Abstract

Aim

We evaluated the outcome of conservative versus surgical treatment in lateral humeral condyle fractures in children. The management in some of these fractures remains controversial, ultimately relying upon the individual practitioner.

Aim: To assess the functional outcomes for patients treated by limb salvage surgery for sarcomas of the upper limb and shoulder girdle.

Materials and methods: Patients who had undergone limb salvage surgery for upper limb sarcoma between 1997 and 2004 were entered into the study. The operation notes were used to obtain details of the surgery. Pathology reports were consulted to identify the type, grade and margins of the tumour. The Toronto Extremity Salvage Score (TESS) questionnaire was used to assess post-operative function, in a postal survey.

Results: A total of 62 patients were identified. Liposarcoma was most common histological diagnosis, and “low” the most common grade (27). Histologically clear margins were achieved in 28 (44%) cases, marginal in 2 (3%), incomplete in 13 (21%) and indeterminate in 20 (32%). 30% had received adjuvant radiotherapy with or without chemotherapy as indicated. A total of 48 (76%) had been treated with excision and primary closure, 7 (11%) with local flaps, and 4 (6%) with endoprostheses. 10 patients had died, and 1 was untraceable. 29 completed TESS questionnaires were returned; with an average follow-up of 33 months post-resection (range 4 to 83). 11 female (38%), 18 male (62%), with an average age at surgery of 55. The average TESS score was 77 +/−10 with a range of 18–100. For the different regions, forearm sarcomas had an average TESS of 81 +/−17, upper arm 76 +/−19 and shoulder 81 +/−14.

Discussion: Surgical excision of soft tissue tumours with limb salvage aims to balance morbidity and mortality. Upper limb amputation has greater morbidity than lower limb and thus the argument for limb salvage should be stronger. A limb-salvage procedure should be considered preferable to amputation provided oncological outcomes are not compromised, and the resulting functional outcome is worth the oncological risk. In this cohort, patients had good functional outcomes, as described by the TESS functional assessment score, with no evidence of compromised oncological outcome during the follow up period.

This paper aims to determine if preoperative characteristics have a significant impact on functional outcome as measured by the WOMAC at 2-years following total knee replacement (TKR) surgery. Patients were recruited as part of a prospective study of outcomes of primary TKR for osteoarthritis in centres in the US (4 centres), UK (6 centres) and Australia (2 centres). Research assistants recruited eligible patients and collected clinical history and physical examination data preoperatively, 3, 12 and 24-months post surgery. The WOMAC, SF-36, patients satisfaction and demographic data were obtained by self-administered questionnaires. All scores were transformed to 0–100 scale (100 best).

We recruited 860 eligible patients and have complete 12-month WOMAC data on 736 patients (86%) and 2-year data on 701 patients (78%). Mean age was 70 years (SD 10), 59% were female, 50% were from the UK, 30% from the US and 20% from Australia. Mean preoperative clinical measures were: knee flexion 107° (SD18), SF36 Mental Health 72 (SD19), body mass index 29 (SD 6) and WOMAC Function 45 (SD 19). 46% of patients reported more than 2 comorbid conditions.

There was no significant difference between mean WOMAC Function scores at 12-months (73, SD 21) and 2-years (74, SD21). In a linear regression model (model R- square= 25), the preoperative predictors of worse WOMAC Function at 2-years, in order of decreasing importance, were: low WOMAC Function (p< 0.0001), higher number of comorbid conditions (p=0.0002), UK patients (p=0.0002), low SF36 Mental Health (p=0.01) and restricted preoperative knee flexion (p=0.02). Patients who come to surgery with poor function, restricted knee flexion, low mental health and other comorbid conditions are more likely to have worse functional outcomes 2-years following surgery. After adjusting for these predictors, the UK patients had significant lower WOMAC Function scores than the US and Australia.