartile 41s) for nerve root blocks, mean 11.2s (range, 1.8-37s, third quartile 13.3s) for single facet joint block and mean 14.6s (range, 0.1-162s, third quartile 15.1s) for single facet rhizolysis.

We found the third-quartile values for setting DRLs for single level nerve root block, single facet joint block and single facet joint rhizolysis to be 209.4, 48.9 and 58.4 cGycm² respectively. We recommend that all spinal units in the UK should establish their own local DRLs to help in establishing national dosage guidelines for fluoroscopy-guided diagnostic and also therapeutic spinal procedures.

The Walter Reed Visual Assessment Scale (WRVAS) is a valid and reliable tool, designed to measure physical deformity as perceived by patients with idiopathic scoliosis. It is unclear whether the type of treatment in patients with thoracic adolescent idiopathic scoliosis affects the patients' perception of cosmesis gain. We studied 40 patients with Adolescent Idiopathic Scoliosis treated with posterior spinal fusion with (20) and without thoracoplasty (20) aiming to assess correlation of improvement in radiological parameters to subjective cosmesis gain.

Patients with Adolescent Idiopathic Scoliosis treated with posterior spinal fusion with thoracoplasty (20) and without thoracoplasty (20) filled out Walter Reed Visual Assessment Scale (WRVAS) forms with their perception of deformity before and after operation at the clinic follow-up. The WRVAS forms include seven aspects of the deformity i.e. spinal deformity, rib prominence, lumbar prominence, thoracic deformity, trunk imbalance, shoulder asymmetry and scapular asymmetry. Each aspect is shown with five figures of increasing severity of the deformity and scored from minimum (1) to maximum (5). Results are presented as the sum of the seven questions. The lowest possible score for the total is 7, while the highest possible total score is 35. The curve magnitude was divided into 5 subgroups as 30 and under, 30-40, 40-50, 50-60 and 70 and over.

Floor and ceiling effects were analysed as percentage of cases with minimum and maximum scores.

Our study confirmed that following posterior scoliosis surgery with and without thoracoplasty, there was significant improvement in perceived appearance. Overall spinal deformity and thoracic deformity correction were comparable in two groups. However, improvement in rib hump prominence, flank prominence, restoration of truncal, shoulder and scapular symmetry were much better rated by the patients with PSF and thoracoplasty group using Walter Reed Visual Assessment Scale.

Chondrosarcomas are uncommon primary malignant cartilaginous tumours, even less common in spine. Surgical excision is the only mode of successful treatment as these tumours are resistant to conventional chemotherapy and radiation therapy. We share our experience of 22 cases of chondrosarcomas of the spine with special reference to their recurrence and survival.

We identified 20 conventional and 2 dedifferentiated chondrosarcomas from the Scottish Bone Tumour Registry database between 1964 and 2009. Radiology and histopathology were documented. The mean follow-up was 5.2 years.

There were 14 men and 8 women with a mean age of 50.1 years. There were 7 under the age of 40 years (31.8%). The majority of lesions occurred in the thoracic spine (16), followed by sacrum (3), lumbar (2) and cervical spine (1). The overall local recurrence rate was 45.4% (10/22 cases-once in 5, twice in 2 and thrice in 3 patients).

Four patients presented with pulmonary metastases leading to death. The estimated overall 5- and 10-year survival rates were 31.8% and 18.1% respectively. We found that 1/3^rd of chondrosarcomas of the spine occured below 40 years of age and 3/4^th in the thoracic spine. Every other case was associated with local recurrence with a 32% 5-year and 18% 10-year survival rates.

Sacro-coccygeal chordomas pose a difficult diagnostic and therapeutic problem due to late presentation, large size, soft-tisue extension, difficulties in obtaining adequate resection margins, higher local recurrence rate and uncertain effectiveness of adjuvant treatment. We present a series of 21 patients of sacral chordomas obtained from Scottish Bone Tumour Registry to analyse predictors of local control and survival.

The clinical and morphologic features, type of treatment and follow-up of 21 consecutive patients with sacral chordoma were retrospectively reviewed and analysed. The data were obtained from Scottish Bone Tumour Registry.

The average age at time of the biopsy was 59 years (range, 12 to 82 years): twelve patients were male and nine were female. Pain was the presenting symptom in all patients. Two had intralesional (both recurred), 9 marginal (4 recurred) and 3 wide resections (1 recurred). Fifteen of the twenty-one patients were treated with adjuvant radiation therapy. In seven patients, the chordoma was inoperable and all but one were treated with adjuvant radiotherapy. Local recurrence and metastases occurred in 7 (50%) and 5 (23.8%) patients. The 5-year and 10-year survival were 38% and 14.2%, respectively.

