Three-vessel view debridement of the open tibial fracture: a surgical technique.

Adequate debridement of an open fracture is a key component of successful management. Despite having set debridement principles, there is no structured technique available in the literature to guide the surgeon in achieving this. We therefore present a technical note detailing the structured approach to the debridement of any open tibial fracture. Our unit has developed a novel stepwise technique termed locally as the "three-vessel view". Identifying all three primary vessels of the leg facilitates confirmation of inspection of all lower limb compartments thus minimising the risk of missed devitalised tissue or neglected areas of contamination and the potential for consequent disastrous outcomes as a result of inadequate exposure.

Bioactive Properties of Syzygium cumini (L.) Skeels Pulp and Seed Phenolic Extracts.

The emergence of bacterial strains resistant to different antibiotics has prompted the search for new sources of antimicrobial compounds. Studies have shown that jambolan [Syzygium cumini (L.) Skeels], a tropical fruit from the Mirtaceae family, contains a great variety of phytochemical compounds with high antioxidant and antimicrobial activity. This study aimed to determine the centesimal composition and physicochemical characteristics of the pulp and seed of S. cumini (L.) Skeels, as well as the content of total phenolic compounds and the antioxidant, antibacterial, antibiofilm and anti-quorum sensing (QS) activities of the phenolic extracts obtained from the pulp and the seeds of this fruit. The in vitro antibacterial and anti-QS activities of active films incorporating phenolic extracts were also evaluated. Additionally, we performed molecular docking of phenolic compounds present in jambolan with the CviR QS regulator of Chromobacterium violaceum. The composition and physicochemical characteristics of the samples presented similar values to those found for the species. However, the seed phenolic extract had a higher content of phenolic compounds and antioxidant activity than the pulp. Both phenolic extracts presented antibacterial activity against Aeromonas hydrophila, C. violaceum, Escherichia coli, Pseudomonas aeruginosa, Salmonella enterica serovar Typhimurium, Serratia marcescens, Listeria monocytogenes, and Staphylococcus aureus. The seed phenolic extract was particularly inhibitory against S. aureus. The pulp phenolic extract inhibited swarming motility and biofilm formation of A. hydrophila, E. coli, and S. marcescens in sub-MIC concentrations. The pulp and seed phenolic extracts inhibited violacein production in C. violaceum. Films incorporating both phenolic extracts inhibited the growth of bacteria, particularly Pseudomonas fluorescens, L. monocytogenes, and S. aureus, as well as QS in C. violaceum. Molecular docking showed that a variety of compounds found in pulp and seed extracts of jambolan, particularly chlorogenic acid and dihydroquercetin, potentially bind CviR protein and may interfere with QS. Our results indicate that pulp and seed of jambolan are good sources of antibacterial, antibiofilm, and anti-QS compounds that can be used in the development of natural preservatives and for application in antibacterial active films.

[Upper extremity kinetics and energy expenditure during walker-assisted gait in children with cerebral palsy]. / Beyin felçli çocuklarda yürüteç kullanimi sirasinda üst ekstremite kinetikleri ve enerji tüketimi.

OBJECTIVES: We evaluated the relationships between upper extremity (UE) kinetics and the energy expenditure index during anterior and posterior walker-assisted gait in children with spastic diplegic cerebral palsy (CP). METHODS: Ten children (3 boys, 7 girls; mean age 12.1 years; range 8 to 18 years) with spastic diplegic CP, who ambulated with a walker underwent gait analyses that included UE kinematics and kinetics. Upper extremity kinetics were obtained using instrumented walker handles. Energy expenditure index was obtained using the heart rate method (EEIHR) by subtracting resting heart rate from walking heart rate, and dividing by the walking speed. Correlations were sought between the kinetic variables and the EEIHR and temporal and stride parameters. RESULTS: In general, anterior walker use was associated with a higher EEIHR. Several kinetic variables correlated well with temporal and stride parameters, as well as the EEIHR. All of the significant correlations (r>0.80; p<0.005) occurred during anterior walker use and involved joint reaction forces (JRF) rather than moments. Some variables showed multiple strong correlations during anterior walker use, including the medial JRF in the wrist, the posterior JRF in the elbow, and the inferior and superior JRFs in the shoulder. CONCLUSION: The observed correlations may indicate a relationship between the force used to advance the body forward within the walker frame and an increased EEIHR. More work is needed to refine the correlations, and to explore relationships with other variables, including the joint kinematics.

