To identify the incidence of a cortical breech on the initial presentation X-rays of patients with distal femoral GCTs, and whether this lead to a higher rate of local recurrence of tumour, a prospective database is kept of all patients seen in the unit. Initial presentation X-rays on 54 patients with distal femroal GCTs were reviewed. The size of the tumour was estimated by measuring the largest dimensions of the tumour (depth, breadth & height). The volume of the distal femur was estimated using the same X-ray and computer programme. The X-rays were then carefully studied for evidence of a cortical breach. The records were also checked for evidence of subsequent locally recurrent disease and subsequent surgery. X-rays were reviewed on 54 patients (29 male, 25 female), range of 18–72 years. All patients had a biopsy-proven GCT of the distal femur, X-rays (prior to biopsy) were reviewed. 34 (63%) patients with a cortical breech on X-ray. The mean tumour volume: distal femoral volumes (TV:DFV) was statistically greater between those patients with a cortical breach and those without, using ANOVA (p The risk of cortical breech in patients with GCTs of the distal femur is dependant upon the tumour volume to distal femur volume ratio. If the ratio is above 54% then present with a cortical breech on X-ray is likely (95% confidence interval).There is no evidence those patients with a cortical breach have a higher rate of local recurrence, an increased number of operations or more radical surgery. Conclusion: The risk of cortical breech in patients with GCTs of the distal femur is dependent upon the tumour volume to distal femur volume ratio.

Giant cell tumours are rare bone tumours that are characteristically benign but locally aggressive, most frequently occurring in the distal femur with pathological fractures being common. This paper investigates relationships between tumour size and cortical breach on initial X-rays and subsequent treatment. The X-rays of 54 patients with distal femoral giant cell tumours were reviewed. The volumes of the tumour, distal femur and a ratio between the two parameters were estimated. The presence of a cortical breach, discrete fracture and Campanacci grade was recorded. X-rays revealed intact cortical rim in 20 patients (37%), cortical breach in 22 patients (41%) and discrete fracture in 12 patients (22%). There was a significant difference in the ratio of tumour volume to distal femoral volume between the discrete fracture group and the cortical breach group. No significant differences in rates of local recurrence were demonstrated. Extended curettage was effective for intact and cortical breach groups; however, patients in the fracture group often required radical treatment.

Introduction and Aims: Endoprosthetic replacement (EPR) following Bone Tumor excision is common. A major complication is infection with serious consequences. The aim is to investigate the cause of infection, management and sequalae. Method: Over 11, 000 patients have been treated in our unit over 35 years. Information collected prospectively on a database, includes demographic data, diagnosis, treatment (including adjuvant), complications, and outcomes. Data was analysed to identify any infection in EPRs, its management and outcome. Factors such as operating time, blood loss, adjuvant therapy, type of prosthesis were investigated. Outcomes of treatment options were evaluated. Results: Data was analysed on 1265 patients undergoing EPR over 34 years. Giving a total follow-up time of over 6500 patient years. One hundred and thirty-seven (10.8%) patients had deep infection (defined by a positive culture [n=128] or a clinically infected prosthesis with pus in the EPR cavity [n=9]). Forty-nine (34%) required amputations for uncontrollable infection. The commonest organisms were Coagulase Negative Staphylococcus, Staphylococcus aureus and Group D Streptococci. The only satisfactory limb salvaging operation was two-stage revision, with a 71% success in curing infection. Systemic antibiotics, antibiotic cement or beads and surgical debridement had little chance of curing infection. Infection rates were highest in tibial (23.1%) and pelvic (22.9%) EPRs (p Conclusion: Infection is a serious complication of EPRs. Treatment is difficult and prolonged. Two-stage revision is the only reliable method for limb salvage following deep infection. Prevention must be the key to reducing the incidence of this serious complication.

Between 1983 and 1996, nine children were treated with extensible endoprosthetic replacements of the proximal femur after resection of primary bone tumors. Four patients died of their disease. The remaining five patients were observed for an average follow-up period of 7.6 years. In these five patients, the authors performed an average of 10.2 operations per patient, including five lengthenings and a mean total extension of 69.7 mm per patient. Acetabular loosening and hip dislocations were the most frequent complications. Only two patients have not had a revision or a major complication. Despite this, four children are alive with a functioning lower limb and a mean Musculoskeletal Tumor Society functional score of 77.6%. Extensible endoprosthesis of the proximal femur is a viable alternative to hip disarticulation and in selected children offers an opportunity for near-normal development of the lower limb by allowing equalization of limb length and the ability to walk without the use of mobility aids.

