Clinical outcomes in periarticular knee fractures with flexible fixation using far cortical locking screws in locking plate: a prospective study.

PURPOSE: Periarticular fractures around the knee joint are treated traditionally by locking plates which provide excellent stability but suppress callus formation. Far cortical locking (FCL) screws allow axial motion and enhance uniform callus formation. Our study aims to evaluate the outcomes of FCL screws in traditional locking plate in periarticular fractures of the knee. METHODS: Thirty patients with periarticular fractures of the knee joint were operated with locking plate using FCL screws. All patients were evaluated clinically and radiographically using X-rays at 6, 12, 24 weeks, 1 year and with CT scan at 12-weeks follow-up. RESULTS: The average time for complete union was 20 weeks in tibial fractures and 24 weeks in femur fractures. Average time to full weight bearing ambulation was 4.8 ± 0.93 weeks. One patient had delayed union in which union was complete after 9 months. CONCLUSION: This study shows that FCL screws in locking plates allow uniform callus formation and fracture union with minimal complication rates.

Minimally invasive fixation for displaced intra-articular fractures of calcaneum: a short-term prospective study on functional and radiological outcome.

INTRODUCTION: Studies have demonstrated a decrease in the incidence of late consequences and the socio-economic burden of intra-articular fractures of calcaneum when treated by surgical fixation. Operative management of displaced intra-articular calcaneal fractures (DIACF) pose significant challenges such as technical difficulty, wound healing and long-term pain and disability. MATERIALS AND METHODS: All patients presenting to the ER with DIACF over a period of 2 years and matching the inclusion criteria were enrolled in the study. Percutaneous fixation with 4 mm CC screw was undertaken with a minimally invasive sinus tarsi approach. All patients were available for a minimum follow-up of 24 months. Six radiological parameters were assessed, and functional outcome was evaluated using AOFAS score. RESULTS: Thirty-four patients with 42 calcaneal fractures were included in the study, and all patients were available for minimum follow-up period. All radiological parameters were attained within anatomic normal range and maintained at 24 months of follow-up. AOFAS score showed a mean value of 90.10 which is considered an excellent outcome. Superficial wound infection was seen in two patients, but no patients required a revision surgery. CONCLUSION: Displaced intra-articular fractures pose a treatment dilemma, more so in cases of soft tissue complications like open injury or blisters. Percutaneous screw fixation with limited sinus tarsi incision has shown good functional and radiological outcome with minimal complications and can be undertaken without delay.

Local administration of morphine for analgesia after iliac bone graft harvest.

BACKGROUND: Harvesting autogenous bone grafts from the ilium may cause considerable pain and may represent a significant source of postoperative morbidity. The local application of morphine can reduce pain in a rat model of bone damage. We evaluated the analgesic efficacy of administering morphine to the donor bone graft site for spinal fusionsurgery. METHODS: Sixty patients undergoing cervical spinal fusion surgery using autogenous bone harvested from the ilium were randomly assigned to one of three groups: Group 1 was given saline infiltrated into the harvest site, group 2 was given 5 mg intramuscular morphine; group 3 was given 5 mg morphine infiltrated into the harvest site. After surgery, all patients were given morphine through a patient-controlled analgesia pump. Pain scores both from the harvest and the incision sites, as well as morphine use, were recorded at 2, 4, 6, 8, 12, and 24 h after surgery. At 1 yr after surgery the presence and subjective characteristics of donor site pain were recorded. RESULTS: Total 24-h morphine use (milligrams) was significantly lower (P < 0.0001) in group 3 (33.7+/-8.3 mg, mean +/- SD), compared with either group 1 (64.3+/-6.6 mg) or group 2 (59.6+/-9.3 mg). Pain from the graft site was scored the same at 2 h but remained significantly lower (P < 0.0001) for group 3 at all later time intervals. Pain scores from the incision site were similar among the three study groups. One year after surgery, 25% of patients reported having chronic donor site pain. The association of chronic donor site pain was significantly higher (P < 0.05) in groups 1 (33%) and 2 (37%) compared with group 3 (5%). CONCLUSION: Low-dose morphine applied to the harvest graft site can reduce local pain, morphine use, and chronic donor site pain after cervical spine fusion surgery.

Diffuse alveolar hemorrhage after clopidogrel use.

Pulmonary hemorrhage following percutaneous coronary intervention is a very rare complication that has been previously reported in association with abciximab and tirofiban, but not with clopidogrel. We report the case of a 56-year-old man who developed diffuse alveolar hemorrhage after receiving clopidogrel for placement of a coronary stent. Since clopidogrel is a commonly used medication, clinicians should be aware of this potentially life-threatening complication.

