As part of a prospective RSA study into a new design of short-stem, trabecular metal, Co-Cr femoral components with modular necks and metal on polyethylene articulation, three patients presented with almost identical symptoms of pain and a large avascular mass within the operated hip. All three cases came to exploration and similar findings of a solid pseudotumour within the hip joint were found in all thee cases. Infection was not present. All cases were submitted to histology and reviewed by a pathologist with specific interest in tissue reactions to foreign materials. All three cases showed histological features classical of published descriptions of ALVAL (Aseptic Lymphocyte-dominated Vasculitis Associated Lesion). A consistent finding was fretting corrosion of the neck-stem junction. These cases demonstrate that Co and Cr ions can provoke adverse tissue reactions even in the absence of metal/metal articulations. This has design implications for all modular Co-Cr necks. The stem used in this study has been voluntarily withdrawn from the Australian market but is still being implanted in Europe. We make recommendations that modular trunnion-style Co-Cr necks not be used and alternative materials and design solutions be sought.

Introduction

Lisfranc joint injuries account for only 0.2% of all fractures but early diagnosis improves the chances of a better outcom]. Radiographic signs, such as diastasis (>2mm) of the 1–2 interspace, are subtle and. often missed, leading to a poorer outcome. We present a new radiographic sign, less likely to result in missed diagnoses. Null nypothesis: The intermetarsal angle remains unchanged in Lisfranc injuries.

Introduction

To report the short to medium term results of acetabular reconstruction using reinforcement/reconstruction ring, morcellised femoral head allograft and cemented metal on metal cup.

Introduction

The aim of this study is to report the results of Revision hip arthroplasty using large diameter, metal on metal bearing implants- minimum 2 year follow up.

Aim

To analyse the results of the use of Recombinant Bone Morphogenic Protein (BMP-7) for treatment of fracture nonunions at our institution.

Purpose: To assess the infection rate following Lower Limb Arthroplasty using single dose gentamicin antibiotic prophylaxis compared to a traditional three doses of cephalosporin.

Method: All patients undergoing Total Hip and Knee replacements over six months (October 2007 to March 2008) at three participating hospitals were prospectively followed to assess perioperative infection rates using Surgical Site Surveillance(SSI) criteria. All patients received single dose antibiotic prophylaxis using intravenous Gentamicin 4.5mg/kg. This was compared with previous data collected over a 6 month period (Jan to Mar 2007 and Oct to Dec 2005) from the same hospitals using 3 doses of Cefuroxime 750mg. Return to theatre data was collected independently after introduction of gentamicin to compare with previous data. The change in creatinine level postoperatively was also measured in a selected group of patients.

Results: Four hundred and eight patients underwent Total Hip Replacements (THR) and 458 patients Total Knee Replacements (TKR) during the study period. This was compared with 414 and 421 patients who underwent THRs and TKRs respectively during a previous six month period. SSI was detected in 9 THRs(2.2%) and 2 TKRs(0.44%) in the study group as compared to 13 THRs(3.1%) and 12 TKRs(2.9%) in the control group. The infection rates in THRs were not significantly different between the 2 groups(p value−0.52) but were significantly reduced in the study group for TKRs(p value−0.005). The rate of Clostridium difficile infection was reduced within the hospital with the use of gentamicin, although other measures to reduce its incidence were also introduced. The return to theatre was 1.64%(23/1402) after introduction of Gentamicin as compared with 1.05%(21/2005) [p value−0.092] before this. This was a cause for concern although not significant. The day1 postoperative creatinine level increased by more than 30 units in 6% of patients on Gentamicin.

Conclusion: This study shows that the use of single dose prophylaxis using Gentamicin is effective for Lower Limb Arthroplasty. However, be wary of increased rate of return to theatre and the rise in creatinine level following use of gentamicin. Further period of evaluation and study is needed before it is recommended for routine use in present or modified form.

Purpose: To analyse the results of the use of Recombinant Bone Morphogenic Protein (BMP-7) for treatment of fracture nonunions at our institution.

