Introduction. To introduce a new classification method and analyze related risk factor about lateral wall perforation associated with lower cervical pedicle screw and free-hand insertion technique. Methods. A Retrospective study was made to analyze 214 patients (1024 screws) with various cervical spine disorders, involved in pedicle screw instrumentation at C3-7 from July 2004 to July 2009. Researchers assessed the position of the screws in the pedicle by carefully probing intraoperatively and studying postoperative thin-slice computed tomography scan. Perforation of lateral wall was classified into two phases. Phase I refers to the burst of the pedicle by screw, which means that the length of screw threads penetrating the external cortex of pedicles on CT scan is 2 mm, whereas in Phase, the length is >2 mm. The Penetrated screws and related factors were analyzed though Backward Stepwise (Wald) Logistic regression. Results. During the follow-up, 2 screws were reported to be broken and 1 screw loosened. Of the screws inserted, total of 129 screws 12.60% have shown violated of lateral pedicle walls, included 101 screws (9.86%) causative of Phase I and 28 screws (2.73%) of Phase II. Two variance were deduced in the regression analysis, which concerned to ratio variance between inner and lateral walls, PRC 0.695, OR value = 2.003and angle difference variance between screws implanted and measurements preoperativePRC −1.542, OR value = 0.214). Conclusions. Free-hand lower cervical pedicle screw insertion in this series was comparatively safety. Phase I Penetration was believed to be safe of vertebral artery and Phase II faced to higher risk of artery damage. The main risk factor of lateral wall perforation was the ratio variance between inner and lateral wall, while the main protection factor was the angle difference variance between screws implanted and CT measurements

In order to achieve satisfactory reduction of complex distal humeral fractures, adequate exposure of the fracture fragments and the joint surface is required. Several surgical exposures have been described for distal humeral fractures. We report our experience using the anconeus pedicle olecranon flip osteotomy approach. This involves detachment of the triceps along with a sliver of olecranon, which retains the anconeus pedicle. We report the use of this approach in ten patients (six male, four female) with a mean age of 38.4 years (28 to 51). The mean follow-up was 15 months (12 to 18) with no loss to follow-up. Elbow function was graded using the Mayo Score. The results were excellent in four patients, good in five and fair in one patient. The mean time to both fracture and osteotomy union was 10.6 weeks (8 to 12) and 7.1 weeks (6 to 8), respectively. We found this approach gave reliably good exposure for these difficult fractures enabling anatomical reduction and bicondylar plating without complications. . Cite this article: Bone Joint J 2014;96-B:1252–7

