Femoral nerve block is a reliable and effective method of providing anaesthesia and analgesia in the peri-operative period but there remains a small but serious risk of neurological complication. We aimed to determine incidence and outcome of neurological complications following femoral nerve block in patients who had major knee surgery. During the period January 2003 to August 2008, medical records of all patients undergoing knee surgery by Dr Myles Coolican and Dr David Parker, who had been administered femoral block for peri-operative analgesia, were evaluated. Patients with a neurological complication were invited take part in the study. A detailed physical examination including sensory responses, motor response and reflexes in both limbs was performed by an independent orthopaedic surgeon. Subjective outcome and pain specific questionnaires as well as clinical measurements were also collected. Out of 1393 patients administered with femoral nerve block anaesthesia during this period, 28 subjects (M:F= 5:23) were identified on the basis of persistent symptoms (more than three months) of femoral nerve dysfunction. All the patients had sensory dysfunction in the autonomous zone of femoral nerve sensory distribution. The incidence of neurological complications was 2.01%. One patient was deceased of unrelated causes and five patients declined to participate in the study. 14 patients out of the 22 have been examined so far. Nine cases had a one shot nerve block and five had continuous peripheral nerve block catheter. Areas of hypoesthesia/anaesthesia involving femoral nerve distribution occurred in 7 subjects and hyperaesthesia/paresthesia occurred in four. One subject had a combination of hypoesthesia and hyperesthesia in different areas of the femoral nerve distribution. Three subjects had bilateral symptoms following bilateral simultaneous nerve blocks. Dysesthesias in the affected dermatomes were found in seven cases and paresthesias were found in eight cases. Douleur Neuropathique en 4 questions (DN4) score of ï. 3. 4 was found in all the patients (average value: 5.55). The average scores for tingling, pins and needles and burning sensation (in a scale from 0 to 10) are 3.8, 3.1 and 2.9 respectively. The incidence of persistent neurological complication after femoral nerve block in our series is much higher compared to the reported incidence in the contemporary literature (Auroy Y. et al. Major complications of regional anesthesia in France: Anesthesiology 2002; 97:1274 80). The symptoms significantly influence the quality of life in the affected cases and question the value of the femoral nerve block in knee surgery

Evaluate the complications and outcomes of off-hours spinal metastasis surgery. Retrospective analysis of a prospective collected data. Preoperative, operative and post-operative data were collected as well as the complications and Frankel score at all time checkpoints. Off-hours surgery was defined as surgery starting between 17:00 and 8:00 the following day or surgery during the weekend. p < 0 .05 was defined as statistical significance threshold. 376 patients were included with an incidence of off-hours surgery of 32%. There was an increase of neurologic complication in the off hours group. This was associated with a higher ASA score and older population group. Oddly, there was decreased operative time with off-hours surgery with no difference in bleeding and number of fusion levels. Nonetheless, there was a higher percentage of neurologic improvement with off hours surgery compared to in-hours surgery. Finally, there were no effect on patients' survival in this patient population. To our knowledge, this is the first report of the effect of off-hours surgery on complications and outcomes of spinal metastasis. Greater neurological compromise and higher age and ASA scores were associated with higher incidence of off-hours surgery. It is associated with decreased surgical time with higher percentage of neurological improvement. Finally, there is no effect of surgical timing on survival rates

