It is generally accepted that urgent debridement and fixation of open tibial fractures minimizes the risk of infection. Traditionally surgeons follow the unwritten six hour rule. The purpose of this study was to determine the association between time to definite surgical management and rates of infection in open fractures of the tibia. One hundred and twenty-seven patients with one hundred and twenty-eight open tibia fractures were retrospectively reviewed. Of these ninety patients with ninety-one one fractures were available for this study. All patients were followed up to clinical and radiological fracture union or until a definitive procedure for infection or non-union had been carried out. The time from injury to surgery ranged from 2 hours 35 minutes to 12 hours with an average time of 5 hours 40 minutes. There were 24 Gustillo type I fractures (26.37%), 11 type II fractures (12.08%), 23 type IIIA fractures (25.27%) and 33 type IIIB fractures (36.26%). 5 patients (5.49%) in this study went onto develop a deep infection and there were 4(4.39%) non-unions. No infection occurred when the surgery was done within 2 hours. All the 5 infections in this study occurred in patients operated between 3 to 8 hours of the injury and were all in Gustillo Grade III fractures. The average time to treatment was not significantly different between the infected versus non infected group across all fracture types. There was no increase in infection rate in those treated after 6 hours compared to those treated within 6 hours. The risk of developing an infection was not increased if the primary surgical management was delayed more than 6 hours after injury provided intravenous antibiotics were administered on presentation to the emergency department. The Gustillo grading of open fractures is a more accurate prognostic indicator for developing an infection.
The purpose of our study was to determine the medium term clinical and radiological outcome of comminuted, displaced fractures of the distal radius. We present our experience in using the Aculoc (Acumed) volar fixed angle plate to treat 100 consecutive fractures of the distal radius.
Biopsy was performed in 11 patients and surgical treatment was carried out in 3 patients including curettage (2) and excision with bone grafting (1). All patients were treated with adjuvant radiotherapy while 87% also received adjuvant chemotherapy. Seven patients were alive with no evidence of disease at a mean 6 year follow-up. Six patients died of metastatic disease, one due to local recurrence and one with persistent primary disease. The mean follow-up time was 65 months (median 28 months; ranging from 12 to 218 months).
The aim of the paper is to provide an independent single surgeon experience with BHR after a seven-year follow-up. A cohort of 117 hips in 101 consecutive patients operated by the senior author between Jan 1998 and Dec 2002 were assessed to note their clinical, radiological and functional outcome after a mean follow-up of 7 years (5–9.4 years). Primary osteoarthritis was seen in 73 hips and secondary in 44 hips. Their mean age at surgery was 54 years (range 20–74years). At latest follow-up their mean flexion was 100°and their mean functional outcome scores were respectively: Oxford hip score of 21.5 (12–52, mode 12); Harris hip score of 84.8 (25–100, mode 97), Charnley modification of Merle d’ Aubigné and Postel scores were 4.8 for pain, 4.3 for walking and 5.4 for movement; and SF-36 (physical component 43.9 and mental component 51.45). Failure in the study was defined as revision for any reason. Revision was undertaken in 8 hips (6.8%), five within the first year for periprosthetic fracture neck of femur and 3 hips after the end of 5-year follow-up (2 for advance collapse of the femoral component in patients’ with avascular necrosis of the femoral head and 1 hip for sepsis). The Kaplan-Meier survival with revision as end point at minimum 5-years of follow-up was 95.7% (95% CI 92–99%) and overall survival at an average 7-years was 91.7% (95% CI 86–97.6%). All the failures were due to the femoral component. However, the reported survival with the use of traditional uncemented and cemented femoral stems is beyond 99% at similar period of follow-up. Patient selection particularly in patients with secondary osteoarthritis is therefore a critical factor when choosing BHR components.
Twenty two tumours were excised and 3 had curettage performed (1 child and 2 adults). There were 2 recurrences (one osteoid osteoma, one osteoblastoma), one from the excision group and one who had curettage, both in adults. These were successfully treated with re-excision. Mean follow-up was 8 years and all were alive at the time of final follow-up.
Prospective data was collected using a paper proforma in frame clinic. Information was gathered on all patients sent for plain radiographs. Radiographers collected data regarding time taken in the X-ray Department and total number of radiographs taken to gain the images required. The senior author recorded if these images were satisfactory and if returned to the department for further imaging. The radiation dose was retrieved from the Radiology computer. The control group consisted of patients from clinics prior to implementation of the spirit-level device. Following a period of familiarization, data was collected from the study group using the spirit-level.
The clinical outcome was measured using Harris, Charnley, Oxford hip scores and quality of life using SF-36. Radiographs were systematically analysed for implant position, fixation, and loosening.
The clinical scores were respectively, Harris 85 (25–100), Oxford 21.5 (12–52), mean Charnley score 4.8 for pain, 5.3 for movement and 4.3 for mobility; the mean SF-36 score were 44 (12–58) for the physical and 51.4 (19–71) for the mental component. With an end point of definite or probable aseptic loosening, the probability of survival at 5 years was 100% and 97.3% (95% CI = 2.9) for acetabular and femoral components respectively. Overall survival at 5years with removal or repeat revision of either component for any reason as the end point was 91% (95% CI: 82 to 97%).
Twenty two tumours were excised and 3 had curettage performed (1 child and 2 adults). There were 2 recurrences (one osteoid osteoma, one osteoblastoma), one from the excision group and one who had curettage, both in adults. These were successfully treated with re-excision. Mean follow-up was 8 years and all were alive at the time of final follow-up.
The predominant presenting symptom was pain. Pathological fracture occurred in 7 patients. The operative treatment consisted of curettage (21), excision (51) and resection (9) with supplemented bone grafting (13). Adjuvant chemo (=61) and radiotherapy (=131) was also used in selective cases. Thirty patients were alive with no evidence of disease at a mean 5 year follow-up. Six were alive with persistent primary disease and/or local recurrence and/or metastases at the time of review. Eighty four patients died with persistent primary disease, 30 patients died of metastatic disease, 9 due to local recurrence and 17 of unrelated causes.
Intraosseous schwannoma is a rare benign neoplasm, which most commonly arises in the head and neck region particularly the mandible, due to the long intraosseous path of sensory nerves in the mandible. We present a 27-year-old lady with an unusual presentation of an intraosseous schwannoma of the first metatarsal. There is only one report published previously of an intraossous schwannoma of the lesser metatarsal bone of the foot. A 27-year-old woman presented with painful left forefoot following a trip while walking. Plain radiographs demonstrated a pathological fracture through a lytic lesion of the first metatarsal of the left foot. MRI scan using axial T1-weighted spin echo and axial and sagittal T2-weighted gradient echo showed an amorphous mass occupying the medulla of the bone but with a breach of the plantar aspect of cortex with apparent localised destruction. Ultrasound-guided biopsy was performed. Haematoxylin and Eosin stained specimen sections showed a proliferation of spindle cells of alternating hypercellularity and hypocellularity. This case was managed by curettage and grafting with autograft and synthetic bone substitute. At two-year follow-up, the radiographs showed complete graft incorporation and a healed cyst. The patient was clinically asymptomatic with return of full functions. There were no clinico-radiological findings to suggest any recurrence. Due to rarity and non-specific clinico-radiological features, this case illustrates the necessity of a multi-disciplinary approach with an accurate histological diagnosis in combination with radiological and clinical appearances.