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Introduction: We developed a technique using an indigenously designed jig to assist pin placement in producing a stable and long-lasting construct to augment the acetabulum combined with a cemented hip replacement in cases of metastatic destruction of the acetabulum. We describe our novel modified Harrington technique and retrospectively assess our cohort's clinical outcomes and complications., Methods: Between 2006 and 2019, 27 patients with a median age of 69 (49-81) years and a median ASA grade of III (II-IV) were managed using our modified 'Harrington' technique. We assessed outcomes on the following criteria: mechanical complications, post-surgery mobility, and functional outcome using Musculoskeletal Tumour Society Score (MSTS)., Results: At the last follow-up, ten patients were alive with disease [median follow-up of 26 months (12-74)], and 17 patients died of their oncological disease [median follow-up of 15 months (9-22)]. There were no perioperative deaths or intra-operative complications in our series. In total, ten complications were noted in nine patients (33%). Mobility-wise, 13 patients (48%) mobilised unaided, ten patients (37%) required a stick or crutch, two patients (7%) required a frame and two patients (7%) were wheel chair-dependent. The median MSTS score of all patients during their latest follow-up was 18 (8-26)., Conclusion: Our jig-aided modified Harrington reconstruction technique assists in safe placement of antegrade pins in acetabulum during surgery and offers a long-lasting solution to these high-risk patients. The use of large diameter pins, appropriate patient selection, and cage used during construction in the acetabulum demonstrated relief of pain, improved mobility, and favorable functional outcomes with minimal complication rates., (© 2022. The Author(s) under exclusive licence to SICOT aisbl.)

Purpose: Deferring cancer surgery can have profound adverse effects including patient mortality. During the COVID-19 pandemic, departmental reorganisation and adherence to evolving guidelines enabled provision of uninterrupted surgical care to patients with bone and soft tissue tumours (BST) in need of surgery. We reviewed the outcomes of surgeries on BST during the first two months of the pandemic at one of the tertiary BST centres in the UK., Materials and Methods: Between 12 March 2020 and 12 May 2020, 56 patients of a median age of 57 years (18-87) underwent surgery across two sites: index hospital (n = 27) and COVID-free facility (n = 29). Twenty-five (44.6%) patients were above the age of 60 years and 20 (35.7%) patients were in ASA III and ASA IV category. The decision to offer surgery was made in adherence with the guidelines issued by the NHS, BOOS and BSG., Results: At a minimum follow-up of 30 days post-surgery, 54 (96.4%) patients were recovering well. Thirteen patients (23.2%) had post-operative complications which included four (7.1%) patients developing pulmonary embolism. The majority of complications (12/13 = 92.7%) occurred in ASA III and IV category patients. Four (7.1%) patients contracted COVID-19, of which three required escalation of care due to pulmonary complications and two (3.6%) died. Patients < 60 years of age had significantly less complications than those > 60 years (p < 0.001). Patients operated on in the COVID-free facility had fewer complications compared with those operated on at the index hospital (p < 0.027)., Conclusion: In spite of the favourable results in majority of our patients, our study shows that patients with sarcoma operated at the height of the pandemic are at a risk of contracting COVID-19 and also having associated with mortality. The use of a COVID-free facility, surgery in patients < 60 60 years and in ASA I & II category are associated with better outcomes. If a second wave occurs, a serious consideration should be given to ways of minimising the risk of contracting COVID-19 in these vulnerable patients either by using COVID-free facilities or delaying treatment until peak of infection has passed.

Background: Various open injury scores have been devised to aid the difficult decision of salvage or amputation following open fractures of the lower limb. Our aim of the study was to compare the performance of mangled extremity severity score (MESS), limb salvage index (LSI), orthopaedic trauma association-open fracture classification (OTA-OFC) and Ganga hospital score (GHS) in our population of type IIIB injuries., Materials and Methods: A total of 219 patients with 225 type IIIB open fractures of the tibia were studied prospectively between July 2016 and June 2017. The decision of salvage or amputation was taken by a combined consensus of senior orthopaedic and plastic surgeons, blinded to the scores. All four open injury scores were calculated by an independent reviewer following initial debridement. The follow-up period was one to two  years., Results: After final follow-up, there were 193 (85.7%) successfully salvaged limbs, 19 primary amputations without attempt of debridement (8.4%), three primary delayed amputations within 72 hours (1.3%) and six secondary amputations after 72 hours from initial debridement (2.7%). Of these, four patients died within one  year and were excluded. All four scores performed well for salvage, while GHS was superior when considering amputation. MESS, LSI and OTA-OFC underscored amputations, since these scoring systems award more points for vascular injuries. There were both salvaged and amputated patients around the threshold value of amputation for all scores, which was only acknowledged by GHS in its unique 'grey zone'. It includes patients who are neither easily salvageable nor definitely requiring amputation., Conclusion: The performance of the GHS was superior to MESS, LSI and OTA-OFC in our study, since it was developed for type IIIB injuries and includes the 'grey zone', where decisions need to be undertaken on a case to case basis., Clinical Relevance: GHS has an improved ability to determine amputation in IIIB open tibia fractures.

