The current study aims to find the role of Enhance Recovery Pathway (ERP) as a multidisciplinary approach aimed to expedite rapid recovery, reduce LOS, and minimize morbidity associated with Non Fusion Anterior Scoliosis Correction (NFASC) surgery. A retrospective analysis of 35 AIS patients who underwent NFASC with Lenke 1 and Lenke 5 curves with a minimum of 1 year of follow-up was done. Patient demographics, surgical details, postoperative analgesia, mobilization, length of stay (LOS), patient satisfaction survey score with respect to information and care, and 90 days complications were collected. The cohort included 34 females and 1 male with a mean age of 15.2 years at the time of surgery. There were 16 Lenke 1 and 19 Lenke 5 in the study. Mean preoperative major thoracic and thoracolumbar/lumbar Cobb's angle were 52˚±7.6˚ and 51˚±4.5˚ respectively. Average blood loss and surgical time were 102 ±6.4 ml and 168 ± 10.2 mins respectively. Average time to commencing solid food was 6.5±1.5 hrs. Average time to mobilization following surgery was 15.5± 4.3 hrs. The average duration to the stopping of the epidural was 42.5±3.5 hrs. The average dose of opioid consumption intraoperatively was 600.5±100.5 mcg of fentanyl i.v. and 12.5±4.5 mg morphine i.v. Postoperatively opioids were administered via an epidural catheter at a dose of 2 mg of morphine every 24 hours up to 2 days and an infusion of 2mcg/hr of fentanyl along with 0.12-0.15% ropivacaine. The average duration to transition to oral analgesia was 55.5±8.5 hrs .20 patients had urinary catheter and the average time to removal of the catheter was 17.5±1.4 hrs. 25 patients had a chest tube and the average time to remove of chest tube was 25.5±3.2 hrs. The average length of hospital stay was 3.1±0.5 days. No patient had postoperative ileus or requirement of blood transfusion or any other complications. No correlation was found between LOS and initial cobb angle. The application of ERP in AIS patients undergoing NFASC results in reduced LOS and indirectly the cost, reduced post-operative opioid use, and overall improve patient satisfaction score

Abstract. Background. Elderly patients with degenerative lumbar disease are increasingly undergoing posterior lumbar decompression without instrumented stabilisation. There is a paucity of studies examining clinical outcomes, morbidity & mortality associated with this procedure in this population. Methods. A retrospective analysis of aged 80–100 years who underwent posterior lumbar decompression without instrumented stabilisation at University Hospitals of Derby &Burton between 2016–2020. Results. Total 167 eligible patients, 163 octogenarians & 4 nonagenarians. Mean age was 82.78 ± 3.07 years. Mean length of hospital stay 4.79 ± 10.92 days. 76% were pain free at 3months following decompression. The average Charleston co-morbidity index (CCI) was 4.87. No association found with CCI in predicting mortality (ODD ratio 0.916, CI95%). 17patients suffered complications; dural tear (0.017%), post-op paralysis (0.017%), SSI(0.01%), and 0.001% of hospital acquired pneumonia, delirium, TIA, urinary retention, ileus, anaemia. High BMI (35+) was associated with increased incidence of complication (CI 95%, p<0.002). There was significant social drift following discharge as 147 patients went home and 4 patients to rehabilitation facility (p<0.001FE test). The mean operative time was 91.408±41.17 mins and mean anaesthetic time was 36.8±16.06 mins. Prolonged operative time was not associated with increased mortality.2year revision decompression rate was 0.011%. Conclusion. Posterior lumbar decompression without instrumented stablisation in elderly is safe & associated with low mortality with 99.5%survival at 1 year. It significantly improves PROMs & has extremely low revision rate. Incidence of post-op complication is <0.05% and 54% of patients get discharged within 72hours of surgery. Careful selection & optimising patients with high BMI would reduced perioperative morbidity and mortality

