A safe technique for insertion of heel wires for hindfoot external fixation frames: an anatomical study.

Aims: Anatomical atlases document classical safe corridors for the placement of transosseous fine wires through the calcaneum during circular frame external fixation. During this process, the posterior tibial neurovascular bundle (PTNVB) is placed at risk, though this has not been previously quantified. We describe a cadaveric study to investigate a safe technique for posterolateral to anteromedial fine wire insertion through the body of the calcaneum. Materials and Methods: A total of 20 embalmed cadaveric lower limbs were divided into two groups. Wires were inserted using two possible insertion points and at varying angles. In Group A, wires were inserted one-third along a line between the point of the heel and the tip of the lateral malleolus while in Group B, wires were inserted halfway along this line. Standard dissection techniques identified the structures at risk and the distance of wires from neurovascular structures was measured. The results from 19 limbs were subject to analysis. Results: In Group A, no wires pierced the PTNVB. Wires were inserted a median 22.3 mm (range 4.7 to 39.6) from the PTNVB; two wires (4%) passed within 5 mm. In Group B, 24 (46%) wires passed within 5 mm of the PTNVB, with 11 wires piercing it. The median distance of wires from the PTNVB was 5.5 mm (range 0 to 30). A Mann-Whitney U test showed that this was significantly closer than in Group A (Hodges-Lehmann shift, 14.06 mm; 95% confidence interval (CI) 10.52 to 16.88; p < 0.0001). In Group B, with an increased angle of insertion there was greater risk to the PTNVB (rs = -0.80; p < 0.01). Conclusion: Insertion of wires using an entry point one-third along a line from the point of the heel to the tip of the lateral malleolus (Group A) appears to be the safer technique. An insertion angle of up to 30° to the coronal plane can be used without significant risk to the PTNVB. Insertion of wires halfway along a line from the point of the heel to the tip of the lateral malleolus (Group B) carried a significantly higher risk of injury to neurovascular structures and, if necessary, an angle of insertion parallel to the coronal plane should be used. Cite this article: Bone Joint J 2018;100-B:1054-9.

Treatment and functional outcomes of complex tibial fractures in children and adolescents using the Ilizarov method.

Aims: The aim of this study was to report the clinical, functional and radiological outcomes of children and adolescents with tibial fractures treated using the Ilizarov method. Patients and Methods: Between 2013 and 2016 a total of 74 children with 75 tibial fractures underwent treatment at our major trauma centre using an Ilizarov frame. Demographic and clinical information from a prospective database was supplemented by routine functional and psychological assessment and a retrospective review of the notes and radiographs. Results: Of the 75 fractures, 26 (35%) were open injuries, of which six (8%) had segmental bone loss. There were associated physeal injuries in 18 (24%), and 12 (16%) involved conversion of treatment following failure of previous management. The remaining children had a closed unstable fracture or significant soft-tissue compromise. The median follow-up was 16 months (7 to 31). All fractures united with a median duration in a frame of 3.6 months (interquartile range 3.1 to 4.6); there was no significant difference between the types of fracture and the demographics of the patients. There were no serious complications and no secondary procedures were required to achieve union. Health-related quality of life measures were available for 60 patients (80%) at a minimum of six months after removal of the frame. These indicated a good return to function (median Paediatric quality of life score, 88.0; interquartile range 70.3 to 100). Conclusion: The Ilizarov method is a safe, effective and reliable method for the treatment of complex paediatric tibial fractures. Cite this article: Bone Joint J 2018;100-B:396-403.

The treatment of segmental tibial fractures: does patient preference differ from surgeon choice?

