The treatment of chronic osteomyelitis: a 10 year audit.

Despite modern surgical techniques and advanced antimicrobial therapy, osteomyelitis remains a difficult and challenging problem. A 10 year audit study from 1990 to 2000 was carried out to assess the outcome of treatment of chronic osteomyelitis. A total of 41 patients with chronic osteomyelitis (26 male, 15 female with an age range of 10-76 years, mean 45.3 years) underwent extirpation and reconstruction with muscle interposition. The duration of osteomyelitis ranged from 1 to 69 years (mean 16.6 years) and many patients had undergone multiple attempted procedures prior to definitive treatment. Thirty-seven patients underwent free microvascular muscle transfer and four patients underwent local transposition muscle flaps. Two of the 41 patients developed recurrent sepsis at 12 months (4.4% recurrence rate). These were treated successfully with elevation of the flap and curettage of the remaining infection and debris and re-insetting of the flap. Only one patient in the series required a below knee amputation and this was as a result of persistent intractable bone pain rather than recurrence of the osteomyelitis.

A simple and fail safe method for digital tourniquet.

Digital tourniquets are commonly used to provide a bloodless field for surgery to the finger. Such tourniquets, however, are potentially harmful and disastrous consequences occur if they are accidentally left in place. We propose a modification of the rubber glove tourniquet technique that will provide a safe and reliable tourniquet.

Free tissue transfer in patients with systemic lupus erythematosus.

Systemic lupus erythematosus is a non-organ specific, autoimmune disease characterised by antinuclear antibodies and vasculitis. This may manifest itself with areas of cutaneous necrosis which may require extensive excision and reconstruction. Major areas of skin and soft tissue loss may require coverage with either local or microvascular free tissue transfer. This presents potential difficulties in patients with generalised vasculitis. We present the case of a professional cellist with extensive soft tissue loss in her dominant hand, successfully reconstructed with a free latissimus dorsi muscle flap, treated with peri- and postoperative anticoagulation and corticosteroids.

The beneficial effects of immunostimulation in posttraumatic sepsis.

Granulocyte macrophage-colony stimulating factor (GM-CSF) is a myelopoietic cytokine that may enhance immune mechanisms directed against bacterial infection. Injury is associated with an increased incidence of such infection. This study assessed the potential immunostimulatory role of GM-CSF in the injured host predisposed to infection. Six- to eight-week old female CD-1 mice underwent trauma and were then randomized to received either GM-CSF or saline vehicle control intraperitoneally for 5 days. They then received a septic challenge in the form of a cecal ligation and puncture. Following this, assessment was made of survival and bacterial growth indices in blood cultures, and peritoneal cells were harvested for assessment of peritoneal immune function. Intraperitoneal GM-CSF administration daily for 5 days following injury was associated with significantly greater survival following cecal ligation and puncture compared to controls (40 vs 5%, P < 0.05). There was a significant increase in peritoneal cell yields in the GM-CSF group compared to the control group (11 +/- 1 x 10(6) vs 8 +/- 1 x 10(6) P < 0.05). PMA-stimulated macrophages released significantly higher amounts of both superoxide anion (1.4 +/- 0.1 vs 0.93 +/- 0.1, P < 0.05) and tumor necrosis factor (5.2 +/- 0.6 vs 2.6 +/- 0.7, P < 0.03) and significantly less nitric oxide compared to the control group (175 +/- 8 vs 267 +/- 24, P < 0.003). Finally, bacterial growth indices were significantly reduced following GM-CSF administration (194 +/- 6 vs 218 +/- 4, P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Granulocyte-macrophage colony-stimulating factor inhibits tumour growth.

The effect of granulocyte-macrophage colony-stimulating factor (GM-CSF) on murine antitumour responses was examined. Sixty mice received Lewis lung carcinoma implants and were then randomized to receive GM-CSF 1 microgram/day, GM-CSF 0.5 microgram/day or saline for 10 days and studied with regard to tumour volume, carcass weight and food intake. Macrophage antitumour mechanisms including oxygen free radical production and nitric oxide release were studied in peritoneal macrophages after co-culture with GM-CSF in vitro and in vivo. GM-CSF 1 microgram/day decreased tumour growth after 5 days (mean(s.e.m.) 0.62(0.14) versus 1.24(0.19) cm3, P = 0.017). GM-CSF upregulated macrophage antitumour mechanisms by enhancing the in vivo production of superoxide radicals (mean(s.e.m.) 0.69(0.06) versus 0.45(0.10) nmol, P < 0.05) and nitric oxide (mean(s.e.m.) 48(3) versus 24(4) mumol, P < 0.01). GM-CSF functions through the enhancement of macrophage tumoricidal activity, suggesting a therapeutic potential for this cytokine in the tumour-bearing host.

Safety of double-stapled anastomosis in low anterior resection.

Clinical leakage of the anastomosis follows low anterior resection for rectal carcinoma in 5-10 per cent of patients despite standard stapling techniques. A modification of this method has obviated the need for a distal purse string. A flexible transverse stapling instrument (Roticulator 55) is applied across the rectum below the tumour, and a double-staggered row of staples is inserted as a substitute for the distal purse string. End-to-end stapled anastomosis is then performed with peranal insertion of a Premium CEEA stapling instrument. In 111 patients the indications for operation were colorectal carcinoma (96 patients), diverticulosis (ten), megarectum (four) and ulcerative proctocolitis (one). Three patients had clinical evidence of anastomotic leakage; all survived. The incidence of radiological leakage on Gastrografin enema 10-12 days after operation was 9 per cent. The perioperative mortality rate was 2 per cent; all deaths were from cardiovascular causes. Local recurrence of tumour occurred in eight patients (7 per cent) after a mean follow-up of 40 months. In conclusion, double-stapled end-to-end anastomosis has made low anterior resection for rectal carcinoma a safe procedure with a low mortality rate, an acceptable local recurrence rate and minimal (clinical) anastomotic leakage.

Let the finger linger.

Retrorectal masses are rare and of insidious onset. We report a consecutive series of six such cases (males = 4, females = 2). The main presenting complaint was back pain and the most reliable physical sign was a palpable mass posteriorly on rectal examination (all cases). C T scan was the most radiologically informative investigation. Surgical intervention was undertaken using both anterior (trans-abdominal) and posterior (retrorectal) approaches. The majority of the masses excised were benign and all patients, to date, remain well.