Floating knee injuries: long-term results of four treatment methods.

One hundred twenty-four consecutive patients with true floating knee injury presented between 1987 and 2001. They were treated with non-operative, operative (external fixation and intramedullary nailing) and combined modalities. Sixty patients were followed up, at an average of 7.2 years, for age, gender, type of trauma and fracture; time to fracture union and time to mobilisation. Complications that were encountered and return to normal activities were recorded. Better and comparable union rates of fractures, earlier return to activities and higher excellent and good long-term functional results were observed among combined and operative (intramedullary nail) groups. Using combined modalities of treatment is an affordable, practicable and effective approach, especially for a resource-poor environment. External fixation of the fractured femur resulted in a decreased range of movement at the knee due to quadriceps muscle fixation. Fractured tibia, treated by any of the method, did not interfere with patient's joint mobilisation whereas associated injuries did.

A follow-up study of patients with spinal cord injury in Sierra Leone.

Over an 18-month period, 24 patients were admitted with spinal cord injuries in a non-governmental organization hospital in one of the world's poorest countries, Sierra Leone. Seven patients died while in hospital. Follow-up data was available for 13 of the 17 survivors an average of 17.4 (10-28) months after discharge. Five patients were still alive.

Antibiotics for preventing infection in open limb fractures.

BACKGROUND: Wound and bone infections are frequently associated with open fractures of the extremities and may add significantly to the resulting morbidity. The administration of antibiotics is routinely used in developed countries as an adjunct to a comprehensive management protocol that also includes irrigation, surgical debridement and stabilisation when indicated, and is thought to reduce the frequency of infections. OBJECTIVES: To quantify the evidence for the effectiveness of antibiotics in the initial treatment of open fractures of the limbs. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group specialised register (April 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library issue 1, 2003), MEDLINE (1966 to April 2003), EMBASE (1988 to April 2003), LILACS (1992 to June 2002) and reference lists of articles. Proceedings of meetings of the American Academy of Orthopaedic Surgeons (1980 to 2001), the Orthopaedic Trauma Association (1990 to 2001) and the Société Internationale de Chirurgie Orthopedique et Traumatologique (1980 to 2001) were hand searched. We also contacted published researchers in the field. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials involving: participants - people of any age with open fractures of the limbs; intervention - antibiotic administered before or at the time of primary treatment of the open fracture compared with placebo or no antibiotic; outcome measures - early wound infection, chronic drainage, acute or chronic osteomyelitis, delayed unions or non-unions, amputations and deaths. DATA COLLECTION AND ANALYSIS: Two reviewers independently screened papers for inclusion, assessed trial quality using an eight item scale, and extracted data. Additional information was sought from three trialists. Pooled data are presented graphically. MAIN RESULTS: Data from 913 participants in seven studies were analysed. The use of antibiotics had a protective effect against early infection compared with no antibiotics or placebo (relative risk 0.41 (95% confidence interval (CI) 0.27 to 0.63); absolute risk reduction 0.08 (95% CI 0.04 to 0.12); NNT 13 (95% CI 8 to 25)). There were insufficient data in the included studies to evaluate other outcomes. REVIEWER'S CONCLUSIONS: Antibiotics reduce the incidence of early infections in open fractures of the limbs. Further placebo controlled randomised trials are unlikely to be justified in middle and high income countries. Further research is necessary to the determine the avoidable burden of morbidity in countries where antibiotics are not used routinely in the management of open fractures.

Femoral shaft fractures in children--a comparison of treatment.

Between April 1986 and March 1997, 83 femoral-shaft fractures in children 4-8 years old were treated at Christian Medical College and Hospital, Ludhiana, India. Among 35 patients with a minimum of 12 months follow-up, 14 were treated with Hamilton-Russell (HR) skin traction and 14 with proximal tibial skeletal traction. The group treated with HR traction had a shorter duration of (a) hospital stay (average 16.8 days versus 29.7 days for skeletal traction, p=0.02), (b) time to fracture consolidation (average 8.8 weeks versus 10.8 weeks for skeletal traction, p=0.04), and (c) return to normal activities (average 12.2 weeks versus 17.2 weeks for skeletal traction, p=0.03). At final follow-up (minimum 1 year), there were no significant differences in functional outcomes. Conservative management is still a gold standard for treatment of closed femoral shaft fractures in children 4-8 years of age. There appears to be no advantage to skeletal traction over skin traction in this age group.

Postoperative infections in asymptomatic HIV-seropositive orthopedic trauma patients.

