Background: Although either anterior or posterior corrective scoliosis surgery has been reported in Jehovah’s Witnesses, we did not find any reports of single stage combined anterior and posterior scoliosis surgery being done in these patients. We report our experience in one such case.

Methods: This is a case report of a 14 year old female Jehovah’s Witness who had cerebral palsy with total body involvement presented with right sided thoracolumbar scoliosis. She was wheel chair bound and was being treated in a spinal brace. She had a partially correctible thoracolumbar curve from T5 to L2 measuring 94°, which reduced to 74° in brace. Her parents were counselled regarding scoliosis surgery. They consented for the surgery and also signed a special consent form for Jehovah’s witnesses specifying that they would prefer their child not to have transfusion of blood or blood products under any circumstances. They were explained that in case of excessive bleeding, further surgery may need to be deferred.

Results: Although her pre-op Haemoglobin was 14.3 g/dl, she was given oral ferrous sulphate because of low serum ferritin level (34 mcg/L). After induction of anaesthesia, intra operative hemodilution was performed using 900 ml of crystalloid. During surgery aprotinin infusion was used with controlled hypotension and cell salvage. Anterior release was performed followed by posterior instrumentation. The operation lasted for 8 hours. Central venous pressure and arterial oxygen saturation remained stable throughout the operation. She recovered well following surgery, with post-operative haemoglobin of 9.8 g/dl and was discharged on the7th post-operative day. Oral iron supplementation has been continued after surgery.

Conclusion: Due to religious reasons, Jehovah’s Witnesses do not accept transfusion of blood and blood products, which makes major surgery like scoliosis correction difficult as it involves a significant amount of blood loss. Such patients benefit from pre-operative iron supplementation, pre-operative haemodilution, intraoperative hemodilution, cell salvage, use of Factor 7, aprotinin and erythropoietin. These modalities have made it possible to perform major operations like scoliosis surgery in this group of patients.

Background: Campbell et al from Texas have pioneered the use of Vertical Expandable Prosthetic Titanium Rib (VEPTR) in congenital scoliosis. Our centre is the first in the UK to use it and we report our experience of 5 cases done in the past 2 years. VEPTR works on the principle of expansion thoracoplasty and thoracic spinal growth of upto 0.8 cms/year has been reported by the developers of this device.

Methods: This case series includes one child who had the index surgery in America and is undergoing sequential expansion in Cardiff. All surgeries were done using a standard technique with monitoring of somatosensory evoked potentials. After appropriate soft tissue and bony releases, VEPTR was inserted and expanded by 0.5 cms to maintain tissue tension. Subsequent expansions were done as day case surgeries at 4–6 month intervals through a small incision over the VEPTR. We assessed clinical and radiographic assessment, which included – hemithorax height ratio, Cobb angle, interpedicular line ratio, space available for the lung.

Results: There were 3 males and 2 females with mean age of 6.3 years (range 0.9 to 9 years) at the time of index operation. Average follow up is 2 years (0.4 to 5 years). Average hospital stay for the index surgery was 5 days (4–7 days). All patients had mean of 3 expansions (range: 0–6). Mean improvement in the Cobb angle was seen from 48° to 36° at last followup. Space available for lung improved from a mean of 72 % to 86 %. Mean improvement in hemithorax height ratio was from 72.5% to 86%. One child had mild pain due to prominent metalwork; 2 children had transient brachial plexus neurapraxia, one of whom had progression of a secondary cervical curve and is awaiting further surgery for the same.

Conclusion: Our early results show good improvement of clinical and radiographic parameters. Transient nerve palsies have been well reported on the concave side and occur due to traction on the nerves as a result of increased height of the thoracic cage. This occurred in one initial case and has not been seen later. These results are encouraging but do indicate a learning curve.

Background: Long waiting lists in the NHS are a cause for public concern especially with regards to progressive conditions like scoliosis. We reviewed records to 61 patients to ascertain whether waiting time had any detrimental influence on their surgical management.

Methods: Retrospective review. Assessment of clinical records and radiographs of 61 patients who had scoliosis surgery over past two years was done by two independent investigators. Patient demographics, waiting times between referral and outpatient review and waiting time for surgery were collected.

Results: There were 41 females and 20 males with mean age of 11.8 years (range, 1– 22 years). Thirty-four patients had thoracic curves (28- right sided), 21 had thoracolumbar curves (19- right sided) and 6 patients had right sided lumbar curves. Mean Cobb angle at presentation was 58° (range,17°–90°) which increased to 71°(range, 30°–120°) at surgery. Average waiting time to be seen in the clinic was 16 months. Average waiting time for surgery was 10 months. Rapid curve progression was seen in twelve patients (20%), of which 10 required more extensive surgery than originally planned. Their mean Cobb angle at presentation was 48° (range, 45°– 80°), which increased to a mean of 59° at surgery (range, 50°–92°). At presentation their Risser grades were: 5 – grade 0, 3- grade 2, 2- grade 4. These 10 patients had waited averagely 7.8 months to be seen in the clinic and for 11 months to have the surgery.

Conclusion: Significant curve progression occurred in 20 % of patients waiting to have scoliosis surgery. Ten of those required much more extensive surgery than originally planned. Long waiting times therefore have a detrimental effect on the surgical management of scoliosis patients.

Aim: To study the role of total elbow replacement in the management of distal humeral fractures in elderly patients.

Patients and methods: Between 1995 and 2003, 25 consecutive patients with fractures of the distal humerus were treated by primary total elbow replacement using the Coonrad-Morrey prosthesis. All surgeries were performed by one of the senior authors in two centers in South Wales. There were 18 females and 7 males and none of them had inflammatory or degenerative arthritis of the elbow. The mean age at the time of injury was 78 years (68–84). According to the AO classification, 16 patients had suffered a C3 injury, five type B3 and three type A3. One fracture was unclassified. The mean time to follow-up was 4 years (1–9 years).

Results: At follow-up 19 patients (76%) reported no pain, five (20%) had mild pain with activity and one had mild pain at rest. The mean flexion arc was 28 degrees to 105 degrees. The mean supination was 69 degrees (50–90) and pronation 70 degrees (50–80). No elbow was unstable. Mean Mayo elbow performance score was 71.5(25–100). Four patients (16%) developed ulnar neuropraxia following surgery that improved with time, 2 patients developed superficial wound infection (staphylococcus aureus), which was treated with antibiotics only. None of the above elbows required revision to date. Radiological evaluation revealed only one patient with a radio-lucent line at the cement -bone interface. It was between 1 and 2mm in length, was present on the initial postoperative radiograph and was non-progressive at the time of follow-up.

Conclusion: Primary total elbow arthroplasty is an acceptable option for the management of comminuted fractures of the distal humerus in elderly patients when the configuration of the fracture and the quality of the bone make reconstruction difficult.