Traumatic atlanto-occipital dislocation in adults is usually fatal and survival without neurological deficit is rare. The surgical management of those who do survive is difficult and controversial. Most authorities recommend posterior occipitoaxial fusion, but this compromises cervical rotation. We describe a case in which a patient with a traumatic atlanto-occipital disruption but no neurological deficit was treated by atlanto-occipital fusion using a new technique consisting of cancellous bone autografting supported by an occipital plate linked by rods to lateral mass screws in the atlas. The technique is described in detail. At one year the neck was stable, radiological fusion had been achieved, and atlantoaxial rotation preserved. The rationale behind this approach is discussed and the relevant literature reviewed. We recommend the technique for injuries of this type.
A 5 year review into the workload and subsequent financial implications of pelvic and acetabular reconstruction at a regional tertiary referral centre. To ascertain the level and means of financial recompense for performing pelvic/acetabular reconstruction on patients from other healthcare trusts at a tertiary referral centre. The records of all 120 patients who underwent either pelvic or acetabular reconstruction between 1995–2000 were examined. Epidemiological data and information on all possible costs of their stay was accumulated (itemised finance department figures were used). The individual patient billing system of ECRs (Extra Contractual Referrals) was changed in 1998 and replaced by the OATs system (Out of Area Treatments) whereby an annual lump sum was received based on historic referral patterns. We investigated the financial effects that occurred. 60 out of 120 patients treated, were from other health-care trusts. From 1995–1998, 25 ECR patients were treated at an estimated cost of £480, 000. The trust received £280, 000, a net loss of £200, 000. From 1998–2000, 34 OATS patients were treated at an estimated cost of £650, 000, amounting to a net gain of £1. 15 million pounds. ‘Out of area’ referrals for pelvic and acetabular reconstruction have increased by 50 % in the last 2 years. However the new payment system i. e. OATS has resulted in the tertiary referral centre being generously rewarded, unlike prior to 1998 and the old ECR system. It is therefore recommended that annual review must be carried out to ensure that funding will meet the demand for specialist services in the future and prevent subsidisation of some centres by other trusts.
