A prospective randomised trial of absorbable versus non-absorbable sutures for wound closure after fasciectomy for Dupuytren's contracture.

After fasciectomy for Dupuytren's contracture the wound has traditionally been closed with non-absorbable sutures. A prospective randomised study of 59 patients was undertaken to compare wound closure after fasciectomy with irradiated polyglactin 910 absorbable sutures and non-absorbable sutures. The outcomes studied were: time spent attending to the wound at the first postoperative visit; the patient's pain score at that visit; and any complications. Wound care required significantly more time when non-absorbable sutures were used. There was no significant difference in pain scores or in complications between the two groups. We recommend the use of irradiated polyglactin 910 absorbable sutures for wound closure after fasciectomy as it saves time and resources without compromising wound healing.

The factors affecting outcome after non-vascular bone grafting and internal fixation for nonunion of the scaphoid.

This study identified variables which influence the outcome of surgical management on 126 ununited scaphoid fractures managed by internal fixation and non-vascular bone grafting. The site of fracture was defined by a new method: the ratio of the length of the proximal fragment to the sum of the lengths of both fragments, calculated using specific views in the plain radiographs. Bone healing occurred in 71% (89) of cases. Only the site of nonunion (p = 1 x 10(-6)) and the delay to surgery (p = 0.001) remained significant on multivariate analysis. The effect of surgical delay on the probability of union increased as the fracture site moved proximally. A prediction model was produced by stepwise logistic regression analysis, enabling the surgeon to predict the success of surgery where the site of the nonunion and delay to surgery is known.

Implementation of RCGP guidelines for acute low back pain: a cluster randomised controlled trial.

BACKGROUND: The Royal College of General Practitioners (RCGP) has produced guidelines for the management of acute low back pain in primary care. AIM: To investigate the impact on patient management of an educational strategy to promote these guidelines among general practitioners (GPs). DESIGN OF STUDY: Group randomised controlled trial, using the health centre as the unit of randomisation. SETTING: Primary care teams in north-west England. METHOD: Twenty-four health centres were randomly allocated to an intervention or control arm. Practices in the intervention arm were offered outreach visits to promote national guidelines on acute low back pain, as well as access to fast-track physiotherapy and to a triage service for patients with persistent symptoms. RESULTS: Twenty-four centres were randomised. Two thousand, one hundred and eighty-seven eligible patients presented with acute low back pain during the study period: 1049 in the intervention group and 1138 in the control group. There were no significant differences between study groups in the proportion of patients who were referred for X-ray, issued with a sickness certificate, prescribed opioids or muscle relaxants, or who were referred to secondary care, but significantly more patients in the intervention group were referred to physiotherapy or the back pain unit (difference in proportion = 12.2%, 95% confidence interval [CI] = 2.8% to 21.6%). CONCLUSION: The management of patients presenting with low back pain to primary care was mostly unchanged by an outreach educational strategy to promote greater adherence to RCGP guidelines among GPs. An increase in referral to physiotherapy or educational programmes followed the provision of a triage service.

Distribution of nerve fibers in the standard incision for carpal tunnel decompression.

Twenty-two paired biopsy specimens of skin and subcutaneous tissue from the proximal and distal halves of the conventional curvilinear incision or carpal tunnel decompression were histologically examined. The specimens were immunohistochemically stained with S100 antibody to highlight the nerve fibers. The mean count of free nerve endings in the proximal biopsy site was 4.42/mm2 (SD, 2.97; range, 1.23-12.27), compared to 4.2/mm2 (SD, 2.71; range, 1.01-10.50) in the distal biopsy specimens. This difference was not statistically significant (p = .20, Wilcoxon's signed ranks [matched pairs] test). The proximal incision site for carpal tunnel decompression did not appear to be more neuroreceptive than the distal incision site, providing no support for the implication of proximal incision sites in proximal scar tenderness.

A rare complication of pectoralis major rupture.

