Introduction: Various techniques are being currently used for the internal fixation of scarf osteotomies. We conducted a prospective study on 23 consecutive cases of hallux valgus treated with scarf osteotomy, which was internally fixed with AO mini fragment screws. The aim of our study was to evaluate the clinical efficacy of the AO mini fragment screws in these cases.

Method: Sixteen women and one man (twenty three feet) were included in our study. Mean age was 46 years at the time of surgery. The mean follow-up time was 18 months. A single surgeon performed surgery. Patients were assessed by clinical and radiological evaluation. Preoperative and postoperative American Orthopaedic Foot and Ankle Society score was obtained.

Results: All the osteotomies united without any failure of fixation or hard ware problems. One patient developed superficial wound infection, which responded to antibiotics. At the time of follow-up all the patients were very satisfied. The mean AOFAS score improved significantly from 55 points pre-operatively to 91.95 at follow-up (p < 0.001). The intermetatarsal and hallux valgus angles improved from the mean pre-operative values of 15.86° and 31.18 degrees to 9.09° and 15.18°, respectively. These improvements were significant (p < 0.0001).

Conclusion: We report no failure of fixation in our series and conclude that this is a safe and simple technique. It is cost effective, provides stable fixation and maintains correction till the union of osteotomy.

Introduction The precise contribution of the posterior longitudinal ligament (PLL) and disc annulus in the burst fracture setting and their potential relative roles during intra operative reduction manoeuvres remains unclear. The anatomical attachments of the posterosuperior fragment most often associated with canal occlusion and potential neurological compromise are not well described in a reproducible model.

Methods Burst fractures were induced using a pendulum impact tester. The jig allowed for accurate positioning in all planes and for precise delivery of both the magnitude and vector of the impact force. This allowed for creation of fracture all three major groups of the AO classification. The A3 (burst fracture) was produced in 10 cadaveric sheep spines by delivering a neutral force vector on a physiologically flexed spine. The morphology of the fracture was confirmed by CT. Subsequent laminectomy was performed and the anatomical attachments of the large fragments were identified.

Results The PLL was identified following laminectomy in each case. In six of the ten spines there had been significant disruption of the longitudinal structure of the PLL .In a further two cases there had been stripping of the PLL from the posterior aspect of the vertebral body in association with the retropulsed canal fragment. Subsequent excision of the PLL from the posterior aspects of vertebral body and discs did not compromise the attachment of the retropulsed fragment to the disc annulus in any case.

Discussion This study confirms the anatomical relationship between disc fragment and disc annulus in the burst fracture setting. The strong attachment between fragment and disc facilitate rotation of the fragment about this hinge and into the canal. Subsequent intraoperative reduction of this fragment by restoration of disc height may require contribution both from this annular attachment and from tension set up in an intact PLL. The relative contributions of each of these structures in the reduction manoeuvre remains unclear.

Introduction A tertiary referral centre for spinal injuries will receive referrals from many different centres. The format and quality of imaging that accompanies these patients varies considerably.

Methods Two cases are reported where initial imaging demonstrated unstable cervical spine injuries that were subsequently found to be normal. The cases and images are presented.

Results A 19-year old female was transferred to our unit having fallen off a wall and sustaining a neck injury. The accompanying CT scan showed a C6 vertebral body fracture with bilateral fracture-subluxations of the facet joints. As there was a discrepancy with the clinical findings, a repeat fine cut CT scan was performed which was completely normal. The previous appearances were entirely due to artifact throughout the scan.

A 46-year old male fell down stairs sustaining a neck injury and loss of consciousness. A CT scan of his cervical spine demonstrated an odontoid peg fracture (type II). Subsequent imaging showed the odontoid peg was completely normal. The initial CT appearances were entirely due to artifact caused by the patients’ tongue piercing!

Discussion CT scans are used with increasing frequency in the assessment of cervical spine injuries. In both these case the abnormalities present on the initial scans were entirely due to artifact that was reciprocated through the entire CT scans. Reporting these cases reinforces the importance of careful clinical examination and correlation with appropriate investigations. If there is a discrepancy between the clinical and radiological findings then it is essential that further imaging is performed.

