An aid to femoral nail removal.

We describe a novel technique to aid the removal of a proximally inserted femoral nail by using a guide wire and the starter reamer. By reaming through the scar tissue, a cylindrical track is created and the threaded top end of the nail is exposed. The soft tissue dissection is therefore limited to the absolute minimum with no further damage to the hip abductors.

Inflammatory-cell subpopulations in keloid scars.

The aim of this study was to investigate the contribution of lymphocytes and macrophages to keloid scarring by morphologically characterising inflammatory cell subpopulations in keloid scars in comparison with normal skin. We took 3mm punch biopsies from the anterior forearms of eight normal healthy volunteers. Eight keloid scars were excised using an intralesional technique. All tissue was snap frozen in liquid nitrogen and serial sections were stained with a panel of anti-inflammatory cell monoclonal antibodies. The numbers of macrophages and lymphocytes and the proportions of the subpopulations were compared. Higher numbers of both macrophages and lymphocytes were found in keloid dermis (P=0.01 and P=0.02, respectively (Mann-Whitney U -test)). There was no significant increase in the expression of the lymphocyte-activation markers, CD25 and CD27. However, there was a significantly higher CD4(+):CD8(+)(Th:Ts) ratio (P= 0.046) in keloid tissue. This suggests that an imbalance in these inflammatory cell subpopulations may contribute to keloid scarring in man.

Pathophysiology of chronic bacterial osteomyelitis. Why do antibiotics fail so often?

In this review the pathophysiology of chronic bacterial osteomyelitis is summarised, focusing on how bacteria succeed so often in overcoming both host defence mechanisms and antibiotic agents. Bacteria adhere to bone matrix and orthopaedic implants via receptors to fibronectin and to other structural proteins. They subsequently elude host defences and antibiotics by "hiding" intracellularly, by developing a slimy coat, or by acquiring a very slow metabolic rate. The presence of an orthopaedic implant also causes a local polymorphonuclear cell defect, with decreased ability to kill phagocytosed bacteria. Osteolysis is determined locally by the interaction of bacterial surface components with immune system cells and subsequent cytokine production. The increasing development of antibiotic resistance by Staphylococcus aureus and S epidermidis will probably make conservative treatment even less successful than it is now. A close interaction between orthopaedic surgeons and physicians, with combined medical and operative treatment, is to be commended.

Arthrodesis of the distal tibiofibular joint for a large osteochondroma in an adult.

A case of a large osteochondroma of the distal tibia with distortion of the distal tibiofibular joint is presented. This could not be managed by traditional means, as excision would have resulted in ankle and tibiofibular joint instability. The problem was overcome by performing an arthrodesis. Only enough bone from both the tibia and the fibula was excised to provide a host bed for bone graft. We believe that symptomatic osteochondromata should usually be excised. However, if this would result in damage, then the method described offers an alternative management strategy.

Blood crossmatching for burn surgery: potential for reduced wastage using a modified dye formula.

Estimating the perioperative crossmatch requirement (CMR) of burn patients is difficult, as losses are variable and hard to predict. Accuracy is important, however, as over-provision risks wasting blood. Blood ordering tariffs have increased efficiency and reduced blood wastage in other branches of surgery. Dye has published a tariff for burn patients in the form of a formula, relating CMR to weight and percentage total body surface area (TBSA) excised. This study examines the efficiency of blood ordering and use among 72 burn patients and compares outcomes with the predictions of Dye's and a modified Dye's formula, for the same patients. All patients were crossmatched, but only 34 patients were transfused. The crossmatch:transfusion ratio was 2.1, with 52% of crossmatched blood being unused. Dye's formula would have reduced the total volume crossmatched for the same patients by 13%. The crossmatch:transfusion ratio would be 1.8, with 44% of cross-matched blood remaining unused. A modified form of Dye's formula was designed to reduce the high rate of blood non-use. This would reduce the total volume crossmatched by 40% and the rate of blood non-use to 20%. The crossmatch:transfusion ratio would be 1.24.

Adult hernia surgery in Wales revisited: impact of the guidelines of The Royal College of Surgeons of England.

This study investigated the impact of the guidelines of The Royal College of Surgeons of England on the practice of hernia surgery in Wales. This was assessed by means of a postal survey to all consultant general surgeons in Wales in 1996-1997. The areas covered were: awareness of the guidelines of The Royal College of Surgeons of England and the impact of such guidelines on their practice, attendance at hernia courses, operative technique, materials used for repair and skin suture, proportion of day case hernias, length of inpatient stay, thromboembolic (TE) prophylaxis and postoperative advice to patients with regard to light work, heavy work and sport. In all, 79 replies were received (85%). Almost all the surgeons had read the guidelines; this changed the practice of 20% of respondents but did not in 32%. A further 48% did not answer the question. In contrast with our 1993 survey results, in Wales there is now a uniform surgical management of adult inguinal hernias: the most common operation is the Liechtenstein, with monofilament non-absorbable suture to secure the mesh, followed by the Shouldice repair. The Bassini and inguinal darn operations are becoming much less common and none now uses braided or absorbable sutures for the repair. Skin closure is still rather variable, with only 58% of respondents adhering to the recommended absorbable subcuticular suture. Postoperative advice is now uniform and in accordance with the guidelines. A trend towards more TE prophylaxis and more day case hernia surgery is also seen.