Introduction. Surgical treatment of spinal metastasis belongs to the standards of oncology. The risk of spinal cord compression represents an operative indication. Intraoperative bleeding may vary, depending on the extent of the surgical technique. Some primary tumors, such as the renal cell carcinoma, present a major risk for hemorrhage and preoperative embolisation is mandatory. The purpose of this study is to evaluate the possible benefit of embolisation in different types of primary tumors. Material and Methods. The charts of 93 patients (42 women, 51 men, mean age 60.5 years) who were operated for spinal metastasis, 30 cases with multiple levels, were reviewed. Surgical procedures were classified as: (1) thoracolumbar laminectomy and instrumentation, (2) thoracolumbar corpectomy or vertebrectomy, (3) cervical corpectomy. A preoperative microsphere embolisation was performed in 35 patients. The following parameters, describing blood loss, were evaluated: hemoglobin variation from beginning to end of surgery, blood volume in suction during the intervention, number transfused packed red blood cells units until day 5 after surgery. A Poisson model was used for statistical evaluation. Results. The origins of spinal metastasis were: 28 breast cancer (30.1%), 19 pulmonary carcinoma (20.4%), 16 renal cell carcinoma (17.2%), 30 other cancers (32.3%). An embolisation was always performed in metastasis of renal cell carcinoma. An embolisation was performed in 8 cases in breast, 3 in pulmonary and 9 in other cancers. In the breast cancer group, there was no difference between embolisation versus non-embolisation concerning intraoperative blood loss and transfusion (P=0.404). In the pulmonary group, no difference was found either, but the number of embolisation cases was limited. For other metastasis types, the embolisation had no significant influence (P=0.697). The type of surgical intervention (2) increased intraoperative bleeding significantly in all groups: breast (P=0.002), pulmonary (P=0007), others (P=0.001). The average intraoperative hemoglobin decrease was: 2.3 in renal, 2.5 in breast, 3.0 in pulmonary, 1.9 in other metastasis (P=0.692). Conclusion. Several studies have clearly shown that the preoperative embolisation of renal cell carcinoma is recommended because of their risk of hemorrhage. However, the benefits of this procedure have been less described for other metastatic vertebral lesions. For breast cancer and other carcinoma (mainly digestive and prostate), the results of this study do not indicate a clear benefit for patients who received an embolisation. The same tendency was observed for pulmonary metastasis. The extent of the operation (corpectomy or vertebrectomy) represents the main factor that influences intraoperative bleeding

To evaluate efficacy and outcome of embolisation following pelvic ring injuries in patients presented with ongoing hypovolaemic shock. Between 2000 and 2003, 200 poly-trauma patients presented in our institutions following pelvic ring injuries. Those with ongoing hypovolaemic shock who were treated within 24h of admission with embolisation were included in this study. Demographics, mechanism of injury, ISS, type of pelvic ring fracture, arterial source of bleeding, hours from injury to embolisation, and outcome were all recorded prospectively. Out of the 200 treated in our institutions 17 (8.5%) underwent angio-embolisation. The mean age of the patients was 37 (14-70) and the mean ISS was 29. Distribution of pelvic ring injuries included: 3LC, 7APC, 7VS. The mean time from injury to embolisation was 15 hours. 8/17 patients were initially treated with an external fixator. The distribution of arterial injuries was: 7 superior gluteal arteries, 8 internal iliac arteries, 1 obturator artery and 1 internal pudental artery. The mean number of units transfused prior to embolisation was 22 (range 6-50). Mortality rate was 4 (23%) out of 17 embolised patients. Angio-embolisation for pelvic ring injuries occurred in 8.5% of our study population. This study indicates that only a small proportion of patients required embolisation secondary to arterial bleeding. The overall survival rate was in accordance to published international experience. Embolisation should be considered as a valid adjunct in some selected group of patients with pelvic fractures where ongoing bleeding refractory to other treatment modalities is present