Minimally invasive placement of iliosacral screws (SI-screw) is becoming the standard surgical procedure for sacrum fractures. Computer navigation seems to increase screw accuracy and reduce intraoperative radiation compared to conventional radiographic placement. In 2012 an interdisciplinary hybrid operating theatre was installed at the University of Ulm. A floor-based robotic flat panel 3D c-arm (Artis zeego, Siemens, Germany) is linked to a navigation system (BrainLab Curve, BrainLab, Germany). With a single intraoperative 3D scan the whole pelvis can be visualised in CT-like quality. The aim of this study was to analyse the accuracy of SI-screws using this hybrid operating theater. 32 SI-screws (30 patients) were included in this study. Indications ranged from bone tumour resection with consecutive stabilisation to pelvic ring fractures. All screws were implanted using the hybrid operating theatre at the University of Ulm. We analysed the intraoperative 3D scan or postoperative computed tomography and classified the grade of perforation of the screws in the neural foramina and the grade of deviation of the screws to the cranial S1 endplate according to Smith et al. Grade 0 stands for no perforation and a deviation of less than 5 °. Grade 1 implies a perforation of less than 2 mm and a deviation of 5–10°, grade 2 a perforation of 2–4 mm and a deviation of 10–15° and grade 3 a perforation of more than 4 mm and a deviation of more than 15°. All patients were tested for intra- and postoperative neurologic complications and infections. The statistical analysis was executed using Microsoft Excel 2010. 32 SI-screws were implanted in the first 20 months after the hybrid operating theatre had been established in 2012. All 30 patients were included in this study (15 men, 15 women). The mean age was 59 years ±23 (13–95 years). 20 patients received a single screw in S1 (66.7%), 1 patient 2 unilateral screws in S1 and S2 (3.3%), one patient 2 bilateral screws in S1 (3.3%) and 8 patients a single screw stabilising both SI-joints (26.7%). 27 screws showed no perforation (84.4%), 1 screw a grade 1 perforation (3.1%) and 4 screws a grade 2 perforation (12.5%). There was no grade 3 perforation. Furthermore there was no perforation of the neural foramina or the ventral cortex in the axial plane of the SI-screws stabilising one SI-joint (24 screws). Only single SI-screws bridging both SI joints showed a perforation of the neural foramina (37% grade 0, 12.5% grade 1, 50% grade 2, 0% grade 3). In the frontal plane 23 screws (71.9%) showed a deviation of less than 5°. In 5 screws a grade 1 deviation (15.6%) and in 4 screws a grade 2 deviation (12.5%) could be found. There was no grade 3 deviation. There were no infections or neurological complications. The high image quality and large field of view in combination with an advanced navigation system is a great benefit for the surgeon. All SI-screws stabilising only one joint showed completely intraosseous placement. Single SI-screws bridging 2 SI-joints intentionally perforated the neural foramina ventrally in 5 cases because of dysmorphic sacral anatomy. This makes image-guided implantation of SI-screws in a hybrid operating theatre a very safe procedure

Bone localization of tuberculosis mainly affects the thoracolumbar spine. The cervical spine is rare. Its diagnosis is often late which exposes to great instability and potentially serious complications. We reported the case of a patient with cervical spine tuberculosis with a rare localisation. A 10-years old boy with no medical history, showed torticolis and high temperature without neurological complication. In the physical examination, he had torticolis and pain in the third, forth and fifth cervical vertebra. The biology showed high CRP 200mg/l. The tomodensitometry of the cervical spine showed a collection of the third cervical spine. The patient took non specific Antibiotics for two months with no radiological improvement. When biopsy was performed, we find an inter apophysis (between C3 and C4) collection. The histological examination confirmed the diagnosis of apophysis tuberculosis. The cervical spine is a rare localisation of the tuberculosis. The apophysis localisation is a more uncommon localisation. The diagnosis is difficult. The histological examination is essential for the diagnosis. The management based on tuberculosis chemotherapy and immobilization started as soon as possible

Hydatid disease of the bone and soft tissue of the musculoskeletal system is uncommon. The dissemination mode leads to local malignancy with severe prognosis. Tunisia is an endemic area of the disease. Therefore we treated many patients affected the disease. We retrosectivelly reviwed 6 cases of bone hydatid cyst from 1990 to 2010. There were 3 males and 3 females. The mean age was 13 years. The localisation were 03 spinal, 2 in the proximal tibia and & localisation in trochanter. The diagnosis were histoligical in all patient. the mean delay for the diagnosis was 3 years. One patient with spinal localisation had neurological complication paraplegia. All the patient had surgical excision of the hydatid cyst. Ther ewere 3 cases with local recurrence. Because of the poor results with medical treatment, osseous hydatidosis must be treated by a radical operation with wide excision, adapted to each localization. In the main, the prognosis of osseous hydatidosis remains poor, especially with spinal and pelvic localizations, which are the most frequent ones. The prognosis and treatment of osseous hydatidosis belong in the same category as a locally malignant lesion

