Introduction

Long-term ankle pain, stiffness or swelling are frequent following ankle fracture. We investigated whether engineered compression stocking (ECS) influenced functional outcome and quality of life (QoL).

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.

Fat embolism occurs following fractures of a long bone or arthroplasty. We investigated whether paradoxical embolisation through a venous-to-arterial circulation shunt (v-a) could lead to cerebral embolisation during elective hip or knee arthroplasty.

Transcranial Doppler ultrasound (TCD), following the intravenous injection of microbubble contrast, identified the presence of a shunt in 41 patients undergoing hip (n=20) or knee (n=21) arthroplasty. Intra-operative cerebral embolism was detected during continuous TCD monitoring. Of the 41 patients, 34 had a v-a shunt of whom 18 had an embolism and embolism only occurred in patients with a shunt (p = 0.012). Spontaneous and larger shunts were associated with a greater number of emboli (r_s = 0.67 and r_s = 0.71 respectively, p < 0.01). Observations in two patients with large spontaneous shunts revealed 368 and 203 emboli and unexplained post-operative confusion and pancreatitis.

Paradoxical cerebral embolisation only occurred in patients with a shunt and may explain both postoperative confusion and fat embolism syndrome following surgery.