Introduction Far lateral disc prolapse (also known as foraminal or extreme lateral prolapse) make up 10% of all disc herniations. In addition, far lateral disc prolapses tend to affect more proximal levels more frequently than do prolapses in the posterolateral location and they are often associated with greater radicular symptoms than typical posterolateral herniations, most likely due to involvement of the dorsal root ganglion. Surgery for far lateral disc protrusions has been associated with a less favourable outcome, perhaps due to delays in diagnosis, inadequate preoperative imaging, and postoperative instability as a result of excessive bony and facet resection during the surgical approach

Methods Twelve patients with far lateral disc herniations operated on by the senior author (RPW) fulfilled the criteria of having both pre- and postoperative Oswestry Disability Index (ODI) scores recorded at each clinic visit. Results of these cases and those of a cohort of age and sex matched patients undergoing standard posterolateral discectomy undertaken by the same surgeon were analyzed. The presence of radiculopathy pre- and postoperatively, workers compensation status, return to work, length of stay and complications, as well as any prior intervention in the form of nerve root sleeve blocks or surgery were recorded

Results Both groups were well matched in terms of age and sex. Follow up ranged from 4 to 18 months. Herniations at more proximal levels (L2/3 and L3/4) were seen more frequently in the far lateral group than in the posterolateral group. Six patients in the far lateral group had preoperative nerve root sleeve blocks compared with one in the posterolateral group. Two patients in each group had had previous (different level) surgery. Patients in each group had similar preoperative ODI scores. Both groups demonstrated a reduction in the preoperative ODI compared with the preoperative score. The mean improvement was 24 (range −26 to +62) for the far lateral group and 22 (range −6 to +46). There was no significant difference between the groups

Discussion The results of this study are encouraging with respect to surgical treatment of far lateral discs. Recent literature has questioned the efficacy of surgical intervention for this pathology. These results show that with carefully selected patients results are comparable with standard posterolateral discectomy

Introduction Reported clinical results suggest that vertebroplasty is a safe and effective technique for providing pain relief. However, information about the long-term effect of PMMA on the adjacent intervertebral discs and the augmented bone is lacking. Adjacent intervertebral discs may be at higher risk of degeneration due to nutritional constraints. Bone loss in augmented vertebrae may occur due to mechanical stress-shielding or toxicological effects.

The aim of the present study was therefore to investigate the effect of PMMA augmentation on intervertebral disc and bone tissue after 6 and 12 months, using an animal model.

Methods In 12 skeletally mature sheep, 2.0ml PMMA (Simplex P) was injected into three lumbar vertebrae (approved by Animal Ethics Committee). Two injection holes were drilled into the middle of three vertebrae at a distance of 5.0mm from the cranial and caudal endplate and 1.0ml PMMA was injected into each hole. Four weeks before euthanasia, animals received an injection of tetracycline for bone labeling.

Postmortem, T1- and T2-weighted sagittal and axial MR images were taken prior to fixation in 80% ethanol. Spines were cut into specimens containing one intervertebral disc and half of the two adjacent vertebrae. The discs which were two levels above the first augmented vertebra served as controls. Microsections were stained with H& E, Goldner, Alcian blue-PAS and Safranin O. MRI signal intensity and morphology of discs were evaluated qualitatively. Histomorphological analysis of discs and endplates was conducted using published criteria [1]. Presence of bone remodeling, fibrous tissue and foreign body reaction in the vertebrae was also recorded.

Results There was no distinguishable loss of MRI signal intensity in the discs in between augmented vertebrae. Cement injection resulted in blocking 50–75% of the endplate lengths. Most discs that were in between augmented vertebrae showed signs of degeneration (chondrocyte proliferation, necrosis) after 6 (80%) and 12 months (88%). Inflammatory reaction to PMMA was observed in some specimens (approximately 25%). Cement had been covered with fibrous tissue in all augmented vertebrae, but tetracycline labeling revealed new bone formation in the vicinity of PMMA.

Discussion Augmentation of three adjacent vertebrae initiated degenerative changes of intervertebral discs in between two augmented vertebrae. This is in contrast to previous animal studies [2] where no degenerative changes after cementing endplates were observed. Current investigations were performed with the specific aim to block the endplates. Clinically, endplates may not get blocked as effectively. On the other hand, discs in older patients are nutritionally constrained due to end-plate calcification and even partial blockage may lead to degenerative changes as documented presently.

The risk of degenerative changes of intervertebral discs should be considered in patients undergoing vertebroplasty.

Introduction: Mazabraud syndrome is a rare disorder characterised by fibrous dysplasia and intramuscular myxomas. We present six new cases.