Introduction. Pedicle screw pullout or loosening is increased in the osteoporotic spine. Recent studies showed a significant increase of pullout forces especially for PMMA-augmentation. With application of conventional viscosity PMMA the risk of cement extravasation is associated. This risk can be reduced by using radiofrequency-responsive, ultrahigh viscosity bone cement. Method. 11 fresh-frozen lumbar vertebral bodies (VB) from 5 cadavers were collected and freed from soft-tissue and ligaments. By DEXA scan (Siemens QDR 2000) 8 VB were identified as severely osteoporotic (BMD 0.8 g/cm3), 3 VB were above this level. Two screws (6×45 mm, WSI-Expertise Inject, Peter Brehm, Weisendorf, Germany) were placed in the pedicles. Through the right screw 3ml of radiofrequency-responsive bone cement (StabiliT® ER2 Bone Cement, DFine, Germany) were injected via hydraulic cement delivery system (StabiliT® Vertebral Augmentation System, DFine, Germany). As control group, left pedicle screws remained uncemented. After potting the whole VB in technical PMMA (Technovit 4004, Heraeus Kulzer, Germany) axial pullout test was performed by a material testing device (Zwick-Roell, Zmart-Pro, Ulm, Germany). Results. The mean BMD of all specimen was 0.771 g/cm3 (min./max. 0.615/1.116, SD ± 0.170). Due to the definition of osteoporosis 8 specimens had a BMD lower than 0.8 g/cm3 (mean 0.677, min./max. 0.615/0,730, SD ±0.045). The non-osteoporotic group consisted of 3 specimens with a mean BMD of 1.020 g/cm3 (min/max 0.928/1.116, SD ±0.094). Overall we observed an increase in the mean axial pullout strength of 284% when using cement augmentated screws (non-cemented 385 N vs. cemented 1029 N, p 0,001). In the osteoporotic group the mean pullout force of the non-cemented screws was 407 N vs. 1022 N for the cemented screws (p 0.001). Similarly the pullout force rose in the non-osteoporotic group from 325 N for the non-cemented screws to 1048 N for the cemented screws p 0,001). All surgical procedures could be performed without technical problems. Conclusion. This cadaver study demonstrates the efficacy and effectiveness of pedicle-screw augmentation with ultra-high viscosity cement. Pullout forces are significantly increased, especially in osteoporotic bone. No complications like clogged in cannulated pedicle-screws or extravasation of bone cement were observed. In daily clinical routine radiation exposure to operator during cement delivery is reduced due to remote-controlled, automated delivery of radiofrequency-responsive bone cement. Furthermore availability of longer time to work with the cement (up to 30 min) is achieved; hectically injection or multiple-cement-mixing is not necessary anymore. The WSI-Expertise cannulated pedicle screws can be inserted and also augmented in a minimal-invasive technique. The PMMA then is injected through an extension adapter. PMMA augmentation of pedicle screws is already well established in spine surgery. With the combination of radiofrequency-responsive, ultra-high viscosity bone cement and cannulated pedicle screws this established procedure could become more controlled and safer for both patient and physician

Introduction. A new triggered electromyography test for detection of stimulus diffusion to intercostal muscles of the contralateral side during thoracic pedicle screw placement was evaluated. Experimental research was carried out in order to determine if, using this test, neural contact at different aspects of the spinal cord and nerve roots could be discriminated. Methods. Nine industrial pigs (60–75 kg) had 108 pedicle screws placed bilaterally in the thoracic spine (T8–T13). Neural structures were stimulated under direct vision at different anatomic locations from T9 to T12. Recording electrodes were placed over the right and left intercostal muscles. Increasing intensity of the stimulus was applied until muscle response was detected at the contralateral side (diffusion phenomenon). After this first experiment, the thoracic spine was instrumented. Screws were placed in the pedicle in two different positions, the anatomic intrapedicular location and with purposeful contact with the neural elements. Results. Response thresholds to direct stimulation of nerve root at different points were significantly lower than those obtained by stimulation of the dorsal aspect of the spinal cord (0.44±0.22 mA vs 1.38±0.71 mA). However, a 24-fold stimulation intensity (6.50±0.29 mA) was necessary to obtain diffusion of the EMG response to the opposite left side if the right nerve root was stimulated. Only a 2-fold increment (3.17±0.93 mA) was able to elicit diffusion of EMG responses to the contralateral side when stimulation was applied to the dorsal aspect of the spinal cord. Contralateral EMG responses after high increases of stimulation thresholds indicated nerve root contact. Diffusion phenomenon after low threshold increments reflected medullar contact. Electromyography recordings after triggered stimulation of the screws showed that only screws in contact with the spinal cord had significantly lower responses (2.72±1.48 mA). Conclusion. Stimulus-triggered EMG could only discriminate screws with violation of the medial pedicle wall if they were contact with neural tissues. Recording EMG-potentials at the contralateral paraspinal muscles (stimulus diffusion phenomenon) proved to be a reliable method to discriminate which of the neural structures was at risk

