Introduction

The objective of this study was to determine if a synthetic bone substitute would provide results similar to bone from osteoporotic femoral heads during in vitro testing with orthopaedic implants. If the synthetic material could produce results similar to those of the osteoporotic bone, it could reduce or eliminate the need for testing of implants on bone.

We analysed the morbidity, mortality and outcome of cervical spine injuries in patients over the age of 65 years in a retrospective review of 107 elderly patients admitted to our tertiary referral spinal injuries unit with cervical spine injuries between 1994 and 2002. The data were acquired by analysis of the national spinal unit database, hospital inpatient enquiry (HIPE) system, chart and radiographic review. Mean age was 74 years (range 66-93yrs). The male to female ratio was 2.1: 1(M=72, F=35). The mean follow-up was 4.4 years (1-9 years) and mean in-hospital stay was 10 days. The mechanism of injury was a fall in 75 and a road traffic accident (RTA) in the remaining 32 patients. The overall complication rate was 18.6% with an associated in-hospital mortality of 11.2%. Outcome was assessed using the Cervical Spine Outcomes Questionnaire (CSOQ) from Johns Hopkins School of Medicine.

Functional outcome scores approached pre-morbid level in almost all patients. Functional disability was more marked in the patients with neurological deficit at the time of injury. Outcome of the injury is related to the increasing age, co-morbidity and the severity of the neurological deficit. Injuries of the cervical spine are a not infrequent occurrence in the elderly and occur with relatively minor trauma.

Neck pain in the elderly patient should be thoroughly evaluated to exclude C2 injuries. Most patients can be managed in an orthosis but unstable injuries require rigid external immobilisation.

Purpose: A systematic review of Health Related Quality of Life Outcomes(HRQOL) in metastatic disease of the spine and content validation of a new Spine Oncology Study Group Outcomes Questionnaire(SOSGOQ). To identify HRQOL questionnaires previously reported for spinal metastases and to validate the content of the new SOSGOQ based on the International Classification of Function and disability(ICF).

Method: A systematic review identified 141 studies. Reported outcome tools were enumerated. The most commonly utilized (ESAS, Karnofsky Scale and ODI) and the SOSGOQ were linked to the ICF. Descriptive statistics examined the frequency and specificity of the ICF linkage. Linkage reliability was evaluated by inter-investigator percentage agreement.

Results: The SOSGOQ contains 56 concepts, with all 4 domains of the ICF represented. 4 concepts could not be linked. There was 100% inter-observer agreement(IOA) for total number of concepts and for those ‘not covered’. 100% of concepts had ‘First and Second’ level linkage. 100% IOA exists at both ‘Component’ and “First Level’ linkage. There was 96.1% IOA at ‘Second’ Level. 33 concepts linked to Third Level with 96.9% IOA. 10 concepts linked at the Fourth Level with 100% IOA.

Conclusion: The SOSGOQ includes all domains relevant for measurement of function and disability and it’s content validity is confirmed by linkage with the ICF. This new questionnaire has superior content capacity to measure disease burden of patients with metastatic disease of the spine than any instruments previously identified in the literature.

Purpose: Apoptosis of osteoblasts and osteoclasts regulates bone homeostasis. Vertebral osteoporotic insufficiency fractures are characterised by pathological rates of osteoblast apoptosis. Skeletal injury in humans results in ‘angiogenic’ responses primarily mediated by vascular endothelial growth factor(VEGF), a protein essential for bone repair in animal models. Osteoblasts release VEGF in response to a number of stimuli and express receptors for VEGF in a differentiation dependent manner. This study investigates the putative role of VEGF in regulating the lifespan of primary human vertebral osteoblasts (PHVO) in-vitro.

Method: PHVO were cultured from biopsies taken at time of therapeutic vertebroplasty and were examined for VEGF receptors. Cultures were supplemented with VEGF(0–50ng/mL), a neutralising antibody to VEGF, mAB VEGF(0.3ug/mL) and Placental Growth Factor (PlGF), an Flt-1 receptor-specific VEGF ligand(0–100 ng/mL) to examine their effects on mineralised nodule assay, alkaline phosphatase assay and apoptosis. The role of the VEGF specific antiapoptotic gene target BCl2 in apoptosis was determined.

