Aims. Diabetic foot care is a significant burden on the NHS in England. We have conducted a nationwide survey to determine the current participation of orthopaedic surgeons in diabetic foot care in England. Methods. A questionnaire was sent to all 136 NHS trusts audited in the 2018 National Diabetic Foot Audit (NDFA). The questionnaire asked about the structure of diabetic foot care services. Results. Overall, 123 trusts responded, of which 117 admitted patients with diabetic foot disease and 113 had an orthopaedic foot and ankle surgeon. A total of 90 trusts (77%) stated that the admission involved medicine, with 53 (45%) of these admissions being exclusively under medicine, and 37 (32%) as joint admissions. Of the joint admissions, 16 (14%) were combined with vascular and 12(10%) with orthopaedic surgery. Admission is solely under vascular surgery in 12 trusts (10%) and orthopaedic surgery in 7 (6%). Diabetic foot abscesses were drained by orthopaedic surgeons in 61 trusts (52%) and vascular surgeons in 47 (40%). Conclusion. Orthopaedic surgeons make a significant contribution to both acute and elective diabetic foot care currently in the UK. This contribution is likely to increase with the movement of vascular surgery to a hub and spoke model, and measures should be put in place to increase the team based approach to the diabetic foot, for example with the introduction of a best practice tariff. Cite this article: Bone Jt Open 2022;3(8):618–622

Aims. Our objective was describing an algorithm to identify and prevent vascular injury in patients with intrapelvic components. Methods. Patients were defined as at risk to vascular injuries when components or cement migrated 5 mm or more beyond the ilioischial line in any of the pelvic incidences (anteroposterior and Judet view). In those patients, a serial investigation was initiated by a CT angiography, followed by a vascular surgeon evaluation. The investigation proceeded if necessary. The main goal was to assure a safe tissue plane between the hardware and the vessels. Results. In ten at-risk patients undergoing revision hip arthroplasty and submitted to our algorithm, six were recognized as being high risk to vascular injury during surgery. In those six high-risk patients, a preventive preoperative stent was implanted before the orthopaedic procedure. Four patients needed a second reinforcing stent to protect and to maintain the vessel anatomy deformed by the intrapelvic implants. Conclusion. The evaluation algorithm was useful to avoid blood vessels injury during revision total hip arthroplasty in high-risk patients. Cite this article: Bone Jt Open 2022;3(11):859–866

Introduction. Critical limb ischemia (CLI) is the reduced blood flow in the arteries of the lower extremities. It is a serious form of peripheral arterial disease, or PAD. If left untreated the complications of CLI will result in amputation of affected limb. The treatment experience of diabetic foot with transverse tibial transport was carried out by Ilizarov technique. Madura foot ulcer is not a common condition. It disturbs the daily activities of the patient. Pain swelling with multiple nodules with discharging sinus with discoloration(blackening) of the affected area is the main problem. Materials and Methods. We treated total case: 36 from Jan. 2003 – Jan. 2020 (17yrs.). Among these-. TAO- 20. Limb Ishchemia- 5. Diabetic Foot- 9. Mycetoma pedis- 2. Infected sole and dorsum of the foot- 5. Results. Transverse corticotomy and wire technique followed by distraction increases blood circulation of the lower limbs, relieving the pain. The cases reported here were posted for amputation by the vascular surgeons, who did not have any other option for treatment. Hence we, re-affirm that Academician Prof. Ilizarov's method of treatment does help some patients suffering from these diseases. Conclusions. By Ilizarov compression distraction device for TAO, modura foot ulcer, diabetic foot ulcer, mycetoma pedis ulcer, infected sole and dorsum of the foot ulcer were treated by introducing K/wires through the bones with proper vertical corticotomy. Application of this noble device will bring angeogenesis within the reach of all deserving patients

