The December 2023 Trauma Roundup. 360. looks at: Distal femoral arthroplasty: medical risks under the spotlight; Quads repair: tunnels or anchors?; Complex trade-offs in treating severe tibial fractures: limb salvage versus primary amputation; Middle-sized posterior malleolus fractures – to fix?; Bone transport through induced membrane: a randomized controlled trial; Displaced geriatric femoral neck fractures; Risk factors for reoperation to promote union in 1,111 distal femur fractures; New versus old – reliability of the OTA/AO classification for trochanteric hip fractures; Risk factors for fracture-related infection after ankle fracture surgery

Aims. Current literature suggests that survival outcomes and local recurrence rates of primary soft-tissue sarcoma diagnosed in the very elderly age range, (over 90 years), are comparable with those in patients diagnosed under the age of 75 years. Our aim is to quantify these outcomes with a view to rationalizing management and follow-up for very elderly patients. Methods. Retrospective access to our prospectively maintained oncology database yielded a cohort of 48 patients across 23 years with a median follow-up of 12 months (0 to 78) and mean age at diagnosis of 92 years (90 to 99). Overall, 42 of 48 of 48 patients (87.5%) were managed surgically with either limb salvage or amputation. Results. A lower overall local recurrence rate (LRR) was seen with primary amputations compared with limb salvage (p > 0.050). The LRR was comparable between free (R0), microscopically (R1), and macroscopically positive (R2) resection margins in the limb salvage group. Amputation was also associated with longer survival times (p < 0.050). Overall median survival time was limited to 20 months (0 to 80). Conclusion. Early and aggressive treatment with appropriate oncological surgery confers the lowest LRR and a survival advantage versus conservative treatment in this cohort of patients. With limited survival, follow-up can be rationalized on a patient-by-patient basis using alternative means, such as GP, local oncology, and/or patient-led follow-up. Cite this article: Bone Joint J 2022;104-B(1):177–182

Introduction. Transtibial osseointegration (TFOI) for amputees has limited but clear literature identifying superior quality of life and mobility versus a socketed prosthesis. Some amputees have knee arthritis that would be relieved by a total knee replacement (TKR). No other group has reported performing a TKR in association with TTOI (TKR+TTOI). We report the outcomes of nine patients who had TKR+TTOI, followed for an average 6.5 years. Materials & Methods. Our osseointegration registry was retrospectively reviewed to identify all patients who had TTOI and who also had TKR, performed at least two years prior. Four patients had TKR first the TTOI, four patients had simultaneous TKR+TTOI, and one patient had 1 OI first then TKR. All constructs were in continuity from hinged TKR to the prosthetic limb. Outcomes were: complications prompting surgical intervention, and changes in daily prosthesis wear hours, Questionnaire for Persons with a Transfemoral Amputation (QTFA), and Short Form 36 (SF36). All patients had clinical follow-up, but two patients did not have complete survey and mobility tests at both time periods. Results. Six (67%) were male, average age 51.2±14.7 years. All primary amputations were performed to manage traumatic injury or its sequelae. No patients died. Five patients (56%) developed infection leading to eventual transfemoral amputation 36.0±15.3 months later, and 1 patient had a single debridement six years after TTOI with no additional surgery in the subsequent two years. All patients who had transfemoral amputation elected for and received transfemoral osseointegration, and no infections occurred, although one patient sustained a periprosthetic fracture which was managed with internal fixation and implant retention and walks independently. The proportion of patients who wore their prosthesis at least 8 hours daily was 5/9=56%, versus 7/9=78% (p=.620). Even after proximal level amputation, the QTFA scores improved versus prior to TKR+TTOI, although not significantly: Global (45.2±20.3 vs 66.7±27.6, p=.179), Problem (39.8±19.8 vs 21.5±16.8, p=.205), Mobility (54.8±28.1 vs 67.7±25.0, p=.356). SF36 changes were also non-significant: Mental (58.6±7.0 vs 46.1±11.0, p=.068), Physical (34.3±6.1 vs 35.2±13.7, p=.904). Conclusions. TKR+TTOI presents a high risk for eventual infection prompting subsequent transfemoral amputation. Although none of these patients died, in general, TKR infection can lead to patient mortality. Given the exceptional benefit to preserving the knee joint to preserve amputee mobility and quality of life, it would be devastating to flatly force transtibial amputees with severe degenerative knee joint pain and unable to use a socket prosthesis to choose between TTOI but a painful knee, or preemptive transfemoral amputation for transfemoral osseointegration. Therefore, TTOI for patients who also request TKR must be considered cautiously. Given that this frequency of infection does not occur in patients who have total hip replacement in association with transfemoral osseointegration, the underlying issue may not be that linked joint replacement with osseointegrated limb replacement is incompatible, but may require further consideration of biological barriers to ascending infection and/or significant changes to implant design, surgical technique, or other yet-uncertain factors

