Traumatic anterior knee dislocation after total knee arthroplasty.

This article describes a traumatic complete anterior knee dislocation of a previously well-functioning total knee arthroplasty. A thorough physical examination with appropriate radiographic imaging study is required for proper evaluation and treatment of this injury, as it is often associated with neurovascular injury and subsequent global instability of the injured knee is likely.

The internal audit of clinical areas: a pilot of the internal audit methodology in a health service emergency department.

QUALITY PROBLEM OR ISSUE: Governing bodies of health services need assurance that major risks to achieving the health service objectives are being controlled. Currently, the main assurance mechanisms generated within the organization are through the review of implementation of policies and procedures and review of clinical audits and quality data. INITIAL ASSESSMENT: The governing bodies of health services need more robust, objective data to inform their understanding of the control of clinical risks. CHOICE OF SOLUTION: Internal audit provides a methodological framework that provides independent and objective assurance to the governing body on the control of significant risks. IMPLEMENTATION: The article describes the pilot of the internal audit methodology in an emergency unit in a health service. An internal auditor was partnered with a clinical expert to assess the application of clinical criteria based on best practice guidelines. EVALUATION: The pilot of the internal audit of a clinical area was successful in identifying significant clinical risks that required further management. LESSONS LEARNED: The application of an internal audit methodology to a clinical area is a promising mechanism to gain robust assurance at the governance level regarding the management of significant clinical risks. This approach needs further exploration and trial in a range of health care settings.

Recurrent incisional hernia, enterocutaneous fistula and loss of the substance of the abdominal wall: plastic with organic prosthesis, skin graft and VAC therapy. Clinical case.

Surgical wounds dehiscence is a serious post-operatory complication, with an incidence between 0.4% and 3.5%. Mortality is more than 45%. Complex wounds treatment may require a multidisciplinary management. VAC Therapy could be an alternative treatment regarding complex wound. VAC therapy has been recently introduced on skin's graft tissue management reducing skin graft rejection. The use of biological prosthesis has been tested in a contaminated field, better than synthetic meshes, which often need to be removed. The Permacol is more resistant to degradation by proteases due to its cross-links. Surgery is still considered the best treatment for digestive fistula. A 58 years old obese woman come to our attention, she was operated for an abdominal hernia. She had a post-operatory entero-cutaneous fistula. She was submitted to bowel resection, the anastomosis has been tailored and the hernia of the abdominal wall has been repaired with biological mesh for managing such condition. She had a wound dehiscence with loss of substance and the exposure of the biological prosthesis, nearly 20 cm diameter. She was treated first with antibiotic therapy and simple medications. In addiction, antibiotic therapy was necessary late associated to 7 months with advanced medications allowed a small reduction's defect. Because of its, treatment went on for two more months using VAC therapy. Antibiotic's therapy was finally suspended. The VAC therapy allowed the reduction of the gap, between skin and subcutaneous tissue, and the defect's size preparing a suitable ground for the skin graft. The graft, managed with the vac therapy, was necessary to complete the healing process.

Osteonecrosis after powered core decompression.

A 44-year-old man with alcohol-related osteonecrosis of his left femoral head, Ficat Stage 2, was treated by femoral head decompression. During this procedure the (1/4)-inch trephine driven by a power reamer became lodged in the femoral head and became hot to the touch. The trephine eventually was removed with difficulty after the decompression was completed. Four and a half years later, the patient continued to have progressive pain and difficulty ambulating. A radiograph at the time revealed a wide zone of symmetric increased density about the core decompression track. A total hip arthroplasty was done, yielding the femoral head and neck for study. Histologic sections of the femoral head and neck showed that the entire length of the core decompression track in the specimen was surrounded by 2.7 cm of unrepaired necrotic bone. The evidence suggests that extensive additional necrosis was produced iatrogenically during the core decompression with the powered trephine. Necrosis secondary to either heat generation or increased pressure along the trephine track is presented as possible mechanisms for this unusual finding.