We report three patients having transoral fusion at C2/3 or C3/4 after fractures, with no infections or surgical complications and sound union. The operative technique and the relative merits of different approaches to the upper cervical spine are discussed and the transoral approach to the anterior aspect of the upper three cervical vertebrae is commended to the specialist surgeon

We reviewed 161 patients, from four centres in Switzerland, who had undergone posterior fusion of the upper cervical spine with transarticular screw fixation of the atlanto-axial joints. They were followed up for a mean 24.6 months. The vertebral artery and the medulla escaped injury and only 5.9% of the complications were directly related to the screws. The rate of pseudarthrosis was 0.6%

1. Three pantalar, one ankle and subtalar, and three ankle arthrodeses have been performed by a technique, the essential step of which is the insertion of a transarticular graft from below. Union has occurred in four to five months. 2. A method is described of determining the degree of equinus before the operation and securing it during the operation. 3. Pantalar fusion by this technique compares favourably with the methods described so far

1. Posterior fusion of the spine in scoliosis cannot be relied upon to maintain correction of the curve or to prevent progression of a vicious resistant curve. It can, however, hold to some extent the correction of a mobile curve and the compensation of a fixed curve. 2. Despite generally poor results as assessed radiographically, the clinical improvement is often gratifying. Most patients claim to be greatly improved: the spine feels stronger, there is less fatigue, and balance is better controlled. Moreover, visible deformity may be improved markedly even though the anatomical correction as observed radiographically is slight (Figs. l0 and 11). 3. It is believed that the true cause of relapse is that the bone formed from sliver grafts remains immature for a long time. Even when incorporated with the immature bone of the child's spine or the mature bone of the adult spine, it remains soft and resilient. When subjected to the stresses and strains of weight bearing and gravity, and then to the unnatural forces which initiated or perpetuated the scoliosis, this immature bone undergoes remodelling to Wolff's Law—like the neck of the femur after slipping of the upper femoral epiphysis. The forces that alter the grafted bone are not only lateral forces but also—perhaps more important—rotational forces. There seems to be a definite link between the degree of rotation and the amount of relapse, correction being maintained best when rotation is least

1. Radiological investigation of cases of flat foot shows that they form three distinct anatomical types according to the precise level of the break in the arch. 2. When the break occurs at the naviculo-cuneiform joint alone, fusion of this joint in normal alignment should correct the deformity. 3. The results of operation on forty-six feet are analysed. Eighty-two per cent proved satisfactory. Failures are discussed and are considered avoidable by careful selection and operative technique

Nineteen patients with thoracic or thoracolumbar spinal tuberculosis and neurological deficits were treated by anterior debridement, decompression and vascularised rib grafting, followed, either during the same procedure or 14 days later, by multilevel posterior osteotomies, instrumentation and fusion. Surgery was performed under cover of four-drug antituberculosis chemotherapy, given for 12 months. The average pre-operative kyphotic angulation of 56 degrees was reduced to 27 degrees postoperatively and 30 degrees at the latest follow-up (3 degrees loss of correction). Radiological fusion between the vascularised rib graft and the vertebrae was seen after an average of 3.3 months. Eighteen patients (95%) had normal neurological function at 14 months, and the other could walk with the aid of crutches

Cervical myelopathy is an uncommon but potentially fatal complication of rheumatoid atlanto-axial subluxation. Computerised myelotomography with three-dimensional reconstruction shows that rheumatoid pannus, together with the odontoid peg, contributes significantly to anterior cervico-medullary compression. These findings were the basis for treatment by transoral anterior decompression and posterior occipitocervical fusion, which removes both bony and soft-tissue causes of compression and allows early mobilisation without major external fixation. We report encouraging results from this combined approach in 14 patients who had progressive neurological deterioration

