'Rapid transit' constipation in children: a possible genesis for irritable bowel syndrome.

Children with chronic idiopathic constipation (CIC) often end up at the surgeon when medical treatments have failed. This opinion piece discusses a recently described pattern of CIC called 'Rapid transit constipation (RTC)' first identified in 2011 as part of surgical workup. RTC was identified using a nuclear medicine gastrointestinal transit study (NMGIT or nuclear transit study) to determine the site of slowing within the bowel and to inform surgical treatment. Unexpectedly, we found that RTC occured in 29% of 1000 transit studies in a retrospective audit. Irritable bowel syndrome (IBS) occurs in 7-21% of the population, with a higher prevalence in young children and with constipation type dominating in the young. While 60% improve with time, 40% continue with symptoms. First-line therapy for IBS in adults is a diet low in fermentable oligosaccharides, disaccharides, monosaccharides and polyols which reduces symptoms in > 70% of patients. In children with functional gastrointestinal disorders, fructose intolerance occurs in 35-55%. Reducing fructose produced significant improvement in 77-82% of intolerant patients. In children with RTC and a positive breath test upon fructose challenge, we found that exclusion of fructose significantly improved constipation, abdominal pain, stool consistency and decreased laxative use. We hypothesise that positive breath tests and improvement of pain and bowel frequency with sugar exclusion diets in RTC suggest these children have IBS-C. These observations raise the possibility that many children with CIC could be treated by reducing fructose early in their diet and this might prevent the development of IBS in later life.

The use of tranexamic acid to reduce blood loss during total hip arthroplasty: an observational study.

INTRODUCTION: To test the hypothesis that the fall in haemoglobin following total hip arthroplasty is reduced by tranexamic acid administration. PATIENTS AND METHODS: A cohort of 64 patients were studied, 32 received tranexamic acid 20 mg/kg on induction. Surgery was performed by the senior author in a standardised fashion. Haemoglobin levels were measured 2 weeks pre- and 3 days postoperatively. Any complications were noted. The study group was matched using the bone and joint research database for age, sex, procedure, disease and pre-operative haemoglobin level. RESULTS: In the group receiving no tranexamic acid, the mean fall in haemoglobin was 3.8 g/dl (CI of mean 3.4-4.3) and in the group treated with tranexamic acid 2.8 g/dl (CI of mean 2.5-3.2) P < 0.05. Complications included one non-fatal pulmonary embolus in the tranexamic acid group. CONCLUSIONS: The administration of 20 mg/kg of tranexamic acid on induction of surgery is an effective method of reducing the haemoglobin fall following hip arthroplasty.

Traumatic patella tendon rupture: early mobilisation following surgical repair.

This study aims to demonstrate that postoperative immobilisation in a cast is unnecessary following suture repair of the patella tendon and retinacula protected by a cerlage wire. We present 11 patients mean age 42 years evaluated at a mean of 26 months (range 14-38 months). The mean Lysholm knee score at review was 97 (range 92-100). The mean Insall Salvati measurement (length patella/length tendon (LP/LT)) was 1 (range 0.95-1.1). No patients had fixed flexion deformities or demonstrated an extensor lag and the average range of motion was 0-137 degrees. The difference between the operated and control knee at the time of assessment was: a mean loss of power of 6% (range 2-11) when measuring concentric extension and a mean loss of 7% power (range 13 to an increase of 12) in concentric flexion. We conclude that primary repair protected with a cerlage wire and early mobilisation gives excellent results in the treatment of isolated traumatic patella tendon ruptures and cast immobilisation postoperatively is not required.

Short-term results of hemi-resurfacing for osteonecrosis of the femoral head.

Published evidence has supported the use of femoral head resurfacing for patients with osteonecrosis of the femoral head. Between June 1999 and April 2001 we prospectively studied 15 femoral heads resurfaced in 12 patients with the Conserve Resurfacing Hemiarthroplasty. The male to female ratio was 8:4 and the mean age 38.7 years (range 26-60). The mean follow-up was 22.8 months (range 4-36). The senior author performed all procedures. There was one case of Ficat stage II, 9 cases of stage III and 5 cases of early stage IV. The mean time from onset of symptoms to surgery was 33.5 months (range 9-60). There were no intra or post-operative complications associated with any of the hemiarthroplasty procedures. RESULTS: Nine of the fifteen patients had a poor result that warranted revision surgery within two years of prosthesis implantation. We conclude that in our hands the results of femoral resurfacing hemiarthroplasty are unpredictable and advise caution when recommending the procedure to patients with osteonecrosis of the femoral head. (Hip International 2004; 14: 174-81).

Dynamic external fixation for pilon fractures of the interphalangeal joints.

Eight consecutive pilon fractures of the finger proximal interphalangeal joint and one of the interphalangeal joint of the thumb were treated by closed reduction and application of a new dynamic external fixator. The average range of movement achieved was 12 degrees -88 degrees and there were no serious complications. The technique described offers an effective and simple solution for treatment of pilon fractures of the interphalangeal joint.