Introduction: A small, yet not uncommon, problem following total joint arthroplasty (TJA) is post-operative ileus (POI). The purpose of this study was two-fold. First the study sought to determine the incidence of POI after TJA in a consecutive series of patients receiving regional anesthesia and an aggressive postoperative rehabilitation protocol. Second, the influence of narcotic medications, including intrathecal medications, in the incidence of POI was examined. Methods: 5,262 patients underwent total joint replacements, including primary and revision surgery, at our institution from 2004 to 2005. All surgeries were performed at a university-affiliated institution where complications, if any, are prospectively recorded in a comprehensive database. Demographic, clinical, surgical, and radiographic details were obtained and examined. Results: 26 (0.5%) patients developed ileus. There were 17 males and 9 female patients, who had a mean age of 67.7 years (range, 52.7 to 91.2 years). The mean BMI was 30.2 kg/m2. The index procedures included 15 primary hip, 4 primary knee, 4 revision hip, and 3 revision knee procedures. Of the patients who developed ileus, intrathecal narcotics were administered in 16 patients (62%). Discussion: There is a very low incidence of postoperative ileus and gastrointenstinal hypomobility following joint arthroplasty. Early patient ambulation, a reduction in the use of postoperative narcotics, supplementation of analgesia with non-narcotic drugs, and reduced length of hospital stay may all have an important role in reducing this complication. Based on our findings, it seems unlikely that intrathecal narcotics have an adverse effect on gastrointestinal motility

Perioperative pain involves both neurogenic and inflammatory mediators. The neurogenic component is produced by the intense stimulation of the surgical procedure itself. However, inflammatory mediators resulting from tissue damage and the release of certain cytokines provoke the inflammatory response. Both the neurogenic and inflammatory elements create central nervous system (CNS) excitability. While conventional pain management responds to pain as it occurs, rather than anticipating it, a more appropriate protocol may involve pre-emptive administration of analgesic medication. By beginning this administration prior to surgery and continuing it throughout the rehabilitation process, CNS pharmacological agents are utilised to achieve the following goals: 1.) decrease the neurogenic component at the wound site; 2.) depress afferent pathways; and 3.) decrease central sensitisation in the spinal column. Our experience with such pre-emptive analgesic clinical trials have included implementation of three different protocols in three groups of patients, Groups A-C. In Group A, a continuous epidural for 72-hours was utilised. A short-term epidural for 2–3 hours, followed by the use of scheduled opioid drugs and the use of anti-inflammatory medications, was used in Group B. Finally, Group C included spinal analgesia with shortacting morphine and the continued use of patient-controlled analgesia (PCA) pumps. In all groups, patients were monitored for the return of motor function, respiratory depression, ileus, pain relief, efficacy in analgesia maintenance, and cost. The following trends were observed among the variances: 1.) approximately equal length of stay in all three groups; 2.) decreased motor function in the continuous epidural group (Group A); 3.) increased ileus in the spinal group (Group C); 4.) equal pain relief in all three groups; 5.) high maintenance in the continuous epidural group (Group A); and 6.) decreased cost when continuous epidurals (Group B) were utilised. In conclusion, of the three methodologies implemented, the continuous epidural had a high failure rate (26%). While spinal analgesia is technically easier and less expensive to perform, it has a poorly defined dose response curve and is associated with an increased incidence of ileus. The scheduled opioid medications proved effective. Pre-emptive analgesia not only significantly suppresses pain, it also provides protective sensation. Our recommendation for pre-emptive pain management consists of the use of multi-modal analgesics attacking various sites along the pain pathway, including regional blocks, oral and parental opioids, topical anaesthetics, and ice. However, ongoing study is required to further delineate appropriate protocol, thorough assessment of consequences, and complications associated with all methodologies. Future protocols to be evaluated at this practice include the local injection of bupivacaine hydrochloride prior to wound closure, in addition to assessing the postoperative integration of rofecoxib into the pain management regime