INTRODUCTION: Segmental tibial fractures are complex injuries with a prolonged recovery time. Current definitive treatment options include intramedullary fixation or a circular external fixator. However, there is uncertainty as to which surgical option is preferable and there are no sufficiently rigorous multi-centre trials that have answered this question. The objective of this study was to determine whether patient and surgeon opinion was permissive for a randomised controlled trial (RCT) comparing intramedullary nailing to the application of a circular external fixator. MATERIALS AND METHODS: A convenience questionnaire survey of attending surgeons was conducted during the United Kingdom's Orthopaedic Trauma Society annual meeting 2017 to determine the treatment modalities used for a segmental tibial fracture (n=63). Patient opinion was obtained from clinical patients who had been treated for a segmental tibial fracture as part of a patient and public involvement focus group with questions covering the domains of surgical preference, treatment expectations, outcome, the consent process and follow-up regime (n=5). RESULTS: Based on the surgeon survey, 39% routinely use circular frame fixation following segmental tibial fracture compared to 61% who use nail fixation. Nail fixation was reported as the treatment of choice for a closed injury in a healthy patient in 81% of surgeons, and by 86% for a patient with a closed fracture who was obese. Twenty-one percent reported that they would use a nail for an open segmental tibia fracture in diabetics who smoked, whilst 57% would opt for a nail for a closed injury with compartment syndrome, and only 27% would use a nail for an open segmental injury in a young fit sports person. The patient and public preference exercise identified that sleep, early functional outcomes and psychosocial measures of outcomes are important. CONCLUSION: We concluded that a RCT comparing definitive fixation with an intramedullary nail and a circular external fixator is justified as there remains uncertainty on the optimal surgical management for segmental tibial fractures. Furthermore, psychosocial factors and early post-operative outcomes should be reported as core outcome measures as part of such a trial.

The treatment of intramedullary osteomyelitis of the femur and tibia using the Reamer-Irrigator-Aspirator system and antibiotic cement rods.

Intramedullary infection in long bones represents a complex clinical challenge, with an increasing incidence due to the increasing use of intramedullary fixation. We report a prospective case series using an intramedullary reaming device, the Reamer-Irrigator-Aspirator (RIA) system, in association with antibiotic cement rods for the treatment of lower limb long bone infections. A total of 24 such patients, 16 men and eight women, with a mean age of 44.5 years (17 to 75), 14 with femoral and 10 with tibial infection, were treated in a staged manner over a period of 2.5 years in a single referral centre. Of these, 21 patients had had previous surgery, usually for fixation of a fracture (seven had sustained an open fracture originally and one had undergone fasciotomies). According to the Cierny-Mader classification system, 18 patients were classified as type 1A, four as 3A (discharging sinus tract), one as type 4A and one as type 1B. Staphylococcus species were isolated in 20 patients (83.3%). Local antibiotic delivery was used in the form of impregnated cement rods in 23 patients. These were removed at a mean of 2.6 months (1 to 5). Pathogen-specific antibiotics were administered systemically for a mean of six weeks (3 to 18). At a mean follow-up of 21 months (8 to 36), 23 patients (96%) had no evidence of recurrent infection. One underwent a planned trans-tibial amputation two weeks post-operatively due to peripheral vascular disease and chronic recalcitrant osteomyelitis of the tibia and foot. The combination of RIA reaming, the administration of systemic pathogen-specific antibiotics and local delivery using impregnated cement rods proved to be a safe and efficient form of treatment in these patients.

The treatment of complex tibial shaft fractures by the Ilizarov method.

We report on the use of the Ilizarov method to treat 40 consecutive fractures of the tibial shaft (35 AO 42C fractures and five AO 42B3 fractures) in adults. There were 28 men and 12 women with a mean age of 43 years (19 to 81). The series included 19 open fractures (six Gustilo grade 3A and 13 grade 3B) and 21 closed injuries. The mean time from injury to application of definitive Ilizarov frame was eight days (0 to 35) with 36 fractures successfully uniting without the need for any bone-stimulating procedure. The four remaining patients with nonunion healed with a second frame. There were no amputations and no deep infections. None required intervention for malunion. The total time to healing was calculated from date of injury to removal of the frame, with a median of 166 days (mean 187, (87 to 370)). Minor complications included snapped wires in two patients and minor pin-site infections treated with oral antibiotics in nine patients (23%). Clinical scores were available for 32 of the 40 patients at a median of 55 months (mean 62, (26 to 99)) post-injury, with 'good' Olerud and Molander ankle scores (median 80, mean 75, (10 to 100)), 'excellent' Lysholm knee scores (median 97, mean 88, (29 to 100)), a median Tegner activity score of 4 (mean 4, (0 to 9)) (comparable to 'moderately heavy labour / cycling and jogging') and Short Form-12 scores that exceeded the mean of the population as a whole (median physical component score 55 (mean 51, (20 to 64)), median mental component score 57 (mean 53, (21 to 62)). In conclusion, the Ilizarov method is a safe and reliable way of treating complex tibial shaft fractures with a high rate of primary union.

