Aims. The aim of this study was to determine the prevalence and impact of tourniquet use in patients undergoing limb salvage surgery with endoprosthetic reconstruction for a tumour around the knee. Methods. We retrieved data from the Prophylactic Antibiotic Regimens in Tumor Surgery (PARITY) trial; specifically, differences in baseline characteristics, surgical details, and postoperative functional outcomes between patients who had undergone surgery under tourniquet and those who had not. A linear regression model was created to evaluate the impact of tourniquet use on postoperative Toronto Extremity Salvage Scores (TESSs) while controlling for confounding variables. A negative-binomial regression model was constructed to explore predictors of postoperative length of stay (LOS). Results. Of the 604 patients enrolled in the PARITY trial, 421 had tumours around the knee joint, of whom 225 (53%) underwent surgery under tourniquet. The tourniquet group was younger (p = 0.014), more likely to undergo surgery for a tumour of the tibia, and had shorter operating times by a mean of 50 minutes (95% confidence interval 30 to 72; p < 0.001). The adjusted linear regression model found that the use of a tourniquet, a shorter operating time, and a higher baseline TESS independently predicted better function at both three- and six-month follow-up. The negative-binomial regression model showed that tourniquet use, shorter operating time, younger age, and intraoperative tranexamic acid administration independently predicted a shorter LOS in hospital. Conclusion. The results of this study show that in patients undergoing resection of a tumour around the knee and endoprosthetic reconstruction, the use of an intraoperative tourniquet is associated with a shorter operating time, a reduced length of stay in hospital, and a better early functional outcome. Cite this article: Bone Joint J 2022;104-B(10):1168–1173

Functional outcomes are important for patients with bone tumors undergoing lower extremity endoprosthetic reconstruction; however, there is limited empirical evidence evaluating function longitudinally. The objective of this study was to determine the changes in function over time in patients undergoing endoprosthetic reconstructions of the proximal femur, distal femur and proximal tibia. We conducted a secondary analysis of functional outcome data from the Prophylactic Antibiotic Regimens in Tumor Surgery (PARITY) trial. Patient function was assessed with the Musculoskeletal Tumor Society Score 93 (MSTS) and the Toronto Extremity Salvage Score (TESS), which were administered preoperatively and at 3, 6 and 12 months postoperatively. Both instruments are scored from 0-100, with higher scores indicated greater function. Mean functional scores were evaluated over time and we explored for differences among patients undergoing proximal femur reconstructions (PFR), distal femur reconstructions (DFR) and proximal tibia reconstructions (PTR). The patient-importance of statistically significant differences in function was evaluated utilizing the minimally important difference (MID) of 12 for the MSTS and 11 for the TESS. We explored for differences in change scores between each time interval with paired t-tests. Differences based on endoprosthetic reconstruction undertaken were evaluated by analysis of variance and post-hoc comparisons using the Tukey test. A total of 573 patients were included. The overall mean MSTS and TESS scores were 77.1(SD±21) and 80.2(SD±20) respectively at 1-year post-surgery, demonstrating approximately a 20-point improvement from baseline for both instruments. When evaluating change scores over time by type of reconstruction, PFR patients experienced significant functional improvement during the 3-6 and 6-12 month follow-up intervals, DFR patients demonstrated significant improvements in function at each follow-up interval, and PTR patients reported a significant decrease in function from baseline to 3 months, and subsequent improvements during the 3-6 and 6-12 month intervals. On average, patients undergoing endoprosthetic reconstruction of the lower extremity experience important improvements in function from baseline within the first year. Patterns of functional recovery varied significantly based on type of reconstruction performed. The results of this study will inform both clinicians and patients about the expected rehabilitation course and functional outcomes following endoprosthetic reconstruction of the lower extremity