Method: A reterospective review was performed on six patients from our institution. This is a consecutive series over 48 months.

Results: The patient group consisted of three females and three males. The six patients were referred to our bone tumour unit from other hospitals (four by orthopaedic teams and two by general surgeons). The referring hospitals had been unable to exclude a malignant process. Imaging was tailored to each individual case. Three of our six patients demonstrated polyostotic fibrous dysplasia. The commonest site of the osseous leision was the proximal femur (n=4). The majority of the patients had solitary myxomas (n=4) with only two being multiple myxomas. The average size of the myxomas was 3.7 cm. All soft tissue leisions were ipsilateral to the osseous leisions.

Five of the six patients were treated with surgical excision.

Discussion: In contrast to the existing literature the majority(n=4) of the six patients had solitary myxomas and the male to female distribution was equal. One of the cases was also unique to the current literature with the syndrome present in the right elbow.

The number of cases that we have seen in a short time may also be an indication that this syndrome is not as rare as scarcity of the published cases would imply.

We propose a grading system for contrast free MRI images of tennis elbow and evaluate the inter and intra observer variability of their interpretation.

Methods: Three senior orthopaedic surgeons were asked to blindly grade 0.2T dedicated extremity contrast free MRI images of elbows of patients who presented with varying degrees of symptomatic tennis elbow.

Our proposed grading system of 1 to 5 based on the pattern around the common extensor tendon was used.

Images of the symptomatic and contralateral non symptomatic elbows were graded blindly twice with an interval of 1 month by each surgeon.

Each surgeon graded 176 MRI images twice.

The grades were subsequently grouped into (I) grades 1 to 2 and (II) grades 3 to 5

Results: With regards to the intra observer agreement, consultant A showed 90.1% agreement, consultant B showed 90.6% agreement and consultant C 96.0% agreement. The mean intra observer agreement rate was 92.2%.

The inter observer agreement between consultant A and B was 82.46%, between A and C 67.1% and between B and C 80.1%.

It was also noted that there were systematic differences to the inter observer variability. Consultant A graded the images 3 to 5 on both occasions 52.9% of the time, consultant B graded 3 to 5 on both occasions 37.8% of the time and consultant C graded 3 to 5 on both occasions 23.3% of the time.

Conclusion: The intra observer agreement rate is high. There is however a greater inter observer variation but this variation is consistent. We suggest that the inter observer differences can be improved by (1) reducing the grades to positive or negative and (2) by group reeducation of the observers.

Introduction Charcot arthropathy is a well recognised complication in denervated synovial joints. This is a late complication of traumatic spinal cord injury that is rarely reported in the literature. Early recognition is important and can be difficult as the clinical presentation can vary from pain, deformity, autonomic dysreflexia and audible noises with motion.

Methods We present 5 cases of Charcot’s arthropathy of the spine in patients with in patients with traumatic paraplegia. All patients had spinal surgery to stabilise the spine shortly after the acute injury.

Results The average time from initial injury to presentation with Charcot’s arthropathy was 27 years (range 10–41). A combination of localised and neuropathic pain was the dominant symptom (4 patients) causing re-presentation, but other symptoms included deformity (1 patient). The level of the initial spinal cord injury was at the thoracolumbar junction patients. The Charcot joint level was usually 1 to 2 segments caudal to the spinal fusion. The features noted on plain radiology were destructive changes of the endplate in 4 patients and deformity in 1. With one exception, all patients went on to have MRI to exclude infection and subsequently all were surgically stabilised. All patients were treated surgically. One had an anterior approach, one had posterior approach and one had staged anterior and posterior approaches. The remaining two had anterior and posterior stabilisation through a lateral extra-cavitary approach.

At an average follow-up of 36 months all patients reported good relief of their symptoms, and had returned to their best function post-injury.

Discussion Surgical stabilisation in this series yielded very good results. We observed a wide variation in presenting symptoms and therefore would indicate that a high index of suspicion is required. We believe that MRI is mandatory to exclude infection and would advocate early stabilisation. The lateral extra-cavitary approach allows posterior and anterior stabilisation in a single procedure and in now the preferred method in our institution. As patients with spinal cord injuries live increasingly active lives, this problem will be seen more frequently.

