Introduction

The clinical and functional outcome following simultaneous fractures of the acetabulum and pelvic ring represent a challenge for the clinician and are currently obscure in the existing literature.

Posterior interoseous nerve (PIN) syndrome is an entrapment of the deep branch of the radial nerve just distal to the elbow joint. It may result in the paresis or paralysis of the fingers and thumb extensor muscles.

We present a review of 26 cases of PIN entrapment syndrome, diagnosed an treated over a ten years period form 1996 to 2005. Their ages ranged form 12 to 57 years, they were 18 men and 8 women. The interval between, the onset or paralysis and operation ranged from 4 months to 1 year. All the patients were diagnosed preoperatively as having PIN palsy from physical examination and electromyographic (EMG) studies of the posterior interoseous innervated muscles and all were treated by operation.

The cause of compression was, ganglia in four cases, fascia thickening at the arcad of frohse in six cases, the radial recurrent vessels in three cases, lipoma in four cases, dislocated head of the radius in two cases, infamed synovium in four cases, tumour in two cases, and Intraneural Perineurioma in one case. The periods of postoperative observation were from 1 to 10 years. The paralysis recovered completely by the six postoperative months in all cases except one girl with intraneural peri-neurioma.

Three patients developed mild reflex sympathetic dystrophy which resolved with physiotherapy and auxilary blocks. Two patients developed hyperaesthesia in the distribution of the superficial radial nerve which recovered in a few weeks.

Having arrived at a diagnosis of PIN syndrome, it is important to select the correct level for the release of the radial nerve. Fair or poor results can be due to incorrect diagnosis, incomplete release or irreversible nerve injury.

Acute fractures of the humeral shaft are usually managed conservatively. The rate of union is high, whereas that of nonunion ranges from 1 – 6%. Various risk factors for nonunion have been identified, including the following: open fracture, mid shaft fracture, transverse or short-oblique fracture, comminuted fracture, unstable fixation, fracture gap.

This paper evaluates the results of treatment of humeral shaft fracture by open reduction and internal fixation with DCP, supplemented with cancelous bone graft but not in all cases.

One hundred and five cases of nonunion of a humeral shaft fracture between 1988 and 2006 were analyzed retrospectively. The study population comprised 66 males and 39 females with an average of 46.2 years (range, 17 – 81 years). Sixty seven fractures were defined as atrophic nonunion, and 20 as hypertrophic nonunion, whereas 18 could not be defined clearly. All the fractures were managed by open reduction and internal fixaztion with DCP and cancelous bone graft. The mean follow up period was 20 months (range, 14 – 28 months).

All nonunion fractures united within an average of 16 weeks (range 10–26 weeks).

Complications included 4 patients with temporary radial nerve palsies, and 3 patients with wound infections. At the final follow-up shoulder and elbow functions of the operated limbs were all satisfactory.

Fixation by DCP with supplemental cancellous bone graft is a reliable and effective treatment for nonunion of a humeral shaft fracture

Objective: Primary reconstruction of soft tissues in acute complex lower limb injuries is often mandatory in order to protect exposed bones, nerves, tendons and/or vessels, however it may be precluded by general clinical and/or local wound conditions. Vacuum assisted closure (VAC^®) has been introduced in the management of complex wounds for its ability to remove third space fluids, improve oxygen delivery to the wound bed, while it promotes angiogenesis and granulation. This retrospective study evaluates the use of VAC^® in lower limb trauma patients unsuitable for immediate reconstruction.

Patients and Methods: Fourty-two patients, 24 males and 18 females, with 49 complex lower limb traumas were treated with VAC^® therapy for a mean of 28 days (range 15–42 days). Mean age of patients was 47 years (range 21–82). All patients included were characterized by poor general condition or adverse local wound factors. VAC^® was applied 24–48 hours after bone fixation, vascular repair and surgical debridement of non viable tissues so as to minimize the risk of bleeding and ensure viability of soft tissues in the wound bed. Wound swab cultures were obtained before the application of VAC^® and before every change of sponge. The duration of therapy, wound flora, final reconstructive technique required, outcome and follow up period were recorded for each patient.

