Purpose of the study: The thin soft tissue cover and the proximity of underlying structures of the ankle are factors favoring cutaneous necrosis which could rapidly expose the bone, joint or tendons. Flap cover is widely used. Several types of flap and donor sits have been described. We report a consecutive series to examine the different indications.

Material and methods: Between 2000 and 2005, we treated 22 cases of tissue defects involving the ankle. Most patients were trauma victims with damage involving the distal quarter of the leg to the forefoot. Mean size of tissue loss was 8 x 6 cm (range 2–13 x 2–9 cm). The localization was medial for nine, anterior for six, and lateral for seven. Several types of flaps were used: distally-based sural (n10), lateral supramaleolar (n=5), medial arch (n=2), pediculated soleus (n=4), island latissimus dorsi (n=1).

Results: The success rate was 72%. There was one total failure (medial arch). The six cases of partial failure (27%), which involved partial distal necrosis of three lateral supramaleolar flaps and three sural flaps, were revised by re-advancement of the pedicle or aspirative dressings.

Discussion: When possible, we prefer pediculated flaps considered to be more reliable. The rate of partial necrosis was high but all of the failure cases involved serious general problems. The sural flap is especially useful for anterior and lateral tissue defects. Its deep pedicle is often intact, improving chances of survival. It can also be used for transverse anteriomedial injuries. Large longitudinal medial defects would be a good indication for free flaps or, in the event of a contraindication and also, in our experience, for pediculated soleus flaps. Supramalleolar flaps can be a problem in this localization: we reserve these flaps for non-traumatic medial or anterior defects. We have found that the risk of failure it too great for the medial supramalleolar flap.

Purpose of the study: Osteitis with loss of distal soft tissue on the medial aspect of the leg raises a problem of cutanous cover, particularly in the event of longitudinal injury. Free flaps are frequently used with variable success in older patients with more risk factors. Four our more frail patients, we have used a retrograde soleus flap pediculated on the posterior tibial artery. We present here the possibilities offered by this flap and assess the different indications.

Material and methods: Six patients, mean age 55 years (range 44–68 years) were treated for cutaneous tissue loss measuring 9.5 x 6.5 cm on average. One patient was diabetic and two were smokers. The decision to use the soleus flap was made because of the presence of cutaneous lesions on the leg contraindicating a local falp. Arteriography revealed the persistence of the three vascular routes with satisfactory distal anastomoses, allowing high ligature of the posterior tibial arery intraopeartiely after a clamprepermeabilization test. The soleus flap was modeled to size and rotated en bloc with the tibial artery which was released to the retromaleolar localization for the distal flap^s. Treatment of osteitis incluced resection, cement filling and antibiotics then bone graft.

Results: All flaps survived. One had to be revised because of partial necrosis. There were no distal vascular problems. At minimum follow-up of 18 months, all the cases of osteitis had healed.

Discussion: The soleus flap pediculated on the posterior tibial artery is a reliable and effective flap. The territory covered can be very distal, reaching the foot. The vascularization of the soleus muscle allows moving the entire muscle, providing a very powerful flap. Deliberate sacrifice of a vascular supply considered as dominant for the leg is certainly a difficult decision, but which must be weighed against the risk of failure of a free flap.

Purpose of the study: Hemophilic arthropathy is often located in the knee joint. Total knee arthroplasty (TKA) is the ultimate solution to total joint destruction, often observed in young patients. The purpose of this study was to evaluate the outcome of TKA in hemophilic patients and to describe specific features.

Material and methods: Hemophilics who underwent TKA between 1990 and 2004 were reviewed at mean 4.7 years follow-up: 30 TKA (7 posterior stabilized, 23 with preservation of the posterior cruciate) were implanted in 21 men, mean age 39 years, 17 with hemophilia A et 4 with hemophilia B. Seventeen patients were HBV-positive and eight were HIV-positive. Coagulation factors substitution was managed by the regional center for the treatment of hemophiliacs starting the day before the operation and for a minimal postoperative period of 21 days. The Knee Society score was used for assessment of clinical outcome.

