The microbiological basis for a revised antibiotic regimen in high-energy tibial fractures: preventing deep infections by nosocomial organisms.

BACKGROUND: Deep surgical site infections (SSI's) complicate Gustilo IIIB tibial fractures in 8-13% of cases. Antibiotic prophylaxis typically covers environmental contaminants. However, nosocomial organisms are usually implicated in deep infection. We used the microbiological profile of infected Gustilo IIIB tibial fractures to define a new, dynamic prophylactic regimen which recognises the need for prophylaxis against nosocomial organisms at the time of definitive closure. METHODS: The microbiological profiles of Gustilo IIIB tibial fractures presenting over a 2-year period from January 2006 to December 2007 were reviewed. The environmental contaminants were compared with the organisms isolated from deep SSI's and correlated with the prophylactic antibiotic regimen used. RESULTS: Fifty-two patients were included. Nine developed a deep tissue infection. The pathogens implicated included resistant Enterococci, Pseudomonas, Enterobacter and MRSA. Standard antibiotic prophylaxis provided cover for these combinations in only one of nine cases. This would have improved to eight of nine cases with the use of teicoplanin and gentamicin, given as a one-time dose during definitive soft-tissue closure. Specimens taken from wound debridement were neither sensitive nor specific for the subsequent development of deep infection and did not predict the organisms responsible. CONCLUSIONS: Following high-energy open fracture, a single prophylactic antibiotic regimen directed against environmental wound contaminants does not provide cover for the organisms responsible for deepest SSI's and may have depopulated the niche, promoting nosocomial contamination prior to definitive closure. We advocate a dynamic prophylactic strategy, tailoring a second wave of prophylaxis against nosocomial organisms at the time of definitive wound closure, and at the same time avoiding the potential complications of prolonged antibiotic use.

Improving lower limb salvage following fractures with vascular injury: a systematic review and new management algorithm.

BACKGROUND: Lower limb fractures with vascular injuries are associated with a high rate of secondary amputation. Reducing ischaemic time is vital for limb salvage. However, the optimal sequence of surgical management remains unclear. We aimed to review the literature to establish an evidence-based management algorithm. METHODS: All identifiable English language or translated literature related to the surgical sequence of lower limb fractures with vascular injuries was reviewed. RESULTS: A total of 101 cases described in 10 publications (median age: 31; range: 2.5-76) were suitable for analysis. The mean MESS was 4.2. The limb-salvage rate with an ischaemic time of less than 6h was 87%, falling to 61% when ischaemic time exceeded 6h. A preoperative angiography caused a significant delay. The rate of re-vascularisation within 6h improved from 46% (33 of 71) to 90% (27 of 30) with the use of a shunt (p=0.04), with a mean ischaemic time of 3.8h (+/-1.7h, 1 standard deviation (SD)) versus 7.6h (+/-3.8h, 1SD) in those re-vascularised using grafts (p<0.001). The amputation rate of 27% was reduced to 13% by using shunts. CONCLUSION: Early recognition of vascular injury is vital. Formal angiograms are unnecessary and cause crucial delays. A vascular shunt can significantly reduce ischaemic time, enabling unhurried assessment of the feasibility of limb salvage, debridement of demonstrably non-viable tissue and safe skeletal fixation prior to definitive vascular and soft-tissue repair.

The relationship between osteonecrosis of the proximal femur identified by MRI and lesions proven by histological examination.

Total hip replacement in patients with advanced osteonecrosis of the femoral head is often complicated by early loosening of the femoral component. Recent evidence has suggested that abnormal bone extending into the proximal femur may be responsible for the early failure of the femoral component. We aimed to identify which patients were at high risk of early failure by evaluating gadolinium-enhanced MR images of histologically-confirmed osteonecrotic lesions beyond the femoral head. Although the MR signal intensity has been shown to correlate well with osteonecrosis in the femoral head, it was found to be relatively insensitive at identifying lesions below the head, with a sensitivity of only 51% and a predictive value of a negative result of only 48%. However, the specificity was 90%, with the predictive value of a positive MRI finding being 86%. Only those patients with osteonecrosis of the femoral head secondary to sickle-cell disease, who are known to be at high risk of early loosening, had changes in the MR signal in the greater trochanter and the femoral shaft. This observation suggests that changes in the MR signal beyond the femoral head may represent osteonecrotic lesions in areas essential for the fixation of the femoral component. Pre-operative identification of such lesions in the neck of the femur may be important when considering hip resurfacing for osteonecrosis of the femoral head, following which early loosening of the femoral component and fracture of the neck are possible complications.

Cemented revision total hip arthroplasty with impaction bone grafting in Gaucher's disease.