Tibiotalocalcaneal (TTC) fusion is indicated in rheumatoid patients with combined ankle and subtalar disease, particularly when severe deformity is present. In theory, if bone stock is good, a staged subtalar/triple arthrodesis followed by total ankle replacement (TAR) can be used. This is so rarely the case that the author has no experience of this. TTC fusion is also useful in rheumatoid patients with previous joint sepsis, to salvage a failed TAR and to salvage a non-united ankle fusion. It allows early weight bearing, which is valuable in those patients who have multiple joint, particularly upper limb, involvement.

In our study, 18 patients underwent 21 TTC fusions from August 1988 to September 2002. The average age was 48 years (range 23–90). Nine patients had undergone previous hindfoot procedures, five were smokers, one was diabetic and one had chronic renal failure. Surgery was performed under GA with tourniquet. Patients were reviewed using a modified American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score and with regard to their personal satisfaction. Follow up was 18–57 months.

Post-operatively, the oldest patient died due to fulminant sepsis. Seven patients had superficial wound infections but none required re-operation. Fusion was achieved in 18 limbs. Average time to radiological union was 36 weeks (range 9–68), two patients required nail dynamisation. In six cases it was necessary to remove irritating locking screws, either the posterior screw for heel rubbing, or the medial tibial screws for stress riser symptoms. One patient required complete nail removal. There were no amputations.

Fourteen patients were very satisfied, two reasonably so and one not. The average AOFAS pain score (max 40) improved from 11 to 32, and the average AOFAS functional score (max 28) from 4 to 21.

We feel that despite the relatively high complication rate, this technically challenging procedure is a very useful salvage option in these very disabled patients.

Introduction Experimental heterotopic bone formation in the canine urinary bladder has been observed for more than seventy years without revealing the origin of the osteoinductive signals. In 1931, Huggins demonstrated bone formation in a fascial transplant to the urinary bladder. Through an elaborate set of experiments, it was found that proliferating canine transitional epithelial cells from the urinary system act as a source of osteoinduction.

Urist performed a similar series of experiments in guinea pigs as Huggins did in his canine model. After two weeks, mesenchymal cells condensed against the columnar epithelium and membranous bone with haversian systems and marrow began to form juxtapose the basement membrane. At no time was cartilage formation noted, only direct membranous bone formation. They also demonstrated the expression of BMP’s in migrating epithelium and suggested that BMP is the osteoinductive factor in heterotopic bone formation.

Method This study was approved by Institutional Animal Ethics Committee. Six dogs underwent a mid-line laparotomy incision followed by mobilisation of a right sided myoperitioneal vascularised flap based on an inferior epigastric artery pedicle. A sagittal cystotomy is made in the dome of the bladder and the vascularised flap was sutured in place with acryl absorbable, continuous suture. The animals were sacrificed at 6 weeks. The bladder samples were removed and assessed by histology and immunohistochemistry. Sections were incubated with optimal dilution of primary antibody for type I collagen, type III collagen, alkaline phosphatase (ALP), bone morphogenetic protein (BMP)-2 and –4, osteocalcin (OCN), osteopontin (OPN), bone sialoprotein (BSP).

Results The mechanism for bone formation induced by the epithelial-mesenchymal cell interactions is not clear. We were able to demonstrate mature lamellar bone formation 6 weeks after transplanting a portion of the abdominal smooth muscle into the bladder wall. The bone formed immediately adjacent to the proliferating transitional uroepithelium, a prerequisite for bone formation in Huggins’ model. Here we report evidence of cartilage formation and therefore endochondral ossification as well as membranous bone formation. This is very similar histologically to the process of endochondral ossification at the growth plate in the growing skeleton. We propose a mechanism for the expression of BMP by epithelial cells.

Discussion This study demonstrates transitional epithelium induced formation of chondrocytes and osteoblasts in muscle tissue. The sequential expression of bone matrix proteins was related to cell proliferation, differentiation and formation of endochondral and membranous bone. Further information regarding the molecular mechanism of bone formation induced by epithelial-mesenchymal cell interactions will improve understanding of cell differentiation during osteogenesis.