Results: Preoperatively, mean flexion was 75° (range 40–100°), mean permanent flexion was 20° (range 5–45°). Range of joint motion was 56° on average (range of range of motion 10–105°). Early postoperative hemarthrosis occurred in eleven knees and seven of these required revision from day 4 to day 15. The four others resolved spontaneously. Six late infections (20%) developed in five patients (one bilateral infection). One patient was treated by arthroscopic wash-out, and four by arthrotomy. One required revision TKA in a two-stage procedure. Five patients received an adapted antibiotic therapy for an identified germ; the germ could not be identified in one patient. At last follow-up, mean flexion was 85°, mean permanent flexion was 10°, and mean range of motion was 71°. None of the patients complained of pain both at rest and during exercise.

Discussion: Hemophilic arthropathy is particularly painful, producing stiff joints in these immunodepressed patients. The known high rate of complications was again observed in this series, particularly infectious complications after TKA in hemophiliacs. These complications did not however alter the functional outcome. The gain in joint motion was modest but the absence of pain was a satisfactory result for these patients.

Purpose of the study: This study was conducted to assess short- and mid-term radiographic outcome of percutaneous posterior osteosynthesis (Sextant®)of thoracolumbar spine fractures and to identify indications and complications.

Material and methods: The Sextant® material was used for 14 patients with a lumbar spine or low thoracic spine fracture. Mean patient age was 40 years (range 19–84). Outcome was reviewed retrospectively. Osteosynthesis was performed for 11 fractures Mager 1 A3, 2 B2, 1 C1 with no neurological deficit. A complementary graft and anterior decompression were used 11 times (9 fibular, 1 posterior crest + rib, 1 cage). The pre- and postoperative and 3 month ART were noted. The position of the implants was assessed on the postoperative CT.

Results: Mean follow-up was 9.2 months (range 2–16). On average, ostheosynthesis was performed 15 days after trauma (range 1–90 days). There were no neurological or infectious complications. Sutures had to be resected in two cases due to cutaneous suffering. Nine patients wore a corset for three months. The absolute ART score improved from 18 preoperatively to 7 postoperatively and was noted at 14 at three months. Seven patients required heterologous blood transfusion after the anterior approach. Three screws (5.3%) were ectopic but without consequence.

Discussion: Indications for percutaneous osteosynthesis include spinal fractures without neurological complications with sagittal deformation for which an anterior approach is planned initially for mechanical reasons. An isolated anterior approach is possible in this type of fracture; nevertheless, percutaneous posterior osteosynthesis enables emergency reduction and fixation of the fracture, a simplified secondary minimal anterior approach for release, and bone grafting without anterior instrumentation. Three patients did nor require complementary anterior stabilization as the percutaneous oseosynthesis played the role of «internal fixation». The advantages of percuteneous osteosynthesis are the absence of bleeding and damage to the paravertebral muscles which limits morbidity, particularly infection. This technique can be performed in the emergency setting, especially for multiple trauma victims. The drawbacks of percutaneous osteosynthesis are the impossibility of performing a posterior fusion and release the spinal canal. The loss of correction observed were probably related to the type of graft (fibular). Use of a cage should limit graft impaction and loss of correction.

Purpose: Malignant primary tumours of the spine require wide resection with preservation of the cord and radicular elements. The purpose of this work was to report our oncological results and complications after spinal surgery for this indication.

Material and methods: Twenty-two patients, mean age 30 years (15–65) underwent surgery. The pathology diagnosis was made preoperatively. There were 16 high-grade tumours, Ewing (n=7), osteosarcoma (n=5), other (n=4), and six low-grade tumours, chondrosarcoma (n=5), osteosarcoma (n=1). Four patients experienced local recurrence after an insufficient initial resection and three required emergency laminectomy. Sagittal hemivertebrectomy was performed in 11 patients for pediculotransverse tumours and total vertebrectomy in 10 patients for corporeal tumours. Posterior fixation was not used in one patient (Ewing tumour) in order to preserve the Adamkiewitz artery.