Excision of the lesion combined with adjuvant radiation therapy provided satisfactory results. Local recurrence presents a major problem in the management of sacral chordomas (50%). Intralesional resection should be avoided as it is associated with 100% local recurrence in our series.

Proponents of thoracoplasty suggest a better correction, obviating iliac crest donor site morbidity, obtaining bone grafts for fusion and better rib hump correction. Opponents suggest increase risk for chest complications, additional operating time and blood loss, and possible longer hospital stay. There are controversies in the literature about thoracoplasty and its effect on lung function changes. The aim of the study was to evaluate the effect and outcome of thoracoplasty in conjunction with pedicle screw construct in the treatment of thoracic adolescent idiopathic scoliosis on lung functions.

It is a retrospective study of consecutive series of 62 patients with thoracic adolescent idiopathic scoliosis surgically treated by single surgeon between 2007 and 2008 at a tertiary referral Orthopaedic Spinal unit. Posterior spinal fusion and thoracoplasty (n=32, all but one girls) were compared with 30 without thoracoplasty (all but one girls). Clinical and radiographic analysis was performed, including the SRS-30 questionnaire and Pulmonary Function Tests (PFT). Absolute and percent-predicted values of forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and total lung capacity (TLC) were evaluated preoperatively and at 3-months, 1 year and/or 2-year follow-up, and comparisons were made between two groups. The minimum follow-up was one year.

No statistical differences were found between the two groups in PFT's both pre-operatively and at latest follow up ranging 1 to 3 years. Our findings suggest that thoracoplasty did not adversely affected long-term PFT's in AIS patients compared to patients treated by posterior spinal fusion alone. Three-month postoperative pulmonary function test values in both groups experienced 15-30% decline which returned to the preoperative baseline at 1 year in > 90% patients. In thoracoplasty group, 5 to 8 ribs were resected and used for bone graft. Chest complications were observed in 2 patients requiring chest drainage. Prolonged donor site morbidity was noted in 3 patients.

Thoracoplasty showed comparable clinical and radiological correction without any significant pulmonary function compromise. Pulmonary function test values returned to the preoperative baseline at 1 year in > 90% patients.

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: 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.

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.

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.

Purpose of study: To test the hypothesis that previous hip involvement leads to earlier presentation and a better outcome for the contra-lateral hip in bilateral Legg-Calve-Perthes’ disease (LCPD).

Method: Case notes and radiographs of 250 patients with LCPD treated by a single surgeon between 1984 and 2003 were retrospectively reviewed. Thirty three patients (4 girls: 29 boys) with a minimum 1 year follow-up were identified with bilateral involvement from a prospectively collected database. Patients were grouped according to age at presentation (Group A-< 6 years; Group B- 6–8 years; Group C-> 8 years). All radiographs were reviewed and consensus was obtained on the presenting Waldenstrom stages. The severity of disease was rated by Catterall and lateral pillar classifications. The outcome was determined by the Stulberg classification. The right hip was the first affected in 25 of the 33 hips.

Results: These are summarized below.

Conclusions: The present report, with 33 patients, is the second largest series of patients with bilateral LCPD to our knowledge. The second hip involvement was milder than the first, but the improvement in outcome was statistically insignificant.

Introduction: Pigmented villonodular synovitis is an uncommon, benign, proliferative, neoplastic process of the synovial membrane presumed to be of histiocytic origin and is likely to cause diagnostic dilemma. We present 4 cases with varied presentations in the form of increasing groin pain, inguinal mass, co-existing osteoarthritis which were subsequently confirmed to have PVNS.

Methods and results: Clinical records and imaging modalities of 4 patients with histologically confirmed Pigmented villonodular synovitis of the hip, accrued from Scottish Bone Tumour Registry between 1969 and 2000 were reviewed.

Discussion: PVNS of the hip is an important differential diagnosis when osteoarthritis is associated with atypical clinical picture or lytic lesions. Although it remains confined to the joint, soft tissue masses extending beyond the capsule in to retroperitoneum or anterior and posterior aspects of hip have been reported as shown here. Radiographs in early stages are normal or include a concentric joint space narrowing. MR is an important non-invasive modality for surgical planning and to define the size and extent of the lesion, recurrence, delineating between synovial proliferations and periarticular or intra-abdominal organs. The role of arthroscopy, both diagnostic and therapeutic, is rapidly emerging, although, it has its own limitations. A carefully performed total excision often prevents recurrence as can be seen in this series.

