Purpose of the study: The goal of palliative surgical treatment of vertebral metastases is to avoid, stabilise, or improve neurological disorders and to relieve pain. We propose early treatment for fixation of threatening lesions and extensive release without resection for programmed surgery outside the emergency context.

Material and methods: From 2001 to 2005, eighty patients underwent scheduled surgery for threatening or symptomatic lesions. Mean age was 59 years (range 32–82). The primary tumour was: breast (n=35), lung (n=19), kidney (n=8), uterus (n=1), prostate (n=2), ENT (n=3), gastrointestinal (n=5), haematology (n=7). Sixty-six patients presented Frankel B to D neurological involvement. The Tokuhashi score was 8 on average (range 5–9) and the Karnofsky index 57% (range 30–70). Sixty-four patients had visceral metastases. On average 7 levels were instrumented (range 4 to 8). The procedure included laminectomy in all cases.

Results: Blood loss was 500 cc (300–2700) and operative time 110″ (65–110). Fifty-nine patients recovered one or more Frankel grade. Six patients (7%) developed a postoperative infection. The actuarial survival at one year was 78%; 95% for patients free of motor neurological involvement and 65% for the others. This difference was significant.

Discussion: Spinal metastases should be detected and treated before emergency care is required. At the present time this treatment is well programmed. Fixation without tumour resection enables prolonged survival and allows time for other treatments in a pluridisciplinary management scheme. Several therapeutic options are possible but converge towards improved quality of life.

Conclusion: Posterior tumour resection is not useful for palliative surgical management of vertebral metastases. We propose an active approach using a simple well-defined surgical procedure without waiting for development of a neurological emergency.

Purpose of the study: Treatment of calcaneal fractures is specific because of the fact that these fractures dis-organise the subtalar joint, requiring precise reduction. The clinical result is not always satisfactory considering the efforts made to obtain reduction and fixation. Functional treatment often gives acceptable clinical results, but leaves important anatomic and functional sequelae. We developed a technique for percutaneous balloon reduction and cementoplasty similar to the method used for vertebral fractures treated with the same material.

Material and methods: We describe four cases of thalamic fractures treated surgically in a semi-emergency setting. The patients were four women, mean age 39 years (range 26–55). Fractures included vertical compression fractures of the thalamic surface in all cases. The operation was performed under radiographic control in the operative theatre and included a phase for percutaneous reduction and a phase for cemented fixation, allowing a minimal incision and control in two planes.

Results: Operative time was 30 minutes and blood loss was negligible. Bone healing with maintenance of the subtalar reduction was achieved in all cases. The clinical result was remarkable, with sedation of the pain and oedema within hours and weight bearing within a few weeks. One patient developed a lateral submaleolar impingement which required infiltration at four months. All patients were totally pain free and had no radiographic evidence of osteoarthritis at two years.

Discussion: Percutaneous reduction cemented fixation is a new method for the treatment of thalamic fractures of the calcaneum. We demonstrated the feasibility in a small series; the procedure was simple and allowed effective treatment compared with the classical methods.

Conclusion: These excellent clinical results are encouraging for the development of the technique and incite us to propose this method as the first-line treatment for displaced thalamic fractures. We are working on the development of this concept.

To determine the functional outcome of floating knee injury a retrospective study was undertaken at 3 level 1 trauma centers.

Methods: Between 1998 and 2004, 96 consecutive patients were identified with at least 2 years follow up. The average age of the cohort is 31 years (15–74) with 76 males. The average ISS was 17.3 (9–57), 31.3% of the patients were multiply injured (ISS > 18). According Fraser’s classification, 78 patients presented a type I lesion. At least one of the fracture was open in 77% of cases.

Results: The preferred fixation method for the femur was IM nailing, either antegrade (58) or retrograde (14). IM nailing of the tibia was performed in 59 cases. Infection occurred at one site in 14 patients and non union in 25. A multivariate analysis did not show any significant increased risk of non union or different clinical result when using a retrograde nailing technique (single knee incision) except a shorter mean operating time (177’ vs. 132’, p=0.0144) and a shorter mean total surgical procedure (155’ vs. 240’, p< 0.0001). The Karlstrom’s score at the latest follow up was obtained in 86 patients (2–4.5 years) and was rated as good or excellent in 63,4% of cases in type 1 injuries versus 16,7% in type 2.

Conclusion: Floating knee injury remain a rare lesion showing extremely bad prognosis factors in general although clinical results remain closely correlated to intra articular involvement at the fracture site.

PURPOSE: Oldest elderly trochanteric fractures treatments are common but long term follow up studies are indistinct. Previous data about all outcomes are not reported for oldest one. The purpose was to update all the results for these oldest old patients.

METHODS: A prospective, longitudinal study was undertaken of 455 “31 A1, A2, A3” (OTA) peritrochanteric femur fractures through 2002. There were 84% female patients. The age was 88 (80–105) ±5 years. Associated hip arthritis rate was 10%. 31 A1 and 31 A2 really trochanteric fractures were 90% (31 A1: 52% and 31 A2: 38%), 31 A3 subtrochanteric were 10%. Surgical treatment was achieved for 97%: [extramedullary internal fixation (dynamic hip screw): 36%, intramedullary (trochanteric nail): 56%, hip arthroplasty: 5%]. Functional treatment (not displaced or contra-indicated) was achieved for 3%. Katz, mental, Parker, walking scores, live place before and at long term after fracture, radiological healing and complications were registered.

RESULTS: The radiological healing rate after 3 months was 85% and after 6 was 97%. Complications rate: the general complications rate during 1st month was 12% and between 1st and 3rd month was 8%. The local complications rate during the 1st month was 4% (local infection: 1%) and between 1st and 3rd month was < 1%. The new surgical procedures rate during the 1st month was < 0.5%, between 1st and 3rd month was 3%, between 3rd and 6th month was 3%. Clinical results: Post-operative weight bearing was uncertain. 6th month after fracture 72% of the patients were alive (dead: 28% and non-surgically treated: twice more). All scores and live place demonstrated dependence increase. > 6th month after fracture mortality was common.

CONCLUSION AND SIGNIFICANCE: Intra/extra capsular hip fractures ratio increases after 80. These are older, more dependant and help demanding. Hip arthritis inflates hip fracture risk. Success points technical procedures had been demonstrated by randomised studies: dynamic hip screws for stable fractures and trochanteric nails for unstable; hip prosthesis for arthritis or poor bone. Practice surgery for all trochanteric fractures. Don’t separate trochanteric/subtrochanteric. The prognostic is rather poor (mortality rate, functional outcomes), depending on initial functional score and dependence. Modern internal fixation is reliable. Arthroplasty should be considered.