Aims. There is an increased risk of dislocation of the hip after the resection of a periacetabular tumour and endoprosthetic reconstruction of the defect in the hemipelvis. The aim of this study was to determine the rate and timing of dislocation and to identify its risk factors. Methods. To determine the dislocation rate, we conducted a retrospective single-institution study of 441 patients with a periacetabular tumour who had undergone a standard modular hemipelvic endoprosthetic reconstruction between 2003 and 2019. After excluding ineligible patients, 420 patients were enrolled. Patient-specific, resection-specific, and reconstruction-specific variables were studied using univariate and multivariate analyses. Results. The dislocation rate was 9.3% (n = 41). Dislocation was most likely to occur in the first three months after surgery. Four independent risk factors were found, one of which was older age at operation (p = 0.039). The odds ratios (ORs) of those aged ≥ 60 years and 30 to 60 years were 8.50 and 4.64, respectively, compared with those aged < 30 years. The other three risk factors were resection of gluteus maximus (p = 0.010, OR = 5.8), vertical shift of the centre of rotation (COR) of the hip by ≥ 20 mm (p = 0.008, OR = 3.60), and a type I+II+III pelvic resection (p = 0.014, OR = 3.04). Conclusion. Hemipelvic endoprosthetic reconstruction after resection of a periacetabular tumour has a dislocation rate of 9.3% (n = 41). Patients are most likely to dislocate in the first three months after surgery. The risk is increased for older patients (especially those aged > 60 years) and for those with gluteus maximus resection, vertical shift of the COR ≥ 20 mm, and a type I+II+III pelvic resection. Cite this article: Bone Joint J 2021;103-B(2):382–390

Paediatric bone sarcomas around the knee are often amenable to either endoprosthetic reconstruction or rotationplasty. Cosmesis and durability dramatically distinguish these two options, although patient-reported functional satisfaction has been similar among survivors. However, the impact on oncological and surgical outcomes for these approaches has not been directly compared. We retrospectively reviewed all wide resections for bone sarcoma of the distal femur or proximal tibia that were reconstructed either with an endoprosthesis or by rotationplasty at our institution between June 2004 and December 2014 with a minimum two year follow-up. Pertinent demographic information, surgical and oncological outcomes were reviewed. Survival analysis was performed using the Kaplan-Meier method with statistical significance set at p<0.05. Thirty eight patients with primary sarcomas around the knee underwent wide resection and either endoprosthetic reconstruction (n=19) or rotationplasty (n=19). Groups were comparable in terms of demographic parameters and systemic tumour burden at presentation. We found that selection of endoprosthetic reconstruction versus rotationplasty did not impact overall survival for the entire patient cohort but was significant in subgroup analysis. Two-year overall survival was 86.7% and 85.6% in the endoprosthesis and rotationplasty groups, respectively (p=0.33). When only patients with greater than 90% chemotherapy-induced necrosis were considered, overall survival was significantly better in the rotationplasty versus endoprosthesis groups (100% vs. 72.9% at two years, p=0.013). Similarly, while event-free survival was not affected by reconstruction method (60.2% vs. 73.3% at two years for endoprosthesis vs rotationplasty, p=0.27), there was a trend towards lower local recurrence in rotationplasty patients (p=0.07). When surgical outcomes were considered, a higher complication rate was seen in patients that received an endoprosthesis compared to those who underwent rotationplasty. Including all reasons for re-operation, 78.9% (n=15) of the endoprosthesis patients required a minimum of one additional surgery compared with only 26.3% (n=5) among rotationplasty patients (p=0.003). The most common reasons for re-operation in endoprosthesis patients were wound breakdown/infection (n=6), limb length discrepancy (n=6) and periprosthetic fracture (n=2). Excluding limb length equalisation procedures, the average time to re-operation in this patient population was 5.6 months (range 1 week to 23 months). Similarly, the most common reason for a secondary procedure in rotationplasty patients was wound breakdown/infection, although only two patients experienced this complication. Average time to re-operation in this group was 23.8 months (range 5 to 49 months). Endoprosthetic reconstruction and rotationplasty are both viable limb-salvage options following wide resection of high-grade bony sarcomas located around the knee in the paediatric population. Endoprosthetic reconstruction is associated with a higher complication rate and may negatively impact local recurrence. Study of a larger number of patients is needed to determine whether the reconstructive choice affects survival

