Scarf osteotomy is a commonly performed method of hallux valgus correction. Release of deforming lateral soft tissue structures is an integral part of this correction. The aim of this study was to determine if there was any difference in the correction achieved by dorsal and transarticular releases as part of a scarf osteotomy. This radiological study was performed at a single institution. One surgeon utilised the dorsal first web approach for the distal soft tissue release and one the transarticular approach. There were 23 patients in each group. The same post-operative regime was used on both sets of patients. Data was collected on hallux valgus angle (HVA), intermetatarsal angle (IMA) and AFS sesamoid scoring. The pre-operative deformity as measured by hallux valgus angle and intermetatarsal angle where similar for both groups (p= 0.25, 0.79 respectively) with a significant difference in severity of AFS scoring in the dorsal group (p < 0.001). Patients who underwent a dorsal approach release had a mean improvement in IMA of 5.46 degrees compared to 3.86 in the transarticular group. The HVA improved by 17.92 degrees in the dorsal group compared to 8.08 in the transarticular group. Both these results were statistically significant (p= < 0.01,< 0.002 respectively). There was a statistically significant difference in number of patients returning to within normal limits of the HVA (p= < 0.05); 18 patients returned to a normal hallux valgus angle after undergoing the dorsal approach compared to 9 patients in the transarticular group. Our study shows that when performing a distal soft tissue release in conjunction with a scarf osteotomy for correction of hallux valgus, a dorsal first web approach is significantly better at correcting the HVA as compared to a transarticular approach. We would, therefore, recommend the use of a dorsal approach when performing this surgery

Introduction: The efficacy and complications of the transarticular screw procedure have been reported by many authors. However, few have reported this procedure for child younger than 10 years old. We have treated two children for atlantoaxial subluxation with transarticular screws, using a soft collar without a halo-vest, and have achieved bone union in good reduced position. Methods/results. Case 1: a 5-year-old boy with mental retardation and cerebellar infarction due to an insufficiency of the vertebral artery resulting in severe atlantoaxial instability. He presented with a high degree of congenital atlantoaxial subluxation complicated by Os odontoideum. He has been treated with transarticular screw and iliac bone graft by Brooks procedure. Case 2: an 8-year-old boy with congenital spondyloepiphyseal dysplasia and a right valgus knee. He, too, presented with a high degree of congenital atlantoaxial subluxation complicated by Os odontoideum, and has been treated with transarticular screw and iliac bone graft by Brooks procedure. In both cases, we used two half-thread cortical screws with a diameter of 2.7mm and a length of 30mm for the transarticular screw procedure. Discussion/conclusion: Rigid external fixation was obtained by Halo-vest. This method, however, would be expected to cause mental stress for the child patient and the family. More rigid internal fixation would be required to resolve this problem. More rigid internal fixation can be obtained with the transarticular screw, and postoperative orthosis can be performed easily, without the need for a Halo-vest

Purpose of study. Transarticular screw fixation offers acceptably high fusion rates but is not possible in 18% of patients due to a high riding vertebral artery. It also requires pre-operative anatomical reduction which is not always possible. The Harms' technique utilises a posterior C1 lateral mass and C2 pedicle screw. This allows easier access due to the angle of drilling and has become an increasingly popular surgical technique. The aim of this study is to review and compare the above techniques with regard to surgery, complications and outcome. Description of methods. This study is a retrospective chart and radiographic review of patients undergoing posterior C1-2 fusion in a single institution in the period 2003 to 2011. The most common aetiology was rheumatoid arthritis and post-traumatic instability. All atlanto-axial instability patients that came to surgery are included in this study, and only cases with less than six months follow-up were excluded. We report on surgical indications, surgical outcomes, complications and radiographic outcomes. Summary of results. No statistically significant differences were found in blood loss (p=0.47) or surgical time (p=0.44) using the Mann-Whitney U test. Complications in patients undergoing transarticular screw fixation included the need to abandon transarticular screws in two cases due to technical difficulty, metalware failure in two cases and intra-operative cerebrospinal fluid leaks in 2 cases. The Harms technique was associated with a single case of cerebrospinal fluid leak. Conclusion. There is no significant difference in surgical time and blood loss between the two techniques. Both are reliable in terms of fusion. The Harms technique offers the advantage of intra-operative reduction and a smaller wound due to the direction of access. The decision to use one or the other is based on the surgeons skill levels, ability to pre-operative reduce the joint and possibly the cost. NO DISCLOSURES