Purpose: To evaluate efficacy and outcome of embolisation following pelvic ring injuries in patients presented with ongoing hypovolaemic shock. Methods: Between 2000 and 2003, 200 poly-trauma patients presented in our institutions following pelvic ring injuries. Those with ongoing hypovolaemic shock who were treated within 24h of admission with embolisation were included in this study. Demographics, mechanism of injury, ISS, type of pelvic ring fracture, arterial source of bleeding, hours from injury to embolisation, and outcome were all recorded prospectively. Results: Out of the 200 treated in our institutions 17 (8.5%) underwent angio-embolisation. The mean age of the patients was 37 (14–70) and the mean ISS was 29. Distribution of pelvic ring injuries included: 3LC, 7APC, and 7VS. The mean time from injury to embolisation was 15 hours. 8/17 patients were initially treated with an external fixator. The distribution of arterial injuries was: 7 superior gluteal arteries, 8 internal iliac arteries, 1 obturator artery and 1 internal pudental artery. The mean number of units transfused prior to embolisation was 22 (range 6–50). Mortality rate was 4 (23%) out of 17 embolised patients. Angio-embolisation for pelvic ring injuries occurred in 8.5% of our study population. This study indicates that only a small proportion of patients required embolisation secondary to arterial bleeding. The overall survival rate was in accordance to published international experience. Conclusion and Significance: Embolisation should be considered as a valid adjunct in some selected group of patients with pelvic fractures where ongoing bleeding refractory to other treatment modalities is present

The surgical treatment of bone tumours can result in large perioperative blood loss due to their large sizes and hypervascularity. Preoperative embolisation has been successfully used to downgrade vascularity, thus reducing perioperative blood loss and its associated complications. Prior to embolization era, blood loss as high as 18,500mL have been reported peri-opratively. Twenty-six patients with a variety of bone tumours (average size 10.5×7.5×5.5cm), who underwent pre-operative embolisation between 2005 and 2009, were retrospectively studied. The group comprised of 17 females and 9 males. Their mean age was 38 years old. All patients underwent surgical resection within 48 hours of embolization. Mean blood loss was 796mL and required on average 1.1units of blood. We experienced no complications. Pre-operative arterial embolisation of large, richly vascular bone tumours in anatomically difficult positions, is a safe and effective method of downstaging vascularity and reducing blood loss

Background: Giant-cell tumour (GCT) of bone is a benign but aggressive tumour, usually treated by radical surgical curettage. Surgical treatment of GCT involving the ischium is associated with a high local recurrence rate. We describe a case in which serial arterial embolisation and bisphosphonate treatment resulted in radiological healing of the tumour. So far we have avoided surgical treatment. Case Report: A 40-year-old lady was referred to the bone tumour unit following a fall. A plain radiograph of the pelvis revealed a lytic lesion in the ischium, extending into the posterior column of the acetabulum and associated with a pathological fracture. Biopsy confirmed a diagnosis of GCT. Given the anatomic location, the tumour was treated with serial arterial embolisation and intravenous zoledronate infusions. Follow up at one-year shows healing of the lesion, with no radiological evidence of recurrence. The patient has so far avoided surgery. Discussion: Serial arterial embolisation has been described in the treatment of giant cell tumours in anatomical regions where surgery is likely to be associated with significant morbidity, such as the sacrum. There is a sound theoretical basis for the use of bisphosphonates in this disease; they have been shown to cause apoptosis of the osteoclast-like giant cells and interfere with osteoclast recruitment. As far as we are aware this is the first case described in which embolisation and bisphosphonate treatment appears to have led to healing and stabilisation of the lesion. The durability of this response remains uncertain

