The April 2023 Foot & Ankle Roundup³⁶⁰ looks at: Outcomes following a two-stage revision total ankle arthroplasty for periprosthetic joint infection; Temporary bridge plate fixation and joint motion after an unstable Lisfranc injury; Outcomes of fusion in type II os naviculare; Total ankle arthroplasty versus arthrodesis for end-stage ankle osteoarthritis; Normal saline for plantar fasciitis: placebo or therapeutic?; Distraction arthroplasty for ankle osteoarthritis: does it work?; Let there be movement: ankle arthroplasty after previous fusion; Morbidity and mortality after diabetic Charcot foot arthropathy.

The Lisfranc fracture dislocation of the tarsometatarsal joint (TMTJ) is a complex injury with a reported incidence of 9.2 to 14/100,000 person-years. Lisfranc fixation involves dorsal bridge plating, transarticular screws, combination or primary arthrodesis. We aimed to identify predictors of poor patient reported outcome measures at long term follow up after operative intervention. 127 patients underwent Lisfranc fixation at our Level One Trauma Centre between November 2007 and July 2013. At mean follow-up of 10.7 years (8.0-13.9), 85 patients (66.92%) were successfully contacted. Epidemiological data including age, gender and mechanism of injury and fracture characteristics such as number of columns injured, direction of subluxation/dislocation and classification based on those proposed by Hardcastle and Lau were recorded. Descriptive analysis was performed to compare our primary outcomes (AOFAS and FFI scores). Univariate analysis and multivariate regression analysis was done adjusted for age and sex to compare the entirety of our data set. P<0.05 was considered significant. The primary outcomes were the American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Score and the Foot Function Index (FFI). The number of columns involved in the injury best predicts functional outcomes (FFI, P <0.05, AOFAS, P<0.05) with more columns involved resulting in poorer outcomes. Functional outcomes were not significantly associated with any of the fixation groups (FFI, P = 0.21, AOFAS, P = 0.14). Injury type by Myerson classification systems (FFI, P = 0.17, AOFAS, P = 0.58) or open versus closed status (FFI, P = 0.29, AOFAS, P = 0.20) was also not significantly associated with any fixation group. We concluded that 10 years post-surgery, patients generally had a good functional outcome with minimal complications. Prognosis of functional outcomes is based on number of columns involved and injured. Sagittal plane disruption, mechanism and fracture type does not seem to make a difference in outcomes

Aims

The aim of this retrospective study was to compare the functional and radiological outcomes of bridge plating, screw fixation, and a combination of both methods for the treatment of Lisfranc fracture dislocations.

Transarticular screw fixation with autograft is an established procedure for the surgical treatment of atlantoaxial instability. Removal of the posterior arch of C1 may affect the rate of fusion. This study assessed the rate of atlantoaxial fusion using transarticular screws with or without removal of the posterior arch of C1. We reviewed 30 consecutive patients who underwent atlantoaxial fusion with a minimum follow-up of two years. In 25 patients (group A) the posterior arch of C1 was not excised (group A) and in five it was (group B). Fusion was assessed on static and dynamic radiographs. In selected patients CT imaging was also used to assess fusion and the position of the screws. There were 15 men and 15 women with a mean age of 51.2 years (23 to 77) and a mean follow-up of 7.7 years (2 to 11.6). Stable union with a solid fusion or a stable fibrous union was achieved in 29 patients (97%). In Group A, 20 patients (80%) achieved a solid fusion, four (16%) a stable fibrous union and one (4%) a nonunion. In Group B, stable union was achieved in all patients, three having a solid fusion and two a stable fibrous union. There was no statistically significant difference between the status of fusion in the two groups. Complications were noted in 12 patients (40%); these were mainly related to the screws, and included malpositioning and breakage. The presence of an intact or removed posterior arch of C1 did not affect the rate of fusion in patients with atlantoaxial instability undergoing C1/C2 fusion using transarticular screws and autograft. Cite this article: Bone Joint J 2013;95-B:972–6