Results: Complete oncological resection was achieved in 14 patients. The surgical margins were in a malignant zone in 7. At mean 6-year follow-up, ten patients were surviving disease-free (4 Ewing, 4 osteosarcoma, 2 chondrosarcoma), and one was living with active disease (chondrosarcoma). Eleven patients died: metastasis (n=4), local recurrence (n=6), infarction 3 months after surgery (n=1). Among the seven patients with local recurrence,osteosarcoma (n=5),chondrosarcoma (n=2), three had local recurrence at initial management and only one was living at last follow-up (active chondrosarcoma). There were no neurological complications; there were four mechanical complications (nonunion) after total vertebrectomy which required four re-operations.

Discussion: Survival rate in this series was 45% at six years, comparable with rates reported in the literature (40 – 50% at 5 years). Local recurrence was observed in 85% of patients whose surgical margins were in malignant tissue (67–100% in the literature). Among the four patients who had recurrent disease at the time of surgery, complete resection was possible in only one. This patient is living (Ewing sarcoma responding to adjuvant therapy). Incomplete surgery or a poor biopsy procedure aggravates the prognosis. Mechanical failure is observed after total vertebrectomy if anterior osteosynthesis is not associated with the posterior fixation.

Conclusion: Wide surgical resection of primary bone sarcomas of the spine provides encouraging results when the initial operation is successful. Better local control of Ewing sarcoma can be explained by its sensitivity to adjuvant therapy. Reconstruction after total vertebrectomy required anterior and posterior fixation.

Purpose: The incidence of postraumatic vertebromedullary syringomyelia is difficult to estimate but the most recent series have reported 28%. The purpose of this retrospective study was to search for risk factors of symptomatic posttraumatic syringomyelia (PTS) and to propose an adapted approach for early management.

Material and methods: Forty-six patients consulted for symptomatic PTS 14 years (range 9 months – 45 years) after their trauma. Half of the patients had initially undergone treatment (osteosynthesis in 74% and laminectomy in 70%). Physical signs, the Frankel score, measure of functional independence (MFI) at discovery of PTS were compared with findings early after trauma. Local kyphosis and residual canal stenosis were measured. The location, length, and extension of the syringomyelic cavity, presence of arachnoiditis, and freedom of the subarachnoid spaces were studied on magnetic resonance images. Intra-cystic and perimedullary fluid flow was also quantified.

Results: Gender, age, vertebral level, and degree of initial neurological deficit were not predictive of symptomatic PTS. Clinical signs of PTS were pain, paraesthesia, or supra-lesion motor deficit in two-thirds of the patients, bladder sphincter disorders or aggravation of sub-lesion residual motricity in the others. The MFIwas statistically decreased compared with the initial evaluation. Clinical signs were significantly correlated with intracavitary velometric measures. There was no correlation between clinical severity, time to development of PTS, initial treatment (surgery versus orthopaedic), and the kyphosis value or degree of stenosis. When residual kyphosis was greater than 35° or when canal narrowing was greater than 30%, the cavity was more extensive.

Discussion: It is important to search for PTS in subjects with a history of vertebromedullary injury who present changes in the clinical or functional presentation (aggravation of MFI) late after trauma. MRI velometry provides a better understanding of progression of postraumatic cystic myelopathy. The degree of kyphosis and canal stenosis appear to be predictive of lesion extension.

Conclusion: Initial correction of spinal deformations after trauma and recalibration of the spinal canal help prevent development and aggravation of PTS.