Introduction. Total knee arthroplasty (TKA) is an effective surgical intervention, which alleviates pain and improves function and health-related quality of life in patients with end-stage arthritis of the knee joint. With improvements in anesthesia, general health care, and surgical techniques, this procedure has become widely accepted for use in very elderly patients. However, many elderly patients tend to have compromised function and low reserve capabilities of organs and are therefore likely to develop various complications during the perioperative period. Thus, elderly patients often hesitate to undergo simultaneous bilateral TKA (SBTKA). Our purpose was to report the short-term results and clinical complications of octogenarians undergoing SBTKA. Materials and Methods. Between 2015 and 2016 all patients greater than 80years of age who underwent SBTKA by a single surgeon were retrospectively evaluated demographics, comorbidity, complications, and 30days mortality following SBTKA. Arthroplasty was performed sequentially under general anesthesia by one team led by primary surgeon. After the first knee, the patient's cardiopulmonary status was assessed by anesthesiology to determine whether or not to begin the second side. Cardiopulmonary decompensation, such as significant shifts in heart rate, oxygen saturation or blood pressure, was not showed. Then the second procedure was undertaken. Inclusion criteria of this study was underlying diseases were osteoarthritis. Exclusion criteria were (1) previous knee surgery; (2) underlying diseases were osteonecrosis, rheumatoid arthritis, fracture, and others. Fifty-seven patients with an average age of 82.7years were identified. The results of these procedures were retrospectively compared with those of patients greater than 80years of age of 89 patients unilateral TKA (UTKA) that had been performed by the same surgeon. Results. The study groups did not differ significantly with regard to age, gender, or body mass index. The mean age was 82.7years with a mean body mass index of 25.8 for the SBTKA group, compared with 84.0years with a mean body mass index of 24.9 for the UBTKA group. The length of hospital stay was longer in SBTKA groups. There was no serious complication. No deaths, no pulmonary embolisms and no nerve paralysis occurred within 30days in both groups. There was one wound problem in SBTKA group, compared 10 wound problem in UBTKA group; this difference was significant. Three deliriums occurred in SBTKA group, compared 13 deliriums in UBTKA group; this difference was significant. Minor complications included urinary tract infection, decubitus ulcer, transfusion reaction and ileus were noted seven in SBTKA group, compared in 11 UBTKA group; this difference was not significant. Conclusions. Complications and mortality are not higher for SBTKA compared to UTKA, SBTKA can be a safe and effective option for octogenarians

Lumbar decompression-fusion surgery involves extensive surgery in prone position and is associated with significant post-op ileus. We compared the post-operative oral intake regimes of our two spinal firms over a 6 months period. The post operative oral intake was commenced as soon as the bowel sounds started in one firm. In the other firm, the oral intake was started only after the patient passed wind. There were 28 patients in the first group (bowel sounds) and 27 patients in the second group (passage of wind). The two groups were comparable for age and sex distribution. The average age was 69 yrs, and the male: female ratio was 1.2:1. The bowel sounds were found to start on an average of 8.5 hours (6-16 hours) post-operatively. The average time between the operation and the patient passing wind was 26 hours (18-73 hours). The patients who were on Patient Controlled Analgesia (PCA) were found to have a delayed passage of wind. There was no significant correlation between the number of fusion levels or the operative time and commencement of bowel sounds/ passage of wind. The patient satisfaction rate was much better when the oral intake was commenced as soon as the bowel sounds start. The incidence of nausea/vomiting was significantly less in the group in which the oral intake was commenced following patient passing wind. The bloating of the abdomen was found in the first group. Audit Committee Interest statement: No conflict of interest

