Aims. The aim of this study was to reassess the rate of neurological, psoas-related, and abdominal complications associated with L4-L5 lateral lumbar interbody fusion (LLIF) undertaken using a standardized preoperative assessment and surgical technique. Methods. This was a multicentre retrospective study involving consecutively enrolled patients who underwent L4-L5 LLIF by seven surgeons at seven institutions in three countries over a five-year period. The demographic details of the patients and the details of the surgery, reoperations and complications, including femoral and non-femoral neuropraxia, thigh pain, weakness of hip flexion, and abdominal complications, were analyzed. Neurological and psoas-related complications attributed to LLIF or posterior instrumentation and persistent symptoms were recorded at one year postoperatively. Results. A total of 517 patients were included in the study. Their mean age was 65.0 years (SD 10.3) and their mean BMI was 29.2 kg/m. 2. (SD 5.5). A mean of 1.2 levels (SD 0.6) were fused with LLIF, and a mean of 1.6 (SD 0.9) posterior levels were fused. Femoral neuropraxia occurred in six patients (1.2%), of which four (0.8%) were LLIF-related and two (0.4%) had persistent symptoms one year postoperatively. Non-femoral neuropraxia occurred in nine patients (1.8%), one (0.2%) was LLIF-related and five (1.0%) were persistent at one year. All LLIF-related neuropraxias resolved by one year. A total of 32 patients (6.2%) had thigh pain, 31 (6.0%) were LLIF-related and three (0.6%) were persistent at one year. Weakness of hip flexion occurred in 14 patients (2.7%), of which eight (1.6%) were LLIF-related and three (0.6%) were persistent at one year. No patients had bowel injury, three (0.6%) had an intraoperative vascular injury (not LLIF-related), and five (1.0%) had ileus. Reoperations occurred in five patients (1.0%) within 30 days, 37 (7.2%) within 90 days, and 41 (7.9%) within one year postoperatively. Conclusion. LLIF involving the L4-L5 disc level has a low rate of persistent neurological, psoas-related, and abdominal complications in patients with the appropriate indications and using a standardized surgical technique. Cite this article: Bone Joint J 2024;106-B(1):53–61

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

The February 2024 Spine Roundup³⁶⁰ looks at: Surgeon assessment of bone – any good?; Robotics reduces radiation exposure in some spinal surgery; Interbody fusion cage versus anterior lumbar interbody fusion with posterior instrumentation; Is robotic-assisted pedicle screw placement an answer to the learning curve?; Acute non-traumatic spinal subarachnoid haematomas: a report of five cases and a systematic review of the literature; Is L4-L5 lateral interbody fusion safe and effective?

The June 2023 Spine Roundup³⁶⁰ looks at: Characteristics and comparative study of thoracolumbar spine injury and dislocation fracture due to tertiary trauma; Sublingual sufentanil for postoperative pain management after lumbar spinal fusion surgery; Minimally invasive bipolar technique for adult neuromuscular scoliosis; Predictive factors for degenerative lumbar spinal stenosis; Lumbosacral transitional vertebrae and lumbar fusion surgery at level L4/5; Does recall of preoperative scores contaminate trial outcomes? A randomized controlled trial; Vancomycin in fibrin glue for prevention of SSI; Perioperative nutritional supplementation decreases wound healing complications following elective lumbar spine surgery: a randomized controlled trial.

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

Acute colonic pseudo-obstruction is a poorly recognised and potentially fatal complication of hip surgery. Between 1991 and 1994 six patients were observed who required laparotomy after failure of medical management. In three the indication was signs of peritonism, while in the other three exploration was required to exclude segmental ischaemia and to decompress the bowel. In all, there was no evidence of mechanical obstruction. Patients having total hip replacement are at risk of developing pseudo-obstruction due to their age, comorbidity, high doses of analgesics and the nature of the operation. If postoperative ileus persists for more than 48 hours acute colonic pseudo-obstruction should be suspected and confirmed by plain radiography. Prompt recognition and treatment with early referral to a colorectal unit are indicated. Laparotomy appears to carry less risk than that for patients with idiopathic pseudo-obstruction, but should be performed only if colonic ischaemia is suspected

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%)