Higher 30-day mortality associated with the use of intramedullary nails compared with sliding hip screws for the treatment of trochanteric hip fractures: a prospective national registry study.

AIMS: The aim of this study was to investigate the association between the type of operation used to treat a trochanteric fracture of the hip and 30-day mortality. PATIENTS AND METHODS: Data on 82 990 patients from the National Hip Fracture Database were analyzed using generalized linear models with incremental case-mix adjustment for patient, non-surgical and surgical characteristics, and socioeconomic factors. RESULTS: The use of short and long intramedullary nails was associated with an increase in 30-day mortality (adjusted odds ratio (OR) 1.125, 95% confidence interval (CI) 1.040 to 1.218; p = 0.004) compared with the use of sliding hip screws (12.5% increase). If this were causative, it would represent 98 excess deaths over the four-year period of the study and one excess death would be caused by treating 112 patients with an intramedullary nail rather than a sliding hip screw. CONCLUSION: There is a 12.5% increase in the risk of 30-day mortality associated with the use of an intramedullary nail compared with a sliding hip screw in the treatment of a trochanteric fractures of the hip.

Open tibial fractures in major trauma centres: A national prospective cohort study of current practice.

AIMS: To assess current national practice in the management of severe open tibial fractures against national standards, using data collected by the Trauma and Audit Research Network. MATERIALS AND METHODS: Demographic, injury-specific, and outcome data were obtained for all grade IIIB/C fractures admitted to Major Trauma Centres in England from October 2014 to January 2016. RESULTS: Data was available for 646 patients with recorded grade IIIB/C fractures. The male to female ratio was 2.3:1, mean age 47 years. 77% received antibiotics within 3 h of admission, 82% were debrided within 24 h. Soft tissue coverage was achieved within 72 h of admission in 71%. The amputation rate was 8.7%. 4.3% of patients required further theatre visits for infection during the index admission. The timing of antibiotics and surgery could not be correlated with returns to theatre for early infection. There were significant differences in the management and outcomes of patients aged 65 and over, with an increase in mortality and amputation rates. CONCLUSIONS: Good outcomes are reported from the management of IIIB/C fractures in Major Trauma Centres in England. Overall compliance with national standards is particularly poor in the elderly. Compliance did not appear to affect rates of returning to theatre or early infection. Appropriately applied patient reported outcome measures are needed to enhance the evidence-base for management of these injuries.

Comparison of upper extremity kinematics in children with spastic diplegic cerebral palsy using anterior and posterior walkers.

This prospective study analyzes the upper extremity kinematics of 10 children with spastic diplegic cerebral palsy using anterior and posterior walkers. Although both types of walkers are commonly prescribed by clinicians, no quantitative data comparing the two in regards to upper extremity motion has been published. The study methodology included testing of each subject with both types of walkers in a motion analysis laboratory after an acclimation period of at least 1 month. Overall results showed that statistically, both walkers are relatively similar. With both anterior and posterior walkers, the shoulders were extended, elbows flexed, and wrists extended. Energy expenditure, walking speed and stride length was also similar with both walker types. Several differences were also noted although not statistically significant. Anterior torso tilt was reduced with the posterior walker and shoulder extension and elbow flexion were increased. Outcomes analysis indicated that differences in upper extremity torso and joint motion were not dependent on spasticity or hand dominance. These findings may help to build an understanding of upper extremity motion in walker-assisted gait and potentially to improve walker prescription.

Delay increases the need for open reduction of type-III supracondylar fractures of the humerus.

Recent reports have suggested that a delay in the management of type-III supracondylar fractures of the humerus does not affect the outcome. In this retrospective study we examined whether the timing of surgery affected peri-operative complications, or the need for open reduction. There were 171 children with a closed type-III supracondylar fracture of the humerus and no vascular compromise in our study. They were divided into two groups: those treated less than eight hours from presentation to the Accident and Emergency Department (126 children), and those treated more than eight hours from presentation (45 children). There were no differences in the rate of complications between the groups, but children waiting more than eight hours for reduction were more likely to undergo an open reduction (33.3% vs 11.2%, p < 0.05) and there was a weak correlation (p = 0.062) between delay in surgery and length of operating time. Consequently, we would still recommend treating these injuries at the earliest opportunity.