Introduction. Legg-Calve-Perthes disease (LCPD), a juvenile osteonecrosis of the femoral head (ONFH), can remain sequelae around hip joint, and results in osteoarthritis necessitating total hip arthroplasty (THA) in middle-age. THA for sequelae of LCPD needs specific concerns for anatomical deformity, leg length discrepancy (LLD), and relatively young patient's age. To date, few studies are available for the results of THA for LCPD sequelae. Moreover, there was no study for the result of Alumina-Alumina THA (Al-Al THA) in patient with LCPD sequelae, even excellent long term outcome of Al-Al THA has been documented in relatively young patients. The aim of this retrospective study is to evaluate the clinical and radiological outcome of Al-Al THA for LCPD sequelae, especially in terms of the restoration of LLD and the occurrence of complication. In addition, we compared the results of THA for LCPD sequelae with those for adult onset ONFH, in which THA is necessitated in relatively young age and excellent long term outcome has been proven after Al-Al THA. Method. Between 1997 and 2007, 41 cementless Al-Al THA were performed in 37 patients with LCPD sequelae and followed up for mean, 10.4 years. Mean age at THA was 43.6 years. Using the propensity score matching with age, gender, and the length of follow-up as variables, 41 THAs in 37 patients were identified from 339 hips in 256 patients who underwent primary Al-Al THA for ONFH during the same period. Clinical and radiological outcomes in terms of implant survival, Harris hip score (HHS), LLD change, and perioperative complication were compared between the two groups. Results. In LCPD group, there was no revision during follow-up period. All stems and cups were survived without osteolysis or loosening at last follow-up. HHS increased significantly from 70.9±12.9 point to 97.4±5.4 point (p<0.001). LLD decreased significantly from 2.0±1.2 cm to 0.2±0.9 cm. (p<0.001). Fourteen intraoperative femoral cracks occurred. One patient showed peroneal nerve palsy after surgery. There was one patient with deep vein thrombosis without pulmonary embolism. In ONFH group, there was also no revision during follow-up and all implant was radiologically stable without evidence of osteolysis or loosening. HHS increased significantly from 44.9±21.4 point to 96.6±4.6 point (p<0.001). LLD decreased significantly from 0.5±0.8 cm to 0.1±0.9 cm. There were 6 intraoperative femoral fractures. Also, there was 2 more postoperative periprosthetic fractures after trauma and 1 postoperative dislocation. Even the implant survival was not different between two groups, LCPD group showed higher rate of overall complication (p=0.04) and intraoperative femoral fracture (p=0.027) than ONFH group. Conclusion. Outcomes of Al-Al THA in patients with sequelae of LCPD were comparable to those in patients with ONFH clinically and radiologically. LLD was restored after THA without troublesome neurologic complication in both groups. Although high rate of intraoperative femoral crack was revealed in LCPD group, fracture union was achieved in all hips without stem loosening. As with ONFH, Al-Al THA may be a reliable treatment option for the patients with LCPD sequelae

Purpose. To review the outcome of multilevel (≥4) instrumented lumbar fusion to sacrum / pelvis performed for degenerative conditions. Methods. Clinical data of 47 consecutive patients from 2002 to 2012 were reviewed retrospectively. Inclusion criteria included fusion from at least L2 to S1 / pelvis, i.e. minimum of 4 levels. Imaging was assessed for restoration of normal sagittal profile as well as subsequent fusion. EQ5D, OSD and VAS scores pre-op and at 6 months post op were analysed. Average age at surgery was 64 years (50–78). Thirteen cases were primary and 34 revisions. Indications were axial back pain either associated with sagittal imbalance (40%) or leg pain (36%) and leg pain alone in 10%. Results. The intra-operative blood loss averaged 2222 (250–7000) ml with 40% re-infusion from cell-saver. The average surgical duration was 268 minutes. Proximal extent of instrumentation was T2 (1), T3 (1), T4 (2), T8 (1), T9 (1), T10 (17), T11 (2), T12 (5), L1 (4) and L2 (13). TLIF's were done in 20 cases mostly at the base of the construct. Pedicle subtraction osteotomies were performed in 14 revision cases. Dural tears occurred in 14 cases, all revision cases except one. Wound infection occurred in 3 cases. Except for transient quadriceps weakness related to osteotomy, no neurological complications occurred. One patient deceased peri-operatively. Subsequent revision was required in 13 cases for instrumentation failure. OSD score improved by 15.3 points on average, which is clinically and statistically significant. Conclusion. Long lumbar fusions remain technically demanding with a high incidence of adverse events. This is due to the nature of revision surgery and high biomechanical demands on constructs. Surgical intervention can however be justified by the desperation of the cohort in terms of pain and poor function which can be modestly improved with this intervention. NO DISCLOSURES

