Audit of open tibial diaphyseal fracture management at a district accident centre.
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Preston Acute Hospital is a designated district accident centre with a 24 h flying squad and on-site plastic and orthopaedic units. We performed a retrospective 5-year survey of open tibial shaft fracture management at our unit and compared our treatment to the guidelines of the British Orthopaedic Association (BOA) and British Association of Plastic Surgeons (BAPS). Deficiencies were highlighted and changes in practice made. We then re-audited our figures over an 18-month period to see if clinical improvements had been made. The audit demonstrated an incidence of open tibial shaft fractures of 15 per 50,000 new patients per year in accident and emergency. Gustilo grading, and thus full appreciation of soft tissues injury, was being underestimated, with 8% of the injuries undergraded at the time of surgery: 17% of Gustilo IIIA and 85% Gustilo IIIB required flap cover. Seventy-four percent of patients received their first orthopaedic procedure within the recommended 6 h of admission, but despite the on-site plastics unit, only 50% of cases in the initial survey had their soft tissue defect covered by the recommended 5 days. After changes to practice, 80% patients received their first orthopaedic procedure within the recommended 6 h of admission, and all had their soft tissue defect covered within 5 days; 5% of cases required fasciotomy to relieve compartment syndrome. We highlight features to alert the high energy (Gustilo III) status and recommend immediate involvement of plastic surgical colleagues with these injuries. We also highlight a high incidence of compartment syndrome in the young male patient with the lower energy Gustilo I injury. (+info)
Long-term outcome for patients with nonmetastatic osteosarcoma of the extremity treated at the istituto ortopedico rizzoli according to the istituto ortopedico rizzoli/osteosarcoma-2 protocol: an updated report.
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PURPOSE: To provide an estimate of long-term prognosis for patients with osteosarcoma of the extremity treated in a single institution with neoadjuvant chemotherapy and observed for at least 10 years. PATIENTS AND METHODS: Patients with nonmetastatic osteosarcoma of the extremity were preoperatively treated with high-dose methotrexate, cisplatin, and doxorubicin (ADM). Postoperatively, good responders (90% or more tumor necrosis) received the same three drugs used before surgery, whereas poor responders (less than 90% tumor necrosis) received ifosfamide and etoposide in addition to those three drugs. RESULTS: For the 164 patients who entered the study between September 1986 and December 1989, surgery was a limb salvage in 136 cases (82%) and a good histologic response was observed in 117 patients (71%). At a follow-up ranging from 10 to 13 years (median, 11.5 years), 101 patients (61%) remained continuously free of disease, 61 relapsed, and two died of ADM-induced cardiotoxicity. There were no differences in prognosis between good and poor responding patients. ADM-induced cardiotoxicity (six patients), male infertility (10 of the 12 assessable patients), and second malignancies (seven patients) were the major complications of chemotherapy. Despite the large number of limb salvages performed, only four local recurrences (2.4%) were registered. CONCLUSION: With an aggressive neoadjuvant chemotherapy, it is possible to cure more than 60% of patients with nonmetastatic osteosarcoma of the extremity and amputation may be avoided in more than 80% of them. Because local or systemic relapses, myocardiopathies, and second malignancies are possible even 5 years or more after the beginning of treatment, a long-term follow-up is recommended for these patients. (+info)
Inappropriate medical management of spinal epidural abscess.
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A 67 year old man with longstanding rheumatoid disease was referred to the regional spinal surgery unit with acute onset of paraparesis due to an extensive spinal epidural abscess of the lumbar spine. Ten months previously, he had started antibiotic treatment at another hospital for an epidural abscess arising at the level of the L2-3 disc space. Despite completing seven months of medical treatment with appropriate antibiotics, he had a recrudescence of acute back pain shortly after restarting methotrexate treatment. Urgent anterior spinal decompression with excision of the necrotic vertebral bodies of L1-3 was performed. The indications for the surgical management of spinal epidural abscess are reviewed. (+info)
Meniscal tears after anterior cruciate ligament reconstruction.
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The aim of this study was to follow patients in whom preoperative MRI demonstrated grade-3 lesions in the medial meniscus but no visible tears at arthroscopic ACL reconstruction, and to ascertain whether these meniscal lesions would progress to definite tears after reconstruction. The Study population consisted of 19 patients with a mean age of 23.2 years. Intraoperative arthroscopy showed normal appearance in 16 of 19 menisci and mild degree superficial legions in 3 menisci. None of the patients had any special treatment for the menisci at surgery. As controls, 39 patients who showed no tears on MRI and arthroscopy were studied. All MR studies were performed on a 0.5 T MR unit with field echo pulse sequences. A slice thickness of 1.5 mm was used with no interslice gap. Grade-3 legions progressed to definite tears in 8 of the 19 studied patients (42.1%) 12 to 33 months after ACL reconstruction. The Remaining 11 patients showed only symptoms or signs suggesting meniscal tears during a mean follow-up of 26.1 months. In the controls, medial meniscal tears occurred in 2 of the 39 patients (5.1%) 15 to 18 months after reconstruction. The studied patients were divided into a tear group (n=8) and a no-tear group (n=11). When the number of slices with grade-3 lesions was compared between the 2 groups, the mean slice number in the tear group (5.8 slices) was significantly greater than that in the no-tear group (3.1 slices) (P<0.05). These results suggest that even if no visible tear is found at surgery, patients in whom grade-3 lesions are identified in many slices have a high risk of developing definite tears after ACL reconstruction. (+info)
The accuracy of MRI in assessing graft integrity after anterior cruciate ligament reconstruction.