Purpose of study. Transarticular screw fixation offers acceptably high fusion rates but is not possible in 18% of patients due to a high riding vertebral artery. It also requires pre-operative anatomical reduction which is not always possible. The Harms' technique utilises a posterior C1 lateral mass and C2 pedicle screw. This allows easier access due to the angle of drilling and has become an increasingly popular surgical technique. The aim of this study is to review and compare the above techniques with regard to surgery, complications and outcome. Description of methods. This study is a retrospective chart and radiographic review of patients undergoing posterior C1-2 fusion in a single institution in the period 2003 to 2011. The most common aetiology was rheumatoid arthritis and post-traumatic instability. All atlanto-axial instability patients that came to surgery are included in this study, and only cases with less than six months follow-up were excluded. We report on surgical indications, surgical outcomes, complications and radiographic outcomes. Summary of results. No statistically significant differences were found in blood loss (p=0.47) or surgical time (p=0.44) using the Mann-Whitney U test. Complications in patients undergoing transarticular screw fixation included the need to abandon transarticular screws in two cases due to technical difficulty, metalware failure in two cases and intra-operative cerebrospinal fluid leaks in 2 cases. The Harms technique was associated with a single case of cerebrospinal fluid leak. Conclusion. There is no significant difference in surgical time and blood loss between the two techniques. Both are reliable in terms of fusion. The Harms technique offers the advantage of intra-operative reduction and a smaller wound due to the direction of access. The decision to use one or the other is based on the surgeons skill levels, ability to pre-operative reduce the joint and possibly the cost. NO DISCLOSURES

Achieving arthrodesis of the ankle can be difficult in the presence of infection, deformity, poor soft tissues and bone loss. We present a series of 48 patients with complex ankle pathology, treated with the Ilizarov technique. Infection was present in 30 patients and 30 had significant deformity before surgery. Outcome was assessed clinically and with patient-reported outcome measures (Modified American Orthopaedic Foot and Ankle Society (MAOFAS) scale and the Short-Form (SF-36)).

Arthrodesis was achieved in 40 patients with the Ilizarov technique alone and in six further patients with additional surgery. Infection was eradicated in all patients at a mean follow-up of 46.6 months (13 to 162). Successful arthrodesis was less likely in those with comorbidities and in tibiocalcaneal fusion compared with tibiotalar fusion.

These patients had poor general health scores compared with the normal population before surgery. The mean MAOFAS score improved significantly from 24.3 (0 to 90) pre-operatively to 56.2 (30 to 90) post-operatively, but there was only a modest improvement in general health; the mean SF-36 improved from 44.8 (19 to 66) to 50.1 (21 to 76). There was a major benefit in terms of pain relief.

Arthrodesis using the Ilizarov technique is an effective treatment for complex ankle pathology, with good clinical outcomes and eradication of infection. However, even after successful arthrodesis general health scores remain limited.

Cite this article: Bone Joint J 2013;95-B:371–7.

To define how pre-operative evaluation guides surgical planning in patients with atlanto-axial subluxation secondary to rheumatoid arthritis and to measure clinical outcome for the same group. Prospective evaluation of a consecutive cohort of 26 patients undergoing C1/2 fusion over 5 years (2004-2009). Pre-operative evaluation of posterior atlanto-dens interval (PADI), C1 lateral mass and C2 pedicle dimensions. Pre- and post-op Ranawat scores and visual analogue scores for neck and C2 pain. C1/2 instability resulted from rheumatoid arthritis (21), trauma (4) and infection (1). C1 lateral mass mean height 4.4mm, C2 pedicle mean height 5.1mm and mean width 3.4mm (30% width <3mm). Ranawat scale improved Grade II to Grade I (p=0.07). Neck pain (pre-op mean 5.5, s.d. 2.8; post-op mean 1.6, s.d. 2.1, t<0.05) and C2 pain (pre-op mean 2.1, s.d. 3.3; post-op mean 0.5, s.d. 1.2, t<0.05) improved. No instrumentation failure. In the rheumatoid group, 17/21 patients had C1 lateral mass and C1/2 transarticular screws. 1 patient had a cranio-cervical fusion and 3 patients had other constructs. 3 patients had C2 numbness. No other neurological deficit. In a rheumatoid population, pre-operative evaluation often precludes the use of C2 pedicle screws. Rigid fixation with a C1 lateral mass and C1/2 transarticular polyaxial screw-rod system is associated with good clinical outcomes

