Between June 1999 and May 2003 we undertook direct primary closure of the skin wounds of 173 patients with Gustilo and Anderson grade-IIIA and grade-IIIB open fractures. These patients were selected from a consecutive group of 557 with type-III injuries presenting during this time. Strict criteria for inclusion in the study included debridement within 12 hours of injury, no sewage or organic contamination, no skin loss either primarily or secondarily during debridement, a Ganga Hospital open injury skin score of 1 or 2 with a total score of ten or less, the presence of bleeding skin margins, the ability to approximate wound edges without tension and the absence of peripheral vascular disease. In addition, patients with polytrauma were excluded.

At a mean follow-up of 6.2 years (5 to 7), the outcome was excellent in 150 (86.7%), good in 11 (6.4%) and poor in 12 (6.9%). A total of 33 complications occurred in 23 patients including superficial infection in 11, deep infection in five and the requirement for a secondary skin flap in three. Six patients developed nonunion requiring further surgery, one of whom declined additional measures to treat an established infected nonunion.

Immediate skin closure when performed selectively with the above indications proved to be a safe procedure.

Limb-injury severity scores are designed to assess orthopaedic and vascular injuries. In Gustilo type-IIIA and type-IIIB injuries they have poor sensitivity and specificity to predict salvage or outcome.

We have designed a trauma score to grade the severity of injury to the covering tissues, the bones and the functional tissues, grading the three components from one to five. Seven comorbid conditions known to influence the management and prognosis have been given a score of two each. The score was validated in 109 consecutive open injuries of the tibia, 42 type-IIIA and 67 type-IIIB. The total score was used to assess the possibilities of salvage and the outcome was measured by dividing the injuries into four groups according to their scores as follows: group I scored less than 5, group II 6 to 10, group III 11 to 15 and group IV 16 or more.

A score of 14 to indicate amputation had the highest sensitivity and specificity. Our trauma score compared favourably with the Mangled Extremity Severity score in sensitivity (98% and 99%), specificity (100% and 17%), positive predictive value (100% and 97.5%) and negative predictive value (70% and 50%), respectively. A receiver-operating characteristic curve constructed for 67 type-IIIB injuries to assess the efficiency of the scores to predict salvage, showed that the area under the curve for this score was better (0.988 (± 0.013 sem)) than the Mangled Extremity Severity score (0.938 (± 0.039 sem)). All limbs in group IV and one in group III underwent amputation. Of the salvaged limbs, there was a significant difference in the three groups for the requirement of a flap for wound cover, the time to union, the number of surgical procedures required, the total days as an in-patient and the incidence of deep infection (p < 0.001 for all). The individual scores for covering and functional tissues were also found to offer specific guidelines in the management of these complex injuries.

The scoring system was found to be simple in application and reliable in prognosis for both limb-salvage and outcome measures in type-IIIA and type-IIIB open injuries of the tibia.

Study Design: An in-vivo serial magnetic resonance imaging study of diffusion characteristics in human lumbar discs over 24 hours in healthy volunteers and patients with low back pain. Objective: Nutrition to the disc is solely by diffusion but no firm data is available on diffusion pattern in humans. This study reports diffusion patterns in a human population studied and documents the 24-hour diffusion pattern.

Methods: T1-weighted images were obtained pre and post-contrast with Gadodiamide-0.3mmol/kg at 5, 10 minutes, 2, 4, 6, 12 and 24hours. Diffusion was calculated by measuring signal intensity values in seven regions of interest (anterior and posterior annulus, anterior, posterior, peripheral (PNP) and central (CNP) parts of nucleus pulposus (NP). Enhancement percentage (EP), Peak enhancement percentage (PEP) and time to achieve PEP (T_max) were calculated.

Subjects: Of the 215 discs in 43 persons (10 volunteers and 33 patients) 96 discs were normal and considered for study.

Results: Diffusion occurred mainly from the endplate (rather than annulus). The mean EP of PNP and CNP at 5 minutes was 6.7, 3.9; 10minutes was 7.5, 4.0; 2 hours was 36.6, 17.9; 4hrs was 42.8, 29.8; 6hrs was 51.7, 40.5; 12hrs was 35.9, 27.8 and 24 hours was 33.3, 27.9. Though PEP was achieved at 6 hours in NP, the CNP lagged behind throughout. Univariate ANOVA showed that there was significant difference (p< 0.0001) in PEP of NP between the age groups of less than ten (72.4) and higher (37.9). The mean PEP at the NP of lower two discs (26.8) was less compared to upper two discs 41.0(p=0.059). Stepwise linear regression analysis showed that diffusion to the CNP was significantly influenced by age (R² =0.324), followed by level of disc (R²=0.5).

Conclusion: This is the first study to document the normal 24-hour diffusion pattern across lumbar discs. The data can form the basis for comparison of diffusion changes in degeneration, Modic’s endplate changes and smoking.