Aims and objective:To evaluate whether graft thickness influences functional outcomes and re-tear rates in massive rotator cuff repairs (RCRs) with graft augmentation, and to compare effectiveness of on-lay versus bridging/interposition techniques. Methods:A systematic review was performed according to PRISMA guidelines. MEDLINE, Embase and CINAHL databases were searched between April 2006 and April 2025. Clinical studies reporting shoulder-specific functional outcomes scores and re-tear rates evaluating RCRs with graft augmentation (on-lay or bridging) using allografts, xenografts and synthetic grafts, as well as comparative studies with standard repair with minimum 12-months follow-up were included. Studies were stratified by graft thickness (≤2 mm vs >2 mm) and technique (on-lay vs bridging). Results:Thirty-eight studies (n = 1761; 23 with grafts ≤2 mm, 15 with grafts >2 mm) with a mean follow-up of 34.2 ± 18.6 months were included. On-lay augmentation with grafts ≤2 mm yielded the greatest reduction in re-tear risk (OR 0.15; 95% CI: 0.05-0.49; p = 0.04) and lowest failure rate (8%). Bridging with ≤2 mm grafts reduced re-tear risk by 67% (RR 0.33; 95% CI: 0.20-0.55), while grafts >2 mm reduced risk by 55% (RR 0.45; 95% CI: 0.27-0.74). The pooled re-tear rate was 12% (95% CI: 9-15%). On-lay augmentation with grafts ≤2 mm significantly improved functional outcomes compared with standard repair (mean difference 9.39 points; 95% confidence interval 1.09-17.68; p = 0.03), whereas no significant difference was observed for grafts >2 mm (MD +4.28 points; 95% CI: 0.09-8.46; p = 0.05). Bridging with grafts ≤2 mm demonstrated the highest pooled mean constant scores (76.29; 95% CI: 69.56-83.68). Conclusion:Both on-lay and bridging augmentation techniques significantly reduced re-tear rates compared with standard repair alone. Grafts ≤2 mm provided a greater reduction in re-tear risk with both techniques and showed a trend towards superior functional outcomes.

Introduction Artificial intelligence (AI) tools, such as ChatGPT, could potentially support junior clinicians in making initial operative decisions for hip fractures. However, the safety and reliability of such use are uncertain. This study compared ChatGPT's management recommendations for patients with intracapsular neck of femur (NOF) fractures to decisions made by orthopaedic consultants and evaluated which patient factors influenced those recommendations. Methods We identified a retrospective cohort of patients admitted with an intracapsular NOF fracture over an 18-week period to a United Kingdom District General Hospital. We collected patients' age, sex, comorbidities, mobility status, and the 4 A's Test (4AT) score. De-identified data were entered into ChatGPT with instructions to recommend management based on National Institute for Health and Care Excellence guidance; ChatGPT's recommendations were compared with the operation recorded at the Trauma Meeting. When ChatGPT and consultants disagreed, we provided ChatGPT with the consultant's decision and rationale and recorded the revised recommendation. We then validated ChatGPT on a separate anonymized patient set. We used Cohen's Kappa to assess agreement and applied multinomial and binomial logistic regression and two-proportion z-tests to assess significance. Results One hundred five patients were included in the primary cohort, and 30 in the validation cohort. Initial agreement between ChatGPT and consultants was low [κ = 0.03, 95% confidence interval (CI) - 0.11 to 0.19, p = 0.70]. After in-session adjustment, agreement rose (κ = 0.93, 95% CI 0.84 - 1.00, p < 0.001), a statistically significant improvement (z = 10.3, p < 0.001). The only post-adjustment factor that significantly influenced ChatGPT's recommendations was age, showing that increasing age was associated with a reduced likelihood of receiving total hip replacement rather than hemiarthroplasty (odds ratio = 0.81, 95% CI 0.70-0.94; p = 0.006). In the validation cohort, agreement fell (κ = 0.29, 95% CI -0.04 to 0.60, p = 0.06) and did not significantly differ from the initial agreement (z = -1.51, p = 0.13). Conclusion ChatGPT did not reliably replicate orthopaedic consultant decision-making for intracapsular NOF fractures. Although in-session adjustments produced high superficial concordance, this effect did not generalize to an independent dataset. The model's tendency to conform to user prompts risks creating false confidence in its outputs. Clinically focused, validated AI systems require further evaluation before they can safely augment operative decision-making.

