The management of critical bone defects: outcomes of a systematic approach.

BACKGROUND: The reconstruction of segmental long bone defects remains one of 'The holy grails of orthopaedics'. The optimal treatment of which remains a topic of great debate. This study aimed to evaluate the outcomes following the management of critical-sized bone defects using a classification-based treatment algorithm. METHODS: A retrospective review of all patients undergoing treatment for segmental diaphyseal defects of long bones at a tertiary-level limb reconstruction unit between January 2016 and December 2021, was performed. The management of the bone defect was standardised as per the classification by Ferreira and Tanwar (2020). RESULTS: A total of 96 patients (mean age 39.8, SD 15.2) with a minimum six months follow-up were included. Most bone defects were the result of open fractures (75/96) with 67% associated with Gustilo-Anderson IIIB injuries. There was a statistical difference in the likelihood of union between treatment strategies with more than 90% of cases undergoing acute shortening and bone transport achieving union and only 72% of cases undergoing the induced membrane technique consolidating (p = 0.049). Of those defects that consolidated, there was no difference in the time to bone union between strategies (p = 0.308) with an overall median time to union 8.33 months (95% CI 7.4 - 9.2 months). The induced membrane technique was associated with a 40% risk of sepsis. CONCLUSION: This study reported the outcomes of a standardised approach to the management of critical-sized bone defects. Whilst overall results were supportive of this approach, the outcomes associated with the induced membrane technique require further refinement of its indications in the management of critical-sized bone defects.

Is there a role for suppression of infection in managing fracture-related infection following intra-medullary nailing?

BACKGROUND: The management of fracture-related infection has undergone radical progress following the development of international guidelines. However, there is limited consideration to the realities of healthcare in low-resource environments due to a lack of available evidence in the literature from these settings. Initial antimicrobial suppression to support fracture union is frequently used in low- and middle-income countries despite the lack of published clinical evidence to support its practice. This study aimed to evaluate the outcomes following initial antimicrobial suppression to support fracture union in the management of fracture-related infection. METHODS: A retrospective review of consecutive patients treated with initial antimicrobial suppression to support fracture healing followed by definitive eradication surgery to manage fracture-related infections following intramedullary fixation was performed. Indications for this approach were; a soft tissue envelope not requiring reconstructive surgery, radiographic evidence of stable fixation with adequate alignment, and progression towards fracture union. RESULTS: This approach was associated with successful treatment in 51/55 (93 %) patients. Fracture union was achieved in 52/55 (95 %) patients with antimicrobial suppression alone. Remission of infection was achieved in 54/55 (98 %) patients following definitive infection eradication surgery. Following antibiotic suppression, 6/46 (13 %) pathogens isolated from intra-operative samples demonstrated multi-drug resistance. CONCLUSION: Initial antimicrobial suppression to support fracture healing followed by definitive infection eradication surgery was associated with successful treatment in 93 % of patients. The likelihood of remission of infection increases when eradication surgery is performed in a healed bone. This approach was not associated with an increased risk of developing multi-drug-resistant infections compared to contemporary bone infection cohorts in the published literature. LEVEL OF EVIDENCE: IV.

Optimising the Orthopaedic Trauma Society Open Fracture Classification system: a proposal for modification in the context of high civilian gunshot fractures.

OBJECTIVES: Uniformly classifying long bone open fractures is challenging. The purpose of this study was to propose a modified Orthopaedic Trauma Society (OTS) Open Fracture Classification System, developed in a setting with a high incidence of civilian gunshot fractures. METHODS: From our prospectively collected database, we identified all patients with open tibia and femur fractures treated with intramedullary nailing over a 4 year period. All open fractures were retrospectively reclassified from the Gustilo-Anderson Classification system to the OTS Open Fracture Classification System. RESULTS: One hundred and thirty-seven cases were identified. Ninety per cent of subjects were males. Their mean age was 34 years. The most common mechanism of injury was low-velocity civilian gunshot wounds (GSW) in 54.7% of cases. Soft tissue management was primary closure in 23.4% and soft tissue reconstruction in 24.1%. In 52.6% of cases (these all being secondary to civilian GSW), soft tissue management was healing via secondary intention. This is not included as a soft tissue management option in the OTS classification system. Fracture reclassification using the OTS Open Fracture Classification System was only possible in 47.5% of cases (Simple in 23.4%, Complex B in 24.1%). CONCLUSION: We conclude that the OTS Open Fracture Classification System is not inclusive of all open tibia and femur fractures as it does not cater for gunshot fractures. We propose a modification as follows: alter 'wound debridement' to 'appropriate wound care' and to subcategorise 'Simple' into type A and B: healing via secondary intention and primary closure, respectively.

