The purpose of our study was to examine the survival and functional outcome of endoprosthetic replacements for non-oncology limb salvage purposes. Although initially designed for bone tumours, such is the versatility of these implants they can be used to salvage failed joint replacements, peri-prosthetic fractures, failed internal fixation and non-union.

Thirty eight procedures were identified from September 1995 to June 2007 from a prospectively kept database, including 17 distal femoral replacements, 12 proximal femoral replacements, 4 proximal humeral replacements, 2 distal humeral replacements, 2 hemi-pelvic replacements and 1 total femoral replacement. The quality of patients’ mobility was used to assess functional outcome and the survival of the prosthesis was calculated using a Kaplan-Meier survival curve.

The Kaplan-Meier implant survival was 91.3% at 5 years, 68.5% at 10 years and 45.7% at 20 years. The limb salvage survival for all reconstructions was 75% at 10 years.

The best survival was as follows pelvic (n=0/2) and total femoral prostheses where there was no failure in either group (n=0/1). Distal femoral replacements survival was 91% at 5 years, a single humeral prosthesis failed at 11 years post surgery, and proximal femoral replacements had a survival at 87.5% at 5 years. Three implants failed, two as a result of infection and required staged revisions and 1 failed as a result of aseptic loosening. Two patients dislocated their proximal femoral replacements, both were treated successfully by closed reduction.

Endoprosthetic replacement appears to be effective and the medium term survival is encouraging. The aim of a pain free functional limb is achievable with this technique. The complication rates are acceptable considering the salvage nature of these patients. We recommend referral of complex cases to a tertiary centre with expertise in this type of surgery.

Introduction: Limb salvage reconstruction evolved from the treatment of primary bone tumours. Endoprosthetic replacements (EPR) were originally designed for this purpose, but the versatility of these implants has resulted in an extension in the indications for their use. Severe bone loss, failed revision surgery and persistent deep infection present similar challenges and when a salvage procedure is required, EPR are occasionally used. The aim of our study was to assess the medium term survival and functional outcome of EPR.

Materials and Methods: 38 patients (23 females and 15 males), who underwent EPR for non-neoplastic conditions were identified from a prospectively kept database of all patient seen at the Royal Orthopaedic Hospital Oncology Service. The indications for replacement included failed joint replacement, fracture non-union, failed internal fixation and periprosthetic fractures.

The 38 procedures were identified from September 1995 to June 2007 and included 17 distal femoral replacements, 12 proximal femoral replacements, 4 proximal humeral replacements, 2 distal humeral replacements, 2 hemi-pelvic replacements and 1 total femoral replacement. EPR survivorship was calculated using a Kaplan-Meier survival curve. The quality of patients’ mobility and performance of activities of daily living was used to assess functional outcome.

Results: Patients had a mean age of 60 years (range 15–85 years) at surgery and had between 0 and 4 previous operations prior to EPR. Seven out of 38 patients had recorded deep infection prior to surgery (18%). The Kaplan-Meier implant survival was 91.3% at 5 years, 68.5% at 10 years and 45.7% at 20 years. The limb salvage survival for all reconstructions was 75% at 10 years.

87.4% of patients who underwent a lower limb EPR achieved a satisfactory or very satisfactory functional outcome. 100% of patients achieved a satisfactory or very satisfactory functional outcome in the upper limb EPR group.

3 implants failed, 2 as a result of infection and required staged revisions, 1 eventually requiring amputation, and 1 failed as a result of aseptic loosening. 2 patients dislocated their proximal femoral replacements, both were treated successfully by closed reduction. Despite the salvage surgery subsequent amputation was only required in one patient.

Conclusion: EPR appears to be effective and the medium term survival is encouraging. The aim of a pain free functional limb is achievable with this technique. The complication rates are acceptable considering the salvage nature of these patients. We recommend referral of complex cases to a tertiary centre with expertise in this type of surgery.

We report our experience of treating 17 patients with benign lesions of the proximal femur with non-vascularised, autologous fibular strut grafts, without osteosynthesis. The mean age of the patients at presentation was 16.5 years (5 to 33) and they were followed up for a mean of 2.9 years (0.4 to 19.5). Histological diagnoses included simple bone cyst, fibrous dysplasia, aneurysmal bone cysts and giant cell tumour. Local recurrence occurred in two patients (11.7%) and superficial wound infection, chronic hip pain and deep venous thrombosis occurred in three. Pathological fracture did not occur in any patient following the procedure.

We conclude that non-vascularised fibular strut grafts are a safe and satisfactory method of treating benign lesions of the proximal femur.

Introduction: To access efficacy of our protocol for treatment of displaced Gartland type 3 supracondylar fracture humerus in children by giving a small incision medially to identify correct entry point of medial wire and to save the ulnar nerve. This incision is extendable for open reduction if required and have no effect on morbidity.

