Background. Masses are not uncommon in the foot and ankle. Most of these masses are benign, often leading clinicians to underestimate their potential for malignancy. Methods. We conducted a retrospective review of our clinical records, on patients with histologically confirmed musculoskeletal tumours of the foot and ankle, treated in a single nstitution between 2010 and 2019. The maximum diameter of each lesion was determined through MRI or Ultrasound analysis in centimeters. To develop a scoring system we compared the risk of malignancy with five criteria: site (proximal or distal to the first TMTJ), gender, age, composition and the diameter as observed. Results. Our study included 496 patients, of whom 39 (7.9%) were identified as having malignancies. The incidence of malignancy demonstrated an increased propensity among male patients, patients over 50 years of age and lesions located proximal to the TMTJ. A ROC Analysis determined that lesions measuring over 2.85 cm had an increased risk of malignancy, with a PPV of 31.1%, a NPV of 94.2%, a Sensitivity of 0.82, and a Specificity of 0.62. These identified patterns of risk were employed to formulate a scoring system, aimed at facilitating informed clinical judgment in the referral of patients to regional tumor services. Conclusion. The new OxFAT scoring system highlights the importance of lesion size, site, age and gender of the patient in determining the risk of malignancy in lump in the foot and ankle. We propose this new scoring system to aid health care professionals in managing these patients. Based on our results any patient with a foot or ankle mass of less than 2.85cm, an OxFAT score < 4/7 and no malignant or sinister features on MRI or USS can be managed locally with excision biopsy. All other patients should be referred urgently to a Regional Tumour Service

Aims. The modern prevalence of primary tumours causing metastatic bone disease is ill-defined in the oncological literature. Therefore, the purpose of this study is to identify the prevalence of primary tumours in the setting of metastatic bone disease, as well as reported rates of pathological fracture, postoperative complications, 90-day mortality, and 360-day mortality for each primary tumour subtype. Methods. The Premier Healthcare Database was queried to identify all patients who were diagnosed with metastatic bone disease from January 2015 to December 2020. The prevalence of all primary tumour subtypes was tabulated. Rates of long bone pathological fracture, 90-day mortality, and 360-day mortality following surgical treatment of pathological fracture were assessed for each primary tumour subtype. Patient characteristics and postoperative outcomes were analyzed based upon whether patients had impending fractures treated prophylactically versus treated completed fractures. Results. In total, 407,893 unique patients with metastatic bone disease were identified. Of the 14 primary tumours assessed, metastatic bone disease most frequently originated from lung (24.8%), prostatic (19.4%), breast (19.3%), gastrointestinal (9.4%), and urological (6.5%) malignancies. The top five malignant tumours resulting in long bone pathological fracture were renal (5.8%), myeloma (3.4%), female reproductive (3.2%), lung (2.8%), and breast (2.7%). Following treatment of pathological fractures of long bones, 90-day mortality rates were greatest for lung (12.1%), central nervous system (10.5%), lymphoma (10.4%), gastrointestinal (10.1%), and non-renal urinary (10.0%) malignancies. Finally, our study demonstrates improved 90-day and 360-day survival in patients treated for impending pathological fracture compared to completed fracture, as well as significantly lower rates of deep vein thrombosis, pulmonary embolism, urinary tract infection, and blood transfusion. Conclusion. This study defines the contemporary characteristics of primary malignancies resulting in metastatic bone disease. These data should be considered by surgeons when prognosticating patient outcomes during treatment of their metastatic bone disease. Cite this article: Bone Jt Open 2023;4(6):424–431