Introduction. Short-segment posterior instrumentation for spine fractures is threatened by unacceptable failure rates. Two important design objectives of pedicle screws, bending and pullout strength, may conflict with each other. Hypothesis. Multiobjective optimization study with artificial neural network (ANN) algorithm and genetic algorithm (GA). Materials & Methods. Three-dimensional finite element (FE) methods were applied to investigate the optimal designs of pedicle screws with an outer diameter of 7 mm using a multiobjective approach for these two objectives. Based on the FE results on an L25 orthogonal array, two objective functions were developed by an ANN algorithm. Then, the trade-off solutions known as Pareto optima were explored by a GA. The optimal design was validated by mechanical tests. Results. The knee solutions of the Pareto fronts had simultaneous high bending and pullout strength ranging from 92 to 94 percent of their maxima. The corresponding range of the design parameters was 3.8 to 4.06 mm for inner diameter and 3.21 to 3.3 mm for pitch; 0 mm for beginning position of conical angle, 0.4 mm for proximal root radius, 5 degrees for proximal half angle, and 0.1 mm for thread width. The optimal design was well validated by mechanical tests, comparing with commercially available pedicle screws. Discussion & Conclusions. The optimal design of pedicle screws obtained could achieve an ideal with high mechanical performance in both bending and pullout tests

Introduction. Correction and arthrodesis for cervical kyphosis associated with atetoid cerebral palsy has been considered to be difficult because of their involuntary neck movements and severe deformity. The aim of this study is to evaluate the surgical outcome of midline T-saw laminoplasty and posterior arthrodesis using pedicle screws. Methods. 15 patients were retrospectively reviewed. There were 6 women and 9 men, with a mean age 52.9 years (range 31–71 years). Mean follow-up period was 43 months (range 24–84 months). For clinical evaluation, the Japanese Orthopaedic Association (JOA) score and Barthel index (BI) which shows independence in ADL were used. For radiographic evaluation, change of C2–C7 Cobb angle of sagittal alignment, adjacent segment instability after the surgery were evaluated. Results. The average JOA score improved significantly from 6.2 preoperatively to 10.5 postoperatively. The average BI improved from 44.2 before surgery to 72.5 after surgery. C2–C7 Cobb angle of sagittal alignment measured 12.3 degrees of kyphosis preoperatively and 1.2 degrees of lordosis postoperatively. Solid posterior bony fusion was achieved in all cases. There was two cases of adjacent segmental instability, which required additional surgery. Seven (5.6%) out of the 125 inserted screws showed more than 2mm deviation. However, there were no neurovascular complications during or after surgery in any cases, and all cases maintained strong internal fixation. Conclusion. Midline T-saw laminoplasty and posterior arthrodesis using pedicle screw is a favorable option for the patient with kyphotic deformity associated with atetoid cerebral palsy, as it preserves cervical alignment, and improve neurological status and ADL

We describe a series of 20 patients with ununited fractures of the femoral neck following neglected trauma or failed primary internal fixation who were seen at a mean of 7.5 months (2 to 18) following injury. Open reduction and internal fixation of the fracture was performed in all patients, together with a myoperiosteal flap on the quadratus femoris muscle pedicle. Union occurred at a mean of 4.9 months (2 to 10) in all patients. The mean follow-up was for 70 months (14 to 144). There was no further progression in six of seven patients with pre-operative radiological evidence of osteonecrosis of the femoral head. One patient had delayed collapse and flattening of the femoral head ten years after union of the fracture, but remained asymptomatic. This study demonstrates the orthopaedic application of myoperiosteal grafting for inducing osteogenesis in a difficult clinical situation

