Three-vessel view debridement of the open tibial fracture: a surgical technique.

Adequate debridement of an open fracture is a key component of successful management. Despite having set debridement principles, there is no structured technique available in the literature to guide the surgeon in achieving this. We therefore present a technical note detailing the structured approach to the debridement of any open tibial fracture. Our unit has developed a novel stepwise technique termed locally as the "three-vessel view". Identifying all three primary vessels of the leg facilitates confirmation of inspection of all lower limb compartments thus minimising the risk of missed devitalised tissue or neglected areas of contamination and the potential for consequent disastrous outcomes as a result of inadequate exposure.

Bioactive Properties of Syzygium cumini (L.) Skeels Pulp and Seed Phenolic Extracts.

The emergence of bacterial strains resistant to different antibiotics has prompted the search for new sources of antimicrobial compounds. Studies have shown that jambolan [Syzygium cumini (L.) Skeels], a tropical fruit from the Mirtaceae family, contains a great variety of phytochemical compounds with high antioxidant and antimicrobial activity. This study aimed to determine the centesimal composition and physicochemical characteristics of the pulp and seed of S. cumini (L.) Skeels, as well as the content of total phenolic compounds and the antioxidant, antibacterial, antibiofilm and anti-quorum sensing (QS) activities of the phenolic extracts obtained from the pulp and the seeds of this fruit. The in vitro antibacterial and anti-QS activities of active films incorporating phenolic extracts were also evaluated. Additionally, we performed molecular docking of phenolic compounds present in jambolan with the CviR QS regulator of Chromobacterium violaceum. The composition and physicochemical characteristics of the samples presented similar values to those found for the species. However, the seed phenolic extract had a higher content of phenolic compounds and antioxidant activity than the pulp. Both phenolic extracts presented antibacterial activity against Aeromonas hydrophila, C. violaceum, Escherichia coli, Pseudomonas aeruginosa, Salmonella enterica serovar Typhimurium, Serratia marcescens, Listeria monocytogenes, and Staphylococcus aureus. The seed phenolic extract was particularly inhibitory against S. aureus. The pulp phenolic extract inhibited swarming motility and biofilm formation of A. hydrophila, E. coli, and S. marcescens in sub-MIC concentrations. The pulp and seed phenolic extracts inhibited violacein production in C. violaceum. Films incorporating both phenolic extracts inhibited the growth of bacteria, particularly Pseudomonas fluorescens, L. monocytogenes, and S. aureus, as well as QS in C. violaceum. Molecular docking showed that a variety of compounds found in pulp and seed extracts of jambolan, particularly chlorogenic acid and dihydroquercetin, potentially bind CviR protein and may interfere with QS. Our results indicate that pulp and seed of jambolan are good sources of antibacterial, antibiofilm, and anti-QS compounds that can be used in the development of natural preservatives and for application in antibacterial active films.

Higher 30-day mortality associated with the use of intramedullary nails compared with sliding hip screws for the treatment of trochanteric hip fractures: a prospective national registry study.

AIMS: The aim of this study was to investigate the association between the type of operation used to treat a trochanteric fracture of the hip and 30-day mortality. PATIENTS AND METHODS: Data on 82 990 patients from the National Hip Fracture Database were analyzed using generalized linear models with incremental case-mix adjustment for patient, non-surgical and surgical characteristics, and socioeconomic factors. RESULTS: The use of short and long intramedullary nails was associated with an increase in 30-day mortality (adjusted odds ratio (OR) 1.125, 95% confidence interval (CI) 1.040 to 1.218; p = 0.004) compared with the use of sliding hip screws (12.5% increase). If this were causative, it would represent 98 excess deaths over the four-year period of the study and one excess death would be caused by treating 112 patients with an intramedullary nail rather than a sliding hip screw. CONCLUSION: There is a 12.5% increase in the risk of 30-day mortality associated with the use of an intramedullary nail compared with a sliding hip screw in the treatment of a trochanteric fractures of the hip.

