Aims. We first sought to compare survival for patients treated surgically for solitary and multiple metastases in the appendicular skeleton, and second, to explore the role of complete and incomplete resection (R0 and R1/R2) in patients with a solitary bony metastasis in the appendicular skeleton. Methods. We conducted a retrospective study on a population-based cohort of all adult patients treated surgically for bony metastases of the appendicular skeleton between January 2014 and December 2019. We excluded patients in whom the status of bone metastases and resection margin was unknown. Patients were followed until the end of the study or to their death. We had no loss to follow-up. We used Kaplan-Meier analysis (with log-rank test) to evaluate patient survival. We identified 506 operations in 459 patients. A total of 120 operations (in 116 patients) were for solitary metastases and 386 (in 345 patients) for multiple metastases. Of the 120 operations, 70 (in 69 patients) had no/an unknown status of visceral metastases (solitary group) and 50 (in 49 patients) had visceral metastases. In the solitary group, 45 operations (in 44 patients) were R0 (resections for cure or complete remission) and 25 (in 25 patients) were R1/R2 (resections leaving microscopic or macroscopic tumour, respectively). The most common types of cancer in the solitary group were kidney (n = 27), lung (n = 25), and breast (n = 20). Results. The one-year patient survival was 47% (95% confidence interval (CI) 38 to 57) for the solitary bony metastases and 34% (95% CI 29 to 39) for multiple bone metastases (p < 0.001). The one-year patient survival was 64% (95% CI 52 to 75) for solitary bony metastases without/with unknown visceral metastases and 23% (95% CI 11 to 36) for solitary bony metastases with visceral metastases (p < 0.001). The one-year patient survival was 75% (95% CI 62 to 89) for a solitary bony metastasis after R0 surgery and 42% (95% CI 22 to 61) for a solitary bony metastasis with R1/R2 surgery (p < 0.001). Conclusion. Our study suggests that the surgical treatment of patients with a solitary bony metastasis to the appendicular skeleton results in better survival than for patients with multiple bony metastases. Furthermore, aggressive treatment of a solitary bony metastasis with R0 surgery may improve patient survival. Cite this article: Bone Joint J 2023;105-B(11):1206–1215

Aims. The aim of this study is to determine the predictors of overall survival (OS) and predictive factors of poor prognosis of conventional high-grade osteosarcoma of the limbs in a single-centre in South Africa. Methods. We performed a retrospective cross-sectional analysis to identify the prognostic factors that predict the OS of patients with histologically confirmed high-grade conventional osteosarcoma of the limbs over ten years. We employed the Cox proportional regression model and the Kaplan-Meier method for statistical analysis. Results. This study comprised 77 patients at a three-year minimum follow-up. The predictors of poor OS were: the median age of ≤ 19 years (hazard ratio (HR) 0.96; 95% confidence interval (CI) 0.92 to 0.99; p = 0.021); median duration of symptoms ≥ five months (HR 0.91; 95% CI 0.83 to 0.99; p < 0.037); metastasis at diagnosis (i.e. Enneking stage III) (HR 3.33; 95% CI 1.81 to 6.00; p < 0.001); increased alkaline phosphatase (HR 3.28; 95% CI 1.33 to 8.11; p < 0.010); palliative treatment (HR 7.27; 95% CI 2.69 to 19.70); p < 0.001); and amputation (HR 3.71; 95% CI 1.12 to 12.25; p < 0.032). In contrast, definitive surgery (HR 0.11; 95% CI 0.03 to 0.38; p < 0.001) and curative treatment (HR 0.18; 95% CI 0.10 to 0.33; p < 0.001) were a protective factor. The Kaplan-Meier median survival time was 24 months, with OS of 57.1% at the three years. The projected five-year event-free survival was 10.3% and OS of 29.8% (HR 0.76; 95% CI 0.52 to 1.12; p = 0.128). Conclusion. In this series of high-grade conventional osteosarcoma of the appendicular skeleton from South Africa, 58.4% (n = 45) had detectable metastases at presentation; hence, an impoverished OS of five years was 29.8%. Large-scale future research is needed to validate our results. Cite this article: Bone Jt Open 2024;5(3):210–217

Periprosthetic joint infection represents a devastating complication after total elbow arthroplasty. Several measures can be implemented before, during, and after surgery to decrease infection rates, which exceed 5%. Debridement with antibiotics and implant retention has been reported to be successful in less than one-third of acute infections, but still plays a role. For elbows with well-fixed implants, staged retention seems to be equally successful as the more commonly performed two-stage reimplantation, both with a success rate of 70% to 80%. Permanent resection or even amputation are occasionally considered. Not uncommonly, a second-stage reimplantation requires complex reconstruction of the skeleton with allografts, and the extensor mechanism may also be deficient. Further developments are needed to improve our management of infection after elbow arthroplasty. Cite this article: Bone Joint J 2024;106-B(11):1321–1326