Results: PHVO expressed functional VEGF receptors. VEGF 10 and 25 ng/mL increased nodule formation 2.3- and 3.16-fold and alkaline phosphatase release 2.6 and 4.1-fold respectively while 0.3ug/mL of mAB VEGF resulted in approx 40% reductions in both. PlGF 50ng/mL had greater effects on alkaline phosphatase release (103% increase) than on nodule formation (57% increase). 10ng/mL of VEGF inhibited spontaneous and pathological apoptosis by 83.6% and 71% respectively, while PlGF had no significant effect. Pretreatment with mAB VEGF, in the absence of exogenous VEGF resulted in a significant increase in apoptosis (14 versus 3%). BCl2 transfection gave a 0.9% apoptotic rate. VEGF 10 ng/mL increased BCl2 expression four fold while mAB VEGF decreased it by over 50%.

Conclusion: VEGF is a potent regulator of osteoblast life-span in-vitro. This autocrine feedback regulates survival of these cells, mediated via the KDR receptor and expression of BCl2 antiapoptotic gene. This mechanism may represent a novel therapeutic model for the treatment of osteoporosis.

Purpose: To evaluate the demographics, presentation, treatment and outcomes of spinal infection in a population of Intravenous Drug Users.

Method: Data on all patients with pyogenic spinal infection presenting to a quaternary referral center was obtained from a prospectively maintain database.

Results: Over the five-year study period, there were 102 patients treated for Primary Pyogenic Infection of the Spine of which 51 were Intravenous Drug Users (IVDU). Of this IVDU group there were 34 males. Mean age was 43 years (range 25 – 57). Twenty-three had HIV, 43 Hepatitis C and 13 Hepatitis B. All were using cocaine, 26 were also using Heroin and 44 more than three recreational drugs. Thirty patients presented with axial pain with a mean duration of 51 days (range 3–120). Thirty-one were ASIA D or worse with eight ASIA A. Mean Motor Score of patients with deficit was 58.6. Most common ASIA Motor Levels were C4 and C5. Mean duration of neurological symptoms was seven days (range 1–60). Blood parameters on admission were in keeping with sepsis in immunocompromised patients. None had previous surgery for spinal infection. Twenty-sex were receiving IV antibiotics for known spinal infection. 44 patients were treated surgically. 32 had infection of the cervical spine, 9 Thoracic and 3 Lumbar. 22 had a posterior approach alone, 13 had anterior only while 9 required combined. Mean operative time was 263 mins (range 62 – 742). 13 required tracheostomy. 7 required early revision for hardware failure and 2 for surgical wound infection. Mean duration of antibiotic treatment was 49 days (range 28–116). 26 patients had single agent therapy. 17 had MSSA and 17 MRSA. At discharge 28 patients had neurological improvement (mean 20 ASIA points, range 1–55), 11 had deterioration (mean 13, range 1–50) and 5 were unchanged. There were no in-hospital deaths. At 2 years after index admission 13 patients were dead and none were attending the unit for follow-up.

Conclusion: Primary pyogenic spinal infection in IVDU’s typically presents with sepsis and acute cervical quadriplegia. Surgical management must be prompt and aggressive with significant neurological improvement expected in the majority of patients.

Purpose: Prospective Observational Population Study to describe the incidence, demographics and pattern of spinal cord injury in British Columbia, Canada, for 10 years to 2004.

Method: Systematic analysis of prospectively collected spine registry data (Vertebase) at Vancouver General Hospital, B.C., Canada from 1995–2004.

Results: During the 10-year study period the 938 patients were admitted with a traumatic spinal cord injury. The Annual Population-Standardized Incidences ranged from 19.94 to 27.27 per million, with a median incidence of 23.34/million and with no significant change over the study period. The mean age was 39.7 years (34.73 in 1995 and 42.1 in 2004, p< 0.05) with a range of 16–92 years. 79.74 % were males. 48.2% of patients were AISA A on admission, of which 48% were quadraparetic. The most common levels of spinal cord injury were C5 (17.3%), C6 (10%), T1 (9.4%), T12 (5.8%). The Mean ASIA score was 50.22 with a range from 0–100. 19.8% of patients had a GCS£13. The mean ISS was 26.02, range of 0 – 75. Motor vehicle collisions and falls were responsible for 59% and 30% of admissions respectively. Mean length of in-hospital stay was 34 days, ranging from 1 – 275 days. In hospital mortality rate was 2.9%. ASIA Grade, Total Motor Score and anatomical level of injury all correlated directly with Length of stay (p< 0.0001).