The 'Retro-Fibular Wire': an anatomical study describing a safe corridor for placement of fine wires in the distal tibia.

Anatomical atlases document safe corridors for placement of wires when using fine-wire circular external fixation. The furthest posterolateral corridor described in the distal tibia is through the fibula. This limits the crossing angle and stability of the frame. In this paper we describe a new, safe Retro-Fibular Wire corridor, which provides greater crossing angles and increased stability. In a cadaver study, 20 formalin-treated legs were divided into two groups. Wires were inserted into the distal quarter of the tibia using two possible corridors and standard techniques of dissection identified the distance of the wires from neurovascular structures. In both groups the posterior tibial neurovascular bundle was avoided. In group A the peroneal artery was at risk. In group B this injury was avoided. Comparison of the groups showed a significant difference (p < 0.001). We recommend the Retro-Fibular wire technique whereby wires are inserted into the tibia mid-way between the posteromedial border of the fibula and the tendo Achillis, at 30 degrees to 45 degrees to the sagittal plane, and introduced from a posterolateral to an anteromedial position. Subsequently, when using this technique in 30 patients, we have had no neurovascular complications or problems relating to tethering of the peroneal tendons.

Changes in regional cerebral blood flow elicited by craving memories in abstinent opiate-dependent subjects.

OBJECTIVE: The brain circuitry of opiate craving was investigated with positron emission tomography (PET) imaging of regional cerebral blood flow (rCBF). METHOD: Twelve abstinent opiate-dependent subjects listened to audiotaped autobiographical scripts of an episode of craving and a neutral episode while undergoing a PET scan with the tracer [(15)O]H(2)O. Statistical parametric mapping was used to analyze the PET images of rCBF changes. RESULTS: Comparison of the drug-related and neutral stimulus conditions revealed activation of rCBF in the left medial prefrontal and left anterior cingulate cortices and deactivation in the occipital cortex in response to the drug-related stimulus. A further statistical parametric mapping analysis with a subjective rating of craving as a covariate showed a positive association of between craving and rCBF in the left orbitofrontal cortex. CONCLUSIONS: The patterns of cerebral activation reflect the different brain regions mediating the salience of opiate-related stimuli and the subjective experience of craving for opiates.

All basic surgical trainees should rotate through an accident and emergency post.

UNLABELLED: A 6-month post in accident and emergency is no longer compulsory for basic surgical training. Meanwhile, trauma teams have emerged in many UK hospitals to receive seriously injured patients, often with no involvement of basic surgical trainees (BSTs). This may lead to the appointment of surgical specialist registrars (SpRs) who have had little exposure to the initial management of seriously injured patients. This study documents the experience of a senior house officer undertaking a 6-month post in the accident and emergency department of a district general hospital. METHODS: Data concerning the nature of cases seen were collected retrospectively from all patient record cards signed by the author during the placement. RESULTS: During the period studied, the author was present in the resuscitation room on 41 occasions, of which 10 episodes involved the management of a multiply injured patient. A total of 159 fractures and significant soft tissue injuries in the upper limb and 122 such cases in the lower limb were seen. There were 25 head injuries, 17 spinal injuries, 5 significant cases of chest trauma, 4 of abdominal trauma and 5 significant urinary tract injuries. Some 86 practical procedures were carried out during the placement. DISCUSSION: The 6-month post in accident and emergency provided the BST with significant exposure to the care of seriously injured patients. Such a post should be compulsory to ensure that SpRs on appointment have already received exposure to managing the seriously injured. The post provided additional benefit in terms of performing practical procedures and exposure to other acute surgical conditions.