Open tibial fractures in major trauma centres: A national prospective cohort study of current practice.

AIMS: To assess current national practice in the management of severe open tibial fractures against national standards, using data collected by the Trauma and Audit Research Network. MATERIALS AND METHODS: Demographic, injury-specific, and outcome data were obtained for all grade IIIB/C fractures admitted to Major Trauma Centres in England from October 2014 to January 2016. RESULTS: Data was available for 646 patients with recorded grade IIIB/C fractures. The male to female ratio was 2.3:1, mean age 47 years. 77% received antibiotics within 3 h of admission, 82% were debrided within 24 h. Soft tissue coverage was achieved within 72 h of admission in 71%. The amputation rate was 8.7%. 4.3% of patients required further theatre visits for infection during the index admission. The timing of antibiotics and surgery could not be correlated with returns to theatre for early infection. There were significant differences in the management and outcomes of patients aged 65 and over, with an increase in mortality and amputation rates. CONCLUSIONS: Good outcomes are reported from the management of IIIB/C fractures in Major Trauma Centres in England. Overall compliance with national standards is particularly poor in the elderly. Compliance did not appear to affect rates of returning to theatre or early infection. Appropriately applied patient reported outcome measures are needed to enhance the evidence-base for management of these injuries.

Single-stage orthoplastic reconstruction of Gustilo-Anderson Grade III open tibial fractures greatly reduces infection rates.

BACKGROUND: Grade III open fractures of the tibia represent a serious injury. It is recognised that combined management of these cases by experienced orthopaedic and plastic surgeons improves outcomes. Previous studies have not considered the timing of definitive soft tissue cover in relation to the definitive orthopaedic management. This paper reviews the outcomes in patients treated in an orthoplastic unit where the emphasis was on undertaking the definitive orthopaedic and plastic surgical procedures in a single stage, following initial debridement and temporary stabilisation as necessary. METHODS: We reviewed medical notes of 73 consecutive patients with 74 Grade III open tibia fractures (minimum 1 year follow up), to compare deep infection rates in patients who had (a) a single-stage definitive fixation and soft tissue coverage vs. those who had separate operations, and (b) those who had definitive treatment completed in <72h vs. >72h. RESULTS: (a) Combined Single-stage Orthoplastic Fixation and Coverage: 48 fractures were managed with definitive orthopaedic fixation and plastic surgical coverage performed at the same time, whilst 26 had these performed at separate stages. Of those subjects that had definitive fixation and coverage in one procedure 2 (4.2%) developed deep infections, compared with 9 (34.6%) deep infections (p<0.001) in those who underwent definitive fixation and coverage at separate operations. (b) Timing of surgery: Of the fractures that had definitive fixation and coverage completed within 72h of injury, 5 (20%) developed deep infections, compared with 6 (12.2%) deep infections (p=0.492) in those whose definitive fixation/coverage was completed at later than 72h. CONCLUSION: Joint orthoplastic operating lists facilitate simultaneous definitive fixation and cover that greatly reduces infection rates. Based on our experience presented in this paper, we believe that emphasis should be placed on timely transfer to a specialist centre, aiming for a single-stage combined orthoplastic procedure to achieve definitive fixation and soft tissue coverage and optimal outcomes.

A biomechanical analysis of upper extremity kinetics in children with cerebral palsy using anterior and posterior walkers.

