''Two-week waits"-are they leading to earlier diagnosis of soft-tissue sarcomas?

Introduction. The ''two-week wait" was established as a potential means of diagnosing malignant tumours earlier. This paper investigated whether these clinics are leading to earlier diagnosis of malignant soft-tissue lumps. Method. We identified all referrals to our centre from a database over a 4-year period. Results. 2225 patients were referred to our unit for investigation of a soft-tissue mass. 576 (26%) were referred under the ''two-week wait" criteria. 153 (27%) of which were found to have a malignant or borderline malignant diagnosis. 1649 patients were referred nonurgently. 855 (52%) of which were diagnosed with a malignant or borderline lesion. The average size at diagnosis was 9.4 cm with no difference in size between the different referral routes. Conclusion. There is little evidence that the two-week wait clinic is leading to earlier diagnosis of soft-tissue sarcomas with the majority still being referred nonurgently.

Total femur replacement: primary procedure for treatment of malignant tumours of the femur

We present our experience of treating patients with tumours involving the whole femur with excision and total femur endoprostheses over the last 30 years (1975-2005). There were 26 consecutive patients (14 men and 12 women). Average age was 40 years (14-82 years) at the time of surgery and 21 of the patients had primary malignant bone tumours with five having the procedure for metastases. 11 patients were still alive of which nine were free of disease at the time of review at a mean follow-up of 57 months (3-348). The overall patient survival at 10 years was 37%. The survival of patients with a primary localised tumour was 50% at 10 years. Revision of the prostheses was necessary in two patients (at 110 and 274 months) because of recurrent dislocation and aseptic loosening. Amputation was necessary in two patients but long term limb survival was 92% at 10 years. Nine patients alive with no evidence of disease had a mean MSTS functional score of 72%.

Chondroblastoma of the femoral head: management and outcome

Chondroblastoma of the femoral head presents particular problems in treatment because the tumour is surrounded by articular cartilage on one side and epiphyseal plate on the other. Ten patients underwent treatment for a chondroblastoma involving the proximal femoral capital epiphysis. The patients were aged between eight and 19 years and in four the epiphysis was not yet fused. Five had curettage via a drill hole created up the femoral neck, of whom two developed local recurrence. Five had a direct approach to the chondroblastoma through the femoral neck, and there were no local recurrences in this group. Both patients with local recurrence were under 14 years of age-one was cured by a direct approach through the neck of the femur and the other by lifting a trap door of articular cartilage. Apart from one patient with a temporary leg length discrepancy, there were no other complications. We conclude that a direct approach is likely to lead to the best outcome for this rare condition.

Soft-tissue metastases

In our database of 7935 patients referred for investigation of a soft-tissue mass, only 100 were found to have a soft-tissue metastasis (1.3%). Our aim was to define the clinical features of such patients and to identify the site of their primary tumour.

The most common presentation was a painful lump, deep to the fascia, ranging between 2 cm and 35 cm (mean 8.3 cm) with 78% of the lumps located deep to the fascia. The mean age of the patients at presentation was 64 years (22 to 84) and there were almost equal numbers of men and women. Of 53 patients with a history of malignancy, 52 had metastases from the same primary (lung in 12, melanoma in ten, kidney in nine, gastrointestinal track in four, breast in five, bladder in four, and others in eight). The other 47 had no history of malignancy and the metastasis was the first presentation. The primary sites in these cases were the lung in 19, gastro-intestinal track in four, kidney in two, melanoma in nine, other in three, and unknown (despite investigations) in ten. There was no correlation between the site of the metastases and the primary tumour.

Of the 7935 patients, 516 had a history of malignancy. Of these, only 10% had a soft-tissue metastasis, 29% had a benign diagnosis, 55% a soft-tissue sarcoma and 6% another malignancy. Patients with soft-tissue metastases have similar clinical features to those with soft-tissue sarcomas and should be considered for assessment at appropriate diagnostic centres for patients with suspicious soft-tissue lumps.

Healing of ungrafted bone defects of the talus after benign tumour removal

BACKGROUND

Curettage of benign tumours commonly results in significant bone defects that are reconstructed with autologous grafts, allografts, bone cement or bone substitute. We have treated such defects in the talus without reconstruction with bone or any other material. We now report the healing of these ungrafted defects in eight patients treated with curettage for benign talar tumours.