Results: Seventeen patients were over 65 years of age, 28 were Intensive Care Unit patients, 11 had heavily exuding wounds and in 9 the viability of soft tissues after initial debridement was questionable. Patients were followed up for 60 to 395 days. Two wounds (4%) healed spontaneously, 6 (12.2%) were managed with delayed direct suture, 31 (63.2%) were managed with skin grafts, 8 (16.3%) required local flaps. Two patients died during therapy due to concurrent conditions. In all but one patient, wound bacterial flora was progressively reduced during therapy. Scars were aesthetically acceptable, however, in 7 wounds hypertrophic scars were treated with triamcinolone injections combined with silicone sheeting.

Conclusion: VAC^® is a safe and effective method facilitating delayed soft tissue reconstruction in complex lower limb traumas in high risk patients. The development of healthy granulation tissue minimizes the need for major conventional reconstructive operations and therefore postoperative morbidity.

The aim of our study was to examine the outcome of ACL reconstruction by using four strand hamstring tendon autografts.

Material and Methods: the study included 44 patients (29 males,15 females;mean age 26;18–45 years). The diagnosis was based on clinical examination and imaging techniques. The operation was performed arthroscopically 4–62 weeks after the injury. The tendon was fixed in the tibia with an interference screw and in the femur with three different methods cross pin in 16 cases, transfix pin in 11 cases and Endo button in 17 cases.

Results: The mean follow up was 28 months (12–42). The mean Lysholm score was improved from 35–65 (mean 49) preoperativelly to 55–100 postoperativelly (mean 88).

5 patients had laxity > 3mm when compared to the healthy knee by using the KT-1000 arhthrometric testing. 2 of the latter patients complained of a feeling of knee joint instability which occurred due to inaccurate positioning of the femoral tunnel. In 2 cases the transfix pins were displaced and removed on the 4th and 15th post-operative month.

The tunnel expansion was measured by an X-Ray or a CT scan. The tibial tunnel expansion was 0–2.5mm (mean 1.2) or 18% and the femoral tunnel expansion was 0–3 mm (mean 1.4) or 26%. 8 patients reported mild pain which did not restrict their activities. A 5 degree loss of extension was noticed in one patient who continues physiotherapy.

28 of the above patients suffered also from a meniscal injury that was managed arthroscopically.

Conclusion: ACL reconstruction by using four strand hamstring tendon autografts is safe, highly successful with very few complications when proper graft preparation and accurate tunnel placement is achieved.

Purpose: The intramedullary nailing is the treatment of choice for the femoral shaft fractures, giving advantages of early mobilization and weight bearing.

The purpose of this study is to present our experience with numerous reamed femoral nails and to report the results and the complications.

Material and Method: From 1993 to 2004, 415 femoral shaft fractures (413 patients) were treated in our hospital. There were 312 males 101 females with mean age was 27.8 yrs (17–84 yrs). The 87 % of fractures were caused by high-energy injuries (traffic accidents). Pathologic fractures were not included.

The 415 fractures according to AO classification were divided as follows: Type A: 105 (25.4%), Type B: 179 (43.1 %), Type C: 131 (31.5 %) There were 341closed fractures and 74 open. Those 74 were classified according Gustilo to 33 Grade I, 24 Grade II, 14 Grade III A, 2 Grade III B and 1 Grade III C.

The fractures were treated with 308 AIM titanium nails and 107 Gross-Kempf nails. Dynamic stabilization was performed in the majority of the type A fractures, and static to those classified as B and C. We encourage our patients to walk with partial weight bearing, from the second post op day, except those with type C fractures who started their weight bearing after a month.

The patients were evaluated 3,6,12,36 weeks and 1 years post surgery clinically and with standing X-Rays.

Results: After a mean follow-up time of 1.5 years, our union rate was 97.8%. Type A fractures were united in an mean time of 16 weeks, type B in 20 weeks and type C in 23 weeks.

Our complications were: 9 non unions (aseptic pseudarthrosis) (2.2%), 14 delayed unions (3.4 %), torsional malunion (more of 5°) in 4 patients (0.96 %). In 6 patients (1.44 %) we had limb shortening of 15 mm. Neurological complications were observed postoperatively in 30 patients, 25 with paresis of the pudendal nerve, due to traction (all recovered in a month), and 5 with paresis of peroneal nerve which were recovered in 3 months. There was found 28 broken screws but no broken nail. We had 3 pulmonary and 2 fat embolisms, but none of them was fatal. In 4 patients was observed clinically vein thrombosis below knee. Also we noticed one superficial and one deep infection, but we didn’t have a case of compartment syndrome.