Introduction The influence of timing of surgery on functional outcomes following spinal cord injury remains controversial. Animal studies suggest that the rate, degree, and duration of cord compression are the principal determinants of spinal cord injury (SCI) severity and prognosis for recovery. Delamarter et al, (J Bone Joint Surg Am 1995) have shown that when experimental cord compression in dogs is relieved within 1 hour, full motor recovery can be achieved. It is suggested by some clinically based research that definitive surgical treatment for unstable injuries results in fewer sequelae than prolonged immobilization and allows more rapid entry into rehabilitation. It is however the timing of this surgery which remains controversial. It has been suggested that early surgical management promotes neurological recovery by limiting secondary damage caused by inflammation, oedema, ischemia and instability. To date few studies have found a link between neurological recovery and timing of surgery (Fehlings, et al; Spine 2001).

Methods Data was gathered retrospectively by chart review of patients referred to the Princess Alexandra hospital with spinal cord injury. Patients were age matched into high and low velocity groups. This data was studied to assess the effects of energy of injury and timing of surgical intervention on neurological outcome. Patients either had anterior, posterior, or combined surgery, external immobilization or traction depending on the preference of the treating surgeon.

Results A cohort of 43 patients all of whom had spinal cord injury was retrospectively studied. Of these, 21 had a high energy injury (eg. MVA) and 21 had a low energy injury (eg. rugby). 28 had anterior stabilization 7 had traction, 4 had external immobilization 2 had a combined anterior / posterior fixation and 1 had posterior stabilization. The data suggest that the prognosis for recovery following a spinal cord injury is unrelated to the energy involved. The low energy group improved on average 0.6 ASIA grades (SEM 0.16) while the high energy improved 0.7 ASIA grades (SEM 0.17). The timing of definitive intervention for patients with incomplete cord lesions was shown to significantly (p=0.029) effect ultimate functional outcomes. Those with early (within 8hrs) intervention improved an average of 1.4 ASIA grades (SEM 0.21) and those with late intervention improved 0.6 ASIA grades (SEM 0.19). This effect was present in both high and low energy injury groups.

Discussion The timing of definitive intervention for spinal cord injury is still controversial. However there is Class II evidence that early surgery can be done safely in a patient with spinal cord injury (Fehlings, et al; Spine 2001). The findings from this retrospective study suggest that early surgical intervention may improve neurological recovery.

Introduction The purpose of this prospective controlled study was to define indications and analyse the clinical and radiographic results of cages in the surgical treatment of traumatic cervical spine instability.

Methods 53 patients were treated by monosegmental anterior discectomy and interbody fusion using either autologous tricortical iliac crest bone graft and cervical spine locking plate (CSLP) (bone graft group, n= 26) or Syncage-C (Synthes) filled with autologous cancellous bone grafts and CSLP (cage group n=27). Indications for surgery were traumatic cervical spine instability were classified by the cervical fracture classification of Blauth et al¹ as B1, B2, B3, C2 or C3 fractures. Intraoperative parameters (operative time, blood loss radiation time and intra- and perioperative complications) were documented. Prior to surgery and at follow-up (6 and 12 months) evaluation included measurement of neck pain, shoulder/arm pain and Neck Pain Disability Index (NPDI). Neurological function was assessed using the ASIA scale. Radiographic evaluation included plain X-rays, flexion-extension views and CT-scans. Patient satisfaction was measured on a five-point Likert scale.

Results There was no statistically significant difference between the two groups in the demographic data. One patient in the bone graft group was not available for the 1-year follow-up evaluation; however, all patients were available for the 2-year follow-up. Operation time was significantly shorter (p< 0.05) in the cage group (67 +/− 6 min) than in the bone graft group (78 +/− 9 min). After 6 and 12 months there was no difference between both groups in pain or NPDI, neurological and overall outcome. The neurological improvement of the two groups was not statistically different. Although the cage group showed a trend for better maintenance of lordosis after 12 months, there was no statistically significant difference between groups in all radiographic parameters. There were no implant-related complications during the follow-up. General complications included one patient with eczema due to the stiff collar (cage group) and one patient with pneumonia (cage group). Complications associated with the harvesting of iliac crest bone grafts included 14 patients (9 patients in the bone graft group, 5 patients in the cage group) with prolonged pain (> 3 months) at the donor site, one superficial wound healing problem (bone graft group) which healed under conservative treatment and one hematoma (bone graft group) which required additional surgery.

Discussion Cages offer a valid alternative to a tricortical iliac crest bone graft in the surgical treatment of mono-segmental traumatic cervical spine instability. Although there was no significant difference between the cage and the bone graft group in the functional and radiographic outcome, less donor site morbidity and a shorter operation time make cages cost effective in this selected group of patients. Although the cages are expensive, less donor site morbidity, shorter operation time and reduced hospital stay might result in cost-effectiveness of this implant.