Introduction: Tarsometatarsal joint (TMTJ) fusion is performed for arthritis or painful deformity. First TMTJ fusion may be performed as a part of corrective surgery for hallux valgus deformity. K-wires and trans-articular screws are often used to stabilize the joints. We present our experience with the use of locking plates (LP) for TMTJ fusion. Patients and Methods: Thirty-three TMTJ’s in 19 patients were fused and stabilised with LP’s between January and September 2008. The procedure was performed for Lisfranc arthritis in 13 patients and Lapidus procedures in six. Two out of 6 were revisions after failed fusion using transarticular screws. Iliac crest bone autograft was used in 26 joints in 12 patients. All patients post-operatively had below knee plaster immobilization and protected weight bearing walking for first 6 weeks. Clinical and radiological surveillance continued until bone union. AOFAS midfoot scale was used as outcome measure. Results: There were 7 male and 12 female patients with average age of 51 (14–68). The American orthopaedic foot and ankle surgery society (AOFAS) midfoot score showed a 42% improvement in pain, 30% improvement in function and 53% improvement in alignment. The average AOFAS overall score improved from 30 preoperativley to 67 postoperativley. All except one joint in one patient had clinically and radiologically fused joints. One patient underwent removal of the metalwork and four had delayed wound healing. The average satisfaction score was 7 out of 10. 86% said of patients said that they would recommend the surgery to a friend, and 91% would undergo the surgery again. Discussion: Locking plates have been recently introduced for ankle and foot surgery. Biomechanical studies have shown that the plates are not as strong or stiff as trans-articular screw fixation, however, they are easy to use, have more flexibility for realignment and can act as a buttress for bone graft. In our series all, except one, patients achieved bony union without loss of alignment. Conclusion: Locking plates provide satisfactory stability for TMTJ fusion, without complications

Introduction: TMTJ fusion is performed for arthritis or painful deformity. First TMTJ fusion may be performed for Hallux valgus deformity. K-wire and trans-articular screws are usually used to stabilize the joints. We present our audit of experience with LP for TMTJ fusion. Patients and Methods: 33 TMTJ in 19 patients were fused and stabilised using LP between January and September 2008. The procedure was performed for Lisfranc arthritis in 13 and Lapidus procedure in 6. Two out of 6 were revisions after failed fusion using transarticular screws. Iliac crest bone autograft was used in 26 joints in 12 patients. All patients post-operatively had below knee plaster immobilization and protected weight bearing walking for first 6 weeks. Clinical and radiological surveillance continued until bone union. AOFAS mid-foot scale was also used as an outcome measure. Results: There were 7 male and 12 female patients with average age of 51 (14–68). AOFAS midfoot scale showed 42% improvement in pain, 30% improvement in function and 53% improvement in alignment. Average total AOFAS score improved from 30 preoperative to 67 postoperative. All except 1 joint in one patient had clinical and radiological fusion of their joints. 1 patient needed removal of metalwork and 4 had delayed wound healing. Average satisfaction score was 7/10. 86% Patients would recommend it to a friend and 91% would have it again. Discussion: Locking plates have been recently introduced for ankle and foot surgery. Biomechanical studies have shown plates are not as strong or stiff as trans-articular screw fixation however they are easy to use, have more flexibility for realignment and can act as a buttress for bone graft. In our review all patients except one had bone union without loss of alignment. Conclusion: TMTJ fusion improves pain and function. Locking plates provide satisfactory stability for TMTJ fusion