Purpose. compare the radiological results in sagittal balance correction obtained with pedicle subtraction osteotomy (PSO) versus anterior-posterior osteotomy (APO) by double approach in adults. Material and Methods. between January of 2001 and July of 2009, fifty-eight vertebral osteotomies were carried out in fifty-six patients: 9 Smith-Petersen osteotomy (SPO), one vertebral resection osteotomy (VRO), 30 anterior-posterior osteotomies (APO) and 18 pedicle subtraction osteotomies (PSO), being the lasts two groups the sample studied (48 osteotomies). The mean age of the patients was 56.3 years (17–72). Initial diagnose was: 28 posttraumathic kyphosis, 7 postsurgical kyphosis, 7 adult degenerative disease, 4 ankylosing spondylitis and 2 congenital kyphoscoliosis. We evaluated the preoperative standing radiographs, the postoperative and at final follow-up by digital measurements with iPACS system viewer (© Real Time Image, USA, 2001). The mean follow-up was 54 months (6–98), and complications were analized. Results. The group APO had a mean preoperative thoracic kyphosis of 67 °, a mean lumbar lordosis of −42° and a mean sagital balance of 8.6°. The group PSO had a mean preoperative thoracic kyphosis of 41°, a mean lumbar lordosis of −22° and a mean sagital balance of 12.3°. The mean correction in the APO group was 29° in its thoracic kyphosis, 8° of lumbar lordosis and 6.5° in its sagital balance. The mean correction in the PSO group was 12° of the thoracic kyphosis, 25 in the lumbar lordosis and 8.4 cm in the sagital balance. The local correction obtained at the osteotomy level was 28° in the APO group and 25.3° in the PSO group. There were no statistically significant differences in the percentage of correction between both groups (p>0.05). In terms of complications, PSO group had lower complication rate (26.6%) comparing to ODV group (44.5%). Conclusions. APO and PSO are useful techniques to correct the global sagital balance in patients with a disturbance of the sagittal profile. The correction obtained with the PSO is similar to obtained with the APO. Patients undergoing an OSP had a lower complication rate than patients undergoing APO

Lowest instrumented vertebra (LIV) selection is critical to preventing complications following posterior spinal arthrodesis (PSA) for thoracolumbar/lumbar adolescent idiopathic scoliosis (TL/L AIS), but evidence guiding LIV selection is limited. This study aimed to investigate the efficacy of PSA using novel unilateral convex segmental pedicle screw instrumentation (UCS) in correcting TL/L AIS, to identify radiographic parameters correlating with distal extension of PSA, and to develop a predictive equation for distal fusion extension using these parameters. We reviewed data (demographic, clinical, radiographic, and SRS-22 questionnaires) preoperatively to 2-years' follow-up for TL/L AIS patients treated by PSA using UCS between 2006 to 2011. 53 patients were included and divided into 2 groups: Group-1 (n=36) patients had PSA between Cobb-to-Cobb levels; Group-2 (n=17) patients required distal fusion extension. A mean curve correction of 80% was achieved. Mean postoperative LIV angle, TL/L apical vertebra translation (AVT), and trunk shift were lower than previous studies. Six preoperative radiographic parameters significantly differed between groups and correlated with distal fusion extension: thoracic curve size, thoracolumbar curve size, LIVA, AVT, lumbar flexibility index, and Cobb angle on lumbar convex bending. Regression analysis optimised an equation (incorporating the first five parameters) which is 81% accurate in predicting Cobb-to-Cobb fusion or distal extension. SRS-22 scores were similar between groups. We conclude that TL/L AIS is effectively treated by PSA using UCS, six radiographic parameters correlate with distal fusion extension, and a predictive equation incorporating these parameters reliably informs LIV selection and the need for fusion extension beyond the caudal Cobb level

Introduction

Adequate exposure is a prerequisite for treatment of distal humeral fractures. In this study, we compared the clinico-radiological and functional outcome of TRAP approach with that of olecranon osteotomy for distal humerus fractures.