Patients returned to their previous activities in a mean time of 10 months.

Conclusion: Our results confirmed that the antegrade intramedullary nailing technique had optimal results and high union rate regarding the treatment of the femoral shaft fractures. Some of the complications could be related with the surgeon’s skills-experience and could be avoided. We prefer the use of titanium nails because their modulus elasticity is closer to bones.

Introduction: Spondylodiscitis is a rare but serious disease due to delay in diagnoses and inadequate treatment. The outcome mainly related to the early diagnosis.

The purpose of our study is to analyze retrospectively our patients, who had received conservative treatment or either posterior or combined approach.

Material and Method: Between 1992 and 2000, 163 patients were hospitalized due to spondylodiscitis; 62 were females and 101 males. The mean age was 56 years (1–83yrs).

The diagnosed was based on clinical examination, cultures, bone histology, X-rays, bone scan and MRI with gadolinium. The location of the infection was in 13 (8%) patients the cervical spine, in 62 (38%) the thorachic, in 10 (6%) the thoracolumbar junction and in 78 (48%) the lumbo-sacral spine. In 95 cases, concomitant diseases were present.

In 67 (41%) patients was not able to detect any microorganism. From the remaining patients, 53 (33%) were infected by staph.aureus and 22 (13%) by mycob tuberculosis.

The patients according to the treatment provided, were divided in three groups:

Group A: 70 patients, which had conservative treatment with antibiotics and bracing.

Results: The 12 months follow up reveals that 8 patients (11.4%) of group-A were operated. On the other hand 24 (42.9%) of the group-B were revised, as well as 6 (16.2%) patients from the group C.

The group A patients had not neurological symptoms. In group B, 11 had altered neurology and the operation was beneficial for 5 of them (45.5%), 4 remained unchanged and in 2 was deteriorate. In group C, 11 patients had altered neurology, from which 9 (81.8%) were improved and 2 remained unchanged.

The in-hospital complications were: 2 pulmonary embolism, 2 post operative haematomas, 1 persistent anaimia, 1 diafragm paralysis, 2 atelectasia and 1 cerebral thrombosis. In addition 3 patients had residual psoas abscess, 2 pancreas abscess, 1 cerebelum abscess and 3 lung infection.

The in-hospital mortality was 3 patients, other 17 patients died during the follow up

Conclusion: Spondylodiscitis is a valid diagnose for persisting back pain. Bacterial isolation is still difficult no matter the improved techniques, but in the majority of the cases is Staph.Aureus.

The conservative management in selected patients is effective up to 89%. From the operations performed the decompression alone had unacceptable high re-operation rate and also, it wasn’t so beneficial regarding the neurological improvement. If it is combined with anterior reconstruction and posterior stabilization provides better results.

Purpose of the Study: To ascertain the role of Dynesys system (Zimmer Spine, Minneapolis) in the surgical management of chronic low back pain

Methods: 55 patients with persistent low back pain despite conservative measures were treated with Dynesys over a period of two and a half years. Participants either underwent Dynesys procedure alone or in combination with fusion or decompression surgery. Oswestry Disability Index (ODI), Visual Analogue Scores (VAS) and SF-36 questionnaires were completed pre-operatively and at one and two years post-operatively. Pre-operative testing using the Distress and Risk Assessment Method (DRAM) identified psychological distress prior to surgery. Patient Oriented Outcome questionnaires were circulated retrospectively following surgery to obtain data regarding patient’s perceptions and expectations of their outcome.

Results: Overall, the mean ODI reduced by 10.23% after one year and 16.15% after two years following surgery. VAS improved by 12mm one year and by 17mm two years after operation. Patients with psychological distress pre-operatively showed less improvement in their ODI and VAS at two-year follow up. The results of fusion were similar to Dynesys alone, and patients who also had decompression had best results. 72.2% patients reported an improvement following their surgery and the same percentage would have the operation again in retrospect.

