Purpose: The purpose of this retrospective study was to report outcome after surgical treatment of posttraumatic syringomyelia (PTS) and examine the different techniques.

Material and methods: Between 1984 and 2001, 31 patients underwent surgery for cyst derivation (group D, n= 21) or arachnoid release (group R, n = 10). Outcome was assessed on the basis of postoperative changes in clinical presentation (pain) and function (measure of functional independence, MFI). Morphology results were assessed using the Vaquero index (VI) measured on the magnetic resonance images (MRI).

Results: After surgery, aggravation of posterior cord sensitivity was observed in 24% of the patients in group D and in 10% in group R. At last follow-up, there was a statistically significant improvement in pain in the supra- and infra-lesion levels. The Frankel score was stable in 77% and the MFImotor score was stable in 76%. Morphologically, there was a significant diminution in the VI in both groups. MRI velometric studies were performed in seven patients. Cystic systolic and diastolic flow rates were higher preoperatively in patients with more severe clinical grade. Postoperatively (mean 14 months), intra-cystic systolic flow rates decreased significantly (p=0.017). Perimedullary systolic flow rates, which were initially very low reached high levels postoperatively due to re-circulation in the perimedullary subarachnoid space. Re-operation rate was 43% at 39 months for patients in group D (man follow-up 36 months), and 20% in group R (mean follow-up 31 months). The complication rate was 11% (two scar infections, one meningitis, one pneumonia, one acute derivation dysfunction).

Discussion: Arachnoid release yielded a lower re-operation rate than derivations with a lower rate of postoperative posterior cord involvement and an identical functional and morphological outcome. We propose a schema for determining the indication for intra- and extra-dural interventions in the treatment of PTS.

Purpose: The Bankart procedure is widely studied in the literature. The general lack of postoperative complications is well recognised. The purpose of this work was to study patient comfort after Bankart procedures performed in the outpatient setting in order to validate the feasibility of this approach.

Material and methods: Thirty patients underwent Bankart procedure from June 2001 to 2002 performed by the same surgeon in an outpatient clinic. There were 28 men and two women, mean age 28 years. Pain was assessed with a visual analogue scale (VAS) at entry into the recovery room (P0), when leaving the recovery room (P1), on day 1 by telephone (P2), and on day 7 at consultation (P3). On day 1 and day 7, the patient was also asked if he/she preferred staying in hospital one night. The general anaesthesia protocol was the same for all patients. Intraopeartive analgesia was 20 mg nefopam (Acupan(r)) in a half-hour infusion, 2g propacetamol (Prodafalgan(r)) or paracetamol (Perfalgan(r)), and 100 mg ketoprofen (Profenid(r)) if there were no contraindications. In the recovery room, 3 mg morphine was delivered in by iv bolus until the VAS was less than 4/10 followed by oral paracetamol-codeine combination. Home treatment used 200 mg/d ketoprofen and paracetamol+codeine.

Results: The only complication was one superficial venous thrombosis of the upper limb diagnosed on day 15. There were no cases of postoperative haematoma or infection. One patient stayed one night in hospital after the procedure due to a vagal malaise which occurred at discharge; the VAS pain score was the same in this patient as in the others. Pain assessment was: D1=2 (5. 0); D2=1 (3, 0). Postoperative comfort was thus considered satisfactory. None of the patients would have preferred 24h hospitalisation.

Discussion: There has been only one series of 25 patients reporting results of patient comfort and cost of outpatient Bankart procedure. Patients underwent surgery with a scalene interblock. Three of the 25 patients preferred a 24h hospitalisation because of pain, perhaps due to the rebound pain effect after the block. Absence of drainage did not lead to any case of haematoma, confirming an earlier unpublished study of 50 consecutive patients who underwent classical hospital procedure without drainage. Only one patient had a subcutaneous haematoma that resolve favourably spontaneously. These results suggest that satisfactory patient comfort can be achieved postoperatively for outpatient procedures. We have decided to pursue this approach.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

