Isolated displaced non-union of a triquetral body fracture: a case report.

INTRODUCTION: Fractures of the body of the triquetral bone are the second most common carpal fractures, and these fractures can be missed on plain X-ray. Although non-union of triquetral body fractures is very rare, such cases are associated with considerable morbidity and reduction in functional activity. CASE PRESENTATION: We report the case of a 29-year-old Caucasian British man who sustained an isolated displaced triquetral body fracture that resulted in non-union, who was treated surgically. We describe an original operative management for this debilitating injury. An open reduction and internal fixation using double headed compression screws was performed, without bone grafting, and with early immobilization of the wrist. CONCLUSIONS: We propose this novel approach and advocate early clinical suspicion of triquetral body fractures in patients with a history of fall on an outstretched hand and ulnar sided wrist pain. We recommend evaluation using computed tomography or magnetic resonance imaging scanning.

Non-union of isolated displaced triquetral body fracture--a case report.

Triquetral fractures are the second most common carpal fractures. Triquetral body fractures are the less common type of triquetral fractures but they can be missed on plain radiographs and a non-union can be associated with considerable morbidity and reduction in functional activities. We report a unique case of displaced isolated triquetral body fracture that was initially missed on plain radiographs and resulted in non-union. The fracture non-union was diagnosed on magnetic resonance imaging and was treated successfully with open reduction and internal fixation using compression screws, without bone grafting, and early mobilisation of the wrist allowing a return to premorbid activity levels. To our knowledge, this has not been previously described in the literature. We advocate early clinical suspicion of triquetral fractures in patients with persistent ulnar-sided wrist pain following trauma, and early evaluation using computed tomography or magnetic resonance imaging.

Optimal intraoperative anticoagulation strategy in patients undergoing off-pump coronary artery bypass.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was what the optimal intraoperative anticoagulation strategy should be in patients undergoing off-pump coronary artery bypass graft (CABG) surgery. A total of 157 papers were identified using the reported search, of which 8 were judged to represent the best evidence. The authors, journal, date, country of publication, study type, patient group studied, relevant outcomes and results were tabulated. The quality of clinical trials was assessed. Off-pump CABG is currently considered as a safe and effective alternative to CABG with the use of cardiopulmonary bypass, especially in the presence of off-pump expertise and certain pathologies. Although most technical steps in off-pump revascularization are standardized, it appears that there is inconsistency in intraoperative anticoagulation practice. Surveys conducted in the USA and Europe confirm the lack of uniform policy, with heparin dose ranging between 70 and 500 U/kg and from full-dose protamine to no reversal of anticoagulation. Although the quality of evidence is low, there is a trend for utilization of heparin at 150 U/kg, followed by half-dose protamine reversal, which appears to provide adequate anticoagulation for the safe conduct of anastomoses and thromboprophylaxis without significantly increasing the risk of postoperative bleeding. However, more research is necessary before firm recommendations can be made.

Does prophylactic therapy with antioxidant vitamins have an effect on atrial fibrillation following cardiac surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether prophylactic therapy with antioxidant vitamins reduces the incidence of postoperative atrial fibrillation (AF). One hundred and fifty-four papers were found using the reported search, of which five were judged to represent the best evidence to answer the question. The authors, journal, date, country of publication, patient group studied, study type, relevant outcomes and results were tabulated. Four of the five studies found antioxidant vitamins to significantly reduce the incidence of postoperative AF. Two of the studies show that prophylactic treatment with adjuvant vitamin C and ß-blockers is more effective than ß-blocker therapy alone. The quality of these studies was assessed using a Jadad scoring system, which identified four of the studies to be of low and one to be of high methodological quality. We conclude that although preliminary evidence suggests that prophylactic antioxidant vitamins may be effective in reducing the incidence of postoperative AF, there is a lack of high-quality data. Additional large-scale, adequately powered clinical studies are warranted before antioxidant vitamins can be considered for routine use in this setting.

Do antioxidant vitamins have an anti-arrhythmic effect following cardiac surgery? A meta-analysis of randomised controlled trials.

BACKGROUND: Postoperative atrial fibrillation (POAF) affects approximately 30% of patients undergoing elective cardiac surgery. While its pathogenesis is multifactorial, increasing evidence supports a role for oxidative stress in the electrophysiological remodelling associated with AF. Although prophylactic antioxidants appear to be a potentially attractive pharmacotherapy, there is still uncertainty regarding their efficacy. This study aims to provide a quantitative summary of the current evidence surrounding antioxidant vitamins and POAF prevention. METHODS: A systematic literature review identified five randomised controlled trials incorporating 567 patients (n = 284 antioxidant, n = 283 control). These were meta-analysed using random effects modelling. Heterogeneity, subgroup analysis, quality scoring and risk of bias were assessed. Primary endpoints were the incidence of POAF and all-cause arrhythmia. Secondary endpoints were length of stay in the intensive care unit (ITU) and length of hospital stay. RESULTS: Vitamins C and E significantly reduced the incidence of POAF (OR 0.43, 95% CI 0.21 to 0.89) and all-cause arrhythmia (OR 0.54, 95% CI 0.29 to 0.99) compared with controls. A significant reduction in both ITU stay (weighted mean difference (WMD) -0.44, 95% CI -0.70 to -0.17) and hospital stay (WMD -1.11, 95% CI -1.70 to -0.52) was also seen in the antioxidant group, without significant heterogeneity. CONCLUSIONS: The prophylactic use of vitamins C and E may significantly reduce the incidence of POAF and all-cause arrhythmia following cardiac surgery. However, the overall quality of current studies is poor and further research should focus on adequately powered randomised controlled trials that standardise AF reporting, antioxidant protocol and the use of concomitant agents. Cost analysis should be considered to establish the potential economic benefit of antioxidant vitamin prophylaxis in POAF.

Antioxidant vitamins in the prevention of atrial fibrillation: what is the evidence?

Atrial fibrillation (AF) is the most common sustained arrhythmia that is associated with significant morbidity and mortality. Current available therapies remain inadequate in symptom control and secondary prevention and are often associated with significant side effects. The mechanisms underlying the pathogenesis of AF are poorly understood, although electrophysiological remodeling has been described as an important initiating step. Recently, increasing evidence implicates oxidative stress and inflammation in the pathogenesis of AF. We searched the literature for evidence to support the use of antioxidant vitamins C and E in the prevention of AF. These vitamins, through their reactive-oxygen-species- (ROS-) scavenging effect, have shown a role in AF prevention in both animal and small clinical studies. The available evidence, however, is currently insufficient to support recommendations for their use in the wider patient population. Larger-scale clinical studies are required to confirm these preliminary results. Research is also required to further the understanding of the processes involved in the pathogenesis of AF and the role of antioxidant therapies to prevent the arrhythmia.

Evolution and current applications of the Cabrol procedure and its modifications.

Operations on the proximal aorta for aneurysms and dissections almost invariably involve the use of an aortic conduit. The optimal method for safe and effective conduit to the coronary anastomosis has been a matter for debate. Although the modified Bentall procedure with use of ostial aortic "buttons" may provide superior results and currently constitutes the standard of care for aortic root reconstruction, anatomic difficulties such as the closeness of the ostia to the aortic annulus, extreme aortic dilatation/calcification, and reoperations, may hinder the safe and tension-free conduit to the coronary anastomosis. In this technical review we examine the evolution of the Cabrol technique and its modifications, as well as its current indications and related outcomes.