Introduction. Open fractures of the tibia are disabling injuries with a significant risk of deep infection. Treatment involves early antibiotic administration, early and aggressive surgical debridement, and may require complex soft tissue coverage techniques. The extent of disruption to the skin and soft-tissue envelope often varies, with ‘simple’ open fractures (defined by the Orthopaedic Trauma Society (OTS) open fracture severity classification) able to be closed primarily, whilst others may require shortening or soft-tissue reconstruction. This study aimed to determine whether OTS simple tibial open fractures received different rates of adequate debridement and plastic surgical presence at initial debridement, compared with OTS complex injuries, and whether rates of fracture-related infection, nonunion, or reoperation differed between the groups. Materials & Methods. A consecutive series of open tibia fractures managed at a tertiary UK Major Trauma Centre between January 2021 and November 2022 were included. Patient demographics, injury characteristics, timing of antibiotic delivery, timing and method of definitive fixation, and frequency of plastic surgical presence at initial debridement were retrospectively collected. The delivery of bone ends at initial debridement was used as a proxy for adequacy of surgical debridement. The primary outcome measure was rate of fracture-related infection, secondary outcomes included rates of reoperation, nonunion, and amputation. Chi2 Tests and independent samples T-tests were used to assess nominal and continuous outcomes respectively between simple and complex injuries. Ordinal data was assessed using nonparametric equivalent tests. Results. 79 patients with open fractures of the tibia were included. 70.8% of patients were male, with mean age 50.4 years (SD 19.2) and BMI 26.4 Kg/m2 (SD 6.0). Injuries were mostly sustained by low-energy falls (n = 28, 35.4%) and from road traffic accidents (n = 26, 32.9%). 27 (34.2%) were OTS simple open fractures. Simple open fractures were most commonly Gustillo-Anderson grade 1 (38.5%), or 2 (30.8%), whilst complex open fractures were mostly grade 3B (66.7%) (p < 0.001). Fracture-related infection rates in OTS simple and complex open fractures were 25.9% and 25.5% respectively (p = 0.967), and nonunion rates were 32% and 37.8% (p = 0.637). Primary amputation was less common in simple (0%) than in complex open fractures (20%, p = 0.012), there were no differences in delayed amputation rates (7.4% and 6% respectively, p = 0.811). Simple open fractures were less likely to have plastic surgeons present at initial debridement compared to complex open fractures (18.5% and 44%, p = 0.025), and less likely to have bone ends delivered through the skin at initial debridement (25.9% and 61.2%, p = 0.003). There were no differences in patient age, delays to antibiotic administration, or reoperation rates between OTS simple and OTS complex fractures (p > 0.05). Conclusions. Despite involving less significant soft tissue injury, OTS simple open tibia fractures had comparable deep infection and nonunion rates to complex fractures and received early plastic surgical input and adequate debridement less frequently. The severity of open fractures with less significant soft tissue injury may be underrecognized and therefore undertreated, although further prospective study is needed

