Update on the management of open fractures of the tibial shaft.

A retrospective study of 133 open tibial fractures in 129 patients treated at the Hennepin County Medical Center between 1986 and 1993 was done. The results of the treatment protocol in this patient group is presented and the current classification schemes, prevention of infection, debridement, antibiotics, soft tissue reconstruction, fracture stabilization methods, bone grafting, and exchange nailing are discussed. Recent studies that have documented interobserver disagreement in the classification of open fractures underscore the difficulties encountered in the initial assessment and treatment of open tibial shaft fractures. Despite repetitive and aggressive debridement, a certain number of fractures will remain contaminated and become infected. Infection after these severe injuries is probably multifactorial, and its prevention requires that the surgeon diligently adhere to the imperatives of open fracture care.

Compartment syndrome of the lower extremity.

Compartment syndrome is a devastating consequence of extremity trauma that is preventable with early recognition and treatment. A high index of suspicion and careful clinical evaluation will detect most impending or established compartment syndromes. Compartmental pressure measurements can be a useful adjunctive evaluation. Once the diagnosis of compartment syndrome is confirmed, or highly suspect, fasciotomy should be performed without delay. The functional and cosmetic results of fasciotomy are always acceptable if done early. The results of inadequate treatment of compartment syndrome are never satisfactory.

Complications of limb lengthening. A learning curve.

Major complication rates during limb lengthening were plotted in a consecutive series to produce a learning curve. All unwanted events during and after treatment were considered complications, and graded as minor, serious, and severe. All serious and severe complications were considered major. A novel system was used to classify the preoperative severity of each deformity. One-hundred ten patients had 140 bone segments lengthened between 2.2 cm and 10.5 cm, with a mean of 4.4 cm. Three methods were used in lengthening: the Wagner method in 22 patients, the DeBastiani method in 34 patients, and the Ilizarov method in 84 patients. Ninety-eight complications categorized as serious or severe occurred, for a total major complication rate of 72%. The percentage of major complications began to drop after 30 lengthenings to a current rate of 25%. Major complications were frequent in patients with more severe deformities, particularly in those whose cases occurred early in the series. Bone healing complications were high (72%) in the Wagner segments but were also high (80%) in the first ten patients treated with the DeBastiani technique. The first ten Ilizarov patients, who were treated later in the series, had a 40% rate of bone-healing complications. The current rate of major complications is 13% for those patients treated with DeBastiani's method and 33% for those patients treated with Ilizarov's method. This difference in complication rates appears to relate to the severity of the deformity, rather than the device used. There was a significant decrease in complications as experience was gained. Directed formal study and surgical instruction should help diminish these complications.

Central effects of thyrotropin-releasing hormone and arginine vasopressin on intraocular pressure in rabbits.

Administration of either thyrotropin-releasing hormone (TRH) or arginine vasopressin (a-VP) into the rabbit third ventricle elevated intraocular pressure (IOP). IOP was increased 3.6 mmHg 45 min after TRH (10 ng/0.1 ml) administration and increased 6.4 mmHg 45 min following delivery of a-VP (5 micrograms/0.1 ml). Outflow facility and episcleral venous pressure were not altered by either agent. Estimated aqueous humor flow 45 min after third ventricle administration was increased 66% after TRH and 91% after a-VP delivery. Posterior chamber aqueous humor ascorbate was reduced 60 min after TRH administration. Pretreatment with either systemic or topical atropine prevented the TRH or a-VP induced increase in IOP. Body temperature (BT), which was unaltered after TRH administration, was elevated by third ventricle delivery of a-VP. The a-VP induced increase in BT was blocked by systemic pretreatment with either indomethacin or atropine.