To progress to a same day surgery program for arthroplasty, it is important that we examine and resolve the issues of why patients stay in the hospital. The number one reason is fear and anxiety for the unknown and for surgical pain. The need for hospital stay is also related to risk arising from comorbidities and medical complications. Patients also need an extended stay to manage the side effects of our treatment, including after-effects of narcotics and anesthesia, blood loss, and surgical trauma. The process begins pre-operatively with an appropriate orthopaedic assessment of the patient and determination of the need for surgery. The orthopaedic team must motivate the patient, and ensure that the expectations of the patient, family and surgeon are aligned. In conjunction with our affiliated hospitalist group that performs almost all pre-admission testing, we have established guidelines for patient selection for outpatient arthroplasty. The outpatient surgical candidate must have failed conservative measures, must have appropriate insurance coverage, and must be functionally independent. Previous or ongoing comorbidities that contraindicate the outpatient setting include: cardiac – prior revascularization, congestive heart failure, or valve disease; pulmonary – chronic obstructive pulmonary disease, or home use of supplemental oxygen; untreated obstructive sleep apnea – BMI >40 kg/m2; renal disease – hemodialysis or severely elevated serum creatinine; gastrointestinal – history or post-operative ileus or chronic hepatic disease; genitourinary – history of urinary retention or severe benign prostatic hyperplasia; hematologic – chronic Coumadin use, coagulopathy, anemia with hemoglobin <13.0 g/dl, or thrombophilia; neurological – history of cerebrovascular accident or history of delirium or dementia; solid organ transplant. Pre-arthroplasty rehabilitation prepares the patient for peri-operative protocols. Patients meet with a physical therapist and are provided with extensive educational materials before surgery to learn the exercises they will need for functional recovery. Enhancement of our peri-operative pain management protocols has resulted in accelerated rehabilitation. The operative intervention must be smooth and efficient, but not hurried. Less invasive approaches and techniques have been shown to decrease pain, reduce length of stay, and improve outcomes, especially in the short term. In 2014, 385 primary partial knee arthroplasty procedures (7 patellofemoral replacement, 13 lateral, and 365 medial) were performed by the author and his 3 associates at an outpatient surgery center. Of those, 348 (95%) went home the same day while 17 (5%) required an overnight stay, with 11 for convenience related to travel distance or later operative time and 6 for medical issues. Outpatient arthroplasty is safe, it's better for us and our patients, and it is here now. In an outpatient environment the surgeon actually spends more time with the patients and family in a friendly environment. Patients feel safe and well cared for, and are highly satisfied with their arthroplasty experience

Single-stage bilateral total knee arthroplasty is an uncommon and often controversial procedure. Recent reports have refined the data relative to bilateral total knee arthroplasty and complications which include myocardial infarction, deep vein thrombosis, pulmonary embolus and death. Less significant complications, including post-operative ileus and pseudo-obstruction are also more common following bilateral replacement. A retrospective study of the cases of total knee arthroplasty performed by the senior authors in the last ten years, examines details of surgery and anaesthesia, pre and post-operative management to identify the occurrence of complications. Patients also completed an Oxford Knee Score and a questionnaire relating to their experience of having a bilateral procedure. While the outcomes and cost benefits of single stage bilateral replacement are established, the risk of complications remains. This study establishes the low complication rate associated with this procedure in the senior authors’ hands, and documents the high patient satisfaction from it. The study demonstrates that, in selected patients, simultaneous bilateral knee replacement surgery can be performed with good outcomes without a definite increase in perioperative risk

This study was conducted to quantify the incidence of gastrointestinal morbidity and identify risk factors for developing gastrointestinal morbidity following spinal surgery in children. A retrospective review was conducted on 253 surgical spinal procedures performed over a 5 year period at Starship Children’s Hospital. Multivariate logistic regression analysis was used to identify significant risk factors. Seventy eight (77.9%) percent of the study population developed gastrointestinal morbidity and this significantly prolonged the median post-operative hospital stay (8 days vs. 4 days; p< 0.0001). Emesis (50.6%), paralytic ileus (42.3%) and constipation (22.5%) were the most frequent gastrointestinal morbidities. Significant risk factors for developing gastrointestinal morbidity were fusion surgery, co-morbidities and duration of post-operative opioid use. The high incidence of gastrointestinal morbidity after paediatric spinal surgery and consequent prolonged hospital stay has clinical implications to both the patient and the institution. Awareness of those with significant risk factors identified by this study could assist in the timely implementation of appropriate treatment

Aims

To map literature on prognostic factors related to outcomes of revision total knee arthroplasty (rTKA), to identify extensively studied factors and to guide future research into what domains need further exploration.