Background. Lack of ankle dorsiflexion secondary to a tight gastrocnemius-soleus complex is believed to be a contributing factor in forefoot pain particularly metatarsalgia. It is believed that by lengthening the gastroc-soleus complex weight is distributed more evenly over the foot reducing symptoms. However lengthening any tendon, especially using a percutaneous method carries risks of over-lengthening. In the summer of 2008 we started to see some patients who complained of significant weakness in their Achilles tendons following the 3 cut percutaneous tenotomy procedure. Method. All patients who underwent a percutaneous tendo-achilles release performed between June 2007 and October 2008 were identified through the clinical coding department and theatre log books. Their clinical notes were reviewed until discharge. Patients who were diabetic or had a foot deformity secondary to neurological complications were excluded. Results. 40 percutaneous tendo-achilles releases were performed in 38 patients, with an average age of 51 (male:female ratio 5:33). 37 were performed in combination with forefoot procedure. 36 were mobilized full weight bearing in a heel weight bearing shoe post operatively, of which 8 developed symptomatic over lengthening of the Achilles tendon at a mean of 7 months (2-15) post-operatively. Of these 7 required surgical treatment in the form of Achilles shortening. Conclusion. We no longer perform percutaneous Achilles tendon lengthening in neurologically normal patients, due to our concern regarding the risk of over lengthening. We now prefer to perform an open gastrocnemius lengthening

Radiographic follow-up of traumatic spondylolisthesis of the axis is well documented in the literature. However, there is a paucity of studies regarding the long-term functional outcome of this type of injury. To study the population, treatment and outcome following traumatic spondylolisthesis of the axis, we reviewed 36 consecutive patients presenting to our institution, a tertiary referral spinal trauma centre, over a 6-year period. We assessed: (a) the mechanism of injury, (b) the mode of treatment, (c) the radiographic classification using the Levine and Edwards system and (d) functional outcome using the Cervical Spine Outcomes Questionnaire (CSOQ) by BenDebba. Of the 36 patients presenting there were 24 males and 12 females with a mean age of 46 (range18-82) years. The commonest mechanism of injury was road traffic accidents. There were 14 Type-I, 11 Type-II and 1 Type-IIA fractures. Twenty-seven patients were treated with halo vest immobilisation and nine were immobilised in a Minerva jacket. Four patients were converted from halo to Minerva because of pin failure. The mean duration of hospital stay was 10 (range 3-30) days. All fractures demonstrated radiographic union at a mean of 12 (range 10-16) weeks. There were no neurological complications. Upon review, all patients, whether Type-I or Type-II demonstrated low CSOQ scores approaching their pre-morbid status. However, Type-II fractures scored higher in 3 functional outcome categories when compared to Type-I fractures. This unique study of an uncommon fracture shows for the first time a difference in the functional outcome scores of Type-II fractures of the axis when compared to Type-I fractures at a mean follow-up of 3 years and 10 months

The aim of the study was to highlight the absence of an important pitfall in the Advanced Trauma Life Support protocol in application of rigid collar to patients with potentially unstable cervical spine injury. We present a case series of two patients with ankylosed cervical spines who developed neurological complications following application of rigid collar for cervical spine injuries as per the ATLS protocol. This has been followed up with a survey of A&E and T&O doctors who regularly apply cervical collars for suspected unstable cervical spine injuries. The survey was conducted telephonically using a standard questionnaire. 75 doctors completed the questionnaire. A&E doctors = 42, T&O = 33. Junior grade = 38, middle grade = 37. Trauma management frontline experience >1yr = 50, <1yr = 25. Of the 75 respondents 68/75 (90.6%) would follow the ATLS protocol in applying rigid collar in potentially unstable cervical spine injuries. 58/75 (77.3%) would clinically assess the patient prior to applying collar. Only 43/75 (57.3%) thought the patients relevant past medical history would influence collar application. Respondents were asked whether they were aware of any pitfalls to rigid collar application in suspected neck injuries. 34/75 (45.3%) stated that they were NOT aware of pitfalls. The lack of awareness was even higher 17/25 (68%) amongst doctors with less that 12 months frontline experience. When directly asked whether ankylosing spondylitis should be regarded as a pitfall then only 43/75 (57.3%) answered in the affirmative. We would like to emphasise the disastrous consequences of applying a rigid collar in patients with ankylosed cervical spine. The survey demonstrates the lack of awareness (∼ 50%) amongst A&E and T&O doctors regarding pitfalls to collar application. We recommend the ATLS manual highlight a pitfall for application of rigid collars in patients with ankylosed spines and suspected cervical spine injuries