Intraosseous schwannoma is a rare benign neoplasm, which most commonly arises in the head and neck region particularly the mandible, due to the long intraosseous path of sensory nerves in the mandible. We present a 27-year-old lady with an unusual presentation of an intraosseous schwannoma of the first metatarsal. There is only one report published previously of an intraossous schwannoma of the lesser metatarsal bone of the foot.

A 27-year-old woman presented with painful left forefoot following a trip while walking. Plain radiographs demonstrated a pathological fracture through a lytic lesion of the first metatarsal of the left foot. MRI scan using axial T1-weighted spin echo and axial and sagittal T2-weighted gradient echo showed an amorphous mass occupying the medulla of the bone but with a breach of the plantar aspect of cortex with apparent localised destruction. Ultrasound-guided biopsy was performed. Haematoxylin and Eosin stained specimen sections showed a proliferation of spindle cells of alternating hypercellularity and hypocellularity. This case was managed by curettage and grafting with autograft and synthetic bone substitute. At two-year follow-up, the radiographs showed complete graft incorporation and a healed cyst. The patient was clinically asymptomatic with return of full functions. There were no clinico-radiological findings to suggest any recurrence.

Due to rarity and non-specific clinico-radiological features, this case illustrates the necessity of a multi-disciplinary approach with an accurate histological diagnosis in combination with radiological and clinical appearances.

Objective: To analyse long term outcome of pedicled patellar implantation in treating the defect of the knee joint after the excision of giant cell tumor of distal femur.

Methods: The geometry of patella has lead to its use for condylar reconstruction following resection for giant cell tumour around knee. 15 such patients were treated at our institute and followed up for a mean period of 7.3 years. Average age at presentation was 14.8 years. All patients had plain x-rays, angiography as needed, CT scan and MRI to check integrity of articular cartilage and ACL. Size of lesion was measured on CT. Predominant lateral condyle involvement was found in 6 and medial in 9 patients. The patella was dissociated with a slip of quadriceps attached to its proximal superior-medial pole and rotated to place it horizontally in the zone of resection. Firm osteosynthesis to intact condyle and autogenous bone grafting was carried out.

Results: Grafts consolidated at a mean of 10.8 months. All joints were fairly stable and 70% had movement of 90 degrees without pain. 11 patients had excellent outcome with ability to carry on occupations involving manual labour. There were reoperations for 2 deep infections, 1 recurrence leading to arthrodesis, 1 supracondylar fracture, 2 arthrolysis and 1 valgus osteotomy. 4 patients had arthritic changes and extensor leg at 6 years follow up. No AVN changes or extensor mechanism problems occurred. Using chi square test for log rank analysis significant relationship was found between size of lesion and range of motion (P=0.03) as well as articular cartilage grading and development of arthrosis. The rate of healing was faster than other series reporting free patella grafting.

Conclusion: Patellar implantation is a suitable way to repair the defect of the knee with better immediate functional results subsequently delaying eventual prosthesis surgery.

Between 1948 and 2004, we report 34 patients with Ewing’s sarcoma of pelvis accrued from Scottish Bone Tumour Registry, aiming to identify the prognostic factors and the influence of various treatment modalities on outcome. There were 19 male and 15 female patients at a mean age of 19 years (range, 3 to 48 years). The Pain was main presenting symptom in 30, swelling in 12 and restriction of hip movements in 11 patients. The commonest anatomical site was ilium. Local control was achieved by surgery, radiotherapy (n=25), chemotherapy (n=23) or a combination. The survival correlated significantly with chemotherapy protocols in favour of the group that received ifosamide (p< 0.01). Metastases at presentation was the most important factor determining survival (P< 0.01). Among the patients who presented without metastases (n=25), there was no statistically significant difference in survival based on the anatomical location of the tumour, age or sex. The mean time to lung metastases from the date of presentation was 13 months, while bone metastases presented at an average of 20 months. None of the patients with the metastasis or local recurrence survived. There were 5 local and 17 systemic (metastatic) relapses. The mean duration of survival was 13 months.