Introduction: The lumbosacral medulla is vascularized by the Adamkiewicz arteria which irrigates the anterior spinal arteria. Occlusion or section of the Adamkiewicz arteria may induce an ischemia of the medulla during anterior or transforaminal spine surgery. An angiography allows to determine the exact topography of this artery. The purpose of this study was to describe its preoperative topography and to analyze the impact of angiography on the surgical strategy. Methods: In this retrospective study, 100 preoperative medullar angiographies, performed by a vascular radiologist between january 1998 and august 2007, were reviewed. Surgical indications were: 50 vertebrectomies in tumors, 20 anterior fusions in dorsolumbar fractures, 10 anterior fusions in malunions, 10 anterior releases in scoliosis, 3 transpedicular osteotomies, 7 disc hernias (T7-L4). The level and the side of foraminal entrance of the Adamkiewicz arteria and collateral arterias irrigating the anterior spinal arteria were analyzed. We looked for the occurence of postoperative ischemic signs of the medulla. Modifications of surgical planning because of Adamkiewicz’ arteria topography were noted. The possibilities of preoperative tumor embolisation were analyzed. Results: The Adamkiewicz arteria was always localized between T8 and L3. It was present at the foraminal levels L1/L2 or L2/L3 in 48% of the cases. The left side was concerned in 65% of the cases. A modification of the surgical strategy was noted in 16% of the cases: 12 side changements of operative approach, 4 contra-indications for anterior surgery. An ischemic syndrome of the anterior lumbosacral medulla were not found. In the group of tumors, the preoperative angiography allowed to perform a selective embolisation of tumor vessels in 80% of the cases. In all other cases, the tumor vascularisation was common with the vascularisation of the medulla which could have made the embolisation dangerous. Conclusion: Although the occurence of a lumbosacral medullar ischemia secondary to an Adamkiewicz arteria lesion is rarely reported in the literature, the preoperative angiography reduces this potential risk. The exact knowledge of the anterior medullar vascularisation allows to better plan the surgical strategy and to adapt the side of operative approach. Furthermore, the angiography enables to perform a selective embolisation of tumors safely

Introduction. Aneurysmal bone cysts are uncommon benign lesions affecting the spinal column. They mostly occur in the lumbar spine and have a propensity to affect adjacent vertebrae. We describe 14 aneurysmal bone cysts affecting the spinal column from the Scottish Bone Tumour Registry with regard to assess the incidence, demography, biological behaviour and recurrence rate. Materials and Methods. We identified 14 patients with aneurysmal bone cysts affecting the spinal column. Case notes and radiographs were retrospectively reviewed from the Scottish Bone Tumour registry. Results. There were 9 female and 5 male patients. The mean age at presentation was 24.5 years (range, 6 to 62 years). The spinal location consisted of cervical (3), thoracic (4), lumbar (6) and sacral (1). The treatment included curettage without bone grafting (3), excision (7) and surgical removal with biopsy in rest. Selective angiographic embolisation was carried out in one patient with a cervical cyst and percutaneous sclerotherapy was carried out on another with a sacral cyst. There were two recurrences, of which one was treated with radiotherapy and other with repeat curettage with successful final outcome. Conclusions. The incidence of aneurysmal bone cysts was 5.5% in our registry of all the spine tumours. The recurrence occurred in 14% (2 of 14). In addition to surgery, one should be aware of the role of angiographic embolisation and radiotherapy in selected primary and recurrent ABCs

Background: When treatment of a spinal arterio venous fistula (SAVF) is anticipated, precise location of the level and side of the feeding artery are necessary. Digital subtraction angiography (DSA) is the reference standard for imaging SAVFs. Non-invasive vascular imaging by multidetector computed tomographic angiography (MDCTA) and magnetic resonance angiography (MRA) are newer imaging modalities, which are able to demonstrate these lesions. Objectives: We performed a retrospective analysis of patients with SAVF in our unit to examine the accuracy of MDCTA and MRA compared with DSA and intraoperative findings to illustrate how non-invasive angiography affects treatment. Results: Between 2001 and 2007, we identified 22 consecutive patients with SAVF. 20 patients had CTA, identifying the site of SAVF in 19. In all of the 11 patients who had MDCTA, the site was correct and confirmed at surgery. 16 patients had MRA, confirming the SAVF in all cases and correct site in 12. DSA failed to demonstrate the abnormality in one patient. Treatment: 5 patients have had no treatment. 3 patients were treated by embolisation, with one patient developing a persistent neurological deficit. 14 patients had primary surgical repair with confirmation of the angiographic lesion. In those cases where pre-operative MDCTA was performed, volume rendered spinal reconstructions aided the operative localisation. Conclusion: Non-invasive angiography for the diagnosis of SAVF is safe and accurate. MDCTA aids operative localisation and DSA should be reserved for patients with inconclusive non-invasive angiography or when identification of the artery of Adamkiewicz is required prior to embolisation