Methods: All Patients with displaced Gartland type 3 supracondylar fractures of humerus admitted from October 1997 to October 2003 were included into this study. They were all treated by closed or open reduction through medial approach and fixed with medial and lateral cross K-wires within 12 hours of admission.

Results: There were 43 children with a mean age of 7.2 years at presentation. Follow up time averaged 48 months (range 12–84 months). No patient had iatrogenic ulnar nerve injury. The postoperative mean value of Bauman’s angle in affected elbow was 76.7° with +/− 1.0° and 74.8° with +/− 0.6° on the unaffected elbow. All patients showed satisfactory results according to Flynn’s criteria.

Discussion: Cross K-wires give reliable results; a small medial incision is cosmetically more acceptable, provides an excellent view for correct entry point of the wire after visualising ulnar nerve with added advantage of extension if fracture required open reduction.

Introduction: Currently, minimal attention has been paid to thorough preoperative planning in primary total knee arthroplasty. The aim of this study was to evaluate the results and the effectiveness of a previously reported x-ray view as a simple way of preoperative planning in total knee arthroplasty.

Materials & Methods: The rotational alignment of the distal end of the femur is usually evaluated by measuring the angle (posterior condylar angle, PCA) between the surgical transepicondylar axis (TEA) and the posterior condylar line (PC line), which connects the posterior aspects of the femoral condyles. A simple and convenient technique for assessing the TEA and PC line using plain radiography is the kneeling view. The kneeling view has been described as a posteroanterior projection at right angles to the tibial shaft with the knee in approximately 80° of flexion and with the hip joint in neutral rotation. Preoperative planning is possible using the kneeling view in measuring the rotational alignment of the distal femur using the posterior condylar angle. Additionally, information about the varus inclination of the upper part of the tibia may be obtained using the same x-ray view. Kneeling views were obtained in fifty patients with advanced osteoarthritis (classified as 4 on the Kellgren–Lawrence scale) that were admitted in our department for primary TKA. The varus inclination of the upper part of the tibia and condylar twist angle were measured using digital protractors.

Results: There was no statistically significant correlation between the posterior condylar angle and the varus inclination of the upper part of the tibia. Bivariate linear regression analysis did not reveal any prediction equation or relation between the two computed variables in advanced osteoarthritic knees.

Conclusions: Using this method of preoperative planning, the current practice of cutting the tibia perpendicular to its mechanical axis and applying a predefined external rotation of the femoral component is strongly disputed, especially in advanced osteoarthritic knees. The results of this study show that preoperative planning may be very helpful in assessing the rotational deformity of the distal femur. The final amount of external rotation of the femoral component must be approached on an individual basis based on a thorough preoperative planning.

INTRODUCTION: Standard approaches to the cra-niocervical junction (CCJ) include the midline posterior approach and the transoral approach. Both of them are limited laterally because of the Vertebral Artery (VA). Lateral approaches in which the VA is controlled and sometimes mobilised or transposed have been developed to reach the lateral corner of the CCJ. The surgical technique and personal experience are presented.

METHODS: From our experience in the VA surgical exposure, we developed since 1980 two lateral approaches directed towards the CCJ: the posterolateral and the anterolateral approach.

The posterolateral approach is a lateral extension of the midline posterior approach with control of the VA above the arch of atlas and opening of the CCJ up to the VA. Minimal drilling of the arch of atlas and occipital condyle is realised. It is mostly applied on intradural tumours but also in some extradural posterolateral lesions.

The anterolateral approach is a superior extension of the lateral approach used to control the VA from the C6 to C2 levels. The field is opened between the sterno-mastoïd muscle and the internal jugular vein. Then the VA is exposed between C1 and C2 transverse processes and above C1. It is essentially applied on extradural and bony lesions around the CCJ.

EXPERIENCE: Posterolateral approach was applied on 109 tumours, mostly meningiomas (N=78) and neurinomas (N=22) and four bony malformations compressing the VA or the neuraxis. Excellent results were obtained with complete tumoural resection (Simpson grade I or II for meningioma) with only one case of worsening of the neurological condition and two cases with stabilisation.

Anterolateral approach was used on 139 patients with different types of tumours including neuromeningeal tumours N=36, primary bone tumours N=51, sarcoma N=16 and others types N=21, and on three cases of VA compression by bone malformations. Satisfying tumoural resection could be achieved in almost all cases. Sacrifice of the VA was deliberately realised in five patients to ensure as radical a resection as possible in case of malignant tumours or chordomas.

There was no mortality in this series. Morbidity is very limited; injury of the VA was observed in two cases in which repair of the vessel could be done successfully. Stretching of the XI nerve was the cause of pain along the trapezius muscle in five patients.