Aims: Mid and long term results of a continuous series, including learning curve, of 500 TKR cruciate sparing implanted between September 1992 and February 1995 by different surgeons of GUEPAR (staff members and residents) Material: Patients average age70.3 years (26–93). Etiology: Primary OA 74%, post traumatic 6%, RA 6%, associated aetiology in 14% (osteonecrosis, microcristalline arthropathy...). No previous surgery in 325 knees. 175 knees operated before (tibial osteotomy: 37, femoral osteotomy: 4, patella:13, other knee surgery: 74% knee arthroplasty mainly unicompartmental: 19.) Operation procedureby medial approach, except 16 lateral (3.2%) and 6 tibial osteotomy (1.2%). Lateral retinacular release in 19.6% aligned patella and 29.2% subluxed or luxed patella. Per operative complications: PCL weakness (24), tibial plateau fissure (16), condylar fracture (1), patellar fracture (3) without consequence on weight bearing. Although anatomic shape of Wallaby 1 trochl, 86.5% inlay and 11.1% resurfacing patellar component have been done. Very few patella (2%) are not resurfaced at the beginning of our experience. Postoperative complications: No specific earliest complications related to the prosthesis. Latest compliations are: 2 infections in the first month treated by lavage debridement with total recovery and 6 latest infections (> 5th month) with prosthesis removed. 1 bipolar aseptic loosening, 1 patellar loosening without fracture and only 2 of 21 patellar fractures have been fixed by wires. 3 reoperations for persistent pain: 2 patella resurfacing and 1 patellar lateral retinacular release, 3 periprosthetic femoral fractures, 2 fixed by plate, 1 treated by conservative treatment with good results.1 medial collateral ligament rupture after trauma revised with another prosthesis. 5 Sudeck syndrome. Results: Femoro tibial alignment is good (between 3° valgus and 2° varus) in 71.1% and reach 90% if between 5° valgus and 5° varus in%. 38 patients (38 knees: 7.6%) are deceased or lost for follow-up before 1 year (without any revision); 462 knees (92.4%) are follow-up between 1 to 5 years and 381 (76.%) more then 5 years. According to International Knee Score results on these 381 knees are: 104∞ of average flexion (pre op. 109∞), 90.6% had any or mild pain. IKS Knee score 90,6 (45–100) (pre op. 25) IKS function score: 59,7 (0–100) (pre op. 28,5) Survival rates at 8 years: 98.2%(confidence interval of 95%: 99.4–96.9) for removed prosthesis whatever the reasons, and 99.2% (confidence interval of 95% 100–98.4)for revision for mechanical failure only. Conclusions: Encouraging results with a true condylar divergent device encourage us to continue Alignment has to be improved, perhaps with navigation tools.

Purpose: Instability of the injured elbow early after repair can lead to recurrent dislocation or failed fixation. Complementary immobilisation increases the risk of stiffness. The purpose of this study was to assess the contribution of dynamic external fixation which allows protected mobilisation and controlled distraction. We wanted to determine feasibility and appropriate indications.

Material and methods: We used the Pennig articulated elbow fixator in twelve trauma victims. Most had complex injuries: five dislocations with lesions of the medial ligaments and fractures of the radial head, including two with early recurrent dislocation; five joint fractures (involving to various degrees the lateral condyle, the head of the radius, the olecranon, and the humeral surface). This fixation method was also used for old or sequelar lesions to achieve reconstruction of the humeral surface (n=3) or after extensive arthrolysis (n=2). Mobilisation was started on day five postop.

Results: For the fresh injuries, the humero-ulnar articulation was centred in all cases. In these patients, mean final flexion was 0.35.130° and pronation-supination was 0.10.155°. One purely lateral dislocation was observed. Radio-ulnar synostosis after fracture of the ulna (n=1) and osteoma (n=1) were also observed.

Discussion: This dynamic external fixation system is a simple and safe procedure if a rigorous technique is applied. This method enabled early rehabilitation without secondary displacement and also enabled reliable contention particularly important in these multiple injury patients. The patients experienced very little pain during rehabilitation exercises, probably due to the distraction which did not appear to provoke reflex dystrophy. For complex instability of the elbow, the reduction of stress forces during mobilisation movements enables an extension of the indications for preservation of the joint fragments. Less reliable results are obtained for stiff elbows with old lesions.

Purpose: Surgery is required for primary tumours invading the sacroiliac joint. The purpose of the present work was to analyse results obtained with surgical treatment in order to better ascertain indications.