The effects of phospholipid unsaturation and alcohol perturbation at the protein/lipid interface probed using fluorophore lifetime heterogeneity.

The influence of phospholipid unsaturation and perturbation by alcohols, on the membrane protein/lipid interface, was probed using the fluorescence decay properties of 1,6-diphenyl-1,3,5-hexatriene (DPH) and DPH attached to the sn-2 chain of phosphatidylcholine (DPH-PC), in lipid bilayers and microsomal membranes. With microsomal membranes it was found that it was appropriate to describe the fluorescence decay of DPH-PC as a range of decay rates, accomplished by fitting the data to a bimodal fluorescence lifetime distribution. The major lifetime center had a broad distributional width, indicative of excited state fluorophore heterogeneity. The effect was attributable to protein, and by inference, the protein/lipid interface, since in vesicles made from total microsomal lipids (i.e., without protein) the fluorescence decay was homogeneous. Upon addition of ethanol or hexanol the width of the lifetime distribution of the major lifetime center increased, indicating increased environmental heterogeneity. It was confirmed that the effect was manifest at the protein/lipid interface, and not due to lipid-reorganizational factors, since it could also be obtained using a simple lipid bilayer vesicle system with apocytochrome c as a model membrane protein, and DPH instead of DPH-PC. Environmental heterogeneity was also found to increase with increased phosphatidylcholine (sn-2) unsaturation. The environmental heterogeneity at the protein/lipid interface could arise from a combination of varying polarities of amino acid side chains and of water that may intercalate in packing defects on the hydrophobic surface of the protein. Therefore the results could be explained on the basis of an increased degree of hydration at the protein/lipid interface. Such an effect offers a route whereby acyl chain perturbation and increased unsaturation might influence protein conformation and hence function.

Chronic ethanol intoxication induces adaptive changes at the membrane protein/lipid interface.

Modifications were found to occur at the membrane protein/lipid interface of liver microsomes in animals that had been subjected to chronic ethanol ingestion. The effects were revealed by probing this region with 1,6-diphenyl-1,3,5-hexatriene (DPH), trimethylammonium-DPH (TMA-DPH) and DPH attached to the sn-2 chain of phosphatidylcholine (1-palmitoyl-2-[[2-[4-(6-phenyl-trans-1,3,5-hexatrienyl) phenyl]ethyl]carbonyl]-3-sn-phosphatidylcholine, DPH-PC). In intact membranes, it was found that the decay of the excited state was heterogeneous, this being modeled by fitting the data to a fluorescence lifetime distribution. The full-width of the distribution at half-maximum, which relates to the degree of excited state environmental heterogeneity, increased for each fluorophore, as a result of chronic ethanol treatment. For TMA-DPH and DPH the excited state heterogeneity could have arisen from, (i) the protein/lipid interface and (ii) varied degrees of water penetration into the lipid, due to the ability of these fluorophores to sample along the bilayer normal. By contrast, the DPH in DPH-PC, due to its tethering, was only able to sample the heterogeneity at the protein/lipid interface, as confirmed by a homogeneous decay in vesicles of microsomal lipid extracts. The increased degree of DPH-PC fluorescence decay heterogeneity in microsomes from chronic ethanol-treated animals as compared to controls, was found to persist in vesicles of extracted lipids, when apocytochrome C was included in the vesicle preparations as a model protein. This effectively eliminated a protein modification from being responsible and indicated that a chronic-ethanol induced alteration in the lipids was being expressed in the form of a physico-chemical modification at the protein/lipid interface. The degree of DPH-PC environmental heterogeneity was also directly increased by ethanol, however, membranes from chronic ethanol-treated animals were resistant to this effect, showing that the phenomenon of 'membrane tolerance' extends to the membrane protein/lipid interface.

A prospective, randomised, controlled trial of the use of drains in total hip arthroplasty.