The reliability of posterior malleolar ankle fracture assessment: a unique perspective.

AIM: This study aims to elucidate the pathology of PMFs in the South African population, establish correlations between fracture patterns and international classification guidelines and evaluate the interobserver reliability of current classifications. METHODS: A retrospective review was conducted in a multicentre analysis over a one-year period from January 2019 to December 2019 at our institution. Computer tomography scans for foot and ankle injuries were reviewed, and posterior malleolus fractures were included. Pathoanatomical data was collected and analysed according to known classification systems and subsequent treatment modalities evaluated. A panel of observers individually reviewed radiographic data to determine interobserver reliability. RESULTS: A total of 71 patients were included with a mean age of 41 ± 13.4 years (range 18-78) and a female predominant population (69%). A greater proportion of injuries were high energy (23.9%), with significant fragment comminution (53.5%), and half (52.1%) of all injuries were subluxated/dislocated at presentation. A total of 93% of injuries were managed operatively, despite theatre access limitations resulting in significant delays to fixation (19.1 days). Despite good pathoanatomical agreement with most international classifications, interobserver reliability was poor (Krippendorff α-coefficient < 0.667). Inconsistent treatment patterns in operative and non-operative strategies are reported. CONCLUSION: A unique patient population of younger, female individuals incurred posterior malleolar fractures due to higher energy mechanisms of injury. Whilst injury patterns were mostly comparable, significant interobserver variability was noted. Resource limitations, diagnostic challenges, poorly defined and inconsistent treatment strategies, inevitably impact outcomes within the South African population. LEVEL OF EVIDENCE: Level III.

Return to Work Following Intramedullary Nailing of Lower-Limb Long-Bone Fractures in South Africa.

BACKGROUND: Injuries are one of the leading causes of global death and disability and commonly have substantial economic implications. The economic impact of injuries is particularly pronounced in low- and middle-income countries, where 90% of injuries occur. In this study, we aimed to assess return-to-work rates of individuals who sustained a lower-limb long-bone fracture in South Africa and to identify factors that influence the ability to return to employment. METHODS: This prospective cohort study was conducted across 2 tertiary trauma centers in Cape Town, South Africa. Adults who received intramedullary nail fixation for a lower-limb fracture between September 2017 and December 2018 were recruited and followed for 18 months postoperatively. The participants' return to employment was assessed at 6 and 18 months post-injury. Multivariate logistic regression was used to identify factors that influence post-injury employment. RESULTS: Of the 194 participants enrolled, 192 completed follow-up. The study population had a median age of 33.0 years, and most of the participants (76.6%) were male. Seventy-five percent of the participants were employed before their injury. At 6 and 18 months post-injury, 34.4% and 56.3% of participants, respectively, were employed. Of those employed pre-injury, 70.1% had returned to work at 18 months. Multivariate regression identified increasing age, unemployment prior to injury, and working in the informal employment sector as factors that impede an individual's likelihood of working 18 months post-injury. For those in employment prior to injury, increasing age was the only factor found to impede the likelihood of returning to work following an injury. CONCLUSIONS: This study highlights the profound effect that lower-limb long-bone fractures may have on an individual's ability to return to work in South Africa, with the potential to cause substantial economic impact on an individual's livelihood and that of their dependents. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Establishing a consensus on research priorities in orthopaedic trauma within South Africa.