Material and methods: Forty patients (24 men and 16 women), mean age 24 years (range 12–56) underwent surgery for high-grade sarcoma (n=30, osteosarcoma 12, Ewing 13, chondrosarcoma five) or more differentiated tumours (n=10, low-grade S chondrosarcoma five, fibro-sarcoma two, others three). Resection was achieved in 37 cases via two approaches and via a lateral approach in three. Resection involved vertical sacrectomy either via the homolateral foramen (n=27) or via the midline (n=10). Reconstruction consisted in stabilising the iliosa-cral assembly generally associated with vertebral osteo-synthesis, an autologous graft in 36 cases, cement in one, and an allograft in three. Functional outcome was assessed with the MSTS (Enneking).

Results: There were three infections (all three with extensive lateral approach) and five cases of postoperative lumbosacral trunk palsy. Late complications were three cases of spondylolisthesis and eight nonunions. Twenty patients died (eight local recurrences, ten metastases, one chemotherapy toxicity, one undetermined cause). Sixteen patients achieved complete remission at six years (follow-up 2–16 years) and four patients were lost to follow-up. Functional outcome was very good in eight, good in ten, fair in twelve, and poor in ten. Survival was 40% among patients with malignant tumours (38 patients) but only 20% for those with osteosarcomas.

Discussion: Technical improvements (combined approach rather than wide lateral approach and omentum flap) have allowed a reduction of cutaneous and infectious complications. Mechanical complications can be prevented by systematic lumbosacral fusion on the side opposite the resection reconstruction. This provides good functional results despite sacrificing a hemi-sacral plexus if the lumbo-sacral trunk is preserved. Reconstruction after extension of the resection to the acetabulum raises an unresolved problem and yields mediocre results. The quality of the surgical resection is determinant since risk of local recurrence is 8/100 after a contaminated resection edge.

Conclusion: Surgical resection of sacroiliac tumours is a source of numerous complications despite real technical improvements. This approach can be proposed if carcinological resection can be reasonably achieved. Local control is very poor in case of large osteo-osteogenic sarcomas.

Treatment by TKR of severe deformities : fixed varus or valgus knee, or flexion contracture, sometimes combined (valgus and flexed knee as for example in rheumatoid arthritis) is frequently a difficult challenge. Seldom a flessum, recurvatum or malrotation have also to be managed.

These deformations, articular, extra-articular or combined can be observed in knee arthritis associated with malalignement, malunion of diaphysis, malunion of lower part of the femur or upper tibia after fracture or osteotomy, chronic juvenile arthritis or rheumatoid arthritis, Paget’s or post-rachitism disease.

In 60′ and 70′ the most difficult cases have been frequently treated by hinge prosthesis with a high percentage of infection and loosening; many of the other cases treated with customary prosthesis had a poor follow-up because instability, luxation, patellar problems, pain or recurrence of the deformity.

Now to obtain the best prosthesis survival rate , the well trained orthopaedic surgeon has to make a good radiographical and clinical examination and the a good planification with the good choices:

- necessity or not to perform, as a first stage, an osteotomy of femur or tibia to correct a mal-union or a deformity in frontal, sagittal or horizontal plane

ARTICULAR OR PARA ARTICULAR DEFORMITIES

1) FIXED VARUS KNEE

Treatment of this deformation is usually not so difficult. In case of postero-stabilized prosthesis implantation, after removal of medial condylar and tibial plateau osteophytes resection of PCL and release of semi-membranosus tendon and postero- medial capsule are performed. Pes anserinus and collateral medial ligament release creating a subperiosteal elevation of the medial envelope is sometimes needed for good soft tissue balance; in such case a constrained plateau can be useful.

It is also possible to try PCL sparing but a good tightening of PCL is difficult and reconstruction by bone graft, metal wedge or cement or medial tibial plateau is in most cases necessary to protect tibial insertions of PCL.

2) FIXED VALGUS KNEE

We prefer the Keblish approach to have a direct look on the tightened formations (iliotibial band, lateral collateral ligament, popliteus.

We agree with the Krackow’s classification of valgus knee in 3 groups.

