Role of prophylactic antibiotics in lesser toe fusion surgery: A prospective randomised controlled trial.

BACKGROUND: This prospective randomised controlled trial was performed to determine whether the incidence of local infection is reduced in patients who are administered prophylactic antibiotics for lesser toe fusion surgery. METHODS: 100 adult patients undergoing toe fusion surgery that required K-wires to be left in situ for 4-6 weeks were randomly allocated into those who received prophylactic antibiotics (Group 1, n=48) and those who did not (Group 2, n=52). Patients were followed up regularly and during each visit K-wire insertion sites were assessed for signs of pin tract infection. RESULTS: The mean age of Group 1 was 58.0 (SD 17.5) and Group 2 was 62.7 years (SD 14.7). The overall infection rate was 4%. Three patients (6.2%) in Group 1 and one patient (1.9%) in Group 2 developed signs of infection, which required treatment by oral antibiotics. All infections were low grade. There were no features suggestive of osteomyelitis in any of the patients. CONCLUSION: The overall infection rate in lesser toe fusion surgery is low and that using prophylactic antibiotics does not reduce the incidence. Inappropriate use of antibiotics, however, may contribute to the development of antibiotic resistance and adds to healthcare costs.

Design, methodological issues and participation in a multiple sclerosis case-control study.

OBJECTIVES: This study was conducted to determine whether the risk of developing multiple sclerosis (MS) was associated with certain environmental exposures or genetic factors previously reported to influence MS risk. This paper describes the methodological issues, study design and characteristics of the study population. MATERIALS AND METHODS: Individuals with definite MS were identified from a prevalence study conducted in three geographic areas. The target number of cases was not reached, so an additional study area was added. Identifying clinic controls was inefficient, so controls were recruited using random digit dialing. All study participants completed a detailed questionnaire regarding environmental exposures using computer-assisted telephone interviewing, and blood was collected for genetic analysis. RESULTS: In total, 276 cases and 590 controls participated, but participation rates were low, ranging from 28.4% to 38.9%. Only one-third (33.6%) of individuals identified in the prevalence study agreed to participate in the case-control study. Cases were more likely to be non-Hispanic white and older than their source populations as identified in the preceding prevalence study (P < 0.05). Most participants provided a blood sample for genotyping (91%; n = 789). CONCLUSIONS: Epidemiological studies play a key role in identifying genetic and environmental factors that are associated with complex diseases like MS. Methodological issues arise in every study, and investigators need to be able to detect, respond to and correct problems in a timely and scientifically valid manner.

An evaluation of the safety and efficacy of simultaneous bilateral total knee arthroplasty.

This study directly compared the clinical and radiographic results and patient satisfaction of a group of simultaneous, bilateral total knee arthroplasties (92) with a year of surgery matched unilateral total knee arthroplasties (92). Death within 1 month of surgery occurred in 1 bilateral patient and no unilateral patients. Significant cardiorespiratory complications were recorded in 6 bilateral patients and 2 unilateral patients. Patients with pre-existing cardiorespiratory conditions were particularly at risk. Analysis revealed a 98% 7-year survivorship for unilateral procedures and 97% for bilateral. In this study, 95% of bilateral patients stated they would choose the same option again.

The use of cold compression dressings after total knee replacement: a randomized controlled trial.

This prospective, controlled study compared cold compressive dressings with wool and crepe in the postoperative management of patients undergoing total knee replacement (TKR). Forty TKR patients were assessed for blood loss, pain, swelling, and range of motion. Patients in the cold compression group had less blood loss through suction drainage (982 mL versus 768 mL). A higher proportion of patients in the treatment group did not require blood transfusion postoperatively. Mean opiate requirements were lower in the cold compression group (0.57 versus 0.71 mg/kg/48 hours). The cold compression device appeared to reduce blood loss and pain following TKR.

Irreducible Lisfranc's injury: the 'toe up' sign.

A new physical sign (the 'toe up' sign) is described in relation to an irreducible Lisfranc injury, the cause being the interposed lateral slip of the tibialis anterior tendon. Surgical exploration is advocated.