Traditionally midshaft clavicle fractures have been treated conservatively. It is recognized that displaced and shortened fractures may be better treated operatively. In particular, patients with greater than 20 mm of shortening and 100 percent displacement have a symptomatic non union rate of 30 percent. The standard technique used previously has been via plate fixation with LC-DCP or DCP. However in the last 5 years intramedullary fixation has been popularized. “Rockwood intramedulary clavicular pin” remedies the past treatment issues including poor blood supply, painful prominent hardware and stress raiser related to removal of metal work.

Aim: The aim of this study was to assess the functional outcome following intramedullary fixation of clavicle using Rockwood pin.

Method: We retrospectively evaluated 17 patients with displaced and shortened mid-shaft clavicular fractures who underwent intramedullary pinning using Rock-wood pins. Each patient was assessed using the ASES, Constant and SF36 scoring system. A physical examination was performed and individual radiographs were assessed to determine union.

Results: The mean age of the patients was 28 (range 15–56). All patients went into union within 2 to 4 months. They had a shorter stay in hospital, earlier mobilization and no scar related paraesthesia. The average ASES score 98.2 (range 92–100) and constant 95.3 (range 89–100).

Summary: Displaced and shortened mid clavicular fractures require operative fixation. Plates and screws on the clavicle requires significant soft tissue stripping leading to compromised blood supply to the bone and multiple bi-cortical screws act as stress raisers. Previous intra-medullary devices presented with the problem of pin migration. Rockwood pins are designed with a differential pitch which leads to compression at the fracture site and prevent pin migration. From this study we now recommend the use of the Rockwood Pin for the management of displaced mid-shaft clavicle fractures.

Aim: To assess the functional outcome following internal fixation with the PHILOS® plating system for displaced proximal humeral fractures by using the ASES and Constant scoring system.

Background: Controversy exists with regards to the management of displaced proximal humeral fractures and many methods of treatment have been proposed over the years. In particular, the role of surgery has not been clearly defined. The current trend is toward limited dissection of the soft tissues with the use of minimal amounts of hardware to gain stability.

Methods: We performed a retrospective analysis of 30 consecutive patients treated surgically with the PHILOS ® plate for a displaced proximal humeral fracture between February 2002 and October 2003. Patients were assessed clinically and radio graphically at an average follow-up time of 9 months. Functional outcome was determined utilising the American Shoulder and Elbow Society score (ASES) and Constant Murley score. The injury was classified using Neer’s 4 part classification.

Results: Average age of the patients was 58 years (19 to 92). There were 6 two part, 14 three part and 10 four part fractures. All the fractures were radio graphically united by 10 weeks. The average overall ASES score is 66.5%. The average overall Constant score is 55%. The average external rotation at 90 of abduction for the ages 15–55 was 55°–64° and the ages 56–95 was 25°–34°. The average forward elevation for the ages 15–55 was 85°–95° and the ages 76–95 was 55°–64°. The most difficult movement for the older subgroup of patients was internal rotation which was up to the sacrum.

Conclusion: Our results show that good fracture stability and functional outcome can be obtained from the use of the PHILOS® plate. Early mobilisation of the shoulder can be achieved without compromising fracture union. We would recommend the use of the PHILOS® plate for the management of displaced fractures of the proximal humerus.

This preliminary report demonstrates the effective use of Apapore in the management of benign cystic bone lesions.

The use and development of bone graft substitutes over the past ten years has increased dramatically to improve their osseo-integration to a level similar to autografting techniques without the drawbacks of comorbidity from the graft site.

Apapore is a synthetic bone graft substitute which consists of a scaffold of synthetic phase-pure hydroxy apatite with micro- and macroporosity and inter-connectivity to favour bone repair.

Nineteen patients (12M:7F) with a mean age of 18.6years (8–33 years) having had procedures for the management of benign cystic lesions of bone with grafting using Apapore were followed up retrospectively for a mean period of 8 months (1–16months). In each case the diagnosis of a benign cystic lesion was made histologically prior to surgery. The subsequent definitive procedure was performed by a consultant on the Bone Tumour Unit at the Royal National Orthopaedic Hospital (Stanmore) in each case involving curettage and impaction of Apapore into the cavity in a standard fashion as a general anaesthetic procedure in the operating theatre.