Aims. Dual plating of distal femoral fractures with medial and lateral implants has been performed to improve construct mechanics and alignment, in cases where isolated lateral plating would be insufficient. This may potentially compromise vascularity, paradoxically impairing healing. This study investigates effects of single versus dual plating on distal femoral vascularity. Methods. A total of eight cadaveric lower limb pairs were arbitrarily assigned to either 1) isolated lateral plating, or 2) lateral and medial plating of the distal femur, with four specimens per group. Contralateral limbs served as matched controls. Pre- and post-contrast MRI was performed to quantify signal intensity enhancement in the distal femur. Further evaluation of intraosseous vascularity was done with barium sulphate infusion with CT scan imaging. Specimens were then injected with latex medium and dissection was completed to assess extraosseous vasculature. Results. Quantitative MRI revealed a mean reduction of 21.2% (SD 1.3%) of arterial contribution in the lateral plating group and 25.4% (SD 3.2%) in the dual plating group (p = 0.051); representing a mean decrease in arterial contribution of 4.2%. The only significant difference found between both experimental groups was regionally, at the lateral aspect of the distal femur with a mean drop in arterial contribution in the lateral plating group of 18.9% (SD 2.6%) versus 24.0% (SD 3.2%) in the dual plating group (p = 0.048), representing a mean decrease in arterial contribution of 5.1%. Gross dissection revealed complete destruction of periosteal vessels underneath either medial or lateral plates in both groups. The network of genicular branches contributing to the posterior and distal femoral condyles was preserved in all specimens. A medial vascular pedicle was found dividing from the superficial femoral artery at a mean 12.7 cm (SD 1.7) proximal to the medial epicondyle and was undisrupted in the dual plating group. Conclusion. Lateral locking-plate application resulted in mean 21.2% reduction in distal femur vascularity. Addition of medial plates did not further markedly decrease vascularity. As such, the majority of the vascular insult occurred with lateral plating alone. Supplemental medially based fixation did not lead to marked devascularization of the distal femur, and should therefore be considered in the setting of comminution and poor bone stock in distal femoral fractures. Further clinical research is required to confirm the results of this study. Cite this article: Bone Joint J 2020;102-B(4):530–538

Aims

The aim of the present study was to assess the outcomes of the induced membrane technique (IMT) for the management of infected segmental bone defects, and to analyze predictive factors associated with unfavourable outcomes.

The treatment of infected exposed implants which have been used for internal fixation usually involves debridement and removal of the implant. This can result in an unstable fracture or spinal column. Muscle flaps may be used to salvage these implants since they provide soft-tissue cover and fresh vascularity. However, there have been few reports concerning their use and these have concentrated on the eradication of the infection and successful soft-tissue cover as the endpoint. There is no information on the factors which may influence the successful salvage of the implant using muscle flaps. We studied the results and factors affecting outcome in nine pedicled muscle flaps used in the treatment of exposed metal internal fixation with salvage of the implant as the primary endpoint. This was achieved in four cases. Factors predicting success were age < 30 years, the absence of comorbid conditions and a favourable microbiological profile. The growth of multiple organisms, a history of smoking and the presence of methicillin-resistant Staphylococcus aureus on wound cultures indicated a poor outcome. The use of antibiotic beads, vacuum-assisted closure and dressing, the surgical site, the type of flap performed and the time from primary surgery to flap cover were not predictive of outcome

Introduction. We present a series of patients who have had secondary reconstruction of war injuries to the upper and lower limbs, sustained during the Iraq and Afghanistan conflicts. Material and Methods. All patients were seen at the combined Peripheral Nerve Injuries Clinic at the Defence Medical Centre for Rehabilitation, Headley Court. All surgery was performed at Odstock Hospital. Procedures include scar excision and neurolysis (all patients), release of scar contractures, tenolysis, tendon transfers, revision nerve grafts, excision of neuroma, and soft tissue reconstruction using pedicled or free flaps. Results. 24 patients have been treated at the time of submission. We have using 13 free flaps (1 free groin flap, 9 anterolateral thigh, 3 parascapular, with 4 as through-flow flaps) and 1 pedicled groin flap, with no flap losses. There were 6 amputation stump revisions (1 above elbow, 5 below knee). The majority (n=23) have had nerve recovery distal to the level of injury following revision surgery. Conclusions. Nerve repairs recover following neurolysis (and revision nerve graft if necessary) with provision of good soft tissue cover. Release of scar contractures with flap cover allows healing of chronic wounds and permits mobilisation of joints. Thin fasciocutaneous flaps provide good contour and can be elevated more easily than skin grafted muscle flaps for secondary surgery. Free or regional flaps are preferable to local flaps in high energy-transfer military wounds. Immediate complex reconstruction is not always appropriate in multiply-injured patients