Conclusion: Acute Traumatic Spinal Cord Injury remains a major cause of significant morbidity among young males. The incidence appears to be increasing in the elderly. Modern multidisciplinary care has greatly reduced the associated acute mortality. Despite multiple prevention strategies the Annual Population-Standardized Incidence remained unchanged over the study period.

Study Design: Retrospective review of patients treated with mineralized collagen matrix hydrated with bone marrow in Anterior Cervical Decompression and Fusion (ACDF).

Background: Autologous iliac crest bone is regarded as the gold standard graft material for ACDF. Postoperative donor site pain and morbidity made us seek for an alternative while still providing a high rate of fusion as attained with autologous bone.

Methods: All patients who underwent ACDF between August 2005 and May 2007 by the senior author for cervical myelopathy or radiculopathy secondary to degenerative changes or trauma were included. Patients with an additional posterior fusion were excluded. A total of 80 patients were observed for 16 months (range, 6–27 months). In all patient we used a mineralized collagen matrix hydrated with bone marrow aspirate from the left iliac crest as our cage graft material. All patients had PEEK interbody cages and anterior cervical plating. Clinical and radiographic follow-up data were obtained. X-rays were reviewed by both the senior author and an independent radiologist. Clinical outcomes were measured as described by Robinson and with the Nurick scale.

Results: 31 single-level fusions, 35 two-level, 13 three-level and 1 four-level fusion were performed. No revision surgery was needed. One patient had a subsequent laminectomy for residual cord compression. All patients achieved a solid fusion. No symptomatic pseudoarthrosis was noted. No donor site morbidities were noted.

With a successful clinical result defined as an excellent or good outcome accompanied by significant pain relief, 73 patients had a successful clinical result.

Conclusion: The use of a mineralized collagen matrix in combination with bone marrow aspirate in ACDF eliminates iliac crest donor site morbidities while still providing high rates of fusion.

Introduction: This study was performed to review the changing patterns of trauma admissions in Ireland over 5 years (1999–2005).

Materials and Methods: A review of prospectively collected admission data of trauma patients admitted to the Adelaide & Meath Hospital (AMNCH). Dublin, Ireland, during 2005. Data obtained from Hospital In Patient Enquiry (HIPE) system. A comparison is made similar data from 1999. Demographic data, mode of presentations, type of injuries, time of injury and place of injury were recorded. Injury severity was defined using the Injury Severity Score (ISS).

Results: 23% increase in number of admission in 5 years period. Mean age of admission reduced from 35 (1999) to 32 (2005). 67% of admission occurred outside normal office hours (9am–5pm). Commonest mode of injury was road traffic accident (RTA) in 1999 and sports related injury in 2005. Work related trauma increases by 40% and assault increases by 35% from 1999 to 2005. High energy trauma cases reduce by 50% but open fracture cases double in 5 years. Mean overall ISS score was 56. 7(1999) decreased to 45.9 (2006).

Conclusion: These changes cause significant impact on the health system. Increase in facilities for management of trauma is essential as this trend is more likely to continue.

Background: It is commonly observed that a good correction of the Cobb angle at scoliosis surgery is accompanied by an acute asymmetry of shoulder height. Kuklo et al in 2002 described (Spine. 26(18):1966–1975) spontaneous reversal of this, using radiographic measures and patient questionnaires.

Objective: To determine the incidence and extent of shoulder-imbalance before posterior spinal surgery and to ascertain its outcome, using radiographic and topographic measures.

Methods: Patients with right thoracic adolescent idiopathic scoliosis who had undergone corrective posterior spinal fusion by one surgeon were identified. Pre- and all postoperative spinal radiographs and surface topography were evaluated and correlated. Any effect from concomitant anterior release procedures was sought.