There have been no complications to date. All patients have made uneventful recoveries. Short-term radiological follow-up demonstrates excellent incorporation of the bone graft substitute and osseo-integration.

When managing malignant bone tumours in the distal femur with limb salvage, resection and reconstruction with a distal femoral replacement (DFR) conventionally entails prosthetic replacement of the knee joint. In younger patients it is desirable to try to preserve the knee joint. We now use a new Joint-Sparing distal femoral prosthesis in those cases where it is possible to resect the tumour and preserve the femoral condyles. Purpose of study: To look at our early results with knee joint preserving DFR’s. Methods: Between June 2001 and March 2004 the prosthesis was implanted in 8 patients (5 males and 3 females) aged between 8 and 24 years at the time of surgery. The diagnosis was osteosarcoma in 6 cases and chondrosarcoma in 2 cases. All patients were followed regularly and knee range of movement was recorded as well as any complications that occurred. Patients were functionally evaluated using the MSTS Scoring System. Results: Six of the patients had a mean follow-up of 20 months (range 8–33) and in this group 4 had good knee flexion with a mean flexion of 122° (110–130), 1 patient had fair flexion of 60° and 1 patient had poor flexion of 20°. The mean fixed flexion deformity in the 3 patients who had such a deformity was 10° (5–15). There were no intraoperative complications but the patient with poor flexion required an arthrolysis and because of the poor result is under consideration for conversion to a conventional DFR. Two patients had follow-up periods of 3 months or less and are still in their early rehabilitation period. One patient in this group developed sepsis that resolved after an open washout. Conclusions: Our early results with this prosthesis, in the patients with adequate follow-up, have been good in the majority but the two cases of fair and poor knee flexion are disappointing. This particular problem may relate to design and technical factors, which will be discussed in detail.

Clear cell sarcoma of soft tissues is a rare, poorly understood tumour with little written about it in peer reviewed literature. The aim of this paper is to present a consecutive series of patients treated at our institution.

All patients were staged using the system of the musculo-skeletal tumour society (MSTS). The aim of surgery was to achieve a wide excision. Adjuvant chemotherapy or radiotherapy was used in some patients depending on the margins, age and general health of the patient. Follow-up comprised clinical examination, magnetic resonance imaging (MRI) of the tumour bed and chest x-rays. Patients were seen 3 monthly for the first 2 years and then 6 monthly.

Between 1997 and 2003 14 patients were included. There were 5 males and 9 females with a mean age of 49 years (21–82). Mean follow-up was 42 months (1–84). Seven tumours occurred in the upper limb and 7 in the lower limb. Four patients were lymph node positive at presentation. The mean maximum diameter of the tumour was 5.6 cm (2–8). Ten patients were referred prior to excision but 4 patients had already undergone inadvertent excision biopsy elsewhere. Four patients developed local recurrence and 3 patients developed metastases. Seven patients remain disease free, 2 have no active disease, 1 is alive with disease and 4 have died of the disease.

The 2 year survival in this series is 71%. Poor prognostic factors include positive lymph nodes at diagnosis, maximum diameter of the tumour greater than 5cm and incomplete initial excision. It is important that these patients are treated early and that wide excision is achieved. We recommend early referral to a recognised musculo-skeletal tumour centre.

Introduction: Spontaneous spinal epidural haematoma is an uncommon clinical problem which may lead to severe and permanent neurological deficit. The treatment options for spinal cord compression by extradural haematoma in the anticoagulated patient are limited. The majority of cases reported have been treated surgically.¹ Operative intervention carries a potential risk of extending the haematoma with further deterioration of the neurological deficit.

Methods: A case of paraplegia following spontaneous epidural haemorrhage is reported with a review of the prognostic factors that determine likely improvement in neurological function post-surgery.

Case report: A 59-year old man was referred to the regional Spinal Trauma Centre with a 34-hour history of severe lower back pain of sudden onset and 14 hour history of neurological deficit in both legs and urinary overflow incontinence. He had undergone aortic valve replacement two years previously, with subsequent anticoagulation with Warfarin. Examination showed complete paraplegia below L3 with grade 1 power on hip flexion only. On catheterisation, the residual volume of urine was 1200mls. The INR was 3.5. An MRI of the spine showed epidural haematoma that extended from the level of T11 to L5.

