Serum Inflammatory Markers and Amputations in Hand Osteomyelitis: A Retrospective Review of 146 Cases.

BACKGROUND: The diagnosis of hand osteomyelitis requires correlation of clinical, radiological, and microbiological findings. The role of serum inflammatory markers in diagnosing and prognosticating hand osteomyelitis remains uncertain. We sought to determine the utility of inflammatory markers in the diagnosis and follow-up of hand osteomyelitis, and their ability to predict outcomes, particularly amputation. METHODS: We retrospectively reviewed 146 patients diagnosed with hand osteomyelitis and with serum inflammatory marker levels measured after the onset of symptoms and within 14 days either side of diagnosis. Blood results at first presentation including white cell count (WCC), neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and C-reactive protein (CRP) were reviewed, and associations with amputations assessed. Follow-up markers taken at 15 to 60 days from diagnosis were analyzed where available. RESULTS: Mean WCC and CRP at diagnosis were 9.2 (SD: 4.6) and 30.2 (SD: 42.4) respectively, compared with 8.2 (SD: 3.9) and 30.2 (SD: 42.4) at follow-up. At diagnosis, sensitivity of CRP was 74%, and WCC was 31%. Each marker had a low positive predictive value for amputation at diagnosis (<29%). A rise in CRP between diagnosis and follow-up was associated with an increased risk of amputation compared with a fall in CRP. The finding that WCC and CRP were both normal at diagnosis had a high negative predictive value against amputation (96%). CONCLUSION: C-reactive protein has a higher sensitivity than WCC, NLR, and PLR when used as a diagnostic adjunct in hand osteomyelitis. White cell count and CRP both within reference ranges at diagnosis was highly negatively predictive against amputation.

The European Working Time Directive: Will Modern Surgical Training in the United Kingdom Be Sufficient?

Purpose The introduction of the European Working Time Directive in 2009 limits doctors in the United Kingdom to a 48-hour working week. The reduction in surgical training time raises concern over the ability of future surgeons to deliver safe and effective care. Methods This interview-based qualitative study was conducted within a tertiary referral centre in the United Kingdom. Nine consultant general surgeons were interviewed with the aim of investigating how surgical trainees can comply with the European Working Time Directive whilst gaining sufficient knowledge, skill and experience to be safe surgeons. Results Consultants felt that the European Working Time Directive has impacted surgical training, patient care, service provision, and the professional attitudes of trainees. They felt that current surgical trainees have a relative lack of experience compared to previous generations, which has impacted their ability to manage complex patients. The consultant-trainee relationship was felt to have suffered due to shorter working hours. Furthermore, the move towards shift work has resulted in a lack of continuity of care for patients. Consultants suggested reconfiguring theatre lists to maximise opportunities for trainees. They also recommended that trainees seek out alternative learning methodologies such as simulation, and consider clinical fellowships at the completion of their training to maximise their experience and surgical skills prior to consultancy. Conclusion This study highlights the concerns that senior surgeons working in a busy tertiary referral centre have towards the European Working Time Directive and modern surgical training. The authors recommend that both trainees and consultants have a responsibility to maximize opportunities during training, and that mentorship will need to continue at the consultant level. Further research in other centres can determine whether these sentiments are widespread, and whether institutional steps should be taken to change the way that modern surgeons are trained.

Hand osteomyelitis in arterial calcification, diabetes mellitus and end-stage renal failure: a comparison of 210 cases over 12 years.

We present 210 patients with hand osteomyelitis in 246 rays over 12 years, including detailed analysis of 29 patients in this cohort with digital artery calcification evident on plain X-ray. Overall 71 patients had diabetes mellitus and/or end-stage renal failure, including 28 of 29 patients with calcification. In the calcification group, 17 patients had ipsilateral arteriovenous fistulae, five had steal syndrome and 15 had digital ulceration or skin necrosis. Compared with 181 controls, patients with calcification had more affected bones, polymicrobial infections, surgical procedures, phalanges and digits amputated and had higher mortality at 1 year (12 of 29) and 5 years (20 of 29), as a result of comorbidities. Absence of calcification in 43 patients with diabetes and/or end-stage renal failure was associated with better outcomes on all the above parameters. Early amputation to maximize disease-free survival may be appropriate for patients with hand osteomyelitis and arterial calcification.Level of evidence: IV.