Postoperative analgesia for outpatient arthroscopic knee surgery with intraarticular clonidine and/or morphine.

Both clonidine, an alpha(2) agonist, and morphine, an opioid agonist, provide enhanced patient analgesia after arthroscopic knee surgery when administered via the intraarticular (IA) route. Clonidine potentiates morphine analgesia in the animal model. We designed this study to determine whether clonidine or morphine results in better analgesia and whether their combination would provide superior analgesia to either drug alone. We evaluated 60 patients undergoing arthroscopic knee meniscus repair under local anesthesia with sedation. After surgery, patients were randomized into four IA groups: Group B received 30 mL 0.25% bupivacaine; Group BC received 30 mL 0.25% bupivacaine and clonidine 1 microg/kg; Group BM received 30 mL 0.25% bupivacaine and morphine 3 mg; and Group BCM received 30 mL 0.25% bupivacaine, clonidine 1 microg/kg, and morphine 3 mg. This study revealed a significant benefit from the individual IA administration of both clonidine and morphine. The combination of these drugs resulted in decreased postoperative pain and analgesic use, as well as an increased analgesic duration compared with either drug alone. We conclude that IA clonidine and morphine improved comfort compared with either drug alone in patients undergoing knee arthroscopy.

Utilization of coronary angiography and revascularization after acute myocardial infarction in men and women risk stratified by the American College of Cardiology/American Heart Association guidelines.

OBJECTIVES: We sought to determine whether men and women are equally likely to receive coronary angiography and revascularization after acute myocardial infarction (AMI) when they are risk stratified according to American College of Cardiology/American Heart Association (ACC/AHA) practice guidelines for post-MI care. BACKGROUND: Several previous studies have suggested that women may undergo angiography and revascularization procedures less frequently than men. METHODS: In 439 consecutive patients admitted to a public hospital with AMI, rates of coronary angiography and revascularization were compared in men and women categorized, according to ACC/AHA practice guidelines, as having strong (class I or IIa) or weaker (class IIb) indications for angiography. RESULTS: Women were older and more likely to be diabetic or hypertensive, but men and women were equally likely to meet class I/IIa criteria for post-MI angiography (both 51%). Angiography rates were nearly identical in men and women overall (63% vs. 64%), as well as in patients in class I/IIa (80% vs. 82%) and class IIb (46% vs. 46%) (all p > 0.80, with >80% power to detect important differences); the only multivariate predictors of post-MI angiography were age and ACC/AHA class. Significant coronary artery disease was equally prevalent in men and women undergoing angiography, and men and women were equally likely to undergo revascularization, whether they were in class I/IIa (both 55%, p = 0.90) or class IIb (59% vs. 58%, p = 0.88). No significant differences in mortality were noted between men and women. CONCLUSIONS: Despite being older and having more risk factors than men, women were equally likely to undergo coronary angiography and revascularization procedures after AMI, and they had in-hospital clinical outcomes that were at least as favorable.

A comparison of two concentrations of bupivacaine and adrenaline with and without fentanyl in paediatric inguinal herniorrhaphy.

This study was designed to determine whether administration of caudal bupivacaine with fentanyl would have any effect on analgesia in paediatric patients undergoing inguinal herniorrhaphy repair. Fifty-six outpatient paediatric patients undergoing inguinal hernia repair were evaluated. Patients received, in a randomized manner, 1 ml.kg-1 of either bupivacaine 0.25% or 0.125% with or without fentanyl 1 microg.kg-1. There was no difference in pain scores in the hospital, the night of surgery, or 24 h postoperatively nor was there a difference in the oral analgesics administered between any of the groups. There was a higher incidence of vomiting at home in both 0.25% bupivacaine groups irrespective of the use of fentanyl. The 0.125% bupivacaine group had significantly more patients who received intravenous fentanyl in the PACU than did the other three groups (P<0.001). Increasing the concentration of bupivacaine from 0. 125% to 0.25% increased the incidence of postoperative vomiting. We recommend that clinicians utilize bupivacaine 0.125% with 1 microg. kg-1 fentanyl as the caudal injectate in paediatric patients undergoing inguinal hernia repair.

Intraarticular morphine in the multimodal analgesic management of postoperative pain after ambulatory anterior cruciate ligament repair.

