Introduction The aim of this study was to assess shoulder hemiarthroplasty for non-reconstructable proximal humeral fractures at a minimum of 12 months and identify factors that aid prognosis.

Methods Patients with a displaced fracture requiring shoulder hemiarthroplasty were studied. Patients were treated using the Neer or Osteonics prosthesis and the decision for hemiarthroplasty was made at the time of surgery. Post-operative management was standardised. An independent functional assessment, record review creating a physiological index on co-morbidities, and a radiological analysis were carried out. Survival analysis was performed for one and five year results and data was analysed by linear regression to identify prognostic factors. From 163 patients there were 138 fitting the criteria, 42 males and 96 females, average age of 68.5 (range 30 to 90) years and follow-up of 6.3 (range 1 to 15) years. The fracture pattern was three or four part in 133 cases and five head split fractures; 58 were associated with dislocation.

Results Survival was 96.4% one year and 93.6% five years, with no significant difference between prostheses. There were eight revisions, (one deep infection, four dislocations and three peri-prosthetic fractures), by 12 months. The average Constant score was 67.1 at one year. Prognostic factors at presentation were patient age and physiological index. At three months factors were implant position, tuberosity union, persistent neurological deficit and any complication.

Conclusion Overall optimum outcome was in patients aged 55 to 60, with minimal co-morbidities and an uncomplicated recovery.

In relation to the conduct of this study, one or more of the authors is in receipt of a research grant from a non-commercial source.

Purpose: Surgery is required for primary tumours invading the sacroiliac joint. The purpose of the present work was to analyse results obtained with surgical treatment in order to better ascertain indications.

Material and methods: Forty patients (24 men and 16 women), mean age 24 years (range 12–56) underwent surgery for high-grade sarcoma (n=30, osteosarcoma 12, Ewing 13, chondrosarcoma five) or more differentiated tumours (n=10, low-grade S chondrosarcoma five, fibro-sarcoma two, others three). Resection was achieved in 37 cases via two approaches and via a lateral approach in three. Resection involved vertical sacrectomy either via the homolateral foramen (n=27) or via the midline (n=10). Reconstruction consisted in stabilising the iliosa-cral assembly generally associated with vertebral osteo-synthesis, an autologous graft in 36 cases, cement in one, and an allograft in three. Functional outcome was assessed with the MSTS (Enneking).

Results: There were three infections (all three with extensive lateral approach) and five cases of postoperative lumbosacral trunk palsy. Late complications were three cases of spondylolisthesis and eight nonunions. Twenty patients died (eight local recurrences, ten metastases, one chemotherapy toxicity, one undetermined cause). Sixteen patients achieved complete remission at six years (follow-up 2–16 years) and four patients were lost to follow-up. Functional outcome was very good in eight, good in ten, fair in twelve, and poor in ten. Survival was 40% among patients with malignant tumours (38 patients) but only 20% for those with osteosarcomas.

Discussion: Technical improvements (combined approach rather than wide lateral approach and omentum flap) have allowed a reduction of cutaneous and infectious complications. Mechanical complications can be prevented by systematic lumbosacral fusion on the side opposite the resection reconstruction. This provides good functional results despite sacrificing a hemi-sacral plexus if the lumbo-sacral trunk is preserved. Reconstruction after extension of the resection to the acetabulum raises an unresolved problem and yields mediocre results. The quality of the surgical resection is determinant since risk of local recurrence is 8/100 after a contaminated resection edge.

Conclusion: Surgical resection of sacroiliac tumours is a source of numerous complications despite real technical improvements. This approach can be proposed if carcinological resection can be reasonably achieved. Local control is very poor in case of large osteo-osteogenic sarcomas.

All patients over 65 yrs with an ISS greater than 15 attending Edinburgh Royal Infirmary between 1997 and 2000 were prospectively entered into the study. Patients were followed until death or discharge home. The patients were divided into, group 1 [patients who survived], and group 2 [those who died.]

A total of 72 patients were included in the study, 42 males and 31 females. 42 patients survived, and 31 died.

Group 1 consisted of 29 males and 15 females with an average age of 75.23yrs. Group 2 consisted of 13 males and 18 females with an average age of 78.05yrs. All incidents involved blunt trauma. The three main mechanisms of injury were RTA, Fall less than 2 meters, and Fall greater than 2 meters.

Five patients required intubation in group 1 and 12 patients in group 2.The average GCS was lower in group 1 compared to the group 2. All Injuries with AIS of greater than 3 were analysed. The total number of injuries was greater in the group 2. Group 1 required 214 days in HDU/ITU and a total of 943 in-patient days. Group 2 in comparison needed 62 HDU/ITU days and 169 in-patient days. The major cause of death was head and spinal injury 11 (35%), and Multiple injuries 9 (29%).