Method: From 2001 to 2006, 23 patients with fracture non-union were treated with BMP-7 for bone healing. There were 14 male and nine females. The mean age of patients was 45 years (Range 21–76 yrs). There were 11 femoral, nine tibial and three humerus fractures. There were four open injuries. The average number of operations before BMP-7 insertion was 2.5 (Range 0–6). The mean time between the injury and BMP insertion was 52 months (Range 5–312). Nine (40%) patients had previous autologous bone graft inserted without union. 4 patients had BMP-7 insertion on its own. In another 4 patients it was mixed with allograft. In the rest of 15 patients BMP-7 was mixed with autologous bone graft. 2 patients needed BMP-7 insertion on 2 separate occasions. In all except 1 patient the original fixation of the fracture had to be revised using various appropriate methods.

Results: All the fracture went on to unite within an average of seven months (Range 4–16). There were no complications from the use of BMP-7.

Conclusion: Use of recombinant BMP-7, bone graft and stable fixation lead to fracture union in all our patients. We believe that the use of BMP-7 improved the chances of fracture healing in persistent non-unions and it is safe and easy to use.

Introduction: The emergence of Independent Sector Treatment Centres (ISTCs) in the UK for the provision of elective orthopaedic services began in 2002–3. Within our trust the bulk of elective orthopaedic surgery is performed in an ISTC however there is a small but significant cohort of patients who are deemed not suitable for treatment at the ISTC. Patients with a BMI (body mass index) ≥40 or an ASA (American society of anaesthesiologists) grade of 3 or more are automatically rejected. With increasing levels of obesity and an aging population the size of the reject cohort is going to rise. These patients are then returned to the NHS to be placed on a new (complex elective) waiting list for their surgery. The aim of this study was to assess the early outcomes and complications following primary knee arthroplasty on our high risk patients.

Methods: A retrospective review of a consecutive series of 214 primary knee arthroplasties in patients rejected from the ISTC was performed. Data (demographics, ASA grade, BMI, length of stay, complications, range of knee movement and requirement for HDU/ICU) were collected from preoperative assessments, inpatient notes, anaesthetic charts, discharge summaries and follow up clinic letters. All patients were followed up for a minimum of 6 months.

Results: 155 (72%) patients were female. 140 (65%) had ASA of 3 or more. 88 (41%) had a BMI of 40 or more. Median length of stay was 8 days (6 to 11 IQR) and did not vary with increasing BMI but increased to 10 days in the ASA 3 and 12 days in the ASA 4 group. There were a total 90 complications in 71 patients. The most common complications were 22 superficial wound infections (10.3%), 11 Pneumonias (5.1%), and 9 symptomatic DVTs (4.2%). There were 16 severe complications (2 Deep infections, 4 PEs, 2 CVAs, 4 acute renal failures and 4 dislocations) in 15 patients. Patients with a BMI < 40 had a total complication rate of 38% (7.9% severe) compared with 26% (5.7% severe) in BMI ≥40 group. Patients with an ASA < 3 had a complication rate of 31% (4.1% severe) vs. 34% (8.6% severe) in patients with an ASA ≥ 3. HDU/ICU beds were required postoperatively for 20 patients (9 planned and 11 unplanned). At six months 72% achieved a knee range of movement ≥ 0 to 90 degrees. Surgeons who performed high volumes of surgery in this difficult group had lower complications then lower volume surgeons.

Conclusion: This is one of the largest consecutive groups of high risk patients undergoing primary total knee arthroplasty. Our results show that elevated BMI does not appear to adversely affect complication rates in knee arthroplasty in our series although ASA grades of 3 and 4 are associated with increased length of stay and complication rates. It is also clear that small groups of surgeons operating on these difficult patients may reduce complications.

A study to evaluate the efficacy of combined grafting (iliac crest autograft – ICAG, and human recombinant osteogenic protein 1 – rhOP1/BMP7) for long bone fracture non-unions (LBFNUs).

At both institutions prospective and retrospective data were collected. (Between Oct 2001 and Aug 2004 all LBFNUs that were grafted with a combination of BMP7 and ICAG). The records of the initial injury incident, treatment course, all operative interventions before and after the combined grafting and the follow up till final clinical & radiological union have been analysed. X2 test was used to analyse the results.

