Tom Cosker’s research while affiliated with Oxford University Hospitals NHS Trust and other places

Introduction Musculoskeletal tumours affecting the lower limb, and the distal fibula in particular, are rare. Substantial variation exists in both reconstructive techniques employed in their management and reported results; a consequence of their low incidence and the specific challenges presented by the location. Advances in imaging and neo-adjuvant chemotherapy have sparked a paradigm shift in the management of these cases. Where amputation was once the mainstay, limb salvage surgery is now a viable option and multiple techniques exist, but outcomes are poorly studied. Method We performed a literature review and report a three-patient case series. All three patients underwent our novel reconstruction technique, utilising a vascularised ipsilateral fibula graft. Results 102 patient cases of distal fibula resection were identified. 57 of these patients had malignant disease. Evidence that limb salvage surgery produces good functional outcomes for sarcoma patients is limited; 25% of patients with malignant disease were reported as having poor outcomes or disease progression. All three patients undergoing our novel reconstructive technique have had good functional and oncological outcomes. Conclusions This is the largest literature review of patients undergoing distal fibula resection. Reconstruction is complex and no single solution exists. We present the use of a vascular proximal ipsilateral fibula graft, which to the best of our knowledge, has not been previously reported. The reconstructive method we present appears to be a durable technique offering an excellent functional outcome and is an appealing alternative to arthrodesis or amputation in appropriate patients.

Introduction: Sarcomas of the head and neck are neoplasms arising from the embryonic mesenchyme. They are rare and heterogeneous in nature and are associated with significant morbidity and mortality. This study evaluates patients referred to the Oxford Sarcoma Service, a tertiary referral centre. Methods: Patients discussed over a three-year period were included. Medical records were analysed using the electronic patient record database. Data were acquired on a range of domains, including: demographics, histopathology, treatment modality, recurrence, mortality, survival, etc. Results: Thirty-two eligible patients, 21 male and 11 female, were identified with a mean age of 58 years; 26 out of 32 patients had high-grade sarcomas. The commonest histological subtype was chondrosarcoma (8/32). Twenty-two underwent planned multidisciplinary team surgical resection after biopsy and staging: negative margins were noted in 9, with close and involved margins in 5 and 8, respectively. Local recurrence was noted in 13 and 6 had metastatic disease out of the 32 eligible patients. Mortality was noted in 10 out of 32 patients. Mean survival was 69.5 months. Five-year overall survival was 64%. Surgery demonstrated statistically significant improvement in survival (p=0.0095). There were no significant differences in survival, recurrence or marginal status between methods of adjuvant or neoadjuvant therapy. Conclusion: Outcomes of head and neck sarcomas are inferior compared with other types of sarcoma. The nature of the complex surrounding anatomy presents unique challenges in surgical management. This in turn affects rates of local recurrence and prognosis. Therefore, it is critical that they are managed in tertiary, specialist centres with a multidisciplinary approach.

Introduction: Macroscopic anatomy has traditionally been taught using cadaveric material, lectures and a variety of additional resources including online modules and anatomical models. Traditional plastic models are effective educational tools yet they have significant drawbacks such as a lack of anatomical detail, a lack of texturisation and cost. Three-dimensional printed models stand to solve these problems and widen access to high-quality anatomical teaching. This paper outlines the use of three-dimensional multiplanar imaging (computed tomography) in the development of an accurate model of the hepatobiliary system. Materials and methods: Computed tomography scans were used to construct a virtual three-dimensional model of the hepatobiliary system. This was printed locally as a full-size colour model. We give a complete account of the process and software used. Discussion: This study is among the first of a series in which we will document the newly formed Oxford Library of Anatomy. This series will provide the methodology for the production of three-dimensional models from computed tomography and magnetic resonance imaging scans, and the library will provide a complete collection of the most complex anatomical areas. We hope that these models will form an important adjunct in teaching anatomy to medical students and surgical trainees.

