Introduction: Diaphyseal femoral allograft is well suited to anterior column reconstruction of the thoracolumbar spine due to its inherent structural properties and bio-compatibility. The Bridwell system of interbody fusion assessment¹ is based on plain x-rays and therefore lacks sensitivity. A new classification system of bony union is proposed using high-speed spiral CT imaging.

Methods: Twenty-six patients who underwent anterior thoracolumbar reconstruction for burst fracture using femoral allograft were followed for a minimum of 2 years. Each subject underwent high speed spiral CT scanning through the reconstructed region of the thoracolumbar spine and a classification system of graft to endplate union and central cancellous autograft incorporation was established.

The classification system reflects gradually increasing biological stability of the construct. Grade I (complete fusion) implies cortical union of the allograft and central trabecular continuity. Grade II (partial fusion) implies cortical union of the structural allograft with partial trabecular incorporation. Grade III (unipolar pseudarthrosis) denotes superior or inferior cortical non-union of the central allograft with partial trabecular discontinuity centrally and Grade IV (bipolar pseudarthrosis) suggests both superior and inferior cortical non-union with a complete lack of central trabecular continuity. Intra- and inter-observer error studies were carried out involving spinal surgeons, radiologists and trainees to examine reliability of the classification

Results: In this series 84% of cases demonstrated Grade I or Grade II characteristics. 1 case (4%) was identified as Grade IV. The classification showed good reliability with a kappa score of over 0.7

Discussion: Plain radiographs have always proved unsatisfactory for the accurate assessment of incorporation of grafts in the thoracolumbar spine. The use of CT imaging in the assessment of graft union has allowed a more accurate assessment of union. The classifi cation system presented allows a reproducible and relevant categorisation of allograft incorporation.

Introduction: The foot is an unusual site for presentation of Ewings tumour. Haemangioma of the vertebra is a common finding in adults, but is rarely reported in children.¹ Although rarely symptomatic, the lesion may cause diagnostic confusion particularly in the presence of comorbidity. A previous case report details an adult patient with a ‘pseudohaemangioma’ that was subsequently found to be an Ewings tumour.²

Methods: A review of the literature and a case report is presented of a boy with a Ewing’s sarcoma of the foot presenting with an asymptomatic lytic lesion in the spine.

Results: The 12-year-old male initially presented with pain and swelling in the right foot. Subsequent investigation and biopsy confirmed a diagnosis of Ewing’s sarcoma in the second metatarsal. The child received 5 cycles of combined chemotherapy, and the primary tumour was excised from the metatarsal with fibular graft reconstruction.

Part of the clinical work up had included an isotope bone scan, which revealed a focal area of increased uptake in the L1 vertebra. On MRI, the vertebral lesion had a ‘halo’ of high intensity signal with infraction of the upper vertebral endplate. There were no clinical symptoms arising from the vertebral lesion. The differential diagnosis of the L1 lesion suggested was either a meta-static Ewing’s tumour or an aggressive haemangioma. Given the possibility of a multifocal or metastatic lesion, a vertebrectomy and reconstruction with femoral allograft was performed. A second stage posterior stabilisation from T12 to L2 was performed. Histological examination of the resected vertebra revealed a benign capillary haemangioma. On recent review one year after treatment, the patient remains in remission from his tumour and has successful graft incorporation with minimal symptoms from his spine.

Discussion: Haemangioma is a benign tumour commonly found in the vertebral body. Asymptomatic spinal haemangiomas do not require surgical excision. Clinico-pathological distinction between vertebral haemangioma and metastatic disease can be difficult, particularly in children where the haemangiomata may be in a ‘blastic’ phase. The combination of an extremely unusual age of presentation and the presence of a separate malignant primary bone tumour in this patient introduced a significant clinical dilemma in treatment.

Introduction: There is increasing evidence that surgical treatment in tumour surgery can influence survival times. Renal cell carcinoma can lead to single or few sites of metastasis that are amenable to extirpative surgery with reconstruction in the spine¹. Such treatment can also be beneficial to improve quality of surviving years.

Methods: Retrospective cohort study of 10 consecutive patients treated for spinal metastatic renal cell carcinoma. Case note review and patient or general practitioner contact was used to ascertain number of metastases, treatment given, survival time from diagnosis and survival time from surgery. All primary tumours were treated with nephrectomy.

Results: Of the 10 patients, 6 had extirpative treatment, while 4 had palliative surgery including decompression of the neural elements. Patients treated with extirpative surgery to spinal metastases from a renal cell carcinoma primary had a significantly longer survival time from surgery to those treated with palliative decompressions alone. There were no significant differences in age or time from diagnosis to surgical treatment between groups. There were no cases of operative mortality, but significant intraoperative bleeding was encountered in extirpative treatment of the affected vertebra, despite preoperative embolisation.

Discussion: The role of surgical treatment in metastasis to the spine is of current interest. Our results have shown significant survival times are possible with extirpative treatment of renal metastases. Whilst this may not apply directly to metastases from other primary tumours, careful selection of cases and co-operation between spinal surgeons and oncologists is important to ensure maximal quality and length of survival for these patients. These cases are surgically challenging, and care is required to minimise and anticipate blood loss.

