Introduction

Depending on patient's age, risk factors and pretraumatic mobility, a total- or hemiarthroplasty of the hip have become the treatment of choice in femoral neck fractures(1–4). Internal fixation has shown to provide minor results. The majority of these patients are therefore treated by a hemiarthroplasty of the hip. Since the primary goal is to regain the pretraumatic level of mobility as soon as possible(3;5), we sought to investigate, if a minimal invasive anterior approach would be beneficial in regard of perioperative blood loss(6), postoperative pain(7;8) and thus postoperative mobility(9).

After establishing anatomical feasibility, functional reconstruction to replace the anterolateral part of the deltoid was performed in 20 consecutive patients with irreversible deltoid paralysis using the sternoclavicular portion of the pectoralis major muscle. The indication for reconstruction was deltoid deficiency combined with massive rotator cuff tear in 11 patients, brachial plexus palsy in seven, and an isolated axillary nerve lesion in two. All patients were followed clinically and radiologically for a mean of 70 months (24 to 125). The mean gender-adjusted Constant score increased from 28% (15% to 54%) to 51% (19% to 83%). Forward elevation improved by a mean of 37°, abduction by 30° and external rotation by 9°.

The pectoralis inverse plasty may be used as a salvage procedure in irreversible deltoid deficiency, providing subjectively satisfying results. Active forward elevation and abduction can be significantly improved.

Intro: Traumatic atlanto-occipital dislocation (AOD) remains a seldom and severe injury which function-ally separates the head from the upper cervical spine and thus can lead to neurological compromise or death. We report on a survivor after AOD, who came back to sportive activity after operative sta-bilization C0–C2.

Case Report: The 32 year old polytraumatized racing-bicyclist was addmitted to our insitution after a crash. Initially, due to the lack of hard diagnostic signs the diagnosis AOD was missed. Thoroughly reevaluation and craniocervical diagnostics particluar dynamic roentgenogramms revealed the atlanto-occipital instability. Thus the patient underwent posterior fusion C0–C2 using a pedicular-rod-based cranio-cervical hardware-system (CerviFix). The patient gained full recovery and after 2 years of active physiotherapy he showed a favourable functional outcome and came back to sportive-cycling.

Discussion: Missing atlanto-occipital dislocation as well as secondary dislocation with conservative treatment of this rare entity can cause serious sequelae or lead to death. Thus a thorough diagnostic scheme has to be installed for cervical spine fractures including dynamic roentgenogramms contrary to fear of neu-rological compromise in this technique as well as CT and MRI. The knowledge based in literature suggest that any concomittant ligamentous instability in case of C0–C1 injury has to be stabilized by operative fusion as there is unsure clinical course, if treated in conservative manner predisposing for secondary hits, epecially in sportive individuals

Conclusion: Actually due to the lack of large single institution series, theres no evidence or proper guidelines concerning diagnostics and treatment of AOD. We recommend CT and dynamic roentgenogramms of the cervical spine in case of a suspected AOD. Dynamic x-rays clearify masked cervical spine in-stabilities including AOD and thus should be performed to reveal AOD prefering to MRI. The treatment of AOD utilizing anchor stable posterior rod-based systems enable early postoperative physiotherapy, rehabilitation and secure healing.