The routine use of surgical drains in total hip arthroplasty remains controversial. They have not been shown to decrease the rate of wound infection significantly and can provide a retrograde route for it. Their use does not reduce the size or incidence of post-operative wound haematomas. This prospective, randomised study was designed to evaluate the role of drains in routine total hip arthroplasty. We investigated 552 patients (577 hips) undergoing unilateral or bilateral total hip arthroplasty who had been randomised to either having a drain for 24 hours or not having a drain. All patients followed standardised pre-, intra-, and post-operative regimes and were independently assessed using the Harris hip score before operation and at six, 18 and 36 months follow-up. The rate of superficial and deep infection was 2.9% and 0.4%, respectively, in the drained group and 4.8% and 0.7%, respectively in the undrained group. One patient in the undrained group had a haematoma which did not require drainage or transfusion. The rate of transfusion after operation in the drained group was significantly higher than for undrained procedures (p < 0.042). The use of a drain did not influence the post-operative levels of haemoglobin, the revision rates, Harris hip scores, the length of hospital stay or the incidence of thromboembolism. We conclude that drains provide no clear advantage at total hip arthroplasty, represent an additional cost, and expose patients to a higher risk of transfusion.

C-reactive protein: a valuable acute investigation. A case of pneumococcal meningitis presenting as ankle pain.

A case is presented in which the decision to admit and treat an adult with musculoskeletal pain and pyrexia was based on her markedly raised c-reactive protein (CRP). At the time of admission she was apyrexial and the CRP was the only haematological investigation that was out of the normal range. She subsequently became precipitously septic with pneumococcal bacteraemia and meningitis. The CRP is an important investigation for emergency departments.

Single-stage orthoplastic reconstruction of Gustilo-Anderson Grade III open tibial fractures greatly reduces infection rates.

BACKGROUND: Grade III open fractures of the tibia represent a serious injury. It is recognised that combined management of these cases by experienced orthopaedic and plastic surgeons improves outcomes. Previous studies have not considered the timing of definitive soft tissue cover in relation to the definitive orthopaedic management. This paper reviews the outcomes in patients treated in an orthoplastic unit where the emphasis was on undertaking the definitive orthopaedic and plastic surgical procedures in a single stage, following initial debridement and temporary stabilisation as necessary. METHODS: We reviewed medical notes of 73 consecutive patients with 74 Grade III open tibia fractures (minimum 1 year follow up), to compare deep infection rates in patients who had (a) a single-stage definitive fixation and soft tissue coverage vs. those who had separate operations, and (b) those who had definitive treatment completed in <72h vs. >72h. RESULTS: (a) Combined Single-stage Orthoplastic Fixation and Coverage: 48 fractures were managed with definitive orthopaedic fixation and plastic surgical coverage performed at the same time, whilst 26 had these performed at separate stages. Of those subjects that had definitive fixation and coverage in one procedure 2 (4.2%) developed deep infections, compared with 9 (34.6%) deep infections (p<0.001) in those who underwent definitive fixation and coverage at separate operations. (b) Timing of surgery: Of the fractures that had definitive fixation and coverage completed within 72h of injury, 5 (20%) developed deep infections, compared with 6 (12.2%) deep infections (p=0.492) in those whose definitive fixation/coverage was completed at later than 72h. CONCLUSION: Joint orthoplastic operating lists facilitate simultaneous definitive fixation and cover that greatly reduces infection rates. Based on our experience presented in this paper, we believe that emphasis should be placed on timely transfer to a specialist centre, aiming for a single-stage combined orthoplastic procedure to achieve definitive fixation and soft tissue coverage and optimal outcomes.

Polyunsaturation in cell membranes and lipid bilayers and its effects on membrane proteins.