Over 2 years, 14 patients with C1/2 instability underwent posterior transarticular screw fixation. Pathologies included atlanto-axial subluxation in five rheumatoid patients, atlanto-axial rotatory subluxation and an odontoid fracture in two patients with ankylosing spondylitis, nonunion of odontoid fractures in three patients, three transverse ligament injuries and one type-III odontoid fracture. This study aimed to assess the use of transarticular screw fixation in terms of technique, union rates and functional outcomes. All operations were performed on a Relton-Hall frame with a Mayfield clamp and lateral fluoroscopy. The mean age of the eight men and six women was 48 years. The mean operation time was 112 minutes (65 to 225) and mean blood loss was 270 ml (150 to 700). Autologous posterior iliac crest bone graft was used in all patients. The procedure was aborted in one patient because of difficulty with reduction and screw angulation and in another because of excessive bleeding from the drill hole. Alternative fixation techniques were used in these two patients. All patients wore a Philadelphia collar postoperatively until stability was confirmed. The time to radiological union was 8 to 10 weeks. Clinical outcomes revealed full ranges of flexion and extension in most patients, with a 50% decrease in cervical rotation. There were no neurological complications postoperatively. There was implant failure in one patient, with screw breakage evident at follow-up, but this patient went on to union without further intervention. Transarticular screw fixation is an inexpensive, effective and safe technique for management of C1/2 instability

To assess the outcome and safety of transarticular C1–C2 screw fixation. The clinical and radiological outcomes of 15 patients treated with posterior atlanto-axial transarticular screw fixation and posterior wiring was assessed at a minimum follow up of 6 months. Indications for fusion were rheumatoid arthritis in 8 (instability in 6 and secondary degenerative changes in 2), non-union odontoid fracture 4, symptomatic os-odontoideum one, C1–C2 arthrosis one and irreducible odontoid fracture one. Fusion was assessed with plain x-rays including flexion extension films. Twenty nine screws were placed under fluoroscopic guidance. Bilateral screws were placed in 14 patients and a single screw in one patient. This patient had a single screw placed due to the erosion of the contralateral C2 pars by an anomalous vertebral artery. All patients had radiological union. Two screws (7%) were malpositioned; neither was associated with clinical sequelae. No neurological or vascular injuries were noted. Transarticular C1–C2 fusion yielded a 100% fusion rate. The risk of neurological or vascular injury can be minimised by thorough assessment of pre operative CT scans to assess position of the vertebral artery and use of intra operative lateral and AP fluoroscopy

To assess the outcome and safety of transarticular C1-C2 screw fixation. The clinical and radiological outcomes of 15 patients treated with posterior atlantoaxial transarticular screw fixation and posterior wiring was assessed at a minimum follow up of six months. Indications for fusion were rheumatoid arthritis in eight (instability in six and secondary degenerative changes in two), non union odontoid fracture four, symptomatic osodontoideum one, C1-C2 arthrosis one and irreducible odontoid fracture one. Fusion was assessed with plain x-rays including flexion – extension films. Twenty nine screws were placed under fluroscopic guidance. Bilateral screws were placed in 14 patients and a single screw in one patient. This patient had a single screw placed due to the erosion of the controlateral C2 pars by an anomolous vertebral artery. All patients had radiological union. Two screws (7%) were malpositioned, neither was associated with clinical sequelae. No neurological or vascular injuries were noted. Transarticular C1-C2 fusion yielded a 100% fusion rate. The risk of neurological or vascular injury can be minimised by thorough assessment of pre operative CT scans to assess position of the vertebral artery and use of intra operative lateral and AP fluroscopy