CONCLUSION: Lateral approach to the CCJ can be realised through two different axis of work; the posterolateral and the anterolateral approach. These approaches give very nice and safe access to the lateral aspect of the CCJ. They complete the other approaches to the CCJ and may be used in association with them.

INTRODUCTION: Results on surgical treatment of chordomas from series published in the literature are disappointing with survival rate of 50% and 35% respectively at five and 10 years. In most reports, surgical resection is limited to a palliative decompression or at best to a subtotal resection. The purpose of this study is to evaluate the results of patients treated aggressively by several surgeries and radiotherapy from 1989 to 2000.

METHODS: From a series of 36 patients presenting with cervical (N=8) or suboccipital (N=28) chordomas, 22 were referred primarily while 14 were sent to us for a recurrence after a previous partial surgical resection. In both groups of patients, we proposed as radical a surgical resection as possible realised in one to four surgical stages followed by radiotherapy (and protontherapy for the more recent cases).

RESULTS: Patients seen at first presentation (group A) underwent 1,9 surgeries in average and 10 of them could have a protontherapy while in group B patients referred after recurrence, 1,4 surgeries were carried out and three could have a protontherapy. Follow-up extends from one to 11 years (mean 4 years).

Actuarial survival rate was 80 and 65% respectively at five and 10 years in group A as compared to 50 and 0% in group B. Actuarial recurrence free rate was 70 and 35% at five and 10 years in group A and 0% at three years in group B. Disease related mortality was 15% in group A and 63% in group B. The rate of recurrence per year was 0,15 in group A and 0,62 in group B. The mean delay before the first recurrence was 43 months in group A and 15 months in group B.

Factors such as sex, age, duration of symptoms, severity of symptoms, extent of tumour, histological type or grading have no influence on the survival rate and the recurrence free rate. Even the comparison between patients having received or not radiotherapy and patients treated or not by protontherapy failed to show any difference. However these groups of patients are very small and include group A and group B patients.

CONCLUSION: Aggressive surgical treatment at first presentation of patients with chordomas seems to provide better results in terms of survival and recurrence. However it requires several surgical stages (up to four) followed by radio and protontherapy. No other factors have proven to influence the prognosis. In case of patients already presenting a recurrence this aggressiveness does not seem to be justified. Therefore after this study, aggressive surgical treatment was only proposed to primary patients (N=12) and not on patients with recurrence (N=7).

INTRODUCTION: Oblique corpectomy is a surgical technique of spinal cord decompression through a limited bone resection of the posterolateral corner of the vertebral bodies. In this study the results of this technique applied in cases of spondylotic myelopathy and tumours are presented.

METHODS: The oblique corpectomy is achieved through a lateral approach with control and sometimes transposition of the VA. It can be used at any level from C2 to T1 and on as many levels as required from 1 to 5. It was mostly applied on cervical spondylotic myelopathy (N=157) or radiculopathy (N=89) but also on hourglass tumours (neurinomas N=67, meningiomas N=7, hemangioblastoma N=1, paraganglioma N=1) and different tumours N=49 involving the lateral part of the vertebral body such as osteoid osteomas N=8, chordomas N=11, aneurysmal cyst N=3, sarcomas N=4. The total series includes 126 tumours. In most cases preservation of the main part of the vertebral bodies permitted to avoid bone grafting and plating. However stabilisation procedure is still necessary when more than one disc is resected and when the discs are soft and not collapsed.

RESULTS: Excellent decompression was obtained in every case of spondylotic myelopathy and radiculopathy. Clinical results are similar to those obtained by any other techniques of decompression through anterior approach but without the complications related to grafting and plating. Improvement of the pre-operative score was noted in 79% of patients with myelopathy stabilisation in 13% and worsening in 8%. In patients with radiculopathy, good and excellent results were obtained in 85%. A better decompression of the intervertebral foramen is achieved through the oblique corpectomy since the whole length of the cervical nerve root from the dural sac to the vertebral artery can be decompressed. Instability requiring further stabilisation procedure was observed only in three cases which in fact were pre-operatively unstable.

Complete tumour resection was achieved in every case especially for the lateral part located into the intervertebral foramen and around the vertebral artery. Even tumours extending from the outside of the spine to the intradural space could be entirely removed through the same approach. Grafting and plating were realised in 13 out of the 126 cases of tumour.

CONCLUSION: Oblique corpectomy technique is a safe technique which permits to decompress the spinal cord and cervical nerve roots from spondylotic elements and tumours.

As compared to other techniques, it achieves a better decompression on the lateral part of the spinal canal and on the intervertebral foramen up to the vertebral artery. In many cases it does not require any complementary stabilisation technique and avoids the use of instrumentation.