BACKGROUND: Musculoskeletal (MSK) injuries are one of the leading causes of disability worldwide. Despite improvements in trauma-related morbidity and mortality in high-income countries over recent years, outcomes following MSK injuries in low- and middle-income countries, such as South Africa (SA), have not. Despite governmental recognition that this is required, funding and research into this significant health burden are limited within SA. This study aims to identify research priorities within MSK trauma care using a consensus-based approach amongst MSK healthcare practitioners within SA. METHOD: Members from the Orthopaedic Research Collaboration in Africa (ORCA), based in SA, collaborated using a two round modified Delphi technique to form a consensus on research priorities within orthopaedic trauma care. Members involved in the process were orthopaedic healthcare practitioners within SA. RESULTS: Participants from the ORCA network, working within SA, scored research priorities across two Delphi rounds from low to high priority. We have published the overall top 10 research priorities for this Delphi process. Questions were focused on two broad groups-clinical effectiveness in trauma care and general trauma public health care. Both groups were represented by the top two priorities, with the highest ranked question regarding the overall impact of trauma in SA and the second regarding the clinical treatment of open fractures. CONCLUSION: This study has defined research priorities within orthopaedic trauma in South Africa. Our vision is that by establishing consensus on these research priorities, policy and research funding will be directed into these areas. This should ultimately improve musculoskeletal trauma care across South Africa and its significant health and socioeconomic impacts.

Filling the gap: a series of 3D-printed titanium truss cages for the management of large, lower limb bone defects in a developing country setting.

INTRODUCTION: Large segmental long bone defects are notoriously difficult to manage. Treatment is resource-intensive due to the complexity, cost, and specialized skills required. Truss designs are known for their triangular shapes organized in web configurations. This allows for maximal mechanical strength, the least mass, and a lattice that can be filled with bone graft. Using a truss cage combined with contemporary internal fixation provides immediate stability for bone ingrowth and long-term potential union. The implant is designed using virtual 3D modelling of the patient's bone defect based on a CT scan. The truss cage can be used in a staged procedure combined with Masquelet's induced membrane technique. This study aims to review the outcomes of patient-specific, locally designed 3D titanium truss cages packed with cancellous autograft in treating segmental, long bone defects in the lower limb in a developing country setting. METHODS: This retrospective series reviewed cases performed at various institutions between January 2019 and March 2022. Parameters assessed included patient demographics, size and location of the defect, time to clinical and radiological union and complications. RESULTS: Nine cases were included for review, with a mean age of 36 years (range 19-52). Defects ranged from 60 to 205 mm, and eight cases were staged procedures. Eight cases used intramedullary reamings as bone graft. Contemporary intramedullary nails were used for fixation in all cases. No peri- or post-operative complications occurred. All cases progressed to functional union. CONCLUSION: 3D-printed titanium truss cages combined with bone graft appear to be an effective treatment of large bone defects in the lower limb in a developing country setting in the short term. No complications were encountered, but longer follow-up is needed before definitive recommendations can be made. LEVEL OF EVIDENCE: Level IV (retrospective case series).

Early outcomes of surgically managed civilian gunshot femur fractures at a level one trauma unit in Cape Town, South Africa: a retrospective review.

PURPOSE: To assess the outcome of surgically fixated femur shaft and distal femur fractures following low-velocity civilian gunshot injuries over a 4-year period. METHODS: A retrospective review was conducted on all patients who sustained femur shaft and distal femur fractures from civilian low-velocity gunshot injuries that required definitive surgical fixation between January 2014 and December 2017. Patient demographics, comorbidities, injury characteristics, duration between injury and surgical fixation and presence of complications were captured. RESULTS: A total of 122 patients (mean age, 29.1 ± 9.5 years) were included. Supracondylar femur fractures (AO 33) accounted for 49% of total injuries, followed by femoral shaft (AO 32) and intra-articular distal femur fractures (AO 33 B & C) with 40% and 11%, respectively. Intramedullary nail fixation was the choice of treatment for femur shaft fractures (49.98%) and supracondylar fractures (63%). Intra-articular injuries were predominantly treated with distal femoral locking plates (85%). Arterial and nerve injuries were the most commonly encountered associated injuries occurring in five patients (4.1%) each. Fracture-related infection was diagnosed in two patients (1.6%). No cases of non-union and compartment syndrome were recorded. CONCLUSION: Femur shaft and supracondylar fractures fixated with intramedullary nails are associated with low complication rates and perfect union rates. Our study suggests that intra-articular distal femur fractures fixated with locking plates and cannulated screws have a high complication rate and poorer surgical outcomes. Non-union and compartment syndrome are rare complications of gunshot femur fractures fixated with either intramedullary nails or locking plates.