Objective: To review the clinical outcome of 37 consecutive patients undergoing C1– C2 transarticular fixation for patients with Rheumatoid Arthritis. Design: Prospective Observational Study. Methods: There were 37 patients at 2 centres. Age range was 37– 82 years. The time since diagnosis to treatment was 2– 23 years. Clinical presentation included suboccipital pain in 26/ 37 patients and neck pain in 29/37 patients. 22 patients had presented with myelopathy ( Ranawat grade II or III A). The preoperative imaging included Plain X Rays, CT scans and MRI scans. All patients underwent C1/ C2 transarticular screws ( Stealth guided) except 4 patients in which an aberrant course of the vertebral artery was identified. Outcome measures: Functional outcome, Complications, Postoperative Neurological Status, Neck Disability index, Myelopathy disability index. Results: 1 patient had died at 12 month followup. Neck pain improved in 22( 75%) of patients by > 5 points on the VAS. Suboccipital pain had improved in all patients. 17 patients (80%) improved following operation on the Ranawat Grading, 2 patient were worse and 3 patients remained the same. > 70% patients reported improvement in neck disability index and > 50% patients reported improvement in myelopathy disability index. Conclusions: C1/ C2 Transarticular fixation with spinal navigation is a safe technique for treating atlantoaxial instability in patients with Rheumatoid Arthritis. This study demonstrates improvement in all domains including neck disability, myelopathy scores and functional outcome

Purpose: The posterior transarticuar screw fixation C1-2 (Magerl) is a demanding procedure to treat atlanto-axial instabilities. In spite of a high primary instability it holds risks to injure the A. vertebralis as well as neurological structures. Furthermore the posterior approach of the upper part of the cervical spine requires a huge and traumatic preparation of the soft tissue. However the anterior transarticular C1-2 fusion is less traumativc and offers approximately the same strengh of the stabilisation. Methods: Since the beginning of 2007 17 multimorbid patients with atlanto-axial instabilities of different entities were treated via the anterior transarticular fusion, were regular examined radioogicaly (x-ray/CT) and the procedure critically judged. Results: C1-2 fusions were performed in 17 patients (13f, 4m, average 81,6 years (68.95)). The main symptoms was pain radiating in the upper cervical spine and the occiput, 2 Patients complaining radiating pain with paraesthesia in both upper extremities, whereas the neurology was predoinant inconspicious. The average operation-time took 64,5 min. On the left side the screws of Ø 39,5mm (32–44mm), on the right side of 36mm (32–44mm) were inserted in addiction to the point of access and the angle of insertion (mediolateral angle Ø 32,0°, ventrodorsal Ø17,6°). There were no intraoperative complications concerning the ceratin procedure, postoperative one revision had to be done because of p.o. bleeding, another because of screw dislocation with clinical relevance 21 days after the first operation. The postoperative x-ray and CT control of the upper cervical spine showed 21/34 screws in 17 patients in correct position (61,7%), 7 (20,6%) screws were too long, 6 (17,7%) screws were placed too anterior and too medial compared to the oppinion of literature. position in the literature. 3 additional positionated dens-screws were in correct position. After a clear learning curve both screws of the 6th patient were positoinated correct. In this connection it could be shown, that two aspects are important for success: A correct entry point as well as the right insertion of the angle of the screws in the coronar and sagittal view. A low intraoperative blood loss, a non traumatic access as well as an immediate postoperative pain decrease have to be valued positively for this procedure. Conclusions: The gentle procedure of the anterior transarticular C1-2 fusion requires-despite of the huge experience in anterior surgery of dens fractures – a learning curve, because of the more proximate insertion point, the flat insertion angle and the closeness of the A. vertebralis. If these aspects are going to be noticed, failed screw positioning and excessive length as well as injuries of the A. vertebralis can be avoided