Thoracic Outlet Syndrome (TOS) is a complex of symptoms representing neurovascular compression in the supraclavicular area and shoulder girdle. Arterial thoracic outlet syndrome represents only 1% of all TOS's. We present two cases of arterial TOS's following internal fixation of clavicular fractures. Two cases of clavicular fractures managed with internal fixation and subsequently diagnosed with symptomatic, position dependent arterial occlusion are presented. The first case of a 16-year-old male treated with an intramedullary compression screw. He developed symptoms and was diagnosed with TOS using dynamic duplex examination performed by a vascular surgeon. Revision surgery was planned to decompress the subclavian artery from the hypertrophic callus at the fracture site. Before this could be performed the patient re-fractured his clavicle and bent the intramedullary screw. This resulted in resolution of the TOS symptoms. Following this second injury the patient went on to unite the fracture. The second case was of a 48-year-old male. He was initially treated non- operatively until the patient reported sensory and motor disturbances involving the hand and forearm. Excess callus was excised and the fracture was fixed using a locking plate. The symptoms improved, but worsened again eight weeks post operatively. Angiogram revealed vascular occlusion on arm abduction. Repeat surgery was performed in conjunction with a vascular surgeon. The plate was removed, vascular structures were released from fibrous tissue in the region of the fracture, and the posterior edge of the clavicle was debrided with a burr to reduce future impingement on vascular structures. Post operatively the TOS symptoms did not recur. Arterial thoracic outlet syndrome is an uncommon complication of trauma involving the clavicle. It can present in the presence or absence of surgical intervention, but can require surgical intervention to resolve

Introduction: Injury to the distal third of the axillary artery is well recognised as a complication of proximal humeral fractures. However the risk of iatrogenic injury at shoulder surgery has not, to date, been fully appreciated. Patients: Four female patients aged 59 and over who suffered iatrogenic injury to the axillary artery at the time of shoulder surgery are reported. Two occurred during surgery for planned elective shoulder arthroplasty, while two occurred while treating elderly patients who had previously sustained a 3 part proximal humeral fracture. In all 4 cases the injury probably started as an avulsion of the anterior or posterior humeral circumflex vessels. Results: Vascular surgeons were called in urgently to help with the management of all 4 cases. In two cases the axillary artery was found to have extensive atheroma, was frail and, after initial attempts at end-to-end repair, it became clear that a reversed vein graft was required. Three patients had a satisfactory outcome after reconstruction, while one patient who had previously had local radiotherapy for malignancy, but was now disease free, developed a completely ischaemic upper limb and required a forequarter amputation to save her life. Message: The axillary artery can be very frail in the elderly, is often diseased with atheroma, and is vulnerable to iatrogenic injury at surgery. If injury occurs at surgery, small bulldog clamps should be applied to the cut ends and a vascular surgeon should be called immediately. A temporary arterial shunt should be considered urgently to provide an early return of vascularisation to the limb and to prevent serious complications. The axillary artery is very difficult to repair, and, in our experience may require a vein graft. In addition, distal clearance of the main brachial artery with a Fogarty catheter which is an essential part of the management

Introduction: Spinal stenosis may present as intermittent claudication and may be indistinguishable from vascular claudication as both could co exist. These patients often required expertise from both the speciality. Combined Vascular and spinal clinic after primary screening with the help of MRI scan may reduce the waiting time to the appropriate speciality. Aim: We prospectively reviewed all the patients referred to senior author from vascular unit to assess the final outcome and evaluate whether primary to referral to vascular surgeon was unnecessary. Study Design: Prospective study from November 2004 to May 2005. Methodology: Review of Hospital case notes – 23 patients were referred to us from one of the vascular surgeons’ unit after excluding vascular etiology as the cause of the leg pain and MRI confirmation of spinal stenosis. Result: Mean waiting time to see the spine consultant 103 days [20–195] from the date of referral by the vascular team. The waiting time to primary referral to vascular team was 164 days [43–194]. 43.5% of the referred patients required to have spinal decompression. Conclusion: To improve the waiting time primary physician should have access of MRI scan to delineate the pathology and combined vascular and spinal clinic may achieve waiting time target