Aims. We aimed to examine the long-term mechanical survivorship, describe the modes of all-cause failure, and identify risk factors for mechanical failure of all-polyethylene tibial components in endoprosthetic reconstruction. Methods. This is a retrospective database review of consecutive endoprosthetic reconstructions performed for oncological indications between 1980 and 2019. Patients with all-polyethylene tibial components were isolated and analyzed for revision for mechanical failure. Outcomes included survival of the all-polyethylene tibial component, revision surgery categorized according to the Henderson Failure Mode Classification, and complications and functional outcome, as assessed by the Musculoskeletal Tumor Society (MSTS) score at the final follow-up. Results. A total of 278 patients were identified with 289 all-polyethylene tibial components. Mechanical survival was 98.4%, 91.1%, and 85.2% at five, ten and 15 years, respectively. A total of 15 mechanical failures were identified at the final follow-up. Of the 13 all-polyethylene tibial components used for revision of a previous tibial component, five (38.5%) failed mechanically. Younger patients (< 18 years vs > 18 years; p = 0.005) and those used as revision components (p < 0.001) had significantly increased rates of failure. Multivariate logistic regression modelling showed revision status to be a positive risk factor for failure (odds ratio (OR) 19.498, 95% confidence interval (CI) 4.598 to 82.676) and increasing age was a negative risk factor for failure (OR 0.927, 95% CI 0.872 to 0.987). Age-stratified risk analysis showed that age > 24 years was no longer a statistically significant risk factor for failure. The final mean MSTS score for all patients was 89% (8.5% to 100.0%). Conclusion. The long-term mechanical survivorship of all-polyethylene tibial components when used for tumour endoprostheses was excellent. Tumour surgeons should consider using these components for their durability and the secondary benefits of reduced cost and ease of removal and revision. However, caution should be taken when using all-polyethylene tibial components in the revision setting as a significantly higher rate of mechanical failure was seen in this group of patients. Cite this article: Bone Joint J. 2020;102-B(2):170–176

The purpose of this study was to evaluate the results of custom-made endoprosthetic reconstruction for both tumourous and non-tumourous conditions around the elbow joint. 28 consecutive cases of endoprosthetic elbow reconstruction, performed between 1989 and 2003, were identified using the unit database. There were 12 males and 16 females, with a mean age 48.9 years, (range 14–84). There were 16 cases of malignant tumour (10 primary, 6 secondary), 3 cases of benign tumour (one each of giant cell tumour, osteoblastoma and pigmented villonodular synovitis) and 10 non-oncological cases, (5 cases of fracture, 3 failed total elbow replacements and 1 infected synostosis). A distal humeral prosthesis was used in 16 patients, distal humeral and proximal ulna in 10 patients, proximal ulna with a humeral component in one patient and proximal radial replacement in one patient. Clinical and radiographic review of all available patients, including a functional assessment with The Toronto Extremity Salvage score (TESS) was undertaken. 28 consecutive cases of endoprosthetic elbow reconstruction, performed between 1989 and 2003, were identified using the unit database. There were 12 males and 16 females, with a mean age 48.9 years, (range 14–84). There were 16 cases of malignant tumour (10 primary, 6 secondary), 3 cases of benign tumour (one each of giant cell tumour, osteoblastoma and pigmented villonodular synovitis) and 10 non-oncological cases, (5 cases of fracture, 3 failed total elbow replacements and 1 infected synostosis). A distal humeral prosthesis was used in 16 patients, distal humeral and proximal ulna in 10 patients, proximal ulna with a humeral component in one patient and proximal radial replacement in one patient. Clinical and radiographic review of all available patients, including a functional assessment with The Toronto Extremity Salvage score (TESS) was undertaken. Endoprosthetic reconstruction around the elbow joint is effective in a wide range of pathologies, allowing in most cases a reasonable level of function, even following two-stage revision for infection

Purpose: The purpose of this study was to evaluate the results of custom-made endoprosthetic reconstruction for both tumourous and non-tumourous conditions around the elbow joint. Methods and Results: 28 consecutive cases of endoprosthetic elbow reconstruction, performed between 1989 and 2003, were identified using the unit database. There were 12 males and 16 females, with a mean age of 48.9 years, (range 14–84). There were 16 cases of malignant tumour (10 primary, 6 secondary), 3 cases of benign tumour (one each of giant cell tumour, osteoblastoma and pigmented villonodular synovitis) and 10 non-oncological cases, (5 cases of fracture, 3 failed total elbow replacements and 1 infected synostosis). A distal humeral prosthesis was used in 16 patients, distal humeral and proximal ulna in 10 patients, proximal ulna with a humeral component in one patient and proximal radial replacement in one patient. Clinical and radiographic review of all available patients, including a functional assessment with The Toronto Extremity Salvage (TES) score was undertaken. The average follow-up was 54.9 months (range 5–144). 5 patients with malignancy died of their disease. One patient required amputation for local recurrence at 5 months. There were two revisions at 4 and 7 years for aseptic loosening of the humeral component. Six patients developed deep prosthetic infection at an average of 21 months (range 6–31), necessitating two-stage revision, of which one patient required subsequent excision arthroplasty. There were no cases of permanent nerve palsy. 18 patients (64.3%) were available for functional follow-up. Average flexion deformity was 33 degrees (7–80) and average flexion was 85 degrees (30–133). The mean TES score was 67.8 (range 36.6–96.6). The mean TES score following two-stage revision for infection, (available in 4/5 patients) was 73.9 (range 54.8–91.6). Conclusion: Custom-made endoprosthetic reconstruction around the elbow joint is effective in a wide range of pathologies, allowing in most cases a reasonable level of function, even following two-stage revision for infection

