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A new fixation device for C1-C2 fusion is presented. It consists of a claw construct for the C1 arch that is rigidly attached to C1-C2 transarticular screws to form an instrument that combines anterior and posterior fixation in the same construct. The new device was successfully applied in a case with failed C1-C2 fusion that was initially stabilized with transarticular screws alone, where the usual posterior wiring was omitted due to a defect of the posterior C1 arch.

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UNLABELLED: The authors describe a case of craniocervical dislocation secondary to rheumatoid arthritis producing important canal narrowing: ventrally by migrated odontoid and dorsally by posterior arch of C-1 with medullary compression. Symptoms of hyperreflexia, spasticity and left hemiparesis with Babinski sign were present. SURGICAL PROCEDURE: transoral odontoidectomy was performed followed by suboccipital approach, C-1 laminectomy and occipitocervical fixation (Olerud device and bone graft). Outcome with neurologic improvement. CONCLUSIONS: Transoral odontoidectomy combined with occipitocervical decompression and fixation is effective approach for treatment of severe craniocerebral dislocation. Its advantages: ventral and dorsal decompression combined with immediate stabilisation.

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We reviewed our first 53 lengthenings performed in 45 patients with an average age of 19 years at the time of lengthening. The shortening was congenital in 16 patients, post-traumatic in 15 and had various causes in the 14 remaining. 31 femurs and 22 tibias with an average shortening of 6 and 5 cm, respectively, were lengthened 6 (2-14) cm. The aim was achieved in all but 4 patients, where lengthening had to be discontinued due to complications. Potential complications of lengthening can be numerous but, if recognized, can in most cases be dealt with during the extended lengthening procedure. 38 cases of pin-tract infections healed with antibiotics. Restricted motion in one or more joints was registered in 49 cases during lengthening; minor restriction of joint motion persisted in 14 patients. 28 cases had angular deviations during lengthening. After additional surgery all but 10 could be corrected. 4 fractures occurred after removal of the external fixator. The total number of complications was 146, and of these 76 were minor, 42 moderate and 28 severe. 36 of the 42 patients available to follow-up were satisfied with the results of the lengthening procedure.

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21 consecutive patients with 23 rotationally and vertically unstable sacroiliac joint disruptions were operated on through an anterior approach. Open reduction and internal fixation with a 2-hole square plate was performed. At follow-up after 5 (2-8) years, 18 patients were rated excellent or good and 3 patients poor. In all the cases the reduction of the SI-joints was maintained.

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Metastatic tumors often spread to the vertebral column. When the mechanical strength of a vertebra is decreased as a result of tumor-induced bone destruction, a pathologic fracture may occur. Such a fracture is often associated with severe pain. If it occurs in the thoracic or upper lumbar region, there is a major risk of paraplegia if the fractured vertebral body is displaced into the spinal canal. Metastases in the vertebral column also can cause neurologic symptoms due to direct infiltration of the tumor into the spinal canal. Due to recent advances in spinal surgery, effective help often can be provided to these patients. The extent and type of surgical intervention, however, must be carefully considered in each individual case.

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Twenty patients with an average posttraumatic leg length shortening of 4.6 cm (range 2.5-9) underwent direct leg lengthening. The operation time averaged 210 min and the peroperative blood loss was 1,800 ml. Angular and rotational malalignment, when present, were corrected. Lengthening averaged 3 cm. At follow-up, two patients had serious sequelae after vascular injuries. Seven patients had postoperative neurological complications, which in four cases resolved completely. The time required for solid union of the lengthened segment averaged 10 months. Bone grafting two or more times was performed in six patients. Seventeen patients were assessed an average of 7 years (range 3-10) after surgery. Thirteen of these were satisfied with the results of the lengthening. Complications of the procedure and/or a remaining major leg length inequality could explain the dissatisfaction of the others. A majority of the patients complained of low-back pain both preoperatively and at follow-up. Few complaints about the joints in the long leg were expressed. Preoperative pain about the hip and knee in the short leg existed in more than half of the patients, and these complaints were reduced on a weak statistical level at follow-up. Walking ability improved in 12 patients, working ability in 10, and recreational activity level in eight. Direct leg lengthening is generally regarded as major, demanding surgery, entailing potential risks of serious complications, and should be used with great care and only in selected cases.

