Time to Initial Debridement and wound Excision (TIDE) in severe open tibial fractures and related clinical outcome: A multi-centre study.

BACKGROUND: Recent national (NICE) guidelines in England recommend that initial debridement and wound excision of open tibial fractures take place within 12 h of the time of injury, a change from the previous target of 24 h. This study aims to assess the effect of timing of the initial debridement and wound excision on major infective complications, the impact of the new guidance, and the feasibility of adhering to the 12 h target within the infrastructure currently existing in four major trauma centres in England. METHODS: A retrospective review was performed of Gustilo-Anderson grade 3B open tibial fractures presenting acutely to four Major Trauma Centres (MTCs) in England with co-located plastic surgery services over a ten-month period. The incidence of deep infective complications was compared between patients who underwent initial surgery according to the new NICE guidance and those who did not. Patients warranting emergency surgery for severely contaminated injury, concomitant life-threatening injury and neurovascular compromise were excluded. Multi-variable logistic regression analysis was performed to assess the effect of timing of surgical debridement on development of deep infective complications. RESULTS: 112 patients with 116 fractures were included. Six fractures (5.2%) developed deep infective complications. 38% (n = 44) underwent primary debridement within 12 h and 90% within 24 h. There was no significant difference in the incidence of major infective complications if debrided in less than or greater than 12 h (4.5% vs 5.6%, p = 1.00). Logistic regression found no significant relationship between timing of wound excision and development of deep infection. There was no significant decrease in mean time to debridement following introduction of new national guidance (13.6 vs 16.1 h) in these four MTCs. CONCLUSION: Overall, the rate of deep infection in high energy open tibial fractures managed within the four major trauma centes is low. Achieving surgical debridement within 12 h is challenging within the current infrastructure, and it is unclear whether adhering to this target will significantly affect the incidence of severe infective complications. Debridement within 24 h appears achievable. If a 12-h target is to be met, it is vital to ensure dedicated orthoplastic capacity is adequately resourced.

Hair thread tourniquet syndrome in a male infant: a rare surgical emergency.

Hair thread tourniquet syndrome (HTTS) is a rare surgical emergency that occurs when one or more appendages are acutely circumferentially strangulated by human hair. If left untreated it may induce prolonged ischaemia, resulting in tissue necrosis or autoamputation of the affected digit. It may involve the fingers, toes, penis or labia. It typically occurs in infants, but cases have also been reported in adults. Prompt recognition and treatment by complete removal of the constricting agent is crucial to preserve the affected tissue. We report a case of HTTS affecting the left middle toe of an 8-week-old male infant successfully treated by surgical release of the hair. The authors aim to raise awareness of HTTS among physicians, emergency doctors, paediatricians and surgeons, as prompt recognition and management prevents adverse outcomes and tissue necrosis.

Systematic review: Predicting adverse psychological outcomes after hand trauma.

STUDY DESIGN: Systematic review. INTRODUCTION AND PURPOSE OF THE STUDY: After traumatic hand injury, extensive physical and psychological adaptation is required following surgical reconstruction. Recovery from injury can understandably be emotionally challenging, which may result in impaired quality of life and delayed physical recovery. However, the evidence base for identifying high-risk patients is limited. METHODS: A PROSPERO-registered literature search of MEDLINE (1946-present), EMBASE (1980-present), PsychInfo, and CINAHL electronic databases identified 5156 results for studies reporting psychological outcomes after acute hand trauma. Subsequent review and selection by 2 independent reviewers identified 19 studies for inclusion. These were poor quality level 2 prognostic studies, cross sectional or cohort in design, and varied widely in methodology, sample sizes, diagnostic methods, and cutoff values used to identify psychological symptoms. Data regarding symptoms, predisposing factors, and questionnaires used to identify them were extracted and analyzed. RESULTS: Patients with amputations or a tendency to catastrophize suffered highest pain ratings. Persisting symptom presence at 3 months was the best predictor of chronicity. Many different questionnaires were used for symptom detection, but none had been specifically validated in a hand trauma population of patients. Few studies assessed the ability of selection tools to predict patients at high risk of developing adverse psychological outcomes. DISCUSSION AND CONCLUSION: Despite a limited evidence base, screening at 3 months may detect post-traumatic stress disorder, anxiety, depression, and chronic pain, potentially allowing for early intervention and improved treatment outcomes. LEVEL OF EVIDENCE: Level 4.

Low energy open ankle fractures in the elderly: Outcome and treatment algorithm.