Pectoralis major rupture is an uncommon injury. Only 85 cases have been reported in the literature. Rupture may be partial or complete. The treatment of partial rupture is conservative, whereas in cases of total rupture surgical repair is advocated, particularly in young active patients. Complications are few. We describe a case of infection of the haematoma following a partial rupture. To the best of our knowledge it is the first case to be reported in the English literature.

Fractures of the distal radius and ulna.

Associated fractures of the distal ulnar metaphysis were present in 19 of 320 distal radial fractures requiring either closed manipulation or surgical treatment over a 2-year period. Four morphological patterns of ulnar fracture were encountered, the commonest being the type 1 simple extra-articular fracture of the distal end of ulna with minimal comminution (eight out of 19). 15 patients were treated conservatively and two each were treated by internal and external fixation. 15 patients were reviewed after a mean follow-up of 23.8 months and there were four excellent, five good, five fair clinical results and one poor result. Radiographically the distal radio-ulnar joint (DRUJ) was normal in eight wrists, but longitudinal or horizontal disruption of the DRUJ was present in seven wrists. Fracture callus encroached on the DRUJ in three patients, who also had limitation of forearm rotation. Two comminuted ulnar fractures (type 4) developed non-union, but both patients had full forearm rotation, in contrast to restriction of forearm rotation in four out of five patients with type 1 fractures.

The results of surgical management of displaced tibial plateau fractures in the elderly.

We retrospectively reviewed 32 elderly patients (mean age 71.7 years, range 66-83 years) with displaced tibial plateau fractures after a mean of 3.7 years (range 1-7 years) after operative treatment. Schatzker type 2 fracture was the commonest pattern of fracture (60.3 per cent). According to the modified Rasmussen clinical and radiographic criteria, there were nine excellent, 14 good, five fair and four poor results clinically, and 11 excellent, 12 good, six fair and three poor results radiographically. There was no significant correlation between the final radiographic appearance and clinical outcome. Fourteen patients mobilized postoperatively on a continuous passive motion machine followed by a cast brace had a better result than those mobilized in a cast brace alone, but the difference was not statistically significant (P = 0.29). Postoperative complications included deep vein thrombosis in two patients.

Fibrous stabilization of the rheumatoid wrist.

19 patients (mean age 59.8 years) underwent fibrous stabilization of the wrist for rheumatoid arthritis. 17 patients were reviewed after a mean follow up of 24.5 months (range 13-40 months). There were four excellent, 11 good, and two poor results according to modified Koka and D'Arcy (1989) criteria. The poor results were due to deep infection in one patient and an unbalanced wrist due to ruptured radial extensors in another. The pre-operative range of wrist movement was an important determinant of the frequency of radio-carpal and/or mid-carpal fusion and the final post-operative range of movement.

Intertrochanteric fractures of the femur and osteoarthritis of the ipsilateral hip.

We retrospectively reviewed the radiographs of 255 patients with intertrochanteric fractures over a 2 year period. The incidence of osteoarthritis of the hip joint in these patients was 12.16%, which is less than that reported in the general population, and which confirms the protective effect of osteoarthritis against intertrochanteric fractures. Osteoarthritis was mild in 14, moderate in 19, and severe in 4 hips. Seventeen of the 33 patients had died or were too ill to attend a review clinic. The remaining 16 patients (18 hips) were followed up clinically and radiographically 1 to 5.5 years (mean 2.25 years) after internal fixation of the hip fracture. Three patients with severe osteoarthritis, who were waiting for a total hip replacement before the hip fracture occurred became asymptomatic. There was no significant clinical or radiographic progression of mild and moderate hip osteoarthritis in the remaining 13 patients (15 hips). Intertrochanteric fractures appear to have a beneficial "osteotomy-like" effect on hip osteoarthritis in symptomatic patients.

Complications of the Attenborough knee replacement.

Of a consecutive series of 144 Attenborough knee replacements, 107 were re-examined between two and six years after operation and revealed a high incidence of complications. Wound problems were common and led to deep infection in four knees. When a patellar implant was used fracture of the patella followed in 17.5% of knees, but when the patella was not resurfaced 16% of knees developed patellofemoral pain of sufficient severity to require a further operation. In 10% of knees, definite loosening of one or both of the major components occurred.