Dead space management strategies in the treatment of chronic osteomyelitis: a retrospective review.

PURPOSE: Dead space management is critically important during the treatment of chronic osteomyelitis. Many dead space management strategies are available, each with their respective advantages and shortcomings. This study aims to present the outcomes and complications of dead space management strategies employed in the treatment of chronic osteomyelitis at a single tertiary level musculoskeletal unit. METHODS: A retrospective review of dead space management strategies employed at a tertiary-level musculoskeletal infection unit was conducted. Patients of any age treated for chronic osteomyelitis of the appendicular skeleton with a minimum follow-up of 6 months were included in the study. Data were collected regarding patient demographics, aetiology and site of infection, dead space management strategy employed, follow-up period and outcome in terms of resolution of infection. RESULTS: A final cohort of 132 patients underwent surgical treatment with a dedicated dead space management strategy for chronic osteomyelitis of the appendicular skeleton. Eleven patients (8%) experienced a recurrence of infection. Seven patients (63%) with recurrence were type B hosts, while four patients (37%) were type A hosts. CONCLUSION: Dead space management is an integral part of treating chronic osteomyelitis; however, no guidelines currently exist regarding the most appropriate strategy. Favourable results are achievable in low to middle-income countries, and it is evident that no dead space management strategy is superior to another. The pursuit for the ideal void filler is ongoing. LEVEL OF EVIDENCE: III.

Temporary circular external fixation for spanning the traumatised ankle joint: A cohort comparison study.

BACKGROUND: Temporary spanning fixation aims to provide bony stability whilst allowing access and resuscitation of the traumatised soft-tissue envelope. Conventional monolateral fixators are prone to half-pin morbidity in feet, variation in construct stability and limited weight-bearing potential. This study compares traditional delta-frame monolateral external fixators to ankle spanning circular fixators. METHODS: Two cohorts were matched for demographics and fracture patterns. The quality of initial reduction and the maintenance of reduction until definitive surgery was assessed by two authors and categorised into four domains. Secondary measures included fixator costs, time to definitive surgery and complications. RESULTS: Fifty-five delta-frames and 51 circular fixators were statistically matched for demographics and fracture pattern. "Excellent" and "Good" initial reduction was achieved in 50 (91%) delta-frames and 51 (100%) circular fixators (p = 0.027). Deterioration of initial reduction quality was seen in 12 (22%) delta-frames and two (4%) circular fixators (p < 0.001). Post-fixator dislocation occurred in five (9%) delta-frames and one (2%) circular fixator (p = 0.147). Median duration in spanned fixation was 11 days in both groups (p = 0.114). Three (5%) delta-frames and 13 (25%) circular fixators were used as definitive fixation. The mean implant cost was 4,307 USD for delta-frames and 3747 USD for circular fixators. CONCLUSION: Temporary spanning circular fixation offers superior intra-operative reduction and maintenance of reduction and provides more opportunity to be used as definitive fixation. Circular fixation implants also proved to be less expensive and protected against further scheduled or unscheduled returns to theatre. LEVEL OF EVIDENCE: IV, retrospective cohort study.

Radiographic union score for tibia (RUST) scoring system in adult diaphyseal femoral fractures treated with intramedullary nailing: an assessment of interobserver and intraobserver reliability.