Conclusion: This is the first study exploring clinical outcomes following surgery using Dynesys dynamic stabilization system in patients with disabling low back pain. Previous studies have reported good outcome in the treatment of spinal stenosis. Over 70% patients in our study reported improvement following the procedure but more evidence is needed to determine if it is a viable alternative to spinal fusion.

Aim: To assess the kinematic changes that occur within the lumbar spine 2 years following insertion of the Dynesys Spinal stabilisation implant.

Materials and Methods: Twenty patients who were treated with Dynesys surgical stabilisation for dominant lower back pain underwent positional MRI scanning before and two years following surgery.

The patients were divided into two groups, A and B. The first, Group A, in which only Dynesys was used and the second, Group B, in which Dynesys was used adjacent to one or more fused segments.

Results: The results of the pMRI measurements showed that the range of movement (ROM) of the L1/S1 angle in Group A reduced by 11.8o{pre-op=37.9o, postop=26.1o(p=0.085)} while in Group-B reduced by 12.3o {pre-op=37.8o, postop=25.5o(p=0.017)}.

The ROM of the end plate angle at the instrumented segments in Group A reduced from 5.72^o to 1.44^o{difference 4.28^o(p=0.005)} and in Group B reduced from 6.00^o to 2.17^o,{difference 3.83^o(p=0.001)}.

The ROM of the end plate angle at the level above instrumentation in Group A reduced from 8.2^o to 5.1^o {reduction 3.1^o(p=0.085)}, while in group-B increased from 7.3^o to 7.5^o, a difference of 0.2^o (p=0.877).

The mean anterior disc height in Group A reduced by 2.1mm (p< 0.001) from 9.59mm to 7.44mm. The posterior disc height also reduced from 6.56mm to 6.26mm, a difference of 0.3mm, (p=0.434). In Group B, the anterior disc height reduced by 1.98mm (pre-op=9.04mm, post-op= 7.06mm, p=0.001) and the posterior height by 0.35mm (pre-op 6.14mm to post op 5.79mm, p=0.443)

Discussion: This study shows that the Dynesys stabilisation system allows some movement at the operated segment two years following surgery. The study also confirms that the adjacent segment hypermobility often seen following spinal fusion surgery is eliminated.

Purpose: To evaluate the changes in lumbar spine kinematics and clinical outcomes of patients with spinal stenosis 2 years after implantation of the X Stop interspinous decompression device.

Methods: 10 patients (6 males; 4 females) underwent X Stop procedure. Age ranged from 57 years to 71 years. 15 levels were operated (5 single levels: L_2-3 - 1, L_4-5 - 4; 5 double levels: L_3-4 +L_4-5 – 4; L_4-5+L₅S₁ – 1). A 0.6 Tesla Upright MRI scanner was used to acquire images in seated (flexion, extension, and neutral) and erect postures at preoperative, 6 months, and 2 years after surgery. The total range of motion of the lumbar spine and the operated segments were measured, along with changes in disc height, areas of the exit foramens, and dural sac. Clinical outcomes were assessed by Zurich Claudication Questionnaire before and 3, 6, 12, and 24 months after surgery.

Results: Mean Zurich Claudication Scores (n=10)

At 6 months, there was a significant increase in the spinal canal and foraminal dimension. However at 2 years there was a reduction in these dimensions such that there was no significant difference from the preop-erative measurements.

Conclusion: The results of this prospective observational study indicate that X Stop offers significant short-term improvement. It is a safe, effective, and less invasive alternative for treatment of lumbar spinal stenosis. The maximum clinical benefit and mechanical efficacy seems to be realized in the early stages postoperatively with gradual reduction thereafter over 2 years. Co-existing co-morbidities such as obesity and osteoarthritis in the lower limbs may influence the clinical results.

Background: It has been demonstrated that a relationship exists between pro-inflammatory cytokine levels and psychological distress. Psychological distress commonly co-exists with back pain and may be detrimental to rehabilitation in such patients undergoing surgery. We aim to establish whether a link exists between psychological distress and increased levels of Interleukin- 6 (IL-6) and it’s soluble receptor (sIL-6r) in patients undergoing surgery for low back pain.

