Derek H. Park

The Use of Massive Endoprostheses for the Treatment of Bone Metastases

Purpose. We report a series of 58 patients with metastatic bone disease treated with resection and endoprosthetic reconstruction over a five-year period at our institution. Introduction. The recent advances in adjuvant and neoadjuvant therapy in cancer treatment have resulted in improved prognosis of patients with bone metastases. Most patients who have either an actual or impending pathological fracture should have operative stabilisation or reconstruction. Endoprosthetic reconstructions are indicated in patients with extensive bone loss, failed conventional reconstructions, and selected isolated metastases. Methods and Results. We identified all patients who were diagnosed with metastatic disease to bone between 1999 and 2003. One hundred and seventy-one patients were diagnosed with bone metastases. Metastatic breast and renal cancer accounted for 84 lesions (49%). Fifty-eight patients with isolated bone metastasis to the appendicular skeleton had an endoprosthetic reconstruction. There were 28 males and 30 females. Twelve patients had an endoprosthesis in the upper extremity and 46 patients had an endoprosthesis in the lower extremity. The mean age at presentation was 62 years (24 to 88). At the time of writing, 19 patients are still alive, 34 patients have died, and 5 have been lost to follow up. Patients were followed up and evaluated using the musculoskeletal society tumour score (MSTS) and the Toronto extremity salvage score (TESS). The mean MSTS was 73% (57% to 90%) and TESS was 71% (46% to 95%). Mean follow-up was 48.2 months (range 27 to 82 months) and patients died of disease at a mean of 22 months (2 to 51 months) from surgery. Complications included 5 superficial wound infections, 1 aseptic loosening, 4 dislocations, 1 subluxation, and 1 case, where the tibial component of a prosthesis rotated requiring open repositioning. Conclusions. We conclude that endoprosthetic replacement for the treatment of isolated bone metastases is a reliable method of limb reconstruction in selected cases. It is associated with low complication and failure rates in our series, and achieves the aims of restoring function, allowing early weight bearing and alleviating pain.

Proximal femoral replacements for metastatic bone disease: financial implications for sarcoma units

Metastatic pathological fractures of the proximal femur are increasingly treated by endoprosthetic proximal femoral replacement. We report the results and the costs incurred performing these procedures at our supra-regional sarcoma unit. Sixty-two patients underwent 63 proximal femoral replacements for metastatic bone disease over a seven-year period. Breast cancer was the most common primary pathology. One patient underwent a revision procedure for infection. Twenty-two patients suffered dislocations, most commonly those undergoing a conventional arthroplasty articulation. The estimated cost of a proximal femoral replacement is £18,002 at our centre. Less than half of this is reimbursed under Payment by Results. Endoprosthetic replacement of the proximal femur is an effective treatment of metastases, but is poorly reimbursed under current funding arrangements.

Volar plating for distal radius fractures--do not trust the image intensifier when judging distal subchondral screw length.

Background: The use of the volar plate to treat distal radius fractures is increasing but despite the theoretical advantages of a volar approach there have been reports of extensor tendon ruptures due to prominent screw tips protruding past the dorsal cortex. The valley in the intermediate column between Lister tubercle and the sigmoid notch of the distal radius makes it difficult to rely on fluoroscopy to judge screw length. Our aim was to quantify the dimensions of this valley and to demonstrate the danger of relying on intraoperative image intensification fluoroscopy to determine lengths of distal screws. Methods and Results: We measured the depth of this valley in the intermediate column of the distal radius in 33 patients with computed tomographic (9 patients) or magnetic resonance image (24 patients) scans of the wrist. There was a consistent valley in all images examined [average 1.8 mm (95% confidence interval, 1.6-2.0 mm)]. Thirty-nine percent of wrists had a valley depth of at least 2 mm. Conclusions: Standard lateral views or rotation of the forearm to obtain oblique views does not identify prominent screw tips; and whatever the rotation of the forearm, screw tips protruding beyond dorsal cortex may look as if it is within the bone when in fact it is out. When drilling we suggest noting the depth at which the drill bit just penetrates dorsal cortex and routinely downsize the distal screw length by 2 mm. We caution against relying on flourosocopy when judging the length of the distal subchondral screws.

Lemierre’s syndrome: AN UNUSUAL MANIFESTATION OF SPINAL INFECTION

We report a case of Lemierres syndrome complicated by an epidural abscess. This manifestation of Lemierres syndrome has not been described previously.

Total knee arthroplasty with an oxidised zirconium femoral component: a 5-year follow-up study

Purpose. To report the early results of the Oxinium Genesis II prosthesis with an oxidised zirconium femoral component in 55 patients. Methods. 71 knees in 21 men and 34 women aged 32 to 75 (mean, 55) years were evaluated; 16 of the patients had bilateral staged total knee replacements with a mean interval of 9 (range, 6–16) months between surgeries. The indications for surgery included osteoarthritis (n=57), rheumatoid arthritis (n=13) and revision from a unicompartmental knee replacement for osteoarthritis (n=1). Postoperatively, patients were evaluated using the Knee Society score (KSS), the modified Oxford Knee Score, and the SF-12 health survey, as were component position, leg and knee alignment, and prosthesis-bone interface or fixation on radiographs. Results. The mean follow-up was 62 (range, 51–88) months. The mean KSS, Oxford Knee Score, and SF-12 physical component score improved significantly. Radiolucent lines (<2 mm) were noted in the tibial cement-bone interface in 17 knees (most commonly in zones 4 and 1) and in the femoral cement-bone interface in one knee. The alignment of the knees and positioning of the components were acceptable. There were no revisions for septic or aseptic loosening. Conclusion. Early results of the Oxinium Genesis II prosthesis are comparable to the standard total knee prostheses.