With advances in imaging, aggressive chemotherapy, surgery and conformal radiotherapy which can deliver high dose of radiation with precision, it is possible to achieve a cure rate of more that 50% in non-metastatic pelvic Ewing’s sarcoma. The results of this study favour a middle-path regime combining all treatment modalities.

Limb salvage surgery includes all of the surgical procedures designed to accomplish removal of a malignant tumour and reconstruction of the limb in order to achieve an acceptable oncological, functional, and cosmetic result. The aim of this study was to evaluate the functional outcome following endoprosthetic replcament for primary upper & lower extremity musculoskeletal neolplasms.

Between 1983 and 2004, we found 68 patients from the Scottish Tumor Register having had an endoprosthetic reconstruction for upper and lower-extremity malignant musculoskeletal tumours, of which 32 were alive for performing functional assessment (lower extremity-26, upper extremity-6). The clinical, radiological and oncological outcomes were evaluated. The functional outcome was measured by the Musculoskeletal Tumor Society and Toronto Extremity Salvage Score.

The average follow-up was 59 months (range, 1 to 21 years). There were 19 female and 13 male patients. These were anatomically distributed as around the knee (n=18 cases), hip (n=8) and shoulder (n=4). The most common diagnosis was chondrosarcoma (n=10) and osteosarcoma (n=11). Most of the patients were completely satisfied with their condition, with a decreased walking distance as the only notable restriction. There was no correlation between the functional outcome and the type or site of resection. Complications occurred in ten cases, including two cases of aseptic loosening and one case each of recurrent instability, sciatic nerve palsy and femoral nerve palsy. The median functional score using the Musculoskeletal Tumour Society system was 56% and Toronto Extremity Salvage Score was 72%.

Limb salvage for malignant musculoskeletal tumours continues to pose therapeutic and oncological challenges with considerable functional issues, but the good function and local tumour control in most patients justifies its continued use.

Primary lymphomas of bone are uncommon malignancies with involvement of spine, long bones, pelvis, ribs and skull in decreasing order of frequency. We describe an unusual case who presented with recurrent knee effusions turned out to be a high grade B-cell non-Hodgkin lymphoma.

A 34-year-old man is presented with painful recurrent knee effusions without any systemic aberration. Multiple aspirations were carried out to help knee pain and swelling with immediate response, but had negative cytology. Hematological and biochemical parameters were normal. Plain radiographic examination of the knee failed to show any bony abnormalities. An MRI scan of the knee showed extensive marrow oedema of the distal femur with breach in the anterior cortex. Subsequently, open biopsy of the lesion was carried out which confirmed the diagnosis of a high grade B-cell Non-Hodgkin lymphoma. Staging CT-scan of the chest, abdomen and pelvis failed to show any other lesions elsewhere. He was subsequently treated with the help of multi-drug chemotherapy and radiotherapy. At 7 months post treatment, the patient had no relapse and a repeat MRI at 7 months showed reduction in the size of lesion.

This case illustrates the limitations of plain radiograph and the usefulness of MRI in the diagnosis of bony lymphoma. The diagnostic dilemmas while investigating recurrent knee effusions due to primary skeletal Non Hodgkin lymphoma should be resolved by timely MRI scan and histological diagnosis.

Background: Extraarticular distal radius fracture is the second most common osteoporotic fracture seen in the elderly patients.

Purpose: To establish relationship between radiological parameters and final functional outcome in conservatively treated displaced extraarticular distal radial fractures in elderly patients.

Methods: Twenty-two wrists with displaced extraar-ticular distal radial fractures in twenty sedentary, low demand elderly patients treated with manipulation under anaesthesia and plaster application between May 1999 and June 2000. The case notes and radiographs of these patients were assessed retrospectively and subjective outcome was evaluated with validated DASH Questionnaire at 3 years post- reduction. Overall satisfaction, ability to return to the previous level of activity and concern over wrist appearance was further analyzed. Only those patients with more than 5 mm of shortening and more than 15 degrees of dorsal angulation at initial radiographs were included. Results were analysed using Pearson Correlation Sig.(2 –Tailed) formula.

Results: There were 16 female and 4 male patients with a mean age of 71 years. The mean follow-up was 3 years. DASH score of less than 25 was seen in 14, between 25-50 in 3 and between 50-75 in 3 patients with mean of 21.426 and standard deviation of 22.353. Despite residual deformity in some patients, there was high degree of patient satisfaction consistent with low level of DASH score found in 71% patients. It was also noticed that Males in the study group were younger and have lower dash scores. Patients with more than 5 mm of shortening and more than 15 degrees of dorsal angu-lation at initial radiographs showed no adverse correlation with subjective outcome. Statistical analysis of the results confirmed that higher the age lower the DASH score there by better functional result.