Forty-nine patients (31 males) with a mean age of 43 years (18–79) with LBFNUs were identified. The mean follow-up was 21.4 months (12–65). 7 were humeral, 13 femoral, and 29 tibial LBFNUs. Eleven were open (3 grade II, 8 grade IIIa–b). All non-unions were atrophic, and 8 had significant bone defects. The mean number of operations prior to the combined grafting was 2.5 (0–6). Clinical and Radiological union occurred within a mean time of 4.4 (3–12) months and 5.4 (4–16) months respectively. All of the fractures united. One patient, with an infected tibial non-union after an open fracture, ultimately underwent a below knee amputation. No complications or adverse effects from the use of BMP-7 were encountered.

BMP-7 was used as a bone-stimulating agent combined with conventional iliac crest bone grafting with a success rate of 98% in this series of patients with LBFNUs. This study supports the view that this combination of BMP-7 is safe and a power adjunct to be considered in the surgeon’s armamentarium for the management of such difficult cases.

Aim: To assess the infection rate following Lower Limb Arthroplasty using single dose gentamicin antibiotic prophylaxis compared to a traditional three doses of cephalosporin.

Material and Methods: All patients undergoing Total Hip and Knee joint replacements over 6 months (October 2007 to March 2008) at 3 participating hospitals were prospectively followed up to assess perioperative infection rates. Joint replacements were defined as having infection by the UK Health Protection Agency Surgical Site Surveillance criteria. All patients received single dose antibiotic prophylaxis using intravenous Gentamicin 4.5mg/kg body weight adjusted for body mass index.

This group of patients were compared with previous data collected over a 6 month period (Jan to Mar 2007 and Oct to Dec 2005) from the same hospitals for infection rates in Lower Limb Arthroplasty using 3 doses of Cefuroxime 750mg as antibiotic prophylaxis.

Results: 408 patients underwent Total Hip Replacements (THR) and 458 patients underwent Total Knee Replacements (TKR) during the study period. This was compared with 414 patients who underwent THR and 421 patients who underwent TKR during a 6 month period over 2 years.

Surgical site infection was detected in 9 THRs (2.2%) and 2 TKRs (0.44%) in the study group as compared to infection in 13 THRs (3.1%) and 12 TKRs (2.9%) in the control group.

Using the Fisher Exact test the infection rates in THRs were not significantly different between the 2 groups (p value – 0.52) but the infection rates were significantly reduced in the study group for TKRs (p value – 0.005).

There were no complications with the use of Gentamicin as antibiotic prophylaxis.

Cefuroxime is known to promote Clostridium difficile infection and was removed from the hospital pharmacy to help meet a UK government targets to reduce the incidence. The rate of Clostridium difficile infection was reduced within the hospital with the use of single dose antibiotic prophylaxis although other measures to reduce its incidence were also introduced.

Conclusions: This study shows that the use of single dose antibiotic prophylaxis using Gentamicin is effective for elective Lower Limb Arthroplasty.

This is recommended for routine use in all elective joint replacements as it is safe, effective and easy to administer.

Aim: To assess the infection rate following Primary Lower Limb Arthroplasty using single dose gentamicin antibiotic prophylaxis compared to a traditional three doses of cephalosporin.

Material And Methods: All patients undergoing primary Total Hip and Knee joint replacements over 6 months (October 2007 to March 2008) at 3 participating hospitals were prospectively followed up to assess perioperative infection rates. Joint replacements were defined as having infection by the UK Health Protection Agency Surgical Site Surveillance (SSI) criteria. All patients received single dose antibiotic prophylaxis using intravenous Gentamicin 4.5mg/kg body weight adjusted for body mass index.

This group of patients were compared with previous data collected over a 6 month period (Jan to Mar 2007 and Oct to Dec 2005) from the same hospitals for infection rates in Lower Limb Arthroplasty using 3 doses of Cefuroxime 750mg as antibiotic prophylaxis.

Return to theatre data was collected independently after introduction of gentamicin to compare with previous data.

Results: 408 patients underwent Total Hip Replacements (THR) and 458 patients underwent Total Knee Replacements (TKR) during the study period. This was compared with 414 patients who underwent THR and 421 patients who underwent TKR during a 6 month period over 2 years.