Current guidelines suggest that most lumps less than 5cm in size will not be malignant. We reviewed our experiences of small lumps at the Royal Orthopaedic Hospital, Birmingham, in order to try and identify factors associated with malignancy. All referrals to our clinic were included and data on size, symptoms, depth and diagnosis were analysed. We identified 325 patients, with 57 (17.5%) malignant and 268 (82.5%) benign lumps. Size >3cm was the most accurate predictor of malignancy (35.8% malignant vs 9.9% <3cm). 23.6% of lumps reported as increasing size were found to be malignant, compared to 8.6% of those that were not. Pain was found to be a poor predictor of malignancy, with only 15.5% of painful lumps found to be malignant and 18.9% of painless lumps found to be malignant. ‘Size >3cm’ has a sensitivity of 73.6% and a specificity of 56.3%, ‘Depth’ has a sensitivity of 73.6% and a specificity of 30.2%, ‘Increasing in Size’ a sensitivity of 71.4% and a specificity of 56.7% and ‘Pain’ a sensitivity of 33.3% and a specificity of 57.1%. If a lump has none of the above features then one can be 89.5% certain that it is not malignant. If it has 1 feature there is a 16.1% chance of its becoming malignant, 2 features a 58% chance, 3 features an 87% chance and if a lump has all 4 features there is a 93.5% chance of its being found to be malignant. The main limitation with this study is that the data set is skewed because all lumps referred to the Oncology Department are by their nature suspicious. This study identifies those factors which suggest malignancy in small lumps and provides the basis for carrying out a large, community-based study on all lumps, to identify features associated with malignancy

The purpose of this study is to emphasise the necessity for caution in assuming the diagnosis of a metastasis when a solitary bone lesion is identified following a prior malignancy. Bone lesions occurring in patients who have previously had a malignancy are generally assumed to be a metastasis from that malignancy. We reviewed 60 patients with a previous history of malignancy, who presented with a bone lesion that was subsequently found to be a different primary sarcoma of bone. These second malignancies occurred in three distinct groups of patients. Patients with original tumours well known to be associated with second malignancies (5%). In patients whose second malignancies were likely to be due to the previous treatment of their primary malignancy (40%). In patients in whom there was no clearly defined association between malignancies (55%). Inappropriate biopsy and treatment of primary bone sarcomas compromises limb salvage surgery and can affect patient mortality. We would advise referral of any aggressive solitary bone lesion to a regional bone tumour service for further assessment and biopsy rather than to assume the lesion is a metastasis

Traditional management of spinal metastases has been for the most part palliative. In this decade however there has been a gradual shift towards extirpative treatment of spinal secondary malignancy in certain circumstances. The techniques of en bloc vertebral resection have gained more widespread acceptance improving the chances of successful wide or marginal resection of both primary and secondary tumours of the spine. Those metastatic lesions which are solitary and associated with a long period of latency from treatment of the primary lesion have a greater likelihood of improved survival with en bloc resection. Although technically demanding, these same techniques coupled with advances in spinal implantation may allow complete excision of extended primary malignancy of the spine previously considered unresectable. This presentation examines the indications for en bloc resection of secondary and extended primary malignancy of the spine. A case for early referral of solitary metastatic spinal lesions is presented in the hope of adding extirpative surgical techniques to the traditional armamentarium of theoncologist

To assess the performance and success of joint sparing limb salvage surgery in high grade malignancy, in terms of function, complications, recurrence and survival, as compared to joint resection. We report a ten-year experience of twenty patients with high grade malignancies of bone which did not cross the epiphyseal plate. They underwent not only limb salvage surgery but also joint preservation. The aim of this is to preserve function in the joint and to prevent the inevitable wear of prosthetic joints requiring revision surgery. The age range was 4 - 25 years (mean 13. 5). The Diagnoses were 14 Osteosarcomas and 6 Ewings sarcomas. Mean follow up was 49 months. There were 13 femoral & 7 tibial malignancies. 12 underwent complex biological fixation with a combination of reimplanted autoclaved or irradiated bone; vascularised fibular graft; femoral or humeral allograft. In 8 cases custom made hydroxyapatite coated prostheses were used to replace the resected bone. This surgery must clearly be evaluated in the context of recurrence, particularly as this is associated with an increased risk of metastases and death. Analysis of our results to date has not shown a greater rate of complications. We experienced one recurrence, and one death. The custom prostheses group had fewer complications and operations. Functionally these patients report near normal limbs and joints and do not report any limitation of activities. Joint sparing limb salvage surgery is extremely worthwhile as it produces a significantly better functioning limb and lower morbidity, with less likelihood of revision surgery. We have not found a higher risk of post-operative complications, recurrence or death. Furthermore massive prosthetic replacement is quicker, osseointegrates reliably and is associated with a lower complication and further operation rate