OBJECTIVES: The Radiographic Union Score for Tibia (RUST) scoring system has been validated in multiple studies assessing the healing of tibial fractures. Our objective was to assess the interobserver and intraobserver reliability for the RUST in diaphyseal femoral fractures treated with intramedullary (IM) nailing. PATIENTS AND METHODS: A total of 60 sets of anteroposterior (AP) and lateral radiographs of diaphyseal femoral fractures treated by reamed IM nailing were randomly selected from a prospectively collected database. The 60 sets of radiographs were then scored by three reviewers using the RUST system. Interobserver reliability was measured at initial scoring. The 60 sets of radiographs were scored again by the three reviewers to calculate the intraobserver reliability. RESULTS: The RUST scores ranged from 4 to 12 with a mean score of 11.3 ± 1.3. The interobserver intraclass correlation coefficient (ICC) was 0.87 (95% CI, 0.81-0.92) and the intraobserver ICC was 0.91 (95% CI, 0.88-0.94), which indicated excellent agreement. CONCLUSION: This study demonstrated that the RUST system can be used reliably in the assessment of healing in diaphyseal femur fractures treated by reamed intramedullary nailing, with excellent interobserver and intraobserver reliability.

Contemporary management of aseptic diaphyseal tibia non-unions - A systematic review.

INTRODUCTION: Tibia fractures are the most common long bone injuries encountered in the trauma population. The majority are treated successfully but non-union remains a common complication. A systematic review of current evidence regarding the management for aseptic diaphyseal tibial non-unions was undertaken. METHODS: A systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA), was conducted. RESULTS: A total of 632 publications were screened for inclusion. Full text review of 91 studies resulted in 26 publications being retained for final review. The majority of patients included in the studies either underwent exchange nailing (n=315) or primary intramedullary nailing (n=174) with respective union rates of 88% and 95% being achieved. The highest union rate (97%) was achieved with the use of fine wire external fixation. The major adjuvant treatment modalities were fibula osteotomies (n=372; 41%), fixation dynamization (n=208; 23%) and bone grafting (n=183; 20%). CONCLUSION: The lack of standardization in reporting of outcomes and the diversity of management strategies employed precludes definitive conclusions or recommendations. Further research is required to ascertain the ideal treatment strategy in the management of aseptic tibial diaphyseal non-unions. LEVEL OF EVIDENCE: IV.

Adamantinoma-like Variant of Ewing Sarcoma in the Metatarsal Bone After Chemotherapy: Report of a Case Successfully Treated with Pedicled Osteocutaneous Fibular Transfer.

Adamantinoma-like Ewing sarcoma is a rare variant of Ewing sarcoma with histologic and immunohistochemical evidence of squamous differentiation. This variant most commonly occurs in the head and neck region with a few cases reported in the long bones of the limbs. It may be associated with poorer clinical outcome and could pose a diagnostic challenge, particularly if it occurs in older patients or as a metastatic lesion. We present a case of Ewing sarcoma in the metatarsal of an 11-year-old boy that manifested adamantinoma-like morphology after neoadjuvant chemotherapy. Chemotherapy has been reported to induce neuronal maturation and rhabdoid morphology in cases of Ewing sarcoma, but no reports of treatment-induced squamous differentiation with P40/P63 expression have been demonstrated. This is also the first documented case treated with a pedicled osteocutaneous fibular transfer in a metatarsal malignancy, which is usually treated by either ray or below-knee amputation.

Civilian gunshot injuries in orthopaedics: a narrative review of ballistics, current concepts, and the South African experience.

The incidence of civilian gunshot injuries is on the rise worldwide.Unfortunately, there is a lack of high-level evidence guiding management. The treatment of orthopaedic injuries from gunshots is complex and requires consideration of multiple aspects, including energy transfer to the tissue, severity of the wound, possible contamination, presence of fractures and associated injuries. With this narrative review we aim to discuss some of the relevant ballistics, current concepts, and controversies in the general management of civilian gunshot-related orthopaedic injuries based on the available evidence and personal experience. Important points which will be highlighted are the initial management in the emergency room, the assessment and management of soft tissue injuries, associated injuries, use of antibiotics, indication and techniques for fracture fixation, and gunshot injuries to joints.

Management of segmental bone defects of the upper limb: a scoping review with data synthesis to inform decision making.