Aim: To investigate the outcome of our management of patients with giant cell tumour of the sacrum and draw lessons from this. Method: Retrospective review of medical records and scans for all patients treated at our unit over the past 20 years with a giant cell tumour (GCT) of the sacrum. Results: Of 517 patients treated at our unit for GCT over the past 20 years, only 9 (1.7%) had a GCT in the sacrum. 6 were female, 3 male with a mean age of 34 (range 15–52). All but two tumours involved the entire sacrum and there was only one purely distal to S3. The mean size was 10cm and the most common symptom was back or buttock pain. Five had abnormal neurology at diagnosis but only one presented with cauda equina syndrome. The first four patients were treated by curettage alone but two patients had intra-operative cardiac arrests and although both survived all subsequent curettages were preceeded by embolization of the feeding vessels. Of 7 patients who had curettage, 3 developed local recurrence but all were controlled with a combination of further embolisation, surgery or radiotherapy. One patient elected for treatment with radiotherapy and another had excision of the tumour distal to S3. All the patients are alive and only two patients have worse neurology than at presentation, one being impotent and one with stress incontinence. All are mobile and active at a follow up between 2 and 21 years. Conclusion: GCT of the sacrum can be controlled with conservative surgery rather than sacrectomy. Embolisation and curettage are the preferred first option with radiotherapy as a possible adjunct. Spino-pelvic fusion may be needed if the sacrum collapses

Haemangiomas are benign tumours with increased number of normal or abnormal appearing blood vessels. They are the commonest soft tissue tumours of infancy and childhood and comprise 7% of all soft tissue tumours. Our study is a retrospective analysis of 120 referred cases of various vascular anomalies in the last 10 years. Eighty cases had confirmed haemangiomas. MRI scan and needle biopsy formed the basis of diagnosis. M:F = 42:38. Mean age at presentation was 34.8 years, with the youngest and eldest patient being 3.5 and 78 years respectively. 5 patients were lost to study. Sites of occurrence were upper limb(32), lower limb(32), axilla(3), foot(5), thumb(1), knee(4), spine(1), posterior chest wall(2). 55/80 patients were managed non-operatively by way of Sclerotherapy/Embolisation, watchful observation or symptomatic treatment. 4/55 cases were assessed to be unsuitable for sclerotherapy and 1 patient was subjected to surgery. 6/55 cases did not respond to sclerotherapy. 25/55 cases were managed with surgical excision. Complete excision was the primary goal of surgery. Intralesional margins were accepted if lesions were close to neurovascular structures. Indications for surgery were 1) Pain with functional and/or developmental disturbance, 2) Sudden increase in size, 3) Recurrent haemarthrosis, 4) Failure of sclerotherapy. There were 3 cases of incomplete excision among those operated. 6/25 cases had recurrence 1-8 years after surgery. Mean follow-up was 38.4 weeks (range6-12 months). We have had a success rate of 81.48% with non-operative management of symptomatic haemangiomas. Surgical excision of haemangiomas has borne 76% satisfactory results for pain relief/functional recovery. We believe that extensive haemangiomata covering large surface areas are not suitable for surgical excision. Majority of cases can be successfully managed non-operatively by way of sclerotherapy/embolisation and watchful observation. MRI scan coupled with trucut needle biopsy has been most successful for diagnosis. Highly vascular sarcomata can mimic haemangiomas, hence histological diagnosis is crucial