The effect of variation of the degree of cis-unsaturation on cell membrane protein functioning was investigated using a model lipid bilayer system and protein kinase C (PKC). This protein is a key element of signal transduction. Furthermore it is representative of a class of extrinsic membrane proteins that show lipid dependent interactions with cell membranes. To test for dependence of activity on the phospholipid unsaturation, experiments were devised using a vesicle assay system consisting of phosphatidylcholine (PC) and phosphatidylserine (PS) in which the unsaturation was systematically varied. Highly purified PKC alpha and epsilon were obtained using the baculovirus-insect cell expression system. It was shown that increased PC unsaturation elevated the activity of PKC alpha. By contrast, increasing the unsaturation of PS decreased the activity of PKC alpha, and to a lesser extent PKC epsilon. This result immediately rules out any single lipid bilayer physical parameter, such as lipid order, underlying the effect. It is proposed that while PC unsaturation effects are explainable on the basis of a contribution to membrane surface curvature stress, the effects of PS unsaturation may be due to specific protein-lipid interactions. Overall, the results indicate that altered phospholipid unsaturation in cell membranes that occurs in certain disease states such as chronic alcoholism, or by dietary manipulations, are likely to have profound effects on signal transduction pathways involving PKC and similar proteins.

Surgical management of the anophthalmic orbit, part 1: congenital.

Congenital microphthalmos and anophthalmos are rare conditions in which orbital growth is deficient. Hypoplasia of the globe affects the bony orbit (micro-orbitism), the conjunctival sac, and eyelids (microblepharism), and it may be associated with abnormalities of the entire hemifacial skeleton (hemifacial microsomia). In the present article, the authors review a series of 19 patients with microphthalmos (nine had right-sided, one had bilateral, and nine had left-sided microphthalmos) who were treated in the Orbitopalpebral Unit at Hospital Foch over a period of 15 years (follow-up, 5 months to 18 years).Orbital expansion was achieved using spherical implants (n = 13), orbital osteotomies (n = 4), and orbital expanders (n = 2). Both expanders were removed within 6 months because of failure (one infection and one rupture). The current preferred method for orbital expansion is to use serial implants in the growing orbit and osteotomies in cases of late referral or insufficient orbital volume in the older child. The target proportions of the reconstructed orbit are not planned to mirror the healthy side exactly. The inferior orbital rim is kept higher to support the orbital implant, and the orbit is kept shallow to avoid a sunken appearance. Cranial bone grafts were used to augment deficient orbital contours; they were assisted by anterior transposition of the temporalis muscle (n = 5) when additional orbital volume was required. Conjunctival sac reconstruction was achieved by the use of serial conformers placed in the conjunctival sac during the neonatal period, followed by grafts of buccal mucosa and full-thickness skin maintained in place with a tarsorrhaphy for 3 to 6 months. Eyelid reconstruction using local flaps and skin grafts proved to be necessary in cases treated by osteotomy expansion, although reconstruction was not required after expansion using serial solid shapes. The results illustrate an evolution in approach and concepts of reconstruction of the microphthalmic orbit and emphasize the need for an integrated craniofacial approach for this complex deformity.

Surgical management of the anophthalmic orbit, part 2: post-tumoral.

Ablative surgery for tumors of the globe and its adnexal structures is frequently the cause of major orbitofacial deformity. Radiotherapy compounds the problem because it suppresses skeletal growth in the growing patient and induces a contraction of the remaining soft tissues in the orbit. Goals for reconstruction in these patients include the restoration of orbital structures to allow the fitting of an ocular prosthesis and the correction of distorted orbitofacial relationships. The authors present a series of 53 patients (mean age, 29 years; 28 male) who were treated over the past 18 years by composite reconstruction of the post-tumoral anophthalmic orbit. The follow-up ranged from 5 months to 18 years (mean, 7.75 years). Four patients were treated primarily (immediate reconstruction after tumor ablation), and 49 were treated secondarily (mean oncological follow-up since ablative surgery, 14.8 years). Twenty-eight patients underwent orbital enucleation (including three bilateral cases), 23 underwent orbital exenteration, and two underwent evisceration. Forty-two patients received radiotherapy, including 20 enucleation patients, 15 exenteration patients, and seven others in whom details of primary therapy were incomplete. A staged reconstruction was undertaken in each case; it considered, in turn, the bony orbital volume (orbital remodeling and cranial bone grafts), orbital contents (implant, temporalis muscle transposition, cranial bone grafts, and dermafat grafts), conjunctival sac (mucosal and skin grafts), ocular prosthesis, eyelids (local flaps and skin grafts), and additional procedures to restore orbitofacial symmetry. The authors conclude that the long-term results of post-tumoral orbital reconstruction are favorable, and they particularly recommend the use of autogenous tissues in irradiated orbits.