Aims. The aims of the study were to analyze differences in surgical and oncological outcomes, as well as quality of life (QoL) and function in patients with ankle sarcomas undergoing three forms of surgical treatment, minor or major limb salvage surgery (LSS), or amputation. Methods. A total of 69 patients with ankle sarcomas, treated between 1981 and 2017 at two tumour centres, were retrospectively reviewed (mean age at surgery: 46.3 years (SD 22.0); 31 females (45%)). Among these 69 patients 25 were analyzed prospectively (mean age at latest follow-up: 61.2 years (SD 20.7); 11 females (44%)), and assessed for mobility using the Prosthetic Limb Users Survey of Mobility (PLUS-M; for amputees only), the Toronto Extremity Salvage Score (TESS), and the University of California, Los Angeles (UCLA) Activity Score. Individual QoL was evaluated in these 25 patients using the five-level EuroQol five-dimension (EQ-5D-5L) and Fragebogen zur Lebenszufriedenheit/Questions on Life Satisfaction (FLZ). Results. Of the total number of patients in the study, 22 (32%) underwent minor LSS and 22 (32%) underwent major LSS; 25 underwent primary amputation (36%). Complications developed in 26 (38%) patients, and were more common in those with major or minor LSS in comparison to amputation (59% vs 36% vs 20%; p = 0.022). A time-dependent trend towards higher complication risk following any LSS was present (relative risk: 0.204; 95% confidence interval (CI) 0.026 to 1.614; p = 0.095). In the prospective cohort, mean TESS was higher following minor LSS in comparison to amputation (91.0 vs 67.3; p = 0.006), while there was no statistically significant difference between major LSS and amputation (81.6 vs 67.3; p = 0.099). There was no difference in mean UCLA (p = 0.334) between the three groups (p = 0.334). None of the items in FLZ or EQ-5D-5L were different between the three groups (all p > 0.05), except for FLZ item “self-relation”, being lower in amputees. Conclusion. Complications are common following LSS for ankle sarcomas. QoL is comparable between patients with LSS or amputation, despite better mobility scores for patients following minor LSS. We conclude that these results allow a decision for amputation to be made more easily in patients particularly where the principles of oncological surgery would otherwise be at risk. Cite this article: Bone Joint J 2021;103-B(3):553–561

Aim. To evaluate clinical outcomes for patients with osteomyelitis at a major trauma centre limb reconstruction unit. Method. We prospectively evaluated 137 patients on the limb reconstruction database with long bone osteomyelitis. Data on initial diagnosis, management (bone resection, use of external fixation, dead space and soft tissue management), microbiology and 2-year outcomes were collated. 11 patients' data was incomplete and 9 underwent primary amputations; these were excluded from microbiology data analysis. The patient data was categorised into microbiological culture negative or culture positive groups. Inter-group comparisons were made to evaluate two-year outcomes and percentage failure rate. Results. Forty percent (55/137) of patients presented with infected non-union, 20% (27/137) infected fractures, 19% (26/137) chronic osteomyelitis without implants and 14% (19/137) had infected metalwork. Removal of metalwork, reaming and debridement were the most frequently performed procedures, often in combination. 3% of patients failed treatment and had persistent infected non-union. The most common microorganisms identified in the culture positive group were Staphylococcus aureus (47.6%), Coagulase Negative Staphylococcus species (11.9%) and Enterobacter cloacae (11.9%), however multiple organism growth was more common than single organism growth, 53% and 47% respectively. 8% of culture negative patients had histological evidence of infection on biopsy. Conclusions. The 2-year failure rate (persistent infective non-union) was higher in the culture negative group (8%) than the culture positive group (1%). The higher failure rate may be secondary to lack of organisms isolated and available sensitivities from deep tissue samples. In 9 cases patient preference led to primary amputation over limb salvage procedures, without further infection. Our work highlights the array of factors contributing to outcome in this patient group. The incidence of micro-organisms commonly encountered in this cohort will provide further evidence to support choice of antibiotic for empirical therapy especially in cases which are culture negative. Finally, there are many challenges in achieving adequate outcomes in patients with long bone infections thus the need for a multidisciplinary team approach in this patient cohort is invaluable. Routine histology testing may be beneficial as this may highlight infective processes in culture negative patents thereby allowing optimization of patient management

Introduction. Blunt trauma of the lower limb can lead to vascular injury causing devastating outcomes, including loss of limb and even loss of life. The primary aim of this study was to determine the limb salvage rate of patients sustaining such injuries when treated at Leeds General Infirmary (LGI) since becoming a Major Trauma Centre (MTC). Secondary aims included establishing the patient complications and outcomes. Materials and Methods. Retrospective analysis found that from 2013–18, 30 patients, comprising of 32 injured limbs, were treated for blunt trauma to the lower limb associated with vascular injury. Long-term functional outcomes were determined using postal and telephone questionnaires. Results. Twenty-four patients were male and 6 were female, their mean ages were 32 and 49 respectively. Of the 32 limbs, 27 (84%) were salvaged. Three limbs were deemed unsalvageable and underwent primary amputation; of the remaining 29 potentially salvageable limbs, 27 (93%) were saved. Eleven limbs had prophylactic fasciotomies, 3 limbs developed compartment syndrome – all successfully treated, and three contracted deep infections – one of which necessitated amputation. All but 1 patient survived their injuries and were discharged from hospital. Of the 15 questionnaire responses, self-reported limb function was understandably worse post-injury with patients experiencing mild pain on average. In addition, there was a long-standing psychological impact and the injuries altered many patients’ normal lives significantly, 10 experiencing financial difficulties and 6 having changed or lost jobs post-injury. Conclusions. Fortunately, 27 (84%) limbs were salvaged and nearly all patients survived these injuries when treated at an MTC. Whilst the number of complications was low, the future challenges these patients face are wide-ranging and significant