Background: Distal biceps tendon ruptures are rare injuries that predominantly affect active men between the fourth and sixth decades, with a higher incidence in weightlifters and bodybuilders. This study aimed to comprehensively review cases involving distal biceps tendon ruptures, focusing on sociodemographic factors (such as sex, age, occupation, and smoking status), injury mechanisms, postoperative outcomes, and recorded complications. Methods: This retrospective review examines distal biceps injuries at Royal Berkshire Foundation Trust NHS Hospital from 2017 to 2023. Analyzed data encompasses demographic information, injury mechanisms, clinical findings, and complications. Outcomes were assessed using the range of movement and Elbow Oxford Score. Results: The average age of 73 patients (72 men and 1 woman) was 45.6 +/- 9.4 years, with 75.3% falling between 36 and 55 years. Manual workers represented 46.6%, and 9.6% reported comorbidities and 6.8% steroid use. Lifting heavy objects and sports injuries were the predominant causes, constituting 43.8% and 13.7%, respectively. Most injuries (91.8%) involved complete tears, and most underwent acute surgery within the initial 4 weeks (84.9%). The most common complications were heterotopic ossification (23.3%) and neurological injury (16.4%). Ongoing weakness and fatigue were reported by 6.8%. At final follow-up, 75.7% of patients demonstrated a range of movement comparable to the contralateral side. However, 13.7% had a limited pronationsupination arch with a mean loss of 20 degrees +/- 14 degrees, 11% had an extension lag with a mean of 15 degrees +/- 7 degrees, and 2.7% showed a 10 degrees flexion loss compared to the contralateral side. Conclusions: Distal biceps injuries are rare but lead to substantial functional loss without operative treatment. Surgical repair yields positive functional outcomes. Our study aligns with existing literature, emphasizing a predominance of middle-aged men and manual workers. It underscores the impact of corticosteroids and smoking, highlights surgical efficacy, and advocates for increased research in distal biceps injury prevention and treatment understanding.

Neurovascular complications associated with clavicular shaft fractures can manifest at presentation, develop gradually over time, or potentially be iatrogenically induced. Conducting a thorough neurovascular examination and, when warranted, pursuing further investigation through modalities such as CT angiogram, MRI, and nerve conduction studies (NCS) are crucial for early diagnosis and pre-operative planning. This comprehensive approach enhances patient outcomes by facilitating timely intervention and addressing any underlying neurovascular issues associated with the fracture. Delayed fixation raises the risk of brachial plexus injury, highlighting the importance of timely intervention. This study aims to explore neurovascular complications associated with clavicle fractures through case presentations and provide management recommendations.

Background Posterolateral rotatory instability of the elbow arises from damage to the lateral ulnar collateral ligament (LUCL). While various methods exist for reconstructing or repairing the LUCL's attachment to the humerus, the most effective approach remains debatable. This study aims to assess the outcomes of directly repairing the LUCL when the injury occurs at the humeral attachment. Methodology This retrospective study, conducted at the Royal Berkshire Foundation Trust NHS hospital in Reading, UK, assessed outcomes through a review of 15 patients who underwent direct repair of the lateral ulnar collateral ligament between 2017 and 2022, evaluating a range of motion, the Mayo Elbow Performance Score, and the Nestor grading system. Results This study included nine males and six females, with an average age of 38.8 years. Most LUCL injuries arose from elbow dislocation (46.7%). The average follow-up period for patients was 26 months. At the final assessment, the mean Mayo Elbow Performance Score reached 99. According to the Nestor grading system, 12 patients achieved excellent results, and three had good outcomes. On average, there was an 11.3° loss of final extension and 5° of final flexion, yet achieving a comparable pronation-supination arch to the contralateral side. Conclusion Direct repair of the LUCL for elbow posterolateral rotary instability yielded excellent outcomes, obviating ligament reconstruction. Recognized as minimally invasive, it accelerates recovery, minimizes trauma, and offers a cost-effective procedure for managing instability.