Purpose: The current gold-standard for atlanto-axial fixation is C1-C2 Transarticular Screw (TS) fixation. In certain cases, the complicated nature of vertebral artery injury could make the application of bilateral transar-ticular screws impossible. This study biomechanically compares three atlantoaxial transarticular salvaging fixation techniques. Method: Nine Fresh ligamentous human cervical spine specimens (C0-C4) were thawed and the tissue surrounding the spine, except the ligaments and discs, was carefully removed. Pure moments were applied to skull in increments of 0.5 Nm from 0 Nm to 2.0 Nm with the help of loading arms, nylon strings and pulleys. The specimens were tested in extension (EXT), flexion (FLEX), left lateral bending (LB), right lateral bending (RB), left axial rotation (LR) and right axial rotation (RR) for all the cases. The positions of the LEDs were recorded using an Optotrak Motion Measurement System (Northern Digital, Waterloo, Ontario, Canada) and was converted into three rotations (flexion/extension, lateral bending and axial rotation) using rigid body kinematic principles in relation to the fixed base. The specimens were tested intact and after type II odontoid fracture, were instrumented and tested with three fixation constructs:. C1-C2 TS on right side and C1LMS-C2PS on contralateral side. C1-C2 TS on right side and C1LMS-C2IL on the contralateral side and. C1-C2 TS on right side with sublaminar wire. Results: All of the three instrumented cases significantly reduced motion across C1-C2 segment in all the modes when compared to intact (P< 0.005, two-tailed unpaired t-test at confidence interval of ninety-five percent) except in extension. TS+C1lM+C2PS is significantly stiffer than TS+ Wire only in axial rotation (P< 0.05) and equivalent in flexion/extension (P=0.75/P=0.51) and left/right bending (P=0.22/P=0.58). TS+C1LM +C2PS is equivalent to TS+C1LM+C2IL in all the loading modes (P> 0.05). TS+C1LM+C2IL is significantly stiffer than TS+Wire in axial rotation (P < 0.05) and equivalent in flexion/extension (P=0.93) and left/right bending (P=0.69/P=0.84). Conclusion: This study showed that TS+C1LMS+C2PS fixation is equivalent to TS+C1LMS+C2ILS fixation in all the rotation modes and superior to TS+Wire fixation in axial rotation averaged over all ranges of motion. Also, TS+C1LMS+C2ILS fixation is superior to TS+Wire fixation in axial rotation averaged over all ranges of motion

Introduction: The management atlanto-axial fractures, particularly those of the odontoid peg, remains controversial. We managed patients with C1/C2 fractures non-operatively in rigid immobilization until CT-scanning confirmed bony union, rather than for the standard 3-month period. We examined whether this improved outcomes and reduced the need for surgery. Method: All patients admitted to our unit with atlanto-axial fractures between 2001–2007 were retrospectively analyzed. All fractures had the ‘intention-to-treat’ conservatively in either halothoracic vest (85%) or Aspen collar (15%). Rigid immobilization was maintained until CT-scanning demonstrated bony fusion. Functional stability was subsequently assessed with flexion-extension radiographs after removal of rigid immobilization. Results: Twenty-seven patients were studied. Nineteen had odontoid peg fractures (10 type II; 9 type III). The remainder consisted of 3 Hangman’s, 3 lateral mass and 2 atlas ring fractures. 83% of patients progressed to union at an average of 13.2 weeks (range 5–22). Six complications related to halo immobilization were observed (three skull perforations/pin-site infections). All of these patients progressed to union non-operatively. Failure of non-operative management was deemed as non-union or poor patient tolerance of halo, and occurred in 4 patients (17%). All four had type II odontoid peg fractures, and had transarticular screw fixation. One postoperative complication of screw fracture was recorded. Conclusion: Non-union rates of conservatively managed atlanto-axial fractures with standard 3-month rigid immobilization have been reported as high as 35%. In our series, CT-imaging to confirm bony union prior to removal of the rigid immobilization (prolonging immobilization where necessary) significantly lowered the rate of non-union and therefore the need for subsequent surgery. Ethics approval: None Audit. Interest Statement: None