Results: Sixty six patients were identified, 56 girls and 10 boys. Their pre-operative major Cobb angle was 73°±14.0 and mean correction was 38.8°±12.333 (56%). Before surgery, surface topography showed the mid-point of the right shoulder to be at a mean or 18.3mm.±10.9 higher than the equivalent left point; eight days later, the difference was −6.7 mm. ±9.68, a mean change of 25.9mm±11.8. At six months, it was −5.1 ±6.86, statistically unchanged. At two years, it was −2.16 (p=0.051) and at three years, 1.76± 6.53 and indistinguishable from zero or perfect balance. The difference between pre-operative and final shoulder level difference was 19.54mm.±9.09. The Cobb angle of the compensatory upper thoracic curve was not significantly changed throughout. There was no statistically significant difference in shoulder height between patients undergoing single or two-stage surgery, either before or at any stage after.

Discussion and conclusion: Correction of post-operative shoulder imbalance does occur spontaneously, as reported by Kuklo et al. and is not a function of spinal accommodation to the new anatomy.

Introduction: The limping child poses a diagnostic challenge. The purpose of this study was to create a clinically useful algorithm of presenting variables to allow the exclusion of ‘musculoskeletal sepsis’ as a differential diagnosis in the child presenting with a limp.

Materials & Methods: This study represents the data collected on all limping children admitted to our centre over a 3-year period. Analysis was based on 229 admissions. Comparison was made between the group with septic arthritis or osteomyelitis and the group without infection, using univariate analysis. With logistic regression analysis, a model consisting of three independent multivariate predictors was constructed, to exclude infection.

Results: Patients with septic arthritis or osteomyelitis differed significantly from patients without infection with regard to duration of symptoms, presence of constitutional symptoms, temperature, white cell count and erythrocyte sedimentation rate (ESR), (p-values < 0.05). Multivariate analysis demonstrated that the best model to describe our patient population was based on three variables: duration of symptoms between 1 and 5 days, temperature > 37.0°C and ESR > 35mm/hr. When all three variables were present, the predicted probability of musculoskeletal infection was 0.66. When none of the three were present, the predicted probability of infection was 0.01.

Discussion: Diagnosis of septic arthritis or osteomyelitis is especially difficult in the early phase and there is no single variable that can serve as a definitive test. The significance of constitutional symptoms and duration of symptoms on univariate analysis emphasises the importance of careful history taking. C-reactive protein, while considered for inclusion, was excluded due to its limited availability at our institution.

Conclusion: The multivariate model enables us to rule out musculoskeletal infection with 99% certainty in limping children with none of these three presenting variables.

Introduction: Bone Morphogenic Proteins (BMP’s) are a family of bone-matrix polypeptides isolated from a variety of mammalian species. Implantation of osteogenic proteins induces a sequence of cellular events that leads to the formation of new bone.

Recombinant human osteogenic protein-1 (rhOP1 or BMP-7) has now been produced and is commercially available.

Rationale: OP.1 has been used in our centre since early 2003 and we now report on our experience with its use in the treatment of fracture non unions in a general orthopaedic trauma setting.

Methodology/Results: OP1 has been used in 19 fracture non unions, the commonest site being the tibia but also in the humerus and forearm. Five of these cases had previous autologous bone grafting. There was one case of deep MRSA infection in a proximal humerus fracture. There were no complications associated with the use of OP1 and specifically there were no instances of symptomatic heterotopic bone formation. Eighteen fractures went on to clinical and radiological union.

Conclusions: Autogenous bone is the current standard in the management of fracture non union because of its high osteogenic potential and biocompatibility. Donor site morbidity and quantity remain drawbacks. The use of OP.1 in the treatment of tibial non unions is well documented in the literature but there is little written about its use in other sites.

We are encouraged by our early experiences with the use of OP1 in numerous anatomical sites and apart from issues of cost would see great potential for further use.

