Bowel preparation prior to percutaneous ilio-sacral screw insertion: is it necessary?

PURPOSE: The aim of this study was to compare the outcomes of ilio-sacral (IS) screw fixation with and without the use of bowel preparation, in terms of obtaining adequate visualisation, malpositioning of screw requiring revision surgery and neurovascular injury. METHODS: A retrospective case control study was performed. We reviewed 74 consecutive cases of IS screw fixation performed at our institution within the last 5 years. We included all patients who had undergone percutaneous IS screw fixation. Two groups, one consisting of patients who underwent bowel preparation prior to surgery (Group 1) and one consisting of patients who had no bowel preparation (Group 2), were compared in terms of the above outcomes. There were 37 patients in each group. The mean age in Group 1 was 41 years (17-63) and in Group 2 was 47 years (12-89). RESULTS: In Group 1 there were two procedures abandoned due to poor visualisation. In Group 2 there were no cases abandoned for poor visualisation. There were two nerve injuries in Group 1 and no nerve injuries in Group 2. Revision surgery was performed in four patients in Group 1-for malposition, persistent buttock pain, sciatic nerve palsy and inadequate fixation while one revision performed in Group 2 for persistent buttock pain. CONCLUSION: Based on these results, we conclude that bowel preparation is not necessary to obtain adequate visualisation for safe and accurate percutaneous IS screw insertion. In fact, in Group 1 two procedures were abandoned and there was higher incidence of complications. Therefore, it would appear that this treatment arm should be abandoned all together. Further studies to prove it conclusively and explain the reasons are required.

A Simple Technique for the Positioning of a Patient with an above Knee Amputation for an Ipsilateral Extracapsular Hip Fracture Fixation.

The positioning of the patient on the fracture table is critical to the successful reduction and operative fixation of hip fractures which are fixed using the dynamic hip screw system (DHS). There is a standard setup which is commonly used with relative ease. Yet the positioning of patients with amputations either above or below knee of the affected side can pose a significant challenge. We describe a novel positioning technique used on a 51-year old patient with a right above knee amputation who sustained an intertrochanteric extracapsular hip fracture.

Bilateral synchronous rupture of the quadriceps tendon.

BACKGROUND: Bilateral simultaneous rupture of the quadriceps tendon is a rare entity. They are often associated with degenerative changes of the tendons and predisposing conditions such as diabetes or excessive steroid use. They most commonly tend to occur in patients of 40 years of age or older. MATERIALS AND METHODS: We describe a case of a 67-year-old man with simultaneous rupture of both quadriceps tendons. CONCLUSION: The diagnosis can be difficult and often delayed or missed in the initial examination. We report bilateral quadriceps tendon rupture in a previously healthy patient with good post-operative functional outcome.

Epidemiology of pelvic and acetabular trauma in a Dublin tertiary hospital: a 10-year experience.

BACKGROUND: Pelvic fractures are usually the result of high-energy trauma and may have associated soft tissue and organ damage resulting in significant morbidity and mortality in these patients. Currently, there is little data from Ireland regarding these injuries. OBJECTIVE: To study the epidemiology of pelvic fractures presenting to a tertiary referral centre in Dublin. METHODS: Patients referred with a pelvic fracture were identified using the Hospital Inpatient Enquiry System (HIPE) from 1998 to 2008. The patient's medical notes were reviewed for demographic data, type and mechanism of fracture and associated injuries. RESULTS: A total of 509 patients were identified over the 10-year period. 466 patients were included in the study. There was a significant male preponderance 76% (n = 354) as compared to females 24% (n = 112). Mean age was 36.5 years (range 16-83). Road traffic accidents (RTA) were the cause in 74% (n = 346) of the cases. CONCLUSION: From our study, the typical patient profile is one of a male in his 30's involved in an RTA requiring acetabular surgery. This is in accordance with previously published international data and highlights the need for specialised units, training in this subspecialty and allocation of resources.

Skin puckering an uncommon sign of underlying humeral neck fracture: a case report.

Skin puckering is a sign that is well associated with certain fractures such as supracondylar humeral fractures in children. To our knowledge, there has been only one clinical report of skin puckering associated with fractured neck of humerus of an adult. This is a second such case of fractured proximal humerus in an adult presenting with skin puckering and the first from the Republic of Ireland. Skin puckering is suggestive of soft tissue interposition and may be an important clinical sign indicating the need for internal fixation.

Analysis of aryl hydrocarbon receptor-mediated signaling during physiological hypoxia reveals lack of competition for the aryl hydrocarbon nuclear translocator transcription factor.

The aryl hydrocarbon nuclear translocator (ARNT) protein functions as a transcription factor after dimerization with other basic helix-loop-helix proteins. Thus, dimerization of ARNT within one pathway may limit the availability of this protein to others. To investigate this issue, aryl hydrocarbon receptor (AHR)-mediated signaling was investigated in mouse (Hepa-1), rat (H4IIE), and human (HepG2) hepatoma cell lines undergoing physiologically induced hypoxia (<1% O(2)). Basal levels of ARNT protein were not affected by hypoxia in any cell line, and ARNT remained exclusively nuclear. Furthermore, quantitative Western blotting revealed that the concentration of ARNT sequestered during hypoxia represented a small fraction of the total ARNT protein pool (12 and 15% in Hepa-1 and H4 cells, respectively). When the AHR-mediated signaling pathway was activated during hypoxia by 2,3,7,8-tetrachlorodibenzo-p-dioxin, the induction of P4501A1 protein was reduced by 55% without changes in the level of mRNA in Hepa-1 cells, whereas the levels of induction of both P4501A1 protein and CYP1A1 mRNA were reduced by >80% in the H4 cell line. Importantly, gel mobility shift analysis and Western blotting showed that the same level of AHR/ARNT complexes could be detected in cells treated with 2,3,7,8-tetrachlorodibenzo-p-dioxin during hypoxia and normoxia. These data suggest that the effects of hypoxia on AHR-mediated gene regulation occur distal to the formation of AHR/ARNT complexes and imply that functional interference between hypoxia and AHR-mediated signaling does not occur through competition for ARNT protein.

Aryl hydrocarbon receptor imported into the nucleus following ligand binding is rapidly degraded via the cytosplasmic proteasome following nuclear export.

The aryl hydrocarbon receptor (AHR) is a ligand-activated transcription factor that dimerizes with the AHR nuclear translocator protein to mediate gene regulation. However, the AHR protein is rapidly depleted in vitro and in vivo following exposure to ligands. The purpose of the studies in this report was to characterize the mechanism of AHR degradation and determine the consequence of blocking the degradation process. Western blot and immunological analysis of rat smooth muscle (A7), murine Hepa-1, and human HepG2 cells show that ligand-induced degradation of AHR is blocked when the proteasome is inhibited by MG-132. AHR degradation is also blocked in Hepa-1 and HepG2 cells when nuclear export is inhibited with leptomycin B. Mutation of a putative nuclear export signal present in the AHR results in the accumulation of AHR in the nucleus and reduced levels of degradation following ligand exposure. In addition, inhibition of AHR degradation results in an increase in the concentration of AHR.AHR nuclear translocator complexes associated with DNA and extends the duration that the complex resides in the nucleus. These findings show that nuclear export and degradation of the AHR protein are two additional steps in the AHR-mediated signal transduction pathway and suggest novel areas for regulatory control.