812 consecutive patients with soft tissue sarcoma of the extremity were studied to compare the characteristics and outcome of patients who had primary amputations and limb preserving surgery. Patients with primary amputations were more likely to have metastases at presentation, high-grade tumours, larger tumours and were older. The most frequent indications for primary amputation were tumour excision which would result in inadequate function and large extracompartmental tumours with composite tissue involvement including major vessels, nerves and bone. The requirement for primary amputation was a poor prognostic factor independent of tumour grade, tumour size and patients’ age

A poor response to chemotherapy (≤ 90% necrosis) for osteosarcomas leads to poorer survival and an increased risk of local recurrence, particularly if there is a close margin of excision. We evaluated whether amputation confers any survival benefit over limb salvage surgery (LSS) with narrow margins in patients who respond poorly to chemotherapy. We only analysed patients with an osteosarcoma of the limb, a poor response to chemotherapy and close margins on LSS (marginal/intralesional) or primary amputation: 360 patients (36 LSS (intralesional margins), 197 LSS (marginal margins) and 127 amputations) were included. Local recurrence developed in 13 (36%) following LSS with intralesional margins, and 39 (20%) following LSS with marginal margins. There was no local recurrence in patients who underwent amputation. The five-year survival for all patients was 41% (95% confidence interval (CI) 35 to 46), but for those treated by LSS with marginal margins was 46.2% (95% CI 38 to 53), 36.3% (95% CI 27 to 45) for those treated by amputation, and 28% (95 CI 14 to 44) for those treated by LSS with intralesional margins. Patients who had LSS and then developed local recurrence as a first event had the same survival as those who had primary amputation without local recurrence. Prophylactic adjuvant radiotherapy was used in 40 patients but had no discernible effect in preventing local recurrence. Although amputation offered better local control, it conferred no clear survival benefit over LSS with marginal margins in these patients with a poor overall prognosis. Cite this article: Bone Joint J 2015;97-B:115–20

Aims. Limb salvage for diabetic foot infections often require multiple procedures. Some patients will eventually end up with below knee amputation (BKA) when all limb salvage attempts fail. We seek to study the patients’ ability to return to normal life, functional status, prosthesis usage and perspectives on multiple limb salvage procedures that culminated in BKA to review if they would undertake a similar path if their situation was repeated. Patients and Methods. A total of 41 patients who underwent BKA between July 2011 and June 2013 were reviewed. They were divided into primary and creeping (prior multiple salvage procedures) amputations. The Barthel’s Index (BI) and the Reintegration to Normal Living Index (RNLI) were used. A questionnaire was used to identify whether the patient would undergo the same multiple attempts at limb salvage again if faced with the same problem. Results. All patients had a good mean BI of 14.2 (3 to 20) and RNLI of 73.2 (31 to 100). There was no difference in prosthesis usage, BI and RNLI between both groups. We found that 16 (94.1%) out of 17 patients with creeping amputation would undergo the same multiple salvage procedures if given a similar option. Conversely, only 15 (62.5%) patients with primary amputation would do the same again while the other nine (37.5%) patients choose to do everything possible to save their leg if faced with a similar situation (p = 0.001). Conclusion. Most patients preferred to undergo multiple procedures to salvage the limb from diabetic foot infection even if it ultimately concluded with a BKA. All the patients had a moderately good functional outcome and ability to return to normal living after BKA. Cite this article: Bone Joint J 2017;99-B:1502–7

1. Nine patients treated for osteogenic sarcoma by elective radical irradiation are reviewed. Five of the nine patients have survived for from three to fourteen years, but one patient has metastases. 2. These results are compared with those from primary amputation. 3. The importance of histological grading in prognosis is emphasised. 4. It is concluded that radical irradiation should be considered in place of primary amputation for osteogenic sarcoma in the upper limb