Surgical site infection was detected in 9 THRs (2.2%) and 2 TKRs (0.44%) in the study group as compared to infection in 13 THRs (3.1%) and 12 TKRs (2.9%) in the control group.

Using the Fisher Exact test the infection rates in THRs were not significantly different between the 2 groups (p value – 0.52) but the infection rates were significantly reduced in the study group for TKRs (p value – 0.005).

There were no complications with the use of Gentamicin as antibiotic prophylaxis.

The return to theatre was 2.42% (28/1157) after introduction of Gentamicin as compared with 1.85% (37/2005) [p value – 0.172] before this. This was a cause for concern, although not a significant difference.

Cefuroxime is known to promote Clostridium difficile infection and was removed from the hospital pharmacy to help meet a UK government targets to reduce the incidence. The rate of Clostridium difficile infection was reduced within the hospital with the use of single dose antibiotic prophylaxis although other measures to reduce its incidence were also introduced.

Conclusions: This study shows that the use of single dose antibiotic prophylaxis using Gentamicin is effective in preventing SSI as defined in the HPA definition. It is safe to use and reduces rate of Clostridium difficile associated diarrhoea.

However, be wary of increased rate of return to theatre following use of gentamicin.

Further period of evaluation and study is needed before it is recommended for routine use in present or modified form.

Introduction: Traditionally flexion deformities in Proximal Interphalangeal joints of lesser toes like hammer toes and curly toes are treated with fusing the PIP joint with a single Large Kwire. We describe a new technique of fusing PIP joints using two 1.1mm K wires.

The advantages of this technique over single K wire are:

Less post operative complications like pain and pin tract infection.

Aim: To compare the clinical and radiological outcomes in two pin fusions with standard single pin fusions described by Coughlin. To prove that this is a technically and biomechanical better procedure.

Materials and Methods: Two pin technique was used for 36 PIP joint fusions in 25 patients with a mean age of 58 years (range–42 to 87 years) and female preponderance. Results were analysed using foot function scale, AOFAS (American Orthopaedic Foot and Ankle Society) lesser metatarsophalageal-Interphalageal scale. Post operative complications were documented.

Technique: Dorsal skin incision was used to approach the PIP joint. Articular surfaces were prepared and two 1.1mm K wires were inserted from the tip of the toe and joint fixed in 15 – 20 degrees of flexion which is optimal functional position of PIP joint. Patients were mobilised non weight bearing for 6 weeks when K wires were removed and weight bearing started.

Results: The results were analysed at 3–6 months post operatively. The foot function scores and objective parameters of AOFAS scores are slightly better in two pin fusions compared with single pin fusions.

Objective parameters of AOFAS scale like adduction/ abduction, flexion, rotational deformities are significantly less with two wire fusions compared with single wire procedures (Coughlin et al). Radiological analysis of the foot showed that 97% had bony union compared 81% with single pin, and only 3% had fibrous union compared to 19% with single wire. Both the procedures didn’t have any non-unions. Only one patient had superficial wound infection, and surprisingly none had pin tract infection.

Conclusion: Two pin PIP Joint fusion is relatively easy procedure with many technical advantages over single pin technique. The clinical and radiological outcomes are good. Results of the biomechanical studies should be available soon.

Lyme disease is a vector-borne multisystem inflammatory disease caused by the spirochete Borrelia burgdorferi sensu lato. This disease is frequently seen in North America and to a lesser degree in Europe. However, its presence in England is uncommon and we present a case in which the patient developed a palsy of the common peroneal nerve

Introduction: Hip fractures are a massive problem in an ageing population with 7–21 million predicted world-wide by 2025. The stabilization of intertrochanteric fractures reduces morbidity, mortality and allows mobilization. The treatment of these fractures has evolved over the past 50 years to the Sliding hip screw and plate, and intramedullary devices Current evidence suggests that the SHS systems are superior in stable fracture patterns and intramedullary devices are superior in unstable fracture patterns such as reverse oblique fractures or subtrochanteric fractures. Accurate implant positioning will prevent failure and the associated morbidity and mortality. The most frequent failure is due to cut out of the screw through the femoral head due to poor positioning. Cut out is directly correlated with tip apex distance (TAD). A TAD < 25mm has been to shown to be key to preventing cut out irrespective of fixation device.