Displaced fractures of the os calcis involving the subtalar joint frequently cause chronic disability due to subsequent osteoarthritis. Early posterior subtalar fusion may prevent this outcome. We have reviewed forty-seven fractures in forty-three patients at an average of seven years after operation. Over 90 per cent of patients had an excellent, good or satisfactory result

1. This paper describes the macroscopic and microscopic changes that are seen in posterior intervertebral joints after anterior vertebral fusion. 2. We now have a reasonably clear view of the types of change seen under these circumstances. The type varies from case to case and in different parts of the same specimen. So far we have no clear idea of the sequence or the pattern that leads from the normal to complete fibrosis or osseous ankylosis. 3. Further experimental work is needed in order to build up a clear concept of the sequence of events and of their relative importance. To do this it will be necessary to immobilise joints for longer than before

Spinal fusion, ending caudally at L5 rather than at the sacrum, is recommended for selected patients with scoliosis due to Duchenne muscular dystrophy. We present a retrospective review of 48 patients operated on for this condition. Patients having spinal curvature with a Cobb angle of less than 40° and with less than 10° between a line tangential to the superior margins of both iliac crests and a line perpendicular to the spinous processes of L4 and L5, were fused to L5 (38 patients); patients not meeting these criteria were fused to the sacrum (10 patients). Spinal and sitting obliquity increased in patients fused to L5, rather than to the sacrum, but the severity of the worsening obliquity was significantly greater in patients in whom the apex of the curve was below L1. Two of the ten latter patients required revision procedures for worsening obliquity when their pulmonary function deteriorated to less than 25% of predicted values. We recommend fusion to the sacrum for scoliosis in Duchenne muscular dystrophy, especially for patients with an apex to their curve below L1

A review is presented of 13 young patients with congenital scoliosis who were treated by epiphysiodesis of part of the vertebral bodies combined with posterior fusion, both on the convex side; the plan was to arrest growth on the convexity which, combined with growth of the concave side, would result in progressive correction of the curve. The first patient was operated on at the age of four years and has now reached skeletal maturity with complete correction of her curve. Several others, still growing, are showing progressive correction. Only three curves, in which kyphosis was more severe than scoliosis, have deteriorated since operation. Although full assessment must await skeletal maturity of all the patients, this approach appears to have sufficient potential to justify an early report

Thirty-three patients who had undergone anterior cervical fusion for degenerative disc disease were reviewed to determine the efficacy of the procedure. Only patients who were available for examination and who had undergone operation at least one year previously were included in the review. Nearly all had had arm pain and three-quarters neck pain. Diminished neck movement and neurological abnormalities in the arms had been frequent findings. Diagnosis from the clinical features and plain radiographs is described. Myelography was not used routinely and discography was not used at all. Indications for operation and surgical technique are described. Results show that pain in the neck and arm was relieved in a high proportion of cases and that the neurological abnormalities often recovered. It is concluded that this operation is safe and has a definite place in the relief of pain from cervical disc degeneration resistant to conservative treatment

1. Intertransverse fusion in the lumbar spine appears to have many advantages over previously described techniques. 2. The disadvantage of profuse bleeding can be overcome by the use of a Hastings frame and by an operative technique designed to demonstrate constant muscular and articular branches of the lumbar arteries. 3. Coagulation of these vessels by cautery and avoidance of dissection anterior to the plane of the transverse processes ensure that the operative procedure can be carried out with a blood loss averaging less than 500 millilitres

Hip arthrodesis remains a viable surgical technique in well selected patients, typically the young manual labourer with isolated unilateral hip disease. Despite this, its popularity with patients and surgeons has decreased due to the evolution of hip replacement, and is seldom chosen by young adult patients today. The surgeon is more likely to encounter a patient who requests conversion to total hip replacement (THR). The most common indications are a painful pseudarthrosis, back pain, ipsilateral knee pain or contralateral hip pain. Occasionally the patient will request conversion because of difficulty with activities of daily living, body image and perceived cosmesis. The technique of conversion and a discussion of the results are presented.