To assess the efficacy of a combined orthoplastic approach to the management of severe grade III fractures of the lower limb, we looked at the functional and radiological outcome of 100 consecutive fractures from a specialist centre. A prospective analysis was performed on 100 consecutive open tibial fractures (98 patients). An early decision was made by a specialist multidisciplinary team as to whether the injured limb was reconstructable. In the reconstruction group there were 84 Gustilo grade IIIB/C injuries. Definitive skeletal stabilisation was most commonly with a circular frame (60%) or intramedullary nail (20%). The mean time to union was 26 weeks for diaphyseal fractures, 20 weeks for metaphyseal fractures and 10 weeks for ankle fractures. There was one aseptic non-union which is still undergoing treatment. The anterolateral thigh free flap was the most common soft tissue reconstruction used (42%). There were minimal surgical complications and only one free flap failure. Mean time to follow-up was 24 months. The mean limb functional score (modified enneking) was 83% of that of the normal limb and was not influenced by the site of fracture or type of fixation. The mean SF-36 score was 75 and there was a high return to employment (70%). In the primary amputation group there were 16 grade IIIB/C injuries. Mean time to follow-up was 38 months. The mean SF-36 score for the below knee amputees was 58 and there was again a high return to employment (58%). In the reconstruction group there is a 99% limb salvage rate with infection-free union to date and no delayed amputations. A higher return to functional activity/employment was achieved in the reconstruction group compared to the primary amputation group. Our results demonstrate that by using a combined orthoplastic approach in a specialist centre excellent results can be achieved for all patients presenting with severe open lower limb injuries

The December 2022 Oncology Roundup³⁶⁰ looks at: Is high-dose radiation therapy associated with early revision with a cemented endoprosthesis?; Neoadjuvant chemotherapy and endoprosthetic reconstruction for lower extremity sarcomas: does timing impact complication rates?; Late amputation after treatment for lower extremity sarcoma; Osteosarcoma prediagnosed as another tumour: a report from the Cooperative Osteosarcoma Study Group; The influence of site on the incidence and diagnosis of solitary central cartilage tumours of the femur: a 21st century perspective.

Background: Extra-compartmental limb soft tissue sarcomas are notoriously difficult to treat. These tumours can exhibit macro or microscopic spread beyond the confines of normal anatomical barriers and require radical resection, often necessitating excision of bone as well as soft tissue. This will inevitably affect the patient’s functional outcome. The primary operations for these aggressive sarcomas include wide local excision of soft tissue and adjacent involved bone, radical resection with endoprosthetic reconstruction and amputation. Methods: 85 patients who underwent such an operation between 1995 to 2000 were reviewed and categorised according to whether they received wide local excision, endoprosthesis reconstruction or amputation. Patient demographics, sarcoma details, recurrence and survival rates were identified and compared between the three groups. Functional outcomes in the 45 patients still alive were assessed using TESS and MSTS scores. Results: Mean age was 61 years (range 8 to 92). There were 51 males and 34 females. Anatomical distribution was as follows: arm 26, leg 47, pelvis 8 and other 4. The commonest histology subtypes were MFH, leiomyosarcoma and undifferentiated soft tissue sarcoma. 17 had wide local excision of bone and soft tissue, 32 underwent endoprosthesis reconstruction and 36 underwent primary amputation. Recurrence rates were highest in the endoprosthesis group at 19%. Five year survival was worst in the amputation group at 49%. Functional outcomes were highest in the wide local excision group, and similar in the other two surgical groups. Conclusions: Unsurprisingly survival is poorest in the primary amputee group because of the highly aggressive nature of these sarcomas, despite having the most radical treatment. The similar functional outcomes shown between endoprosthesis reconstruction and primary amputation may be influential when considering cases in which this decision is unclear and function is the main issue at stake

We looked at the outcome of management of 16 patients (19 limb segments) with congenital fibular hemimelia treated in our unit over a 24-year period from 1978 to 2001. Eight boys and eight girls, all with associated musculoskeletal abnormalities in the lower limbs, were presented for management at or before the age of six months. On four patients no surgery was performed. In the other 12, orthopaedic management was completed during the skeletal growth period. Primary amputations (one below-knee, one Syme and one Boyd) were performed on three patients and prostheses fitted in early childhood. Three patients with bilateral fibular hemimelia were treated initially with a Gruca ankle reconstruction procedure. Using the Ilizarov technique, we performed tibial lengthening procedures on nine patients. At the latest follow-up, the three patients who had amputations were functioning well and had no complications. The nine patients in whom tibial lengthening was the main reconstructive procedure suffered numerous complications and all needed further corrective surgery or footwear alterations. None required or requested late amputation because of poor function or cosmesis. Analysing results by parameters such as restriction of activity, pain, complication rate, treatment costs, hospital and clinic visits, periods of absence from school, and patient satisfaction, we found notably better results among patients who underwent early primary amputation than among those who underwent tibial lengthening. This needs to be kept in mind when advising parents of the most appropriate course of management of their child’s disorder