It is the prime responsibility of the treating surgeon to identify and treat the vascular injury along with the skeletal trauma. Limbs with combined Orthopaedic and Vascular injuries are traditionally admitted as an Orthopaedic emergency. In a 17 year period we treated 67 cases of vascular injuries (including 16 pseudo aneurysms) associated with fractures and dislocations or soft tissue injuries of the limbs. Three cases have been followed up for over 20 years. All patients were operated by Orthopaedic residents on duty with limited resources, without the help of vascular surgeons. We relied on clinical diagnosis and immediate exploration of the blood vessels rather than time consuming procedure of arteriography. Skeletal stabilisation was achieved by internal or external fixation. Vascular reconstruction involved end to end repair or vein grafting. Fasciotomy was performed in selected cases where the injury-revascularisation time was more than 6 hours. Post-operative care involved limb placement at body level, Sympathetic blockade for 48 hours, vasodilators, Lomodex, Mannitol, Aspirin and antibiotic therapy. Urine was monitored for smoky color indicating myoglobinuria. Though only 17 were repaired within six hours, limb viability with good function was obtained in 51 cases. Complications included 7 deaths, 6 amputations, 2 acute renal failures and delayed occlusion in one case

Giant synovial cyst is commonly seen in association with rheumatoid arthritis. The Baker’s cyst around the knee is the commonest example but it has also been described at the elbow and hip. The possibility of a synovial cyst around the hip is unfamiliar to most clinicians including those who regularly deal with inguinal swellings and those specialising in musculoskeletal conditions. This is often overlooked as a cause of symptoms in inguinal area and lower limb. We present a report on two patients in whom abnormal pulsatile masses in the groin caused diagnostic difficulty. Patients were initially admitted under vascular surgeons with a clinical diagnosis of aneurysm. Ultrasound examination was useful in excluding aneurysm. Detailed clinical examination revealed painful restricted hip movements and an X–ray showed evidence of arthritis in hip joint. CT Scan confirmed it to be a synovial cyst. Computed Arthrotomogram or Arthrography showed communication of the cyst with hip joint. Synovial cysts and iliopsoas bursa enlargement may be more common than previously reported. They may present as a pulsatile mass due to close proximity to femoral vessels and should be considered as a differential diagnosis in patients with unusual inguinal swelling

Background: Vascular injuries associated with total joint arthroplasty are the most feared complication. The arterial and venous injury can occur due to direct or indirect trauma. A high index of suspicion, recognition of the injury and prompt treatment, with the immediate availability of a vascular surgeon is vital for good outcome. Methods: Using prospectively collected data on 13624 patients undergoing total joint arthroplasty at our institution, all incidences of vascular injury were identified. Detailed data regarding the mode of presentation, the type and the outcome of intervention delivered, and the eventual functional outcome of the total joint arthroplasty were determined. Results: There were a total of 17 vascular injuries (0.1%). Majority (16/17) of these vascular injuries were detected in the postoperative recovery area. 9 injuries occurred after TKA and 8 occurred after THA. Indirect injury was the mechanism in TKA patients with popliteal artery thrombosis being the mechanism. In contrast direct injury was the mechanism in THA patients. Fasciotomy was performed in all TKA patients and none were needed in the THA patients. One patient died of complications related to vascular injury. 12 of 17 patients (70%) had launched a legal suit against the operating surgeon. Conclusions: After more than 80 years of accumulated experience and more than 35000 joint replacements performed by 5 surgeons in our center, the vascular complication still continues to occur. Patient awareness regarding this real problem may play a role in defraying the extremely high likelihood of legal suits associated with this complication