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The anatomical reduction of intra-articular knee fractures is a major challenge if a satisfying functional result and limited post-traumatic arthrosis is to be obtained. In some cases even after malunion a good result can be achieved. In this paper, our experience with reconstructive surgery is described after a description of possible extended approaches to the knee and osteotomy techniques and advanced osteosynthesis. Four illustrated cases of distal femoral and three of proximal tibial reconstruction are discussed. In all patients the primary treatment led to malunion of the comminuted fractures. The only complication seen was the breaking of an angulated plate at the distal femur and even here, after re-osteosynthesis, normal healing occurred. In all cases a satisfactory knee motion was achieved: 90 degrees of flexion in the femoral group and 120 degrees in the tibial group was reached without any extension deficit. Alignment and axial correction were optimal in all patients. From these results we believe that reconstructive surgery can ba advocated for malunited knee fractures and that it represents a primary alternative to joint replacement surgery and arthrodesis.

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By an anterior approach, six pathologic dens fractures were stabilized with screws and methyl methacrylate cement. All the patients had immediate pain relief and could be mobilized without external support. Using the anterior approach, the tumor can be removed and the instability neutralized at the site of the lesion.

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The techniques earlier used for leg lengthening were notorious for their complications, and as late as the 1960s some authorities would not consider lengthening unless amputation was the alternative. The method introduced by Wagner in the 60s had the advantage of a stable external fixation, permitting the patients to be mobilized. The drawback was that at least three operations were needed: external fixation and osteotomy, bone grafting and internal fixation, and, finally, removal of the plate. With the Ilizarov technique, no bone grafting is needed and bone lengthening up to at least 15 cm is possible. The main problems in leg lengthening are related to joints and soft tissue. Every surgeon performing leg lengthenings should be familiar with the possible problems and complications. He must establish very good relations with the patient and be ready to spend a considerable amount of time with the patient during the process.

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Surgical treatment of thoracolumbar vertebral fractures is a controversial issue, especially in light of its doubtful advantages. Moreover, methods previously available have been associated with certain drawbacks, including insufficient stability. With the application of a new therapeutic principle in which the screws of the fixation instrument are placed in the pedicles of the vertebrae, the stability of vertebral fractures is improved considerably. This will increase the degree of mobilization, shorten the period of disability, and improve the comfort of the patient. Early effective stabilization, combined with decompression if necessary, also provides the best possibility for restoration of neurologic function.

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The treatment of unstable fractures of thoracolumbar vertebrae is a controversial issue in the orthopedic community. The various methods employed for operative stabilization of these injuries have to date been found to have major disadvantages. A new therapeutic principle and a new device for stable internal fixation are presented.

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The most frequent surgical treatment of thoracolumbar fractures is still the Harrington rod system despite some adverse effects, the most serious being the locking of five to seven segments. The new pedicular fixation modifications suggested by Magerl and Dick lock only two segments and give far better stability of the fractures. Used internally, the system is convenient for the patient, permitting early mobilization, often without any external support. The instrument, called the "posterior segmental fixator" (PSF), is used both as a reduction device and as a fixation device. The injured vertebra is grafted through the pedicle, giving security against late collapse after device removal. Twenty patients treated with this method had an average follow-up period of ten months. The primary reduction attains 88% of the calculated height of the injured vertebra, with only a few percent loss during follow-up time. Clearance of fragments in the spinal canal, diagnosed with computed tomography scan in eight patients, was successfully accomplished in all but one, with only distraction or reduction of the fragment through a limited laminotomy. The instrumentation in these cases was lateral to the dura. Nine patients with neurologic deficits improved and could walk without support or with crutches within a few months. One patient with complete paraplegia remained unchanged.

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The treatment of fractures of the cervical spine, like that of fractures of the extremities, has been considerably improved in the last decade. The aim of these changes has been to prevent and correct deformities and to achieve such a high degree of primary stability with the use of different internal fixation techniques that traditional external fixation can be avoided. Non-stable internal fixation and laminectomies, which invariably result in further loss of stability, have thus been completely eliminated from the therapeutic arsenal. The new system implies a considerably milder course of treatment for the patient. Confinement to bed is limited to a few days, even for tetraplegic patients. The duration of stay in the hospital is short and any necessary rehabilitation can be started at an extremely early stage. This article describes some of the new techniques and provides examples of indications for and methods of performing stable internal fixation.

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