PURPOSE: Injuries to the long bones of the upper limb resulting in bone defects are rare but potentially devastating. Literature on the management of these injuries is limited to case reports and small case series. The aim of this study was to collate the most recent published work on the management of upper limb bone defects to assist with evidence based management when confronted with these cases. METHODS: Following a preliminary search that confirmed the paucity of literature and lack of comparative trials, a scoping review using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) was conducted. A literature search of major electronic databases was conducted to identify journal articles relating to the management of upper limb long bone defects published between 2010 and 2020. RESULTS: A total of 46 publications reporting on the management of 341 patients were reviewed. Structural autograft, bone transport, one-bone forearm and the induced membrane technique were employed in an almost equal number of cases. The implemented strategies showed similar outcomes but different indications and complication profiles were observed. CONCLUSION: Contemporary techniques for the management of post-traumatic upper limb bone defects all produce good results. Specific advantages, disadvantages and complications for each modality should be considered when deciding on which management strategy to employ for each specific patient, anatomical location, and defect size.

Limb reconstruction in a resource-limited environment.

INTRODUCTION: Limb salvage and reconstruction are often challenging and even more so in the limited resource setting. The purpose of this narrative review is to explore the strategies for addressing the unique obstacles and opportunities of limb reconstructive surgery in resource-limited environments globally. METHODS: We review (1) the global burden and dimension of the problem, (2) the relevance of orthopedic forums and communication, (3) free and open-access software for deformity analysis and correction, (4) bidirectional learning opportunities, and the value of fellowships and mentoring between resource-rich and resource-limited countries, and (5) how societies like SICOT can help to tackle the problem. Finally, case examples are presented to demonstrate the choice of surgical implants, their availability in regions with limited resources, and how the universal principles of limb reconstruction can be applied, irrespective of resource availability. RESULTS: Limb reconstruction can often be life-changing surgery with the goals of limb salvage, improved function, and ambulation. The contradiction of relatively few severe limb deformities in high-income countries (HICs) with abundant resources and the considerable burden of limb deformities in resource-limited countries is striking. Free, open access to education and software planning tools are of paramount importance to achieve this goal of limb reconstruction. Bidirectional learning, i.e., knowledge exchange between individual surgeons and societies with limited and abundant resources, can be reached via fellowships and mentoring. The presented cases highlight (1) fixator-assisted wound closure obliviating the need for plastic surgery, (2) open bone transport, and (3) hinged Ilizarov frames for correction of severe deformities. These cases underline that optimal clinical outcome can be achieved with low-cost and readily available implants when the principles of limb reconstruction are skillfully applied. DISCUSSION: Limb lengthening and reconstruction are based on universally applicable principles. These have to be applied regardless of the planning tool or surgical implant availability to achieve the goals of limb salvage and improved quality of life.

Two stage reconstruction of septic non-union of the humerus with the use of circular external fixation.

Achieving quiescence in chronic osteomyelitis remains challenging. Wide resection of all infected and necrotic tissues improves the chances of achieving remission of the disease. Extensive debridement however decreases the already compromised bone stock that increases the complexity of reconstruction. We report on the outcome of eight patients with Cierny and Mader stage IV chronic osteomyelitis of the humerus who underwent debridement followed by bone graft and circular fixator application as a second stage procedure. Resolution of infection and humeral shaft union was achieved in all patients. Our study finds that two-stage reconstruction of stage IV chronic osteomyelitis with the use of circular external fixation is effective in achieving infection control and union in these complex cases.

Closed Distraction and Gradual Deformity Correction of Stiff Hypertrophic Tibial Nonunions with Hexapod External Fixation.