Aims

Autologous bone graft (ABG) is considered the ‘gold standard’ among graft materials for bone regeneration. However, complications including limited availability, donor site morbidity, and deterioration of regenerative capacity over time have been reported. P-15 is a synthetic peptide that mimics the cell binding domain of Type-I collagen. This peptide stimulates new bone formation by enhancing osteogenic cell attachment, proliferation, and differentiation. The objective of this study was to conduct a systematic literature review to determine the clinical efficacy and safety of P-15 peptide in bone regeneration throughout the skeletal system.

Introduction This study was conducted to quantify the incidence of gastrointestinal morbidity and identify risk factors for developing gastrointestinal morbidity following spinal surgery in children. Method A retrospective review was conducted on 253 surgical spinal procedures performed over a 5 year period at Starship Children’s Hospital. Multivariate logistic regression analysis was used to identify significant risk factors. Co-morbidity included co-existing cardiac, respiratory, genitorurinary or central nervous system problems, or delayed development. Results Seventy eight (77.9%) percent of the study population developed gastrointestinal morbidity and this significantly prolonged the median post-operative hospital stay (8 days vs.4 days; p< 0.0001). Emesis (50.6%), paralytic ileus (42.3%) and constipation (22.5%) were the most frequent gastrointestinal morbidities. Significant risk factors for developing gastrointestinal morbidity were fusion surgery (p< 0.01), co-morbidities (p-value) and duration of post-operative opioid use (p-value). Discussion There is a high incidence of gastrointestinal morbidity after paediatric spinal surgery. The consequent prolonged hospital stay has clinical implications to both the patient and the institution. We have further identified risk factors for developing gastrointestinal morbidity, of which the duration of post-operative opioid use is modifiable. Awareness of those with the other significant risk factors identified by this study could assist in the timely implementation of appropriate treatment

Introduction: The population of the UK is getting older. Patients over the age of 80 (the older old) are increasingly presenting with musculoskeletal tumours that require major surgery. We have investigated the success or otherwise of endoprosthetic replacements after tumour excision in this population. Methods: We looked at an oncological database to identify patients over the age of 80 who had an endprosthetic replacement after tumour excision. We reviewed the records of all patients over the age of 80 who had an endoprosthetic replacement to assess the oncological and functional outcomes of the procedure. Results: 17 patients over the age of 80 had an endoprosthesis over the past 10 years. The main indication was for metastatic disease (9 patients) but 6 had primary malignant bone tumours. The most common site was the distal femur in 9 followed by the proximal femur in 5. Most of the patients had associated co-morbidity (12 were ASA 2 or 3). There were no perioperative deaths but 2 patients had early complications with one having a paralytic ileus and one a chest infection. The median survival of the patients was 2 years with death being due to progressive metastases in most. 3 had late complications to do with the prosthesis including one infection in a proximal tibial replacement and a late dislocation at 2 years in a proximal femoral replacement. Two patients developed local recurrence treated by local excision and radiotherapy. There were no amputations or revisions. Conclusions: Endoprosthetic replacements have a useful role to play in the surgical management of elderly patients. Although they have significant comorbidity most do well. Functional results are less good than in the younger population but most patients regain their independence and are free of pain

