Summary

Wear particles from joint replacements may result in loosening and periprosthetic osteolysis. Interference with systemic macrophage trafficking to the implant, modulation of macrophage phenotype from M1 to M2, and inhibition of NFκB may mitigate these adverse effects.

Purpose

Secondary degenerative changes of the knee are a well recognized complication of Giant Cell Tumor (GCT). Osteoarthritis (OA) may be a consequence of the lesion itself or its treatment. Total Knee Arthroplasty (TKA) is a treatment option for end stage knee arthritis. In the current study we describe the short term follow up of three patients that underwent TKA for treatment of GCT related OA between 2006–2007.

To evaluate and describe the plain radiographic changes observed with time in fusions using SiS-CaP. We describe, for the first time, 4 stages of bone substitute fusion mass (BSFM) radiographic appearance in relation to time post-op.

Retrospective, radiological evaluation.

Over 200 plain radiographs were evaluated. 70 consecutive fusions for degenerative spinal stenosis were included, in all cases performed by the same surgeon using the same operative technique. Follow-up was from 3 months to 2 years post-op.

Radiographs were evaluated for the presence or absence of SiS-CaP granules, bone formation and for evidence of pseudarthrosis.

Trends were seen within the BSFM with respect to time. At 6-12 weeks post-op a ‘homogenous granular stage’ indicates the presence of the unchanged SiS-CaP.

At 12 weeks, small pockets appear within the BSFM in the ‘vacuolation stage’, indicating bioresorption of the graft. Vacuoles become increasingly radio-opaque indicating bone proliferation during the ‘homogenous lamellar stage’. At variable time between 6 months and 2 years, the BSFM becomes encapsulated in the ‘cortication stage’ visible as a sclerotic rim around the BSFM.

We have seen a clear trend in the behaviour of the fusion mass in this case series. The radiological stages we have described above can be closely correlated with previously reported in-vitro and in-vivo studies looking at the micro-function of SiS-CaP. We hope that this description will help to judge the progress of graft incorporation and fusion. Further study of inter and intra-observer correlation will be required.

To report on the management of a patient with grade 1 holocord pilocytic astrocytoma and scoliosis.

Case report of a rare spinal cord tumour and a management of the scoliosis.

An 11 year boy complained of gradually worsening neck, back pain and pain in all limbs. This was accompanied by unsteadiness, weakness of lower limbs and bed wetting of recent onset. There was a family history of spinal cord tumour.

Examination revealed signs of spinal cord compression and a left thoracic scoliosis. Magnetic resonance imaging showed an intra-medullary tumour extending through the spinal cord and syrinx formation.

He underwent T1-3 approach for drainage of syrinx, biopsy of tumour and laminoplasty with plates. He was started on chemotherapy for 14 months. During this period a syringo-peritoneal shunt was inserted. There was further growth of the tumour and neurological deterioration. He subsequently underwent T8-L1 laminoplasty, debulking of tumour and insertion of dual diameter growing rods.

There has been no significant neurological deterioration. There was good correction of the scoliosis with Cobb angle reducing from 50 to 15 degrees. Lengthening of growing rods has been done 4 times with good length achieved.

Excision of tumour and growing rod insertion (not previously reported) is a good way of controlling neurological symptoms and the scoliosis in this rare spinal cord tumour.

To evaluate the efficacy of Vacuum Assisted Closure (VAC) in the management of post surgical spinal sepsis.

A retrospective analysis was performed of patients with severe post operative spinal wound infections treated using a combination surgical debridement, antibiotics and VAC therapy.

Full records were available for a total of twenty adult all of whom had had prior thoracic or lumbar instrumentation. Comorbidities included disseminated carcinomatosis (25 % of patients), Ankylosing spondylitis (5 %), rheumatoid arthritis (5%) and Polio (5%). In one patient there had been a prior history of irradiation of the surgical field. Most infections treated by this regime were identified within two weeks following surgery. At surgery infection deep to the dorso-lumbar fascia was found in 87 % of cases. It was possible to retain instrumentation in 60 % of cases. An average of three trips to theatre were required prior to wound closure, which was possible in 95 % of cases. The VAC device was left in situ for an average of 11 days. Complications included recurrence of infection necessitating further treatment in 20 % of cases, wound dehiscence necessitating healing by secondary intention in 5%, the need for free flap wound cover in 5 % and death from unrelated causes in 5%.