For group 1, according to Whiteside it is possible to spare the PCL in the majority of cases if we accept to use a bone graft or a metal wedge on the lateral femoral condyle or/and tibial plateau taking the medial compartment as a reference.This choice of arthroplasty with PCL retention maintains the right level of the knee joint and offers often a best stability than postero-stabilized prosthesis does; PCL well tightened is a “third ligament” giving frontal stability as proved in traumatology. In fact many surgeons prefer to use postero-stabilized arthroplasty to avoid difficulties in PCL managing, and they release in different controversed steps the lateral elements. If there is instability they implant a more constrained tibial insert than usually. As communicated by Burdin it is also possible to prevent instability by performing a sagittal osteotomy of the lateral condyle around the insertions of popliteus and collateral ligament, and screw it after obtaining a good balance of the knee with the displacement of the osteotomized bone downward and/or posteriorly.

For group 2, which is caracterized by medial collateral ligament instability, it is safer to treat these knees with a postero-stabilized more or less constrained prosthesis than using a PCL sparing one and advancement of the medial ligament.

For group 3, severe overcorrection in valgus after lateral closed osteotomy for tibia varus realizes an upper tibial malunion. Prosthesis implantation is difficult: difficulties of soft tissue balance, conflict between upper tibial lateral cortex and tibial metalback stem, and bad coverage or overlapping of the tibial metalback, unless using a twisted stem. Different options can be choosen:

postero-stabilized prosthesis needs a release of lateral side; the tibial cut perpendicular to mechanical axis resecting bone to the bottom of the lateral defect takes off a too big amount of bone on the medial tibial plateau to have a safe support for metal back. If bone graft of lateral plateau is done to avoid this fact a constrained insert is potentially necessary.

implantation of a PCL sparing prosthesis with also release of lateral soft tissue, and reconstruction of medial tibial plateau and eventually condylar bone loss. For stability of the knee PCL acts as a collateral ligament. correction of the deformity by a new tibial osteotomy and after its consolidation implantation of the prosthesis some months later.

tibial osteotomy and prosthesis can be performed during the same operation, using a long tibial stem, cemented or not to stabilize the osteotomy site.

3) FLEXION CONTRACTURE

Correction of the deformity can be difficult when flexion is more than 30 or 40 degrees; PCL is not always an obstacle for correction. Sometimes initialy anterior bony deformity of the upper tibia has to be resected , especially in rheumatoid arthritis. After regular cut of the distal femur and removing of posterior osteophytes and loose bodies, elevation of posterior capsule from the distal femur is less dangerous than transverse incision of its middle part. If needed proximal attachements of gastrocnemius can also be stripped from the femur. Then if knee extension is not possible with trial component the tightened PCL has to be sacrified, or released or lengthened for some surgeons wanting to spare it. Finally a choice between lengthening of hamstrings and pes anserinus or a new cut of distal femur is necessary with use in some cases of a more constrained tibial plateau. For good tracking of patella lateral retinacular release is also mandatory.

4) FLESSUM, RECURVATUM, MALROTATION

Small flessum or recurvatum in metaphyseal area can be managed with the femoral anterior and posterior distal femoral cuts or tibial cut with sometimes incidence on prosthesis choice and biomechanical consequences.

Malrotation around 15 degrees can also be corrected by implants positioning, and perhaps a little more than 15° using a mobile bearing prosthesis.

EXTRA ARTICULAR OR COMBINED DEFORMITIES

In this type of deformity it can be necessary to perform in the same or in two separate operations its correction by a diaphyseal osteotomy preferably at the site of the deformity.

It is mandatory to have a good fixation of the bone to allow a quick and strong rehabilitation of the knee after prosthesis implantation. Plating, nailing or stabilization by the stem of prosthesis can be used.

At the present time the trend is to reach good correction of the deformity and implantation of the prosthesis at the same time even if the deformity is extra-articular; this challenge can be difficult.

