ABSTRACT
PURPOSE: Trapeziometacarpal joint (TMC) arthrodesis has a high rate of nonunion. This biomechanical analysis sought to determine the stiffness of 5 fixation methods in a TMC joint arthrodesis model. METHODS: Five fixation constructs were tested in a validated porcine model: crossed 1.1-mm K-wires, crossed 1.6-mm K-wires, crossed headless compression screws (HCSs), compression plating (CP), and locked compression plating (LCP). The cantilever bending stiffness was measured in abduction, adduction, flexion, and extension. Samples were loaded to failure in extension, and the mode of failure was examined. RESULTS: The crossed HCSs performed consistently well in all tests. Loading to failure resulted in screw pullout. In abduction and adduction, HCS and 1.6-mm K-wires were significantly stiffer than the other constructs. The mean load to failure in extension was similar in the HCS, CP, and LCP groups (304 N/mm, 311 N/mm, and 293 N/mm, respectively). There were no differences between CP and LCP in any biomechanical tests, and the mode of failure was through plate bending. The crossed 1.1-mm K-wires performed poorly in all tests. CONCLUSIONS: Crossed HCS displayed the greatest overall stability. Standard plating in compression mode and LCP had a similar biomechanical performance. CLINICAL RELEVANCE: The ideal construct stiffness required for the successful union after TMC joint arthrodesis is unknown, but HCS has the best overall biomechanical performance and, therefore, might be considered the best choice for this clinical setting.
ABSTRACT
With today's National Health Service (NHS) facing huge financial pressures the healthcare profession cannot afford to carry on spending at the current rate. Individual clinicians should be encouraged to critically appraise their own practices to bring about a more efficient and cost-effective service. The purpose of this project was to analyse the way that carpal tunnel surgery was being performed within our institution and bring about safe changes to practice that reduce expenditure. By critiquing our practices and applying simple changes based around sound evidence an annual saving of over £15 500 to the department was made. The changes instigated are simple, sustainable and safe to implement while providing improved patient satisfaction. They are also easily transferrable across institutions and to other minor hand surgical procedures to afford even greater ongoing savings to the NHS.
ABSTRACT
INTRODUCTION: Emphysematous pyelonephritis (EPN) is a severe acute necrotising infection of the renal parenchyma and perirenal tissue, characterised by gas formation. 90% of cases are seen in association with diabetes mellitus. We report a case of undiagnosed ureteric obstruction in a type II diabetic, leading to EPN requiring emergency nephrectomy. CASE PRESENTATION: A 59-year-old type II tablet controlled diabetic woman presented complaining of a five day history of right sided abdominal pain associated with vomiting, abdominal distension and absolute constipation. There were no lower urinary tract symptoms. Past surgical history included an open appendectomy and an abdominal hysterectomy. On examination, she was haemodynamically stable, the abdomen was soft, distended, and tender in the right upper and lower quadrants with no bowel sounds. Investigations revealed a CRP of 365 and 2+ blood and nitrite positive on the urine dipstick. The AXR was reported as normal on admission, however when reviewed in retrospect revealed the diagnosis. She was managed, therefore, as having adhesional bowel obstruction and a simple UTI. After four days, a CT was organised as she was not settling. This showed a right pyohydronephrosis with gas in the collecting system secondary to an 8 mm obstructing ureteric calculus. The kidney was drained percutaneously via a nephrostomy and the patient was commenced on a broad spectrum intravenous antibiotics. Despite this, she went on to need an emergency nephrectomy for uncontrolled severe sepsis. She was discharged in good health 15 days later. CONCLUSION: EPN carries a mortality of up to 40% with medical management alone. Early recognition of EPN in an obstructed kidney is essential to guide aggressive management, and in the presence of continued severe sepsis or organ dysfunction an urgent nephrectomy should be carried out. Diabetic patients who are known to have renal or ureteric calculi, whether symptomatic or not, should be considered for percutanous or ureteroscopic treatment. In the acute abdomen, the plain abdominal radiograph should always be viewed with respect to general surgical, vascular and urological differential diagnoses.