In a retrospective study of 476 surgical orthopedic trauma patients, we compared postoperative infection rates between individuals seropositive for the human immunodeficiency virus (HIV) and with no associated clinical symptoms with HIV-seronegative patients. Overall, the surgical postoperative infection rate was 16.7% in seropositive patients and 5.4% in the seronegative group (Chi-square, p = 0.035). When open fractures were considered separately, the seropositive group had a 55.6% infection rate compared with 11.3% in the seronegative group (Fisher's exact test, p = 0.004). Similarly, seropositive patients also had significantly increased rates of postoperative non-wound infections and complications (Chi-square p < 0.001). Asymptomatic HIV-seropositive orthopedic trauma patients are at significantly higher risk for postoperative infections than their seronegative counterparts. For HIV-seropositive patients with open fractures, this risk is especially pronounced.

Double-blind randomized prospective study of the efficacy of antibiotic prophylaxis for open reduction and internal fixation of closed ankle fractures.

Antibioprophylaxis has been proven to be efficient for some orthopaedic procedures. However, its efficacy for clean limited procedures with metallic implants is not clear. One hundred twenty-two closed ankle fracture patients undergoing open reduction and internal fixation were randomized, double-blindly, to receive either cephalothin (1 g i.v. every 6 h x four doses) or a placebo starting before tourniquet application. Mean trauma-surgery delay was 30.2 h, and average tourniquet duration was 65.4 min. Four patients (three of 62 on placebo and one of 60 on cephalothin) developed a superficial wound infection. One of the patients in the placebo group was hospitalized and treated with i.v. antibiotics. However, there was no osteomyelitis or premature hardware removal. The difference between the two groups was not statistically significant (chi 2 test of appreciation p = 0.33, two-tailed probabilities). Therefore, cephalothin prophylaxis does not seem justified in this patient population. A larger series is needed to avoid a type II error.

Outcome of arterial repairs in 23 consecutive patients at the ICRC-Peshawar hospital for war wounded.

Arterial injuries represent a formidable challenge to surgeons working in war zone conditions. A series of 23 consecutive patients with combat wounds from the Afghan conflict with acute arterial injury were treated at the ICRC hospital in Peshawar. The mean injury-treatment delay (lag time) was 34 hours, with 14 of the 23 patients (60%) treated more than 12 hours after injury. The overall amputation rate was 65%, but only 22% for patients revascularized within 12 hours of injury and 93% for those undergoing surgery after 12 hours. This was a highly significant statistical difference (Chi-square > 13.0, p < 0.005). We recommend attempting revascularization procedures only in patients seen within 12 hours of sustaining a military-type injury to an artery in an extremity.

Heterotopic ossification of the patellar tendon following intramedullary nailing of the tibia: report on two cases.

Heterotopic ossification (HO) of the patellar tendon following intramedullary nailing of the tibia for fracture, which has not been previously documented, occurred in 2 of 31 patients reviewed who had adequate follow-up after this procedure. One suffered grade IV HO and the other grade II HO using a modification of the Brooker classification. The patient with grade IV HO had serious disability from pain and decreased range of motion. Risk factors previously suggested were associated with the formation of heterotopic bone in our two patients. These factors included head injury and long-term hypoxemia.

The vertical axis fracture: a report on three cases.

We report on three cases of a rare fracture of the posterior body of C2. This is a variant of the classic traumatic spondylolisthesis and appears to respond to conservative management.

Scapulothoracic arthrodesis for patients who have fascioscapulohumeral muscular dystrophy.

In nine patients who had fascioscapulohumeral muscular dystrophy, thoracoscapular arthrodesis was done for the treatment of symptomatic winging of the scapula. The objective was to improve the use of the upper extremity in the performance of activities of daily living. Seven patients had a bilateral procedure. The active range of motion of the shoulder improved in all patients, with flexion increasing an average of 33 degrees and abduction, 25 degrees. Complications included pneumothorax, pleural effusion, atelectasis, fracture of the scapula, and pseudarthrosis. The length of follow-up averaged sixty-nine months, and the results did not deteriorate with time.

Scenarios for pharmacy manpower in the years ahead.

Many of the statistics on the elderly are well-known, but they bear repetition. The steady growth in the number of elderly is both large and striking. Every day, nearly 1600 persons join the group classified as elderly. There may be more than 40 million elderly people in the United States by the year 2020. It is of the utmost importance to realize that the proportion of elders in the 75-year and older group is increasing most sharply. By the year 2000, almost 45% of all elders will be 75 years and older. It is among the frail old that the most serious health problems are encountered, that the most serious adverse drug reactions are encountered, and that even minor health probelms, if left untended, may well develop into major ones. Pharmacists, therefore, need to look toward an increasing involvement in acute as well as chronic care for their elderly patients and must develop expertise in the delivery of preventive care.