Aims. Dislocation of the hip remains a major complication after periacetabular tumour resection and endoprosthetic reconstruction. The position of the acetabular component is an important modifiable factor for surgeons in determining the risk of postoperative dislocation. We investigated the significance of horizontal, vertical, and sagittal displacement of the hip centre of rotation (COR) on postoperative dislocation using a CT-based 3D model, as well as other potential risk factors for dislocation. Methods. A total of 122 patients who underwent reconstruction following resection of periacetabular tumour between January 2011 and January 2020 were studied. The risk factors for dislocation were investigated with univariate and multivariate logistic regression analysis on patient-specific, resection-specific, and reconstruction-specific variables. Results. The dislocation rate was 13.9% (n = 17). The hip COR was found to be significantly shifted anteriorly and inferiorly in most patients in the dislocation group compared with the non-dislocation group. Three independent risk factors were found to be related to dislocation: resection of gluteus medius (odds ratio (OR) 3.68 (95% confidence interval (CI) 1.24 to 19.70); p = 0.039), vertical shift of COR > 18 mm (OR 24.8 (95% CI 6.23 to 128.00); p = 0.001), and sagittal shift of COR > 20 mm (OR 6.22 (95% CI 1.33 to 32.2); p = 0.026). Conclusion. Among the 17 patients who dislocated, 70.3% (n = 12) were anterior dislocations. Three independent risk factors were identified, suggesting the importance of proper restoration of the COR and the role of the gluteus medius in maintaining hip joint stability. Cite this article: Bone Joint J 2022;104-B(10):1180–1188

Segmental bone defects with complex fractures or chronic infections comprise a very special subset of patients. Modular endoprosthetic reconstruction is an operative solution. Without reconstruction amputation/disarticulation is the likely outcome. Aim of the study was to analyse preliminary results of modular endoprosthetic reconstruction in nonneoplastic limb salvage. 11 patients(9 – distal femoral replacement, 2 – total femoral replacement) underwent salvage reconstruction between January 2005 and March 2008 for chronic periprosthetic infections(6 – single stage revision; 2 – two stage revision) and complex periprosthetic fractures(3) with segmental bone defects. Microbiological and haematological evidence of infection was confirmed in the infection group and treated with concomitant community based antibiotic therapy as per guidance from specialist team. The mean age and follow up were 74.2 years and 27.5 months respectively. No intraoperative complications identified. Average post operative mobilisation was with frame at 5 days, 2 sticks at 2 weeks. 1 patient required plastic surgical intervention at index operation. 1 patient had recurrence of infection. Radiographs at 6, 12 & 24 months showed no changes from immediate post-op. Microbiological and haematological evidence of infection eradication was considered as successful treatment. Knee range of movements averaged full extension to 95 degrees. Oxford knee scores showed maximal improvement in the single stage revision group. We conclude that salvage endoprosthetic reconstruction has provided an oppourtunity to avoid amputation. A significant improvement in overall range of motion, knee scores, pain relief and stability was achieved in this highly complex subset of patients. Multidisciplinary support from plastic surgeons and specialist microbiologists is essential