Cite this article: Bone Joint J 2013;95-B, Supple A:114–19.

Gunshot injuries to the shoulder are rare and difficult to manage. We present a case series of seven patients who sustained a severe shoulder injury to the non-dominant side as a result of a self-inflicted gunshot wound. We describe the injury as ‘suicide shoulder’ caused by upward and outward movement of the gun barrel as the trigger is pulled. All patients were male, with a mean age of 32 years (21 to 48). All were treated at the time of injury with initial repeated debridement, and within four weeks either by hemiarthroplasty (four patients) or arthrodesis (three patients). The hemiarthroplasty failed in one patient after 20 years due to infection and an arthrodesis was attempted, which also failed due to infection. Overall follow-up was for a mean of 26 months (12 to 44). All four hemiarthroplasty implants were removed with no feasible reconstruction ultimately possible, resulting in a poor functional outcome and no return to work. In contrast, all three primary arthrodeses eventually united, with two patients requiring revision plating and grafting. These patients returned to work with a good functional outcome. We recommend arthrodesis rather than replacement as the treatment of choice for this challenging injury.

Cite this article: Bone Joint J 2013;95-B:820–4.

A prospective study to investigate changes in the rib hump or rib deformity after correction of the lateral curvature in adolescent idiopathic scoliosis is reported. The operative treatment for 47 patients was by a Harrington distraction rod and posterior fusion. Before operation and at follow-up, measurements of the Cobb angle, of vertebral rotation, and of the rib deformity were taken. Despite operative correction of the lateral curve, there was a progression of the rib deformity in 64% of the cases after four years. Correction of the lateral curve may thus have no effect on vertebral rotation and cannot be guaranteed to effect a permanent reduction of the rib hump

Salvage of a failed total ankle replacement is technically challenging and although a revision procedure may be desirable, a large amount of bone loss or infection may preclude this. Arthrodesis can be difficult to achieve and is usually associated with considerable shortening of the limb.

We describe a technique for restoring talar height using an allograft from the femoral head compressed by an intramedullary nail. Three patients with aseptic loosening were treated successfully by this method with excellent symptomatic relief at a mean follow-up of 32 months (13 to 50).

We report the outcomes of 20 patients (12 men, 8 women, 21 feet) with Charcot neuro-arthropathy who underwent correction of deformities of the ankle and hindfoot using retrograde intramedullary nail arthrodesis. The mean age of the patients was 62.6 years (46 to 83); their mean BMI was 32.7 (15 to 47) and their median American Society of Anaesthetists score was 3 (2 to 4). All presented with severe deformities and 15 had chronic ulceration. All were treated with reconstructive surgery and seven underwent simultaneous midfoot fusion using a bolt, locking plate or a combination of both. At a mean follow-up of 26 months (8 to 54), limb salvage was achieved in all patients and 12 patients (80%) with ulceration achieved healing and all but one patient regained independent mobilisation. There was failure of fixation with a broken nail requiring revision surgery in one patient. Migration of distal locking screws occurred only when standard screws had been used but not with hydroxyapatite-coated screws. The mean American Academy of Orthopaedic Surgeons Foot and Ankle (AAOS-FAO) score improved from 50.7 (17 to 88) to 65.2 (22 to 88), (p = 0.015). The mean Short Form (SF)-36 Health Survey Physical Component Score improved from 25.2 (16.4 to 42.8) to 29.8 (17.7 to 44.2), (p = 0.003) and the mean Euroqol EQ‑5D‑5L score improved from 0.63 (0.51 to 0.78) to 0.67 (0.57 to 0.84), (p = 0.012).

Single-stage correction of deformity using an intramedullary hindfoot arthrodesis nail is a good form of treatment for patients with severe Charcot hindfoot deformity, ulceration and instability provided a multidisciplinary care plan is delivered.

Cite this article: Bone Joint J 2015;97-B:76–82.