A total number of 1952 days were spent in rehabilitation prior to discharge, with an average of 46.48 days. Post trauma the level of independence was significantly reduced.

The injuries are exclusively blunt and in the majority of cases secondary to motor vehicle accidents. Predictors of mortality appear to include, intubation, head and neck injuries, GCS, and chest injuries. Current outcome scores correlate inaccurately. These patients require long hospital stays with a large amount of intensive care input. After discharge rehabilitation is universally required. These patients place a large demand on the NHS and social services; the total cost of their care was approximately £2,500,000.

Humeral hemi arthroplasty has become widely used as a form of surgical management for severe fractures. However there is still no consensus as to the role for prosthetic replacement in displaced proximal humeral fractures.

The aim was to assess shoulder hemi arthroplasty for un-reconstructable three and four part proximal humeral fractures at a minimum of twelve months and identify factors that guide to prognosis.

Criteria for inclusion were patients with a fracture that went onto shoulder hemi arthroplasty with Constant scoring at a minimum follow up of one year. Patients were treated using a Neer or Osteonics prosthesis, with the decision for hemi arthroplasty being made at the time of surgery. Post-operative management was standardised. An independent functional assessment, record review establishing a physiological index according to comorbidities, and a radiological analysis were carried out. A survival analysis was performed for the one and five year results and data was analysed by linear regression to identify prognostic factors.

Of 163 patients there were 138 fitting the criteria, 42 males and 96 females with an average age of 68.5 (range30–90) years and average follow up of 6.3 (range1–15) years. The fracture pattern was three or four part in 133 cases and 5 head split fractures; 58 were associated with a dislocation. Survival was 96.4% at 1 year and 93.6% at 5 years, with no significant difference between prostheses. There were 8 revisions, (1 deep infection, 4 dislocations and 3 peri-prosthetic fractures), most within 12 months. The average Constant score was 67.1 at one year.

Prognostic factors on presentation were the age of the patient and their physiological index. Factors at 3 months were any complication, the position of the implant, tuberosity union and persistent neurological deficit. Overall optimum outcome was gained by patients aged 55–60, with minimal comorbidities and an uncomplicated recovery.

Purpose: Rotation dislocation of C1-C2 subsequent to trauma is not often described in adults. The clinical, radiological and computed tomographic diagnostic criteria are not well known and can lead to false positive diagnosis. The Fielding classification was described for children. We report five cases of traumatic rotation dislocation of C1-C2 in adults and propose computed tomographic criteria for diagnosis. The Fielding classification is discussed.

Material and methods: In two cases, the diagnosis was suggested by the clinical presentation and the plain x-rays. In three cases, it was revealed by the systematic CT performed in multiple trauma patients. In three cases, MRI enabled visualisation of ligament tears (transverse ligament, alaire ligament). Finally, the C1-C2 relations in neutral position and in rotation were studied on the CT scans in the study patients and in ten healthy subjects to establish diagnostic criteria. The patients were treated with cervical traction until reduction was achieved (checked with CT) then with an “Indian”collar for 45 days. One patient did not wear the collar and experienced a recurrent dislocation.

Results and discussion: In patients who can be examined, the diagnosis is suggested by suboccipital pain, slight rotation inclination of the head to the contralateral side, impossibility of turning the head to the opposite side beyond the mid line. The open-mouth x-ray can be a source of false positive diagnosis but can be suggestive. The CT scan must be performed under precise conditions: patient positioned without rotation or inclination of the head (false positive); superposition of the two slices passing through the C1 and C2 faces (unilateral loss of congruency); sagittal reconstruction. In case of doubt, homo and contralateral rotation slices can provide more sensitive images. The five dislocations were uin-lateral (Fielding type II) with posterior displacement in two cases, a finding not described in this classification. In addition, type I could be a variant of the normal (as seen in control scans). Treatment in the early phase is conservative with reduction by simple cervical traction (verification on CT), followed by complementary immobilisation until ligament healing.

Conclusion: The diagnosis of traumatic rotation dislocation of C1-C2 in adults is based on CT evidence. Certain injuries should be added to complete the Fielding classification. When recognised early, this rotation dislocations can be treated conservatively.

Purpose: En bloc resection can be proposed for lung cancer involving the apex with invasion of the ribs or the transverse process using a transcervical anterior approach. Cancers invading the intervertebral foramen cannot be resected via this approach despite the classical indication for surgical resection. We report results of a novel surgical technique allowing cancerological resection of these tumours.

