Missed adolescent acetabular apophyseal avulsion with late hip dislocation.

BACKGROUND: Chronic hip dislocation associated with acetabular apophyseal avulsion in adolescence is rare. Whilst superior acetabular rim fractures have a documented theoretical risk of hip instability, we have not found a case of chronic dislocation resulting from this. METHODS: We report a case of a 12-year-old healthy boy who initially sustained a missed right acetabular apophyseal avulsion after falling from a quad bike. This was missed on the initial radiograph and a subsequent radiograph following weight bearing a few days later showed a hip dislocation that was also missed. Upon diagnosis at 6 weeks, he underwent open reduction but also required acetabuloplasty to stabilise the hip. RESULTS: At 2 years follow-up, he was enjoying pain free swimming, cycling and walking. His Harris hip score was 87. CONCLUSION: This case reinforces the need for recognition that in the patient presenting with knee or thigh pain, exclusion of hip pathology is required. It also explores the pitfalls of diagnosis associated with rare patterns of injury and the need for adequate investigations such as examination under anaesthetic, arthrography and MRI. The use of acetabuloplasty is shown to be a useful strategy for the unstable hip resulting from irreparable acetabular rim fracture.

Meta-analysis of warmed versus standard temperature CO2 insufflation for laparoscopic cholecystectomy.

BACKGROUND: There is conflicting evidence for the use of warmed, humidified carbon dioxide (CO2) for creating pneumoperitoneum during laparoscopic cholecystectomy. Few studies have reported less post-operative pain and analgesic requirement when warmed CO2 was used. AIM: This systematic review and meta-analysis aims to analyse the literature on the use of warmed CO2 in comparison to standard temperature CO2 during laparoscopic cholecystectomy. METHODS: Systematic review and meta-analysis carried out in line with the PRISMA guidelines. Primary outcomes of interest were post-operative pain at 6 h, day 1 and day 2 following laparoscopic cholecystectomy. Secondary outcomes were analgesic usage and drop in intra-operative core body temperature. Standard Mean Difference (SMD) was calculated for continuous variables. RESULTS: Six randomised controlled trials (RCTs) met the inclusion criteria (n = 369). There was no significant difference in post-operative pain at 6 h [3 RCTs; SMD = -0.66 (-1.33, 0.02) (Z = 1.89) (P = 0.06)], day 1 [4 RCTs; SMD = -0.51 (-1.47, 0.44) (Z = 1.05) (P = 0.29)] and day 2 [2 RCTs; SMD = -0.96 (-2.30, 0.37) (Z = 1.42) (P = 0.16)] between the warmed CO2 and standard CO2 group. There was no difference in analgesic usage between the two groups, but pooled analysis was not possible. Two RCTs reported significant drop in intra-operative core body temperature, but there were no adverse events related to this. CONCLUSIONS: This review showed no difference in post-operative pain and analgesic requirements between the warmed and standard CO2 insufflation during laparoscopic cholecystectomy. Currently there is not enough high quality evidence to suggest routine usage of warmed CO2 for creating pneumoperitoneum during laparoscopic cholecystectomy.

Is there a need for weekend face-to-face inpatient assessments by hospital specialist palliative care services? Evaluation of an out-of-hours service.

There is an increasing demand for hospital specialist palliative care services to be made more accessible outside of normal working hours. However, it has been argued that extended service provision could be misused and that specialist telephone advisory services are an adequate response to this demand. A 'routine' Saturday face-to-face visiting service was introduced into a hospital palliative care team and the service was evaluated to determine whether it was being utilised appropriately. A retrospective notes review of out-of-hours assessments was undertaken. Anonymised data relating to the nature of the interaction with the palliative care team and the outcome of the consultation were entered into an electronic database. A random sample of routine weekday interactions was also evaluated. A total of 336 Saturday and 93 weekday assessments were analysed. Most of the Saturday assessments resulted in a significant change in management (57%) or were undertaken on patients close to death (10%). There were 39/336 (12%) new referrals assessed on Saturdays. There were few differences between the nature of the Saturday and the weekday service and no evidence of 'inappropriate' referrals. We found clear evidence of the need for a specialist out-of-hours face-to-face inpatient visiting service for hospital palliative care.