Methods: All individuals selected for spinal fusion or stabilisation surgery, in whom low back pain was the predominant feature, were eligible for inclusion. Participants completed both the Distress and Risk Assessment Method (DRAM) and Hospital Anxiety and Depression Score (HADS) questionnaires pre-operatively. Blood samples for serum IL-6, sIL-6r and high sensitivity C-Reactive Protein (CRP) levels were extracted at recruitment and results were compared with questionnaire findings.

Results: 63 patients were recruited of whom 90.5% had some degree of measurable psychological distress. Patients were divided into two groups based upon the degree of their distress.

Mean IL-6 levels were higher in groups of patients with more distress measured by the DRAM and HADS depression component but were lower in patients with more anxiety. IL-6 receptor levels were higher in patients with raised DRAM and HADS anxiety scores.

No significant correlation between questionnaire responses and cytokine levels was found. A correlation exists between IL-6 and CRP levels even at normal levels of CRP.

Conclusion: There does not appear to be a significant relationship between IL-6 and sIL-6r levels and psychological distress in back pain patients.

Aim: To assess the kinematic changes that occur within the lumbar spine 2 years following insertion of the Dynesys Spinal stabilisation implant.

Materials and Methods: Twenty patients who were treated with Dynesys surgical stabilisation for dominant lower back pain underwent positional MRI scanning before and two years following surgery.

The patients were divided into two groups, A and B. The first, Group A, in which only Dynesys was used and the second, Group B, in which Dynesys was used adjacent to one or more fused segments.

Results: The results of the pMRI measurements showed that the range of movement (ROM) of the L1/S1 angle in Group A reduced by 11.8o{pre-op=37.9o, postop=26.1o(p=0.085)} while in Group-B reduced by 12.3o {pre-op=37.8o, postop=25.5o(p=0.017)}.

The ROM of the end plate angle at the instrumented segments in Group A reduced from 5.72^o to 1.44^o{difference 4.28^o(p=0.005)} and in Group B reduced from 6.00^o to 2.17^o,{difference 3.83^o(p=0.001)}.

The ROM of the end plate angle at the level above instrumentation in Group A reduced from 8.2^o to 5.1^o {reduction 3.1^o(p=0.085)}, while in group-B increased from 7.3^o to 7.5^o, a difference of 0.2^o (p=0.877).

The mean anterior disc height in Group A reduced by 2.1mm (p< 0.001) from 9.59mm to 7.44mm. The posterior disc height also reduced from 6.56mm to 6.26mm, a difference of 0.3mm, (p=0.434). In Group B, the anterior disc height reduced by 1.98mm (pre-op=9.04mm, post-op= 7.06mm, p=0.001) and the posterior height by 0.35mm (pre-op 6.14mm to post op 5.79mm, p=0.443)

Discussion: This study shows that the Dynesys stabilisation system allows some movement at the operated segment two years following surgery. The study also confirms that the adjacent segment hypermobility often seen following spinal fusion surgery is eliminated.

Purposes Of The Study-Background Data: Dynesys is claimed that allows motion in the operative levels. This study measures the changes in the lumbar spine in different postures, pre- and after insertion of the device.

Thirty patients with were treated with Dynesys system. All had discography and positional MRI preoperatively and nine months post-operatively.

The patients were divided in to two groups. The first in which only Dynesys was used and the second in which Dynesys was used with fusion.

Results: The operated levels were 63. The results of the pMRI measurements showed that the range of movement(ROM) of the L1/S1 angle in group-A reduced by 11.89^o{pre-op=39.26^o,postop=27.37^o(p=0.008)} while in group-B reduced by 13.73^o {preop=36.18^o,po stop=22.45^o(p=0.002)}.

The ROM of the end plate angle at the instrumented segments in group-A reduced from 5.24^o to 2.18^o{difference 3.06^o(p< 0.005)} and in group-B reduced from 6.69^o to 2.46^o,{difference 4.23^o(p=0.008)}. The ROM of the end plate angle at adjacent level in group-A changed from 8.26^o to 7.0^o {reduction 1.26^o(p=0.388)},while in group-B increased from 6.91^o to 8.64^o, {difference 1.73^o(p=0.149)}

The mean anterior disc height in-group A reduced by 1.43mm (p< 0.005) from 9.75mm to 8.32mm, and the posterior one was increased from 6.27mm to 6.77mm {difference of 0.5mm,(p=0.008)}. In group-B the anterior disc height reduced by 1.11mm (pre-op=10.44mm,post-op= 9.33mm,p=0.049) and the posterior one by 0.16mm (pre-op 6.98mm to post-op 6.82mm,p=0.714).