Purpose: The literature on management of advanced soft tissue tumours is limited because of the rarity of cases following increased awareness and improved diagnostic resources. Method: Our experience of managing 18 patients with fungating soft tissue tumours of the extremities and one patient with a sarcoma involving the scapular region (limb girdle) is presented. There were 14 males and 5 females. Average age was 70.6 yrs ranging between 37 – 98 years. 13 tumours involved lower limb and 6 the upper limb. Results: The follow-up ranged from a minimum of 6 months to 10 years from the initial referral. The histological diagnosis was Sarcoma in 15 patients (Spindle cell sarcoma in 4, Fibrous Histiocytoma in 2, Pleomorphic sarcoma in 3, liposarcoma in 2, leiomyosarcoma in 2, Fibrosarcoma in 1 and 1 Round cell sarcoma). In the remaining 3 patients immunohistochemistry studies confirmed a Metastatic Squamous cell Sarcoma, a Metastatic Malignant Melanoma and a Metastases from a poorly differentiated upper GI malignancy each. Primary wide local excision was performed in 15 patients and primary amputation was performed in two patients. In 2 patients when tumour was unresectable due to the location and local spread, an embolisation was performed in both for palliation. Lung Metastases were present at the time of referral in 6 patients and developed later during follow-up in 4 patients. A histologically proven recurrence occurred in 6 patients after an average of 15.83 (4 to 41) months. Revision surgery was needed in 9 patients for either a positive margin on histology or a recurrence, including 3 secondary amputations. Local adjuvant Radiotherapy was given for 7 patients and a combination of radio and chemotherapy was used in 2 patients for metastases. Mortality was 53 % (9 patients) by the end of 32 months of follow-up. Conclusion: Fungation in soft tissue tumours is rare and often a sign of locally advanced disease and a high grade nature, patients either have systemic spread by the time or develop later inspite of good local disease control. Primary wide local excision in such patients is difficult and has a high chance of a positive margin hence primary amputation may be better for local clearance. Recurrence of tumour and revision surgery is common and the mortality was > 50% at the end of 3 years from presentation to treatment in our series

Background: The literature on description and management of advanced fungating soft tissue tumours (FSST) is limited because of the rarity of cases. Recent advances in diagnostic resources and an increased awareness of the disease has made early recognition easier. Manchester Royal Infirmary is a Regional Sarcoma Centre in the North West of England. We describe our experiences in managing patients with FSST of the extremities. Patients and Methods: Between 1997 and 2007, 18 patients presented with FSST of the extremities (13 involving the lower limb, and 5 involving the upper limb), and 1 patient with a sarcoma involving the scapular region (limb girdle). The cohort included 14 males and 5 females with a mean average age of 68.5 ± 13.7 years. Follow-up ranged from a minimum of 6 months to 10 years from the initial referral. Results: The histological diagnosis was sarcoma in 15 patients, subclassified into spindle cell sarcoma (4), fibrous histiocytoma (2), pleomorphic sarcoma (3), liposarcoma (2), leiomyosarcoma (2), fibrosarcoma (1) and round cell sarcoma (1). In the remaining 3 patients immunohistochemistry studies confirmed a metastatic squamous cell sarcoma, a metastatic malignant melanoma and a metastasis from a poorly differentiated upper gastrointestinal malignancy. Lung metastases were present at the time of referral in 6 patients and developed later during follow-up in 4 patients. For patients where curative surgery was an option, primary wide local excision (15 patients) or primary amputation (2 patients) was performed. The remaining 2 patients presented with unresectable disease due to the location and localised spread; an embolisation was performed for palliation in both cases. Revision surgery was needed in 9 patients for either a positive resection margin confirmed by histology, or a recurrence; these included 3 secondary amputations. A histologically proven recurrence occurred in 6 patients after an average of 15.8 (4 to 41) months. Local adjuvant radiotherapy was administered to 7 patients and a combination of radio–and chemotherapy was used in 2 patients for metastases. Mortality was 53% (9 patients) by the end of 36 months follow-up period. Conclusion: Fungation in soft tissue tumours is a rare phenomenon and often a sign of locally advanced disease with a high grade nature. Patients present with either systemic spread, or have a tendency to develop metastases despite good local disease control. Primary wide local excision is difficult with a high chance of a positive margin; hence primary amputation may be better for local clearance. Tumour recurrence and revision surgery, however, is common. We report a mortality rate of > 50% at the end of 3 years from presentation to treatment