Background Joint replacement remains the most effective healthcare measure in improving patient health related quality of life (HRQOL) and pain incompatible with normal daily living remains the primary indication for both hip and knee arthroplasty. Quality of life outcome and patient satisfaction after total hip arthroplasty are complex phenomena and many confounding determinants have been identified. Degenerative disease of the hip joint may present with variable patterns of pain referral in the lower limb. However the effect of varied pain referral patterns on patient outcome and satisfaction after total hip arthroplasty has not previously been examined. Methods From 2000 to 2003, 236 eligible patients scheduled to undergo primary total hip arthroplasty were prospectively enrolled. The principle pain referral pattern (as hip, thigh or knee) was identified in all patients. HRQOL was examined using the Harris Hip score (HHS), the Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) and the 36-Item Short-Form Health Survey (SF-36) pre-operatively, 1 year and 2 years postoperatively and with the HHS at 3 months postoperatively. All patients were followed up for a minimum of 2 years. Results The frequency of the pain referral distributions were; hip pain 41%, knee pain 32% and thigh pain 27%. Patients in all groups were comparable preoperatively with respect to age; HHS, and both mean and domain specific WOMAC and SF-36 scores. The mean duration of symptoms was significantly greater in patients with knee pain when compared to the remaining two pain patterns. All patients demonstrated as expected improvements in HHS, SF-36 and WOMAC scores after surgery. At all times postoperatively there were significant differences in mean HHS and mean and domain specific WOMAC and SF-36 scores between patients with hip or thigh pain and those with knee pain (p< 0.001). While notable, differences between hip and thigh pain were not as consistent however. Conclusions Pre-operative pain referral patterns of hip arthritis determine patient outcome and satisfaction after total hip arthroplasty, as measured using validated HRQOL scoring systems. Level of evidence Level I-1 (Prognostic Study-Investigating the Outcome of Disease. Prospective study).

Background Apoptosis of osteoblasts and osteoclasts regulates bone homeostasis. Skeletal injury in humans results in angiogenic responses primarily mediated by vascular endothelial growth factor(VEGF), a protein essential for bone repair in animal models. Osteoblasts release VEGF in response to a number of stimuli and express receptors for VEGF in a differentiation dependent manner. This study investigates the putative role of VEGF in regulating the lifespan of primary human osteoblasts(PHOB) in vitro.

Methods PHOB were examined for VEGF receptors. Cultures were supplemented with VEGF(0–50ng/mL), a neutralising antibody to VEGF, mAB VEGF(0.3ug/mL) and Placental Growth Factor (PlGF), an Flt-1 receptor-specific VEGF ligand(0–100 ng/mL) to examine their effects on mineralised nodule assay, alkaline phosphatase assay and apoptosis.. The role of the VEGF specific antiapoptotic gene target BCl2 in apoptosis was determined.

Results PHOB expressed functional VEGF receptors. VEGF 10 and 25 ng/mL increased nodule formation 2.3- and 3.16-fold and alkaline phosphatase release 2.6 and 4.1-fold respectively while 0.3ug/mL of mAB VEGF resulted in approx 40% reductions in both. PlGF 50ng/mL had greater effects on alkaline phosphatase release (103% increase) than on nodule formation (57% increase). 10ng/mL of VEGF inhibited spontaneous and pathological apoptosis by 83.6% and 71% respectively, while PlGF had no significant effect. Pretreatment with mAB VEGF, in the absence of exogenous VEGF resulted in a significant increase in apoptosis (14 vs 3%). BCl2 transfection gave a 0.9% apoptotic rate. VEGF 10 ng/mL increased BCl2 expression 4 fold while mAB VEGF decreased it by over 50%.

Conclusions VEGF is a potent regulator of osteoblast lifespan in vitro. This autocrine feedback regulates survival of these cells, mediated via the KDR receptor and expression of BCl2 antiapoptotic gene.

Management of symptomatic residual acetabular dysplasia in adolescence and early adulthood remains a major therapeutic challenge. At our unit the two senior authors review all patients preoperatively and simultaneously perform each procedure. In the four years from 1998 forty-three Bernese osteotomies were performed in 40 patients with residual acetabular dysplasia. The mean average age at surgery was 21 years (range 12 – 43 years) and there were 34 female patients. The indication for surgery was symptomatic hip dysplasia (all idiopathic but for one male with a history of slipped capital femoral epiphysis) presenting with pain and restricted ambulation. 4 patients had previous surgery on the affected hip (2 Salter’s osteotomy, one Shelf procedure and one proximal femoral osteotomy). 27.5% of patients had symptomatic bilateral disease. 42% of patients had Severin class IV or V dysplasia at presentation. 100% of patients had preservation of the hip joint at last follow-up evaluation (mean 2.4 years), with excellent results in 82%, an average post-operative Harris hip score of 96, and an average d’Aubigne hip score of 16.1. The mean post-operative improvements in radiographic measures were as follows: Anterior centre edge angle +19.4°, Lateral centre angle +25.8°, Acetabular Index – 10.7°. Head to Ischial distance – 7.3mm. Surgical operative time decreased from 128 minutes to 43 minutes from the first to the most recent case. Average blood loss has reduced from 1850mls to 420mls over the four years experience. Predonation of 2 units of blood requested from all patients with baseline hemoglobin of > 12g/dl. When combined with intraopera-tive cell salvage the need for transfusion of homologous blood has been eliminated. All complications occurred in the first 9 patients: (one major – iliac vein injury requiring no further treatment; four moderate – lateral cutaneous nerve injuries; four minor – asymptomatic heterotopic ossification). Our experience confirms that the Ganz periacetabular osteotomy is an efficacious procedure for the treatment of the residually dysplastic hip, providing excellent clinical results, where early intervention is the key to improved outcome. It is a technically demanding procedure with a significant early learning curve and we believe that a two

