Carotid endarterectomy is being performed frequently under local rather than general anaesthetic utilising either superficial alone or combined superficial and deep cervical plexus block with both techniques being equally effective. 1,2 Complications related to local anaesthetic vary between 1.6-7.4% depending on the method used and incomplete blocks requiring further local anaesthetic supplementation by the surgeon during carotid endarterectomy are common problem. 3We overcame this difficulty by utilising an additional inferior alveolar nerve block (IANB) in 6 patients with high carotid bifurcations.
Since the introduction of flexible intramedullary nails, the treatment of femoral shaft fractures in adolescents has been revolutionized and this has become the routine treatment in most units, with minimal complications. We report a rare complication of an ipsilateral fractured neck of femur in a fit and healthy 12-year-old girl 6 months after treatment of a traumatic fractured femoral shaft; this was treated effectively with cannulated screws and the patient was successfully discharged without any further complication.
Background Minimally invasive surgery is an alternative therapeutic option for treating unstable spinal pathologies to reduce approach-related morbidity inherent to conventional open surgery. Objective To compare the safety and therapeutic efficacy of percutaneous fixation to that of open posterior spinal stabilisation for instabilities of the thoraolumbar spine. Study Design Comparison study of prospective historical cohort versus retrospective historical control at a tertiary care centre. Methods Patients who underwent open or percutaneous posterior fixation for thoracic-lumbar instabilities secondary to metastasis, infection and acute trauma were included. Minimally access non traumatic instrumentation system (MANTIS) was used for percutaneous stabilisation. Outcome Measures The differences in surgery-related parameters including operative time, blood loss, radiation exposure time, analgesia requirement, screw related problems and length of hospitalisation between the groups were analyzed. Results There were a total of 50 patients with 25 in each group. There were no significant differences concerning age, sex, ASA, pathology causing instability, level and number of segments stabilised between the groups. There were significant differences between the MANTIS and open group in terms of blood loss (492 versus 925 ml, p 0.05) Open group patients had less radiation exposure (average of 0.6 minutes) compared to MANTIS cohort (3.1 minutes). There were 2 patients with screw misplacements comprising one from each group that needing revision. Conclusion Percutaneous spinal stabilisation using mini-invasive system is a good surgical therapeutic choice in thoracic-lumbar instabilities. It has the advantage of less trauma, quick recovery and shortened hospital stay with accuracy of screw placement as similar to those reported for other techniques. Indications and limitations of this technique must be carefully identified. Interest Statement There was no commercial support or funding of any sort.
Modifications in design and surgical technique have been directed at improving the long-term survival of total hip replacement. This study examines the failure rate, with revision as endpoint, of two large cohorts of primary total hip replacement carried out over consecutive six-year intervals. The intention of the study was not to compare specific prostheses or techniques, but to examine failure rates between two time periods which embraced significant changes of practice. At one specialised centre in Bristol, 2747 primary total hip replacements were performed between 1980 and 1986. Seventy-six failed within 5 years (2.8%) with 23 of these failing in the first year (0.8%). Between 1987 and 1992, 3232 primary total hip replacements were carried out, with 98 hips requiring revision within 5 years (3.0%), 21 of these in the first year (0.6%). There was no statistical difference in the incidence of failure between these two time periods; however, the failure rate for the more recent time period was marginally higher. This indicates that, although techniques and prosthetic design have changed significantly, the anticipated reduction in incidence of failure has not materialised. There is undoubtedly a need for ongoing review to ensure that changes in technique and component design are producing the desired long-term effect.
The presence of polyethylene wear particles at the bone-cement interface after joint replacement is considered a major cause of prosthetic loosening. Nevertheless, many surgeons continue to use winged Hardinge polyethylene restrictor of which fragments are frequently seen to detach during insertion into the femoral canal, and to emerge during medullary lavage. The extent to which such fragments may be retained in the femoral cement mantle is not clear, and there is obvious concern that such fragments may result in polyethylene granuloma formation. We reviewed 89 post-operative X-rays after hip replacement employing the Hardinge restrictor. The following issues were examined: 1. Dimensions and number of distal radiolucencies in the cement and their correspondence with the wing size of the restrictor, 2. method of suction used during pressurised lavage, 3. Proximal and distal canal diameter and amount of taper, 4. Gruen zone location of radiolucencies. Linear lucencies corresponding exactly to the wings of the restrictor were found on 14 X-rays (15.7%), 7 were seen out of 54 cases in which distal suction was used during lavage, and 7 were seen in 35 cases in which proximal suction only was employed. There was no statistical difference between these two methods of suction in limiting the number of retained fragments of restrictor (P= 0.156). There was no correlation between the likelihood of fragment detachment and canal taper or distal diameter. A total of (17) detached fragments were identified, distributed in the following Gruen zones; 3 (35.3%), 4 (38.2%), 5 (26.5%). We suggest that the above observations should alert surgeons who wish to use this type of restrictor to the importance of meticulous femoral preparation, preferably under direct vision, to ensure that no fragments of restrictor become detached
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