Utility of follow-up radiographs in conservatively managed acute fifth metatarsal fractures

Fifth metatarsal fractures are the most common fracture of the foot, with the majority being managed conservatively. A variety of treatment methods are described in the literature. Follow-up radiographs are taken to identify fracture displacement, and subsequently to assess for bony union throughout treatment. We assessed the utility of serial radiographic assessment in management of these fractures. Clinical notes and radiographs of 79 patients with fifth metatarsal fractures were analysed retrospectively. Serial radiographs were studied to identify displacement and the last X-ray was reviewed for evidence of fracture union. 96% of fractures were managed conservatively. 29% showed radiological healing at last clinic visit, the rest being discharged as were considered clinically healed. Similar fracture types were managed differently. 3 fractures were surgically treated after failed conservative management. 1 fracture showed displacement from initial radiographs, and was successfully managed conservatively.Without clear guidelines, these injuries are managed differently from a radiological perspective. Follow-up radiographs taken before 6–8 weeks do not appear to alter patient management. Based on the current study we present our recommendations for radiographic assessment of acute fifth metatarsal fractures.     

Haemorrhage in pancreatic disease

Haemorrhage is a life-threatening complication in pancreatic disease. Twenty-five patients with this complication are described; 15 had major bleeding, nine had minor bleeding and one patient had a pseudoaneurysm identified at operation. Of the 15 patients with major bleeding, six presented with this complication and in nine cases it followed pancreatic resection. Of the six patients who presented with major bleeding, five underwent resection with one death while the patient managed conservatively died. The nine patients who had major bleeding after pancreatic resection were managed by ligation of the bleeding artery in six cases with one death, and one patient who rebled after ligation of the bleeding artery was successfully managed by further resection. Three patients with postresection major bleeding were managed conservatively with one death. All minor haemorrhages were managed conservatively without mortality. Deaths after major bleeding were a result of sepsis in three cases and respiratory failure in one. The severity of the underlying pancreatitis was an important factor in two patients. Pseudocysts and pancreatic fistulae were important underlying factors leading to the complication. It is recommended that patients with sepsis, a pancreatic fistula or severe underlying pancreatitis should have their haemorrhage treated by pancreatic resection, while those patients with bleeding following pancreatic resection without such complications can be managed by ligation.     

Pancreatic abscess: 10 years experience

Background: Secondary infections of pancreatic and peripancreatic necrosis account for most of the deaths following acute pancreatitis. These infections occur in the form of ‘infected pancreatic necrosis’ and ‘pancreatic abscess’. The latter is a rare complication of acute pancreatitis in comparison with the former. Methods: Twenty‐one patients with pancreatic abscess were managed over a 10‐year period at a tertiary care centre in Northern India. The present report details the clinical profile, investigations performed and management strategy (surgery and intervention radiology) of these patients. The role of surgery and percutaneous catheter drainage (PCD) in the management of pancreatic abscess is discussed, with emphasis on the successful outcome seen in a properly selected group of patients managed by PCD. Results: Of the 21 patients, 12 were managed by percutaneous intervention, nine were managed surgically (of these, two had a prior PCD) and two patients were managed conservatively. The overall mortality was 9.5% (2/21). Thus, percutaneous management was suitable for 57% patients, was successful in 83.3%, with a mortality of 8.3%. Surgical therapy alone was offered to 33% of patients, was successful in 85.7%, with a mortality of 14.2%. Complications were seen in four of the nine patients managed by percutaneous drainage alone and eight of the nine patients managed surgically. Conclusions: Pancreatic abscess is a potentially lethal complication in patients recovering from acute pancreatitis. Early diagnosis and prompt intervention with careful selection of patients based on computed tomography imaging for surgical or percutaneous radio­logical management, is met with a successful outcome in a majority of patients. The roles of surgery and PCD are complementary.     

Giant acquired tracheoesophageal fistulas: strategy for successful management

Giant tracheoesophageal fistulas (TEF) present a significant management problem for the head and neck surgeon. Chronic aspiration and sepsis are associated complications that occur in these patients, who are frequently already debilitated from pre-existing medical calamities. The combination results in prolonged morbidity and frequent mortality. Recently, we have managed two patients with this difficult problem. The first patient was managed using conventional methods well described in the literature with an unsuccessful outcome. The second was managed differently using a two-stage approach. The esophageal stream was first excluded from the respiratory system via a surgical approach, which to the best of our knowledge has not been previously described in the literature. After a period of convalescence, the patient's alimentary tract is reconstituted with a gastric pull-up, reversed gastric tube, or colon interposition. We propose this as an alternative method of management for TEF.     

Improvement of the bone-pin interface strength in osteoporotic bone with use of hydroxyapatite-coated tapered external-fixation pins. A prospective, randomized clinical study of wrist fractures

BACKGROUND: Achieving adequate fixation strength in osteoporotic bone is a challenge. In this study, we examined the use of hydroxyapatite-coated tapered external-fixation pins for the fixation of wrist fractures in patients with osteoporosis. METHODS: Twenty female patients with osteoporosis and a fracture of the wrist were divided into two paired groups and randomized to receive either standard tapered pins or hydroxyapatite-coated tapered pins. Two pins were inserted in the distal part of the radius, two pins were inserted in the second metacarpal, and an external fixation device was mounted. All fixation devices were removed six weeks after surgery. RESULTS: The mean pin-insertion torque (and standard deviation) was 461 +/- 254 Nmm in the group managed with standard pins and 332 +/- 176 Nmm in the group managed with hydroxyapatite-coated pins (p = 0.01). The mean pin-extraction torque was 191 +/- 155 Nmm in the group managed with standard pins and 600 +/- 214 Nmm in the group managed with hydroxyapatite-coated pins (p < 0.0001, power 95%). The mean extraction torque was lower than the corresponding insertion torque at each pin position in the group managed with standard pins (p < 0.05), whereas the mean extraction torque was higher than the corresponding insertion torque at each pin position in the group managed with hydroxyapatite-coated pins (p = 0.001). Two patients managed with standard pins and no patient managed with hydroxyapatite-coated pins had a pin-track infection. Pain during pin removal did not differ between the two groups. CONCLUSIONS: The present study showed that hydroxyapatite-coated tapered external-fixation pins provided improved fixation in the treatment of wrist fractures in patients with osteoporosis.     