Endoprosthetic replacement (EPR) following Bone Tumour excision is common. A major complication of EPRs is infection, which can have disastrous consequences. This paper investigates the cause of infection, management and sequelae. Over 10, 000 patients have been treated in our unit over 34 years. Information collected prospectively on a database includes demographic data, diagnosis, treatment (including adjuvant), complications, and outcomes. Data was analysed to identify any infection in EPRs, its management and outcome. Factors such as operating time, blood loss, adjuvant therapy, type of prosthesis (extendable or standard) were investigated. Outcomes of treatment options were evaluated. Data was analysed on 1265 patients undergoing EPR over 34 years, giving a total follow up time of over 6500 patient years. 137 (10.8%) patients have been diagnosed with deep infection (defined by a positive culture [n=128] or a clinically infected prosthesis with pus in the EPR cavity [n=9]). Of these 49 (34%) required amputations for uncontrollable infection. The commonest organisms were Coagulase Negative Staphylococcus, Staphylococcus aureus and Group D Streptococci. The only satisfactory limb salvaging operation was 2 stage revision, which had 71% success in curing infection. Systemic antibiotics, antibiotic cement or beads and surgical debridement had little chance of curing infection. Infection rates were highest in the Tibial (23.1%) & Pelvic (22.9%) EPRs (p Patients who had subsequently undergone patella resurfacing and rebushing also had a higher rate of infection (p=0.019 and p=0.052). Infection is a serious complication of EPRs. Treatment is difficult and prolonged. 2 stage revision is the only reliable method for limb salvage following deep infection. Prevention must be the key to reducing the incidence of this serious complication.

This retrospective clinical study describes our experience of the use of growing endoprostheses in children with primary malignant tumours of the proximal femur and analyses the results. Between 1983 and 1996 we treated nine children with primary bone tumors of the proximal femur by resection and proximal femoral extensible replacements. Outcomes measured were function of the limb using Musculoskeletal Tumor Society score, oncologic outcome, complications and equalization of limb length. Results: Four patients died as a result of pulmonary metastases. The remaining five patients were observed for an average follow-up period of 7. 6 years (range 11–12. 7 years). One patient had a hindquarter amputation for uncontrolled infection. In these five patients we performed an average of 10. 2 operative procedures per patient (range of 3–17 procedures) including 5 lengthening procedures (range of 1–8 procedures) and a mean total extension of 69. 7 mm per patient. Acetabular loosening and hip dislocations were the most frequent complications. Only two patients have not had a revision or a major complication. Despite this, 4 children are alive with a functioning lower limb and a mean Musculoskeletal Tumour Society functional score of 77. 6%. The limb length discrepancy was less than 1 0 mm in three of these patients. The remaining patient has a discrepancy of 50 mm and is awaiting further limb equalization procedures. Extendible endoprostheses of the proximal femur in selected children is a viable reconstructive procedure. It allows for equalization of limb length and the ability to walk without the use of mobility aids.

This is a retrospective study of 70 patients with chondroblastoma treated between 1973 to 2000. Of these 70 patients, 53 had their primary procedure performed at our unit in the form of an intralesional curettage. The purpose of this study was to determine the rates of recurrence and the functional outcomes following this technique. Factors associated with aggressive tumour behaviour were also analysed. The patients were followed up for at least 22 months, up to a maximum of 27 years. 6 out of these 53 cases (11. 3%) had a histologically proven local recurrence. Three patients underwent a second intralesional curettage procedure and had no further recurrences. Two patients had endoprosthetic replacement of the proximal humerus and one patient underwent a below knee amputation following aggressive local recurrences. One patient had the rare malignant metastatic chondroblastoma and died eventually. The mean MSTS score was 94. 1%. We conclude that meticulous primary intralesional curettage without any additional procedure can achieve low rates of local recurrence and excellent long-term functional results.