BJJ News | I ssue 6 | M arch 2015
subspecialty of enormous interest. Advances in research, greater understanding of pathologies and better communication and cooperation both within and outside the speciality will herald improvements in outcome for this devastating area of disease.
Fig. 5 Navigation Intraoperative discussed by George Gosheger in 2008, 6 when he showed that titanium megaprostheses had a lower rate of infection than cobaltchrome implants. Silver has been known for its bactericidal properties for millennia. Recently, it has been developed for use in orthopaedic implants either as a surface coating or as a surface modification. The introduction of a silver treatment to tumour and revision endoprostheses has shown some promising results. In a recent study which compared highrisk patients managed with either a silvertreated endoprosthesis or a standard endoprosthesis, the silver-treated group showed a reduction in the risk of prosthetic infection of up to 30% as well as a better success rate with two-stage revision after a minimum of 6 months follow-up.7 If these results can be maintained, the improvements in morbidity associated with implant infection will easily offset any additional cost. Extracorporeal irradiation Limb salvage and reconstruction can be challenging after en-bloc resection of malignant or aggressive bone tumours. Various options exist for the management of bone defects. Prosthetic replacement or allografting are frequently the treatments of choice, but depending on the site, have loosening rates of up to 57% in some studies. In some anatomical areas, like the pelvis, options can be
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limited. In the ideal situation, a purely biological solution is preferred, but is often very difficult to achieve. Extracorporeal irradiation of resected bone has been used in many centres since the 1990’s, and more recently several outcome studies have been published.8 It is a process whereby, after en-bloc resection, the excised bone and tumour are sampled, sent immediately for high-dose irradiation, which is lethal to the tumour cells, and then returned to the operating theatre for re-implantation as a dead, acellular anatomical bone graft. The aim is for the graft to become reincorporated within the host. A study from Paul Stalley and the NSW Bone and Soft Tissue Sarcoma Service in Sydney, reviewed 50 patients who had undergone extracorporeal irradiation after en-bloc resection for malignant bone tumours.9 After a mean 38 months follow-up, 84% of patients were disease-free. Of that group, 73% had excellent or good functional results on the Mankin score and most had achieved bony union. Complications specific to the graft included avascular necrosis and bone resorption. Encouragingly, there were no reports of tumour recurrence specific to the reimplantationof the bone graft. Some concerns remain about its use for highly radioresistant tumours such as chondrosarcoma. Extracorporeal irradiation is a useful adjunct to the management of bone defects in the patient with musculoskeletal tumour. Orthopaedic oncology is a growing surgical
REFERENCES: 1. Smith G, Johnson G, Grimer R, et al. Trends in presentation of bone and soft tissue sarcomas over 25 years: little evidence of earlier diagnosis. Ann R Coll Surg Eng 2011;93:542-547. 2. Grimer R. Hunterian Lecture: Size matters for Sacoma. Ann R Coll Surg Eng 2006:88:519–524. 3. Chawla S, Henshaw R, Seeger L, et al. Safety and efficacy of denosumab for adults and skeletally mature adolescents with giant cell tumour of bone: interim analysis of an open-label, parallel- group, phase 2 study. Lancet 2013;14:901-908. 4. Young P, Findlay H, Patton J, et al. Computer Assisted Navigation in Musculoskeletal Oncology. Orthop Trauma 2014;28:294-302. 5. Jeys L, Grimer R. Carter S, et al. Periprosthetic Infection in Patients Treated for an Orthopaedic Oncological Condition. J Bone Joint Surg [Br] 2005;87-B:842-849. 6. Gosheger G, Goetze C, Hardes et al. The Influence of the Alloy of Megaprostheses on Infection Rate. J Arthroplasty 2008;23: 916-920. 7. Wafa H, Grimer R, Carter S, et al. Retrospective Evaluation of the Incidence of Early Periprosthetic Infection with Silver-Treated Custom Endoprostheses in High Risk Patients: Case Control Study. Presentation ISOLS Conference Bologna 2013. 8. Poffyn B, Sys G, Mulliez A, et al. Uyttendaele. Extracorporeally irradiated autograft for the treatment of bone tumours: tips and tricks. Int Orthop (SICOT) 2011;35:889-895. 9. Davidson A, Hong A, McCarthy S, et al. Enbloc resection, extracorporeal irradiation and reimplantation in limb salvage for bony malignancies. J Bone Joint Surg [Br] 2005;87-B:851-857. A uthor
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Sam Patton Consultant Orthopaedic Surgeon, Royal Infirmary of Edinburgh Sam.Patton@luht.scot.nhs.uk Catherine J McDougall FRACS, Orthopaedic Fellow, Royal Infirmary of Edinburgh cathmcdougall@hotmail.com