Functional outcomes are commonly reported in studies of musculoskeletal oncology patients undergoing limb salvage surgery; however, interpretation requires knowledge of the smallest amount of improvement that is important to patients – the minimally important difference (MID). We established the MIDs for the Musculoskeletal Tumor Society Rating Scale (MSTS) and Toronto Extremity Salvage Score (TESS) in patients with bone tumors undergoing lower limb salvage surgery. This study was a secondary analysis of the recently completed PARITY (Prophylactic Antibiotic Regimens in Tumor Surgery) study. This data was used to calculate: (1) the anchor-based MIDs using an overall function scale and a receiver operating curve analysis, and (2) the distribution-based MIDs based on one-half of the standard deviation of the change scores from baseline to 12-month follow-up, for both the MSTS and TESS. There were 591 patients available for analysis. The Pearson correlation coefficients for the association between changes in MSTS and TESS scores and changes in the external anchor scores were 0.71 and 0.57, indicating “high” and “moderate” correlation. Anchor-based MIDs were 12 points and 11 points for the MSTS and TESS, respectively. Distribution-based calculations yielded MIDs of 16-17 points for the MSTS and 14 points for the TESS. The current study proposes MID scores for both the MSTS and TESS outcome measures based on 591 patients with bone tumors undergoing lower extremity endoprosthetic reconstruction. These thresholds will optimize interpretation of the magnitude of treatment effects, which will enable shared decision-making with patients in trading off desirable and undesirable outcomes of alternative management strategies. We recommend anchor-based MIDs as they are grounded in changes in functional status that are meaningful to patients

We reviewed retrospectively the results in 211 consecutive patients who had undergone limb salvage for bone neoplasia with endoprosthetic reconstruction of the proximal femur (96), distal femur (78), proximal tibia (30) and total femur (7). Their mean age was 50 years (11 to 86) and the mean follow-up period was 37.3 months (1 to 204). A total of 35 (16.6%) prostheses failed. Overall, implant survival was 78% (95% confidence interval (CI) 0.29 to 0.54) at five years, 60% (95% CI 0.93 to 2.35) at ten years and 60% (95% CI 1.27 to 3.88) at 15 years. Survivorship of the limb was 97.6% (95% CI 1.73 to 3.35) at ten years. The gender, age, diagnosis and location of the tumour were not prognostic variables for failure. Modular endoprosthetic replacement in the lower limb is a durable long-term reconstructive option, with the implants generally outlasting the patient

Introduction: Despite advances in limb-sparing techniques, the proximal tibia remains a difficult area in which to perform a wide resection of extensive bone tumors due to the intimate relationship to the nerves and blood vessels, inadequate soft-tissue coverage, and the need to reconstruct the extensor mechanism. The current long-term follow-up study, based on the experience with 55 patients who underwent proximal tibia endoprosthetic reconstruction emphasizes reconstruction of the extensor mechanism. Materials and Methods: Between 1980 and 1997, 55 patients underwent proximal tibia resection with endoprosthetic reconstruction. There were 34 males and 21 females whose age ranged from 8 to 56 years (median, 27 years. Diagnoses were: primary bone sarcomas – 48, benign aggressive lesions – 6, and failure of previous osteoarticular allograft reconstruction – 1. Intra-articular resection with en bloc removal of the tibial tuberosity was performed in all cases. Endoprosthetic reconstruction was performed with 39 modular, 16 custom-made prostheses. Reconstruction of the extensor mechanism included reattachment of the patellar tendon to the prosthesis with a Dacron tape and reinforcement with a gastrocnemius flap and bone grafting of the patellar tendon-prosthesis interface. Rehabilitation emphasized prolonged immobilization of knee joint in full extension. Results: All patients were followed for a minimum of 2 years (range 24–235 months, median – 75.5 months). Full extension to extension lag of 20° was achieved in 44 patients (78%), extension lag of 20° to 30° was found in 10 patients (19%), and extension lag of 40° was found in 1 patient (3%). Eight patients required an additional procedure which involved reinforcement of the patellar tendon with either combined quadriceps tendon and Goretex graft construct (seven patients) or simple plication of the tendon (one patient). Seven of these patients gained an extension lag of less than 20°. Overall, function was estimated to be good to excellent in 48 patients, fair in 6, and poor in one patient. Discussion: Extension lag of up to 20° is considered compatible with activities of daily living. Emphasis on reattachment of the patellar tendon to the prosthesis and its reinforcement with a gastrocnemius flap and bone graft achieved that goal in the majority of the patients. Secondary reinforcement of the patellar tendon is recommended for extension lag of more than 20°