Goals: Advantage of the dorsal fixation of C1/2. Materials and Methods: From 01/2006 to 12/2006 22 patients with a traumatic fracture of C1/2 were operativly stabilized. The avarage age was 79 year (66–92). No neurological deficit. Diagnostic was always a CT-scan for classification of fracture typ. 7 patients were temporarily immobilized with HALO fixateur. Within th next 8 days final operation hab been carried out. 7 patients with Anderson fractures typ II were stabilized with open fixation from ventral (group 1). 4 Jefferson fractures and 2 combined C1/2 fractures were were stabilized with open fixation from dorsal (Magerl) (group 2). Percutanous fixation from dorsal was done in 5 patients with fractures of the atlas, 4 with Anderson fractures typ II (group3). Clinical and radiological follow up was done in 18 patients. Results: Duration for operation was in 64min in group1, 134min in group 2 and in 42min in group3. No neurological deficit or damage of A.vertebralis occurred. Blood loss was in group 1 and 3 under 50ml in group 2 750ml. In group3 one slightly dislocation of screw happened without need of revision. Movement of cervical spine was reduced in group 2 and 3. During follow up 3 of seven ventral stabilized Anderson fractures typ II (group1) were dislocated. Dorsal percutanous fixation for operatively revision was done. Discussion: Percutanous dorsal transarticular screw fixation C1/2 is a challanging procedure for stabilization of atlantoaxial fractures. Main advantages compared to other operation techniques are less blood loss, short operation time, high rate of success

We reviewed the outcome of a retrospective case series of eight patients with atlantoaxial instability who had been treated by percutaneous anterior transarticular screw fixation and grafting under image-intensifier guidance between December 2005 and June 2008. The mean follow-up was 19 months (8 to 27). All eight patients had a solid C1–2 fusion. There were no breakages or displacement of screws. All the patients with pre-operative neck pain had immediate relief from their symptoms or considerable improvement. There were no major complications. Our preliminary clinical results suggest that percutaneous anterior transarticulation screw fixation is technically feasible, safe, useful and minimally invasive when using the appropriate instruments allied to intra-operative image intensification, and by selecting the correct puncture point, angle and depth of insertion

Introduction: The literature regarding the functional outcome following C1–C2 surgeries for non-rheumatoid C1–C2 pathologies following selective arthrodesis is sparse. Aim: To determine the long term correlation between functional outcome and radiological determinants following C1–C2 fusion for conditions other than RA. Methods: All C1–C2 surgeris performed between 1988–2002 for non-RA etiologies were reviewed retrospectively. Selective C1–C2 fusion performed in 32 pts with a min f/u of 5 yrs formed the study group. The mean age at surgery was 57.2 yrs (r 22–84yrs). The etiologies were trauma (15), non-union (6), congenital AAD (2), C1–C2 deg. arthropathy (2), os odontoideum (2), tumours (4) and instability due to TB (1). Neurodeficit were present in 7 pts. Transarticular (TA) screws supplemented with posterior wiring was performed in 27 & posterior wiring alone in 5 pts respectively. A monocortical H-shaped autograft from iliac crest was used in all cases. There were two deaths & two pts were lost for F/U. The mean F/U was 7.8 yrs (r 5–13 yrs). Disability & pain using NDI & VAS and subjective satisfaction were recorded in all pts. We measured 1) C1/2 fixation angle, 2) Inclination of C1, 3) Anterior shift of C2 and 4) C2–7 lordosis on pre and final F/U lateral x-rays. Results: Optimal TA screw placement was seen in 78.5% of pts. The mean improvement in NDI & VAS were from 55.4% to 19.6% and 8.4 to 1.6 respectively and was better in younger pts. Fusion was seen radiologically in 82.1% of pts at 12 mo post surgery. Segmental stability and resolution of symptoms was seen in all patients despite implant failure in 4 and incomplete fusion 5 cases respectively. Two wound dehiscences needed debridement of which one elderly pt died of MRSA sepsis 2 mo post-op. The C1–C2 segmental lordosis was significantly increased by surgery (−4.2 0 vs. −11.80; P=0.016). The subaxial cervical spine became less lordotic in initial few months post-op but eventually regained more lordosis as time progressed. The C1 inclination came into more extended position w.r.t horizontal line post-op with minimal loss of inclination subsequently. C1–C2 fixation angle and anterior shift of C2 did not have significant correlation with long term functional outcome i.e. NDI and VAS (r=0.35, p=0.17). Conclusion: The functional outcome following C1–C2 arthrodesis is usually good despite metalwork issues and incomplete fusion in these selective group of non-rheumatoid arthritis pathologies