Study Design: Case report of four consecutive case reports of revision surgery for anterior dislocation of the Acroflex disc (DePuy Acromed, MA, USA) all of whom required vascular surgery are described. Objective: To describe vascular complications of explanting an artificial inter-vertebral disc replacement following spontaneous anterior displacement. Subjects: Four consecutive patients required explantation of the Acroflex disc. Two patients were male and two female with median age 44 years (range 33–51). All patients gave informed consent to enter a clinical trial, which had ethical approval. Outcome measures: Symptom relief, vascular injury and deep vein thrombosis. Results: All patients gained good symptomatic relief following disc replacement. Four patients suffered anterior displacement of the disc with a deterioration in symptoms during the 1. st. year. Three suffered vascular damage to the iliac vessels. In two cases division and re-anastomosis of the iliac vein was required to allow disc removal. Ilio-femoral deep vein thrombosis occurred pre-operatively in one patient and post-operatively in a second, no deaths occurred. Conclusions: Anterior intervertebral disc displacement is associated with vascular injury. Preventing anterior disc displacement must form an essential part of disc design with (i) rapid fixation to bone and (ii) a failsafe design to prevent local damage in case of failure. In the case of displacement, disc removal should be planned and performed with a vascular surgeon

This is a prospective review of the results of our first 20 Prodisk disc replacements. The prosthesis is designed to maintain lumbar motion and, in theory, to avoid adjacent disc overload. Nine men and 11 women scheduled for fusion were given the option of arthroplasty. The advantages and disadvantages were explained, as well as the ‘experimental’ nature of the product. Six (30%) of the 20 were Workmen’s Compensation patients. Permission to use patient data was obtained. The mean follow-up was 18 months. All patients completed a back pain questionnaire at initial and last follow-up. Preoperative and postoperative visual analogue scores (VAS) were recorded. The length of time to return to work was documented. All patients presented with severe low back pain and 12 had radiculopathy. All had positive discograms. The senior author performed the operations after appropriate training, and a vascular surgeon assisted with the exposure. All cases were single level replacements, one at L3/L4, six at L4/L5 and 13 at L5/S1. The mean preoperative VAS score was 8.6. Postoperatively it was 2.6. Mean anaesthesia time was 100 minutes (55 to 120). In patients other than pensioners, the time to return to work averaged 8 weeks. A special forces policeman and a military helicopter pilot both returned to their pre-injury levels of activity and another patient returned to first league basketball. No serious intraoperative complications occurred. One patient developed DVT in spite of prophylactic Enoxiparine. One ‘upper plate’ dislodged slightly at 20 months. The reason is unclear but the patient remains asymptomatic. In selected patients, a Prodisk disc replacement is an excellent alternative to fusion, but it is imperative that the guidelines for indications are carefully followed

PURPOSE OF THE STUDY. The anterior approach to the thoracic and lumbar spine is used with increasing frequency for various indications. With the advent of prosthetic intervertebral disc replacement, its use has become even more frequent and has often been associated with serious complications. The aim of this study was to evaluate vascular complications in patients who underwent anterior spinal surgery of the thoracic and lumbar spine. MATERIAL. We performed a total of 531 operations of the thoracolumbar spine from the anterior approach. In 12 cases, after exposure of the body of the first or second thoracic vertebrae, we employed the Smith-Robinson technique to expose the cervical spine. We used sternotomy in six, posterolateral thoracotomy in 209, pararectal retroperitoneal approach in 239, anterolateral lumbotomy in 58 and the transperitoneal approach in seven patients. The aim of surgery was somatectomy in 190 patients and discectomy in 341 patients. Sternotomy and transperitoneal approaches were carried out by a thoracic or vascular surgeon and all the other procedures were done by the first author. The indications for spinal surgery included an accident in 171, tumour in 56, spondylodiscitis in 43 and a degenerative disease in 261 patients. METHODS. The Smith-Robinson approach was used for exposure of T1 or T2. Sternotomy was indicated for treatment of T2–T4 and also T1 in the patients with a short, thick neck. Access to T3–L1 was gained by posterolateral thoracotomy, in most cases performed as a minimally invasive transpleural procedure. For access to the lumbar spine we usually used the retroperitoneal approach from a pararectal incision or lumbotomy. We preferred the pararectal retroperitoneal approach in L2–S1 degenerative disease, L5 fractures, and L5–S1 spondylodiscitis. We carried out lumbotomy in patients with trauma, tumors and L1–L4 spondylodiscitis. The transperitoneal approach from lower middle laparotomy was used only in tumors at L5 or L4. The patients were followed up for 2 to 96 months (average, 31.4 months) after anterior spinal surgery. RESULTS. In 12 patients treated by the Smith-Robinson procedure and in six patients undergoing sternotomy, neither early nor late signs of any injury to major blood vessels or internal organs were recorded. The 209 patients with posterolateral thoracotomy were also free from any signs of vascular injury, but trauma to the thoracic duet was recorded in one case. We found injury to major blood vessels in three patients in the group treated by the pararectal retroperitoneal procedure. In the total of 531 anterior spinal surgery procedures this accounts for 0.56 %; of the 304 lumbar operations and 239 pararectal retroperitoneal operations it is 0.99 % and 1.26 %, respectively. In one patient the vascular injury was associated with trauma to the ureter. CONCLUSIONS. The technique of anterior approach is safe only in the hands of experienced spinal surgeons with long experience. In institutions where anterior spinal surgery is not a routine method it is advisable to involve a vascular or cardiac surgeon. However, the most important point is to know when not to operate