Aim: To review our experience of managing patients with aneurysmal bone cysts (ABC). Method: We reviewed the medical records and radiographs of all patienst with aneurismal bone cyst treated at our unit over a 25 year period. During that time the policy of the unit was to treat ABCs with biopsy/curettage without use of adjuvants or bone grafting. Patients were followed up with regular Xrays until healing had taken place. Local recurrences were again treated with curettage, occasionally supplemented with embolisation or bone grafting. Results: 237 patients (128 female, 109 male), with a median age of 14 yrs (range 1 to 76) received treatment. The cyst size varied from 1 to 20 cm and the median duration of symptoms was 16 weeks (range 0 to 8 yrs). The most common sites were the tibia (55) followed by the femur (41) then the pelvis (29) and humerus (27). 35 (15%) of the patients presented with a pathological fracture. Primary treatment was by curettage alone in 195, curettage and bone grafting in 7, aspiration and injection of steroids or bone marrow in 7, excision in 5 and observation alone in 17. The rate of local recurrence requiring further surgery was 12% with all local recurrences (bar one) arising within 18 months. Local recurrence was not related to site, age, sex or whether the patient had previous treatment or not. Local recurrences were managed with curettage alone in 19 of the 23 cases, with one having embolisation, one excision and 2 curettage and bone grafting. This was successful in all but 3 cases who were controlled with a third procedure. Conclusion: The local control rate of ABCs with simple curettage is 88% which is as good as those published for any other technique. We recommend biopsy in all cases and limited curettage at the same time, many ABCs will heal with this simple procedure. Full curettage is needed for those showing no signs of healing within 4 weeks. Local recurrence is very unusual after 18 months

Aim: To review our experience of managing patients with aneurysmal bone cysts (ABCs). Method: We reviewed the medical records and radiographs of all patients with ABCs treated at our unit over a 25 year period. During that time the policy of the unit was to treat ABCs with biopsy/curettage without use of adjuvants or bone grafting. Patients were followed up with regular Xrays until healing had taken place. Local recurrences were again treated with curettage, occasionally supplemented with embolisation or bone grafting. Results: 237 patients (128 female, 109 male), with a median age of 14 yrs (range 1 to 76), received treatment. The cyst size varied from 1 to 20 cm and the median duration of symptoms was 16 weeks (range 0 to 8 yrs). The most common sites were the tibia (55), followed by the femur (41), then the pelvis (29) and the humerus (27). Thirty-five (15%) of the patients presented with a pathological fracture. Primary treatment was by curettage alone in 195, curettage and bone grafting in 7, aspiration and injection of steroids or bone marrow in 7, excision in 5 and observation alone in 17. The rate of local recurrence requiring further surgery was 12% with all local recurrences (but one) arising within 18 months. Local recurrence was not related to site, age, sex or whether the patient had previous treatment or not. Local recurrences were managed with curettage alone in 19 of the 23 cases, with one having embolisation, one excision and 2 curettage and bone grafting. This was successful in all but 3 cases who were controlled with a third procedure. Conclusion: The local control rate of ABCs with simple curettage is 88%, which is as good as the results published for any other technique. We recommend biopsy in all cases with limited curettage at the same time, and many ABCs will heal with this simple procedure. Full curettage is needed for those showing no signs of healing within 4 weeks. Local recurrence is very unusual after 18 months