The effect of rheumatoid arthritis on the anatomy of the cervical spine has not been clearly documented. We studied 129 female patients, 90 with rheumatoid arthritis and 39 with other pathologies (the control group). There were 21 patients in the control group with a diagnosis of cervical spondylotic myelopathy, and 18 with ossification of the posterior longitudinal ligament. All had plain lateral radiographs taken of the cervical spine as well as a reconstructed CT scan. The axial diameter of the width of the pedicle, the thickness of the lateral mass, the height of the isthmus and internal height were measured. The transverse diameter of the transverse foramen (d1) and that of the spinal canal (d2) were measured, and the ratio d1/d2 calculated.

The width of the pedicles and the thickness of the lateral masses were significantly less in patients with rheumatoid arthritis than in those with other pathologies. The area of the transverse foramina in patients with rheumatoid arthritis was significantly greater than that in the other patients. The ratio of d1 to d2 was not significantly different. A high-riding vertebral artery was noted in 33.9% of the patients with rheumatoid arthritis and in 7.7% of those with other pathologies. This difference was statistically significant. In the rheumatoid group there was a significant correlation between isthmus height and vertical subluxation and between internal height and vertical subluxation.

Objective: To review the clinical outcome of 37 consecutive patients undergoing C1– C2 transarticular fixation for patients with Rheumatoid Arthritis. Design: Prospective Observational Study. Methods: There were 37 patients at 2 centres. Age range was 37– 82 years. The time since diagnosis to treatment was 2– 23 years. Clinical presentation included suboccipital pain in 26/ 37 patients and neck pain in 29/37 patients. 22 patients had presented with myelopathy ( Ranawat grade II or III A). The preoperative imaging included Plain X Rays, CT scans and MRI scans. All patients underwent C1/ C2 transarticular screws ( Stealth guided) except 4 patients in which an aberrant course of the vertebral artery was identified. Outcome measures: Functional outcome, Complications, Postoperative Neurological Status, Neck Disability index, Myelopathy disability index. Results: 1 patient had died at 12 month followup. Neck pain improved in 22( 75%) of patients by > 5 points on the VAS. Suboccipital pain had improved in all patients. 17 patients (80%) improved following operation on the Ranawat Grading, 2 patient were worse and 3 patients remained the same. > 70% patients reported improvement in neck disability index and > 50% patients reported improvement in myelopathy disability index. Conclusions: C1/ C2 Transarticular fixation with spinal navigation is a safe technique for treating atlantoaxial instability in patients with Rheumatoid Arthritis. This study demonstrates improvement in all domains including neck disability, myelopathy scores and functional outcome

Traumatic atlanto-occipital dislocation in adults is usually fatal and survival without neurological deficit is rare. The surgical management of those who do survive is difficult and controversial. Most authorities recommend posterior occipitoaxial fusion, but this compromises cervical rotation. We describe a case in which a patient with a traumatic atlanto-occipital disruption but no neurological deficit was treated by atlanto-occipital fusion using a new technique consisting of cancellous bone autografting supported by an occipital plate linked by rods to lateral mass screws in the atlas. The technique is described in detail. At one year the neck was stable, radiological fusion had been achieved, and atlantoaxial rotation preserved.