Introduction The aim of the study was to investigate the incidence, in Australia, of popliteal artery injury during knee surgery; to assess the distance from the popliteal artery to the posterior tibia in flexion and extension; and to investigate the influence of major trauma or surgery on the anatomy. Methods A questionnaire was sent to Australian members of the ANZ Society of Vascular Surgeons. Duplex ultrasound studies were obtained through the Vascular Laboratory University of Melbourne. Studies in extension and 90° of flexion assessed the distance from the popliteal artery to the posterior tibia. Twelve persons with normal knees were assessed bilaterally. Eight patients with a posterior cruciate ligament deficient knee were assessed bilaterally. Seventy vascular surgeons responded documenting 115 popliteal artery injuries occurring during knee surgery. There were 69 lacerations, 27 thromboses, 13 AV fistula and 19 false aneurysms. In 12 normal people (24 knees) the popliteal artery was 5.5 mm (2.9 to 9.9) from the tibia in extension and 5.7 mm (2.9 to 10.0) in 90° of flexion. In ten of 24 knees the artery moved closer in flexion. In the eight posterior cruciate ligament deficient knees the artery was 4.7 mm (2.7 to 6.9) from the tibia in extension and 3.8 mm (2.6 to 4.5) at 90° of flexion. In all eight PCL knees the artery moved closer in flexion. In normal knees the popliteal artery may move closer to the tibia in flexion, the average distance being about 5.5 mm. Conclusions The popliteal artery is closer to the knee joint following trauma or surgery and specifically closer in flex-ion than in extension. Risks of injury are significant

Aims: Only gangrene of the entire foot and life-threatening sepsis with severe infection require a high amputation. Method: Between 1984 and 1999, 188 amputations in the area of the lower extremity were carried out at Bad Düben specialist hospital for orthopaedics. In 31 cases, partial amputation (so-called amputation of border zones) was required in the area of the foot owing to diabetic foot syndrome. The medical records were analysed and the patients who were still living underwent a follow-up examination; 8 patients had died. Results: Of the 31 patients, 20 were men and 11 were women. From 1982 to 1987 there were 4 partial amputations of the foot, from 1988 to 1993 there were 12 and from 1994 to 1999 there were 11. The average age was 69.1 years. In 11 cases, amputation of the lower leg as a subsequent operation was necessary. Here the average age was 71,8 years. It was noted that from 1994 to 2001 subsequent amputation of the lower leg had only been required twice (eight times from 1984 to 1993). The patients who underwent a follow-up examination were satisfied after partial amputation of the foot. Conclusions: For diabetic feet with neuropathy and infection, partial amputation of the foot can be regarded as the treatment of choice. Prompt referral to hospital is necessary to ensure optimum glucose adjustment and any treatment required for accompanying diseases. With interdisciplinary management between the physician, vascular surgeon and orthopaedist, and with treatment in a team with the orthopaedic shoemaker, in addition to surgical measures, we the necessary local can prevent gangrene of the entire foot and life-threatening sepsis from leading to a high amputation

