PURPOSE OF THE STUDY. Occipitocervical fixation and spondylodesis is indicated in various cases of occipitocervical instability. The aim of this retrospective study was to evaluate the results of occipitocervical fixation at our institutions. MATERIAL + METHODS. Between 1997 and 2007, a total of 57 patients underwent occipitocervical fixation (OC) there were 25 men and 32 women, from 4 to 77 years of age. 2 groups, group one - tying wires or cables and group two - screw-rod or screw-plate systems. Indications included trauma in 15, rheumatoid arthritis (RA) in 28, destruction due to psoriasis in one, tumour in eight, and congenital anomalies in five patients. The patients were evaluated at a final follow-up ranging between 12 and 132 months after the primary surgery (average, 42.7 months). Indications for surgery and the method and extent of instrumentation were recorded. The evaluation included pain and neurological deficit assessment, radiographic evidence of the stability of fixation and bone union and intra-operative and early and late post-operative complications. RESULTS. Of the 57 patients, bone fusion was the aim of surgery in 52. Five patients died of associated injuries or serious medical complications shortly after the operation. Of the remaining 47, bone union was achieved in 44 patients (93.6%). Pseudoarthrosis developed in three patients who. In terms of bone union, there was no difference between a short (C0–C2) and a long (C0-CX or C-T) fixation. No differences among fixation materials were found. The differences in percent bone union after spondylodesis between the tying-wire and screw-rod fixation systems were not statistically significant (p>0.05). In the patients treated for RA, psoriasis or congenital anomaly, the Nurick scale score significantly improved at 2 years after surgery (p<0.05). In comparison with the others, the RA patients had a significantly higher number of complications (p<0.05). The patients treated for tumour showed a significant difference between the pre- and post-operative VAS values (p<0.05). DISCUSSION. Of the patients with RA, psoriasis or congenital anomaly, 57.6% showed post-operative improvement in the Nurick scale score by 1–2 but never more than by 2. A decrease in pain intensity and neurological findings was recorded in 88.2% of the patients. This is in agreement with the results published in the international literature. In the patients treated for trauma, a high proportion (53.3%) had neurological deficit, which is unusually high for craniocervical injuries. This can be explained by the fact that OC fixation is used only in the most serious injuries. Of five patients with neurological deficit of Frankel grade A or B, three died and two required mechanical ventilation. Less serious neurological findings of Frankel grade C or D in three patients improved to a normal condition. CONCLUSIONS. Rigid OC fixation is a very effective method for the treatment of craniocervical junction instability. The currently used implants allow us to achieve high stability and efficiency of bone union. Regardless of the instrumentation used, fusion is achieved in more than 90%, and clinical improvement in more than 80% of the patients

Tibial nonunion represents a spectrum of conditions which are challenging to treat, and optimal management remains unclear despite its high rate of incidence. We present 44 consecutive patients with 46 stiff tibial nonunions, treated with hexapod external fixators and distraction to achieve union and gradual deformity correction. There were 31 men and 13 women with a mean age of 35 years (18 to 68) and a mean follow-up of 12 months (6 to 40). No tibial osteotomies or bone graft procedures were performed. Bony union was achieved after the initial surgery in 41 (89.1%) tibias. Four persistent nonunions united after repeat treatment with closed hexapod distraction, resulting in bony union in 45 (97.8%) patients. The mean time to union was 23 weeks (11 to 49). Leg-length was restored to within 1 cm of the contralateral side in all tibias. Mechanical alignment was restored to within 5° of normal in 42 (91.3%) tibias. Closed distraction of stiff tibial nonunions can predictably lead to union without further surgery or bone graft. In addition to generating the required distraction to achieve union, hexapod circular external fixators can accurately correct concurrent deformities and limb-length discrepancies.

Cite this article: Bone Joint J 2015;97-B:1417–22.