Upper extremity (UE) joint kinetics during aided ambulation is an area of research that is not well characterized in the current literature. Biped UE joints are not anatomically designed to be weight bearing, therefore it is important to quantify UE kinetics during assisted gait. This will help to better understand the biomechanical implications of UE weight bearing, and enable physicians to prescribe more effective methods for treatment and therapy, perhaps minimizing excessive loads and torques. To address this challenge, an UE model that incorporates both kinematics and kinetics has been developed for use with walkers instrumented with load cells. In this study, the UE joint kinetics are calculated for 10 children with cerebral palsy using both anterior and posterior walkers. Three-dimensional joint reaction forces and moments are fully characterized for the wrist, elbow, and shoulder (glenohumeral) joints for both walker types. Statistical analysis methods are used to quantify the differences in forces or moments between the two walker types. Comparisons showed no significant differences in kinetic joint parameters between walker types. Results from a power analysis of the current data are provided which may be useful for planning longer term clinical studies. If risk factors for UE joint pathology can be identified early, perhaps a change in gait training routine, walker prescription, or walker design could prevent further harm.

[Upper extremity kinetics and energy expenditure during walker-assisted gait in children with cerebral palsy]. / Beyin felçli çocuklarda yürüteç kullanimi sirasinda üst ekstremite kinetikleri ve enerji tüketimi.

OBJECTIVES: We evaluated the relationships between upper extremity (UE) kinetics and the energy expenditure index during anterior and posterior walker-assisted gait in children with spastic diplegic cerebral palsy (CP). METHODS: Ten children (3 boys, 7 girls; mean age 12.1 years; range 8 to 18 years) with spastic diplegic CP, who ambulated with a walker underwent gait analyses that included UE kinematics and kinetics. Upper extremity kinetics were obtained using instrumented walker handles. Energy expenditure index was obtained using the heart rate method (EEIHR) by subtracting resting heart rate from walking heart rate, and dividing by the walking speed. Correlations were sought between the kinetic variables and the EEIHR and temporal and stride parameters. RESULTS: In general, anterior walker use was associated with a higher EEIHR. Several kinetic variables correlated well with temporal and stride parameters, as well as the EEIHR. All of the significant correlations (r>0.80; p<0.005) occurred during anterior walker use and involved joint reaction forces (JRF) rather than moments. Some variables showed multiple strong correlations during anterior walker use, including the medial JRF in the wrist, the posterior JRF in the elbow, and the inferior and superior JRFs in the shoulder. CONCLUSION: The observed correlations may indicate a relationship between the force used to advance the body forward within the walker frame and an increased EEIHR. More work is needed to refine the correlations, and to explore relationships with other variables, including the joint kinematics.

Comparison of upper extremity glenohumeral joint forces in children with cerebral palsy using anterior and posterior walkers - biomed 2009.

Walkers are prescribed with the notion that one type of walker will be better for a child than another. One underlying justification for this practice is the theory that one walker may produce less stress on the upper extremities as the patient uses the walker. Nevertheless, upper extremity joint loading is not typically analyzed during walker assisted gait in children with spastic diplegic cerebral palsy. It has been difficult to evaluate the theory of walker prescription based on upper extremity stresses because loading on the upper extremities however has not been quantified until recently. In this study, weight bearing on the glenohumeral joints was analyzed in five children with spastic diplegic cerebral palsy using both anterior and posterior walkers fitted with 6-axis handle transducers. Though walkers' effects on the upper extremities proved to be similar between walker types, the differences between the walkers may have some clinical significance in the long run. In general, posterior walker use created larger glenohumeral joint forces. Though these differences are not statistically significant, over time and with repetitive loading they may be clinically significant.

Comparison of upper extremity kinematics in children with spastic diplegic cerebral palsy using anterior and posterior walkers.

This prospective study analyzes the upper extremity kinematics of 10 children with spastic diplegic cerebral palsy using anterior and posterior walkers. Although both types of walkers are commonly prescribed by clinicians, no quantitative data comparing the two in regards to upper extremity motion has been published. The study methodology included testing of each subject with both types of walkers in a motion analysis laboratory after an acclimation period of at least 1 month. Overall results showed that statistically, both walkers are relatively similar. With both anterior and posterior walkers, the shoulders were extended, elbows flexed, and wrists extended. Energy expenditure, walking speed and stride length was also similar with both walker types. Several differences were also noted although not statistically significant. Anterior torso tilt was reduced with the posterior walker and shoulder extension and elbow flexion were increased. Outcomes analysis indicated that differences in upper extremity torso and joint motion were not dependent on spasticity or hand dominance. These findings may help to build an understanding of upper extremity motion in walker-assisted gait and potentially to improve walker prescription.