Introduction: Total scapular resection causes a significant functional loss because of the sacrifice of the glenoid, which serves as a stable base for shoulder motion. The authors analyze their experience with two types of reconstructions following total scapular resection; suspension of the humeral head from the clavicle without endoprosthetic reconstruction of the scapula and endoprosthetic scapular reconstruction. Materials and Methods: Between 1979 and 1997, the authors treated 23 patients with scapular tumors that required total scapular resection. Patients were diagnosed with 14 bone and 9 soft-tissue tumors. Resection included total scapulectomy in 12 patients and enbloc resection of the scapula and humeral head in 11 patients. Reconstruction: All eleven patients who had resection of their humeral head underwent reconstruction of the humerus with endoprosthesis. Scapular endoprosthesis was further installed in 7 patients and suspension of the humeral head from the clavicle with a Dacron tape was performed in 16 patients (Suspension of the prosthetic humeral head from the clavicle – 4 patients; suspension of the native humeral head from the clavicle – 12 patients). Endoprosthetic reconstruction of the scapula was feasible only when the periscapular musculature was sufficient for endoprosthetic attachment and coverage. The scapular prosthesis was attached to the prosthetic humeral head with a Goretex® sleeve, which served as an artificial joint capsule. All patients were followed for a minimum of 2 years; follow-up included physical examination, radiological evaluation and functional evaluation according to the American Musculoskeletal Tumor Society system. Results: Elbow range-of-motion and hand dexterity were similar in the two groups of patients. However, compared with patients who undergone humeral suspension, those who had scapular endoprosthesis had better abduction (60°–90° vs. 10°–20°) of the shoulder joint. Moreover, these patients had better cosmetic appearance of the shoulder girdle. There were no deep wound infections, prosthetic failures, or secondary amputations. Overall, 6 patients who had scapular prosthesis (86%) and 10 patients who had humeral suspension (62%) had a good-to-excellent functional outcome. Conclusions: The number of patients who underwent a scapular endoprosthetic reconstruction is small and does not allow a valid statistical analysis; however, the authors feel that scapular endoprosthesis reconstruction is associated with better functional and cosmetic outcomes, when compared to humeral suspension. The authors recommend reconstruction of the scapula with endoprosthesis when periscapular musculature, remaining after tumor resection allows attachment and coverage of the prosthesis

Periprosthetic infection with extensive bone loss is a complex situation. The appropriate management of large bone defects has not been established. Without reconstruction amputation/disarticulation is the likely outcome. Aim of the study was to Analyse preliminary results of direct exchange endoprosthetic reconstruction for periprosthetic infection associated with segmental bone defects. Study of patients with periprosthetic infection and severe osteolysis treated by direct exchange tumour prostheses between June, 2005 and May, 2008 (4 – Distal femoral & 2 – Total femoral Replacements). Microbiological evidence of infection was confirmed with regular monitoring of radiograph, crp, esr and wcc. Community based antibiotic therapy was provided by infectious disease team based in our institution. The mean age and follow up were 74.2 years and 26.5 months respectively. Mean duration of antibiotics was 6 weeks intravenous(community based) and 3.5 months oral. 1 patient required intervention by plastic surgeons at index procedure. Radiographs at 6, 12 & 24 months showed no changes from immediate post-op. CRP, ESR and WBC count were within normal limits at the end of antibiotic therapy. One patient required prolonged pain relief with poor mobility due to instability in the opposite knee. One patient had infection recurrence. Knee range of movements averaged full extension to 95 degrees. The mean oxford knee scores pre and post operatively were 58 and 39.4 respectively. We conclude that salvage endoprosthetic reconstruction has provided effective pain relief, stability and improved mobility in our experience. It has provided an oppourtunity to avoid amputation. Multidisciplinary support from plastic surgeons and specialist microbiologists is essential

Introduction: Periprosthetic infection with extensive bone loss is a complex situation. The appropriate management of large bone defects has not been established. Without reconstruction amputation/disarticulation is the likely outcome. Aim: To Analyse preliminary results of direct exchange endoprosthetic reconstruction for periprosthetic knee infection associated with segmental bone defects. Methods: Study of patients with periprosthetic knee infection and severe osteolysis treated by direct exchange tumour prostheses between June, 2005 and May, 2008 (4 - Distal femoral & 2 - Total femoral Replacements). Exclusion criteria included polymicrobial infection, resistant organisms, depressed immunity and poor peripheral perfusion. At each clinical visit they were monitored for clinical, microbiological, haematological and radiological evidence of infection. Community based antibiotic therapy was provided by specialist microbiologists. All patients were counselled and consented by the operating surgeon and specialist microbiologist prior to surgery. Results: The mean age and follow up were 70.2 years and 30.5 months respectively. The most common infecting organism was Staphylococcus epidermidis (four), followed by Streptococcus species. Mean duration of antibiotics was 6 weeks intravenous(community based) and 8 weeks oral. 1 patient required intervention by plastic surgeons at index procedure. Radiographs showed no changes at final followup. One patient had superficial wound infection, which was successfully debrided. Knee range of movements averaged full extension to 95 degrees. The mean oxford knee scores pre and post operatively were 58 and 39.4 respectively. Conclusion: Salvage direct exchange endoprosthetic reconstruction has provided effective pain relief, stability and improved mobility in our experience. Isolation of sensitive organism, specialist microbiologist input, availability of specialist physiotherapy and plastic surgery service, appropriate community care, good patient compliance and surgeon’s experience are key to success in these patients. Morbidity was significantly reduced due to early mobilisation