METHODS

Eight consecutive patients were reviewed retrospectively at a mean follow-up of 82 months (range: 28-180 months). Mean age was 21.7 years (range: 12.3-31.3 years) and mean defect size was 16.5 cm(3) (range: 3.5-48 cm(3)). Outcome measures included time to radiological consolidation, ankle pain and stiffness, talar collapse, and tibiotalar joint osteoarthritis.

RESULTS

Full consolidation of the defect occurred within 6-12 months in all patients. One patient had minor discomfort over the scar, but there was no ankle joint pain. Two patients had some ankle stiffness, although one had established ankle osteoarthritis prior to surgery. No talar collapse, fracture or new significant osteoarthritis of the ankle was observed.

CONCLUSIONS

We conclude that bone grafting is not a necessary adjunct to the curettage of talar lesions.

Unipolar proximal femoral endoprosthetic replacement for tumour

We undertook a cemental unipolar proximal femoral endoprosthetic replacement in 131 patients with a mean age of 50 years (2 to 84). Primary malignant tumours were present in 54 patients and 67 had metastatic disease. In addition, eight patients had either lymphoma or myeloma and two had non-oncological disorders. The mean follow-up was 27 months (0 to 180). An acetabular revision was required later in 14 patients, 12 of whom had been under the age of 21 years at the time of insertion of their original prosthesis. The risk of acetabular revision in patients over 21 years of age was 8% at five years compared with 36% in those aged under 21 years. All the unipolar hips in this younger age group required revision within 11 years of the initial operation.

We conclude that unipolar replacement should not be used in younger patients and should be avoided in patients with a life expectancy of more than five years.

Modular endoprosthetic replacement for tumours of the proximal femur

Endoprosthetic replacement of the proximal femur may be required to treat primary bone tumours or destructive metastases either with impending or established pathological fracture. Modular prostheses are available off the shelf and can be adapted to most reconstructive situations for this purpose. We have assessed the clinical and functional outcome of using the METS (Stanmore Implants Worldwide) modular tumour prosthesis to reconstruct the proximal femur in 100 consecutive patients between 2001 and 2006. We compared the results with the published series for patients managed with modular and custom-made endoprosthetic replacements for the same conditions. There were 52 males and 48 females with a mean age of 56.3 years (16 to 84) and a mean follow-up of 24.6 months (0 to 60). In 65 patients the procedure was undertaken for metastases, in 25 for a primary bone tumour, and in ten for other malignant conditions. A total of 46 patients presented with a pathological fracture, and 19 presented with failed fixation of a previous pathological fracture. The overall patient survival was 63.6% at one year and 23.1% at five years, and was significantly better for patients with a primary bone tumour than for those with metastatic tumour (82.3% vs 53.3%, respectively at one year (p = 0.003)). There were six early dislocations of which five could be treated by closed reduction. No patient needed revision surgery for dislocation. Revision surgery was required by six (6%) patients, five for pain caused by acetabular wear and one for tumour progression. Amputation was needed in four patients for local recurrence or infection. The estimated five-year implant survival with revision as the endpoint was 90.7%. The mean Toronto Extremity Salvage score was 61% (51% to 95%). The implant survival and complications resulting from the use of the modular system were comparable to the published series of both custom-made and other modular proximal femoral implants. We conclude that at intermediate follow-up the modular tumour prosthesis for proximal femur replacement provides versatility, a low incidence of implant-related complications and acceptable function for patients with metastatic tumours, pathological fractures and failed fixation of the proximal femur. It also functions as well as a custom-made endoprosthetic replacement.

The treatment of benign lesions of the proximal femur with non-vascularised autologous fibular strut grafts

We report our experience of treating 17 patients with benign lesions of the proximal femur with non-vascularised, autologous fibular strut grafts, without osteosynthesis. The mean age of the patients at presentation was 16.5 years (5 to 33) and they were followed up for a mean of 2.9 years (0.4 to 19.5). Histological diagnoses included simple bone cyst, fibrous dysplasia, aneurysmal bone cysts and giant cell tumour. Local recurrence occurred in two patients (11.7%) and superficial wound infection, chronic hip pain and deep venous thrombosis occurred in three. Pathological fracture did not occur in any patient following the procedure. We conclude that non-vascularised fibular strut grafts are a safe and satisfactory method of treating benign lesions of the proximal femur.