INTRODUCTION. Management of neglected residually displaced acetabular fractures is a big challenge. ORIF is often doomed to failure so a primary total hip replacement is usually kept in mind as a method of choice. However THR is a technically difficult and results are quiet unpredictable. OBJECTIVE. To present our experience with THR in maltreated grossly displaced acetabular fractures and to discuss operative technique and prognostic factors in that complicated surgery. MATERIAL. THR was applied in 14 patients (11 males and 3 females, mean age 51 years) with at least three-months old and significantly displaced acetabular fractures. In 12 cases preceding treatment was conservative, and in 2 it was operative. Fracture nonunion was recognized in 5 cases, old hip dislocation in 4 and protusion in 3. Large interfragmentary gaps and local bone defect were detected in almost all cases. METHOD. THR was performed 3–31 months after injury. Extensile iliofemoral or Y-shaped approach with trochanteric osteothomy was used in most cases. Depending of particular situation a variety of techniques were applied to provide adequate bone stock for the cup, such as an approximate ORIF, periacetabular osteotomy, structural or morcelised bone grafting. Reinforcement ring was used in 6 cases. The cup fixation was cemented in 12 procedures and uncemented in 2. Cemented stem was introduced in 10 cases and uncemented in 4. Preoperative selective embolisation of superior gluteal artery was carried out in 1 patient. RESULTS. The operative duration was 3–7 hours and blood loss was 850–2200 ml. The only intraoperative accidentwas jatrogenic lesion of superior gluteal artery required embolisation. The follow up was a 16–94 months. Average postoperative Harris Hip Score was 78, compared with 54 before surgery (P<0.01). There was 2 aceptic and 1 septic loosenings with subsequent revisions (21.4%). In 2 cases sight asymptomatic migration of the cap was noted. DISCUSSION. The most difficult but most important stage of operation is a creating of sufficiently stable bone stock for the acetabular cap, impeded by by fragment displacement, nonunion or prolonged hip dislocation. If nonuion the achievement of bone healing is essential. Any instability should be overcomed by stable osteosynthesis. The gaps should be filled by ORIF or bone grafting. We consider cemented fixation possibly with reinforcement ring as a most secure way to provide strong cup anchorage. Uncemented pess-fit cup may be used in cases with lesser initial displacement. In spite of all late results are considerable worse than in conventional hip replacement. CONCLUSION. THR after neglected acetabular fractures is a challenging and demanding procedure. Successful outcome may be only expected if a solid bone stock is made using various surgical techniques

Introduction and Aims: Acute intramedullary stabilisation of femoral shaft fractures in multiply injured patients remains controversial. Intravasation of medullary fat during nailing has been suspected to trigger ARDS. This study investigates the effect of a filter placed into the ipsilateral common iliac vein during medullary canal pressurisation in a canine experiment. Method: Using an established model, 12 mongrel dogs were randomised into two groups. Under general anesthesia, cannulations were performed to measure left and right-sided pressures. Transoesophageal echocardiography was performed in all dogs. A special ‘TRAP ‘filter was inserted percutaneously into the left common iliac vein in six dogs, whereas the other six served as controls. In all dogs, the left femora and tibiae were then pressurised by injection of bone cement and insertion of intramedullary rods. Hemodynamic measurements and echocardiography images were recorded continuously. After one hour, the animals were sacrificed and the lungs were harvested for histomorphommetric analysis. Results: The mean pulmonary artery pressure at three minutes of pressurisation was 12mm of Hg in the filter group and 28mm of Hg in the control group. There was increase in the peak systolic pulmonary artery pressure and the right ventricular pressure after canal pressurisation in the control group, whereas no such changes were observed in the filter groups. The pulmonary vascular resistance as denoted by the difference between the mean pulmonary artery pressure and the end diastolic left ventricular pressure increased significantly (p< 0.05) at three, five, 10,15 and 30 minutes after pressurisation in the control group when compared to the baseline value. In the filter group, the pulmonary vascular resistance increased only slightly after pressurisation. Transesophageal echocardiography images were analysed by a blinded echocardiologist. There was evidence of moderate to severe embolisation in the control group with detection of large echogenic particles. In comparison, there was mild grade of embolisation in the filter group. Histological analysis showed statistically significant difference between the two groups, when comparison of the percentage of area of lung tissue occupied by fat, the percentage of pulmonary vasculature occupied by fat and the maximum size of the embolus were made (p< 0.05). Conclusion: This study has conclusively demonstrated that mechanical blockade by venous filters prior to medullary canal pressurisation, significantly reduces the embolic load and its effect on the lungs. A retrievable filter with a system to remove the accumulated marrow content is being developed for use in high-risk patients