Conclusion: This study shows that in the Dynesys stabilizing system allows small range of movement at the instrumented levels, with no significant increased mobility in the adjacent levels. Also the device acted to compress the anterior annulus.

Purpose: To measure the effect of the X-Stop interspinous distraction device on spinal canal, exit foramina, and disc height dimensions at the operated level; and adjacent segment endplate angle, and lumbar spine movement in patients with symptomatic lumbar spinal stenosis using upright MRI.

Methods /Results: 14 patients (9 M;5 F) were scanned before and six months after operation. Age ranged from 57 to 88 years. All had symptomatic lumbar spinal stenosis- single level- 9 (L2/3-1; L3/4-1; L4/5-7); double level 5 (L3/4, L4/5).

Images were taken in sitting flexed, extended, neutral, and standing. The total range of motion of the lumbar spine and of the individual segments were measured, along with changes in disc height, areas of the exit foramina, and dural sac.

The mean area of the dural sac at the operated levels increased from 62.46mm2 to 77.69mm2 (p=0.004) in the standing posture and from 70.85mm2 to 94.62mm2 (p=0.019) in extension postoperatively. The area of the exit foramina in extension increased from 83.57mm2 to 107.88mm2 (p=0.002) on the left side and from 83.77mm2 to 108.69mm2 (p=0.012) on the right. The overall changes in the range of movement of the individual segments or of the lumbar spine were statistically insignificant.

Conclusions: This is the first study carried out using an upright MRI scanner in patients with lumbar spinal stenosis. The X-Stop device increases the cross-sectional area of the spinal canal and exit foramina by distracting the spinous processes of the operated level without significantly affecting overall posture of the lumbar spine.

Introduction Symptoms of neurogenic intermittent claudication in spinal stenosis are explained by the narrowing of the spinal canal in the extended (upright) position and widening in the sitting (flexed) position. The XStop inter-spinous process distraction device is a new product that is designed to hold the affected segments in a flexed posture. This prospective study looks at the changes in the lumbar spine in a variety of postures from pre- to post insertion.

Methods Using a positional magnetic resonance imaging (pMRI) scanner, patients were scanned before and six months after the insertion of the device. Images were taken in sitting flexed and extended, and standing positions. The change in the total range of movement of the lumbar spine and in the individual operated segments was measured along with changes in the surface areas of the exit foramen, the dural sac, and the disc height.

Results 12 patients with 17 levels distracted have been scanned and measured. The cross sectional area of the dural sac at the level of the stenosis has increased from a mean of 77.8 mm² to 93.4 mm² in the standing position (p=0.006) and from 84.56mm² to 107.35mm² on extension (p=0.008). There were no statistically significant changes in the range of movement of the whole lumbar spine, or at levels adjacent to the device.

Discussion This study demonstrates that the X Stop device increases the cross sectional surface area of the spinal canal at the stenosed level, without causing extensive changes in the posture of the lumbar spine.

Introduction The Dynesys device uses transpedicular screws linked by a cord and spacers. It is claimed that the advantage is that it allows some motion, in all directions, in the operative levels. In vitro laboratory biomechanical studies show that the movement permitted is similar to rigid fusions.

This study measures the changes in the lumbar spine in different postures, pre- and after insertion of the device.

Material-method In our study 20 patients with dominant low back pain, with or without leg pain, were treated with Dynesys system. Stress discography was made to evaluate the symptomatic level

All had a positional MRI preoperatively and nine months post-operatively in flexion-extension-lateral bending.

The patients were divided in to two groups:

Group(A) with 8 patients in which Dynesys was used with fusion (disc-height< 40 %)

Group(B) with 12 patients was the Dynesys-only group (disc-height=40–90%).