Purpose: Rotation dislocation of C1-C2 subsequent to trauma is not often described in adults. The clinical, radiological and computed tomographic diagnostic criteria are not well known and can lead to false positive diagnosis. The Fielding classification was described for children. We report five cases of traumatic rotation dislocation of C1-C2 in adults and propose computed tomographic criteria for diagnosis. The Fielding classification is discussed.

Material and methods: In two cases, the diagnosis was suggested by the clinical presentation and the plain x-rays. In three cases, it was revealed by the systematic CT performed in multiple trauma patients. In three cases, MRI enabled visualisation of ligament tears (transverse ligament, alaire ligament). Finally, the C1-C2 relations in neutral position and in rotation were studied on the CT scans in the study patients and in ten healthy subjects to establish diagnostic criteria. The patients were treated with cervical traction until reduction was achieved (checked with CT) then with an “Indian”collar for 45 days. One patient did not wear the collar and experienced a recurrent dislocation.

Results and discussion: In patients who can be examined, the diagnosis is suggested by suboccipital pain, slight rotation inclination of the head to the contralateral side, impossibility of turning the head to the opposite side beyond the mid line. The open-mouth x-ray can be a source of false positive diagnosis but can be suggestive. The CT scan must be performed under precise conditions: patient positioned without rotation or inclination of the head (false positive); superposition of the two slices passing through the C1 and C2 faces (unilateral loss of congruency); sagittal reconstruction. In case of doubt, homo and contralateral rotation slices can provide more sensitive images. The five dislocations were uin-lateral (Fielding type II) with posterior displacement in two cases, a finding not described in this classification. In addition, type I could be a variant of the normal (as seen in control scans). Treatment in the early phase is conservative with reduction by simple cervical traction (verification on CT), followed by complementary immobilisation until ligament healing.

Conclusion: The diagnosis of traumatic rotation dislocation of C1-C2 in adults is based on CT evidence. Certain injuries should be added to complete the Fielding classification. When recognised early, this rotation dislocations can be treated conservatively.

Purpose: En bloc resection can be proposed for lung cancer involving the apex with invasion of the ribs or the transverse process using a transcervical anterior approach. Cancers invading the intervertebral foramen cannot be resected via this approach despite the classical indication for surgical resection. We report results of a novel surgical technique allowing cancerological resection of these tumours.

Material and methods: Fifteen patients with the same grade of cancer were operated using the same surgical technique. The first operative time included: superior lobectomy via anterior cervicothoracic access (without removal of the lobe), dissection of the subclavian vessels and the brachial plexus, section of the ribs and the T1 root, spinal exposure from C6 to T5, hemi-disectomy C7-T1 and discectomy at the level below the invaded foramen, medial vertebral groove, closure. The second operative time included: posterior access, extended instrumentation of the spine, hemi-laminectomy C7 extended as needed, section of the roots (depending on the level of the resection) within the canal, oblique posterior vertebral osteotomy along the medial border of the pedicle terminating in the anterior groove. Finally en bloc ablation via the posterior access of the surgical piece including the lung, the ribs and the hemi-vertebrae.

Results: Three- and four-level hemivertebrectomy was performed in eleven and three patients respectively. One patient had two hemivertebrectomies associated with one vertebrectomy. There were six resections (with repair) of the subclavian vessels for tumour invasion. Peroperative mortality was zero. Mean blood loss was 3000 ml. There were no neurological complications. There were eight postoperative complications: pneumonia five patients, cerebrospinal fluid fistula one patient, skin dehiscence one patient, haemorrhage one patient requiring reoperation. All patients were given postoperative radiotherapy. Three- and five-year survival was 36% and 27% respectively. Among the nine deaths, three had local relapse and six had general relapse.

Discussion: This techniques enables resection of tumours considered to be inextirpable using other techniques. Survival was the same as for tumours of the apex without invasion of the foramen and better than without surgery. This major surgery requires a well-trained multidisciplinary team (thoracic and vascular surgeons, spinal surgeon, anaesthesiologists, intensive care specialists). Contraindications for this type of surgery are invasion of the spinal canal, the brachial plexus and the vertebral body as well as the presence of a spinal artery entering the foramen to be resected.