We performed a retrospective review of 98 patients with malignant tumours of the periacetabular region, treated by resection and endoprosthetic reconstruction between 1971 and 2005 at the Royal National Orthopaedic Hospital, Stanmore and The Royal Orthopaedic Hospital, Birmingham. The mean age of the patients was 43.6 years (10 to 76). 53 patients (54%) were male. The age distribution demonstrated peaks in the 2nd and 6th decades. The mean follow up was 65 months (2 to 405. The overall 10-year survival rate was 56% (determined by the Kaplan-Meier method). 54 patients (58.1%) had one or more complications. Infection was the most common (30%) with the majority occurring in the first 2 years. Dislocation occurred in 19 (20%) of our patients all in the first year following surgery. All were recurrent with a mean of 2.9 (2 to 6) episodes. Operations performed before 1994 were associated with a dislocation rate of 40.5% and after 1996 the rate was only 3.9% (p < 0.001). Function was assessed according the Toronto Extremity Salvage Sore (TESS). The overall TESS was 59.4. In patients that had a major complication the TESS was 37.1 but in the group that did not the TESS was 70.3 (p < 0.001). Men experienced higher rates of death, infection and revision than women (p < 0.05). The local recurrence rate was 31% with high grade tumours associated with higher recurrence rates (p < 0.05). Tumour resection in the ilium is associated with higher rates of infection than tumours located in the periacetabular region alone (p < 0.05). This method of reconstruction is still associated with high complication rates. Function is good if a major complication can be avoided. The lower dislocation rate more recently is probably the result of improved surgical technique and the use of larger femoral heads

Parosteal osteosarcoma is an uncommon tumour. Different methods of surgical treatment have been reported. Aim of this study was to investigate differences in outcome after biological and prosthetic reconstruction. Since August 1969, 28 patients have been treated at our institution. Average age was 26 years, range 15 to 59 years. Patient data was retrospectively reviewed within the prospective database of the Vienna Tumour Registry. Average follow-up was 133.9 months, range 8.4 to 382.6 months. Two patients died of disease 8.4 and 81.4 months after operation, respectively, another patient died due to unrelated causes 330.4 months postoperatively. All surviving patients were followed for a minimum of 3.6 months. Location of the lesion was the distal femur (19), proximal humerus (four), proximal tibia (three), mid-diaphyseal and proximal femur (one each). In 12 patients endoprosthetic reconstruction was indicated. Biological reconstruction was performed in 11 patients. Three patients underwent rotationplasty, two patients were amputated. Eight of 12 patients with endoprostheses have been revised, five have had multiple revisions. Causes for revision were bushing wear (four), aseptic loosening (four), infection (three) and periprosthetic fracture (one). There was no local recurrence in the endoprosthetic group. Two of 11 patients with biological reconstruction underwent revision due to pseudarthrosis and femoral fracture, respectively. There were two cases of local recurrence requiring secondary amputation. Two patients with rotationplasty underwent revision for wound healing disturbance and thrombectomy, respectively. Three patients developed lung metastases, leading to death of disease in two cases of amputation and rotationplasty. One patient with endoprosthetic reconstruction was alive 129.0 months after pulmonary metastasectomy. Functional outcome was satisfactory in all patients; there were no significant differences between patients with endoprosthetic or biological reconstruction. Biological reconstruction showed less revisions compared to endoprostheses, however, exact preoperative planning is required to obtain clear margins of resection

