A five-year-old child with severe arthrogryposis multiplex congenita and malnutrition underwent surgery for chronic osteomyelitis of the head of the left humerus. The child had typical features of arthrogryposis multiplex congenita, including a difficult airway. Propofol was used for induction and maintenance. Spontaneous respiration was maintained with a nasal airway. Analgesia was provided with an interscalene brachial plexus block placed using a nerve stimulator. No opioid was given. The child had an uneventful recovery with good postoperative analgesia.The anaesthetic implications of arthrogryposis multiplex congenita are discussed.

Valve prosthesis have played an important role in the management of patients with valvular heart disease. However, the prosthetic heart valves used are not without complications. Almost all prosthetic heart valves are obstructive compared with native valves and associated with physiological washing jets. Because of shielding and artifacts it is very difficult to assess the prosthetic valve with TTE. Multiple thrombi and aortomitral continuity detection is cumbersome by TTE. Multiple angulations and off axis view in TEE help not only to characterize the prosthetic heart valve but also gives a three-dimensional surgical view to aid in reaching a diagnosis.