Purpose: The current gold-standard for atlanto-axial fixation is C1-C2 Transarticular Screw (TS) fixation. In certain cases, the complicated nature of vertebral artery injury could make the application of bilateral transar-ticular screws impossible. This study biomechanically compares three atlantoaxial transarticular salvaging fixation techniques. Method: Nine Fresh ligamentous human cervical spine specimens (C0-C4) were thawed and the tissue surrounding the spine, except the ligaments and discs, was carefully removed. Pure moments were applied to skull in increments of 0.5 Nm from 0 Nm to 2.0 Nm with the help of loading arms, nylon strings and pulleys. The specimens were tested in extension (EXT), flexion (FLEX), left lateral bending (LB), right lateral bending (RB), left axial rotation (LR) and right axial rotation (RR) for all the cases. The positions of the LEDs were recorded using an Optotrak Motion Measurement System (Northern Digital, Waterloo, Ontario, Canada) and was converted into three rotations (flexion/extension, lateral bending and axial rotation) using rigid body kinematic principles in relation to the fixed base. The specimens were tested intact and after type II odontoid fracture, were instrumented and tested with three fixation constructs:. C1-C2 TS on right side and C1LMS-C2PS on contralateral side. C1-C2 TS on right side and C1LMS-C2IL on the contralateral side and. C1-C2 TS on right side with sublaminar wire. Results: All of the three instrumented cases significantly reduced motion across C1-C2 segment in all the modes when compared to intact (P< 0.005, two-tailed unpaired t-test at confidence interval of ninety-five percent) except in extension. TS+C1lM+C2PS is significantly stiffer than TS+ Wire only in axial rotation (P< 0.05) and equivalent in flexion/extension (P=0.75/P=0.51) and left/right bending (P=0.22/P=0.58). TS+C1LM +C2PS is equivalent to TS+C1LM+C2IL in all the loading modes (P> 0.05). TS+C1LM+C2IL is significantly stiffer than TS+Wire in axial rotation (P < 0.05) and equivalent in flexion/extension (P=0.93) and left/right bending (P=0.69/P=0.84). Conclusion: This study showed that TS+C1LMS+C2PS fixation is equivalent to TS+C1LMS+C2ILS fixation in all the rotation modes and superior to TS+Wire fixation in axial rotation averaged over all ranges of motion. Also, TS+C1LMS+C2ILS fixation is superior to TS+Wire fixation in axial rotation averaged over all ranges of motion

Purpose. In stabilisations of atlantoaxial instabilities it holds risks to injure the A. vertebralis as well as neurological structures. Furthermore the posterior approach of the upper part of the cervical spine requires a huge and traumatic preparation of the soft tissue. However the anterior transarticular C1-2 fusion (ATF) is less traumatic and offers almost the same strengh of the stabilisation. Methods. Since the 01/2007 22 multimorbid patients with atlanto-axial instabilities of different entities were treated via the ATF, were regular examined radiologicaly (x-ray/CT) and the procedure critically judged. Results. C1-2 fusions were performed in 22 patients (17f, 5m, Ø 81,67 years). Main symptoms was pain radiating in the upper cervical spine and the occiput, 2 Patients complaining radiating pain with paraesthesia. The average operation-time took 64,5 min. Leftside the screws of Ø 39,5mm (32–44mm), rightside of 36mm (32–44mm) were inserted in addiction to the point of access and the angle of insertion (mediolateral angle Ø 32,0°, ventrodorsal Ø17,6°). No introperative complications occured, one revision had to be done because of p.o. bleeding, one because of screw dislocation. Postoperative x-ray and CT control of the upper cervical spine showed 30/44 screws in 22 patients in correct position. 8 (18,2%) screws were too long, 3 (6,8%) screws were placed too anterior and 3 (6,8%) too medial. 8 additional positionated dens-screws were in correct position. After a clear learning curve both screws of the 6th patient were positoinated correct. Two aspects are important for success: Correct entry point and right insertion of the angle in the coronar and sagittal view. A low intraoperative blood loss, a non traumatic access as well as an immediate pain decrease have to be valued positively for this procedure. Conclusions. The gentle procedure of the ATF requires-despite of the huge experience in anterior surgery of dens fractures - a learning curve, because of the more proximate insertion point, the flat insertion angle and the closeness of the A. vertebralis. If these aspects are going to be noticed, failed screw positioning and excessive length as well as injuries of the A. vertebralis can be avoided