Introduction:The Putti-Platt procedure is a historical technique for anterior shoulder stabilization, largely abandoned because it severely restricts movement, and causes arthritis and chronic pain. Patients continue to present with these sequelae, which can be difficult to manage. Here, we present the first published subscapularis re-lengthening for the reversal of Putti-Platt.Case Report:Patient: A 47-year-old Caucasian manual worker presented 25 years post-Putti-Platt, with chronic pain and movement restriction. External rotation was 0°, abduction was 60°, and forward flexion was 80°. He was unable to swim and struggled to work. Multiple arthroscopic capsular releases had provided no benefit. Technique: The shoulder was opened through the deltopectoral approach, and a coronal Z-incision lengthening tenotomy was made in subscapularis. The tendon was lengthened by 2 cm and the repair was reinforced using a synthetic cuff augment.Results:External rotation improved to 40°, and abduction and forward flexion to 170°. Pain resolved almost completely; Oxford Shoulder Score at 2-year follow-up was 43 (22 pre-operative). The patient returned to normal activity and reported complete satisfaction.Conclusion:This is the first application of subscapularis lengthening to Putti-Platt reversal. Two-year outcomes were excellent, demonstrating potential for significant benefit. Although presentations like this one are rare, our results support the potential of subscapularis lengthening (with synthetic augmentation) in the management of stiffness resistant to conventional treatment after Putti-Platt procedure.

Background: Uncertainty remains regarding the role and long-term outcomes following uncemented reverse shoulder replacements (RSRs) in managing displaced proximal humeral fractures (PHFs). Although RSRs for trauma have traditionally undergone cemented fixation of the humeral component, there is increasing interest in uncemented RSRs. Our primary aim was to evaluate 2-year outcomes following uncemented RSR fixation for 3-and 4-part PHFs in the elderly. A secondary aim was to evaluate if timing of surgery affected outcomes.Methods: This cohort series evaluated 2-year outcomes for 42 patients with Neer 3-and 4-part PHFs treated with uncemented RSRs between October 2016 and December 2019. Thirty-eight patients (90%) had clinical and radiologic follow-up at a minimum of 2 years. The primary outcomes compared postoperative range of movement, radiographic outcomes, and patient-reported outcome measures (PROMs). The PROMs collected included Oxford Shoulder Scores (OSSs), satisfaction scores, and the Friends and Family Test. The secondary outcome involved a subanalysis to see if outcomes were affected by treatment timingdwithin 2 weeks, 2-12 weeks, and >12 weeks.Results: The mean age of patients was 74.1 years (range 58-89). There were 11 males and 31 females. No intraoperative fractures were sustained. There was 1 transient axillary neurapraxia, which fully resolved by 4 months. Three patients required postoperative transfu-sions. During the study follow-up period, no patients developed either deep infections requiring a washout or dislocation, and none un-derwent further surgery. At 2-year follow-up, radiologic follow-up demonstrated tuberosity union in 29 of 38 cases (76%). Eight of 38 patients (21%) demonstrated some glenoid notching (Sirveaux 1 or 2 only) on radiographic follow-up. There was no evidence of loosening. The mean OSS was 38 (range 15-48). Mean range of movement achieved at 2 years was as follows: forward flexion 122 degrees (50 degrees-180 degrees), abduction 116 degrees (46 degrees-180 degrees), and external rotation 25 degrees (range 5 degrees-60 degrees). Eighteen patients (47%) described their result as excel-lent, 17 (45%) as good, and 3 (8%) as poor. When comparing the time from injury to treatment, there was no statistically significant difference in complications or radiographic outcomes between the groups. Patients had a reduced forward flexion when treated between 2 and 12 weeks compared with the other groups (P = .019).Conclusion: Uncemented RSR is a safe treatment option for the management of complex PHFs in the elderly. We report low compli-cation rates, high patient satisfaction, and good outcomes at 2-year follow-up. Level of Evidence: Level III; Retrospective Cohort Comparison; Prognosis Study Crown Copyright (c) 2022 All rights reserved.

PURPOSE:This single-centre study aimed to review the postoperative outcomes of distal biceps avulsion repair using a single incision with the endo-button technique.METHODS:A retrospective cohort study was performed of a single surgeon series of distal biceps repairs performed consecutively from September 2016 to September 2020. At two years, outcome measures included Oxford Elbow Score (OES), range of movement (ROM), complications and ongoing issues.RESULTS:Forty-five distal biceps tendon repairs were performed on 43 patients with a mean follow-up of 3.2 years (1.1-5.3). The average OES was 46 (11-48), and 90% of patients recovered a comparable range of movement to the contralateral side. Two patients developed re-rupture (4%) on days 0 and 9 of surgery, but there were no late re-ruptures of the repair.CONCLUSION:Short-term outcomes from distal biceps tendon repair show low complication rates, high patient satisfaction and good functional outcomes. The results would support acute surgical treatment of active, working-age, patients with distal biceps tendon ruptures.