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To evaluate the efficacy of MRI in assessing anterior cruciate ligament (ACL) reconstruction graft integrity, we compared MRI findings with arthroscopic findings in 52 patients who had undergone arthroscopically assisted ACL reconstruction using semitendinosus and gracilis tendons augmented by woven polyester. MRI and arthroscopy were carried out 12 months after the operation. The MR appearance of ACL grafts was categorized into 3 types by signal intensity and continuity of the ligament according to Rak's method: 1. well-defined type: the graft was visualized as a smoothly continuous band with low signal over the entire course; 2. intermediate type: signal intensity increased and a low-signal band was visualized only in part of the graft; 3. indiscernible type: the graft was not identified through the joint cavity due to markedly increased signal intensity. When the MR appearance of intermediate or indiscernible types was defined as torn, the grafts were presumed to be torn in 9 patients whose arthroscopic findings were 7 intact and 2 torn grafts. All cases with intact MRI findings were intact on arthroscopic examination. Thus, the sensitivity, specificity and accuracy of MRI as an evaluative tool for ACL graft tears were 100%, 86% and 86.5%, respectively. (+info)
Penile prosthesis implantation in a transsexual neophallus.
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Reconstruction surgery for a female to male transsexual usually involves mastectomy, hysterectomy and creating an aesthetically appealing neophallus. We have successfully inserted an inflatable prosthesis using the AMS CX prosthesis in a 45 year old transsexual, who had a large bulky neophallus constructed from the anterior abdominal subcutaneous fat, about 9 years ago. The single cylinder CX prosthesis was well anchored to the symphysis pubis using a dacron windsock tubing, the activation pump was placed in the dependent pouch of the right labium and the reservior in the usual perivesical space. The patient subsequently had debulking procedure using liposuction to create a more aesthetic and functional phallus. To date, the inflatable neophallus prosthesis is functioning well. (+info)
Use of local anaesthetic agents among New Zealand plastic surgeons--their practices and philosophies.
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PURPOSE: Skin lesions are treated by a variety of medical practitioners. To describe the method and techniques of use of local anaesthetic (LA) for excision of skin lesions amongst a group of surgeons who are frequent users. METHODS: An open-ended questionnaire was designed to investigate the way LA was used for local excision and reasons behind the practice. All registered Plastic and Reconstructive Surgeons in New Zealand were sent the questionnaire. This group was chosen because they are high frequency users of local anaesthetic for excision of skin lesions. RESULTS: Questionnaires were sent to all 28 Plastic and Reconstructive Surgeons in New Zealand of which twenty-three (82%) responded. The reasons for selection of specific products relate to convenience of product (14), speed of onset (6), effect duration (4), ease to add bicarbonate (3), others (5). Lignocaine and bupivicaine were the most popular LA agent used except when there was concern about cardiac toxicity when Prilocaine was used instead. Adrenaline was used for vasoconstriction induced haemostasis, and avoided in anatomical areas with end arteries due to the risk of tissue ischaemia. This complication was identified as medicolegally indefensible despite a lack of scientific evidence in the literature. The techniques used to reduce patient discomfort of local anaesthetic infiltration relate to patient oriented techniques (15), injection related techniques (25), LA agent related techniques (19). Details of these specific techniques are presented in detail. CONCLUSIONS: LA uses vary according to the specific surgical situation, patient risk factors and according to the individual surgeon. The main reason for selection of a specific LA agent relates to convenience and not pharmacokinetics. Injection related techniques are the most common method to reduce pain from LA. (+info)
Evolution of an inguinal hernia surgery practice.
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BACKGROUND: Inguinal hernia surgery has undergone numerous advances in the last few years. This study analysed the changes in the practice of one surgeon in a district general hospital over a seven year interval. The effect of changing from Bassini to Lichtenstein repair in 1994 was evaluated. METHODS: The study involved two parts: first a search of a computerised database of inguinal hernia procedures, and second, postal audits of men who had an inguinal hernia repair in 1993 and 1994 with outpatient follow up for those with a possible recurrence. RESULTS: A total of 1037 hernias were repaired over the seven years. There was an increase in the proportion of day cases from 18% to 70% and the number of operations performed under local anaesthetic rose from 1% to 45%. The postal audits had response rates of 79% (1993) and 66% (1994). Some 5/98 (5%) recurrent hernias were identified from the 1993 (Bassini) patients compared with 1/67 (1.5%) from the 1994 (Lichtenstein) cohort. CONCLUSION: Lichtenstein hernia repair can be performed safely as a day case using local anaesthetic in the majority of patients and appears to have a lower recurrence rate than Bassini repair. (+info)