Introduction: Fractures of the femoral neck are common in elderly patients. Malignancy increases in incidence with increasing age. Therefore, it is inevitable that a proportion of patients with a history of malignancy will suffer a fracture of the femoral neck. Our aim was to quantify the proportion of patients admitted with a femoral neck fracture and a co-existent history of malignancy, and determine if full-length femoral radiographs are beneficial in preoperative screening of distal metastatic disease. Methods: 133 patients (47 males, 86 females) were admitted with a femoral neck fracture and co-existent history of malignant disease from January 2004 to 2006. The mean age was 80.1 years (range, 30–96 years). In 114 cases the fracture was traumatic in origin. In 19 cases the fracture was pathological, presenting most commonly with increasing pain. Primary malignancies included breast (34.6%), large bowel(21.8%), prostatic (18.0%) and bronchogenic carcinomas (6.8%). There were 73 extracapsular fractures and 60 intracapsular fractures. For the intracapsular fractures 49 cases were treated with hemiarthroplasty, 4 cases by total hip arthroplasty and 7 cases using cannulated screws. For the extracapsular fractures, 59 cases were stabilized using a DHS and 14 cases were managed by intramedullary nailing. Results: A consultant radiologist reviewed all 133 full-length femoral radiographs (AP and lateral). No patients had evidence of distal pathology visible. No patients were re-admitted with a secondary fracture relating to the development of disease in the distal femur. Conclusion: Femoral neck fractures do occur in patients with a co-existent history of malignancy. Full-length femoral radiographs of the femur are of no additional benefit for preoperative planning. These patients can be managed similarly to other patients presenting with a femoral neck fracture

Introduction:. 25% of patients with an unknown primary tumour present to the orthopaedic surgeon with skeletal metastases. The onus is on the orthopaedic surgeon to establish the diagnosis, not only to decrease the patient's anxiety but also because the median survival increases from 6–9 months to 23 months when the primary is identified and allows for specific cancer treatment. The diagnostic work up of an unknown primary includes a multitude of special investigations. Since PET/CT has high sensitivity and specificity for detecting the primary tumours, we asked the question: Can you diagnose the unknown primary in patients with skeletal metastases with a PET/CT?. Method:. We included all PET/CT scans done in our institution between 2010 and 2013 for patients with malignancies known to metastasize to bone (melanoma, breast, lung, head and neck, GIT, other) and all scans done in patients with unknown primaries. After reviewing 686 PET/CT scans, 492 showed metastatic disease, with 78 of these having either spinal or skeletal metastases. Results:. Of these 78 patients, 68 primaries could be detected on the PET/CT scan. Thus the PET/CT detected the primary in 87% of cases. This number could possibly be higher as some were melanoma and breast cancer patients who had already undergone surgical resection. The most common primary detected was lung, followed by a group of other and unknown primaries which included cervical, kidney and thyroid carcinoma. Conclusion:. PET/CT scan is a good modality to use when looking for a primary malignancy in patients who present to the orthopaedic surgeon with bone metastases. We postulate that this might be a possible first line investigation when looking for the primary

Pathological fractures in children can occur as a result of a variety of conditions, ranging from metabolic diseases and infection to tumours. Fractures through benign and malignant bone tumours should be recognised and managed appropriately by the treating orthopaedic surgeon. The most common benign bone tumours that cause pathological fractures in children are unicameral bone cysts, aneurysmal bone cysts, non-ossifying fibromas and fibrous dysplasia. Although pathological fractures through a primary bone malignancy are rare, these should be recognised quickly in order to achieve better outcomes. A thorough history, physical examination and review of plain radiographs are crucial to determine the cause and guide treatment. In most benign cases the fracture will heal and the lesion can be addressed at the time of the fracture, or after the fracture is healed. A step-wise and multidisciplinary approach is necessary in caring for paediatric patients with malignancies. Pathological fractures do not have to be treated by amputation; these fractures can heal and limb salvage can be performed when indicated

Clear-cell sarcoma is a very rare tumor, and is almost always associated with tendons or aponeuroses or is metastatic from other organs. Sporadic cases only have been reported involving primarily the bone or extending from soft tissues to surrounding bones. To our knowledge, the ilium has not been previously reported as the primary site for clear cell sarcoma.