Aims: Firm bandaging of the knee following knee replacement may prevent bleeding into the joint by a tamponade effect, but the presence of a tight bandage around the knee may obstruct venous return and lead to thromboembolic complications. We have studied the pressure required, and then compared clinically the use of a compression bandaging with the use of either a drain, or a standard crepe bandage. Method: Transducers were used to measure the pressure achieved on the surface of the knee under different bandages, and within the knee following release of tourniquet. Three series of 50 patients have been compared: with compression bandaging from toes to mid-thigh, with crepe alone, or with suction drain and crepe. Results: The pressure within the joint at which tamponade occurs is 52–57 mm Hg. The pressure on the skin under a properly applied compression bandage is between 28 and 32 mmHg and this controls bleeding within the joint. Patients treated with compression bandaging recovered quicker from the operation had a shorter hospital stay and a greater range of ßexion on discharge. They had no swelling of the limb, rarely suffered a tense haemarthrosis and had fewer complications. Conclusions: The use of compression bandage incorporating the foot and calf following knee replacement surgery confers speciþc advantages over the use of crepe bandage alone.

INTRODUCTION: Regular review [1, 2] of cervical injuries occurring in rugby players is an important step toward maximising the safety of the players. It is hoped that the recognition of recurring patterns of injury would lead to appropriate rule modification by the regulatory bodies of the sport. Serious cervical injuries in rugby have been reported to occur by a range of mechanisms, including those involved with scrummaging, tackling, rucking and mauling.

Spinal flexion is the commonest mechanism of injury and has been associated with scrum engagement, scrum collapse, rucking or mauling, and mistimed tackling. The second most common mechanism of cervical spinal injury is hyper-extension. This commonly occurs during tackling, particularly the ‘gang tackle’ involving several participants simultaneously, where sudden deceleration of a player’s head may lead to cervical hyperextension, focal spinal stenosis and potential damage to the spinal cord by a “pincer” mechanism.

The most commonly reported levels of injury are C5/6 and C4/5 [3].

METHODS: A retrospective review of neck injuries presenting to a major spinal injuries facility and resulting from all codes of football (rugby union, rugby league, soccer, indoor soccer and touch) was conducted and 38 cases identified.

RESULTS: Of the 38 patients, 14 were injured playing rugby union, 15 rugby league, three soccer, one indoor soccer, one touch football and four were playing an unidentified code. Six players were injured while scrummaging, five rugby union and one rugby league. 21 people were injured as tacklees, four as tacklers and two with unspecified involvement in a tackle. One person was injured whilst “heading” the ball, and three people were injured in a non-contact or unspecified action. At final follow-up, four people were found to be quadriplegic (ASIA A), 10 quadriparetic (ASIA B – 0 C –1 and D –9) and 24 recovered completely (ASIA E).

We aim to present an 18 Month Review of one Surgeons Practice Involving 16 Patients with 3 or 4 part Fractures or 3 part Fracture-Dislocations of the Proximal Humerus in patients under 60 years of age.

Management principles include anatomic reduction, internal fixation and early movement.

The implants used in this series include:

The PLANTAN PLATE from ATLANTECH

The STRATEC 4.5 mm ANGLE BLADE PLATE

The POLARUS NAIL and various small cannulated screw systems.

3 patients were treared with minimal fixation, 5 with the AO Bladeplate, 4 with the PLANTAN plate and 4 with the Polarus nail.

Surgical Treatment, Radiographic and Clinical Outcomes will be reviewed. Anatomic considerations, surgical technique and outcomes will be discussed.

Purpose: In this ongoing trial we are analysing the performance of both a fixed bearing total knee replacement and a mobile bearing total knee replacement using gait analysis and a patient-based questionnaire. We aim to find out if there is a difference in the functional performance of the two types of prosthesis.

Method: Patients are taken from the in-patient waiting list of three consultants and introduced to the trial if deemed suitable. Each patient is analysed once pre-operatively and on three occasions post-operatively (6 weeks, 3 months and 1 year) at the university gait analysis laboratory. At each visit various anthropological measurements are recorded and the patient fills in an “Activities of Daily Living” questionnaire. After calibration and measurement of the passive range of motion of both knees each patient has their gait analysed over a series of six walks using a standard 5 camera system with skin marker clusters, the kinematic data from this is supplemented with force-plate recordings and video analysis of each set of walks. Data is recorded for both of the patient’s knees. The staff in the gait analysis laboratory are blinded as to which prosthesis has been used for each patient in an effort to eliminate bias.

We present our methodology and some preliminary results.

Introduction: The natural history of bone bruises of the knee and their clinical significance remains unclear with only a few short term studies in the literature.

Aim: This study was designed to try and elucidate the long term outcome of bone bruises of the knee following trauma.

Materials and Methods: 60 patients with bone bruises identified in their knees by MRI scans following trauma were included in the study. All patients were reviewed in a research clinic with a minimum 5 year follow up. A detailed history including mechanism of injury, persistent symptoms and functional status was obtained. Clinical examination to identify intra-articular pathology was then undertaken. All patients had a repeat MRI scan of the knee. The relationship between the injury and the bone bruise, the effect of treatment if any and the long term outcome of such lesions was studied.

Results: 80% of the patients had a twisting injury with our without a hyperextension of valgus/varus force. 58% of our series had ACL injuries and 68% of the bone bruises were in the medial condyle. 72% of the patients did not return to their pre-accident status and had continuing symptoms although the majority of them did not have signs of clinical instability. There was MRI evidence of lasting sequelae of bone bruises in the majority of patients. Detailed results will be discussed.

Conclusions: bone bruises identified on MRI following trauma to the knee are significant lesions with the potential for long term sequelae.