BACKGROUND: With an aging but still active population, open ankle fractures are increasingly presenting as low energy fragility injuries, sharing many characteristics with that of hip fractures. Yet, there is little in the literature on the management and outcome of these fractures. The primary aim of this study was to describe the outcome following open, ankle fragility fracture. Our secondary aim was to identify potential factors that improved outcome. METHODS: All consecutive, low energy open ankle fractures treated at a Level I Trauma Centre over a five-year period were included. The method of fracture fixation, soft tissue closure, patient demographics, complications and mortality were recorded. Functional outcome was assessed using the Enneking Scoring system. RESULTS: The cohort comprised 61 patients with a mean age of 73 years (range 27-100); 50 (82%) were females and all patients requiring operative intervention. The overall rate of complication was 24.5% (n=15), with reoperation due to loss of reduction, non-union, infection or amputation required in 7 cases (11.5%). The one-year mortality was 23%. The mean Enneking score, measuring functional outcome, was 36 out of 40 (SD: 6, range: 16-40). It was significantly higher for those treated with internal fixation (37, SD: 5 range: 16-40) than those with external fixation (31, SD: 6 range: 21-38) (p=0.01). Similarly, definitive wound closure - primary closure (37, SD: 5) or flap with split thickness skin graft (SSG) (36, SD: 6) - led to better outcomes than non-definitive closure (31, SD: 8). CONCLUSIONS: The high morbidity associated with low energy ankle fractures is likely to reflect the hosts' reserves and is comparable to other fractures seen in the elderly. It is evident that definitive fracture fixation providing absolute, rather than relative stability; and definitive wound cover, with either primary closure or flap and SSG, enable early mobilization and shorter hospital stays with improved overall functional outcomes.

Local recurrence and assessment of sentinel lymph node biopsy in deep soft tissue leiomyosarcoma of the extremities.

BACKGROUND: Leiomyosarcoma of deep soft tissues of the extremities is a rare malignant tumour treated primarily by surgery. The incidence of local recurrence and lymph node metastasis is uncertain and it is not known whether a sentinel lymph node biopsy is indicated in these tumours. METHODS: A retrospective review of patients treated for extremity deep soft tissue leiomyosarcoma at our institution over a 10-year period was conducted. Patients developing local recurrence or lymph node metastasis were identified. The presence or absence of lymphatics in the primary tumours was assessed by immunohistochemical expression of LYVE-1 and podoplanin. RESULTS: 27 patients (mean age 62 years) were included in the study. 15 were female and 12 male. Lymph node metastasis was seen in only two cases (7%); intratumoural lymphatics were identified in the primary tumours of both these cases. Local recurrence occurred in 25.9% of cases despite complete excision and post-operative radiotherapy; the mean time to recurrence was 10.1 months. CONCLUSION: On the basis of this study, we do not advocate sentinel lymph node biopsy in this group of patients except in those cases in which intratumoural lymphatics can be demonstrated. Close follow up is important especially for high grade leiomyosarcomas, particularly in the first year, as these tumours have a high incidence of local recurrence.

Cerebrotendinous xanthomatosis presenting with bilateral Achilles tendon xanthomata.

We report on a case of a 36-year-old lady who presented with large, painful soft-tissue swellings of both Achilles tendons. MRI demonstrated fusiform enlargement involving the Achilles tendons bilaterally. The tendons returned heterogeneous signal intensity characterised by a diffuse reticulated appearance. The right tendon mass was treated with a wide marginal excision and Achilles tendon reconstruction. The histology confirmed Achilles tendon xanthoma. Further metabolic investigation revealed the patient to have a rare autosomal recessive condition called cerebrotendinous xanthomatosis (CTX). Her brother was also affected. CTX is easily treatable if diagnosed early, and should be suspected in patients presenting with bilateral Achilles tendon xanthomas and normal plasma lipid levels.

Small bowel obstruction secondary to intestinal schistosomiasis.

Intestinal obstruction caused by chronic schistosomiasis infection is rare, with only 12 previously recorded cases in the literature. We report the first recorded case presenting to a European hospital. A 36-year-old Caucasian man, who was born and lived in the UK, presented with small bowel obstruction. He had visited China and Indonesia 8 years previously. At laparotomy, there was an obstructing inflammatory mass close to the ileocaecal junction and several small bowel strictures. Initially he was thought to have Crohn's disease. However, subsequent histology diagnosed intestinal schistosomiasis.