Use of the palmaris brevis flap for preventing recurrent median nerve compression in mucolipidosis.

In a patient with severe, recurrent bilateral carpal tunnel syndrome secondary to mucolipidosis, the 'turnover' palmaris brevis flap was used in conjunction with internal neurolysis. The procedure was effective in alleviating symptoms of recurrent carpal tunnel compression in both hands.

A review of the observational data-collection and reliability procedures reported in The Journal of Applied Behavior Analysis.

The research published in the Journal of Applied Behavior Analysis (1968 to 1975) was surveyed for three basic elements: data-collection methods, reliability procedures, and reliability scores. Three-quarters of the studies reported observational data. Most of these studies' observational methods were variations of event recording, trial scoring, interval recording, or time-sample recording. Almost all studies reported assessment of observer reliability, usually total or point-by-point percentage agreement scores. About half the agreement scores were consistently above 90%. Less than one-quarter of the studies reported that reliability was assessed at least once per condition.

Comparison of upper extremity glenohumeral joint forces in children with cerebral palsy using anterior and posterior walkers - biomed 2009.

Walkers are prescribed with the notion that one type of walker will be better for a child than another. One underlying justification for this practice is the theory that one walker may produce less stress on the upper extremities as the patient uses the walker. Nevertheless, upper extremity joint loading is not typically analyzed during walker assisted gait in children with spastic diplegic cerebral palsy. It has been difficult to evaluate the theory of walker prescription based on upper extremity stresses because loading on the upper extremities however has not been quantified until recently. In this study, weight bearing on the glenohumeral joints was analyzed in five children with spastic diplegic cerebral palsy using both anterior and posterior walkers fitted with 6-axis handle transducers. Though walkers' effects on the upper extremities proved to be similar between walker types, the differences between the walkers may have some clinical significance in the long run. In general, posterior walker use created larger glenohumeral joint forces. Though these differences are not statistically significant, over time and with repetitive loading they may be clinically significant.

A biomechanical analysis of upper extremity kinetics in children with cerebral palsy using anterior and posterior walkers.

Upper extremity (UE) joint kinetics during aided ambulation is an area of research that is not well characterized in the current literature. Biped UE joints are not anatomically designed to be weight bearing, therefore it is important to quantify UE kinetics during assisted gait. This will help to better understand the biomechanical implications of UE weight bearing, and enable physicians to prescribe more effective methods for treatment and therapy, perhaps minimizing excessive loads and torques. To address this challenge, an UE model that incorporates both kinematics and kinetics has been developed for use with walkers instrumented with load cells. In this study, the UE joint kinetics are calculated for 10 children with cerebral palsy using both anterior and posterior walkers. Three-dimensional joint reaction forces and moments are fully characterized for the wrist, elbow, and shoulder (glenohumeral) joints for both walker types. Statistical analysis methods are used to quantify the differences in forces or moments between the two walker types. Comparisons showed no significant differences in kinetic joint parameters between walker types. Results from a power analysis of the current data are provided which may be useful for planning longer term clinical studies. If risk factors for UE joint pathology can be identified early, perhaps a change in gait training routine, walker prescription, or walker design could prevent further harm.

Engineered hybrid dimers: tracking the activation pathway of caspase-7.

Caspase-7 is an obligate dimer of catalytic domains, with generation of activity requiring limited proteolysis within a region that separates the large and small chains of each domain. Using hybrid dimers we distinguish the relative contribution of each domain to catalysis by the whole molecule. We demonstrate that the zymogen arises from direct dimerization and not domain swapping. In contrast to previous conclusions, we show that only one of the catalytic domains must be proteolyzed to enable activation. The processed domain of this singly cleaved zymogen has the same catalytic activity as a domain of fully active caspase-7. A transient intermediate of singly cleaved dimeric caspase-7 can be found in a cell-free model of apoptosis induction. However, we see no evidence for an analogous intermediate of the related executioner caspase-3. Our study demonstrates the efficiency by which the executioner caspases are activated in vivo.