Aims. To describe the epidemiology of acetabular fractures including patient characteristics, injury mechanisms, fracture patterns, treatment, and mortality. Methods. We retrieved information from the Swedish Fracture Register (SFR) on all patients with acetabular fractures, of the native hip joint in the adult skeleton, sustained between 2014 and 2020. Study variables included patient age, sex, injury date, injury mechanism, fracture classification, treatment, and mortality. Results. In total, 2,132 patients with acetabular fractures from the SFR were included in the study. The majority of the patients were male (62%) and aged over 70 years old (62%). For patients aged > 70 years, the 30-day mortality was 8% and one-year mortality 24%. For patients aged ≤ 70 years, the 30-day mortality was 0.2% and one-year mortality 2%. Low-energy injuries (63%) and anterior wall fractures (20%) were most common. Treatment was most often non-surgical (75%). Conclusion. The majority of patients who sustain an acetabular fracture are elderly (> 70 years), of male sex, and the fracture most commonly occurs after a simple, low-energy fall. Non-surgical treatment is chosen in the majority of acetabular fracture patients. The one-year mortality for elderly patients with acetabular fracture is similar to the mortality after hip fracture, and a similar multidisciplinary approach to care for these patients should be considered. Cite this article: Bone Jt Open 2023;4(9):652–658

Introduction:. Distal femoral replacement is recognised as the optimum treatment for malignant distal femoral tumours. Aseptic loosening is known to be a major cause for failure in these implants. Studies have indicated that the HA coated collar promotes osteointegration and bony in growth. This study compares long term aseptic loosening in implants with HA coated collars to those without in the immature skeleton. Objectives:. To assess the effect of HA coated collars on aseptic loosening in extendable distal femoral replacement prosthesis in the immature skeleton. Methods:. All paediatric patients undergoing distal femoral replacement with extendable prosthesis were retrospectively reviewed between 1980–2003. A total of 32 patients were reviewed. 24 patients underwent distal femoral replacement with extendable prostheses without a HA coated collar. This cohort was compared to 18 patients who were treated with an extendable prosthesis with a HA coated collar between 2001–03. Average follow up in patients without a collar was 10.1 yrs (6–18) and 8.1 yrs in those with a collar (4–11). All patients with identified infection were excluded. Radiographs taken at last follow-up were analysed for loosening. Results:. Thirty-one patients were treated for primary osteosarcoma and one for a histiocytoma. Average age at operation was 13 yrs for both groups (non-collared 6–17, collared 4–11). Three of 24 patients in the non-collared cohort underwent revision compared to 1 of 18 in the collared group. The cause of revision in the collared group was infection. One patient in each cohort died within 5 years of surgery. Mean loosening score at last follow up for the non-collared group was 11.2 compared to 2.5 for the collared group with a p value of <0.05 (Mann Whitney-U). Conclusions:. Aseptic loosening is a major cause of failure for distal femoral replacement prosthesis. HA coated collars have been shown to promote osteointegration. Little comparable data exists between collared and non-collared extendable prosthesis in the immature skeleton. Our data demonstrates that HA coated collars significantly reduce long term loosening in the immature skeleton

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

Purpose: Reconstruction of long bones with significant loss of bone stock is a major challenge particularly if the gap is greater than 5 cm. Complementary bone resection is often necessary. A conventional cancellous graft may be used when loss of bone substance is not too extensive, but when the defect extends over several centimeters a vascularised bone graft with a microanastomsed fibular graft may be indicated. This technique is widely used for the lower limb but rarely applied for the forearm. The purpose of this work was to examine the modalities and report our experience. Material and methods: This retrospective study included six microvascularised free fibular grafts performed to reconstruct the forearm bones after massive loss of bone stock. The mean age of the five men and one woman was 34 years. Bone loss (mean 10 cm, range 6 – 18 cm) involved the radius in five cases and the ulna in one. All six patients were victims of crush injuries with open fractures and expulsion of part of the forearm skeleton. Initial treatment included debridement, wound closure, and temporary external fixation. The fibular graft was performed eight weeks (mean) after trauma in five patients and six months after trauma in the sixth patient who also had multiple autologous cancellous grafts which left a nonunion of the ulna and an 18 cm defect. The Meyer method using a saphenous loop was used for vessel anastomosis in five cases. A vascularised fibular bypass was used in one. Osteosynthesis was achieved with screw or plate fixation. Results: Bone healing was achieved in all patients four to six months after grafting. Mean follow-up was three years (range 1–5). There were no secondary fractures. Mean flexion-extension of the elbow was 100° at last follow-up. Mean pronation-supination was 100°. Discussion and conclusion: Free fibular transfer enabled reconstruction of the forearm skeleton after massive bone loss. The vascularised graft shortened time to bone healing for these extensive defects with a mechanical quality superior to that obtained with conventional non-vascularised grafts. These vascularised grafts can be indicated for infected nonunion because the vascularised graft favours antibiotic diffusion