Inserting screws into the vertebral pedicles is a challenging step in spinal fusion and scoliosis surgeries. Errors in placement can lead to neurological complications. The more experienced the surgeon, the better the accuracy of the screw placement. A physical training system would provide residents with the feel of performing pedicle cannulation before operating on a patient. The proposed system consists of realistic bone models mimicking the geometry and material properties of typical patients, coupled with a force feedback probe. The purpose of the present study was to determine the forces encountered during pedicle probing to aid in the development of this training system. We performed two separate investigations: [1] 15 participants (9 expert surgeons, 3 fellows and 3 residents) were asked to press a standard pedicle awl three times onto a mechanical scale, blinded to the force, demonstrating what force they would apply during safe pedicle cannulation and during unsafe cortical breach; [2] three experienced surgeons used a standard pedicle awl fitted with a one-degree of freedom load cell to probe selected thoracolumbar vertebrae of eight cadaveric specimens to measure the forces required during pedicle cannulation and deliberate breaching. A total of 42 pedicles were tested. Both studies had wide variations in the results, but were in general agreement. Cannulation (safe) forces averaged approximately 90 N (20 lb) whereas breach (unsafe) forces averaged approximately 135–155 N (30–35 lb). The lowest average forces in the cadaveric study were for pedicle cannulation, averaging 86 N (range, 23–125 N), significantly lower (p<0.001) than for anterior breach (135 N; range, 80–195 N); medial breach (149 N; range, 98–186 N) and lateral breach (157 N; range, 114–228 N). There were no significant differences between the breach forces (p>0.1). Cannulation forces were on average 59% of the breach forces (range, 19–84%) or conversely, breach forces were 70% higher than cannulation forces. To our knowledge, these axial force data are the first available for pedicle cannulation and breaching. A large range of forces was measured, as is experienced clinically. Additional testing is planned with a six-degree-of-freedom load cell to determine all of the forces and moments involved in cannulation and breaching, throughout the thoracolumbar spine. These results will inform the development of a realistic bone model as well as a breach prediction algorithm for a physical training system for spine surgery

INTRODUCTION. Isolated injuries of the sacral bone are rare. The pathomechanism of these injuries are usually high velocity accidents or falls from large heights. The computer-assisted implantation of iliosacral screws (SI-screw) becomes more important in the treatment of dorsal pelvic ring fractures. The advantage of the minimal-invasive screw placement is the reduction of the non-union and deep wound infection rate. Another advantage of computer-navigated SI-screw placement is the reduction of intraoperative radiation for the patient and the surgical staff. The purpose of this study was to analyse the position of navigated iliosacral screws. METHODS. In the study group 74 screws (49 patients) were included and radiologically analysed. All screws were implanted using 3D-navigation (BrainLAB Vector Vision, Brainlab, Germany). Navigation was always executed with the same 3D c-arm (ARCADIS Orbic 3D, Siemens, Germany) and navigation system. We determined the grade of perforation and angular deviation in the postoperative CT-scans in all screws. The classification was performed according to Smith et al in 4 grades. Grade 0 implies no perforation and grade 1 a perforation less than 2 mm. Grade 2 correlates a perforation of 2–4 mm and grade 3 a perforation of more than 4 mm. Furthermore the intra- and postoperative complications as well as the body-mass-index, the co-morbidities and the duration of radiation were documented. The statistical analysis was executed using Microsoft Excel 2003. RESULTS. The mean age of the 49 patients was 42.2 years ± 18 (16–79 years). 28 male and 21 female patients were included. 25 patients received a single iliosacral screw in S1. In 19 cases a screw in S1 and S2 was placed on the same side. Four patients got bilateral SI-screws in S1 and another patient received bilateral screw placement in S1 as well as an additional screw in S2. The mean operation time was 100 min ±103 (20–540 min). The isolated time for SI-placement was 50 min ± 20 (20–93 min). The mean radiation time was 3 min ± 1.7 (0.9–7.4 min) (n = 28). Altogether 84% of the screws showed an intraosseous position (grade 0). In the axial plane 7 screws perforated ventrally, 5 screws penetrated the adjacent neural foramen. In the frontal plane the screws showed greater variations, 61% deviated less than 5° (grade 0). In the study group 5 screws needed surgical revision because of either malplacement or postoperative pain. There were no infections or neurological complications. There was no statistical correlation between screw perforation and the body-mass-index. CONCLUSION. The computer-assisted implantation of iliosacral screws is a safe method in relation to screw perforation. It shows a high security and accuracy concerning the ventral and dorsal cortical perforation. There is a frequent angular deviation in the frontal view without appearance of screw perforation or mechanic, neurologic and angiologic complications. The minimal-invasive procedure shows a low postoperative revision rate

