The Gustilo-Anderson classification system as predictor of nonunion and infection in open tibia fractures.

PURPOSE: We sought to conduct the largest retrospective study to date of open tibia fractures and describe the incidence of complications and evaluate the potential predictive risk factors for complications. METHODS: Patients with open tibia fractures treated with reamed intramedullary nail (IMN) across a 10-year period were evaluated. Patient charts were reviewed for demographics, type of open fracture (T), comorbidities, and postoperative complications. A multivariate model was conducted to determine the risk factors for each type of complication. RESULTS: Of the 486 patients with open tibia fractures, 13 % (n = 64) had infections, 12 % (n = 56) had nonunions, and 1 % (n = 7) had amputations. TIII fractures had much higher rates of each complication than TI and TII fractures. Fracture type was the only significant risk factor for both nonunion and infection. CONCLUSION: Our study found that the Gustilo grade of open tibia fracture is by far the greatest predictor of nonunion and infection.

Plasminogen activator content and secretion in explants of neoplastic and benign human prostate tissues.

The plasminogen activators of surgically excised prostate cancers (43 specimens) and benign prostatic hyperplasias (33 specimens) were extracted with an acetate:arginine:detergent buffer, and the activities were quantitated with azocaseinolytic tests. Immunoinhibition with anti-urokinase antibody served to distinguish between activator types. The mean activator activities (total; urokinase type; and nonurokinase type) of the neoplastic group were about 2 times higher (p less than 0.05) than that of the benign prostatic hyperplasia tissues. Each group had more non-urokinase-type activator activity relative to urokinase type. Studies with autopsy tissues (13 specimens) revealed that different anatomical compartments of the prostate contain about the same mean activator activity, indicating that the site of origin of the disease did not influence the results. Immunoperoxidase staining for urokinase revealed its presence in the tumor cells and, to a lesser extent, in the epithelial elements of some benign ducts and glands but not in the connective tissue. The secretion and synthesis of activator activities were monitored in short-term (approximately 120 hr) organ cultures (serum-free media) of 21 neoplastic tissues. On the average, about 12 times more activity (approximately 80% as urokinase type) was recovered in the media and postculture tissue extracts than was present in preculture tissues. Similar results were observed with 10 benign prostatic hyperplasia specimens. Wide individual variations were present in both groups (1.5 to 322 times more activity than the initial values). Except for one case, urokinase-type activity was secreted continuously, while nonurokinase was secreted only initially in quantities similar to that present in preculture tissue extracts. After culture, tissue explants contained higher quantities of both activator activities than were present initially. Dexamethasone (10 or 100 microM) decreased secretion and/or synthesis of activators by about 70%. This human organ culture model appears to be a reproducible system for individual tissues and may prove to be a valuable tool for further studies.

Open distal tibial shaft fractures: a retrospective comparison of medial plate versus nail fixation.

PURPOSE: Studies comparing open reduction internal fixation (ORIF) vs. intramedullary nailing (IMN) for distal tibia shaft fractures focus upon closed injuries containing small patient series with open fractures. As such, complication rates for open fractures are unknown. To characterize complications associated with ORIF vs. IMN, we compared complications based on surgical approach in a large patient series of open distal tibia shaft fractures. METHODS: Through retrospective analysis at an urban level I trauma center, 180 IMN and 36 ORIF patients with open distal tibia fractures from 2002 to 2012 were evaluated. Patient charts were reviewed to identify patient demographics, fracture grade (G), patient comorbidities, and postoperative complications including nonunion, malunion, infection, hardware-related pain, and wound dehiscence. Fisher's exact tests compared complications between ORIF and IMN groups. Multivariate regression identified risk factors with statistical significance for the development of a postoperative complication. RESULTS: One hundred and eighty IMN (G1 22, G2 79, and G3 79) and 36 ORIF (G1 10, G2 16, and G3 10) patients were included for analysis. ORIF patients had a higher rate of nonunion (25.0 %, n = 9) compared with IMN patients (10.6 %, n = 20, p = 0.03). No additional complication had a significant statistical difference between groups. Multivariable analysis shows only surgical method influenced the development of complications: ORIF patients had 2.52 greater odds of developing complications compared with IMN patients (95 % CI 1.05-6.02; p = 0.04). CONCLUSIONS: ORIF leads to higher rates of nonunion and significantly increases the odds of developing a complication compared with IMN for open distal tibia fractures. This is the first study investigating complication rates based on surgical approach in a large cohort of patients with exclusively open distal tibia fractures.

Improved medium for extraction of plasminogen activator from tissue.

Quantitation of plasminogen activators present in tissue may depend to a large extent on the extraction procedure used to solubilize the enzymes. Potassium thiocyanate solution is known to be an efficient solubilizer, but it can inhibit assay systems other than fibrin plates. An equally effective acetate-detergent extractant is reported here which can be used with the highly sensitive azocaseinolytic assay procedure. The results indicate that a three-fold increase in activator activity can be extracted from selected tissues relative to that previously reported for a phosphate-detergent extractant. The extraction medium contains 75 mM K acetate, 0.3 M NaCl, 0.1 M L-arginine, 10 mM EDTA, 0.25% Triton X-100, final pH 4.2.

Laparoscopic Nissen fundoplication for severe gastroesophageal reflux disease: pros and cons.

The advent of the laparoscopic approach to Nissen fundoplication has led to a resurgence in enthusiasm for the surgical treatment of gastroesophageal reflux disease (GERD). However, controversy exists as to which subgroups of GERD patients are best treated surgically. The relative success of treatment with medical and surgical intervention in terms of both symptom control and objective resolution of esophageal injury must be weighed against the relative costs of each therapeutic strategy in both the short and long term, given that GERD tends to be a lifelong disorder. The following is the transcribed text of a debate held at the Medical College of Virginia as part of a continuing medical education program in which the statement "Laparoscopic antireflux surgery is superior to medical treatment for severe gastroesophageal reflux disease" was contested. Representatives from the departments of surgery and gastroenterology provided arguments supporting their respective sides of this issue. The purpose was not to promote polarization in treatment selection, but to review the available data in a forum that could promote development of a rational algorithm for clinical decision-making in patients with GERD who might benefit from antireflux surgery. Final comments from the authors are provided in an attempt to synthesize the arguments into a reasonable strategy for individual case management.