Engineered hybrid dimers: tracking the activation pathway of caspase-7.

Caspase-7 is an obligate dimer of catalytic domains, with generation of activity requiring limited proteolysis within a region that separates the large and small chains of each domain. Using hybrid dimers we distinguish the relative contribution of each domain to catalysis by the whole molecule. We demonstrate that the zymogen arises from direct dimerization and not domain swapping. In contrast to previous conclusions, we show that only one of the catalytic domains must be proteolyzed to enable activation. The processed domain of this singly cleaved zymogen has the same catalytic activity as a domain of fully active caspase-7. A transient intermediate of singly cleaved dimeric caspase-7 can be found in a cell-free model of apoptosis induction. However, we see no evidence for an analogous intermediate of the related executioner caspase-3. Our study demonstrates the efficiency by which the executioner caspases are activated in vivo.

Identification of early intermediates of caspase activation using selective inhibitors and activity-based probes.

Caspases are cysteine proteases that are key effectors in apoptotic cell death. Currently, there is a lack of tools that can be used to monitor the regulation of specific caspases in the context of distinct apoptotic programs. We describe the development of highly selective inhibitors and active site probes and their applications to directly monitor executioner (caspase-3 and -7) and initiator (caspase-8 and -9) caspase activity. Specifically, these reagents were used to dissect the kinetics of caspase activation upon stimulation of apoptosis in cell-free extracts and intact cells. These studies identified a full-length caspase-7 intermediate that becomes catalytically activated early in the pathway and whose further processing is mediated by mature executioner caspases rather than initiator caspases. This form also shows distinct inhibitor sensitivity compared to processed caspase-7. Our data suggest that caspase-7 activation proceeds through a previously uncharacterized intermediate that is formed without cleavage of the intact zymogen.

Delay increases the need for open reduction of type-III supracondylar fractures of the humerus.

Recent reports have suggested that a delay in the management of type-III supracondylar fractures of the humerus does not affect the outcome. In this retrospective study we examined whether the timing of surgery affected peri-operative complications, or the need for open reduction. There were 171 children with a closed type-III supracondylar fracture of the humerus and no vascular compromise in our study. They were divided into two groups: those treated less than eight hours from presentation to the Accident and Emergency Department (126 children), and those treated more than eight hours from presentation (45 children). There were no differences in the rate of complications between the groups, but children waiting more than eight hours for reduction were more likely to undergo an open reduction (33.3% vs 11.2%, p < 0.05) and there was a weak correlation (p = 0.062) between delay in surgery and length of operating time. Consequently, we would still recommend treating these injuries at the earliest opportunity.

A prospective, randomised, controlled trial of the use of drains in total hip arthroplasty.

The routine use of surgical drains in total hip arthroplasty remains controversial. They have not been shown to decrease the rate of wound infection significantly and can provide a retrograde route for it. Their use does not reduce the size or incidence of post-operative wound haematomas. This prospective, randomised study was designed to evaluate the role of drains in routine total hip arthroplasty. We investigated 552 patients (577 hips) undergoing unilateral or bilateral total hip arthroplasty who had been randomised to either having a drain for 24 hours or not having a drain. All patients followed standardised pre-, intra-, and post-operative regimes and were independently assessed using the Harris hip score before operation and at six, 18 and 36 months follow-up. The rate of superficial and deep infection was 2.9% and 0.4%, respectively, in the drained group and 4.8% and 0.7%, respectively in the undrained group. One patient in the undrained group had a haematoma which did not require drainage or transfusion. The rate of transfusion after operation in the drained group was significantly higher than for undrained procedures (p < 0.042). The use of a drain did not influence the post-operative levels of haemoglobin, the revision rates, Harris hip scores, the length of hospital stay or the incidence of thromboembolism. We conclude that drains provide no clear advantage at total hip arthroplasty, represent an additional cost, and expose patients to a higher risk of transfusion.