We report a rare case of Primary clear cell sarcoma involving right ilium region in a 18-year-old boy presented with a painful swelling over right ilium and limp on right lower limb of ten month duration. He was initially suspected having tuberculosis based on clinicoradiological evaluation and diagnosis of primry clear cell sarcoma could be established on histopathology. Patient was treated with partial excision of the ilium, the remaining ilium was fused with sacrum. Stabilization was achieved with a cortical autograft harvested from the right fibula and fixation with a titanium plate.

The patient had no local recurrences but the plate holding ilium to sacrum broke and was removed in the subsequent surgery after which he developed Trendelenberg’s gait.

Introduction: Swellings of the medial end of the clavicle in children and adolescents are common. The vast majority represent either osteomyelitis, or a benign conditions such as eosinophilic granuloma. Their radiographic and early clinical appearance, however, are difficult often to discriminate from Ewing’s sarcoma. Unrewarding biopsies are often performed.

Aims: To identify incidences of malignant neoplasm at the medial end of clavicle in patients aged 18 and under from the Scottish Bone Tumour Registry (SBTR), and by questionnaire from European tumour databases.

Methods: The SBTR was searched for childhood malignant neoplasms as above. Questionnaires were sent to 171 European regional and national tumour databases. Information requested included details of patients with malignant neoplasms as above, longevity of database operation and population served. An estimate of European child population rates was made based on a conservative (North Italian) calculation of children aged under 18 representing 14.4% of the population (comparison our region 21.9%). Confidence intervals were calculated using Wilson method.

Results: The SBTR identified 7 children with neoplasms of the clavicle out of a total register of 4009 cases. Only 1 was malignant and this at the lateral end.

Responses were gained from 56 European databases. National databases were less able to identify this detailed anatomical site than regional ones. 30 databases from 12 countries responded with complete data representing 1.619 billion total population person-years. Four malignant tumours at the medial end of clavicle were identified from a total of 233.2 million children-years at risk.

Discussion: By extrapolation, in our region (population 779,000) a malignant childhood medial clavicle tumours is estimated to occur once every 342 years (95%CI 91 years – ∞). It is recommended that biopsy of such childhood swellings should be restricted to patients who present with features atypical of infection or benign lesions.

We report our clinical experience with three patients in whom squamous cell carcinomas developed secondarily to chronic bone infections. The diagnosis was delayed in each case.

There are several well recognised warning signs which should alert the physician to the possibility of malignant change having occurred in the region of chronic bony infection.

Close attention to these signs will prevent undue delay in diagnosis and avoid the associated complications.

As chronic osteomyelitis becomes less common in first world countries we need to remain aware of the possible complications which can be encountered.

The diagnosis in each of our cases was delayed by the fact that the possibility of malignant change was not considered by several experienced orthopaedic surgeons.

When there is change in signs and symptoms or altered flora within the discharge one must be alerted to the possibility of malignant change. This should prevent delays in diagnosis. Radiological progression should probably be regarded as malignant change until proven otherwise.

With early diagnosis and treatment the prognosis for a patient with squamous cell carcinoma is good. Key words: Osteoclastoma, Osteomyelitis, Sinus tract, Squamous cell carcinoma.

This is a retrospective study performed to analyse the functional outcome, complications and survival following intramedullary nailings for pathological fractures of long bones in a District General Hospital.

There were fifteen intramedullary nailings (Femur-11, Tibia- 2 , Humerus- 2) done in twelve patients during June 1999 and December 2002. There were twelve nailings in pathological fractures and three cases of prophylactic nailings. Nine patients had metastasis with known primary cancers from Ca Breast (3), Ca Bronchus (3), Ca Prostate (1), Ca Oesophagus (1) and Renal Cell Carcinoma (1). Two patients had metastasis without known primary site. There was one patient who had multiple myeloma with pathological fracture of femur.

We assessed the outcome of the treatment based on pain relief, post-fixation mobility and complications associated with the procedure.