Introduction: This retrospective study examined the clinical characteristics, radiological findings, management, and functional outcome in 34 rehabilitated patients who presented with traumatic central cord syndrome.

Methods: Between 1994 and 2004 a total of 34 patients with central cord syndrome were admitted to the National Spinal Injuries Unit. There were 29 men and 5 women. The mean age was 56.1 years (15 to 88). The mean follow up time was 4.9 years. Patients were divided into three groups by age, < 50 years (10 patients), 50–70 years (16 patients), and > 70 years (8 patients). The American Spinal Injury Association (ASIA) system recorded the motor and sensory scores, of upper and lower limbs, on admission, discharge and during rehabilitation. Patients underwent radiological investigation that included plain film, CT, and MRI of the cervical spine.

Results: The mechanism of injury was a fall in 58.8%, road traffic accident in 35.2% and other in 6%. Alcohol was a contributing factor in 32.4% of cases. Seven patients had a spinal fracture. The cervical spine was involved in 5 cases with the remaining 2 cases involving the thoracic spine. Seventy percent of patients received intravenous steroids. Over half (53%) of the patients had some degree of cervical spondylosis while cord changes were seen in almost all of the patients (79.4%). In the majority of cases (70.4%) the affected level was C3/4. Disc herniation was present in one third of cases (33.2%). The mean upper limb ASIA score on admission was 7.6, on discharge was 12.4 and at follow up was 20.2. A similar pattern was also observed in the lower limb with scores of 12.1, 13.7, and 20.5 respectively. Sensory loss also improved with time. 88.2% of those admitted required urinary catheterization, with 23.5% being discharged to the National Rehabilitation Hospital with a catheter in situ. Surgical decompression was performed in 7 cases. The remainder of patients wore a Miami-J cervical collar.

Conclusion: As was shown in the original paper by Schneider et al (1954), hyperextension of a degenerative cervical spine was the predominant mechanism of injury. The return of lower limb function precedes that of upper limb, with autonomic function recovering in the majority of cases.

Discussion: In this study patients in the younger age groups had better recovery of function and had fewer complications. The original paper by Schneider et al. stated that conservative treatment was most appropriate, however, in this review surgery was performed in specific cases such as those with cord compression secondary to disc herniation. Alcohol was a significant contributing factor.

Introduction: Fixation of the atlantoaxial complex has traditionally involved transarticular screws combined with posterior wiring techniques and structural bone grafting. Although this does lead to excellent fusion rates, the technique has a potential risk of injury to the vertebral artery. In addition, it cannot be used in fixed subluxation of the C1/2 complex. We describe the use of C1 lateral mass screws in combination with C2 pedicle screws for safe and versatile C1/C2 fixation.

Methods: Over a fifteen month period, (July 2003–October 2004) a total of 10 patients underwent posterior C1/ C2 fixation alone, or as part of a more extensive posterior construct. The average age was 54.25 years, ranging from 20–78 years. There were 7 women and 3 men. The average length of stay was 18.5 days ranging from 5–36 days.

Technique: A midline posterior approach was used in all cases. The C2 roots were mobilized and the C1 lateral masses identified bilaterally. A drill was inserted into the middle of each lateral mass under image intensification. Bicortical polyaxial screws were then inserted. The C2 pedicle screws were inserted under direct vision, as were the other pedicle screws in the more extensive constructs. Contoured rods and posterior iliac bone graft were used in all cases.