Comparison of terbinafine and clotrimazole in treating tinea pedis.

OBJECTIVE: To compare the efficacy and safety of terbinafine 1% cream and clotrimazole 1% cream in the treatment of tinea pedis. DESIGN: Multicentre, double blind parallel group study. SETTING: 32 general practices and one hospital. PATIENTS: 256 patients with mycologically confirmed tinea pedis. Of the 211 patients evaluable, 107 were randomised to terbinafine (75 male, 32 female; mean (range) age 40 (12-81) years) and 104 to clotrimazole (79 male, 25 female; mean (range) age 36 (12-71) years). INTERVENTIONS: Terbinafine 1% cream applied twice daily for one week and inert cream applied twice daily for the next three weeks. Clotrimazole 1% cream applied twice daily for four weeks. MAIN OUTCOME MEASURES: Mycological cure (negative results on microscopy and culture) and effective treatment (mycological cure plus no or minimal signs and symptoms) measured at weeks 1, 2, 3, 4, and 6. RESULTS: At week four rates of mycological cure were 93.5% for terbinafine and 73.1% for clotrimazole (p = 0.0001); and at week six 97.2% for terbinafine and 83.7% for clotrimazole (p = 0.001). Rates of effective treatment at week 4 were 89.7% for terbinafine and 58.7% for clotrimazole (p = 0.0001); and 89.7% for terbinafine and 73.1% for clotrimazole (p = 0.002) at week 6. CONCLUSION: These results indicate that a one week course of terbinafine 1% cream is more effective in the treatment of tinea pedis than a four week course of clotrimazole 1% cream, both in terms of mycological cure and effective treatment.

Treatment of selected extension supracondylar fractures of the humerus by manipulation and strapping in flexion.

The long-term results after the manipulation and strapping in flexion of selected extension supracondylar fractures of the humerus were evaluated in 43 children. Reduced fractures that were stable when immobilized in approximately 110 degrees of flexion, without producing circulatory obstruction, were treated in this manner. After a minimum review of 4 years, 95 per cent of the children had an excellent or good range of elbow motion and 88 per cent had excellent or good elbow alignment. No child had Volkmann's ischaemic contracture. Five children had cubitus varus which was due to malunion in three, but was unrelated to the treatment of the supracondylar fracture in two children. If these two latter children were excluded then excellent or good alignment was observed in all children who had a Baumann (humerocapitellar) angle of 80 degrees or less at the time of reduction and 84 degrees or less 10 days after the fracture. We concluded that manipulation and strapping in flexion was suitable for approximately 60 per cent of children with isolated displaced supracondylar fractures of the humerus.

Normal characteristics of the Baumann (humerocapitellar) angle: an aid in assessment of supracondylar fractures.

We evaluated the normal Baumann (humerocapitellar) angle in 114 children aged 2-13 years because the angle has been proposed to be useful in assessing alignment of the elbow in children with supracondylar fractures of the humerus. In this age range, the angle did not change significantly, nor was there any significant difference between the angle in boys and girls. The mean Baumann angle was 72 degrees (SD 4 degrees), and 95% of normal elbows had a Baumann angle of 64 degrees-81 degrees.

Cubonavicular coalition: an unusual cause of peroneal spastic flat foot.

Cubonavicular coalition is a rare form of tarsal coalition which has only been previously described in an asymptomatic patient. A case is reported where this type of coalition caused symptoms of bilateral peroneal spastic flat feet.

Vertical subluxation of the patella: an unusual feature of multiple epiphyseal dysplasia.

Abnormally shaped, usually double-layered, patellae are recognized as occurring in multiple epiphyseal dysplasia. The case described is unusual in that an associated defect appeared in the femur and resulted in mechanical symptoms.

Treatment of ipsilateral supracondylar and forearm fractures in children.