The patient was treated non-operatively. On discharge at 10 weeks he had normal sensation to L3 and grade 5-power on left knee extension and grade 4-power on the right. There was no motor recovery distal to this. He had a hypotonic neurological bladder with sufficient resting tone in the sphincter to prevent incontinence.

Discussion: Although associated with a definite mortality, surgical decompression of the spinal cord and evacuation of the haematoma improves neurological outcome and is the treatment of choice.¹ The decision to treat non-operatively should be based on the duration and severity of the neurological deficit. A literature review identifies neurological deficit greater than 12 hours and severe neurological deficit on presentation are poor prognostic indicators.² The prognosis for neurological recovery in this case was poor. In a patient with severe coexisting medical problems these factors can assist when making the decision to operate on an individual patient with spinal epidural haematoma.

Introduction: Anterior lumbar interbody fusion (ALIF) with posterior stabilisation is an established treatment for degenerative disc disease.¹ Some previous reports have advocated a goal of 360 degree fusion, and condemned posterior stabilisation as it does not achieve fusion of the posterior facet joints.² Others have claimed that the concept of a ‘locked pseudarthrosis’ gives satisfactory clinical results.³ There is also a contention that private or self-funding patients achieve better results after spinal fusion compared to those treated under compensation or Dept. Veterans Affairs (DVA) schemes.

Methods: Twenty patients who had undergone an ALIF with posterior stabilisation were retrospectively reviewed. All had a follow-up greater than 12 months. 13 patients were private and 7 non-private. The groups were aged and sex matched. Radiological assessment of fusion was made with reconstruction CT scans. Oswestry Disability Index (ODI) scores were recorded preoperatively, 6 months and 12 months post operation.

Results: Patients with locked pseudarthrosis showed no significant difference in outcome compared to those with radiological fusion. Both groups showed signifi cant improvement in ODI scores after ALIF (mean preop. = 52 – range 16-74; mean postop. = 18 – range 0-52; p< 0.01). There was a significantly greater improvement (p< 0.02) in ODI scores in private patients (mean reduction = 41 points) compared to worker’s compensation or DVA patients (mean reduction = 22 points).

Discussion: The results indicate that ALIF with posterior stabilisation can achieve good clinical results even with a ‘locked pseudarthrosis’. While there is no significant difference between outcomes in different health funding groups shown in the study, carefully patient select for this treatment is the key to success.

Introduction: Pelvic fixation is undertaken in order to restore stability to an unstable pelvis or correct severe scoliotic degeneration of the spine. Instability of the pelvic ring can result from resection of tumours, fractures of the pelvis or infection of the pelvic joints and bones. A number of methods for stabilising the pelvis have been described in the literature including the Galveston Reconstruction (GR)¹ and the triangular frame reconstruction (TFR)². These are associated with an improvement in functional ability, however failure of instrumentation or loosening often occurs.³ A recent mechanical analysis of these techniques has found the technique used in this hospital (GR) performed most poorly.²

Methods: A scoring system was developed from a retrospective analysis of 8 patients. The patients were categorised into two groups (high score and low score) based on age, presence of infection and serious non-associated comorbidities. A patient aged 60 years or over scored 5 points. Patients with bony infection scored 10 points. The presence of serious comorbidity including osteoporosis scored 5 points with minor comorbidities scoring 1 point.

Results: Eight patients who underwent pelvic fixation for varied indications (2 after resection of tumours, 1 fracture, 2 scoliotic degeneration, 3 for infection) were analysed. Three patients had a good functional improvement without loosening of screws beyond 1 year after surgery. These patients were otherwise healthy, relatively young and had no disease processes that affected local bone quality at the site of fixation or serious comorbidities. The other 5 patients all showed evidence of early screw loosening within one year. Of these patients, 2 had a number of serious comorbidities well recognised to compromise bone quality (osteoporosis, long term steroid use) and 3 had pre-existing extensive bony infection.

Discussion: Bone quality of the pelvic bones appears to be the primary predictor of long term functional outcome after pelvic fixation. The 5 patients who had a number of comorbidities well recognised to compromise bone quality all saw early screw loosening within 1 year. Since fixation of the pelvis requires extensive surgery necessitating both posterior and anterior approach and has a number of severe complications such as alteration of urinary, sexual and recto-sigmoid functions the benefit of pelvic fixation should be considered in light of these factors which appear to predict long term outcomes. Further prospective studies of patients undergoing pelvic fixation are required to validate our scoring system.