The aim of this paper is to present our experience from the surgical treatment of lower limb fractures in the developing skeleton with the use of bio-absorbable PLLA implants as a means of internal fixation. From 1997 until 2002, twenty-three patients (15 boys and 8 girls, ages ranging from 7 to 15 years old, mean of 12 years) who had suffered from 30 lower limb fractures were operated on in our department, with the use of PLLA screws as a means of internal fixation that followed the standard open reduction procedure. We surgically treated 20 tibial fractures (distal metaphysis:1,medial malleolar:6,distal epiphysis lesions:9,tibial spine:2, lateral tibial condyle:1, tibial shaft:1), 8 fibular fractures (distal metaphysis:2, distal epiphysis lesions:5, fibular shaft:1), one transtrochanteric fracture and 1 patellar fracture. All patients were operated on under constant radiographic control. A cast was applied, post-operatively, to all patients, for a period of 3–4 weeks. Gradual and assisted weight-bearing and ambulation, was commencing immediately after the cast removal. All patient’s (with the exception of 1 case of delayed callus formation) post-operative period was completely normal. However, follow-up revealed the development of osteolytic lesions (bone absorption cysts) in 3 of our patients. All lesions were located in the border between epiphysis and metaphysis, at the exact position were the PLLA screws had been placed. The use of PLLA implants in the treatment of fractures renders unnecessary a second operation for the removal of the osteosynthesis’ material. Nevertheless, we should be quite reluctant when deciding to use the PLLA screws in the treatment of these fractures in the developing skeleton, especially of the lower limbs, were the applied weight bearing forces are quite powerful

Introduction: A retrospective analysis was performed to determine the oncological outcome of patients with Ewing’s sarcoma of the spine treated with combined chemotherapy and radiotherapy for definitive local control. Materials and Methods: Fifteen patients were identified from the Scottish Bone Tumour Registry with a histologically confirmed Ewing’s sarcoma affecting the axial skeleton. All case notes and imaging were retrospectively reviewed. Results: Primary vertebral Ewing’s sarcoma accounted for 8.3% of all malignant spinal lesions in our registry. The mean age was 17.8 years (between 4 and 39 years). There was a male predilection with 9 male and 6 female patients. Site was evenly distributed between cervical (4), dorsal (5) and lumbosacral (6) regions. Progressively worsening back pain was the first symptom in all the patients. Satisfactory imaging studies were available in all with plain radiographs (15), bone scan (11), CT-scan (12) and MR Scan (9) patients. Biopsy was performed in 11 patients and surgical treatment was carried out in 3 patients including curettage (2) and excision with bone grafting (1). All patients were treated with adjuvant radiotherapy while 87% also received adjuvant chemotherapy. Seven patients were alive with no evidence of disease at a mean 6 year follow-up. Six patients died of metastatic disease, one due to local recurrence and one with persistent primary disease. The mean follow-up time was 65 months (median 28 months; ranging from 12 to 218 months). Conclusions: Primary vertebral Ewing’s sarcoma comprised 8.3% of our National Registry’s primary malignant spinal lesions. Progressive vertebral pain in the late second decade and male gender should raise the suspicion of Ewing’s sarcoma. Ewing’s sarcoma of the spine treated with combined chemotherapy and radiotherapy for definitive local control achieved a 45% five year survival

Purpose: The supracondylar fractures of the distal humerus are the second most frequent fractures of the developing skeleton. Also their immediate and late complications are very often. The aim of this study is to describe their neurological complications. Material – methods: In our department 178 children were admitted with supracondylar fracture of the distal humerus during the period 1998–2002. Their age ranged from 2 to 16 years of age (the average was 7 years old, 63 girls and 115 boys). Forty-six patients were treated conservatively and 132 surgically. Neurological complications were appeared in 18 patients that had, according to Gartland classification, II and III type fractures. Manipulations for closed reduction had been made to 6 of them. Neurological deficit of the median nerve appeared to 10 patients, of the radial nerve to 6 patients and of ulnar nerve to 2 patients. The treatment of the fractures was surgical (open reduction, internal fixation with Kirschner wires and immobilization with a long arm cast for 4 weeks). The treatment of the neurological complications was conservative (free mobilization of the elbow was followed after the removal of the arm cast and Kirschner’s wires). Results: The results of the conservative treatment of the neurological complications of the supracondylar fractures of the distal humerus were excellent and the surgical exploration on the injured nerve was not necessary on any patient. The function of the nerves recovered completely in 2–3 months after the elbow’s fracture. Conclusion: The prognosis on the neurological complications of the upper limbs due to supracondylar fracture of the distal humerus is very good. They are successfully treated conservatively and the surgical exploration on the injured nerve is rarely necessary

