No abstract

The authors present a technical note for a prone positioning system developed to facilitate cervical extension osteotomy for ankylosing spondylitis in the presence of severe deformity and frailty. Chin-on-chest deformity represents one of the most debilitating changes of ankylosing spondylitis. Where the chin-brow angle approaches or exceeds 90°, prone positioning becomes problematic due to the fixed position of the head. Furthermore, the challenge is compounded where physiological deconditioning leads to frailty, and the side effects of medical therapies decrease muscle mass and skin quality. Conventional prone positioning equipment is not able to cater to all patients. A versatile system was developed using a 3D reconstruction to enable a positioning simulation and verification tool. The tool was used to comprehensively plan the perioperative episode, including spatial orientation and associated equipment. Three-dimensional printing was used to manufacture a bespoke positioning device that precisely matched the contours of the patient, reducing contact pressure and risk of skin injury. The authors were able to safely facilitate surgery for a patient whose deformity and frailty may otherwise have precluded this possibility. The system has potential safety and economic implications that may be of significant utility to other institutions engaging in complex spinal surgery.

It is believed that many surgeons, by adopting 'stripping' as the routine surgical treatment of significant varicose veins may be sacrificing many major leg veins which could be potentially valuable arterial grafts. A protocol of surgery is suggested which replaces stripping by the stab-avulsion technique. Thus all varices are removed and distal incompetent perforators controlled. Freed from an inevitable 'high ligation', it enables selective ligation at proximal valves, only when they are incompetent. It is suggested that this protocol treats varices effectively whilst preserving undamaged veins. The results presented show a 3 year recurrence rate of about lo%, but evidence is offered that better results will be obtained, now that Dopplerequipment is readily available.

A review of the important steps required in the surgical procedure for treatment of varicose veins suggests a protocol in which all damaged veins are removed by the stab avnlsion technique, only veins with incompetent proximal valves are ligated, and the long saphenous vein is never removed unless it is too damaged to use for arterial grafting. With this protocol of selective conservation it is possible to preserve valuable undamaged major leg veins and at the same time treat varicose veins efficiently. A a-year postoperative review of 171 patients with 295 affected limbs treated in this way was done by independent observers. They found a recurrence rate of only 10.5%. There is evidence to suggest that Doppler testing for proximal valve competence will further improve results in the future.

Background: In the presence of chin-on-chest deformity of ankylosing spondylitis, positioning for extension osteotomy of the spine is a challenging endeavor. Conventional prone positioning equipment cannot safely accommodate all patients with advanced deformity where the chin brow angle approaches or exceeds 908. Issues such as inability to accommodate the head and associated equipment while providing operative stability and venous congestion of the head represent significant perioperative risks. The sitting position has been advocated as an alternative but is suboptimal for surgical access and anesthetic care. We present a technical note for a positioning system developed to facilitate extension osteotomy in the prone position.Methods: A positioning device was designed to accommodate patients with advanced deformity. A series of patients with chin brow angles of up to 898 were positioned using our new system.Results: We were able to facilitate safe extension osteotomy in the prone position, for procedures lasting up to 14 hours. All our patients were discharged home without significant complication.Conclusions: Our device is simply constructed and may be easily replicated in other institutions engaging in complex spine surgery. We hope our system provides clinicians with greater freedom to provide optimal perioperative care to their patients.