Purpose of the Study: To document and compare the functional outcome of neutral alignment and under-correction after total knee arthroplasty (TKA) in severe varus knees of more than 15° at three and 12 months post-surgery., Materials and Methods: One hundred twenty-four consecutive patients (163 TKAs) of an average age of 61.9 years (52-79) with a pre-operative varus more than 15° were managed with jig-based TKA. Based on the post-operative mechanical femorotibial alignment (FTMA), they were categorised into three groups, namely neutral (180 + 3 ° ), mild varus (173° to 176°) and severe varus (172° and below). The outcomes of these three groups were assessed at three and 12 months by the Oxford knee score and the WOMAC score were calculated and co-related to the extent of correction., Results: At three months, knees in the mild varus group (n = 88) had the best results with an Oxford knee score of 41.76 + 1.44 and a WOMAC score of 19.29 + 2.93 compared to the severe varus group and the neutral alignment group which had Oxford knee scores (OKS) of 37.43 + 2.51 and 31.91 + 3.51 and WOMAC scores of 22.57 + 1.51 and 24.46 + 4.15 respectively. However at 12 months, knees in all the groups (neutral, mild varus, severe varus) had similar good functional outcomes with OKS of 39.08 + 1.68, 39.24 + 1.88, 39.29 + 1.11 and WOMAC scores of 17.42 + 2.15, 16.48 + 2.11, 16.14 + 1.21 respectively. A scatter plot done for post-operative FTMA and the functional outcome score for both scores showed a bell curve with the best outcome corresponding to a FTMA of 175° at 3 months and equal distribution for both scores at 12 months., Conclusion: The results of our study showed that minimal under-correction gave superior functional outcomes at three months. But this advantage was temporary and both, under-correction and neutral alignment achieved equally good outcomes at one year. Considering the increased prosthesis longevity associated with neutral alignment, we propose that neutral alignment must be aimed for during TKA for knees with severe varus., Study Design: Prospective study.

Purpose of the Study: To evaluate the outcomes and complications using cemented megaprosthesis in elderly patients with distal femur nonunions (DFN)., Materials and Methods: Between 2012 and 2016, 24 patients of DFN with an average age of 71.8 years (66-83) and an average 1.9(1-3) prior surgery was managed with distal femur replacement using cemented modular endoprosthesis. Outcomes were analysed on the following criteria: implant status, complications, knee range of motion, Knee Society Score (KSS) and Musculoskeletal Tumor Society (MSTS) score., Results: All patients were extremely satisfied with their outcomes. At an average 22.1 months (10-43) follow-up, patients had an average 69.5° (40°-110°) knee flexion, an average KSS of 75.7 (63-88) and an average MSTS score of 19.3 (17-25). Four patients died at an average 21.3 months after surgery due to causes unrelated to the fracture. One patient (4.1%) had implant-related complication; deep infection which required debridement and intravenous antibiotics. There were no late amputations or peri-operative deaths and no patient had aseptic loosening of components., Conclusion: By permitting immediate full weight-bearing ambulation and with most patients returning to an acceptable functional status, cemented megaprosthesis is a viable and useful single-stage management option in elderly patients with DFN.

Background: Recalcitrant distal femur nonunions (RDFN) are a challenge in management due to factors including poor bone stock, multiple surgeries, metaphyseal bone loss, and joint contractures. There are no specific guidelines in the management of cases of RDFN. Based on our experience, we devised an algorithm and we present the results of 62 cases of RDFN managed following it., Materials and Methods: Our algorithm was formulated after analyzing 34 cases of RDFN and it involved four factors which were hypothesized to influence outcomes namely: distal femoral bone stock, extent of medial void, alignment of the fracture, and stability of fixation. Each factor was addressed specifically to achieve a good outcome. Between 2012 and 2015, 62 patients with RDFN at a mean age of 47.4 years (26-73) and 2.3 prior surgeries (2-6) were managed following the algorithm., Intervention: 58 patients required revision osteosynthesis to improve alignment and achieve a stable fixation. 4 elderly patients with poor bone stock were managed with arthroplasty. Extent of medial void was found to significantly influence surgical decision making. Five patients without medial void required only cancellous autograft bone grafting, 47 patients with < 2 cm void were treated with an allograft fibular strut inserted in the metaphysis and 6 patients with a void > 2 cm were managed with medial plating., Outcomes and Results: 57 patients treated with osteosynthesis achieved union at an average of 7.4 months (6-11) and the 4 patients managed with arthroplasty also had a favourable outcome. One patient who was managed with revision osteosynthesis had a nonunion with an implant failure and needed an arthroplasty procedure. The average LEFS (lower extremity functional score) of all our patients was 67 (51-76) at an average follow-up of 18.2 months (12-33)., Conclusion: Our stepwise surgical algorithm would help surgeons to identify the factors that need to be addressed and guide them towards the interventions that are necessary to achieve a successful outcome while managing cases of RDFN., Level of Evidence: III., Level of Clinical Care: Level I Tertiary trauma centre.