Background: Multiple non-arthroplasty surgical techniques are described for the management of large and massive irreparable rotator cuff tears. There is currently no consensus on the best management strategy. Our aim was to compare clinical outcomes following arthroscopic debridement, arthroscopic partial cuff repair, superior capsule reconstruction, balloon spacers or graft interposition for the management of large and massive irreparable rotator cuff tears.Methods: A comprehensive search was performed of the following databases: Medline, Embase, CINAHL and Cochrane Database of Systematic Reviews. Data were extracted from relevant studies published since January 2000 according to the pre-specified inclusion criteria. The primary outcome was the post-operative improvement in shoulder scores. Meta-analysis of the primary outcome was performed. Secondary outcomes included retear rates and complications.Results: Eighty-two studies were included reporting the outcomes of 2790 shoulders. Fifty-one studies were included in the meta-analysis of the primary outcome. The definition of an irreparable tear varied. All procedures resulted in improved shoulder scores at early follow-up. Shoulder scores declined after 2 years following balloon spacers, arthroscopic debridement and partial cuff repair. High retear rates were seen with partial cuff repairs (45%), graft interposition (21%) and superior capsule reconstruction (21%).Conclusions: Large initial improvements in shoulder scores were demonstrated for all techniques despite high retear rates for reconstructive procedures. Shoulder scores may decline at mid- to long-term follow-up.

Shoulder arthroplasty audit is the evidence based process of reviewing the delivery of care, to monitor the short term and long term measures of shoulder replacements. It has been used to evaluate the patient reported functional and objective outcomes, surgeon related experience and implant related radiological outcomes and survivorship. An audit is used to improve the quality of care and to give impetus for future research. Arthroplasty of the shoulder offers pain relief and improved function when the native gleno-humeral articulation is affected by arthritis, trauma and cuff arthropathy.

Background: Scapula fractures are uncommon in sports and are poorly understood in this patient group. Purpose: To report on scapula fractures in contact and collision athletes and assess the injury patterns of different mechanisms of injury. Study Design: Case series; Level of evidence, 4. Methods: A retrospective case series was performed of all sports-related scapula fractures treated at a single institution between 2007 and 2015. The mechanisms of injury were divided into direct lateral impact, fall onto an outstretched arm, or abduction/external rotation. Results: A total of 11 patients were identified: 9 professional rugby players, 1 professional soccer player, and 1 amateur soccer player. The mean age was 28 years (range, 18-35 years). The mean return to play was 127 days in those treated nonoperatively and 163 days in those treated operatively. A direct impact mechanism occurred in 7 patients, all of whom sustained glenoid neck and body fractures and were treated nonoperatively. Two rugby players had a concomitant suprascapular nerve injury. An outstretched arm mechanism occurred in 2 cases, leading to posterior and inferior glenoid fractures. Both patients were treated operatively. An abduction/external rotation mechanism occurred in 2 cases, resulting in an anteroinferior and an anterior glenoid rim fracture. One case was treated operatively and the other was treated nonoperatively. Of those with glenoid fractures, 75% were not visible on plain radiographs and required further imaging. Conclusion: Scapula fractures acquired in sports are a serious injury with a prolonged recovery period. The mechanism of injury can help predict the injury pattern and highlight the need for further imaging. There is a high association with suprascapular nerve injuries.

Two stage revision for infection is considered the gold standard with a success rate of 80–90%. Overall functional outcomes of these patients are commonly overlooked. There is a trend towards single stage revision to improve functional outcomes.We examined the functional scores of 2 stage revision for total hip arthroplasty (THR) and total knee arthroplasty (TKR). 72 revisions were identified over 9 years: 30 THR and 42 TKR. Two year survivorship was 96% in THR revision and 88% TKR revision. Five year survival was 83% and 84% respectively. 50 patients (without recurrence of infection) had recorded functional scores at a minimum of 1 year.The mean Harris-hip score (HHS) of THR was 75 (21 patients) prior to developing symptoms of infection. Once infected, the mean score fell to 46. At 1 year post revision it returned to 77. At 3 years HHS of 78 (12 patients) and at 5 yrs 62 (3 patients).The mean knee society score (KSS) of TKR was 66 (29 patients) prior to developing symptoms of infection. Once infected, th...