Two hundred and forty-one patients with extremity osteosarcoma presented to our institution between 1989 and August 2002, thirty-six of whom had a pathologic fracture. There were twenty-five limb salvage surgeries and ten primary amputations, with three limb salvage surgeries requiring secondary amputations. One patient had an unresectable tumor and was treated palliatively. At mean follow-up of 96.9 months there was one local recurrence and eighteen patients were alive without disease in the pathologic fracture group. There was no survival difference between the pathologic fracture group with no metastases at presentation and the non-pathologic fracture group with no metastases (119.4 months vs 134.3 months, log rank 0.83, p=0.36). To examine the outcome of osteosarcoma patients that present with a pathologic fracture as compared to those patients without a pathologic fracture. There was no significant difference in the rate of amputation vs limb salvage surgery in osteosarcoma patients that presented with a pathologic fracture as compared to those without. There was no difference in the two groups’ disease-free and overall survival, for those patients that presented without metastatic disease. Presentation with a pathologic fracture in osteosarcoma does not preclude limb salvage surgery and is not a prognostic indicator for decreased survival. Retrospective review of all patients presenting to our institution with extremity osteosarcoma between 1989 and August 2002. There were two hundred and forty-one patients with extremity osteosarcoma, thirty-six of whom presented with a pathologic fracture. In the pathologic fracture group, there were nineteen males and seventeen females. Twenty-five were treated with limb salvage surgery, ten required a primary amputation and one was unre-sectable. Three limb salvage surgery patients required a secondary amputation. Sevenpatients presented with metastatic disease. Twenty-eight of the thirty-six patients received (neo) adjuvant chemotherapy. At last follow-up, eighteen patients were alive no evidence of disease (51.4%), three were alive with disease, eleven were dead of disease and three were deceased from other causes. There was one local recurrence (2.8%). Mean overall survival was 119.4 months (0–147.1) for patients with a pathologic fracture and no metastasis at presentation and 134.3 months (0–172.5) for patients with no pathologic fracture and no metastasis (log rank 0.83, p=0.36)

Introduction. The available scoring methods and outcome analysis methods in lower extremity skeletal trauma with vascular injuries are not always specific. Biochemical parameters like venous blood lactate, bicarbonate and serum CPK (at the time of admission and serial monitoring) were measured to assess whether they supplement clinical parameters in predicting limb salvageability in lower extremity skeletal trauma with vascular injuries. Materials and methods: 74 adult patients with long bone fracture of lower limb associated with vascular injury (open and closed) were included in the study group. Patients with significant head injury (who cannot provide informed consent) and those with mangled extremities (MESS score>8) were excluded. Methodology. Pre-operative requirement for fasciotomy was recorded. A vascular surgery consultation was obtained. CT angiography and DSA were performed if needed only. Venous blood samples from the injured limb were withdrawn for lactate and bicarbonate analysis. Serum CPK was estimated at the time of admission and repeated at 6, 12, 24, 48 and 72 hours after admission. A record was maintained about the type and duration of surgery, blood loss, type of anaesthesia used and fasciotomy in the post-operative period. Results. Of the 74 patients included in the study, 55 patients were taken up for a revascularization procedure, 13 patients for primary amputation and in remaining six patients, no vascular surgery was required. If the level of bicarbonate in the injured limb was less than 16.5 mmol/L, pH < 6.89 the probability of survival of the limb after a revascularization procedure is low and the injured limb will need an amputation eventually. Lactate levels and creatinine kinase were not of any predictive value regarding the outcome of the injured limb. Conclusion. Along with clinical signs, low levels of bicarbonate (<16.5 mmol/L), pH (<6.89), and high levels of pCO2, base deficit in the injured limb at the time of presentation were associated with the less favorable outcome-amputation