Aims: The aims of this audit were to review TAD in proximal femoral fractures stabilized with a SHS system at one hospital to ensure:

TAD is < 25mm.

Results: Radiographs over a period of 1 year where reviewed. There were 86 cases of SHS fixation. 72% of cases were female (62:24). The mean age was 84(65 to 97). The mean preoperative delay before surgery was 4.5 range (0 –15). 13% of cases (11/86) had no postoperative radiographs either digitally or hard copies stored in the notes. The mean value of TAD was 20.8mm (Std dev 6.89). There was no correlation between fracture patterns and TAD, or surgeon grade and TAD. However there was a trend for higher TAD in inexperienced surgeons and in more complex fracture patterns.

The majority of cases were operated on by Registrars 67%, Staff grade 15%, Research fellows 9%, SHOs 6% and Consultant grades 3%. Registrars achieved Centre–Centre positions in 62% of cases with staff grade 47% of cases. The majority of SHS were performed for Types 2 and 4 according to Jensen & Michaelson classification. SHS implants were used in one subtrochanteric fracture and zero reverse oblique fractures. 21 cases had a TAD> 25mm and one of these has gone on to failure, requiring THR.

Conclusion: The mean TAD was within recommendations and there was no correlation between surgeon grade, fracture pattern and TAD. The positioning of screws corresponds closely to published data and remains acceptable as does the use of SHS devices. Both the preoperative delay and number of inadequate radiographs is unacceptable and needs improvement.

Purpose: The purpose of this study was to evaluate the efficacy of a combined application of iliac crest autograft (ICAG) and human recombinant osteogenic protein 1 (BMP-7) for the treatment of non-unions of long bones fractures (LBF).

Patients and Methods: At both institutions we have prospectively and retrospectively collected and analysed data of patients admitted between October 2001 and August 2004 with a LBF nonunion (humerus, femur, tibia) and whose nonunion sites have been grafted with a combination of BMP7 and ICAG. All the records of the patients’ initial injury incident and treatment course, together with following operative interventions till and after the BMP7 application, and their follow up till final union have been analysed. Painless full weight bearing or use of the upper limp in the case of humerus (clinical union), and presence of bridging callous of two cortices visible on two x-ray views (radiological union). Chi square test was used to analyse the results.

Results: Forty-nine patients (31 males) with a mean age of 43 years (18–79) with LBF non-unions were identified. The mean follow-up was 21.4 months (range 12–65). 7 were humerus, 13 femurs, and 29 tibias. Eleven cases were open (3 grade II, and 8 grade IIIa-b). All non-unions were atrophic, and 8 were initially associated with bone loss. The mean number of operations performed prior to the combined ICAG and BMP7 application was 2.5 (0–6), including ICAG in 12 cases and bone marrow injection in 1 case. All but one of the fractures have united. Clinical and Radiological union occurred within a mean time of 4.4 (3–12) months and 5.4 (4–16) months respectively. One patient, with an infected tibial non-union following an open fracture, ultimately underwent a below knee amputation, secondary to recurrence of deep sepsis. The only patient whose (tibial) fracture has not still united is currently on an Ilizarov frame and slow progression has been reported following a recent CT. No complications or adverse effects from the use of BMP-7 were encountered.

Conclusion: BMP-7 was used as a bone stimulating agent combined with conventional iliac crest bone grafting with a success rate of 98% in this series of patients with LBF non-unions. This study supports the view that this combination of BMP-7 is safe and a power adjunct to be considered in the surgeon’s armamentarium for the management of such difficult cases.