Simulation in surgical training has become a key component of surgical training curricula, mandated by the GMC, however commercial tools are often expensive. As training budgets become increasingly pressurised, low-cost innovative simulation tools become desirable. We present the results of a low-cost, high-fidelity simulator developed in-house for teaching fluoroscopic guidewire insertion. A guidewire is placed in a 3d-printed plastic bone using simulated fluoroscopy. Custom software enables two inexpensive web cameras and an infra-red led marker to function as an accurate computer navigation system. This enables high quality simulated fluoroscopic images to be generated from the original CT scan from which the bone model is derived and measured guidewire position. Data including time taken, number of simulated radiographs required and final measurements such as tip apex distance (TAD) are collected. The simulator was validated using a DHS model and integrated assessment tool. TAD improved from 16.8mm to 6.6mm (p=0.001, n=9) in inexperienced trainees, and time taken from 4:25s to 2m59s (p=0.011). A control group of experienced surgeons showed no improvement but better starting points in TAD, time taken and number of radiographs. We have also simulated cannulated hip screws, femoral nail entry point and SUFE, but the system has potential for simulating any procedure requiring fluoroscopic guidewire placement e.g. pedicle screws or pelvic fixation. The low cost and 3D-printable nature have enabled multiple copies to be built. The software is open source allowing replication by any interested party. The simulator has been incorporated successfully into a higher orthopaedic surgical training program

Background. With an ageing population, the incidence of traumatic injuries in those aged over 65 years is increasing. As a result, strategies for dealing with these patients must be developed. At present the standard management of open tibial fractures is described by the BOAST4 guidelines. We describe our experience of managing elderly patients presenting with open tibial fractures to our Major Trauma Centre. Methods. Patients were identified via prospectively collected national and departmental databases. Data collated included patient demographics, injury details, orthopaedic and plastic surgery operative details, and long term outcomes. Results. Between April 2013 and January 2016, 97 patients aged over 65 were admitted with open fractures, 38 of these were open tibial fractures. 10 patients required soft tissue reconstruction for Gustillo and Anderson IIIB tibial fractures (age range 67–95). In this group there were 4 midshaft (AO 42), 1 proximal (AO 41) and 5 distal (AO 43) fractures. Five patients were treated with internal fixation and 5 with circular frames. The median length of hospital stay was 33 days (range 16–113 days), 50% longer than comparable patients under 65. Four patients received pedicled local flaps and six underwent free tissue transfer. Of the 6 patients treated with free tissue transfer, one required pre-operative femoral angioplasty. There were no flap losses. Two patients had fasciocutaneous flaps, one an EDB flap and one gastrocnemius flap. All patients went on to unite and return to their pre-morbid weight-bearing status (2 using frames, 3 using sticks, 5 independent). Discussion. Although the literature suggests a significantly higher complication rate in elderly patients with open fractures, we have demonstrated comparable rates of flap survival and bony union to those observed in younger patients. Challenges are presented in terms of patient physiology and these must be carefully managed pre- and post-operatively. These challenges are reflected in the significantly longer length of stay in comparably injured patients under the age of 65

Introduction. Large numbers of patients with open tibial fractures are treated in our major trauma centre. Previously, immediate definitive skeletal stabilisation and soft tissue coverage has been recommended in the management of such injuries. We describe our recent practice, focusing on soft tissue cover, including patients treated by early soft tissue cover and delayed definitive skeletal stabilisation. Methods. Between September 2012 and January 2016, more than 120 patients with open tibial fractures were admitted to our unit. Patients were identified through prospective databases. Data collected included patient demographics, injury details, orthopaedic and plastic surgery procedures. Major complications were recorded. Paediatric cases were excluded and one patient was lost to follow up. Results. Fifty-seven patients (median age 41 years (range 16–95)) were identified with open tibial fractures classified grade IIIB or IIIC requiring soft tissue coverage. Of these 57 patients, 39 were treated by initial temporary external fixation, soft tissue cover, and circular frame and 18 by initial temporary external fixation, soft tissue cover and internal fixation (ORIF). Of the 57 patients, 51 were acutely managed by Leeds MTC, and 6 were tertiary referrals primarily managed elsewhere. Soft tissue cover constituted free tissue transfer in 43 patients (19 gracilis, 15 ALT, 6 LD, 2 radial forearm and 1 groin flap), pedicled flap in 12 patients (6 gastroc, 4 fasciocutaneous, 1 soleus, 1 EDB), and skin graft in 2 patients. Complications included flap failure (n=3), return to theatre (n=1). Long term soft tissue cover was definitely achieved in 100% of cases. Chronic deep infection was reported in 1 acutely managed case. There were no cases of soft tissue failure after delayed circular frame fixation following soft tissue reconstruction. Conclusions. Evolution of orthopaedic techniques has meant that the management of these complex fractures using delayed definitive fixation with a circular frame is increasingly commonplace. This case series demonstrates that a joint orthoplastic approach, with circular frame application undertaken a short time after soft tissue reconstruction (including free flap surgery) is safe and can be undertaken without risk to the soft tissue coverage