Patients with solitary spinal metastases from Renal Cell Carcinoma (RCC) have better prognosis and survival rates compared to other spinal metastatic disease. Adjuvant therapy has been proven ineffective. Selected patients can be treated with Total En bloc Spondylectomy (TES) for solitary intra-osseous metastasis in the thoracolumbar spine secondary to renal cell carcinoma. Five patients with solitary vertebral metastasis secondary to RCC underwent TES for radical resection of the spinal pathology after pre-operative embolisation. The procedure involves en bloc laminectomy and corpectomy with posterior instrumented fusion and anterior instrumentation with cage reconstruction following the spondylectomy. All patients were fully staged pre-operatively and assessed according to the Tokuhashi scoring system. Recurrence of spinal metastasis and radiological failure of reconstruction. All patients demonstrated full neurological recovery and reported significant pain relief. One patient died at 11 months post-op due to a recurrence of the primary. The other four are well at 24, 45, 52 and 66 months post-op without evidence of recurrence in the spine. There were no major surgical complications. Careful patient selection is required to justify this procedure. The indication is limited to solitary intra-osseous lesions where complete resection of the tumour is possible. The main advantage of this treatment is that it affords significant pain relief and restores spinal stability whilst minimizing local recurrence

Introduction. Corrective femoral osteotomy in adults, as a closed procedure with the use of an intramedullary saw, is an elegant, minimally invasive technique for the correction of lower limb length inequalities or problems of torsion. Stabilisation following the osteotomy was achieved with a cephalo-medullary nail. We report the indications, results and complications following use of this technique. Aim. The aim of the study was to review consecutive patients who underwent closed femoral rotational or shortening osteotomy using an intramedullary saw over a ten-year period. Material & Methods. Forty femoral rotational and/or shortening osteotomies using an intramedullary saw were performed on thirty-six patients, between January 2001 and June 2011. The main indications were post-traumatic leg length discrepancies and congenital rotational abnormalities. Clinical & radiological follow up mean was 16.3 months. Results. Twenty one osteotomies were performed for femoral shortening with the mean correction of 3.5 cm. Nineteen osteotomies were performed for correction of torsion; there was a mean correction of 28.64 degrees with Internal rotation and 35 degrees with external rotation osteotomies. Fourteen patients required removal of locking screws. There were two patients with heterotrophic ossification, two patients with wound infection (one deep infection). One patient had a materiovigilance incidence and one patient had vascular complication requiring embolisation. The subjective results showed 37 osteotomies were satisfied with their operation, functional recovery and aesthetic appearance of the scars. Conclusion. Closed osteotomy of femur for correction of LLD and torsion using an intramedullary saw represents a reliable and effective procedure. Despite the complications, the original goal of the surgery was achieved in 37 of the 40 limbs treated. Patient satisfaction was achieved in 92.5 % of 40 osteotomies

To determine presenting features, treatment modalities and associated outcome following treatment of spinal dural arteriovenous fistulas in a tertiary centre. Retrospective cohort study of patients with SDAVF assessed at a single tertiary referral centre, between 1999 and 2009. Medical records were used to identify intervention type, pre- and post-intervention Aminoff-Logue disability score (ALDS), recurrence rate, follow-up time and discharge status. Statistical analysis was performed using Wilcoxon signed rank. 26 patients were identified with 23 receiving intervention. Two were unavailable for follow up. Endovascular embolization was performed successfully in 13 patients, recurrence occurred in 6 of these, 3 of which were subsequently treated surgically. Surgery was the initial treatment for 10 patients due to either unsuccessful embolization attempt or proximity of the fistula to spinal artery feeders; only 1 of these recurred. ALDS-gait reduced (improved) by a mean of 0.33 points following intervention but this was not statistically significant (P=0.0645). There was negligible change in micturition and bowel ALDS. Improvement in ALDS was greater in patients treated with surgery first and also in patients whose fistula did not recur. Mean follow-up was 38 months with 56% of working age patients returning to work. Both embolisation and surgery achieved the primary aim of reducing disease progression, leading to an improved ALDS. Outcome was superior if initially treated surgically and recurrence occurred more frequently in patients treated endovascularly. The small number of patients in our cohort emphasise the need for further studies into this group of patients