Conclusion: It was noted that the higher the age the lower the dash score. Radiological picture and functional outcome are found to be two independent variables in the elderly subgroup of patients with displaced extrar-ticular distal radius fractures. Nonoperative treatment yields satisfactory results with high patient satisfaction rate and is advocated in elderly patients.

Does the type of implant have any correlation with critical fusion time of hallux metatarsophalangeal joint? There are few cadaveric biomechanical studies published in the literature assessing the strength and rigidity of different fixation methods. Although it is still unclear whether the amount of metal affects the fusion rate, the aim of this study was to assess whether using a supplementary dorsal ¼ tubular plate in addition to a compression screw gives any added rigidity to the fusion area leading to an earlier fusion.

A retrospective analysis was conducted on the first metatarsophalangeal joint fusion in 26 consecutive patients (34 feet) between April 1998 to February 2002 comparing using single screw versus a screw supplemented with a dorsal ¼ tubular plate. There were 18 females and 8 males with a mean age of 51.5 years and a mean follow-up of 2.9 years. The final fusion was assessed clinically and radiologically by trans-articular trabeculation.

There was a fusion rate of 97%. All patients except one had solid fusion. One case had non-union. Four cases had superficial wound infection, which settled down with appropriate antibiotic therapy. Paraesthesia over the dorso-medial aspect of the big toe in three patients and transfer metatarsalgia in two patients were documented.

The type of implant did not show any direct correlation with the complication rate. There is no evidence to suggest in this study relating the amount of implant to final outcome. Therefore the choice of implant fixation can be at the discretion of the operating surgeon.

Necrotising fasciitis is a rapidly spreading, life-threatening condition. We report a case of necrotising fasciitis in a 71-year-old woman after a primary total hip replacement which became deeply infected as a result.

There are few reports describing dislocation of the metacarpophalangeal joint of the thumb in children. This study describes the clinical features and outcome of 37 such dislocations and correlates the radiological pattern with the type of dislocation.

The mean age at injury was 7.3 years (3 to 13). A total of 33 children underwent closed reduction (11 under general anaesthesia). Four needed open reduction in two of which there was soft-tissue interposition. All cases obtained a good result. There was no infection, recurrent dislocation or significant stiffness.

So-called ‘simple complete’ dislocations that present with the classic radiological finding of the joint at 90° dorsal angulation may be ‘complex complete’ injuries and require open reduction.

Introduction: The thumb metacarpophalangeal (MCP) joint dislocations in children are relatively uncommon and scarcely described in the English literature. The aim of this study was to report the clinical course and outcome of traumatic dislocations of the thumb metacarpophalangeal joints in children.

Materials and methods: We retrospectively reviewed a cohort of 37 traumatic dislocations of the thumb metacarpophalangeal joints in 37 children between 1990 and 2005. All patients were treated by five orthopaedic surgeons at a tertiary referral children’s hospital. The outcome measures included patient demographics, method of reduction and short-term outcome. The mean follow-up was 6 weeks.

Results: The mean age at injury was 7.3 years. These occurred predominantly in boys (78.3%) and were dorsal dislocations in 97.2%. Thirty-three presented acutely on the day of injury, while 3 within 1–2 weeks. Four patients needed open reduction with or without temporary stabilisation. Thirty-three had a closed reduction (under general anaesthesia-12, under ring block-5, under sedation-9 and without anaesthesia-7). All patients undergoing closed or open reduction under anaesthesia had 1–4 unsuccessful relocation attempts. Two of four open reductions revealed soft tissue interposition of volar plate and flexor pollicis longus. Post-reduction, the thumb was immobilised in a thumb spica or plaster for 2 to 3 weeks period. All gained good result. There were no infections, recurrent dislocation or gross stiffness.

Conclusion: Thumb metacarpophalangeal (MCP) joint dislocations in children are mostly dorsal and managed non-operatively in majority with satisfactory outcome. Irreducible dislocations may need open reduction due to volar plate and flexor pollicis longus tendon interposition.

Introduction: There is paucity of literature describing complex lateral condylar mass (LCM) fractures of the elbow in children, which we define as a LCM fracture occurring concurrently with another fracture or dislocation in the same elbow. The aim of this study was to evaluate the management, outcome and complication rate of 26 complex LCM fractures and to analyse difference in the outcome between the isolated and complex LCM fractures.

