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

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

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

Osteotomies are commonly carried out in orthopaedic surgery, particularly in limb reconstruction. Complications are uncommon provided that sufficient care is taken and a sound technique used. We describe three cases of formation of false aneurysm after osteotomy, with acute, delayed and asymptomatic onset. The diagnosis was supported by ultrasound investigation, and confirmed by angiography. Embolisation with coils was a successful method of treatment. We recommend a safe method of osteotomy with good bone exposure and adequate soft-tissue protection

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

The straddle fractures represent a distinct anatomical pattern of pelvic trauma. Their specific clinical characteristics, associated injuries and clinical outcome remain mostly underreported and ambiguous. Over a 3-year period all straddle fractures were identified from a prospective database of a tertiary referral hospital. For all cases, excluding children < 16 years and pathologic fractures, demographic characteristics, associated trauma, ISS-2005, transfusion requirements, surgical procedures, post-operative course, complications and clinical outcome were recorded over a median follow-up of 19 months (7-36). All fractures were classified by the two senior authors separately. Of 280 pelvic fractures, 31(11%) straddle fractures were identified. The median age was 38 years (17-88) and the male/female ratio was 1.38. Half of them were classified as lateral-compression (51.6%), 19.4% as anteroposterior-compression, and 29% combined mechanism of injury. 9 cases had an intra-articular extension to one or both acetabula. Median ISS was 21 (9-57), while 71% had a serious (AIS>2) associated thoracic injury, 48.4% head injury, 38.7% abdominal injury, 51.6%- lower extremity fracture, and 38.7% significant urogenital injuries. Six underwent acute embolisation, and the mean transfusion rates over the initial 72hrs were 7.5 units-cRBC, 2.3 units-FFP, 0.5 units-PLTs. All cases were treated operatively, either with ORIF (14 cases), closed reduction and percutaneous screw fixation (10 cases), while an external fixator was used in 21 cases. The median length of stay was 21 days (1-106). The mortality rate was 6.5% (one on the day of admission and another after 15 days at the ICU). Eight superficial infections, 2 deep sepsis of pfannestiel wounds, as well as 1 asymptomatic nonunion of an inferior pubic rami were recorded. 5 cases underwent further surgery for late urogenital repair and 4 cases have chronic incontinence and sexual dysfunction symptoms. Straddle fractures represent a severe type of pelvic trauma, associated with severe mostly thoracic, head and extremity trauma, severe urogenital complications, and suggest pelvic ring instability that requires surgical stabilisation in the acute setting. They are easily identifiable at the initial radiological investigations and should alert the clinician for multidisciplinary assessment and early referral

Introduction. The importance of frontal and rotational alignment in total knee arthroplasty has been published. Together with conventional instrumentation, computer navigation has been used for many years now. The pro's and con's of navigation are well known since. Materials & Methods. We present the results of our first 200 total knee arthroplasties with a Patient Specific Instrument System, called Signature (Biomet). With this system an MRI of the hip, knee and ankle is performed. Based on these images, mechanical axis and rotational landmarks are decided. Preoperative planning and templating is done with a computer program. Alignment, rotation, slope, size, positioning and gaps are planned with the software. Based on this templating a femoral guide and a tibial guide are custom made (Materialise) for each patient that will allow only one unique fit and position. Both of these guides are no cutting guides but pinning guides. From that stage on Vanguard Total Knee (Biomet) is implanted with this system applying conventional surgical techniques and rules. Preoperative alignment was measured on standing full leg X-rays. Rotational alignment was set according to the epicondylar axis. Slope was by default fixed at 3° posterior slope. Femoral flexion was set at 3° by default. Sizing was done with the system. Tourniquet time, blood loss, mean Hb drop and lateral release rate as hospital stay were analyzed. Postoperative full leg X-rays and CT scan were analyzed. Results. Preoperative alignment range between 18° varus and 19° valgus. Sizing was accurate in 82% of cases. Postoperative alignment was accurate in 90% of cases with a range between 0° and 2°. The 2° of varus was often seen on a standing full leg but not on the lying CT scan. Our normal range of alignment is +/− 3°. Rotational alignment was better in valgus knees in the PSI group. Tourniquet time was 10 minutes shorter. The blood loss was dramatically reduced since intramedullary canals were not violated. Mean Hb drop was 1,2 g/dl. No lateral releases were performed. Hospital stay was 5 days (return to home). Extra cost was MRI and guides for a total of 500 euros. Conclusions. Patient specific templating gives excellent results both clinically and radiographically. OR time is reduced resulting in cost reduction. Avoiding IM rods will reduce blood loss and possible bone marrow embolisation. Especially in minimally invasive valgus knees this system is advantageous, helping in femoral rotational and tibial alignment. Signature allows to apply conventional surgical techniques with navigation-like control on the cuts

The use of robots in orthopaedic surgery is an emerging field that is gaining momentum. It has the potential for significant improvements in surgical planning, accuracy of component implantation and patient safety. Advocates of robot-assisted systems describe better patient outcomes through improved pre-operative planning and enhanced execution of surgery. However, costs, limited availability, a lack of evidence regarding the efficiency and safety of such systems and an absence of long-term high-impact studies have restricted the widespread implementation of these systems. We have reviewed the literature on the efficacy, safety and current understanding of the use of robotics in orthopaedics.

Cite this article: Bone Joint J 2015; 97-B:292–9.

Limb lengthening by callus distraction and external fixation has a high rate of complications. We describe our experience using an intramedullary nail (Fitbone) which contains a motorised and programmable sliding mechanism for limb lengthening and bone transport. Between 2001 and 2004 we lengthened 13 femora and 11 tibiae in ten patients (seven men and three women) with a mean age of 32 years (21 to 47) using this nail. The indications for operation were short stature in six patients and developmental or acquired disorders in the rest.

The mean lengthening achieved was 40 mm (27 to 60). The mean length of stay in hospital was seven days (5 to 9). The mean healing index was 35 days/cm (18.8 to 70.9). There were no cases of implant-related infection or malunion.