Total hip arthroplasty in Gaucher's disease has been associated with high rates of loosening after all types of arthroplasty. We present a patient with type 1 Gaucher's disease who underwent revision cemented total hip arthroplasty for aseptic loosening after 12 months of enzyme replacement therapy. Major osteolysis was managed by impaction morcellized bone grafting. An excellent clinical and radiographic result was obtained at 5-year follow-up. Enzyme replacement therapy combined with modern revision techniques may offer improved outcomes for patients with Gaucher's disease.

The extent of osteocyte death in the proximal femur of patients with osteonecrosis of the femoral head.

Our aim was to assess the local extent of osteocyte death in the proximal femur of 16 patients with osteonecrosis of the femoral head. We performed histological examination of the femoral heads and cancellous bone biopsies from four regions of the proximal femur in patients undergoing total hip arthroplasty. A control group consisted of 19 patients with osteoarthritis. All histological specimens were examined in a blinded fashion. Extensive osteonecrosis was shown in the proximal femur up to 4 cm below the lesser trochanter in the group with osteonecrosis. There was an overall statistically significant difference in the extent of osteocyte death distal to the femoral head between the two groups (p < 0.001). We discuss the implications of these findings as possible contributing factors in regard to the early failure of total hip arthroplasty reported in patients with osteonecrosis of the femoral head.

Screw versus suture fixation of Mitchell's osteotomy. A prospective, randomised study.

We studied prospectively 30 patients who had a Mitchell's osteotomy secured by either a suture followed by immobilisation in a plaster boot for six weeks, or by a cortical screw with early mobilisation. The mean time for return to social activities after fixation by a screw was 2.9 weeks and to work 4.9 weeks, which was significantly earlier than those who had stabilisation by a suture (5.7 and 8.7 weeks, respectively; p < 0.001). Use of a screw also produced a higher degree of patient satisfaction at six weeks, and an earlier return to wearing normal footwear. The improvement in forefoot scores was significantly greater after fixation by a screw at six weeks (p = 0.036) and three months (p = 0.024). At one year, two screws had been removed because of pain at the site of the screw head. Internal fixation of Mitchell's osteotomy by a screw allows the safe early mobilisation of patients and reduces the time required for convalescence.

Periprosthetic acetabular fracture associated with extensive osteolysis.

Periprosthetic fracture of the acetabulum is an uncommon complication of total hip arthroplasty. The management is reported to be difficult, and complications such as nonunion and implant loosening are common. We described herein a case of nontraumatic periprosthetic acetabular fracture associated with significant osteolysis, which was successfully managed by addressing the fracture and osteolysis independently.

A model curriculum vitae: what are the trainers looking for?

In this new era of Calman, the curriculum vitae (CV) still remains the most important document in furthering the careers of doctors. A survey of postgraduate deans and college regional training advisors opinions on CVs was undertaken. The results have allowed a model CV to be compiled expressing the layout and most of the features which senior trainers feel are important when producing a CV.

Symmetrical Brodie's abscess.

Chronic recurrent multifocal osteomyelitis is often confused with symmetrical Brodie's abscess as it has a similar pathogenesis. We report an otherwise healthy 17-year-old boy presenting with a true symmetrical Brodie's abscess. We conclude that a symmetrical Brodie's abscess presenting in an otherwise healthy patient is a separate clinical condition with a different management protocol.

Susceptibility of normal and arthritic human articular cartilage to degradative stimuli.

Recombinant interleukin-1 (IL-1) alpha and beta stimulated significant loss of glycosaminoglcan (GAG) content from normal (non-arthritic) articular cartilage explants but only after incubation for 14 days and only in specimens from 8/21 (38%) individuals. By contrast, all cartilage specimens but one from patients with osteoarthritis (OA) and rheumatoid arthritis (RA) were degraded (as judged by their reduced GAG content) by the recombinant cytokines but again only after 14 days' incubation. The reduction in GAG induced by IL-1 was also greater for both OA and RA cartilage than normal cartilage. Synovial fluids (SFs) from RA patients stimulated greater loss of GAG content from OA cartilage explants than normal explants although in both cases the loss was evident within 2 days. It is concluded that cartilage explants from some individuals are susceptible to the degradative effects of IL-1 whereas others are refractory and that arthritic cartilage is more susceptible to degradation by both IL-1 and RA SFs than non-arthritic cartilage.

The Exeter bipolar prosthesis in the active elderly patient: the results at 7 years.

Seventy one Exeter bipolar hemiarthroplasties were reviewed after a mean follow up of 3.2 years (range 1-7 years). Patients with displaced subcapital fractures were selected for operation on the basis of good mobility before the fracture. The operation was well tolerated and the mortality at 1 month and 6 months was 3.7% and 6.5% respectively. Using a newly devised hip scoring system 89% had a good or excellent result and 94% had no or only occasional pain. There was no radiological evidence of acetabular erosion.