Peri-acetabular resection and endoprosthetic reconstruction for tumours of the acetabulum

We treated 98 patients with peri-acetabular tumours by resection and reconstruction with a custom-made pelvic endoprosthesis. The overall survival of the patients was 67% at five years, 54% at ten years and 51% at 30 years. One or more complications occurred in 58.1% of patients (54), of which infection was the most common, affecting 30% (28 patients). The rate of local recurrence was 31% (29 patients) after a mean follow-up of 71 months (11 to 147). Dislocation occurred in 20% of patients (19). Before 1996 the rate was 40.5% (17 patients) but this was reduced to 3.9% (two patients) with the introduction of a larger femoral head. There were six cases of palsy of the femoral nerve with recovery in only two. Revision or excision arthroplasty was performed in 23.7% of patients (22), principally for uncontrolled infection or aseptic loosening. Higher rates of death, infection and revision occurred in men.

This method of treatment is still associated with high morbidity. Patients should be carefully selected and informed of this pre-operatively.

The effect of an unplanned excision of a soft-tissue sarcoma on prognosis

We investigated whether our policy of routine re-excision of the tumour bed after an unplanned excision of a soft-tissue sarcoma was justified. Between April 1982 and December 2005, 2201 patients were referred to our hospital with the diagnosis of soft-tissue sarcoma, of whom 402 (18%) had undergone an unplanned excision elsewhere. A total of 363 (16.5%) were included in this study. Each patient was routinely restaged and the original histology was reviewed. Re-excision was undertaken in 316 (87%). We analysed the patient, tumour and treatment factors in relation to local control, metastasis and overall survival. Residual tumour was found in 188 patients (59%). There was thus no residual disease in 128 patients of whom 10% (13) went on to develop a local recurrence. In 149 patients (47%), the re-excision specimen contained residual tumour, but it had been widely excised. Local recurrence occurred in 30 of these patients (20%). In 39 patients (12%), residual tumour was present in a marginal resection specimen. Of these, 46% (18) developed a local recurrence. A final positive margin in a high-grade tumour had a 60% risk of local recurrence even with post-operative radiotherapy. Metastases developed in 24% (86). The overall survival was 77% at five years. Survival was related to the grade of the tumour and the finding of residual tumour at the time of re-excision. We concluded that our policy of routine re-excision after unplanned excision of soft-tissue sarcoma was justified in view of the high risk of finding residual tumour.

Endoprosthetic reconstruction for the treatment of musculoskeletal tumors of the appendicular skeleton and pelvis

BACKGROUND

Excision of a bone tumor requires reconstruction if limb salvage is a priority. Reconstruction with an endoprosthetic implant is preferred in our unit, as the patient typically can return rapidly to full weight-bearing and functional activities. Long-term complications, such as deep infection, aseptic loosening, and mechanical failure of the implants, have led to concerns about the efficacy of reconstruction and the ability to revise failed implants while maintaining limb salvage in the longer term. The purpose of this study was to investigate the survival of endoprosthetic reconstructions in the medium to long term in order to determine the factors associated with their failure.

METHODS

A consecutive series of 776 patients underwent endoprosthetic reconstruction following resection of a bone tumor at a minimum of ten years prior to this investigation. One hundred and nine children with a so-called growing endoprosthesis were excluded as they often require revision to an adult prosthesis near skeletal maturity. Six patients were excluded because of a lack of adequate follow-up data, leaving 661 patients for analysis. Kaplan-Meier survival analysis of the implant was performed, with implant revision for any cause (infection, local recurrence, and mechanical failure), mechanical failure alone, and amputation used as the end points.

RESULTS

The mean duration of follow-up was fifteen years for patients who survived the original disease. Two hundred and twenty-seven patients (34%) had revision surgery because of mechanical failure (116 patients), infection (seventy-five patients), and locally recurrent disease (thirty-six patients). Implant survival at ten years was 75% with mechanical failure as the end point and 58% with failure from any cause as the end point. The limb salvage rate was 84% at twenty years.

CONCLUSIONS

We believe these medium to long-term results with first-generation endoprostheses are encouraging and justify the continued use of endoprostheses for reconstruction following the excision of a bone tumor.

The risks and benefits of radiotherapy with massive endoprosthetic replacement

Between 1966 and 2001, 1254 patients underwent excision of a bone tumour with endoprosthetic replacement. All patients who had radiotherapy were identified. Their clinical details were retrieved from their records.