The Lisfranc fracture dislocation of the tarsometatarsal joint (TMTJ) is a complex injury with a reported incidence of 9.2 to 14/100,000 person-years. Lisfranc fixation involves dorsal bridge plating, transarticular screws, combination or primary arthrodesis. We aimed to identify predictors of poor patient reported outcome measures at long term follow up after operative intervention. 127 patients underwent Lisfranc fixation at our Level One Trauma Centre between November 2007 and July 2013. At mean follow-up of 10.7 years (8.0-13.9), 85 patients (66.92%) were successfully contacted. Epidemiological data including age, gender and mechanism of injury and fracture characteristics such as number of columns injured, direction of subluxation/dislocation and classification based on those proposed by Hardcastle and Lau were recorded. Descriptive analysis was performed to compare our primary outcomes (AOFAS and FFI scores). Univariate analysis and multivariate regression analysis was done adjusted for age and sex to compare the entirety of our data set. P<0.05 was considered significant. The primary outcomes were the American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Score and the Foot Function Index (FFI). The number of columns involved in the injury best predicts functional outcomes (FFI, P <0.05, AOFAS, P<0.05) with more columns involved resulting in poorer outcomes. Functional outcomes were not significantly associated with any of the fixation groups (FFI, P = 0.21, AOFAS, P = 0.14). Injury type by Myerson classification systems (FFI, P = 0.17, AOFAS, P = 0.58) or open versus closed status (FFI, P = 0.29, AOFAS, P = 0.20) was also not significantly associated with any fixation group. We concluded that 10 years post-surgery, patients generally had a good functional outcome with minimal complications. Prognosis of functional outcomes is based on number of columns involved and injured. Sagittal plane disruption, mechanism and fracture type does not seem to make a difference in outcomes

Background: We present a prospective two to ten year follow-up of soft tissue balancing surgery at the subluxated second MTP joint. The purpose of this study was to find out the effect of soft tissue balancing techniques of the second MTP joint on long term VAS and AOFAS results. As second hypotheses we compared the results of two different techniques, one group with additional transarticular Kirschner wire (KW) fixation of the second MTP joint temporary for 3 weeks postoperative and the other group without. Materials and Methods: Fifty-four patients, 45 women and nine men, with a total of 62 operative interventions were included in our follow-up evaluation. Soft tissue balancing techniques we used were capsulotomy, lengthening of the extensor tendons, incision of the collateral ligaments and intrinsic muscles with or without temporary transarticular Kirschner wire (KW) fixation. Pre- und postoperative VAS and AOFAS scores, as well as clinical and radiological findings were analyzed. One weightbearing and one without weightbearing dorsoplantar radiograph as well as a 45 degrees rotated radiograph were done pre and postoperatively to proof the position of the second toe. Results: The statistical calculations showed a highly significant outcome (p< 0.0001) comparing pre- to postoperative scores. Explorative data analysis as well as chi-square tests comparing the two groups - 29 second toes with and 33 second toes without temporarily additional transarticular KW fixation of the MTP joint - showed homogeneous distribution of all scores. Conclusion: Our evaluation showed highly significant improvement with soft tissue balancing for subluxated second MTP joint of the second metatarsal, but no benefit from additional KW fixation of the MTP joint

Introduction: Occipito-cervical fusion has evolved from the used of simple onlay bone grafts to the use of sophisticated modular implants. Initial stiffness prevents micromotion and allows a higher fusion rate. Methods: A composite occipito-cervical model (OCM) was developed and validated using data obtained from cadaveric specimens. A jig was designed to pot the OCM, which allowed the application of independent moment forces to simulate flexion, extension, lateral flexion and rotation. The following implants were used 1 ) Grob plate with C1/C2 transarticular screw fixation.2) Grob Plate without C1/C2 transarticular screw fixation.3) Cervifix rod system 4) A Ransford loop system 5.) Olerud plate fixation. A three dimensional ultrasonic motion analysis system (Zebris Inc.) was used to record motion at three positions: 1)C0 2) C2 3) C4.A separate OCM was used for each instrumentation system. Results: The Grob plate with C1/C2 transarticular fixation was found to confer the greatest initial stiffness. The Ransford loop construct was found to confer the least initial stiffness. Plate fixation offered greater stability then rod or loop constructs. We found the three dimensional motion analysis system to be ideal for displacement analysis in complex spinal instrumentation constructs