Material and methods: Fifteen patients with the same grade of cancer were operated using the same surgical technique. The first operative time included: superior lobectomy via anterior cervicothoracic access (without removal of the lobe), dissection of the subclavian vessels and the brachial plexus, section of the ribs and the T1 root, spinal exposure from C6 to T5, hemi-disectomy C7-T1 and discectomy at the level below the invaded foramen, medial vertebral groove, closure. The second operative time included: posterior access, extended instrumentation of the spine, hemi-laminectomy C7 extended as needed, section of the roots (depending on the level of the resection) within the canal, oblique posterior vertebral osteotomy along the medial border of the pedicle terminating in the anterior groove. Finally en bloc ablation via the posterior access of the surgical piece including the lung, the ribs and the hemi-vertebrae.

Results: Three- and four-level hemivertebrectomy was performed in eleven and three patients respectively. One patient had two hemivertebrectomies associated with one vertebrectomy. There were six resections (with repair) of the subclavian vessels for tumour invasion. Peroperative mortality was zero. Mean blood loss was 3000 ml. There were no neurological complications. There were eight postoperative complications: pneumonia five patients, cerebrospinal fluid fistula one patient, skin dehiscence one patient, haemorrhage one patient requiring reoperation. All patients were given postoperative radiotherapy. Three- and five-year survival was 36% and 27% respectively. Among the nine deaths, three had local relapse and six had general relapse.

Discussion: This techniques enables resection of tumours considered to be inextirpable using other techniques. Survival was the same as for tumours of the apex without invasion of the foramen and better than without surgery. This major surgery requires a well-trained multidisciplinary team (thoracic and vascular surgeons, spinal surgeon, anaesthesiologists, intensive care specialists). Contraindications for this type of surgery are invasion of the spinal canal, the brachial plexus and the vertebral body as well as the presence of a spinal artery entering the foramen to be resected.

Purpose: Use of massive allografts for reconstruction of major bone stock defects remains a controversial issue. We reviewed our experience to compare results with other methods, particularly free vascularised bone transfer reconstructions.

Material and method: Between 1983 and 1995, 36 patients (15 men and 21 women) underwent cancerological resection of a long bone shaft for primary malignant tumour. Mean age was 19 years (8–84). The tumour was a high-grade sarcoma in 26 cases, low grade sarcoma in eight and adamantinoma in two. Mean length of resection was 19 cm (14–34). Cryopreserved allografts were used in 24 cases, gamma irradiated allografts in 12. Various osteosynthesis procedures were used, generally combining an axial assembly with a single or dual epiphyseal construct. Localisations were: femur 24, tibia ten and humerus four. All patients were reviewed at a minimum follow-up of five years (range 5–16 years, mean 8 years). Functional outcome was assessed with the Enneking criteria. Bone healing at junctions was considered to be achieved when there was no clinical expression and radiographic images remained unchanged for two years.

Results: All immediate complications were infections (one femur four tibias) and required partial or total ablation of the allograft in four cases and amputation in one (tibia). The predominant late complications were late consolidation (n=13) and stress fracture of the allograft (n=6). Six patients died before bone healing and were not retained for analysis. Among the 28 patients retained for analysis (eight excluded: six deaths, one amputation, one total ablation of the allograft), only ten achieved bone healing after one procedure. The other eighteen required on the average four reoperations to achieve consolidation (3–11 procedures for osteosynthesis and new allograft material). All patients had achieved bone healing at last follow-up. Functional outcome was excellent for femurs, good for tibias, and fair for humeri due to the impact on shoulder function. There was no significant difference in consolidation with cryopreserved and irradiated bone material but two irradiated grafts could not be used correctly because they were to friable.

Discussion: These more or less satisfactory results must be examined in light of the context. Cancerologicl resection (periosteum + soft tissue), generally combined with adjuvant treatment (chemotherapy for 24 patients and radiotherapy for three), places the patient in conditions highly unfavourable for bone healing. Use of allografts alone, combined with approximate fixation procedures early in our experience, demonstrated the limitations of the technique (only two primary consolidations among 18 patients). However, when the allograft was combined with axial fixation and immediate allograft or allograft after adjuvant treatment, primary consolidation was achieved in 80% of the cases (eight out of ten). All patients who achieved long-term remission conserved a functional limb with relatively preserved bone stock.

Conclusion: Despite controversial results, massive allograft reconstructions can provide a useful alternative to fill major bone stock defects of the femur or humerus. For the tibia the risk of infections may require further discussion before determining the best approach. These results should be compared with those in a homogeneous series of patients treated with a vascularised free bone transfer, but to our knowledge no such series is available in the literature.