VAC therapy may facilitate the management of wound sepsis following spinal surgery in susceptible patients allowing the maintenance of instrumentation and surgical correction.

To assess radiological fusion rates in posterolateral fusions using SiS-CaP.

Retrospective, radiological follow-up study.

Single surgeon series of 76 consecutive patients were evaluated, in a regional spinal unit. All patients had clinical and radiological (MRI) spinal canal stenosis secondary to degenerative spondylosis or spondylolisthesis. Surgery consisted of instrumentation, decompression and meticulous preparation of the posterolateral graft bed by removal of all soft tissues posterior to the inter-transverse membrane and decortication of transverse processes (TPs). SiS-CaP putty was injected into this gutter and moulded around the instrumentation. Good quality, well prepared bone chips from the posterior decompression were seeded into the putty. Patient radiographs were reviewed at 3-6 months, 1 year and 2 years.

Radiographs were assessed using a protocol to examine granularity, bone formation and evidence of pseudarthrosis, based upon previously reported literature ¹ and our personal experience.

Of the 76 patients, 26 were excluded. M:F was 21:29. Mean age was 58yrs. Average number of motion segments fused per case was 2.2. There was one pseudarthrosis with metalwork fracture, and thus a total fusion rate of 98%. In addition, one patient had scanty bridging of TPs, and one patient had lucency around the S1 screws.

SiS-CaP, as a bone graft substitute in posterolateral instrumented fusions, gives comparable results to published fusion rates using autologous iliac crest grafting and/or Bone Morphogenic Protein ². Moreover, it avoids the associated morbidity of iliac bone harvest.

To determine the current practice of scoliosis surgery in the UK.

A 10 point questionnaire was constructed to identify the philosophy of surgeons on various aspects of scoliosis surgery such as choice of implant, bone graft, autologous blood transfusion (ABT), cord monitoring and computer assisted surgery. Results are compared with the current best evidence.

Consultants and Fellows attending the 2009 British Scoliosis Society meeting. 50 questionnaires were completed: 45 Consultants and 5 Fellows.

All pedicle screw construct favored by 25/50, hybrid 24/50 (one undecided). Posterior construct of less than 10 levels, 20/50 would not cross-link, 11/50 used one and 19/20 used two or more. More than ten levels 17/50 considered cross-links unnecessary, 4/50 used one and 29/50 used two or more. 88% preferred titanium alloy implants, while a mixture of stainless steel and cobalt chrome was used by others. For bone graft, substitutes (24), iliac crest (14), allograft (12) and demineralised bone matrix (9) in addition to local bone. 10/50 would use recombinant bone morphogenetic protein (3 for revision cases only). 39/50 routinely used intra-operative cell salvage or ABT drains and 4/50 never used autologous blood. All used cord monitoring, Sensory (19/50), Motor (2/50) and combined (29/50). None used computer-aided surgery. 26 operated alone 12 operated in pairs and 12 varied depending on type of case.

This survey has brought to light interesting variations in scoliosis surgery in UK. It may reflect the conflicting evidence in the literature.

Purpose of the study: To investigate whether autologous blood transfusion (ABT) drains and peri-operative cell salvage reduce allogeneic transfusion requirements for scoliosis surgery in our unit.

Methods: Prospective data collection on transfusion requirements of patients undergoing scoliosis surgery between January 2006 and February 2008. Cases were split into three groups, representing recent stepwise changes in transfusion practice. Group A received ‘traditional treatment’ of allogeneic red cell transfusion (ARCT) in response to intra- or post-operative anaemia (Hb< 8g/dL or symptomatic anaemia). Group B received peri-operative cell salvage in addition to ‘traditional treatment’. In group C, ABT wound drains were used alongside peri-operative cell salvage and ‘traditional treatment’.

Results: ARCT was required for 23 of the 35 procedures (66%) in group A, 22 of 37 (59%) in group B and 10 of 20 (50%) in group C. Where patients required ARCT, those in group C received fewer units (mean 2.6) than group B (mean 3.1) and group A (mean 3.7). There was no difference in mean preoperative haemoglobin levels (A – 13.56g/dL SD 1.36; B – 13.35g/dL SD 1.46; C – 13.94g/dL SD 1.25). Mean length of inpatient stay was lowest in group C (9.11 days), and lower in group B (12.02) than group A (13.75).

Conclusion: Use of ABT drains and peri-operative cell salvage lead to reduced allogeneic transfusion needs for scoliosis surgery in our unit. Lowest transfusion rates were seen when both were used together, leading to a 16% reduction in the need for ARCT.