A total of 63 patients (5%) had received adjunctive radiotherapy, 29 pre-operatively and 34 post-operatively. The mean post-operative Musculoskeletal Tumor Society scores of irradiated patients were significantly lower (log-rank test, p = 0.009). The infection rate in the group who had not been irradiated was 9.8% (117 of 1191), compared with 20.7% (6 of 29) in those who had pre-operative radiotherapy and 35.3% (12 of 34) in those who radiotherapy post-operatively. The infection-free survival rate at ten years was 85.5% for patients without radiotherapy, 74.1% for those who had pre-operative radiotherapy and 44.8% for those who had post-operative radiotherapy (log-rank test, p < 0.001). The ten-year limb salvage rate was 89% for those who did not have radiotherapy and 76% for those who did (log-rank test, p = 0.02).

Radiotherapy increased the risk of revision (log-rank test, p = 0.015). A total of ten amputations were necessary to control infection, of which nine were successful. Radiotherapy may be necessary for the treatment of a bone sarcoma but increases the risk of deep infection for which amputation may be the only solution.

Radiation-induced sarcomas of bone: factors that affect outcome

We identified 42 patients who presented to our unit over a 27-year period with a secondary radiation-induced sarcoma of bone. We reviewed patient, tumour and treatment factors to identify those that affected outcome. The mean age of the patients at presentation was 45.6 years (10 to 84) and the mean latent interval between radiotherapy and diagnosis of the sarcoma was 17 years (4 to 50). The median dose of radiotherapy given was estimated at 50 Gy (mean 49; 20 to 66). There was no correlation between radiation dose and the time to development of a sarcoma. The pelvis was the most commonly affected site (14 patients (33%)). Breast cancer was the most common primary tumour (eight patients; 19%). Metastases were present at diagnosis of the sarcoma in nine patients (21.4%). Osteosarcoma was the most common diagnosis and occurred in 30 cases (71.4%). Treatment was by surgery and chemotherapy when indicated: 30 patients (71.4%) were treated with the intention to cure. The survival rate was 41% at five years for those treated with the intention to cure but in those treated palliatively the mean survival was only 8.8 months (2 to 22), and all had died by two years. The only factor found to be significant for survival was the ability to completely resect the tumour. Limb sarcomas had a better prognosis (66% survival at five years) than central ones (12% survival at five years) (p = 0.009). Radiation-induced sarcoma is a rare complication of radiotherapy. Both surgical and oncological treatment is likely to be compromised by the treatment received previously by the patient.

The relative safety of one-stage bilateral total knee arthroplasty

Patients with osteoarthritis of the knee often require bilateral knee replacement before fulfilling their full ambulatory potential. Despite extensive research there is considerable debate about the risks of performing simultaneous bilateral knee replacements under the same anaesthetic. Our aim was to compare the relative short-term morbidity of one-stage bilateral with unilateral total knee arthroplasty in a retrospective, consecutive cohort of patients. Seventy-two bilateral knee replacements were case-matched for age and gender with 144 unilateral knees. One-stage bilateral arthroplasty was associated with increased morbidity with respect to wound (6.0 vs 0.7%; p = 0.003) and deep prosthetic (3.5% vs 0.7 %; p = 0.02) infections, cardiac complications (3.5% vs 0.7%; p = 0.04) and chest infections (7.0% vs 1.4%; p = 0.04). No differences were observed in the mortality rates (p = 0.30) and risk of thrombo-embolism (p = 0.70). We conclude that one-stage bilateral total knee arthroplasty is associated with increased morbidity compared with unilateral knee replacement.

Post Operative Infection and Increased Survival in Osteosarcoma Patients: Are They Associated?

BACKGROUND

Despite neo-adjuvant chemotherapy osteosarcomas having significant mortality, recent studies have shown survival advantages following infections for some tumour types. This study investigates the effect of post-operative infection in patients treated for osteosarcoma using endoprosthetic replacement and neo-adjuvant chemotherapy.

MATERIAL AND METHODS

A consecutive series of 547 patients underwent surgery between 1981 and 2001 for osteosarcoma. Patients were excluded from the study if over 60 years old at diagnosis (n = 14) as they would not routinely receive chemotherapy. Studies showed that 70% of deep infections occur within one year from reconstruction. Therefore landmark analysis was performed; all patients infected after 12 months of reconstruction were excluded (15 patients, 2.7%) and those who died within 12 months from diagnosis due to metastases were excluded (105 patients, 19.2%), leaving 412 patients. Any survival advantage of early infection was analysed by Kaplan-Meier survival analysis from this landmark point.