INTRODUCTION: Atlanto-axial instability due to Rheumatoid arthritis has been treated by posterior C1/C2 wiring techniques supplemented with bone graft. Magerls technique of Transarticular fixation provides a three-point fixation by eliminating motion, promoting fusion, increased mechanical strength and treating instability. It allows fixation across the plane of movement and prevents basilar invagination. The clinical results of transarticular fixation are satisfactory in terms of clinical outcome with few complications. However there are concerns that these patients develop subaxial kyphosis. It is important to highlight that none of these patients in our series had supplementary wiring techniques with TAS The purpose of this study is to analyse postoperative Xrays of patients who have undergone transarticular atlantoaxial fixation and look at the following parameters;. What percentage of patients develop subaxial kyphosis?. Are the ADI and PADI maintained postoperatively?. Is there a late failure rate of TAS despite the absence of supplementary wiring techniques?. MATERIALS & METHODS: 15 patients underwent pre and postoperative cervical spine X-rays in the AP and lateral projections. In addition flexion/extension views were also obtained pre and postoperatively. We analysed the following parmeters:. Pre and Postoperative ADI and PADI. C0/C1, C1/C2, C1/C7, C2/C7 angles. C2/C3 slip and C2/C3 osteoarthritis. Any breakage or pullout of screws. Postoperative basilar invagination. It is important to highlight that all these 15 patients had bony fusion at the C1/C2 joints and these findings have been analysed and published in the clinical counterpart of this study (Fusion rates 97% in 36/37 patients). RESULTS: As highlighted, the clinical outcome of these patients has been published. We would like to present the radiological parameters of this subgroup of patients. The ADI improved in 13 patients with a preoperative median of 7 and postoperatively 3.5. The preoperative and postoperative PADI remained at 15. The C0/C1 angle changed from 12 to 17 postoperatively. The C2/C7 angle changed from 21 to 26 postoperatively. C1/C7 angle changed from 39 to 41. The spinal cord diameter remained at 15 pre and postoperatively. There was only 1 patient with C2/C3 slip on flexion/extension views. 2 patients developed subaxial kyphosis with evidence of significant disc degeneration on preoperative imaging. There are some interesting conclusions from these 15 xrays. Only 2 out of 13 patients have developed a subaxial kyphosis. The 2 patients that have developed subaxial kyphois had subaxial disc degeneration at the level of the kyphois. There was only 1 patient with a C2/C3 spondylolisthesis on flexion/extension. The ADI and SAC were maintained at the craniocervical junction. There is no late failure rate despite the absence of a modified gallie fusion

To define how pre-operative evaluation guides surgical planning in patients with atlanto-axial subluxation secondary to rheumatoid arthritis and to measure clinical outcome for the same group. Prospective evaluation of a consecutive cohort of 26 patients undergoing C1/2 fusion over 5 years (2004-2009). Pre-operative evaluation of posterior atlanto-dens interval (PADI), C1 lateral mass and C2 pedicle dimensions. Pre- and post-op Ranawat scores and visual analogue scores for neck and C2 pain. C1/2 instability resulted from rheumatoid arthritis (21), trauma (4) and infection (1). C1 lateral mass mean height 4.4mm, C2 pedicle mean height 5.1mm and mean width 3.4mm (30% width <3mm). Ranawat scale improved Grade II to Grade I (p=0.07). Neck pain (pre-op mean 5.5, s.d. 2.8; post-op mean 1.6, s.d. 2.1, t<0.05) and C2 pain (pre-op mean 2.1, s.d. 3.3; post-op mean 0.5, s.d. 1.2, t<0.05) improved. No instrumentation failure. In the rheumatoid group, 17/21 patients had C1 lateral mass and C1/2 transarticular screws. 1 patient had a cranio-cervical fusion and 3 patients had other constructs. 3 patients had C2 numbness. No other neurological deficit. In a rheumatoid population, pre-operative evaluation often precludes the use of C2 pedicle screws. Rigid fixation with a C1 lateral mass and C1/2 transarticular polyaxial screw-rod system is associated with good clinical outcomes