INTRODUCTION: Closed distraction of stiff tibial nonunions with a hexapod external fixator can predictably lead to union without the need for additional surgery or bone graft. STEP 1 FIBULAR OSTEOTOMY: Resect 5 to 10 mm of the fibula, from its distal half or at the level of the fibular deformity if present. STEP 2 APPLICATION OF HEXAPOD PROXIMAL RING USING "RINGS FIRST" METHOD: Apply the proximal ring orthogonal to the proximal bone segment. STEP 3 APPLICATION OF HEXAPOD DISTAL RING USING "RINGS FIRST" METHOD: Apply the distal ring orthogonal to the distal bone segment. STEP 4 CONNECTION OF STRUTS AND APPLICATION OF STERILE DRESSING: Connect the proximal and distal rings with 6 oblique struts. STEP 5 POSTOPERATIVE PLANNING DEFORMITY CORRECTION AND DISTRACTION: Perform gradual deformity correction and distraction at a rate of 1 mm per day. STEP 6 POSTOPERATIVE CARE UNTIL UNION: Perform pin-site care and functional rehabilitation. STEP 7 "TRIAL OF UNION" AND FRAME REMOVAL: Ensure adequate union prior to removal of the circular fixator. RESULTS: Hexapod closed distraction has been successfully used for the management of stiff hypertrophic tibial nonunions in our practice over the last 6 years.

Pre-treatment serum lactate dehydrogenase and alkaline phosphatase as predictors of metastases in extremity osteosarcoma.

BACKGROUND: The prognosis of patients with metastatic osteosarcoma remains poor. However, the chance of survival can be improved by surgical resection of all metastases. In this study we investigate the value of serum alkaline phosphatase (ALP) and lactate dehydrogenase (LDH) in predicting the presence of metastatic disease at time of diagnosis. METHODS: Sixty-one patients with histologically confirmed conventional osteosarcoma of the extremity were included in the study. Only 19.7% of cases presented without evidence of systemic spread of the disease. Pre-treatment serum ALP and LDH were analysed in patients with and without skeletal or pulmonary metastases. RESULTS: Serum LDH and ALP levels were not significantly different in patients with or without pulmonary metastases (p=0.88 and p=0.47, respectively). The serum LDH and ALP levels did however differ significantly in patients with or without skeletal metastases (p<0.001 and p=0.02, respectively). The optimal breakpoint for serum LDH as a marker of skeletal metastases was 849 IU/L (AUC 0.839; Sensitivity=0.88; Specificity=0.73). LDH >454 IU/L equated to 100% sensitivity for detected bone metastases (positive diagnostic likelihood ratio (DLR)=1.32). With a cut-off of 76 IU/L a sensitivity of 100% was reached for serum ALP predicting the presence of skeletal metastases (positive DLR=1.1). In a multivariate analysis both LDH ≥850 IU/L (odds ratio [OR]=9; 95% confidence interval (CI) 1.8-44.3) and ALP ≥280 IU/L (OR=10.3; 95% CI 2.1-50.5) were predictive of skeletal metastases. LDH however lost its significance in a multivariate model which included pre-treatment tumour volume. CONCLUSION: In cases of osteosarcoma with LDH >850 IU/L and/or ALP >280 IU/L it may be prudent to consider more sensitive staging investigations for detection of skeletal metastases. Further research is required to determine the value and the most sensitive cut-off points of serum ALP and LDH in the prediction of skeletal metastases.

Management of tibial non-unions according to a novel treatment algorithm.

Tibial non-unions represent a spectrum of conditions that are challenging to treat. The optimal management remains unclear despite the frequency with which these diagnoses are encountered. The aim of this study was to determine the outcome of tibial non-unions managed according to a novel tibial non-union treatment algorithm. One hundred and eighteen consecutive patients with 122 uninfected tibial non-unions were treated according to our proposed tibial non-union treatment algorithm. All patients were followed-up clinically and radiologically for a minimum of six months after external fixator removal. Four patients were excluded because they did not complete the intended treatment process. The final study population consisted of 94 men and 24 women with a mean age of 34 years. Sixty-seven non-unions were stiff hypertrophic, 32 mobile atrophic, 16 mobile oligotrophic and one true pseudoarthrosis. Six non-unions were classified as type B1 defect non-unions. Bony union was achieved after the initial surgery in 113/122 (92.6%) tibias. Nine patients had failure of treatment. Seven persistent non-unions were successfully retreated according to the tibial non-union treatment algorithm. This resulted in final bony union in 120/122 (98.3%) tibias. The proposed tibial non-union treatment algorithm appears to produce high union rates across a diverse group of tibial non-unions. Tibial non-unions however, remain difficult to treat and should be referred to specialist units where advanced reconstructive techniques are practiced on a regular basis.