The rationale behind this approach is discussed and the relevant literature reviewed. We recommend the technique for injuries of this type.

The purpose of this study is the biomechanical comparison of five C1 – C2 posterior arthrodesis techniques. Ten adult human cadaveric upper cervical spine specimens were sectioned at the C3 level. The occiput and C3 vertebra were potted in PMMA. The specimens were tested intact; after destabilizing with odontoid transection and sectioning of the transverse and capsular ligaments; and after stabilization with Brooks-Jenkins cable fixation, Brooks-Jenkins with unilateral transarticular screw, Gallie posterior wire construct with unilateral transarticular screw, Brooks-Jenkins with bilateral screws, and Gallie with bilateral screws. Data were analysed with special attention paid to the motion at C1 – C2. The neutral zone (NZ) and range of motion (ROM) were measured in the main plane of each motion, as well as in coupled planes. In flexion / extension and lateral bending, the ROM and NZ increased significantly in the injured specimens as compared to the intact (p< 0.0001). In axial torsion, there was no significant difference between the intact and injured spines at C1 – C2 level. In the different fixation systems, the ROM and NZ were significantly lower than in injured and intact spines in all motions (p< 0.01), except the lateral bending in intact spine. Among the 5 instrumentations, the NZ and ROM in flexion / extension for the Gallie construct with one screw were significantly higher than for the Brooks-Jenkins construct with one or two screws (p< 0.05). In axial torsion, the Gallie construct with one screw displayed a larger NZ and ROM than any of the other four constructs (p< 0.05)

Introduction: Fixation of the atlantoaxial complex has traditionally involved transarticular screws combined with posterior wiring techniques and structural bone grafting. Although this does lead to excellent fusion rates, the technique has a potential risk of injury to the vertebral artery. In addition, it cannot be used in fixed subluxation of the C1/2 complex. We describe the use of C1 lateral mass screws in combination with C2 pedicle screws for safe and versatile C1/C2 fixation. Methods: Over a fifteen month period, (July 2003–October 2004) a total of 10 patients underwent posterior C1/ C2 fixation alone, or as part of a more extensive posterior construct. The average age was 54.25 years, ranging from 20–78 years. There were 7 women and 3 men. The average length of stay was 18.5 days ranging from 5–36 days. Technique: A midline posterior approach was used in all cases. The C2 roots were mobilized and the C1 lateral masses identified bilaterally. A drill was inserted into the middle of each lateral mass under image intensification. Bicortical polyaxial screws were then inserted. The C2 pedicle screws were inserted under direct vision, as were the other pedicle screws in the more extensive constructs. Contoured rods and posterior iliac bone graft were used in all cases. Results: Five patients required isolated C1/C2 fusion for instability, two patients had an odontoid fracture non-union, one had an unstable C2 fracture, and the remaining two patients had C1/C2 subluxation secondary to rheumatoid arthritis. More extensive posterior instrumentation was performed for the following cases, these included; occipitothoracic fixation in one patient with rheumatoid arthritis with multi-level cervical subluxation, and occipitocervical fixation in three patients, two who had metastatic disease in the cervical spine, and the remaining patient who had rheumatoid arthritis. The final patient was instrumented from C1–C5 posteriorally following removal of a C3 giant cell tumour. No neurological or vascular complications were observed. One patient, with rheumatoid arthritis and osteoporosis, had a halo applied to protect an occipitothoracic construct. All other patients were discharged in a Miami-J cervical collar. The early follow up data, clinical and radiological, showed fusion in all patients. There were no implant failures. Conclusion: The combination of C1 lateral mass and C2 pedicle screws allows safe, effective and versatile fixation of the C1/C2 complex