C-reactive protein: a valuable acute investigation. A case of pneumococcal meningitis presenting as ankle pain.

A case is presented in which the decision to admit and treat an adult with musculoskeletal pain and pyrexia was based on her markedly raised c-reactive protein (CRP). At the time of admission she was apyrexial and the CRP was the only haematological investigation that was out of the normal range. She subsequently became precipitously septic with pneumococcal bacteraemia and meningitis. The CRP is an important investigation for emergency departments.

Rehabilitation of the paralysed or lax lower eyelid using a graft of conchal cartilage.

Excessive laxity of the tarso-ligamentous sling of the lower eyelid may be caused by inadequate muscular support (resulting from injury to the muscle, facial palsy or senile degeneration) or prolonged mechanical distension (exophthalmia). Numerous techniques have been devised for functional reconstruction of the distended lower eyelid, based upon the principle that restoring the lower eyelid to its anatomical position will improve lacrimal transit andre-establish its natural protective function. We now use an autologous conchal cartilage graft to treat the distended or atonic lower eyelid. We review our results in a retrospective study of 20 patients, and aim to identify the indications for this procedure and to evaluate its advantages and disadvantages relative to other existing methods. All of our patients reported functional improvement after the operation in terms of decreased dry-eye symptoms, less epiphora and a decline in keratitis and conjunctivitis. All patients also reported a visible cosmetic improvement postoperatively. The major drawback of this operation is the partial loss of the visual field when looking down, due to the limited lowering of the lower eyelid. The stability of our results compares favourably with that achieved using other currently available techniques. We conclude that autologous conchal cartilage grafting is an effective procedure for improving both the function and the appearance of the atonic lower eyelid.

Surgical management of the anophthalmic orbit, part 1: congenital.

Congenital microphthalmos and anophthalmos are rare conditions in which orbital growth is deficient. Hypoplasia of the globe affects the bony orbit (micro-orbitism), the conjunctival sac, and eyelids (microblepharism), and it may be associated with abnormalities of the entire hemifacial skeleton (hemifacial microsomia). In the present article, the authors review a series of 19 patients with microphthalmos (nine had right-sided, one had bilateral, and nine had left-sided microphthalmos) who were treated in the Orbitopalpebral Unit at Hospital Foch over a period of 15 years (follow-up, 5 months to 18 years).Orbital expansion was achieved using spherical implants (n = 13), orbital osteotomies (n = 4), and orbital expanders (n = 2). Both expanders were removed within 6 months because of failure (one infection and one rupture). The current preferred method for orbital expansion is to use serial implants in the growing orbit and osteotomies in cases of late referral or insufficient orbital volume in the older child. The target proportions of the reconstructed orbit are not planned to mirror the healthy side exactly. The inferior orbital rim is kept higher to support the orbital implant, and the orbit is kept shallow to avoid a sunken appearance. Cranial bone grafts were used to augment deficient orbital contours; they were assisted by anterior transposition of the temporalis muscle (n = 5) when additional orbital volume was required. Conjunctival sac reconstruction was achieved by the use of serial conformers placed in the conjunctival sac during the neonatal period, followed by grafts of buccal mucosa and full-thickness skin maintained in place with a tarsorrhaphy for 3 to 6 months. Eyelid reconstruction using local flaps and skin grafts proved to be necessary in cases treated by osteotomy expansion, although reconstruction was not required after expansion using serial solid shapes. The results illustrate an evolution in approach and concepts of reconstruction of the microphthalmic orbit and emphasize the need for an integrated craniofacial approach for this complex deformity.