RESULTS

Overall population survival was 65% at 10 years after landmarking. There were 41 patients (10%) who developed an infection within one year of implantation. These patients had significantly better survival (p = 0.017). The 10-year survival for patients with osteosarcoma with infection was 84.5% compared to 62.3% in the non-infected group after landmarking. There was no significant difference in the percentage post-chemotherapy specimen necrosis between the two groups (p = 0.36). Infection was an independent prognostic factor on cox regression analysis.

CONCLUSIONS

There was evidence for increased survival after deep post-operative infection in osteosarcoma patients, in keeping with other research. The authors feel this warrants further investigation.

Does the method of treatment affect the outcome in soft-tissue sarcomas of the adductor compartment?

We have investigated the significance of the method of treatment on the oncological and functional outcomes and on the complications in 184 patients with soft-tissue sarcomas of the adductor compartment managed at three international centres. The overall survival at five years was 65% and was related to the grade at diagnosis and the size of the tumour. There was no difference in overall survival between the three centres. There was, however, a significant difference in local control with a rate of 28% in Centre 1 compared with 10% in Centre 2 and 5% in Centre 3. The overall mean functional score using the Toronto Extremity Salvage Score in 70 patients was 77% but was significantly worse in patients with wound complications or high-grade tumours. The scores were not affected by the timing of radiotherapy or the use of muscle flaps. This large series of soft-tissue sarcomas of the adductor compartment has shown that factors influencing survival do not vary across the international boundaries studied, but that methods of treatment affect complications, local recurrence and function.

A custom-made prosthesis attached to an existing femoral component for the treatment of peri- and sub-prosthetic fracture

Peri- and sub-prosthetic fractures, or pathological fractures below an existing well-fixed femoral component, with or without an ipsilateral knee replacement, present a difficult surgical challenge.

We describe a simple solution, in which a custom-made prosthesis with a cylindrical design is cemented proximally to the stem of an existing, well-fixed femoral component. This effectively treats the fracture without sacrificing the good hip. We describe five patients with a mean age of 73 years (60 to 81) and a mean follow-up of 47 months (6 to 108).

The mean overlap of the prosthesis over the femoral component was 7.5 cm (5.5 to 10). There have been no mechanical failures, no new infections and no re-operations. We suggest that in highly selected cases, in which conventional fixation is not feasible, this technique offers a durable option and avoids the morbidity of a total femoral replacement.

Malignant triton tumour of the thigh—A retrospective analysis of nine cases

Malignant triton tumour (MTT) is a very rare soft tissue tumour.

AIM

To report nine patients diagnosed with malignant triton tumour of the thigh between January 1996 and January 2005 to determine the natural history and factors that may affect survival in this aggressive tumour.

METHODS

Due to the association of Neurofibromatosis (NF Type I) with malignant triton tumour, two groups of patients were identified: those with NF type I (Group I cases); and those without (Group II).

RESULTS

Group I patients accounted for four cases and arose predominantly in young males, all tumours being high grade, >10 cm in size and all four patients died within two years of diagnosis. By contrast, the five patients of Group II were older, had smaller size and lower grade tumours and three patients are long-term survivors.

CONCLUSION

Although the number of cases is small, our data supports the views that the natural history of MTT is more aggressive in patients with NF type I. This poor outlook could be attributed to the high frequency of Grade III histology in this disease and the large tumour size.

Fracture of the femoral neck, the risk of serious underlying pathology

Between 1997 and 2003, a total of 2223 patients presented to our hospital with the neck of femur fracture. This retrospective study examines the histological results of 90 patients (4%) suspected of having a fracture associated with serious underlying pathology. The mean age at the time of fracture was 80 years (44-97). The patients were divided into four groups. Group I: 34 patients with fracture without history of fall or trauma. Group II: 21 patients with suspicious lesions on the standard pelvic radiograph taken on admission. Group III: 27 patients with past history of malignancy without known bone metastases. Group IV: 8 patients with past history of malignancy and known bone metastases. None of the patients in groups I and II had significant abnormalities other than osteoporosis. Four patients (15%) in group III and six patients (75%) in group IV had metastases on histological examination. It is concluded that only groups III and IV are likely to have fractures due to metastatic disease.