Pain relief was achieved in about 92% cases. 67% cases with fracture of lower limbs were able to walk within a week postoperatively following nailing. One patient had deep infection leading to implant failure that needed nail removal to eradicate the infection. One patient had nonfatal pulmonary embolism. There was an incidence of thromboembolism of brachial artery that was treated by embolectomy without any sequelae.

The patients survival rate was 33% at six months and 0% at 2 years.

Reamings sent from nailing were helpful in confirming the diagnosis in 75% cases.

Despite poor life expectancy our results show good functional improvement following intramedullary nailing of pathological fractures of long bones. It is a safe way to restore limb function and improve quality of life.

Neck of femur fracture (NOF#) is the commonest reason for admission to an orthopaedic ward with 70-75,000 cases each year in the UK. 1. The femoral head is often sent to pathology if there is clinical suspicion of a malignant cause. There is limited evidence in the literature to support the efficacy of this. 2. The purpose of this project was to study the incidence of femoral head pathology analysis in NOF # patients with a background of malignancy and evaluate the impact this investigation has on guiding future management. Retrospective analysis of all neck of femur fractures admitted to the Queen Elizabeth University Hospital between 01/01/2021 and 31/12/2021. The electronic notes were accessed and for patients with past medical history of malignancy, it was confirmed whether femoral head or bone reamings were sent to pathology, resultant findings and the impact on subsequent management. In 2021, 784 patients were admitted to the QEUH with a NOF#. Of these, 770 (98.2%) underwent operative management, 138 (17.3%) of whom had a past medical history (PMH) of malignancy. Intra-operative pathology was sent from 19 (13.7%) of these 138 patients. No malignant cells were found in 13 (69%) samples, and in 6 (31%), the known active malignancy was confirmed. In all cases where samples were sent for pathology, none caused any change in management. In this retrospective study, pathological investigations in NOF# patients with a PMH of malignancy had no impact on further management. The authors would not advocate for sending pathology results in this cohort group

Neck of femur fractures are a common trauma presentation and patients with a history of malignancy are sent for long leg femur views (LLF), to exclude a distal lesion which would alter the management plan (Intra-medullary nail/Long stem Hemiarthroplasty). The aim of this is to identify incidence of malignancy on LLF views, the length of time in between each xray (XR) and to identify demographics. Data was retrospectively collected from 01/01/2021 to 31/01/2021 from a single centre. All patients admitted to the Queen Elizabeth University Hospital had their electronic records (Bluespier, PACS, Clinical Portal) accessed. These confirmed if patients had a past medical history of malignancy, if they had LLF view and the time differences between diagnostic pelvis XR and LLF XR. A total of 784 patients were identified in the specified time period. Of these, 138 were identified with a malignancy and there were 85 LLF views completed. LLF views diagnosed 1 patient with known prostate cancer that had a new distal femoral metastasis (Incidence = 1.28 cases per 1000). This patient underwent further imaging (MRI Femur) and received a long stem hip hemiarthroplasty. The average length of wait between the images was 9 hours 27 minutes. LLF views can alter management of patients with malignancy and are therefore useful to perform. There can be a long delay between each image. Therefore we recommend imaging tumour with common bony metastasis (Renal, Thyroid, Breast, Prostrate, Lung) and other remaining tumours with known secondary metastasis. Imaging primary low risk (eg basal cell carcinoma) can lead to long delays in a frail patient cohort and consideration should be given to rationalise appropriate use of resources