Results: Five patients required isolated C1/C2 fusion for instability, two patients had an odontoid fracture non-union, one had an unstable C2 fracture, and the remaining two patients had C1/C2 subluxation secondary to rheumatoid arthritis. More extensive posterior instrumentation was performed for the following cases, these included; occipitothoracic fixation in one patient with rheumatoid arthritis with multi-level cervical subluxation, and occipitocervical fixation in three patients, two who had metastatic disease in the cervical spine, and the remaining patient who had rheumatoid arthritis. The final patient was instrumented from C1–C5 posteriorally following removal of a C3 giant cell tumour. No neurological or vascular complications were observed. One patient, with rheumatoid arthritis and osteoporosis, had a halo applied to protect an occipitothoracic construct. All other patients were discharged in a Miami-J cervical collar. The early follow up data, clinical and radiological, showed fusion in all patients. There were no implant failures.

Conclusion: The combination of C1 lateral mass and C2 pedicle screws allows safe, effective and versatile fixation of the C1/C2 complex.

Over the past four decades, internal fixation has continued to gain popularity as a method for treating fractures because of significant improvements in both implant design and materials. This biomechanical study compares the compressive forces generated by a conventional 4.5 AO/ASIF cortical screw lag screw with a differential pitch cortical compression screw in a simulated fracture model using whole bone composite femur. The differential pitch screw investigated in this study generates 82% of the compression generated by a conventional 4.5mm AO/ASIF cortical screw. Proving compression in diaphyseal fractures is achievable using a differential pitch screw. Sufficient compression is generated to allow osteosynthesis using a plate to be preformed independent of the lag screw positioning. It is thus advantageous over the traditional compromise that arises when exposure to the fracture site is limited, of either incorporating the lag screw into the plate of choosing a non-optimal plate or screw position. It is proposed as an adjunct to the internal fixation of long bone fractures and not a single fixation device.

Between 1994 and 2002, 42 patients aged over 65 years were admitted to the spinal injuries unit with odontoid fractures. Data was retrospectively collected by analysis of the national spinal unit database, hospital inpatient enquiry (HIPE) system, chart and x-ray review. Mean age of patients was 79 years (66–88). Mean following-up with 4.4 years (1–9 yrs). Male to female ratio was 1:1.2 (M=19, F=23). Among the mechanism of injury, simple fall (low-energy) was the commonest underlying cause in 76% of the odontoid fracture, whereas 23% fractures were sustained as a result of motor vehicle accident.

Fractures were classified according to Anderson and D’Alonzo method. There were 29 (69%) type 11 fractures, 13 (30%) were type 111 fractures and there was no type 1 fracture. Anterior and posterior displacements were recorded with almost equal frequency. Seven fractures displaced anteriorly and six fractures posteriorly. Primary union occurred in 59% of fractures. Forty (95.3%) fractures were treated non-operatively. Two fractures were stabilized primarily with C1/C2 posterior interspinous fusion. These fractures were odontoid type 11, anteriorly displaced. Three fractures (7.1%) failed to unite and another three fractures (7.1%) united with prolonged interval (9–11 months). Neurological compromise was mainly related to displacement of the fracture. The overall complication rate was significant (48%) with an associated in-hospital mortality of 11.1%. Loss of reduction, non-union after non operative treatment, pin site problems and complication due to associated injuries accounted primarily for this significant complication rate. Most fractures can be managed in orthosis but unstable fractures require rigid external immobilization or surgical fixation.

Outcome was assessed using a cervical spine outcome questionnaire from Johns Hopkins School of Medicine. Questionnaires were sent by post to all patients identified. Non responders were subsequently contacted by phone, if possible, to complete the questionnaire.

In the follow-up, additional 6(14.2%) patients were found deceased, 4 patients were unavailable for review and the remaining 69% had significant recovery. Functional outcome scores approached pre-morbid level in all patients. Outcome of these patients are related to increasing age, co-morbidity and the severity of neurological deficit.

Background: By the end of the current Bone and Joint Decade (2000–2010) the World Health Organisation predicts that 55% of post-menopausal women will have osteoporosis, as defined by fragility fracture and / or BMD. Volume aside, fragility fractures also represent a significant technical challenge in operative care. Current aggressive medical management is aimed to minimize the resource impact of this pandemic.