Aims We present our experience of using a metal-backed prosthesis and autologous bone graft to treat gross glenoid bone deficiency. Patients and Methods A prospective cohort study of the first 45 shoulder arthroplasties using the SMR Axioma Trabecular Titanium (TT) metal-backed glenoid with autologous bone graft. Between May 2013 and December 2014, 45 shoulder arthroplasties were carried out in 44 patients with a mean age of 64 years (35 to 89). The indications were 23 complex primary arthroplasties, 12 to revise a hemiarthroplasty or resurfacing, five for aseptic loosening of the glenoid, and five for infection. Results Of the 45 patients, 16 had anatomical shoulder arthroplasties (ASA) and 29 had reverse shoulder arthroplasties (RSA). Postoperatively, 43/45 patients had a CT scan. In 41 of 43 patients (95%), the glenoid peg achieved > 50% integration. In 40 of 43 cases (93%), the graft was fully or partially integrated. There were seven revisions (16%) but only four (9%) required a change of baseplate. Four (25%) of the 16 ASAs were revised for instability or cuff failure. At two-year radiological follow-up, five of the 41 cases (11%) showed some evidence of lucent lines. Conclusion The use of a metal baseplate with a trabecular titanium surface in conjunction with autologous bone graft is a reliable method of addressing glenoid bone defects in primary and revision RSA setting in the short term. ASAs have a higher rate of complications with this technique.

The management of glenoid bone loss is a major challenge in both complex primary and revision arthroplasty surgery. To deal with this problem, a number of techniques have been advocated, although there has been no previous systematic review of the literature. In the present review, we have attempted to identify a coherent strategy for addressing this problem, taking into account the degree of bone loss, the advantages and limits of standard implants, bone reconstruction techniques and the use of customized prostheses.

Background: Given the degree of variation in clavicular morphology, 4 clavicle plating systems were examined for their congruity as superior, midshaft, anatomic clavicle (SMAC) plates in a cadaveric study.Methods: SMAC plates from 4 manufacturers were applied to 79 dry right human clavicles. Two systems offered multiple (4) variations of plates (MP), 1 offered two variations (TP), and 1 had a single plate (SP). Two examiners applied and clamped the best-fitting plate from each system onto each of the 79 clavicles and then graded them: 1, poor fit; 2, good fit; and 3, anatomic fit. Each examiner repeated the process to assess intraobserver and interobserver reliability. The scores were averaged to produce a final score for each system for each clavicle.Results: The MP systems scored the highest (32%-37% anatomic, 54%-63% good, 5%-8% poor), followed by the TP system (30% anatomic, 53% good, 17% poor), and finally the SP system (9% anatomic, 59% good, 32% poor). Of note, clavicular length significantly correlated with a higher degree of conformity in all plating systems (Spearman rank correlation P < .05 for each system). In clavicles longer than 150 mm, the MP and TP systems performed identically, with the SP system close behind. Contouring of the plate is needed in 73% of cases overall.Conclusion: Plating systems with multiple plate shape variations are more advantageous when dealing with smaller-sized clavicles, typically in females. However, when dealing with larger clavicles, there was no real difference. (C) 2016 Journal of Shoulder and Elbow Surgery Board of Trustees.