Many surgical approaches at decompression have been attempted for the thoracic outlet syndrome (TOS), but only the transaxillary and supraclavicular routes carry the best outcomes. More recently, a selective and tailored approach via the supraclavicular route has been favoured. We performed a retrospective review between 1978 and 1998, and report the outcome of the ‘’two surgeon approach’’ for TOS via the supraclavicular method. An orthopaedic and vascular surgeon jointly conducted 30 operations for disabling symptoms relating to TOS in 27 patients (21F, 6M), mean age of 29 yrs (range 18–63 yrs), having performed the preoperative assessment in conjunction with a neurologist. In all cases, it was essential that patient selection for surgery was determined on clinical grounds rather than the presence of a cervical rib. Anterior scalenectomy was performed via the supraclavicular route except in one case where the infraclavicular route was utilised. Additional surgical procedures were carried out according to the underlying abnormalities, i.e. excision of cervical rib or band or medial scalenectomy. The first rib was always spared. At mean follow-up of 37 mths (range 3-228 mths), 26/30 sides (87%) had excellent or good results. The results were fair or poor in three cases where scalenec-tomy alone was performed. There were no major complications and no patients required a re-operation. 24 patients (89%) returned to their previous lifestyle or occupation. Our results suggest that, with a multidisciplinary assessment and two-surgeon team, good to excellent surgical outcomes can be achieved via the supraclavicular route without resection of the first rib. Instead of the current practise of routine transaxillary first rib resection, we recommend decompression via this approach with further procedures tailored to the abnormality identified

Between 1990 and 2000, 15 patients with open 3C fractures of the lower extremity were treated at our institution. Demographic data such as age, sex, associated injuries and co-morbidities were recorded. The mechanism of injury, ISS [Injury Severity Score] and MESS [Mangled Extremity Severity Score] were ascertained. The minimum follow up was 2 years. All the fractures were classified according to the AO system. The patients received a combined treatment by the orthopaedic and plastic surgeons and when necessary by the vascular surgeons. Treatment options, were based on the extent of soft-tissue damage and the configuration of the fracture. Intra-operative details including arteries and nerves involved, type of flap cover, quality of fixation and need for fasciotomy were recorded and analysed. A final follow up was carried out at a special clinic and the outcome was analyzed using SF-36 and EUROCOL. MESS and ISS were analyzed for possible predictors of final functional outcome. The patients were predominantly males. The main mechanism of injury was due to a road traffic accident and 6 of the patients had associated injuries in other parts of the body. In two thirds of the patients the fracture site was in the tibia, and in 3 cases there was a combined fracture in femur and tibia. The posterior tibial artery was involved in the vast majority of the cases, which was either disrupted or avulsed. The Salvage and reconstruction was carried out in 13 patients, which accounted for 77% of the cases and 2 patients underwent immediate amputation. Both had a Mangled Extremity Severity Score of 10. The bone fixation was mainly achieved by plating, or nailing. Half of the patients underwent fasciotomy, in the rest the compartments were decompressed due to the nature and extent of the injury. All the patients required secondary procedures, the mean total number of operations was 2.6. Although only one-fifth of the patients had some problems with self care, half experienced some problems with mobility. Anxiety and depression was a problem in two thirds of the patients, and about the same proportion of patients experienced moderate to severe pain. The mobility was correlated to the MESS score. Conclusion: the functional outcome was most closely related to the severity of injury and the injury-surgery interval. Our study showed that improved functional outcome is possible following surgical treatment of these challenging injuries especially when prompt response is instituted by combined ortho/plastic/vascular surgical teams