We present our results with a modified Mann-Thompson procedure in 47 patients (86 feet). Minimum follow up was 24 months. All patients had moderate to advanced forefoot deformities. Methods:. M:F=12:35. 43/47 bilateral. Simultaneous procedures in bilateral cases. Popliteal block analgesia used routinely. Technique:. Medial incision centered on MTP1 joint. Minimal bony and soft tissue resection. Fixation carried out with staples (78 feet),K-wires (8 feet). Transverse incision centered on the lesser MTP joints made. Combination of soft tissue release, lesser MT head resection in cascade fashion from dorsal distal to proximal plantar performed. Lesser toe deformities treated by a combination of closed osteoclasis, soft tissue release and bony resection. Transarticular K-wire fixation then performed for all lesser toes. Bulky postop dressing and post op shoes used. Immediate FWB permitted. Transarticular K-wires removed at 4/52. Results:. AOFAS Forefoot Scores assessed at preop,6/12,12/ 12,and24/12. Subjective patient assessment of procedure requested. Average AOFAS scores improved from 37to72(67 – 84). 40 patients extremely pleased with the results. 5 patients pleased with reservations and 2 patients disappointed with the outcome. Complications:. 3 superficial wound infections. 2 metal work related problems. 2 early loss of lesser toe correction. 3 late deformities of lesser metatarsals requiring surgery. Conclusion: This procedure offers excellent, reproducible biomechanical correction with high rates of patient satisfaction

The purpose of this study is the biomechanical comparison of five C1 – C2 posterior arthrodesis techniques. Ten adult human cadaveric upper cervical spine specimens were sectioned at the C3 level. The occiput and C3 vertebra were potted in PMMA. The specimens were tested intact; after destabilizing with odontoid transection and sectioning of the transverse and capsular ligaments; and after stabilization with Brooks-Jenkins cable fixation, Brooks-Jenkins with unilateral transarticular screw, Gallie posterior wire construct with unilateral transarticular screw, Brooks-Jenkins with bilateral screws, and Gallie with bilateral screws. Data were analysed with special attention paid to the motion at C1 – C2. The neutral zone (NZ) and range of motion (ROM) were measured in the main plane of each motion, as well as in coupled planes. In flexion / extension and lateral bending, the ROM and NZ increased significantly in the injured specimens as compared to the intact (p< 0.0001). In axial torsion, there was no significant difference between the intact and injured spines at C1 – C2 level. In the different fixation systems, the ROM and NZ were significantly lower than in injured and intact spines in all motions (p< 0.01), except the lateral bending in intact spine. Among the 5 instrumentations, the NZ and ROM in flexion / extension for the Gallie construct with one screw were significantly higher than for the Brooks-Jenkins construct with one or two screws (p< 0.05). In axial torsion, the Gallie construct with one screw displayed a larger NZ and ROM than any of the other four constructs (p< 0.05)