The treatment of ipsilateral supracondylar fractures of the humerus and fractures of the forearm bones was evaluated in 11 children. After an average of 6 years, 10 children had excellent or good results and one had a poor result from Volkmann's ischaemic contracture. Displaced supracondylar fractures of the humerus associated with distal fractures of the forearm bones are best treated by closed reduction and percutaneous pin fixation of the humeral fracture and a below-elbow plaster backslab.

Biodegradable pin fixation of elbow fractures in children. A randomised trial.

A prospective randomised clinical trial was undertaken to compare biodegradable polyglycolic acid pins with standard Kirschner wires used to fix displaced elbow fractures in children. Twenty-four children were enrolled in the trial; 14 had fractures of the lateral condyle of the humerus, eight of the medial epicondyle and two had olecranon fractures. Eleven fractures were fixed with Kirschner wires and 13 with polyglycolic acid pins. Fracture union with full function occurred in all cases within six months. Kirschner wires caused problems including infection in three cases, soft-tissue ossification in one and they required removal under general anaesthesia in nine cases. No such complications occurred with polyglycolic acid pins but one patient in this group developed avascular necrosis and premature fusion of the medial epicondyle.

Flexion supracondylar fractures of the humerus in children: treatment by manipulation and extension cast.

We have reviewed, at an average of 7 years, 14 children with flexion supracondylar fractures of the humerus. These fractures accounted for 6 per cent of the 288 displaced supracondylar fractures treated from 1981 to 1985. A total of 12 patients had typical fractures that were treated by manipulation and immobilization in an extension cast. Two patients had atypical fractures with anterior displacement and posterior angulation of the distal fragment; they were treated by manipulation, but were more stable when immobilized with the elbow flexed with strapping and collar and cuff support. Overall, excellent or good results were achieved in 10 cases and poor results in four cases. Of the poor results, two were due to cubitus varus. These children were the only ones under 2 years of age, and in each the deformity was due to the persistence of an abnormally large Baumann angle. Plaster immobilization was inadequate at this stage. The other two poor results were due to mild stiffness of the elbow. For typical fractures, we conclude that excellent results can be expected in most children over the age of 2 years when treated with manipulation and immobilization in extension for 3 weeks. For the rarer atypical fractures, we conclude that excellent results can be expected after manipulation and immobilization in flexion for 3 weeks.

Septic arthritis complicating hip osteoarthritis.

Four patients with osteoarthritis of the hip, who developed septic arthritis of the affected joint, are reported. The septic arthritis developed insidiously and was diagnosed with difficulty. One patient died, two required subsequent joint excision, and one arthrodesis despite antibiotics. The presence of a recognised predisposing factor to septic arthritis, such as rheumatoid arthritis or a surgically replaced joint, can provide a diagnostic pointer. These cases suggest that osteoarthritis, similarly, is a predisposing factor. It is concluded that joint sepsis should be considered if a patient with osteoarthritis develops new symptoms from a single joint with associated systemic features.

Glove punctures in an orthopaedic trauma unit.

A series of 421 operations in an orthopaedic trauma unit have been studied for glove punctures; 37.5 per cent of operations had a puncture demonstrated in the surgeon's gloves. The procedures at a high risk of glove punctures were hip operations (57 per cent) and internal fixation (54 per cent). The use of double gloving reduced the contamination of the surgeon's hand in these operation groups to 17 per cent (P less than 0.05). The potential risk of the surgeon being infected by his patients has become increasingly important with the increase in the number of people infected with HIV. The trauma surgeon is at a high risk due to frequent spillage of body fluids in trauma and the difficulty in identifying patients who may be at risk. Reducing the risk to the surgeon is difficult but awareness of the areas of potential contamination such as glove puncture may help.

Thoracic spine translocation without cord injury.

We report three cases of thoracic spine translocation without neurological deficit. In each case bilateral pedicular fractures, demonstrated by computed tomography, produced 'floating arches' which account for the sparing of the cord. If computed tomography demonstrates adequate canal dimensions, these patients may be treated conservatively, but the treatment of choice at specialist spinal centres is operative stabilisation.