The impact of trauma teams on basic surgical training.

An analysis of the number of trauma teams and the extent of involvement of basic surgical trainees in these teams in the South-West region is presented.

Chest wall thickness may limit adequate drainage of tension pneumothorax by needle thoracocentesis.

Tension pneumothorax in a large man was inadequately drained by needle thoracocentesis with a 4.5 cm cannula. Unsuccessful needle thoracocentesis of a clinical tension pneumothorax in a large patient should be followed immediately by chest drain insertion, without local anaesthetic, as dictated by clinical urgency. If the clinical situation is still not improved other diagnoses should be considered.

Early (34-56 days from last menstrual period) ultrasonographic measurements in normal pregnancies.

To assess early embryonic growth and development, 361 pregnancies were studied from 34 to 56 days from last menstrual period. All pregnancies had a subsequent successful outcome. Transvaginal ultrasonography was performed using an Acuson 128 x P/10 with a 5-7.5 MHz probe. Gestational sac diameter, embryonic pole length and embryonic heart rates were measured. Embryonic heart rates were determined by M-mode. Gestational sac diameter, embryonic pole length and embryonic heart rate increased linearly relative to gestational age and to each other. Regression equations comparing gestational sac diameter and embryonic pole length as well as comparing embryonic heart rate with gestational sac diameter and embryonic pole length were constructed. To be normal, gestations that have (i) sac diameter of 20 mm and 30 mm should contain at least a 2 mm and 5 mm embryo with embryonic heart rates of at least 75 and 100 beats per min, respectively, and (ii) embryos measuring 2 mm, 5 mm, 10 mm and 15 mm should display embryonic heart rates of at least 75, 100, 120 and 130 beats per minute respectively.

Needle thoracocentesis in tension pneumothorax: insufficient cannula length and potential failure.

Advanced Trauma Life Support guidelines recommend the use of a cannula 3 to 6 cm long to perform needle thoracocentesis for life-threatening tension pneumothorax. The chest wall thickness in the 2nd intercostal space, mid-clavicular line, was determined by ultrasound in 54 patients aged 18 to 55 years, and ranged from 1.3 to 5.2 cm (mean 3.2 cm). In thirty-one patients (57 per cent) the chest-wall thickness (CWT) was greater than 3 cm, the minimum recommended cannula length, although in only two (4 per cent) was it greater than 4.5 cm, the length of cannula commonly used in the UK. As a 3 cm cannula would fail to reach the pleural cavity in over half of patients, we suggest that the recommended shortest length be increased to 4.5 cm. Unsuccessful needle thoracocentesis using a 4.5 cm cannula should be followed immediately by insertion of a longer cannula or a definitive chest drain.

Comparison of pulsatility indices on the day of oocyte retrieval and embryo transfer.

Transvaginal ultrasonography with colour blood flow imaging and analysis of impedance to uterine arterial blood flow has been used to provide an index of uterine receptivity for implantation after IVF/embryo transfer. A mean uterine arterial pulsatility index (PI) > 3.0 at the time of embryo transfer predicted 35% of failures to become pregnant. Cryopreserving embryos in non-receptive cycles and transferring them in receptive cycles would be expected to improve pregnancy rates. Earlier decisions regarding embryo cryopreservation can be made if receptive cycles can be predicted at the time of oocyte retrieval rather than at embryo transfer. To assess differences in uterine artery impedance, PI were measured serially in 107 women on both the day of oocyte retrieval and the day of embryo transfer. Mean PI on the day of oocyte retrieval was 2.52 +/- 0.59, and on the day of embryo transfer was 2.78 +/- 0.45. No significant difference was observed when PI determined on the day of oocyte retrieval were compared with PI on the day of embryo transfer. These data suggest that the PI measurement done on the day of oocyte retrieval could substitute for the measurement done on the day of embryo transfer. This would allow prediction of non-receptive endometria earlier in the cycle. Further studies are needed to evaluate whether cryopreservation of embryos and transfer when the uterus is more receptive will increase the implantation rates.