Results The operated levels were 42, 10 of those were fused levels. The results showed that there was a statistically significant difference in flexion-extension range of movement of the whole lumbar spine (mean= −13.45)(p< 0.005), but it wasn’t significant in the level above (mean=0.056)(p=0.972) and at a single instrumented segment was (mean=−4.06°)(p< 0.05)

The changes in the anterior disc height was (mean= −1.18)(p< 0.05) and to the posterior (mean=0.37)(p=0.134). In bending were (mean=−0.87°)(p=0.18) for left and (mean=−0.24°)(p=0.75) for the right

Discussion This study shows that in the Dynesys stabilizing system allows small range of movement at the instrumented levels, with no significant increased mobility in the adjacent levels. Also the device acted to compress the anterior annulus

Introduction Symptoms of neurogenic intermittent claudication in spinal stenosis are explained by the narrowing of the spinal canal in the extended (upright) position and widening in the sitting (flexed) position. The X-Stop® inter-spinous process distraction device (St. francis Medical Technologies) is a new product designed to hold the affected segments in a flexed posture. This prospective study looks at the changes in the lumbar spine in a variety of postures from pre- to post-insertion.

Method Using positional MRI (pMRI), patients were scanned before and six months after operation. Images were taken in sitting flexed, extended, neutral, and standing positions. The total range of motion of the lumbar spine and of the individual operated segments were measured, along with changes in disc height, areas of the exit foramina, and dural sac.

21 patients (11 males; 10 females) were included in the study. Age ranged from 57 – 88 years. All had symptomatic lumbar spinal stenosis- single level- 13 (L2/3-1; L3/4-3; L4/5-9); double level 8(L3/4, L4/5 – 7; L4/5, L5/ S1 – 1).

Results The mean area of the dural sac at the operated levels increased from 89.25mm2 to 108.96mm2 (p< 0.001) in the standing posture and from 103.96mm2 to 124.94mm2 (p< 0.001) in extension postoperatively. The area of the exit foramina in extension increased from 79.15mm2 to 100.41mm2 (p< 0.001) on the left side and from 80.86mm2 to 98.74mm2 (p< 0.001) on the right side. The overall changes in the range of movement of the individual segments or of the lumbar spine were statistically insignificant.

Discussion Previous, radiologic (Willen J, et al; Spine 1997) and cadaveric studies have demonstrated reduction in area of the dural sac and exit foramina as the lumbar spine moves from flexion into extension. Our study is the first to quantify these changes in symptomatic patients with lumbar spinal stenosis using postional MRI. This study supports previous studies using positional MRI scanner in patients with lumbar spinal stenosis and also demonstrates that the X-Stop device increases the cross-sectional area of the spinal canal and exit foramina by distracting the spinous processes of the operated level without significantly affecting overall posture of the lumbar spine.

Introduction The Dynesys® stabilisation system (Zimmer Spine) uses transpedicular screws linked by a cord and spacers; the advantage claimed is that it allows some motion, in all directions, in the operated levels. In vitro laboratory biomechanical studies show that the movement permitted is similar to rigid fixation systems.

This study measures the changes in the lumbar spine in different postures, pre- and after insertion of the device. Methods In our study 25 patients with dominant low back pain, with or without leg pain, were treated with Dynesys system, 14 females and 11 males with mean age 43.5 yrs. Discography was done to evaluate the symptomatic painful level. All patients had a positional magnetic resonance imaging (pMRI) scans preoperatively and nine months post-operatively in standing; sitting flexion and extension, and left and right bending postures. The patients were initially divided into two groups. The first (Group A) with 14 patients in which only Dynesys was used (disc height 40–90%) and the second (group B) with 11 patients in which Dynesys was used with fusion (disc height < 40 %).

Results The operated levels were 51, 13 of which were fused. The results of the pMRI measurements showed that the mean range of movement of the lumbosacral angle reduced by 10.3° from pre-op of 39.2° to postop. of 28.9° (p= 0.016) in group A while in group B it reduced by 13.7° from 36.2° preop. to 22.5° postoperatively (p= 0.02).