Abstract. Introduction. Total joint arthroplasty (TJA) is one of the commonest and most successful orthopaedic procedures, used for the management of end-stage arthritis. With the recent introduction of robotic assisted joint replacement, Computed Tomography (CT) has become part of required pre-operative planning. The aim of this study is to quantify and characterise incidental CT findings, their clinical significance, and their effect on planned joint arthroplasty. Methodology. All consecutive patients undergoing an elective TJR (hip or knee arthroplasty) were retrospectively identified, over a 3-year period (December 2019 and December 2022). Data documented and analysed included patient demographics, type of joint arthroplasty, CT findings, their clinical significance, as well as potential delays to the planned arthroplasty because of these findings and subsequent further investigation. Results. A total of 624 patients (637 studies, 323 (51.8%) female, 301 (48.2%) male) were identified of which 163 (25.6%) showed incidental findings within the long bones or pelvis. Of these 52 (8.2%) were significant, potentially requiring further management, 32 (5.0%) represented potential malignancy and 4 (0.6%) resulted in a new cancer diagnosis. Conclusion. It is not currently national standard practice to report planning CT imaging as it is deemed an unnecessary expense and burden on radiology services. Within the study cohort 52 (8.2%) of patients had a significant incidental finding that required further investigation or management and 4 (0.6%) had a previously undiagnosed malignancy. In order to avoid the inevitability of a missed malignancy on a planning CT, we must advocate for formal reports in all cases

Total joint arthroplasty (TJA) is one of the commonest and most successful orthopaedic procedures used for the management of end-stage arthritis. With the recent introduction of robotic-assisted joint replacement, Computed tomography (CT) has become part of required pre-operative planning. The aim of this study is to quantify and characterise incidental CT findings, their clinical significance, and their effect on the planned joint arthroplasty. All consecutive patients undergoing an elective TJA (total joint arthroplasty; hip or knee) were retrospectively identified, over a 4-year period (December 2019 and November 2023). Data documented and analysed included patient demographics, type of joint arthroplasty, CT findings, their clinical significance, as well as potential delays to the planned arthroplasty because of these findings and subsequent further investigation. A total of 987 patients (female: 514 patients (52.1%)) undergoing TJA were identified (THA: 444 patients (45.0%); TKA: 400 patients (40.5%); UKA: 143 patients (14.5%)). Incidental findings within imaged areas were identified in 227 patients (23.0%). Of these findings, 74 (7.5%) were significant, requiring further investigation or management, 40 (4.1%) of which represented potential malignancy and 4 (0.4%) resulting in a new cancer diagnosis. A single patient was found to have an aneurysm requiring urgent vascular intervention. Surgery was delayed for further investigation in 4 patients (0.4%). Significant findings were more frequent in THA patients (THA: 43 (9.7%) TKA/UKA: 31 (5.7%). Within our cohort, 74 (7.5%) patients had significant incidental findings that required further investigations or management, with 4 (0.4%) having a previously undiagnosed malignancy. We strongly advocate that all robotic arthroplasty planning CTs are reviewed and reported by a specialist, to avoid missing undiagnosed malignancies and other significant diagnoses

Abstract. Objectives. To analyse the costs and benefits of sending femoral head specimens for histopathological analysis and whether our practice had changed since the original study five years ago. Methods. The cohort definition was patients who had both undergone hip hemiarthroplasties (HHAs) and had femoral head specimens sent for histopathological analysis at our tertiary care institution from 2013 to 2016. Retrospective review of clinical and electronic notes was performed on these patients for history of malignancy, histopathological diagnosis of femoral head, indication for histopathological examination and radiological studies. The total number of HHAs performed at the centre and the costs involved in analysing each femoral head specimen were identified. Results. A total of 805 HHAs were performed at the centre. We identified 56 femoral head specimens from 56 patients (6.96%) that were sent for histopathological analysis after HHA. 29 patients (51.79%) had a known history of malignancy. Three femoral head specimens (10.34%) were histologically positive for malignancy. Two patients had hip radiographs demonstrating metastasis to the femoral head. The third patient had a PET-CT scan two weeks prior to fracture that did not show signs of metastatic disease. 27 patients (48.21%) had no history of malignancy. None of their femoral head specimens were found to be histologically positive for malignancy. 10 patients had no appropriate indication for histopathological analysis. The cost savings for 27 patients with no previous history of malignancy ranged from €2,295 to €9,504. The cost savings for 10 patients with no appropriate indication ranged from €850 to €3,520. Conclusions. Histopathological analysis of femoral head specimens after HHA has little benefit for patients without a history of malignancy. The practice at our institution had not changed significantly in the past five years. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Introduction. Spine is a common site for haematological malignancies. Multiple myeloma affects the spine in 70% of cases. New guidelines were published in 2015 to help manage spinal haematological malignancies. Despite neural compression or spinal instability, instrumentation of the spine should be avoided. Surgery carries significant risks of wound complications and more importantly delaying the definitive chemotherapy and radiotherapy. Cement augmentation and bracing for pain and prevention of deformity is key to the new strategies. We aimed to evaluate the different treatment modalities adopted in the spine unit at St George's hospital for spinal haematological malignancies. We compared our practice to the current guidelines published in 2015. Methods. Retrospective review of all spinal haematological malignancy patients who were discussed in the spinal MDT and managed through the spine unit at St George's hospital in the period between April 2019 and February 2021. We analysed the demographics of the patients treated in this period and compared the management modalities adopted in the unit to the current British haematological guidelines. Results. 139 patients were included in this study, 61.9% of them were male. 70 cases came through the MSCC pathway. 15 patients had their spinal involvement in the lumbar spine only below the conus. The Bilsky Grades of the other 124 cases were B0: 35.97 % 1a: 4.31%%, 1b: 7.19%, 1c: 3.59%, 2: 5.75% 3: 32.37%. 43 patients (30.9 %) had neurological deficits on presentation. 70 cases were treated conservatively (50.35%), 21 were treated with brace only (15.1%), 25 had BKP (17.98%) and 23 were treated with instrumentation (16.54%). The number of instrumented cases was small and trending down and cement augmentation and bracing were more frequently chosen for these patients. This comes in accordance to the British haematological guidelines. Conclusion. Utilising BJH 2015 guidelines we have reduced our instrumented operative case load. There is a higher percentage of BKP and Bracing in accordance to the algorithm