The management of ingrowing toenails

#### Summary points #### Sources and selection criteria We searched Medline (PubMed), the Cochrane Database of Systematic Reviews , Cochrane central register of controlled trials, and CINAHL using the search terms “ingrowing toenails”, “ingrown toenails”, and “onychocryptosis”. We identified additional literature from the references of identified papers. In addition, we consulted standard orthopaedic textbooks on the subject and reviewed the main references quoted. Ingrowing toenails are a common condition that causes pain and disability in the foot. The condition occurs when the nail plate traumatises the nail fold, giving rise to pain, inflammation, or infection (or a combination thereof). It commonly occurs in the great toe but can also affect the lesser toes. Patients with ingrowing toenails are usually male, between the ages of 15 and 40 years; they are often encountered in general practice, with an estimated 10 000 new cases presenting in the United Kingdom each year.1 The condition is managed by a wide variety of healthcare professionals including general practitioners, podiatrists, dermatologists, general surgeons, and orthopaedic surgeons. The surgical treatments for ingrowing toenails include procedures on the nail plate, the nail bed (germinal matrix), and the surrounding soft tissues. Historically, a recurrence rate of 13-50% has been reported after surgical treatment,2 although more recent papers have reported recurrence rates of less than 5%, particularly with the use of wedge resection of the nail and phenol ablation …

Intra-neural Ewing’s sarcoma of the upper limb mimicking a peripheral nerve tumour. A report of 2 cases

Ewings sarcoma is a malignant round cell tumour of bone commonly affecting children and young adults. Intra-neural Ewings is very rare form of extraosseous Ewings sarcoma (EES), posing diagnostic and therapeutic challenges. We report two cases of intra-neural EES presenting with elbow pain and swelling, mimicking an upper limb peripheral nerve sheath tumour. Following a CT guided biopsy to confirm diagnosis, the patients were treated with a combination of surgical resection, chemotherapy and radiotherapy. These cases highlight the potential diagnostic challenges as their presentation can be misleading due to the non-specificity of symptoms. These are highly aggressive tumours with the propensity to metastasize. We review importance of collective radiological and immunohistochemical analysis followed by early, aggressive multimodal treatment within a multidisciplinary setting. This provides the best prognosis in the context of upper limb peripheral nerve tumours.

The management of the orthopaedic sequelae of meningococcal septicaemia PATIENTS TREATED TO SKELETAL MATURITY

Septicaemia resulting from meningococcal infection is a devastating illness affecting children. Those who survive can develop late orthopaedic sequelae from growth plate arrests, with resultant complex deformities. Our aim in this study was to review the case histories of a series of patients with late orthopaedic sequelae, all treated by the senior author (CFB). We also describe a treatment strategy to address the multiple deformities that may occur in these patients. Between 1997 and 2009, ten patients (seven girls and three boys) were treated for late orthopaedic sequelae following meningococcal septicaemia. All had involvement of the lower limbs, and one also had involvement of the upper limbs. Each patient had a median of three operations (one to nine). Methods of treatment included a combination of angular deformity correction, limb lengthening and epiphysiodesis. All patients were skeletally mature at the final follow-up. One patient with bilateral below-knee amputations had satisfactory correction of her right amputation stump deformity, and has complete ablation of both her proximal tibial growth plates. In eight patients length discrepancy in the lower limb was corrected to within 1 cm, with normalisation of the mechanical axis of the lower limb. Meningococcal septicaemia can lead to late orthopaedic sequelae due to growth plate arrests. Central growth plate arrests lead to limb-length discrepancy and the need for lengthening procedures, and peripheral growth plate arrests lead to angular deformities requiring corrective osteotomies and ablation of the damaged physis. In addition, limb amputations may be necessary and there may be altered growth of the stump requiring further surgery. Long-term follow-up of these patients is essential to recognise and treat any recurrence of deformity.

Re: Scaphoid fracture in bilateral congenital synostosis of the scaphoid and trapezium.

edge of the sagittal band. The most difficult aspect of this case was the diagnosis. The initial clinical diagnosis was thought to be a muscle strain with an organising haematoma. It was only after symptoms persisted despite adequate splinting that an MRI was obtained, which made the diagnosis clear. Based on this experience, we feel that tender web space masses should initially be managed conservatively (if radiographs are negative), but an MRI should be performed if the painful mass persists.

Large Osteoarthritic Cyst Presenting as Soft Tissue Tumour – A Case Report

Large osteoarthritic cysts can sometimes be difficult to distinguish from primary osseous and soft tissue tumours. We present such a case involving a cyst arising from the hip joint and eroding the acetabulum which presented as a soft tissue malignancy referred to a tertiary bone and soft tissue tumour centre. We discuss the diagnostic problems it may pose, and present a literature review of the subject.