Surgical management of the anophthalmic orbit, part 2: post-tumoral.

Ablative surgery for tumors of the globe and its adnexal structures is frequently the cause of major orbitofacial deformity. Radiotherapy compounds the problem because it suppresses skeletal growth in the growing patient and induces a contraction of the remaining soft tissues in the orbit. Goals for reconstruction in these patients include the restoration of orbital structures to allow the fitting of an ocular prosthesis and the correction of distorted orbitofacial relationships. The authors present a series of 53 patients (mean age, 29 years; 28 male) who were treated over the past 18 years by composite reconstruction of the post-tumoral anophthalmic orbit. The follow-up ranged from 5 months to 18 years (mean, 7.75 years). Four patients were treated primarily (immediate reconstruction after tumor ablation), and 49 were treated secondarily (mean oncological follow-up since ablative surgery, 14.8 years). Twenty-eight patients underwent orbital enucleation (including three bilateral cases), 23 underwent orbital exenteration, and two underwent evisceration. Forty-two patients received radiotherapy, including 20 enucleation patients, 15 exenteration patients, and seven others in whom details of primary therapy were incomplete. A staged reconstruction was undertaken in each case; it considered, in turn, the bony orbital volume (orbital remodeling and cranial bone grafts), orbital contents (implant, temporalis muscle transposition, cranial bone grafts, and dermafat grafts), conjunctival sac (mucosal and skin grafts), ocular prosthesis, eyelids (local flaps and skin grafts), and additional procedures to restore orbitofacial symmetry. The authors conclude that the long-term results of post-tumoral orbital reconstruction are favorable, and they particularly recommend the use of autogenous tissues in irradiated orbits.

A 5-year review of 71 consecutive anterior skull base tumours.

Techniques used in craniofacial surgery have found extensive application in the management of skull base tumours. The improved exposure gained via osteotomies for facial disassembly has facilitated the en-bloc resection of tumours with clear surgical margins, and the advent of vascularised seals has significantly reduced the risk of meningeal contamination. We present our experience with the extirpation and reconstruction of 71 benign and malignant tumours of the anterior skull base over a 5-year period. Survival and functional outcome data are presented, with an emphasis on the wide range of pathologies and primary treatment strategies seen at presentation. Criteria used in flap selection and the role of prosthetics are discussed. Observations are offered on salvage surgery, demonstrating that excellent palliation can be achieved, even in cases with massive recurrent disease.

Use of the palmaris brevis flap for preventing recurrent median nerve compression in mucolipidosis.

In a patient with severe, recurrent bilateral carpal tunnel syndrome secondary to mucolipidosis, the 'turnover' palmaris brevis flap was used in conjunction with internal neurolysis. The procedure was effective in alleviating symptoms of recurrent carpal tunnel compression in both hands.

Synergistic activation of protein kinase Calpha, -betaI, and -gamma isoforms induced by diacylglycerol and phorbol ester: roles of membrane association and activating conformational changes.

Protein kinase Calpha (PKCalpha) has been shown to contain two discrete activator sites with differing binding affinities for phorbol esters and diacylglycerols. The interaction of diacylglycerol with a low-affinity phorbol ester binding site leads to enhanced high-affinity phorbol ester binding and to a potentiated level of activity [Slater, S. J., Ho, C., Kelly, M. B., Larkin, J. D. , Taddeo, F. J., Yeager, M. D., and Stubbs, C. D. (1996) J. Biol. Chem. 271, 4627-4631]. In this study, the mechanism of this enhancement of activity was examined with respect to the Ca2+ dependences of membrane association and accompanying conformational changes that lead to activation. The association of PKCalpha with membranes containing 12-O-tetradecanoylphorbol 13-acetate (TPA) or 1, 2-dioleoylglycerol (DAG), determined from tryptophan to dansyl-PE resonance energy transfer (RET) measurements, was found to occur at relatively low Ca2+ levels (