Infected non-union after severe open fracture or unsuitable fracture operation is frequently associated with bone defect and its treatment has been controversial. We have used microsurgical vascularised composite graft for these problematic cases. Fifty one patients aged 17∼70 year old (43.6 years old in average), including 41 men and 10 women. Follow-up has been more than 6 months. The vascularised composite graft included a free fibular osteocutaneous flap in 41 cases, a vascular pedicled fibular osteocutaneous flap in 2 cases, a free iliac osteocutaneous flap in 5 cases, a vascularised cutaneous flap in 2 cases and other in one case. All infected non-unions were united without trouble and co-existing infection was successfully eradicated. This method also enables the patients rapid bone union and subsequent early functional recovery. This success was attributed to greater transport of oxygen and good antibiotic perfusion in presence of good blood supply. We conclude that microsurgical vascularised composite graft for infected non-union is an extremely useful method with early bone union and subsidence of infection

Study Design. Retrospective review. Objective. To report the technique and results of vertebral column decancellation (VCD) for the management of sharp angular spinal deformity. Summary of Background Data. The goal of management of sharp angular spinal deformity is to realign the spinal deformity and safely decompress the neurological elements. However, some shortcomings related to current osteotomy treatment for these deformities are still evident. Methods. From January 2004 to March 2007, 45 patients (27 males/18 females) with severe sharp angular spinal deformities at our institution underwent VCD. The diagnoses included 29 congenital kyphoscoliosis and 16 Pott's deformity. The operative technique included multilevel VCD, disc removal, osteoclasis of the concave cortex, compression of the convex cortex accompanied by posterior instrumentation with pedicle screws. Preoperative and postoperative radiographic evaluation was performed. Intraoperative, postoperative and general complications were noted. Results. For a kyphosis type deformity, an average of 2.2 vertebrae was decancellated (range, 2to 4 vertebrae). The mean preoperative kyphosis was +98.6° (range, 82° to 138°), and the meankyphosis in the immediate postoperative period was +16.4° (range, 4° to 30°) with an averagepostoperative correction of +82.2° (range, 61° to 124°). For a kyphoscoliosis type deformity, thecorrection rate was 64% in the coronal plane (from 83.4° to 30.0°) postoperatively and 32.5°(61% correction) at 2 years follow-up. In the sagittal plane, the average preoperative curve of88.5° corrected to 28.6° immediately after surgery and to 31.0° at 2 years follow-up. All patientshad solid fusion at latest follow-up. Complications were encountered in 8 patients (17.8%) andincluded transient neurological deficit and complete paralysis (n = 1). Conclusion. Single stage posterior vertebral column decancellation (VCD) is an effective option to manage severe sharp angular spinal deformities

Limb salvage after loss of bone and soft tissue may require many operations to obtain soft-tissue cover and bony continuity. We describe a fibula-flexor hallucis longus osteomuscular flap which can provide both soft tissue and bone in a single stage. The flap is based on the peroneal vessels and is covered by a split-thickness skin graft. We report the results in five patients with an average bone defect of 8.3 cm and soft-tissue and skin loss. All regained a normal gait on the donor side; four had clinical and radiological union with excellent soft-tissue cover, but one required later amputation due to diffuse coagulopathy. The flap provides free vascularised bone with muscle cover. It has a dependable, long pedicle with minimal morbidity at the donor site, and allows monitoring of the vascularity of the fibular graft