Endoprosthetic replacement of diaphyseal bone defects. Long-term results

We retrospectively studied 35 patients who underwent endoprosthetic reconstruction of diaphyseal bone defects after excision of primary sarcomas. The patients were treated between February 1979 and May 1999 and had more than 5 years follow-up. There were 22 males and 13 females and the median age at diagnosis was 29 (8-75) years. The bone defect measured a mean of 19 (10-27.6) cm. There were 29 femoral reconstructions, three tibial and three humeral. Cumulative overall survival for all patients was 65% at 10 years. Cumulative overall survival for prosthetic reconstruction, using revision surgery as an end point, was 63% at 10 years. Cumulative risk of failure of reconstruction, including infection, fracture, aseptic loosening, local recurrence and amputation, was 60% at 10 years. Tibial and humeral reconstructions fared less well than femoral. Endoprosthetic replacement is a useful method of reconstructing long intercalary defects, especially if situated in the femur.

An investigation into the wound-healing properties of essential oil of Ocimum gratissimum Linn

OBJECTIVE

To investigate the effects of Ocimum oil and two antibacterial preparations, Cicatrin (GlaxoWellcome) and Cetavlex (AstraZeneca), on the healing of full-thickness excisional and incisional wounds, created under anaesthesia, on the back of test and control groups of adult albino rabbits.

METHOD

Treatment was by topical application of the test substances onto the wound surface for 15 days. Observation continued for a further six days. Quantitative parameters of wound healing were determined daily. Swabs were taken from wound sites that appeared not to be healing for identification of wound contaminants and sensitivity tests.

RESULTS

There was a marked enhancement in the inflammatory and proliferative phases of wound healing in the rabbits treated with Ocimum oil, suggesting that the oil facilitated the healing process to a greater extent than the control and reference products. Wounds treated with Cetavlex showed no sign of healing for eight days but responded to Ocimum oil after a three-day wash-out period.

CONCLUSION

The essential oil Ocimum gratissimum can promote wound healing. However, large studies will need to be carried out using domestic pigs, followed by clinical trials on human wounds.

DECLARATION OF INTEREST

None.

Endoprosthetic replacement of the proximal humerus. Long-term results

We studied 100 patients who had undergone endoprosthetic replacement of the proximal humerus between 1976 and 1998. The outcome was assessed with regard to the survivorship of the patients, the salvaged limbs and the prostheses. Function was determined in the 47 surviving patients, of whom 30 were assessed using the Musculo-Skeletal Tumour Society (MSTS) rating scale and 38 completed the Toronto Extremity Salvage Score (TESS) questionnaire. The median age of the patients was 34 years (10 to 80). The mean follow-up period for surviving patients was nine years (2 to 20). The mean MSTS score at follow-up was 79% and the mean TESS score was 72%. The length of bone which was resected influenced the functional outcome. Abduction of the shoulder was to 45 degrees in most patients. The overall survival was 42% at ten years and that of the limb without amputation 93%. The survival of the prostheses using mechanical failure as the endpoint was 86.5% at 20 years. Endoprosthetic replacement of the proximal humerus is a predictable procedure providing reasonable function of the arm with a low rate of complications at long-term follow-up.

Endoprosthetic replacement of the proximal humerus. Long-term results

We studied 100 patients who had undergone endoprosthetic replacement of the proximal humerus between 1976 and 1998. The outcome was assessed with regard to the survivorship of the patients, the salvaged limbs and the prostheses. Function was determined in the 47 surviving patients, of whom 30 were assessed using the Musculo-Skeletal Tumour Society (MSTS) rating scale and 38 completed the Toronto Extremity Salvage Score (TESS) questionnaire. The median age of the patients was 34 years (10 to 80). The mean follow-up period for surviving patients was nine years (2 to 20). The mean MSTS score at follow-up was 79% and the mean TESS score was 72%. The length of bone which was resected influenced the functional outcome. Abduction of the shoulder was to 45 degrees in most patients. The overall survival was 42% at ten years and that of the limb without amputation 93%. The survival of the prostheses using mechanical failure as the endpoint was 86.5% at 20 years. Endoprosthetic replacement of the proximal humerus is a predictable procedure providing reasonable function of the arm with a low rate of complications at long-term follow-up.