Introduction: Duchenne’s Muscular Dystrophy (DMD) is a progresssive sex linked recessive disorder predominantly involving skeletal muscle. Scoliosis is almost universal in patients with DMD. Surgical stabilisation carries significant risks and complications with per-operative mortality of < 6%. Cardiopulmonary complications along with severe intraoperative blood loss requiring massive nlood transfusion are the major cause of morbidity. Aim: To evaluate the efficacy of single rod fusion technique in reducing the peroperative and post operative complications especially blood loss, duration of surgery and progression of curve. Materials and Methods: Retrospective review- 32 patients with scoliosis secondary to DMD with an average age of 14 years (range, 11–18) underwent either single rod fusion technique (19 patients) using Isola rod system or Hartshill rectangle/double rod fusion technique (13 patients). Blood loss was measured directly from the peroperative suction and postoperative drainage, indirectly by weighing swabs. Vapour free hypotensive anaesthesia was used in all cases. Progression of curve was followed up in the outpatients. Results: The mean operative time was 130 minutes (range, 80–180) for the single rod fusion technique in comparison to 250 minutes (range, 170–300) for the Hartshill/Double rod technique. The average blood loss for the single rod fusion technique was reduced, 2.2 L (range 0.4–4) versus 3.1L (0.8–4). The mean follow up was 35 months (range, 5–72). The inpatient stay was 12 days (range, 6–23). Seven patients developed complications: 3 ileus, 2 respiratory tract infections, one patient had loosening and migration of the rod, which required revision under LA, and one patient developed a superficial wound infection, which resolved with intravenous antibiotics. Conclusion: In our experience, single rod stabilisation is a safe and quick method of correcting the DMD scoliotic spine, with less blood loss and complications compared to traditional methods

Purpose: A retrospective review of 180 consecutive luque unit rod instrumentations for neuromuscular scoliosis revealed a low rate (7%) of reoperation for hardware related issues. The results of this cost effective instrumentation are good, and we question whether moving to more expensive systems (eg pedicle screws) will provide benefit to patients. Method: A retrospective clinical and radiographic review of 180 consecutive patients, treated with the unit rod and sublaminar wires for progressive neuromuscular scoliosis and cerebral palsy, between 1994 and 2004 was done. Preoperative, intraoperative, and outcome data were obtained from hospital and clinic records with 2 to 12 years of followup. Results: Mean age at surgery was 13 years. Of 180 patients, 158 were full time wheelchair users. 112 patients underwent isolated posterior surgery, 68 underwent anterior & posterior surgeries. Allograft was used in 96%. Mean surgical time was 5 hours 45 minutes, blood loss was 1325 cc. Mean cobb angles improved from 72° to 32°, pelvic obliquity improved from 20° to 9°. Overall postoperative complications were 222, with 36 (20%) of 180 patients experiencing no complication. Only 13 patients of 180 required revision surgery for hardware related problems. Pseudoarthrosis was seen in 7 patients. 18 patients had prominence of the rod. Of 22 ambulatory patients, 3 became wheelchair dependent. 8 showed coronal decompensation. Medical complications included respiratory in 52 patients, deep or superficial infection in 29, ileus in 23, UTI in 19, SMA syndrome in 5, and other in 18. Conclusion: Although overall complications were high in this patient group, hardware related complications of the unit rod were low. Respiratory and other medical problems were most of the complications and would not be minimized with different hardware. The unit rod achieved and maintained spinal balance and fusion with only 13 hardware related revisions in 180 patients (7%)

Background: Lumbar disc replacement is a good alternative to fusion in young patients with degenerative disc disease or discogenic back pain. Despite the increase in the use of anterior lumbar disc replacement, there has been little published data of the specific types and frequencies of the complications associated with its use. Aims & Methods: Purpose of the study is to retrospectively study the perioperative complications associated with CHARITÉ® Artificial Disc replacement. The lumbar spine is retroperitoneally approached, viscera and major vessels retracted and the disc replaced. We reviewed the operative and hospital records of 54 charite disc replacements done by the senior author from 2004 till September 2006. Results: The study group had 23 men and 31 women with a mean age of 38 years (range 31–47). Preoperative diagnosis was degenerative disc disease in 42 patients (78%); discogenic back pain in 12 patients (22%). The most common level replaced was L4/5 (48%) followed by L5/S1 (35%). The most common complication during the procedure was venous injury involving one of the left iliac vein tributary (9 patients, 16%). There was no arterial injury. The median blood loss was 450ml (100–1500ml). There was peritoneum breach in six patients, but no case of bowel, ureter, and bladder or kidney injury. There were two incidences of significant post operative ileus and one developed S1 radiculopathy from lateral disc placement. One developed incisional hernia and two patients had to be revised to fusion. Retrograde ejaculation was reported in 3 patients. No incidence of epidural vein bleed, CSF leak, infection, paraplegia or death. Conclusions: Anterior spinal surgery is a relatively safe procedure with a lower complication rate than was previously reported. Vascular injury was the most frequent complication. The incidence of autonomous dysfunction affecting pelvic floor function appears to be under-estimated and needs further study