Limb salvage surgery includes all of the surgical procedures designed to accomplish removal of a malignant tumour and reconstruction of the limb in order to achieve an acceptable oncological, functional, and cosmetic result. The aim of this study was to evaluate the functional outcome following endoprosthetic replcament for primary upper & lower extremity musculoskeletal neolplasms. Between 1983 and 2004, we found 68 patients from the Scottish Tumor Register having had an endoprosthetic reconstruction for upper and lower-extremity malignant musculoskeletal tumours, of which 32 were alive for performing functional assessment (lower extremity-26, upper extremity-6). The clinical, radiological and oncological outcomes were evaluated. The functional outcome was measured by the Musculoskeletal Tumor Society and Toronto Extremity Salvage Score. The average follow-up was 59 months (range, 1 to 21 years). There were 19 female and 13 male patients. These were anatomically distributed as around the knee (n=18 cases), hip (n=8) and shoulder (n=4). The most common diagnosis was chondrosarcoma (n=10) and osteosarcoma (n=11). Most of the patients were completely satisfied with their condition, with a decreased walking distance as the only notable restriction. There was no correlation between the functional outcome and the type or site of resection. Complications occurred in ten cases, including two cases of aseptic loosening and one case each of recurrent instability, sciatic nerve palsy and femoral nerve palsy. The median functional score using the Musculoskeletal Tumour Society system was 56% and Toronto Extremity Salvage Score was 72%. Limb salvage for malignant musculoskeletal tumours continues to pose therapeutic and oncological challenges with considerable functional issues, but the good function and local tumour control in most patients justifies its continued use

The October 2023 Oncology Roundup. 360. looks at: Are pathological fractures in patients with osteosarcoma associated with worse survival outcomes?; Spotting the difference: how secondary osteosarcoma manifests in retinoblastoma survivors versus conventional cases; Accuracy of MRI scans in predicting intra-articular joint involvement in high-grade sarcomas around the knee; Endoprosthetic reconstruction for lower extremity soft-tissue sarcomas with bone involvement; Local relapse of soft-tissue sarcoma of the extremities or trunk wall operated on with wide margins without radiation therapy; 3D-printed, custom-made prostheses in patients who had resection of tumours of the hand and foot; Long-term follow-up for low-grade chondrosarcoma; Evaluation of local recurrence and diagnostic discordance in chondrosarcoma patients undergoing preoperative biopsy; Radiological scoring and resection grade for intraosseous chondrosarcoma

Objectives. The diagnosis of surgical site infection following endoprosthetic reconstruction for bone tumours is frequently a subjective diagnosis. Large clinical trials use blinded Central Adjudication Committees (CACs) to minimise the variability and bias associated with assessing a clinical outcome. The aim of this study was to determine the level of inter-rater and intra-rater agreement in the diagnosis of surgical site infection in the context of a clinical trial. Materials and Methods. The Prophylactic Antibiotic Regimens in Tumour Surgery (PARITY) trial CAC adjudicated 29 non-PARITY cases of lower extremity endoprosthetic reconstruction. The CAC members classified each case according to the Centers for Disease Control (CDC) criteria for surgical site infection (superficial, deep, or organ space). Combinatorial analysis was used to calculate the smallest CAC panel size required to maximise agreement. A final meeting was held to establish a consensus. Results. Full or near consensus was reached in 20 of the 29 cases. The Fleiss kappa value was calculated as 0.44 (95% confidence interval (CI) 0.35 to 0.53), or moderate agreement. The greatest statistical agreement was observed in the outcome of no infection, 0.61 (95% CI 0.49 to 0.72, substantial agreement). Panelists reached a full consensus in 12 of 29 cases and near consensus in five of 29 cases when CDC criteria were used (superficial, deep or organ space). A stable maximum Fleiss kappa of 0.46 (95% CI 0.50 to 0.35) at CAC sizes greater than three members was obtained. Conclusions. There is substantial agreement among the members of the PARITY CAC regarding the presence or absence of surgical site infection. Agreement on the level of infection, however, is more challenging. Additional clinical information routinely collected by the prospective PARITY trial may improve the discriminatory capacity of the CAC in the parent study for the diagnosis of infection. Cite this article: J. Nuttall, N. Evaniew, P. Thornley, A. Griffin, B. Deheshi, T. O’Shea, J. Wunder, P. Ferguson, R. L. Randall, R. Turcotte, P. Schneider, P. McKay, M. Bhandari, M. Ghert. The inter-rater reliability of the diagnosis of surgical site infection in the context of a clinical trial. Bone Joint Res 2016;5:347–352. DOI: 10.1302/2046-3758.58.BJR-2016-0036.R1