Very early (24-56 days from last menstrual period) embryonic heart rate in normal pregnancies.

To determine embryonic heart rate in early gestations, 426 ultrasonographic examinations from 24 to 56 days from onset of last menstrual period (LMP) were studied. All pregnancies had a subsequent successful outcome. Transvaginal ultrasonography was performed using an Acuson 128 10XP with a 5 MHz probe. Embryonic heart rate was determined by M-mode. No embryonic heart rate was observed prior to 34 days of gestation from onset of LMP (n = 65). At 35 days, two of 13 (15%) pregnancies had cardiac activity, and by 36 days 16 of 19 (82%) pregnancies had cardiac activity. By day 37 from onset of LMP all pregnancies demonstrated embryonic cardiac activity. From days 34 to 56, mean embryonic heart rate rose from 94 to 166 beats/min. We conclude that embryonic cardiac activity is first apparent at day 34 and should be visible by day 37 in normal pregnancies.

Ultrasonographic predictors of implantation after assisted reproduction.

OBJECTIVE: To assess the utility of endometrial thickness, echogenic endometrial pattern, and uterine artery impedance measured as pulsativity index in predicting implantation. DESIGN: Prospective case-controlled study of infertile patients undergoing assisted reproductive technologies (ARTs). PATIENTS: Four hundred five women undergoing ARTs were studied: 100 women after ET of thawed embryos in natural cycles (frozen ET), 107 women after standardized IVF-ET, 99 women receiving donor oocytes after controlled endometrial development with estrogen and P, and 99 women undergoing IUI with various ovarian stimulation regimens (none, 16; GnRH, 7; clomiphene citrate [CC], 29; hMG, 47). INTERVENTIONS: Transvaginal ultrasonographic examination performed on the day of hCG administration during stimulated cycles; on E2 day 15 during controlled endometrial cycles; and on the day of ovulation during natural, CC, and GnRH pump cycles. MAIN OUTCOME MEASURE: The endometrial thickness, echogenic pattern, and pulsativity index results in 170 conception cycles were compared with 235 nonconception cycles. RESULTS: When conception and nonconception cycles were compared, no difference in mean endometrial thickness and significant differences in the frequency of nonmultilayered pattern and pulsativity index > 3.3 were observed. Forty-seven percent of nonconception and 9% of conception cycles were associated with at least one of these factors. CONCLUSION: Ultrasonic measurements of pulsativity index, resistance index, and echogenic pattern are useful in predicting implantation after assisted reproduction.

Effect of inhaled bradykinin on indices of airway responsiveness in asthmatic subjects.

Asthma is characterized by airway hyperresponsiveness, a physiopathological abnormality which may result from the complex interplay between inflammatory cells and proinflammatory mediators. Although kinins are thought to play a role in the pathogenesis of bronchial asthma, it is not known whether bradykinin is able to induce airway hyperresponsiveness. We have, therefore, investigated the effect of inhaled bradykinin on the changes in airway calibre and in airway hyperresponsiveness to histamine, in a double-blind, randomized study of nine asthmatic subjects. Subjects were studied on two study periods, separated by at least 15 days. On the first day of each study period, subjects inhaled either a single dose of bradykinin or methacholine (placebo) with changes in airway calibre being followed as forced expiratory volume in one second (FEV1) and as the maximum expiratory flow rate measured at 70% of the vital capacity below total lung capacity (TLC) from a partial forced expiratory manoeuvre (Vp30) at 3, 5, 10, 15, 30, 45 and 60 min, and then every hour for 7 h. Airway responsiveness to histamine, expressed as the provocative concentrations producing a 20% fall in FEV1 and 40% fall in Vp30 (PC20FEV1 and PC40Vp30), was measured at 3 and 7 h after inhaling the agonists, then on days 1, 3, 7 and 14. Inhalation of bradykinin caused rapid bronchoconstriction that peaked at 3-5 min. When compared to placebo, no significant difference in histamine responsiveness was seen after bradykinin in terms of changes in PC20FEV1 values.(ABSTRACT TRUNCATED AT 250 WORDS)