The aim was to review patients that had single stage bilateral total hip joint replacements (SSBTHJR) of two surgeons in the Wellington area, to assess symptomatic relief and overall quality of life before and after surgery. To also review xrays of this population to assess acetabular component orientation. Fifty patients from two hospitals, with minimum follow up of two years, who had SSBTHJR, were reviewed for duration of stay, time to mobilisation, and complications (eg. wound infections, venous thrombus and embolism (VTE), gastrointestinal ileus, and cardiac events). Patient opinions on hip joint function (Oxford Hip Score) and overall quality of life (EQ-5D Score) were performed (37/50 patients could participate). Patient’s postoperative radiographs were analysed with Polyware Auto Version 6.00 to measure acetabular cup orientation for both sides. Oxford Hip Score mean was 20.5 (range 12 – 56), compared to the national mean 19.3. The median score was 14. Most patients (65%) had no symptoms of pain, difficulty in mobilising, or performing activities of daily living (ADL). 19% of patients had mild to moderate symptoms/difficulty, and 16% had significant pain/difficulty On average, using a visual analogue scale, patients felt their health was 42% better after having their surgery. Complication rates were minimal, and were primarily superficial wound infections. Hip acetabular cup positioning analysis was performed (statistical analysis pending). Patients undergoing SSBTHJR have comparable results for Oxford Hip Scores compared to unilateral THJR patients, improved lifestyle, but not increased complications

Introduction. Dissemination of Total hip Arthroplasty through the direct anterior approach has, depending upon one's experience and perspective, benefitted from or been plagued by aggressive marketing. Although first developed over 60 years ago it was all but unknown until the past decade. This study exams one community surgeon's experience and thus sheds light on whether the ATHA is a viable operation for all orthopaedic surgeons. Methods. 332 hips having a THA through the direct anterior approach were prospectively studied. Side and sex distribution were approximately equal; primary OA was by far the most common diagnosis. 4 hips were converted from a previous operation for fracture. No hips were excluded; all hips were replaced through the direct anterior approach. All hips had the same HA coated, cementless triple-taper stem; a variety of cups were used. 92% of the bearings were ceramic on poly including 22% “dual mobility” design; 88% of the heads were 28 or 32 mm. A special orthopaedic table and intraoperative c-arm were used universally. Charnley Merle D'Aubigne, Harris, and WOMAC scores were obtained before surgery and annually thereafter. Anti-embolic prophylaxis was with intraop bilateral thigh high sequential pumps, early mobilization and aspirin for most. Those patients deemed at risk received lovenox, and those already on Coumadin continued – with bridging lovenox. Results. The mean time for surgery was 70 minutes (60 to 175); for c-arm use: 7 seconds (maximum 21). 78% went directly home after an average hospital stay of 2 days. Less than 10% required a blood transfusion. 80% had none or a leg length difference less than 5 mm. Acetabular abduction angle was within the safe zone for all hips; 1 hip was outside the anteversion safe zone. Hip scores improved significantly for all hips (p < 0.001). There were 5 (1.5%) intra-operative complications; all were recognized and none required further treatment or modification of the usual postop regimen. 3 dislocations occurred (0.9%). 3 reoperations (0.9%) were required: 1 early (a fall and fractured femur) and 2 late (1 fall with acetabular fracture and 1 recurrent dislocation). Another fracture occurred from a fall but additional surgery was not needed. There were 4 (1.2%) systemic complications: 1 PE, 1 UGI bleed, 1 ileus, 1 CVA. 2 patients died for reasons unrelated to the arthroplasty. Discussion/Conclusion:. These data suggest that satisfactory or better results with few complications can be achieved through the direct anterior approach utilizing a special orthopaedic table and intraop fluoroscopy. Using an HA coated triple-taper stem there was no atraumatic loosening in this short term follow-up. C-arm time was comparatively minimal and seems to contribute to good implant positioning. The dislocation rate was low even though large head sizes were rarely employed. There were no periprosthetic infections suggesting that claims for relative soft tissue sparing may be factual