Vascularised fibular grafts (VFGs ) are a valuable surgical technique in limb salvage after resection of a tumour. The primary objective of this multicentre study was to assess the risk factors for failure and complications for using a VFG after resection of a tumour. The study involved 74 consecutive patients (45 men and 29 women with mean age of 23 years (1 to 64) from four tertiary centres for orthopaedic oncology who underwent reconstruction using a VFG after resection of a tumour between 1996 and 2011. There were 52 primary and 22 secondary reconstructions. The mean follow-up was 77 months (10 to 195). In all, 69 patients (93%) had successful limb salvage; all of these united and 65 (88%) showed hypertrophy of the graft. The mean time to union differed between those involving the upper (28 weeks; 12 to 96) and lower limbs (44 weeks; 12 to 250). Fracture occurred in 11 (15%), and nonunion in 14 (19%) patients. In 35 patients (47%) at least one complication arose, with a greater proportion in lower limb reconstructions, non-bridging osteosynthesis, and in children. These complications resulted in revision surgery in 26 patients (35%). VFG is a successful and durable technique for reconstruction of a defect in bone after resection of a tumour, but is accompanied by a significant risk of complications, that often require revision surgery. Union was not markedly influenced by the need for chemo- or radiotherapy, but should not be expected during chemotherapy. Therefore, restricted weight-bearing within this period is advocated. Cite this article: Bone Joint J 2015;97-B:853-61. ©2015 The British Editorial Society of Bone & Joint Surgery.

The surgical repair of an extensive anterior glenohumeral soft tissue defect is complicated by glenohumeral instability and subsequent significant functional deficit. This surgical note offers a relatively simple reconstruction of the anterior capsule and subscapularis muscle using a pectoralis minor pedicle flap. This reconstruction is supplemented with functional reconstruction of the anterior glenohumeral joint. A conventional deltopectoral approach is utilized and pectoralis minor is freed from its coracoid insertion, released, and mobilized without compromising the pedicle entering from the dorsum and inferior one-third of the muscle. The mobilized pectoralis minor vascular pedicle has sufficient length for the pectoralis minor to be transferred to provide coverage of the anterior shoulder joint even in full external rotation, providing anterior stability. To further improve glenohumeral stability and shoulder function, the pectoralis major muscle can be split with the clavicular part reinserted lateral to the bicipital groove onto the lesser tuberosity replacing subscapularis function while stabilising the glenohumeral joint.

Background Complex symptomatic ganglion cysts arising from the proximal tibio-fibular joint (TFJ) are not an uncommon presentation in specialist knee clinics and can be managed by aspiration or excision. There is however a high rate of recurrence and often there is progressive involvement of the common peroneal nerve (CPN) and its branches, and permanent nerve damage may result. Methods This study is a review of the outcome of recalcitrant and recurrent cyst disease with CPN involvement treated by proximal fibulectomy. Nine patients with clinical and radiological diagnosis of a ganglion cyst involving the proximal tibio-fibular joint were treated by proximal fibulectomy. Average age was 47.2 years (19 to 75). Patients were followed up clinically and radiologically. Medical notes were reviewed to assess clinical/pathological characteristics, surgical outcome, recurrence rate and the symptoms of instability and nerve function. Results None of the patients were lost to follow up. After an average follow up of 83 months (15 to 150), none of the patients had clinical or radiological evidence of recurrence. All patients were pain free and had a complete resolution of nerve symptoms and no evidence of CPN injury. None of the patients complained of localised pain or knee instability and there were no wound healing problems. Conclusions MRI now confirms TFJ-ganglion cysts to be more common than previously recognised. Where there is refractory disease with progressive nerve symptoms and evidence of nerve sheath involvement, joint excision by proximal fibulectomy gives a satisfactory functional result in controlling disease and preventing further nerve damage. Level of evidence IV

Purpose: Elderly patients with bone cancer are thought to have poorer access to specialist treatment and therefore suboptimal outcome. The aim of this study was to review the clinical course, outcome and survivorship in geriatric patients with primary bone tumours. Methods: We analysed 66 consecutive patients aged 60 years or older who were surgically treated for primary bone tumours between 1997 and 2012. The cohort was divided into two groups: elderly (60-70 years, n = 31) and very elderly (>70 years, n = 35). Clinicopathologic characteristics, treatment, outcome and survival were analysed. The mean follow up was 58.5 months (range two to 188). Results: There were 51 chondrosarcomas (grade I, n = 29; grade II, n = 15; grade III, n = 7), ten osteosarcomas and four of other primary malignant bone tumours. Twenty-three prostheses for joint reconstruction were implanted; procedures involving the transposition of free vascularised flaps were performed in six patients. Seven patients had amputation as a primary procedure, four in the elderly and three in the very elderly group. Local recurrence was recorded in eight cases (12.1%). Secondary surgery was performed in nine (13.6%) patients (six recurrences, two haematomas, one deep infection). At final follow up, 77.3% of patients were alive (elderly 83.9%, very elderly 71.4%) and there was no significant difference in the five-year survival rates between both groups. Conclusions: Elderly and very elderly patients with bone tumours receive satisfactory treatment and achieve good surgical outcome. Treatment decisions in the geriatric population should not be influenced by age alone.