Ethics approval: None

Interest Statement: None

Abstract: It is known that the treatment of intra or extraspinal paediatric tumours with surgery and radiotherapy or radiotherapy alone can lead to the onset of progressive spinal deformity the management of which can be extremely challenging. We review our series of patients who have developed a spinal deformity in these circumstances.

Methods: A review of all patients seen between 1996 and 2007 in the spinal department who have developed a significant spinal deformity following treatment for an intra or extra spinal tumour.

Results: 14 patients were identified. The age of presentation to the spinal service was between 2 years 6 months and 15 years 3 months. The underlying diagnoses were Wilms Tumour treated with surgery and radiotherapy in 3, 1 extraspinal sarcoma treated with surgical resection, radiotherapy and chemotherapy, 1 extraspinal neuro-blastoma treated with surgery, radiotherapy, chemotherapy and stem cell rescue and 9 intra spinal tumours (PNET, astrocytoma, ganglioneuroblastoma and der-moid) all managed with resection with or without radiotherapy. The spinal deformities that have developed were thoracic kyphoscoliosis, thoracolumbar kyphosis and lumber hyperlordosis. The spinal management of these deformities has been conservative in 12 with regular assessment to allow intervention if indicated. 2 patients have undergone surgery, a vascularised fibular strut graft and anterior instrumentation in 1 and a non vascularised rib graft in 1 for progressive deformity felt to lead to neurological dysfunction or lung hypoplasia. The cases managed operatively were complicated by poor posterior soft tissues following previous surgery and radiotherapy requiring an anterior approach. In all patients who were treated with radiotherapy platyspondyly was always seen in the vertebral bodies anteriorly and this corresponded to the apex of the deformity.

Conclusion: In all children who undergo spinal surgery and or radiotherapy for paediatric tumours there must be ongoing surveillance for the development of a spinal deformity. We feel that this is as much a result of anterior growth arrest secondary to radiotherapy as to posterior laminectomy for intra canal tumour excision. The surgical management of this problem is complex and may require innovative solutions.

Introduction: The natural history of scoliosis in the presence of a cord syrinx, either treated conservatively, or post surgically, is disputed. It is generally believed to be associated with a greater likelihood of rapid deformity progression pre-operatively and a much greater likelihood of intraoperative neural injury.

In this study we aimed to retrospectively assess the local experience by reviewing patients, treated over the last 10 years, in whom scoliosis has been established, by means of MR imaging, to be associated with a cord syrinx.

Methods: A retrospective cohort study was undertaken of paediatric patients attending the Leeds Spinal Unit between the years of 1997 and 2007. The entry criteria for this study were spinal deformity with MRI proven cord syrinx, in a patient without underlying tumour or other cord anomaly. Given the association with Chiari malformation this was a measured parameter rather than exclusion criteria. Other parameters assessed were mode of presentation, progression of scoliosis, details of the identified syrinx, chosen mode of treatment for the syrinx and the scoliosis (including conservative) and outcome measures (neurological function and sequelae, change in Cobb angle/deformity correction).

Results: A total of 46 patients were identified with scoliosis and an associated syrinx. The age range was from 3 to 18 years. Only 12 were male. The syrinx was associated with an Arnold Chiari malformation in 24% of patients, and located at the apex of, or local to, the maximum deformity in 73%.

The syrinx was treated surgically in 10 patients, with 80% of these achieving either deformity arrest, or no longer requiring surgical deformity correction. In the 2 patients from the same subset who did undergo deformity correction there was no neurological sequelae. Of the conservatively managed syrinxes, deformity correction with intraoperative cord monitoring was nevertheless undertaken in 31%, all without neurological sequelae. In just 4 patients (of 69%) who did not proceed to deformity correction, surgery was precluded by the inherent risks in the presence of an untreated syrinx.

Conclusion: This small series does not lend support to the literature and anecdotal evidence for significantly increased surgical risk in deformity correction without treatment for syrinx first. However, this may reflect the fact that all syrinxes likely to compromise the surgical procedure were assessed as such and treated first. In the cohort of patients whose syrinxes were treated conservatively, a significant proportion did not require subsequent deformity surgery. Identifying a syrinx by, the mandatory, MR imaging of a patient with a deformity before considering surgical correction, appears to identify a significant proportion of syrinxes which neither significantly accelerate the progression deformity, or which do not lead to poor outcome after deformity surgery.