Introduction: The magnitude of the initial chondral injury and the residual articular step-off are amongst prognostic factors implicated in outcome following intra-articular fractures. The alignment of an intra-articular fracture line may be an as yet unrecognised prognostic variable. Hypothesis: That fractures in the coronal plane of the medial femoral condyle result in worse outcomes than those in the sagittal plane. Aim: To compare the effect of displaced intra-articular osteotomies (ie simulating fractures fixed in an incongruent position) of the medial femoral condyle – in one group performed in the sagittal plane, in the other in the coronal plane. Materials and Methods: The study was conducted in two arms: in vitro and in vivo. In vitro study: A pneumo-electric rig was designed and built. Ten freshly harvested porcine knee joints underwent osteotomy (test specimens: 5 sagittal, 5 coronal). 5 control specimens underwent no osteotomy. Specimens were mounted on the rig and subjected to cyclical flexion and extension under load (40,000 cycles over 11 hours). Transarticular pressure measurements were performed before and after testing. Surface roughness was measured following testing using laser interferometry. In vivo study: Three groups (A to C), each comprising 15 New Zealand white rabbits were utilised. Rabbits from each group were consigned to a control (5), coronal osteotomy (5) or sagittal osteotomy (5) group. Rabbits in group A were sacrificed at 3 weeks (early outcome), group B at 10 weeks (immediate) and group C at 20 weeks (long term). The knee was then harvested en bloc and prepared for light microscopy. A further 10 specimens underwent electron microscopy of the medial meniscus. Results:. In vitro study: A significant difference in loading patterns was noted between the sagittal, coronal and control groups. Specimens from the sagittal group sustained significantly more wear on the apposing medial tibial articular surface (p=0.04), with the meniscus having a protective effect on the underlying articular surface. In vivo study: Light microscopy confirmed degenerative changes in the apposing tibial articular cartilage, being more marked in sagittal specimens. On the femoral side of the knee, the healing response of the femoral osteotomy was significantly better in sagittal test specimens than coronal (p< 0.05). Conclusion: In contrast to the hypothesis, sagittal femoral step-offs gave rise to more tibial wear. This can be explained by the short duration of exposure of the coronal incongruity to the apposing joint during the flexion extension cycle. The sagittal step-off was constantly exposed, giving rise to persistently elevated tibial joint loading pressures opposite the high side of the step-off. In contrast, the coronal femoral osteotomies had a worse healing response. The alignment of the fracture line perpendicular to the plane of motion of the joint exposes the repair tissue within it to increased shear and tensile stresses. This may play a negative role in the repair of these coronal defects when compared to sagittal osteotomies, which are relatively protected from the high transarticular pressures and showed a greater tendency to remodel their articular surface

Aims

Complete ruptures of the ulnar collateral ligament (UCL) of the thumb are a common injury, yet little is known about their current management in the UK. The objective of this study was to assess the way complete UCL ruptures are managed in the UK.

Lisfranc fracture dislocations of the midfoot are uncommon but serious injuries, associated with posttraumatic arthrosis, progressive deformity, and persistent pain. Management of the acute injury aims to restore anatomic tarsometatarsal alignment in order to minimise these complications. Reduction and stabilisation can be performed using image-guided percutaneous reduction and screw stabilisation (aiming to minimise the risk of wound infection) or through open plating techniques (in order to visualise anatomic reduction, and to avoid chondral damage from transarticular screws). This retrospective study compares percutaneous and open treatment in terms of radiographic reduction and incidence of early complications. Case records and postoperative radiographs of all patients undergoing reduction and stabilisation of unstable tarsometatarsal joint injuries between 2011 and 2014 in our institution were reviewed. Dorsoplantar, oblique and lateral radiographs were assessed for accuracy of reduction, with malreduction being defined as greater than 2mm tarsometatarsal malalignment in any view. The primary outcome measure was postoperative radiographic alignment. Secondary outcome measures included the incidence of infection and other intra- or early postoperative complications. During the study period, 32 unstable midfoot injuries were treated, of which 19 underwent percutaneous reduction and screw stabilisation and 13 underwent open reduction and internal fixation. Of the percutaneous group, no wound infections were reported, and there were four (21.1%) malreduced injuries. Of the open group, two infections (15.4%) were observed, and no cases of malreduction. In conclusion, our study shows a strong trend towards increased risk of malreduction when percutaneous techniques are used to treat midfoot injuries, and an increased risk of infection when open surgery is used. Whilst conclusions are limited by the retrospective data collection, this study demonstrates the relative risks to consider when selecting a surgical approach