The range of movement of the end plate angle at the instrumented segments in group A reduced from 5.6° preoperatively to 2.6° with a difference of 3.0° (p=0.016) while in group B it reduced from 6.7° to 2.5° postoperatively with a difference of 4.2°(p=0.008). The range of movement of the end plate angle at adjacent level in group A changed from 8.8° preop. to 7.2° with a reduction of 1.6° (p=0.427) while in group B it increased from 6.9° to 8.6°, difference of 1.7° (p=0.149)

The mean anterior disc height in group A reduced by 1.2mm (p< 0.005) from 10.1mm to 8.9mm postoperatively, and the posterior one was increased from 6.5mm to 8.9mm with a difference of 0.6mm (p= 0.013). In group B the anterior disc height was reduced by 1.1mm (pre-op 10.4mm to post-op 9.3mm; p=0.049) and the posterior one by 0.16mm (pre-op 6.98mm to post-op 6.82mm; p=0.714)

Discussion This study shows that in the Dynesys stabilising system allows a small range of movement at the instrumented levels, with no significant increased mobility in the adjacent levels. Also the device acted to compress the anterior annulus more than to distract the posterior annulus.

Introduction: The combined fractures of the clavicle (or A-C dislocation) and the scapular neck are complex injuries related to high energy trauma. Their management varies depending on the degree of instability and the presence of neurovascular complications. We evaluated the results of the treatment given to this rare injury.

Material and Method: During a five year period (1997–2001) we treated 12 patients with floating shoulder. The injury was in all cases the result of severe road traffic accident. Nine patients were males and three females with age ranging from 20 to 51 years. Seven patients had injured the right shoulder, the remaining five having injured the left one. Eight patients had additional injuries (chest in four, head in two, fracture of the T4 with complete paraplegia in one, chest and abdominal in one).

Three patients had neurovascular complications and were operated upon. Two of them with vascular injury were operated ungently and had arterial graft and stabilization of the clavicle or the A-C joint with tension band. The third patient with only neurological injury (axillary and suprascapular nerves) had similar stabilization of his clavicle. The remaining nine patients with minor displacement of the fractures and stable shoulder girdle were managed conservatively.

Results: We reexamined eleven patients. The mean follow-up period was 19 months (8–56 months). In nine patients-including the three operated-the fractures had healed in satisfactory position. In the remaining two the fracture of the scapular neck was malunited, resulting in loss of shoulder normal configuration and restriction of shoulder elevation. In two of the operated patients the coexistence of neurological injury resulted in poor functional outcome. The third one-with the axillary and suprascapular nerve injury-improved in relation to the axillary nerve within six months from the injury and had a fairly useful upper extremity. In the Constant-Murley scale the score ranged from 28–89 points (average 67 points).

Conclusion: In conclusion, fractures of the clavicle (or A-C dislocations) and the scapular neck are injuries of high energy and are usually encountered in multiplez injured patients. Severe displacement is usually related to instability of the shoulder girdle and neurovascular injuries; urgent operation is then necessary and the final result is often poor. In cases of severe displacement the stabilization of only the clavicle is not sufficient and open reduction and internal fixation of the scapular neck is recommended.

During the decade 1986–1996 were admitted in our hospital 2267 patients with hip fractures. From them 179 (7.98%) had already operated on for fracture to their other hip and the majority of them had a good way of life after the first operation. In 125 cases (69.83%) the second fracture was similar to the first.

The mean age was 78.5 years. From the 179 patients, 145 were women and 34 men (rate 4.3/1). The 94 (52.5 %) were intertrochanteric and the other 85 (47.5%) subcabital fractures. The mean time between fractures was 6.5 years in patients under 70 years and decreased in those over 80 years in 3.5 years.

On the bases of our follow up, mean time 18 months (12m–24m), from the 179 patients, 55 (30.7%) died during the first six months, (3 during hospitalization) and 13 (tot 37.98%) later but before our re-examination.

The evaluation of the remaining 111 patients, according pain and activities of the patients was: 16 (14.3%) very good, 52 (47%) good and 43 (38.7%) fair.

The patients with the better results were those under 75 years, who had similar hip fractures and had been operated on the first 3 days. In the other hand the majority of the 43 patients with the fair results were over 85 years.

We found out that the bilateral non simultaneous hip fractures had a high mortality incidence. We believe that, except the age, there were other risk factors for this high mortality, such as, cardiovascular diseases, chest and urinary infections, bed sores etc.

We noticed also that in all patients there was a decrease of the bone mass as a result of the extended immobilization and poor nutrition.