Background: The accuracy of reconstruction is thought to impact on functional outcome following glenohumeral joint arthroplasty. The objective of this study was to define an area of minimal anatomic variation at the cartilage/metaphyseal interface of the proximal humerus to optimize the osteotomy of the humeral head, enabling accurate reconstruction with a prosthetic component.Methods: Hand held digitization and 3D surface laser scanning techniques were used to digitize 24 cadaveric arms and determine the normal geometry. Each humeral head was then examined to identify the most consistent anatomical landmarks for the ideal osteotomy plane to optimize humeral component positioning.Findings: The novel, posterior referencing, osteotomy resulted in a mean increase in retroversion of only 0.4 degrees when compared to the original geometry. A traditional anterior referencing osteotomy, by comparison, produced a mean increase in retroversion of 11 degrees. In addition, the novel osteotomy only increased axial diameter by 0.71 mm and head height by 0.02 mm compared to an anterior referencing osteotomy (3.0 mm and 2.7 mm respectively).Interpretation: The traditional osteotomy, referencing the anterior border of the cartilage/metaphyseal interface potentially resulted in an increase in prosthetic head size and retroversion. The novel osteotomy, referencing from the posterior cartilage/metaphyseal interface enabled a more accurate recovery of head geometry. Importantly, the increase in retroversion created by the traditional osteotomy was not replicated with the novel technique. Referencing from the posterior cartilage/metaphyseal interface produced a more reliable osteotomy, more closely matching the original humeral geometry. (C) 2014 Elsevier Ltd. All rights reserved.

Background and purpose: Increasing resistance among post-operative Coagulase-negative Staphylococci (CNS) infections have been reported. We present our experience changing resistance patterns.Methods: We examined microbiological results from hip and knee revisions from 2001 to 2010 and compared resistance to all Staphylococcus aureus (SA) and CNS cultured from regional pan-speciality sources, in order to examine the patterns of antibiotic resistance.Main findings: 72 revisions in 67 patients were included. The most common organisms were SA (36%) and CNS (35%). Resistance to methicillin was 72% for CNS versus 20% for SA and resistance to gentamicin was 40% for CNS versus 4% for SA. Among all regional (background pan-speciality) cultures SA resistance to methicillin fell from 32% to 16% from 2006 to 10 with no change in gentamicin resistance at 3%. During the same period resistance of CNS to methicillin and gentamicin increased from 63% to 70% and 32%-47% respectively.Conclusions: Resistance of CNS to both methicillin and gentamicin is higher than with SA and appears to be increasing. At least 32% of CNS and 4% of SA from infected TKRs/THRs were resistant to our current prophylaxis regime. These changing patterns of resistance may have implications for future antibiotic prophylaxis regimes. (C) 2014 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.

Since1986 we have monitored the actual diagnosis of all cases referred to our Unit with the diagnosis of ‘possible primary malignant bone tumour’. We have excluded all patients referred with a known diagnosis of either a benign condition or known to have bone metastases. In most cases the suspected diagnosis was based on X-rays alone, sometimes supported by further imaging. Method Retrospective review of a prospective database that was started in 1986 identifying the actual diagnosis. Results There were 5922 patients with a confirmed diagnosis over the 23 year time period of this study. 2205 (37%) were found to have a primary malignant bone sarcoma and 1309 (22%) had a benign bone tumour. 992 patients had a general orthopaedic condition (e.g. geode or a vascular necrosis) whilst 303 (5%) had a haematological malignancy and 289 (4.9%) infection. 533 patients (9%) had metastases. There was a similar pattern of frequency of all diagnoses except for metastatic disease and haematologic malignancy at different ages. The incidence of metastases increased from the age of 35 onwards Discussion Analysis of this data has led to an algorithm for investigating ‘worrying’ bones that should lead to earlier diagnosis whilst avoiding unnecessary investigations.

Low-grade central osteosarcoma (LGCO) is a rare variant of osteosarcoma which is difficult to diagnose. If not treated appropriately, the tumour can recur with higher-grade disease. We reviewed our experience of this condition to try and identify factors that could improve both diagnosis and outcome. 18 patients out of 1540 osteosarcoma cases (over 25 years) had LGCO (1.2%). Only 11 patients (61%) were direct primary referrals. Almost 40% (7 of 18) cases were referred after treatment elsewhere when the diagnosis had not been made initially and all presented with local recurrence. Of the 11 who presented primarily, the first biopsy was diagnostic in only 6 (55%) cases. Of the remaining cases, up to three separate biopsies were required before a definitive diagnosis was made. Overall survivorship at 5 years was 90%. 17 patients were treated with limb salvage procedures, and one patient had an amputation. The diagnosis of LGCO remains challenging due to the relatively nonspecific radiological and histological findings. Since treatment of LGCO is so different to a benign lesion, accurate diagnosis is essential. Any difficult or nondiagnostic biopsies of solitary bone lesions should be referred to specialist tumour units for a second opinion.