INTRODUCTION. We conducted a review of the Leeds Regional Bone Tumour Registry for primary bone tumours of the spine since establishment in 1958 until year 2000.

AIM. To analyze the incidence of primary tumours of the spine and to record the site of occurrence, sex distribution, survival and pathology of these tumours.

Summary of the Background Data. Primary tumours of the spine are particularly rare, accounting for between 4% and 13% of published series of primary bone tumours.

METHOD. The Leeds Bone Tumour Registry was reviewed and a total of 2750 cases of bone tumours and tumour-like cases were analyzed. Consultants in orthopaedic surgery, neurosurgery, oncology and pathology in North and West Yorkshire and Humberside contribute to the Registry.

RESULTS. Primary bone tumours of the osseous spine constitute only 126 of the 2,750 cases (4.6%). Chordoma was the most frequent tumour in the cervical and sacral regions, while the most common diagnosis overall was multiple myeloma and plasmacytoma. Osteosarcoma ranked third. The mean age of presentation was 42 years and pain was the most common presenting symptom, occurring in 95% of malignant and 76% of benign tumours. Neurological involvement occurred in 52% of malignant tumours and usually meant a poor prognosis,

CONCLUSIONS. The establishment of Bone Tumour Registries is the only way that sufficient data on large numbers of these rare tumours can be accumulated to provide a valuable and otherwise unavailable source of information for research, education and clinical follow-up.

Purpose: We conducted a review of the Leeds Regional Bone Tumour Registry for primary bone tumours of the axial skeleton since establishment in 1958 until year 2000 to analyze the incidence of primary tumours of the axial skeleton and to record their site of occurrence, sex distribution, survival and pathology.

Method: Primary tumours of the axial skeleton are particularly rare, accounting for between 4% and 13% of published series of primary bone tumours. The Leeds Bone Tumour Registry was reviewed and a total of 2750 cases of bone tumours and tumour-like cases were analyzed. Consultants in orthopaedic surgery, neurosurgery, oncology and pathology in North and West Yorkshire and Humberside contribute to the Registry.

Results: Primary bone tumours of the axial skeleton constitute only 126 of the 2,750 cases (4.6%). Chordoma was the most frequent tumour in the cervical and sacral regions, while the most common diagnosis overall was myeloma. Osteosarcoma ranked third. Mean age of presentation was 42 years. Pain was the most common presenting symptom, occurring in 95% of malignant and 76% of benign tumours. Neurological involvement occurred in 52% of malignant tumours and usually meant a poor prognosis,

Conclusions: The establishment of Bone Tumour Registries is the only way that sufficient data on large numbers of these rare tumours can be accumulated to provide a valuable and otherwise unavailable source of information for research, education and clinical follow-up.

Primary bone tumours in the elderly population are relatively rare.

We reviewed the Leeds regional bone tumour registry between 1990–1999 and found them to constitute only 43 of the 341 (12%) bone tumour cases.

Malignant tumours (65%) were more common than benign tumours with primary tumours accounting 92 % and metastatic tumours only 8 % of all the malignancies. Females were more affected than males (55% versus 45 %).

Chondrosarcoma was the most frequent tumour, constituting 24% of primary malignant tumours and 18 % of all bone tumours.

Chondroma was the most common benign tumour accounting for 50% of all benign tumours, and 11% of all tumours.

Survival rate was relatively poor in elderly population with primary malignant tumours.

The majority of malignant tumours were in the lower limb (femur 25%, tibia 14 %).The upper limb accounted for 14% and the axial skeleton 5%.

Bone tumour registries provide a valuable source of cumulative information about both common and uncommon tumours. Such information could not easily be gathered by personal experience. It is also a very good source of information for research education and service.

Bone tumours are not common in the bones of the feet. We reviewed 10 years of referrals to the Leeds regional bone tumour registry between 1990 and 1999 which revealed twenty such tumours accounting for 5% of the total number of 341 bone tumours.

The mean age of the patients was 32 years (range 2 yrs to 80 yrs).

Men were affected more commonly than women (60% versus 40%).

40% affected the tarsal bones, 25% affected the hind foot, and 35 % affected the small tubular bones of the foot.

80% of tumours were benign. Malignant tumours accounted for only 20 % of all foot tumours and of these, 95% were primary tumours and only 5 % were metastases. Malignant tumours were found more frequently in the older population mean age (50 years).

Bone tumour registries offer a reliable source of data to study rare neoplasms in a large population group.