Materials and methods: Between 1990 and 2005, we identified 26 complex LCM fractures in the departmental database (1% of 2502 elbow/humeral injuries). Information was collected from theatre-charts, casenotes and radiographs. The mean follow-up was 5.9 months (range, 6 weeks to 4 years).

Results: These were complex because of their association with elbow dislocation (n=12; mean age 8.2 years), olecranon fracture (n=8; mean age 4.1 years) and medial condylar fracture (n=6; mean age 8 years). Nine were treated conservatively. The remaining 17 were fixed with K-wires (9), a screw (7) or both (1). A concomitant elbow dislocation was managed by closed reduction followed by open K-wiring or screw fixation of the LCM fracture. An associated olecranon fracture was treated non-operatively for minimally displaced fractures, although one needed internal fixation. All displaced T-condylar fractures required open reduction and internal fixation. There were no complications of non-union, mal-union, avascular necrosis, cubitus valgus or tardy ulnar palsy. Healing and return of normal function occurred in all, although six patients had minor loss of extension.

Conclusion: We found no obvious difference in the outcome between the isolated displaced LCM fractures described in the literature and our complex LCM group. However the importance of careful assessment of the preoperative radiographs and testing of elbow stability by examination under anaesthesia is stressed.

Introduction: There remains little evidence to discern whether K-wires or screws have different outcomes in the management of lateral condylar mass (LCM) fractures in children. We studied 77 displaced (Jacob types II and III) fractures of the lateral humeral condyle in 77 children in order to infer the relative benefit of one strategy over another.

Materials and methods: Between 1995 and 2005, we identified 77 LCM fractures in the departmental database. Information was collected from theatre-charts, casenotes and radiographs. We analysed demographic data, fracture features, treatment modalities, complications, and clinical and radiographic results. We excluded all complex LCM associated with elbow dislocations, olecranon fractures and bi-condylar fractures. The mean follow-up was 5.3 months (range, 6 weeks to 3 years).

Results: We reviewed the results of screw osteosynthesis (n=44) versus K-wire (n=33) at an average age of 5.3 years (range, 8 months to 10.9 years). There were 49 boys and 28 girls. The average interval between the injury and the operation was 1.6 days. The mean duration of implant removal was 3.6 weeks (for K-wires, removed without anaesthesia) and 20.7 weeks (for screws, removed under general anaesthesia). There was no non-union in this series. None of the patient needed a revision of osteosynthesis. Superficial wound infection (all K-wires) was found in three patients, which was completely settled with antibiotic therapy. One patient had cubitus valgus deformity (screw), which required a corrective osteotomy. Loss of range of motion of 10–50° was found in 6 cases (3 in each group).

Conclusions: Based on our observations, we believe that K-wire fixation had comparatively similar outcome to screw fixation, although, this necessitates a second procedure for removal of screw.

This study aimed to analyse clinical, radiological and histological features of 29 cases of pathological fractures of the long bones either presented as or occurred during the course of sarcomatous degeneration in Paget’s disease of bone utilising Scottish Bone Tumour Registry between 1950 to 2000. The mean age was 67.2 (range, 53–81) years with 16 males and 13 females. The commonest bone affected was the femur (n=13) followed by humeral (n=8), tibial (n=5), ilium (n=2) and os calcis (n=1) fracture. The mean duration of symptoms prior to presentation was two months. Fourteen patients presented with pain associated with a pathological fracture. One patient presented with painless lump and eleven with painful swelling followed by a pathological fracture. In the remaining three, the patients reported with a delayed or non-union of the pathological fracture. Nine patients presented acutely as pathological fracture being their main presenting symptom. The typical radiological appearance was a lytic (n=22). Histology showed predominantly osteosarcoma (n=17) followed by malignant fibrous histiocytoma (n=7) and pleomorphic sarcoma (n=5). Amputation was carried out in 16, internal fixation in 5 and replacement arthroplasty in two (1-cemented bipolar and 1-Charnley’s total hip arthroplasty). In addition, adjuvant radiotherapy in 13, adjuvant chemotherapy in 3 and combined radiotherapy-chemotherapy in 2 patients was instituted. The mean survival was 19.3 months (humeral=4.6, pelvifemoral=30, tibiocalcaneal=23.3 months). In conclusion, the majority of the pathological fractures in Paget’s sarcoma behave differently from their counterparts (non-Pagetic pathological fractures) with regard to their limb ablation treatment rather than stabilisation operation. The actual occurrence of a pathological fracture did not show to significantly affect the overall survivorship.

