The change in energy absorbed post removal of metalwork in a simulated paediatric long bone fracture.

PURPOSE: The surgical treatment of paediatric fractures is increasing. Open reduction and internal fixation (ORIF) with plates and screws is long established, whilst the use of elastic stable intramedullary nailing (ESIN) has become increasingly popular. This study quantifies, in terms of the energy required to produce a fracture, the biomechanical sequelae of both techniques post removal of metalwork, to provide clinicians with evidence to guide post-operative advice. METHODS: An immature bovine model was adopted to ascertain whether these techniques exposed the bone to a greater re-fracture risk following removal of the device. Bones were prepared to reflect ORIF or ESIN techniques, or prepared intact for the acquisition of control data. Each bone was tested to failure at 90 °/s, with the absorbed energy then being calculated to determine the relative difference between each technique and versus control data. Data describing peak shear stress and torque were recorded. RESULTS: Absorbed energy was reduced by 47 % in the ORIF group compared to both the control (p = 0.011) and ESIN (p = 0.018) groups. The peak shear stress and torque were also significantly different. All ORIF bones failed through drill holes, suggesting stress localisation around the defects. CONCLUSION: This study suggests that there is a significantly higher re-fracture risk following the removal of ORIF plates when compared to both ESIN and the control environment. Whilst this may reflect the intuitive view of many clinicians, this study provides a quantitative value of the reduction in strength and should help clinicians to appropriately caution patients and parents prior to surgery.

A retrospective review of the assessment of current perioperative management of diabetes in patients undergoing knee replacement surgery.

OBJECTIVES: The prevalence of diabetes mellitus is increasing. Previous work has shown that suboptimal glycaemic control is associated with poor perioperative outcomes with increased rates of postoperative morbidity and mortality in several surgical specialities. Recently published UK guidelines have laid out the standards of perioperative care for patients with diabetes. Because an increasing number of patients with diabetes undergo surgery, it is important that these nationally agreed standards of care are adhered to. DESIGN: A retrospective review of the standard of care of patients against existing audit standards laid down in national guidelines, and a comparison of outcomes with people without diabetes. SETTING: A single major orthopaedic department. PARTICIPANTS: Fifty consecutive patients undergoing knee arthroplasty between July 2010 and June 2011. MAIN OUTCOME MEASURES: Postoperative complications; pre, peri and postoperative glucose control; hospital length of stay. RESULTS: Although there were no serious postoperative complications, the pre, peri and postoperative management was found to be suboptimal, particularly with reference to optimization of blood glucose control, both in terms of HbA1c preoperatively and blood glucose monitoring perioperatively. The average length of hospital stay was not different between groups; however, 36 patients with diabetes had at least one documented hyperglycaemic episode and four at least one hypoglycaemic episode. CONCLUSIONS: Perioperative care of diabetes in patients undergoing knee arthroplasty could be improved. Several changes have been made since this audit was carried out, in particular adoption of the comprehensive Joint British Diabetes Societies Guideline on the perioperative management of adult patients with diabetes.

Total knee arthroplasty in a patient with hemophilic arthropathy and high-titer inhibitors: a cost analysis.

A patient with hemophilia A, who developed factor VIII inhibitors and initially had funding for his total knee arthroplasty declined, is discussed. A total of £1 542 000 (US $2 474 603) was spent on medical treatment for recurrent hemarthroses over a 4-year period, while funding was sought. In comparison, the total cost for his knee arthroplasty was £542 858 (US $871 084) including perioperative recombinant clotting factors. Postoperatively, with 1-year follow-up, no further hemoarthroses have occurred; his analgesic requirement is significantly reduced; he has a much improved level of function; and treatment costs are significantly reduced, leading to a substantial overall saving. Our findings suggest that surgical treatment is beneficial and cost-effective for patients with hemophilia with inhibitors. Hospitals should not deny operative treatment based on cost alone.

Laundry detergent and possible nonaccidental injury.

Nonaccidental injury is always a concern when children present with unusual injuries. The case of a child who presented with a partial thickness burn secondary to prolonged contact with a liquid biological laundry detergent is described. Initially there was some doubt as to whether the agent in question could cause this injury but a small experiment on a volunteer confirmed it was possible.

Giant anterior urethral diverticulum in a neonate.

Congenital anterior urethral diverticulum is an uncommon condition that tends to present in older children with signs of chronic urinary problems. A neonate presented following recurrent collapse, and cystography revealed a giant urethral diverticulum. The diverticulum was incised at cystoscopy, leading to a full recovery.

Elevated amylase in childhood.

A 3-year-old boy was referred to a regional centre with an acute abdomen. On admission, his abdomen was clinically benign but an extremely high serum amylase titre noted. The patient was treated with simple observation and over the following period he was found to have an inflamed parotid gland.