The aim of this prospective study was to report the mid-term results of arthroscopic repair of full thickness rotator cuff tears. Arthroscopic cuff repair, under regional interscalene block and balanced anaesthesia, was performed in 104 shoulders (102 patients). There were 52 female and 50 male patients with a mean age of 64 years (range 41 to 79). The mean size of the cuff tear was 3cm (range 1cm to 6 cm). Patients were discharged within 24 hours and followed a specific rehabilitation protocol. An assessment was performed pre-operatively and at a mean follow-up of 7 months (range 3 to 24 months). Outcome measures included pain, activities of daily living, shoulder function and level of patient satisfaction. Satisfactory pain relief was achieved in 98 patients (94%) with significant pain relief in 87 patients (83.6 %) and good in 12 patients (11.5 %). Ninety -six patients (92.3%) reported a satisfactory improvement in activities of daily living, with significant improvement in 89 (85.6%) and good in seven (6.7%). High levels of patient satisfaction were noted in 93 patients. Seven patients were moderately satisfied and two patients were not satisfied. The mean shoulder score improved from 29 pre-op to 82 post-op, and the shoulder function score from 32 pre-op to 84 post-op. No difference in outcome was found when the subgroup of 65 patients over the age of sixty was compared to the group of 37 patients under the age of sixty. We believe that this study has shown that the arthroscopic repair of the rotator cuff can consistently achieve a satisfactory outcome. It may therefore be considered as an alternative to the traditional open techniques.

The aim of this prospective study was to report the mid-term results of arthroscopic repair of full thickness rotator cuff tears.

One hundred and four shoulders in 102 consecutive patients were operated within a two-year period. There were 52 female and 50 male patients with a mean age of 64 years (range 41 to 79). Standard arthroscopic techniques of cuff repair were used, under regional inter-scalene block and balanced anaesthesia. The mean size of the cuff tear was 3 cm (range 1 to 6 cm). Patients were discharged within 24 hours and followed a specific rehabilitation protocol. An assessment was performed pre-operatively and at a mean follow-up of 7 months (range 3 to 24 months). Outcome measures included pain, activities of daily living, shoulder power and function and level of patient satisfaction.

Satisfactory pain relief was achieved in 98 patients (94%) with significant pain relief in 87 patients (83.6 %) and good in 12 patients (11.5 %). Ninety -six patients (92.3%) reported a satisfactory improvement in activities of daily living, with significant improvement in 89 (85.6%) and good in 7 (6.7%). Shoulder power was markedly improved in 95 patients (93%). High levels of patient satisfaction were noted in 93 patients. Seven patients were moderately satisfied and two patients were not satisfied.

The mean shoulder score improved from 29 pre-op to 82 post-op, and the shoulder function score from 32 pre-op to 84 post–op. Similar results were found when the subgroup of 65 patients over the age of sixty was compared to the group of 37 patients under the age of sixty. No difference in outcome was also noted in relation to the size of the tear, length of follow –up or sex of the patient.

We believe that this study has shown that the arthroscopic repair of the rotator cuff can consistently achieve a satisfactory outcome. It may therefore be considered as an alternative to the traditional open techniques.

To evaluate a peri-operative protocol developed to facilitate day case open shoulder procedures that historically have required overnight hospital admission. 75 consecutive day-case open shoulder procedures were performed in 75 patients (aged 18 – 65) followed up prospectively for a minimum of 6 months. The procedures included Open Primary Anterior Capsulo-Labral Reconstruction (ACLR) (24), open Revision ACLR (4), open Posterior Capsulo-Labral Reconstruction (2), mini-arthrotomy and rotator cuff repair (6), mini-arthrotomy and sub-acromial decompression (28), modified Weaver Dunn Reconstruction of Acromio-clavicular joint (ACJ) (2), decompression of ACJ (7), open release for frozen shoulder (2). Exclusion criteria included concomitant medical problems, and patients who would have no assistance in their care for the first 24 post operative hours. All patients received general anaesthesia, peri-operative analgesia using intravenous Fentanyl, and Diclofenac (PR), and local Bupivicaine 0.5% to incisions and intra-articular spaces; patients were discharged with oral analgesics. Patient satisfaction with overall experience, pain control, the incidence of nausea that was difficult to manage, the incidence of unplanned admission, attendance or delayed admission to hospital and postoperative complications were measured. 98% of patients were satisfied with their pain management. None of the patients suffered intractable post operative pain, nausea or vomiting; none required unplanned hospital admission or unexpected re-admission. All the patients were satisfied with their overall experience. There were no short or long term post operative complications. In conclusion, the anaesthetic protocol and surgical techniques used in this study permitted same day discharge for a wide variety of open shoulder procedures. For selected patients, open shoulder surgery as a day case appears to be safe effective and acceptable to the patient.