We reviewed the results of the treatment of 30 tibial fractures with minor to severe bone loss in 29 patients by early soft-tissue and bony debridement followed by primary locked intramedullary nailing. Subsequent definitive closure was obtained within the first 48 hours usually with a soft-tissue flap, and followed by bone-grafting procedures which were delayed for six to eight weeks after the primary surgery. The time to fracture union and the eventual functional outcome were related to the severity and extent of bone loss. Twenty-nine fractures were soundly united at a mean of 53.4 weeks, with delayed amputation in only one patient. Poor functional outcome and the occurrence of complications were usually due to a departure from the standard protocol for primary management. We conclude that the protocol produces satisfactory results in the management of these difficult fractures, and that intramedullary nailing offers considerable practical advantages over other methods of primary bone stabilisation.

We reviewed 63 patients with fractures of the distal tibial metaphysis, with or without minimally displaced extension into the ankle joint. The fractures had been caused by two distinct mechanisms, either a direct bending force or a twisting injury. This influenced the pattern of the fracture and its time to union. All fractures were managed by statically locked intramedullary nailing, with some modifications of the procedure used for diaphyseal fractures. There were few intra-operative complications. At a mean of 46 months, all but five patients had a satisfactory functional outcome. The poor outcomes were associated with either technical error or the presence of other injuries. We conclude that closed intramedullary nailing is a safe and effective method of managing these fractures.

We describe a new technique for open reduction, bone grafting and fixation with a single Kirschner wire of unstable fractures of the distal radius. Of the 83 patients treated by this technique, most had regained volar tilt when seen at an average of 13 months after injury. Malunion was seen in 18 patients due either to poor placement of the graft and Kirschner wire or because of both volar and dorsal comminution. Assessment of hand and wrist function showed an average recovery of 63% of mass grip strength with an excellent return of specialised grip strength and range of movement. The advantages of this technique over closed methods include the ability to regain the volar tilt of the distal radius and to achieve reduction at any time before union of the fracture.

We performed an epidemiological analysis of 523 fractures treated in the Edinburgh Orthopaedic Trauma Unit over a three-year period using modern descriptive criteria. The fractures were defined in terms of their AO morphology and their degree of comminution, location and cause. Closed fractures were classified using the Tscherne grading system and open fractures according to the Gustilo classification. Further analysis of fractures caused by road-traffic accidents and football was carried out. The use of the AO classification allowed the common fracture patterns to be defined. Correlation of the classification systems showed an association between the AO morphological system and the Tscherne and Gustilo classifications. The relative rarity of severe tibial fractures is indicated and it is suggested that in smaller orthopaedic units the infrequency of these fractures has implications for training and the development of treatment protocols.

Exchange nailing for failure of union after primary intramedullary nailing of the tibia is widely used but the indications and effectiveness have not been reported in detail. We have reviewed 33 cases of uninfected nonunion of the tibia treated by exchange nailing. This technique was successful without open bone grafting in all closed fractures and in open fractures of Gustilo types I, II and IIIa. The requirement for open bone grafting was reduced in type-IIIb fractures, but exchange nailing failed in type-IIIb fractures with significant bone loss. For these we recommend early open bone grafting. The most common complication was wound infection, seen more often than after primary nailing. We discuss our protocol for the use and timing of exchange nailing of all grades and types of tibial fracture.

We report the results of a three-year study of bifocal fractures of the tibia and fibula, excluding segmental shaft fractures. In our whole series, these formed 4.7% of all tibial diaphyseal fractures. We describe three groups: bifocal fractures of both the proximal and the distal joint surfaces, fractures of the shaft and tibial plateau, and fractures of the shaft and ankle. These groups of fractures had different characteristics and prognoses. We discuss treatment protocols for each of these three groups.

We reviewed a series of 79 distal radial fractures with volar displacement which had been fixed internally using a buttress plate. The fractures were classified using the Frykman and AO systems; 59% were intraarticular. Complications occurred in 40.5% of cases; malunion was most frequent (28%). Functional recovery in patients with malunion was significantly worse than in those with good anatomical restoration (p < 0.001). The AO and Frykman classifications and the degree of restoration of volar tilt were predictive of outcome.