Bone metastases from renal cell carcinoma are aggressive, osteolytic lesions that often require operative intervention for fracture prophylaxis, fracture fixation or palliation. The lesions are hypervascular and intraoperative bleeding is a serious challenge for the orthopaedic surgeon. The purpose of this study was to determine the efficacy of preoperative tumour embolization in reducing blood loss during operative management of renal cell carcinoma metastases to bone. Patients were identified from a prospectively accumulated database (1996–2006). Inclusion criteria included operative management for renal cell metastasis to the pelvis or appendicular skeleton. Patients that were not embolised preoperatively due to renal insufficiency or obesity were excluded. Embolizations were performed the day of surgery by an interventional radiologist. Post-embolization runs were used to determine the percentage of blood flow reduction to the tumour. Variables analyzed included patient age, gender, location of tumour, surgical procedure, surgical time, number of units of packed red blood cells (PRBC) transfused, estimated intraoperative blood loss (EBL) and percentage embolised according to the post-embolization run. Student’s t-test was used to determine the effects of percentage embolization on EBL and number of units of transfused PRBCs. Thirty-five cases (twenty-eight patients) met the inclusion criteria. There were twenty males and eight females with an average age of sixty-five years (range, forty-three to eighty-nine years). The most common metastatic sites were the femur (nineteen cases), humerus (seven cases) and pelvis (six cases). There were ten cases of intramedullary nailing and twenty-five cases of tumor resection and reconstruction. Average surgical time was 4.5 hours (range, 0.75–10 hours) and average EBL was 1.5 litres (range, 0.25–12 litres). Embolization that successfully blocked at least 75% of the blood flow to the tumour significantly decreased surgical EBL (3.2 vs 0.6 litres, P< 0.05) and units of PRBCs transfused (5.6 vs 1.9, P=0.05) compared to those that did not. Two embolization-associated complications occurred including one case of toe gangrene and one case of muscle ischemia. Preoperative embolization significantly reduces blood loss and red blood cell transfusions resulting from surgical stabilization of renal cell metastases to bone. Close communication between the orthopaedic surgeon and interventional radiologist is imperative to maximise these benefits

Skeletal sequels of traumatisms, diseases or surgery often lead to bone defects that fail to self-repair. Although the gold standard for bone reconstruction remains the autologous bone graft (ABG), it however exhibits some drawbacks and bone substitutes developed to replace ABG are still far for having its bone regeneration capacity. Herein, we aim to assess a new injectable allogeneic bone substitute (AlloBS) for bone reconstruction. Decellularized and viro-inactivated human femoral heads were crushed then sifted to obtain cortico-spongious powders (CSP). CSP were then partly demineralized and heated, resulting in AlloBS composed of particles consisting in a mineralized core surrounded by demineralized bone matrix, engulfed in a collagen I gelatin. Calvarial defects (5mm in diameter, n=6/condition) in syngeneic Lewis1A rats were filled with CSP, AlloBS±TBM (total bone marrow), BCP (biphasic calcium phosphate)±TBM or left unfilled (control). After 7 weeks, the mineral volume/total volume (MV/TV) ratios were measured by µCT and Movat's pentachrome staining were performed on undemineralized frontal sections. The MV/TV ratios in defects filled with CSP, AlloBS or BCP were equivalent, whereas the MV/TV ratio was higher in AlloBS+TBM compared to CSP, AlloBS or BCP (p<0.01; Mann-Whitney). Histological analyses exhibited a collagen-rich matrix in all the defects, and osteoid at the surface of all implanted biomaterials. Our data indicates that AlloBS is a promising candidate for bone reconstruction, with ease of manipulation, injectability and substantial osteogenic capacity. Further experiments in larger animal models are under consideration to assess whether AlloBS may be a relevant clinical alternative to ABG.

Of 290 Ugandan children and adolescents with proven Burkitt's lymphoma 11 had lesions in the long bones or the pelvis. These started in the medulla as small osteolytic foci which coalesced and penetrated the cortex causing subperiosteal new bone formation in layers or spicules, and giving rise to large soft-tissue masses. Common sites were the femoral and tibial diaphyses and the metaphyses around the knee. Five were in the epiphyses. Other sites were the pelvis, humerus and ulna. One patient had a lymphomatous synovial effusion of the knee. In the lower limbs the lesions were often bilateral and symmetrical. Five patients had pathological fractures. Radiologically the lesions mimicked Ewing's sarcoma, osteosarcoma, osteomyelitis, acute leukaemia, syphilis and yaws, but clinically they were relatively painless, an important differential diagnostic feature. In the five patients with sustained remissions after chemotherapy the lesions and fractures healed well and the growth plates were undamaged.