Rej Bhumbra

Fixation of pathological humeral fractures by the cemented plate technique

Pathological fractures of the humerus are associated with pain, morbidity, loss of function and a diminished quality of life. We report our experience of stabilising these fractures using polymethylmethacrylate and non-locking plates. We undertook a retrospective review over 20 years of patients treated at a tertiary musculoskeletal oncology centre. Those who had undergone surgery for an impending or completed pathological humeral fracture with a diagnosis of metastatic disease or myeloma were identified from our database. There were 63 patients (43 men, 20 women) in the series with a mean age of 63 years (39 to 87). All had undergone intralesional curettage of the tumour followed by fixation with intramedullary polymethylmethacrylate and plating. Complications occurred in 14 patients (22.2%) and seven (11.1%) required re-operation. At the latest follow-up, 47 patients (74.6%) were deceased and 16 (25.4%) were living with a mean follow-up of 75 months (1 to 184). A total of 54 (86%) patients had no or mild pain and 50 (80%) required no or minimal assistance with activities of daily living. Of the 16 living patients none had pain and all could perform activities of daily living without assistance. Intralesional resection of the tumour, filling of the cavity with cement, and plate stabilisation of the pathological fracture gives immediate rigidity and allows an early return of function without the need for bony union. The patients local disease burden is reduced, which may alleviate tumour-related pain and slow the progression of the disease. The cemented-plate technique provides a reliable option for the treatment of pathological fractures of the humerus.

Using the CUSUM Test to Control the Proportion of Inadequate Open Biopsies of Musculoskeletal Tumors

BackgroundBiopsies of musculoskeletal tumors lead to alterations in treatment in almost 20% of cases. Control charts are useful to ensure that a process is operating at a predetermined level of performance, although their use has not been demonstrated in assessing the adequacy of musculoskeletal biopsies.Questions/purposesWe therefore (1) assessed the incidence of and the reasons for inadequate musculoskeletal biopsies when following guidelines for performing the procedure; and (2) implemented a process control chart, the CUSUM test, to monitor the proportion of inadequate biopsies.MethodsWe prospectively studied 116 incisional biopsies. The biopsy was performed according to 10 rules to (1) minimize contamination in the tissues surrounding the tumor; and (2) improve accuracy. A frozen section was systematically performed to confirm that a representative specimen was obtained. Procedures were considered inadequate if: (1) another biopsy was necessary; (2) the biopsy tract was not appropriately placed; and (3) the treatment provided based on the diagnosis from the biopsy was not appropriate.ResultsFive (4.3%) of the 116 incisional biopsy procedures were considered failures. Three patients required a second repeat open biopsy and two were considered to receive inappropriate treatment. No alarm was raised by the control chart and the performance was deemed adequate over the monitoring period.ConclusionsThe proportion of inadequate musculoskeletal open biopsies performed at a referral center was low. Using a statistical process control method to monitor the failures provided a continuous measure of the performance.

Overuse of antibiotics in pets must be tackled to reduce resistance, conference hears

The overuse of antibiotics in domestic animals, and not just livestock, needs to be considered if antibiotic microbial resistance is to be tackled in the long term, a conference of doctors and veterinary surgeons was told this week. Prescribing of antibiotics across Europe is returning to the high levels of the 1990s, Peter Hawkey, from the Public Health Laboratory in the University of Birmingham, told the conference in London, which was organised jointly by the Royal College of Physicians and the Royal College of Veterinary Surgeons. Susan Dawson, head of the School of Veterinary Science at the University of Liverpool, said that half of all …

Cleaning up joint replacement services in the UK

New report calls for clinicians to play a key role in service redesign

Surgical considerations when reporting MRI studies of soft tissue sarcoma of the limbs

Soft tissue sarcomas (STS) are rare tumours that require prompt diagnosis and treatment at a specialist centre. Magnetic resonance imaging (MRI) has become the modality of choice for identification, characterisation, biopsy planning and staging of soft tissue masses. MRI enables both the operating surgeon and patient to be optimally prepared prior to surgery for the likelihood of margin-negative resection and to anticipate possible sacrifice of adjacent structures and consequent loss of function. The aim of this review is to aid the radiologist in performing and reporting MRI studies of soft tissue sarcomas, with particular reference to the requirements of the surgical oncologist.

Experts point out pitfalls of using patient reported outcomes to guide NHS care.

Experts have sounded a warning bell over the use of reports of patients’ experiences of NHS care to judge how well hospitals are performing and to decide the flow of funding. When they were launched by the government in April 2009, patient reported outcome measures (PROMs) were billed simply as a means of capturing information on how patients believed that their NHS care had benefited them. However, as the patient agenda has expanded, policy makers are looking to the data—currently collected for hip and knee replacements, groin hernia surgery, and varicose vein surgery—to assess performance of providers, commissioning, treatments, and even individual doctors, said speakers at a meeting at the healthcare think tank the King’s Fund in London on 22 November. David Beard, director of the Orthopaedic Surgery and Interventional Trials Unit at Oxford University, is a supporter of PROMs. However, he cautioned, “As we are using patient reported outcomes more we [must] understand that …

“It’s just a muscle sprain”

A 10 year old boy presented to his general practitioner with a four week history of left mid-thigh pain with no associated history of systemic symptoms. He had no memory of a preceding trauma and no history of infection, locally or systemically. The pain was relapsing and remitting in its extent and frequency. It was also activity related, with occasional night waking and pain at rest. His GP took a full history, conducted a complete hip examination, and at initial presentation decided that the pain was caused by a muscle sprain. Two months later the pain has not abated and the child re-presented to his GP, who requested a plain radiograph of the hip, the results of which were normal. A further three months later, his father noticed an associated distal thigh mass and immediately took the boy to the emergency department. On presentation to hospital, he was walking pain free but had an obvious mass, which did not limit his range of movement. He did not have a fever; his C reactive protein was 6 mg/L, erythrocyte sedimentation rate was 4 mm in the first hour, and total white blood cell count was 8×109/L. The on-call orthopaedic team requested anterioposterior and lateral radiographs of the thigh (figs 1⇓ and 2⇓). Fig 1 Anterioposterior radiograph of the distal femur Fig 2 Lateral radiograph, midshaft femur ### 1 Are there any red flag symptoms in the initial presenting history? #### Short answer The four week …