Study Design: This prospective study of 3000 consecutive fractures treated in a Level 1 trauma unit identified 977 fragility fractures requiring operative management, 803 of which were in patients over the age of 65 years. In every case the GP was informed of the diagnosis of osteoporosis and appropriate recommendations were made regarding medical management. We present the demographic features of this population and the resource impact of their management. We also examine the outcome of our efforts to improve care of the elderly with osteoporotic fractures, as all GP’s were contacted 6 months following discharge to determine the uptake of medical treatment as recommended.

Materials and Methods: Our computerized operative database was utilized to prospectively collect demographic and operative data on all 977 patients. All medical charts were examined to identify medications on admission, GP contact details and other relevant information. GP’s were contacted by telephone and post to determine patient 6-month mortality and the uptake in the use of recommended medication. Data represents the mean ± SD.

Results: Of the 803 patients over the age of 65 years, the average age was 80.5 ± 7.5 years, with a 75% female preponderance. 14% of these had had a previous wrist or vertebral insufficiency fracture, while 2.2% had a previous contralateral hip fracture. Hip fractures accounted for 70% (566 patients) of fragility fractures with 25% AMP, 24% Bipolar, 51% DHS. There were 121 wrist fractures. On admission 23% of hip fracture patients were resident in a Nursing Home. Despite the relatively large number with previous fracture (16.2%) only 3.4% were taking calcium / vitamin D supplementation while only 2.1% were on anti-resorptive therapy, eg a bisphosphonate. The median interval between admission and operation was 1 calendar day with a range of 1–10 days. 57% of all cases were performed outside of routine trauma lists. The average length of stay for this hip fracture population was 11.5 days with a further 16.5 days spent at a step down facility. Only 14.8% went directly home. Of 240 GP’s contacted, 74% replied resulting in complete follow-up data on 730 patients. The inpatient mortality rate was 5.8% while that at 6 months follow up was 19%. By this time 54% of hip fracture patients were living in Nursing Homes. The number of patients taking only calcium / vitamin D was 4%, a bisphosphonate alone 6%, while the use of both had risen dramatically to 16%.

Conclusions: To our knowledge this is the largest reported study documenting the epidemiology, demography and short-term follow-up of hip fractures in an elderly Irish population. Such data is essential to appropriately plan for the impending national health crisis consequent to the predicted dramatic rise in the elderly population with bone fragility. In a short time, we have achieved significant success in improving awareness and treatment of osteoporosis in the elderly following hip fracture.

Aim: To evaluate the necessity for further radiological investigation in patients with suspicion of rotatory subluxation of the atlanto-axial complex on plain radiography following acute cervical trauma. To outline guidelines for assessment of patients with atlanto-axial asymmetry on plain radiography.

Methods: A retrospective review of all patients who had undergone atlanto-axial CT scanning as a result of radiographic C1–C2 asymmetry following cervical spine trauma in the 3 year period from January 1999 to December 2001. The plain X-ray and CT images were reviewed retrospectively and correlated with their clinical presentation and outcome by the senior author.

Results: Twenty-eight patients were included in the study. Acute cervical spine trauma had occurred most commonly following a road traffic accident. No patient was found to have acute cervical spine torticollis or severe cervical pain. Patients age ranged from 21–44 years (M:F – 15:13). All patients were found to have atlanto-odontoid asymmetry on initial plain X-ray. No patients were found to have rotatory subluxation on CT images. 3 patients were found to have minor degrees (< 10°) of rotation on the CT scan which is within normal limits. 9 patients (32%) were found to have congenital odontoid lateral mass asymmetry. All patients were treated conservatively and had no further intervention. All plain radiographs were then assessed to determine the underlying reason for asymmetry. In 19 cases the orientation of the radiographic beam in combination with head rotation was found to be at fault.

Conclusion: Rotatory subluxation of the cervical spine is a rare but serious condition in the adult. The condition is suspected radiologically in the presence of odontoid lateral mass asymmetry on open mouth view. The application of ATLS principles in the initial assessment of trauma patients has resulted in a significant increase in the number of radiological examinations performed. This has led inevitably to an increase in the number of anomalies identified. An average of 400 c-spine X-rays per year are performed for trauma in our casualty department. In this study, we have identified 9 patients out of a total of 29 with congenital odontoid lateral mass asymmetry over a 3 year period. This represents approximately 0.75% of the cervical spine X-rays and should be considered in the differential diagnosis following acute cervical trauma. We outline guidelines for recognising benign atlanto-axial asymmetry.