Introduction The management of cervical spine facet fractures, dislocations and subluxations in the literature is controversial. Many implants have been tested biomechanically and clinically. The overall biomechanical evidence points to greater stability with posterior constructs, however anterior surgery has practical advantages in terms of less dissection and local trauma than the posterior approach. The aim of this audit was to assess radiological results of facet joint fracture dislocations treated between January 2000 and August 2004. The audit was designed to examine the hypothesis that anterior fixation is inferior to posterior or combined anterior and posterior fixation. Methods The clinical notes and radiological images of patients who present with a uni- or bifacet fracture dislocation during the study period were retrospectively reviewed. There were 21 patients treated during this period. 4 patients had incomplete radiological follow-up and were excluded. 12 Patients underwent anterior procedures, 3 posterior and 2 combined. Radiological follow-up included analysis of post-operative and final follow up x-rays. Failures were defined as evidence of nonunion, failure of metal ware, persisting kyphosis greater than 11 degrees or change in translation greater than 4 mm. Complications noted were 2 superficial infections, 1 psuedarthrosis 1 aspiration pneumonia, 1 ileus. Results Overall 1 patient receiving anterior surgery developed a pseudarthrosis. This patient went on to develop fusion with posterior wiring and graft. Two patients developed wound infections following posterior wiring. All patients developed radiological fusion. Statistically there was no difference in radiological failure between anterior, posterior or combined anterior and posterior fusion. Discussion There is insufficient evidence to reject the null hypothesis, anterior plating is inferior to posterior wiring or combined anterior and posterior procedures, and neither can the alternative be accepted. Better biomechanical results have been reported for posterior instrumentations and some authors have reported high rates of radiological failure with anterior fixation. However the anterior approach is associated with fewer complications in the literature6. The complicated nature of the facet fracture and the accompanying ligament injuries require patients to be assessed on an individual basis and treated as such

Aim: To analyse clinical, radiological & survival results of Charite III Disc Replacement. Study Design: Ethical committee approved retrospective study. Methodology: 160 patients (Av. Age 46yrs; Std.Dev 8.06; 62 Males & 98 Females) who underwent disc replacement surgery through transperitoneal approach using a midline incision, between Jan1990 and Dec2000 were identified from hospital records. An independent observer administered Oswestry Disability Index, Pain Score by telephone at the time of review (Aug2003) and reviewed Clinical and radiographic features that were recorded in pre designed form. Results:Clinical: At an average follow up of 79 (range 31 to 161) months, mean improvement in ODI and pain score were 18.01(p< 0.001) and 1.69(p< 0.001) respectively. Radiological: Movement between the disc spaces, defined as greater than 4 degree on flexion-extension lateral view was preserved after surgery at L4L5 (4.01 degree) & L5S1(4.8 degree) level but not at L3L4( 1.5 degree) level. Average disc height was 19.7mm, and gross radiological loosening was observed after 04, Facet osteoarthritis after 65 and Heterotrophic ossification after 23 operations. Survival: Kaplan-Meier survival analysis showed mean survival time of 147(95% C.I. 140 to 154) months with cumulative survival of 55% at 156 months with implant removal as an endpoint. A mean survival time of 124(95% C.I. 116 to 133) months with cumulative survival of 35% was observed with all radiological failures as an endpoint. Complications: Commonest complication was post-operative incisional hernia seen in 17(10.6%) patients. Other complications were: post-operative ileus 4(2.5%), wound infection 9(5.6%) and retrograde ejaculation in 5(3.1%) patients. Conclusion: Charite III Disc Replacement results in a clinical significant (> 15, p< 0.001) improvement in ODI, it however does not result in clinical significant (> 2 points) improvement in back pain.Preservation of motion is of questionable clinical significance and it has low survival. Prospective studies are required to confirm the efficacy of this technique