Study Design: A prospective observational study of scoliosis patients who were on non-invasive night ventilation for respiratory failure.

Objective: To report the results of spinal deformity correction in a group of patients with progressive scoliosis and rare forms of muscular dystrophy/myopathy with respiratory failure who were on nocturnal ventilatory support at the time of surgery.

Subjects: 9 patients (6 males, 3 females) with scoliosis and respiratory failure. The mean age at surgery was 12.4years (range 8–16yrs). There were 4 patients with multicore myopathy, 2 with merocin negative congenital muscular dystrophy, 1 with Ullrichs muscular dystrophy, 1 patient with congenital AcylCOA dehyrogenase deficiency and 1 with congenital scoliosis and dextrocardia. All the patients had overnight pulse oximetry, which showed episodes of desaturation at night. This was reversed with the onset of nocturnal ventilation. All the patients underwent posterior fusion performed by the same surgeon. Mean follow-up was 40 months (range 10 to 75)

Outcome Measures: Lung function, Cobb angle, Length of ICU stay, complications

Results: Mean vital capacity at time of surgery was 20% (range 13–28%). All patients recovered well following surgery with no cardiac or pulmonary complications. The mean stay in the ICU was 2.7 days (range 2–5). The mean hospital stay was 14.2 days (range 10–21). The mean preoperative Cobb angle was 70.2 degrees (range 55–85). The average change in the Cobb angle post-operatively was 32 degrees (range 16–65 degrees). The mean vital capacity of patients at latest follow up was 18% (range 10–32%). There was no loss of correction at latest follow-up. None of these patients lost their ambulatory capacity following surgery.

Conclusion: This is the first study reporting results of deformity correction in patients on ventilatory support. Spinal deformity correction in patients on non-invasive nocturnal ventilation presented no increased risk of complications.

Study Design: A prospective observational study of 12 Adolescent Idiopathic Scoliosis patients undergoing corrective surgery.

Objective: To assess the recovery of respiratory function (specifically diaphragmatic function) after thoracotomy or thoraco-abdominal surgery for Adolescent Idiopathic Scoliosis (AIS) using spirometry and Sniff Nasal Inspiratory Pressure (SNIP).

Summary of Background Data: SNIP is one of the best measures of global inspiratory muscle strength and specifically of diaphragmatic muscle strength. FVC and FEV1 are a better measure of restrictive and obstructive lung function than muscle strength. To the best of our knowledge no study has specifically looked at the recovery of diaphragmatic function following scoliosis surgery.

Subjects: 6 patients (2M, 4F) with thoracic scoliosis underwent a thoracotomy followed by a second stage posterior instrumentation 5–7 days later. The other 6 patients (1M, 5F) with thoraco-lumbar curves had a single stage correction and instrumentation using thoraco-abdominal approach. All patients were operated by the same surgeon.

Outcome Measures: All patients underwent conventional lung function tests (spirometry) and SNIPs during their pre-operative assessment. Spirometry and SNIPs were repeated postoperatively before discharge, at 6 weeks, 3 months and 6 months follow up. The values were compared between the thoracic and thoraco-abdominal groups.

Results: Overall mean preoperative SNIP was 56.75 cm H₂O and overall FVC was 2.79L. The mean SNIP in the thoracotomy group was 57.8 and 55.67 in the thoraco-abdominal group. The mean FVC in the thoracotomy group was 2.9 and in thoraco-abdominal group was 2.66. The difference between the 2 groups was not statistically significant. SNIP values returned to normal within 3 months in the thoraco-abdominal as well as in the thoracotomy groups. The FVC returned to within 95% of pre-operative values in 6 months in the two groups.

Conclusion: This study shows that SNIP return to pre-operative values within 3 months of scoliosis surgery after both thoracotomy and thoraco-abdominal approaches. The thoraco-abdominal approach appears not to have a more detrimental effect on global inspiratory muscle function and diaphragmatic function when compared to thoracotomy.