Aim. Patient quality of life (QoL) in untreated bone infection was compared to other chronic conditions and stratified by disease severity. Method. Patients referred for treatment of osteomyelitis (including fracture related infection) were identified prospectively between 2019 and 2023. Patients with confirmed infection completed the EuroQol EQ-5D-5L questionnaire. Clinicians blinded to EQ-index score, grouped patients according to JS-BACH Classification into ‘Uncomplicated’, ‘Complex’ or ‘Limited treatment options’. A systematic review of the literature was performed of other conditions that have been stratified using EQ-index score. Results. 257 patients were referred, and 219 had suspected osteomyelitis. 196 patients had long bone infection and reported an average EQ-index score of 0.455 (SD 0.343). 23 patients with pelvic osteomyelitis had an average EQ-index score of 0.098 (SD 0.308). Compared to other chronic conditions, patients with long-bone osteomyelitis had worse QoL when compared to different types of malignancy (including bladder, oropharyngeal, colorectal, thyroid and myeloma), cardiorespiratory disease (including asthma, COPD and ischaemic heart disease), psychiatric conditions (including depression, pain and anxiety), endocrine disorders (including diabetes mellitus), neurological conditions (including Parkinson's disease, chronic pain and radiculopathy) and musculoskeletal conditions (including osteogenesis imperfecta, fibrous dysplasia and x-linked hypophosphataemic rickets). QoL in long-bone infection was similar to conditions such as Prada-Willi syndrome, Crohn's disease and juvenile idiopathic arthritis. Patients who had a history of stroke or multiple sclerosis reported worse QoL scores compared to long-bone infection. Patients who had pelvic osteomyelitis gave significantly lower QoL scores when compared to all other conditions that were available for comparison in the literature. In long bone infection, 41 cases (21.0%) were classified as ‘Uncomplicated’, 136 (69.4%) as ‘Complex’ and 19 (9.7%) as ‘Limited treatment options available’. Within classification stratification, patients with ‘Uncomplicated’ long bone infections reported a mean EQ-index score of 0.618 (SD 0.227) which was significantly higher compared to ‘Complex’ (EQ-index: 0.410 SD 0.359, p=0.004) and ‘Limited treatment options available’ (EQ-index: 0.400 SD 0.346, p=0.007). Conclusions. Bone and joint infections have a significant impact on patient quality of life. It is much worse when compared to other common chronic conditions, including malignancy, cardiovascular and neurological diseases. This has not been previously reported but may focus attention on the need for more investment in this patient group