Giant cell tumors (GCT) of the sacrum have a high recurrence rate, up to 33%. Treatment of Giant Cell Tumors (GCT) of the sacrum has many options. Although curettage is more often performed than partial sacral resection the indications are not well described. Large resection in the sacral area is limited, and adequate local adjuvant therapy potentially damages the nervous system. Therefore the type of surgical treatment of sacral GCT is still under debate. The purpose of this study was to compare clinical outcome after surgical treatment in GCT of the sacrum using two different surgical techniques: curettage and Extended Cortical Excision (ECE). Pre-operative embolisation was routinely performed, followed by curettage or PSR followed by reconstruction if indicated. Between 1994–2005 11 patients were treated for GCT of the sacrum. Eight were female, 3 men. The median age was 43.5 (14–66) years. The median follow-up period was 60 (6–156) months. Five patients were eventually treated by ECE. The other patients were operated on using different techniques, mainly curettage and/or adjuvant therapy. Two patients died disease-related 42 and 6 months after primary treatment, both metastasized. All other patients are alive and currently disease-free. Six patients had a recurrence, after 33 (4–140) months. Three patients had a recurrence twice. Three patients received radiotherapy, 1 as palliative treatment and 2 as (adjuvant) therapy for recurrence. No recurrences were seen after ECE compared to 86% (6/7) after curettage only, and 50% (2/4) after curettage with adjuvant therapy. Extended cortical excision may improve the recurrence rate in sacral GCT

Periprosthetic osteolysis after total joint replacement is a well described complication. This normal slowly increasing process is caused by infection, implant loosening or more special, debris induced. However malignant processes may rarely occur at exact this location too. Based on clinical presentation and imaging it is sometimes difficult to exclude a local malignant process. We report two cases of extensive osteolysis after total hip replacement, including their follow up and a review of the relevant literature. Two female patients developed massive osteolysis in periprosthetic areas (pelvic area and proximal femur as well as distal femur) after being treated by total hip arthroplasty 14 and 18 years ago. In both cases a tumorous process was suspected after imaging and they were therefore referred to our clinic. In one case a rapidly progressing soft tissue swelling with extensive peri-articular osteolysis was considered to be a malignant tumour. After an incisional biopsy, an embolisation had to be performed due to continuous massive bleeding. Histology revealed a superinfected polyethylene disease, treated with a two stage revision surgery. The second patient presented with an impending fracture due an unusual osteolysis at the tip of the stem. Here again polyethylene debris was found at biopsy. Extensive osteolysis and/or soft tissue swelling caused by polyethylene debris may sometimes be difficult to differ from a tumorous process. As a guideline presented by Min WK. et al in 2008 a reactive bone-destroying process normally proceeds slowly in contrast to a more rapid progression in malignant disease. However, as presented in the first of our cases, exemptions may occur. In these cases a biopsy or at least a frozen section at operation should be obtained in order to exclude a real neoplasm

Introduction: Patients with solitary spinal metastases from Renal Cell Carcinoma (RCC) have better prognosis and show longer survival rates compared to other spinal metastatic disease. Adjuvant control by chemotherapy and hormonal therapy has been proven ineffective to treat this relatively radio resistant tumour, which can often present with both back pain and neurological deficit. Selected patients can be treated with Total En bloc Spondylectomy (TES) for solitary intra-osseous metastasis in the thoracolumbar spine secondary to renal cell carcinoma. Methods: Four patients with solitary vertebral metastasis secondary to RCC underwent TES for radical resection of the spinal pathology after pre-operative embolisation. The procedure involves en bloc laminectomy and corpectomy with posterior instrumented fusion and anterior instrumentation with cage reconstruction following the spondylectomy. All patients were fully staged pre-operatively and assessed according to the Tokuhashi scoring system to determine predictive life expectancy. Results: All patients demonstrated full neurological recovery and reported significant pain relief. One patient died at 11 months post-op due to a recurrence of the primary in the nephrectomy bed. The other three are alive and well at 33, 40 and 54 months post-op with no radiological evidence of tumour recurrence in the spine. There were no major surgical complications. Discussion: Careful patient selection is required to justify this procedure. The indication is best limited to solitary intra-osseous lesions where complete resection of the tumour is possible. The main advantage of this treatment is that it affords significant pain relief and restores spinal stability whilst minimizing local recurrence. Conclusion: TES can improve symptomatic control of isolated solitary spinal metastases of the thoracolumbar spine in Renal Cell Carcinoma