Background:. A large percentage of the patients who present for unilateral TKA have bilateral disease. Performing simultaneous, bilateral TKA has been debated and currently there is no consensus on the risks and benefit of this approach. In addition, specific selection criteria have not been defined to more accurately identify which patients are potentially appropriate candidates for this approach. Objectives:. The purpose of this study was to evaluate the clinical outcomes and peri-operative complications in simultaneous, bilateral TKA's using pre-operative patient selection criteria. Methods:. A retrospective analysis of 117 consecutive patients, (234 knees), was performed between February 2008 and March 2012 who underwent simultaneous, bilateral TKA performed by one surgeon under a single anesthetic. Pre-operative selection criteria were used for all patients to qualify for a simultaneous bilateral approach. This included the following: . 1). BMI less than 34,. 2). Minimum arc of motion to 100 degrees flexion,. 3). Flexion contracture less than 10 degrees,. 4). Varus or valgus alignment less than 10 degrees,. 5). No prior history of cardiovascular disease. 6). Age Less than 70 years old. Clinical outcomes were assessed including anesthesia type, tourniquet time, length of stay, transfusion rate, pre- op hemoglobin, post-op hemoglobin, pre-op range of motion, post-op range of motion, DVT and PE. Knee Society Score (KSS) and Functional KSS were assessed pre-operatively and 1 year post-operatively. Anatomic and mechanical axis evaluation was also performed on all patients with long standing radiographs pre and post operatively. A control group of 573 consecutive patients undergoing unilateral total knee arthroplasty during this same time period were identified and matched for the year of surgery, and prosthesis type. The same selection criteria were used for the control group and the same data points were evaluated. Results:. One hundred and seventeen consecutive patients, (234 knees), undergoing simultaneous, bilateral TKA were reviewed. There were no DVT's, or PE's. Nineteen percent required a transfusion for post-operative anemia. There were no cases of deep infection. Average pre-op KSS score was 49, with a post KSS score of 89 at an average follow-up of 1 year. Average pre-op Functional KSS score was 52, with an average post-op Functional KSS score of 91. Average ROM at one year post-op was 0 degrees of extension and 123 degrees of flexion. Average anatomic axis was 6 degrees valgus with a neutral mechanical axis restored in all patients. The clinical outcomes of the control group were comparable, with no statistically significant increase in the incidence of perioperative complications between the study group and the control group. Conclusion:. When the degenerative process involves both knees with comparable severity, the decision to perform total knee arthroplasty on one knee at a time with a staged approach, verses a simultaneous bilateral approach, has been challenging for many surgeons. There have been previous reports of increased perioperative complications associated with bilateral total knee arthroplasty, including increased risks of cardiovascular, neurological complications, as well as the increased demands on rehabilitation. Similarly, benefits of simultaneous bilateral total knee arthroplasty have also been identified such as, shortened rehabilitation, improved patient satisfaction, and decreased costs both to the patient and the hospital system. Using pre-operative patient selection criteria, the decision process in determining which patients are appropriate candidates for a bilateral approach can be facilitated, with clinical outcomes comparable to unilateral total knee arthroplasty

Aims

Despite the increase in the surgical repair of proximal hamstring tears, there exists a lack of consensus in the optimal timing for surgery. There is also disagreement on how partial tears managed surgically compare with complete tears repaired surgically. This study aims to compare the mid-term functional outcomes in, and operating time required for, complete and partial proximal hamstring avulsions, that are repaired both acutely and chronically.