UNLABELLED: Reconstruction of the anterior cruciate ligament (ACL) is associated with a considerable degree of postoperative pain. Our customary multimodal approach to postoperative analgesia after ambulatory ACL surgery includes perioperative nonsteroidal antiinflammatory drugs, pre- and postincisional intraarticular (I.A.) bupivacaine (B), and postoperative cryotherapy using an external cooling system. This study was designed to determine whether the addition of I.A. morphine (MS) provides improved postoperative analgesia. One hundred patients scheduled for elective ambulatory ACL repair received our standard multimodal therapy. After surgery, patients were randomized to one of four study groups. Group 1 received 30 mL of 0.25% B I.A. Group 2 received 30 mL of normal saline I.A. and 5 mg of MS I.A. Group 3 received 30 mL of 0.25% bupivacaine I.A. and 5 mg of MS I.V.. Group 4 received 30 mL of 0.25% B I.A. and 5 mg of MS I.A. The addition of I.A. B postoperatively provided prolonged analgesia and decreased postoperative pain and analgesic requirements. The addition of MS to I.A. B did not provide additional postoperative analgesia. We conclude that patients undergoing ambulatory ACL repair using our standard multimodal analgesic regimen failed to receive additional postoperative analgesia when MS was added to the I.A. B. IMPLICATIONS: Patients receiving a multimodal analgesic regimen of perioperative nonsteroidal antiinflammatory drugs, intraarticular bupivacaine, and external cooling did not receive any additional analgesia from intraarticular morphine.

Clinical and angiographic findings in black patients with suspected coronary artery disease.

To determine the clinical variables and coronary angiographic findings in black patients with suspected coronary artery disease, we analyzed the data on consecutive black patients undergoing their first coronary angiogram over a three year period at the Cook County Hospital, Chicago, Illinois. We compared these findings to those of black and white patients from previous studies. There were 654 patients with a mean age+/-standard deviation of 56+/-10 years; 309 (47%) were men. Two hundred nineteen patients (33%) presented with unstable angina, 75 patients (12%) with acute myocardial infarction and 338 patients (52%) with chronic stable angina. Three hundred forty-six patients (53%) had 50% or greater stenosis in at least one of the major vessels. Among the patients with coronary artery disease, 128 patients (37%) had one vessel disease, 102 patients (29%) had two-vessel disease, and 116 patients (34%) had three-vessel disease. Black patients who undergo coronary angiography for suspected coronary artery disease have a high frequency of normal coronary angiogram or non-obstructive coronary artery disease. The frequency of 1-, 2- and 3-vessel disease in blacks with coronary artery disease is comparable to those observed in whites in previous reports.

Microalbuminuria and progressive renal disease.

Microalbuminuria is a predictor of excess cardiovascular morbidity and mortality in both hypertensive and diabetic subjects. The reasons for this are multifactorial and relate to metabolic and haemodynamic problems seen in this population. In diabetic patients, microalbuminuria correlates more with glycosylated haemoglobin than with the duration of diabetes. The pathogensis of microalbuminuria includes alterations in glomerular shunting of albumin, increased intraglomerular pressure and increased amounts of certain growth factors that alter cell permeability. The urine Micral test is an easy way to screen for the presence of microalbuminuria. The increase in microalbuminuria over time can be documented by annual quantitation using a radioimmunoassay technology. Aggressive control of BP is vitally important in order to preserve renal function. Antihypertensive agents that lower both intraglomerular pressure and volume are preferable, since they consistently attenuate both the increase in microalbuminuria and structural changes within the glomerulus. In addition to BP control, other measures known to reduce the rise in microalbuminuria include a reduced dietary protein intake and good long-term blood glucose control. Unfortunately, there is no definitive study, in humans, that conclusively demonstrates a preservation of renal function directly relates to an attenuated rise in microalbuminuria. Thus, while microalbuminuria is clearly a risk factor for development of diabetic nephropathy and an indicator of hypertensive renal disease, its reduction has not demonstrated functional or structural benefit in humans. This is in large part due to the inpracticality of such a trial because of the duration needed to see an effect. Interestingly, a beneficial effect on renal survival has been shown with albuminuria reduction independent of BP reduction.

Cocaine and scleroderma: is there an association?

Scleroderma is a multisystem disease of unknown etiology. A disease predominantly of women, it is distinctly rare in young men. A case of scleroderma in a young male cocaine user is presented, and the possibility that cocaine may play a part in its etiology is explored.

Pneumocephalus after posterior fossa exploration in the sitting position.

Entrainment of air following exploration of posterior cranial fossa in the sitting position was studied in five patients. Intracranial pressure was monitored through a ventriculostomy catheter after closure of the dura. In three patients nitrous oxide was added to the breathing mixture only after the baseline intracranial pressure had stabilised following closure of the dura. A marked rise in intracranial pressure was observed immediately. A rapid decrease in intracranial pressure occurred when nitrous oxide administration was stopped. Two patients were nitrous oxide from the beginning. No change in intracranial pressure was noted. Computerised tomogram on the first postoperative day revealed a significant amount of air in eight cases.