Introduction Based on 27 years of peripheral vascular surgery practice and 21 years of experience in performing anterior lumbar spine approaches the author will make recommendations for management of the more common complications of the approach to the lumbar spine. Methods A database of 2020 cases performed since August of 1997 has been evaluated to determine the best way to manage the complications of the approach encountered in that time period. Results 6 patients had left iliac artery thrombosis (0.29%) and 24 had major vein lacerations (1.1%). Two patients developed compartment syndrome and two other patients required arterial reconstruction. One of the patients had ureteral injury. None of the patients had retrograde ejaculation, lymphoedema, bowel injury or neurological injury. Left iliac artery thrombosis is best managed by immediate thrombectomy using balloon catheters, either via the main incision of via a left femoral incision. The diagnosis is clinical and the patient should not be taken to the radiology department for diagnostic angiography. Avoidance of delay is important in preventing compartment syndrome. If ischemia is present for 4 hours or more a prophylactic fasciotomy may be indicated. For patients with intimal disruption or atherosclerosis, in whom thrombectomy fails, arterial reconstruction or stenting may be necessary and is best left to a vascular surgeon. Venous lacerations can be repaired using 5-0 monofilament sutures. Lacerations of 5mm or less that are not easily accessible can be treated with hemostatic agents and pressure. For major disruptions of the iliac veins or inferior vena cava ligation of these vessels is an acceptable option. Proximal and distal control of vessels during exposure is not necessary and may actually lead to a higher incidence of arterial thrombosis. Control of bleeding can usually be obtained by pressure with sponge sticks or balloon catheters. The sympathetic fibres run with the peritoneum and retrograde ejaculation can be avoided by carefully elevating the peritoneum away from the promontory with blunt dissection while exposing L5-S1. The ureter similarly runs with the peritoneum and should be lifted away with it to prevent devascularization. Lymphedema is due to the disruption of the lymphatics while mobilising the iliac vessels. It is very rare and unavoidable. Injury to the genito-femoral nerve is avoided by identifying it over the psoas muscle and preserving it from injury. Bowel injury is prevented by staying retroperitoneal. Discussion Anterior exposure to the lumbar spine carries with it a low complication rate, but these complications can have significant negative results. Prompt recognition and management of these complications will result in lower overall morbidity

Purpose: En bloc resection can be proposed for lung cancer involving the apex with invasion of the ribs or the transverse process using a transcervical anterior approach. Cancers invading the intervertebral foramen cannot be resected via this approach despite the classical indication for surgical resection. We report results of a novel surgical technique allowing cancerological resection of these tumours. Material and methods: Fifteen patients with the same grade of cancer were operated using the same surgical technique. The first operative time included: superior lobectomy via anterior cervicothoracic access (without removal of the lobe), dissection of the subclavian vessels and the brachial plexus, section of the ribs and the T1 root, spinal exposure from C6 to T5, hemi-disectomy C7-T1 and discectomy at the level below the invaded foramen, medial vertebral groove, closure. The second operative time included: posterior access, extended instrumentation of the spine, hemi-laminectomy C7 extended as needed, section of the roots (depending on the level of the resection) within the canal, oblique posterior vertebral osteotomy along the medial border of the pedicle terminating in the anterior groove. Finally en bloc ablation via the posterior access of the surgical piece including the lung, the ribs and the hemi-vertebrae. Results: Three- and four-level hemivertebrectomy was performed in eleven and three patients respectively. One patient had two hemivertebrectomies associated with one vertebrectomy. There were six resections (with repair) of the subclavian vessels for tumour invasion. Peroperative mortality was zero. Mean blood loss was 3000 ml. There were no neurological complications. There were eight postoperative complications: pneumonia five patients, cerebrospinal fluid fistula one patient, skin dehiscence one patient, haemorrhage one patient requiring reoperation. All patients were given postoperative radiotherapy. Three- and five-year survival was 36% and 27% respectively. Among the nine deaths, three had local relapse and six had general relapse. Discussion: This techniques enables resection of tumours considered to be inextirpable using other techniques. Survival was the same as for tumours of the apex without invasion of the foramen and better than without surgery. This major surgery requires a well-trained multidisciplinary team (thoracic and vascular surgeons, spinal surgeon, anaesthesiologists, intensive care specialists). Contraindications for this type of surgery are invasion of the spinal canal, the brachial plexus and the vertebral body as well as the presence of a spinal artery entering the foramen to be resected