Between 1944 to 2003, eighty nine cases were registered with a diagnosis of Paget’s sarcoma in the Scottish Bone and Soft Tissue Tumour Registry. We found thirteen cases of sarcomatous degeneration of the spine (0.26% of the total bone tumour registry case) which were analysed in this study elaborating clinical, radiological and histopathological features. The mean age was 66.9 years (range 56 to 79 years). There were ten males and three females. There were seven cases involving sacral spine (63.6%), three cases involving lumbar vertebrae and two affecting dorsal spine. One case had diffuse dorso-lumbar involvement from D11 to L3 vertebrae. The mode of presentation was increasing low back pain (in all 13), unilateral sciatica (6, left sided-5, right sided-1), bilateral sciatica (2), lower limb weakness (8) and autonomic dysfunction (4, presented as chronic cauda equina syndrome). The majority of the cases (69.23%) were osteosarcomas. Out of these osteosarcomas, two showed giant cell rich matrix and one revealed predominant telengiectatic areas. Rest of the histological types was shared by chondrosarcoma, fibrosarcoma and malignant fibrous histiocytoma. Decompression laminectomy was performed in three cases. Eight patients had received radiotherapy. The mean survival was 3.93 months (range, 1 week to 7 months), nearly half to the whole Scottish Paget’s sarcoma series with a mean survival of 7.5 months. We found a constellation of symptomatology due to radiculo-medullary compression with a fatal evolution, predominantly lumbosacral involvement, predominantly osteosarcomatous histopathology with a poorest prognosis of all Paget’s sarcoma. Although, decompression laminectomy and adjuvant radiotherapy provided reasonable pain relief and palliation; however, there was no significant influence on the overall prognosis of the patients with Paget’s sarcoma of spine in the last six decades.

Ten cases of histologically proven chondromyxoid fibroma (CMF) of the Foot and Ankle with a mean follow-up of 6.1 years were reviewed. The mean age was 19 years (12.8 for skeletally immature and 25.2 for remaining skeletally mature patients). There were 6 males and 4 females. There were 5 phalangeal (3-proximal, 1-middle and 1-terminal phalanx), 3 metatarsal, 1 tarsal affecting body of os calcis and one case of distal tibial involvement. The mean delay in presentation was 16.7 months. The common modes of presentation were pain only (n=4), painful lump (n=4) and painless lump (n=2). Typical x-ray finding was an expansile, lobulated, cystic metaphyeal lesion. Cortical erosion was documented in 50% patients. Histology confirmed by several pathologists due to difficulty in diagnosis. There were two atypical CMF. In four cases, curettage alone was carried out, while 5 underwent curettage along with autogenous bone grafting. One case of distal phalangeal CMF had primary toe amputation. Postoperatively, calcaneal CMF had infection (treated with wound debridement and re-curettage). Two cases observed recurrences after 9 and 16 months from their initial operation. Both of them were male, had preliminary proximal phalangeal CMF, showed to have cortical erosion and were treated with curettage only. Re-curettage was done for one, while toe amputation through the metatarsal neck was performed for another recurrence. Foot phalangeal CMF which were initially treated with curettage only should be kept under close follow-up as we observed 20% recurrence rate within two year period. Cases with cortical erosion should be supplemented with autogenous bone grafting.

A 68 year old lady presented with one year history of painful right heel. She noticed slowly growing swelling resulting in broadening of the heel and difficulty in putting on her shoe-wear for a period of two months. On physical examination, there was a diffuse swelling over the posterior aspect of the right heel. The mass was firm to hard, mildly tender on palpation, fixed to bone and deep-seated. There was no erythema with increased warmth over the area of the mass. Plain x-ray of the affected heel revealed a pathological avulsion fracture of the posterosuperior corner of the calcaneus with typical Pagetoid features in the form of diffuse cortical thickening, coarsened trabeculae, loss of corticotrabecular differentiation and poorly demarcated osteolytic destruction. The lateral radiograph of the left heel showed normal radiological appearance of the os calcis. Chest x-ray was normal. The histological examination showed malignant fibrous histiocytoma characterised by the abundance of pleomorphic cells, spindle cells, lipid containing macrophages and touton type giant cells. The microvascular invasion and amount of mitosis declared the tumour as a high grade anaplastic, pleomorphic tumour. A below knee amputation was done approximately 3 weeks from the date of biopsy and after full staging. The patient died after surviving for a period of 6 years and 8 months from the date of biopsy. It is important to recognise the fact that an avulsion fracture can be pathological in nature and secondary to Paget’s sarcoma in patients with Paget’s disease. This case highlights that a high index of suspicion should be observed in patients presenting with a chronic heel pain who are shown to have pre-existing Paget’s disease on radiological grounds and who may have an avulsion fracture or other localising signs of underlying sarcomatous degeneration.

