RLiMBS service was set up to address the surgical management of patients with metastatic bone disease of the limbs.

Our hospital offers highest level of cancer care for most types of cancers. However, up to 3 years ago cancer that has spread to the bones was being managed in a slightly haphazard manner.

The patients of Cheshire and Merseyside were being directly affected. Our interaction with national tumour units demonstrated this to be a nationwide problem. Despite new guidance from British Orthopaedic Oncological Society, management of metastatic bone disease remained inconsistent.

As a tertiary referral unit, we were being referred patients who had been managed incorrectly and without a multidisciplinary approach. We decided to not only address the problem but do it in a way that would offer care of the highest quality beyond current practice, be cost effective as well as providing care nearer home for the patients of Cheshire and Merseyside.

We discussed set up of a new service with various teams including the Regional Oncology Centre, Haematology, Radiology and Breast surgery teams. The proposal was presented to the Commissioners with an extremely favourable response from every team. The service was set up to be a tertiary care service. Referrals were received from Oncology, Haematology and neighbouring Orthopaedic units.

Currently, we offer treatment or advice regarding treatment to the whole of the Cheshire and Merseyside region, for a population of 2.3 million.

As with most cancer care, quality rises once multidisciplinary approach is used. A weekly MDT meeting was set up. A weekly clinic was set up to allow rapid access for patient referrals. Close collaboration with existing Spinal cancer and sarcoma service was beneficial.

More recently, appointment of a part time Metastatic tumour Clinical Nurse Specialist has allowed allocation of a key liaison person to each patient. All of this was done within the existing job plans by the clinicians.

To understand the importance of this service, we have to highlight a case, which is not uncommon.

A 47-year-old patient with breast cancer presented with spread to her thighbone to a nearby hospital. This was an isolated spread. She underwent nailing of her thighbone (rod inside the bone). Within six months she had severe pain in her thigh and was wheelchair bound with regular morphine for pain. Her life expectancy was still up to 3 years.

Unfortunately, by now her cancer had spread to the rest of her bone. We were able treat her in conjunction with the oncologists with an appropriate procedure which was a total femur replacement.

We now have the capability to perform most challenging reconstructions if required to keep our patients mobile and pain free. There is increasing evidence that Endoprosthetic Replacements reduce skeletal related events (SRE). These procedures are technically demanding. They are also perceived to be expensive. However, it has been shown using health economic models that conservative or ineffective treatment of these conditions can lead to equal or higher costs albeit with significantly poorer quality of life.

Patients with metastatic bone disease not only have to deal with cancer and its aggressive treatment, but also have to deal with severe bone pain, fractures and immobility. They need well-planned, safe and robust reconstruction that allows full weight bearing mobilisation. This allows restoration of dignity and quality of life.

To our disadvantage, such a service had not yet been set up in the country previously. Pioneering this kind of service involved significant hard work not only from clinical but also from logistical perspective. We have so far treated 180 patients.

The service was started in February 2015. We have so far treated 102 of these patients with surgical intervention. 32 endoprosthetic replacements, 30 primary hip replacements and 40 internal fixations.

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