Objective. Posterior vertebral column resection (PVCR) is indicated in the management of severe rigid spine deformities. It is a complex surgical procedure and is only performed in a few spine centres due to the technical expertise required and associated risk. The purpose of this study is to review the indications, surgical challenges and outcomes of patients undergoing PVCR. Methods. 12 patients with severe spinal deformities who underwent PVCR were retrospectively reviewed after a follow-up of 2 years. Surgery was performed with the aid of motor evoked spinal cord monitoring and cellsaver when available. The average surgical duration was 310 minutes (100–490). The average blood loss was 1491 ml (0–3500). The indication for PVCR was gross deformity and myelopathy which was due to congenital spinal deformities and one case of old tuberculosis. Clinical records and the radiographic parameters were reviewed. Results. Kyphosis of an average of 72 degrees was corrected to 28 degrees. The associated scoliosis was corrected from an average of 49.2 to 21.2 degrees. Ten patients improved neurologically to ASIA D and E. One patient deteriorated markedly, required revision with no initial improvement but reached ASIA E at 6 months after surgery. Four patients had associated syringomyelia. All were re-scanned at 1 year. The three with small syrinx's demonstrated no progression on MRI and the large syrinx resolved completely. In addition to the neurological deterioration, complications included 1 right lower lobe pneumonia. Conclusion. PVCR is an effective option to correct complex rigid kyphoscoliosis. In addition it allows excellent circumferential decompression of the cord and neurological recovery. When the congenital scoliosis is associated with syringomyelia with no other cause evident, it may allow resolution of the syrinx. Key words: Posterior vertebral column resection, severe spinal deformities, myelopathy, syringomyelia. NO DISCLOSURES

Over a two-year period, 265 Norwegian orthopaedic surgeons working at 71 institutions performed 63 484 operations under a tourniquet. Their replies to a questionnaire revealed that they mostly followed modern guidelines in their use of the tourniquet. Most felt that the tourniquet could be left on for two hours, and that it could be re-applied after 15 minutes. A total of 26 complications (one in 2442 operations) that might have been due to the tourniquet were reported, of which 15 were neurological. Three were in the upper limb (one in 6155 operations) and 12 in the lower limb (one in 3752 operations). Two were permanent (one in 31742 operations), but the remainder resolved within six months. One permanent and one transient complication occurred after tourniquet times of three hours. The incidence of tourniquet complications is still at least as high as that estimated in the 1970s.

Using a computer-based quality assurance program, we analysed peri-operative data on 160 patients undergoing one-stage bilateral hip or knee arthroplasties under regional anaesthesia with routine anaesthetic monitoring and only using peripheral intravenous access for peri-operative safety. We monitored defined intra-operative adverse events such as hypotension, myocardial ischaemia, arrhythmias, hypovolaemia, hypertension and early post-operative complications. We also determined post-operative hip and knee function, and patient satisfaction with different aspects of the anaesthetic management. Those patients undergoing one-stage bilateral arthroplasties were matched according to a cross-stratification which used three variables (American Society of Anesthesiologists’ physical status scoring system, age and joint replaced) to patients undergoing unilateral hip or knee arthroplasties. Serious intra-operative adverse events were, with the exception of intra-operative hypotension, very infrequent in patients undergoing bilateral (nine adverse events) as well as unilateral arthroplasties (five adverse events). Early post-operative complications were also infrequent in both groups. However, the risks of receiving a heterologous blood transfusion (odds ratio 2.5; 95% confidence interval (CI) 1.3 to 5.0, estimated by exact conditional logistic regression) or vasoactive drugs (odds ratio 3.9; 95% CI 2.0 to 7.8) were significantly greater for patients undergoing bilateral operations. Patient satisfaction with anaesthesia was high; all patients who underwent the one-stage bilateral operation would choose the same anaesthetic technique again.