We describe a 65 year old gentleman presented with a three month history of painful lump in the right forearm which was subsequently confirmed to be osteosarcomatous degeneration in the Paget’s disease of the radius.

A 65 year old gentleman presented with a three month history of painful lump in the right forearm with overlying redness thought by the patient to be the result of recent sun exposure. On physical examination, there was an 8 x 10 cm sized mass over the radial aspect of the right forearm. The mass was soft to firm, mildly tender to palpation, fixed to bone and deep-seated. There was erythema with increased warmth over the area of the mass. There was significant restriction of forearm supination and pronation. Neurovascular examination was normal. Chest x-ray was normal. Plain x-ray of the affected forearm revealed a mixed pattern (both sclerotic and lytic appearance) affecting the entire diaphyseal portion of the radius with soft tissue extension in the mid-shaft. There were alterations in the trabecular pattern of the bone, thickened cortices, encroachment of the medullary space and an increase in the size and deformity of the entire length of the radius with cortical destruction sparing the ulna. Bone scan showed multiple hot foci with an increase uptake in the sacrum, left hemipelvis, L3 vertebra and intensely increased uptake over the right radius. On the 10th day of presentation, an open incisional biopsy was done. Microscopy showed a high grade sarcomatous tumour with areas of osteoid formation. There was evidence of vascular invasion. The presence of preexisting Paget’s disease of bone was confirmed in the specimen. An above elbow amputation was done 4 weeks from the date of biopsy and after full staging. The patient died 16 months with multiple metastases from the date of diagnosis.

Any patient with Paget’s disease who develops new pain in a previously pain-free area of Paget’s disease, or worsening of pain, or a painful progressive mass or a lytic area in sclerotic Paget’s bone should be evaluated for possible sarcomatous degeneration.

Fourteen cases of pigmented villonodular synovitis (PVNS) of the foot and ankle (between January 1957 and December 1999) accrued from Scottish bone tumor registry are presented with an average follow-up of 4.6 years aimed to analyse the clinical, radiological and histopathological features in order to investigate the clinical behaviour of PVNS in the foot and ankle, and to determine the factors influencing recurrence. The mean age was 26.4 years (range, 8 to 52 years). There were eight females and six males. The mean delay in presentation was 10.3 months. The anatomical sites were foot phalanges (n=2), tarso-metatarsal area (n=3) and hindfoot (n=9). Hindfoot cases comprised of 6 extra-articular soft tissue swelling around the ankle, two affecting the ankle joint and one involving the subtalar joint. There were eight (57.1%) cases presented with painless lump, five (35.7%) patients with painful lumps and one case with a lump associated with toe deformity. The clinical suspicion were ganglion, gout, soft tissue swelling (? tumour) and exostosis. Peri-articular tissue invasion and cortical infiltration was found in one third on plain films. CT scan showed multiple lytic lesions and MRI scan findings were consistent with extensive low signal soft tissue hypertrophy and bone erosion, two of which were suspected with synovial sarcoma. Excision of the lump was done in 4 cases with a complete recovery. Foot phalangeal PVNS were treated with toe amputation through metatarsophalangeal joint and no cases had recurrence of the lesion. There were two recurrences affecting the ankle and the subtalar joint. Recurrent ankle PVNS was treated with re-exploration, open synovectomy, curettage of talar cyst and autogenous bone grafting. The second recurrent case involving subtalar joint was treated with re-excision and curettage. Both recurred cases were primarily treated with intralesional excision for their diffuse variety. There were no recurrences in the nodular variety. Complete recovery was achieved in 85.7% case (12/14). A high index of suspicion for PVNS should be observed for cases presenting with a painless or painful mass in the foot and ankle region. Complete recovery can be achieved in the majority by complete excision. Toe amputation may be considered for foot phalangeal PVNS.