Managed care Auswirkungen auf das Gesundheitswesen der USA, insbesondere im Bereich Anästhesie und Intensivmedizin

Managed care, i.e., the integration of health insurance and delivery of care under the direction of one organization, is gaining importance in the USA health market. The initial effects consisted of a decrease in insurance premiums, a very attractive feature for employers. Managed care promises to contain expenditures for health care. Given the shrinking public resources in Germany, managed care seems attractive for the German health system, too. In this review the development of managed care, the principal elements, forms of organisation and practical tools are outlined. The regulation of the delivery of care by means of controlling and financial incentives threatens the autonomy of physicians: the physician must act as a ”double agent”, caring for the interest for the individual patient and being restricted by the contract with the managed care organisation. Cost containment by managed care was achieved by reducing the fees for physicians and hospitals (and partly by restricting care for patients). Only a fraction of this cost reduction was handed over to the enrollee or employer, and most of the money was returned with profit to the shareholders of the managed care organisations. The preeminent role of primary care physicians as gatekeepers of the health network led to a reduced demand for specialist services in general and for university hospitals and anesthesiologists in particular. The paradigm of managed care, i.e., to guide the patient and the care giver through the health care system in order to achieve cost-effective and high quality care, seems very attractive. The stress on cost minimization by any means in the daily practice of managed care makes it doubtful if managed care should be an option for the German health system, in particular because there are a number of restrictions on it in German law.     

Laparoscopic Management of a Large Duodenal Lipoma Presented as Gastric Outlet Obstruction

Lipoma of the duodenum is a rare tumor, with fewer than 230 cases reported to date. A majority of these tumors were managed by endoscopic and open surgical intervention, with published data on one case that was managed by total laparoscopy. We report a case of a 43-year-old woman with signs and symptoms of gastric outlet obstruction who was diagnosed as having a large duodenal lipoma that was managed successfully with laparoscopic excision.     

Laparoscopic removal of a gigantic non-functioning kidney via retroperitoneal access

Hugely dilated kidneys can sometimes present as abdominal masses. These kidneys are invariably non-functioning and are managed by nephrectomy.We describe a case of massive kidney containing 12.5 litres on fluid which was managed by retroperitoneoscopic nephrectomy. The patient was a 24-year-old male who presented with a huge abdominal mass, anorexia and weight loss. Laparoscopic surgery for such a large kidney has not been previously reported. We discuss salient features of the procedure and elaborate on the modifications required in the case of significantly enlarged kidneys. This revised version was published online in August 2006 with corrections to the Cover Date.     

Ruptured umbilical hernia in a case of alcoholic cirrhosis with massive ascites

Umbilical hernias are common in patients with cirrhosis of the liver and ascites. However, spontaneous rupture of the hernia is not frequently seen. This is a serious complication and carries a high mortality. A search of the literature shows that patients have been managed both operatively and nonoperatively for this condition. We present a case of spontaneous rupture of an umbilical hernia in a patient with cirrhosis and ascites which was managed successfully with hernia repair.     

The management of posterior urethral valves by initial vesicostomy and delayed valve ablation

We managed 32 neonates and infants with temporary vesicostomy and delayed valve ablation. The criterion on which successful management was gauged was estimated creatinine clearance. Renal failure or death occurred in 30% of the patients and 7% required transplantation. There was no apparent difference between our patients managed initially with vesicostomy and other series managed initially with valve ablation in preventing the complications of posterior urethral valves.     

Comparison of enoxaparin and warfarin for the prevention of venous thromboembolic disease after total hip arthroplasty. Evaluation during hospitalization and three months after discharge.

BACKGROUND: Venous thromboembolic disease in the form of deep venous thrombosis and pulmonary embolism is a major risk after a total hip arthroplasty. Enoxaparin, a low-molecular-weight heparin, has been shown to reduce the prevalence of deep venous thrombosis after total hip arthroplasty. Warfarin, an orally administered anticoagulant, has been used historically to reduce the risk of deep venous thrombosis after total hip arthroplasty. METHODS: We compared enoxaparin and adjusted-dose warfarin with respect to their safety and their efficacy in the prevention of clinically important venous thromboembolic disease, defined as distal or proximal deep venous thrombosis or pulmonary embolism, or both, during hospitalization after total hip arthroplasty. We also evaluated the prevalence of complications and mortality from venous thromboembolic disease within three months after discharge. RESULTS: Three thousand and eleven patients at 156 centers were randomly assigned to prophylactic treatment with injection of enoxaparin or oral administration of adjusted-dose warfarin during hospitalization. During the study, fifty-five (3.6 percent) of the 1516 patients who were managed with enoxaparin and fifty-six (3.7 percent) of the 1495 patients who were managed with warfarin had venous thromboembolic disease. Twenty-one patients (0.7 percent), which included four (0.3 percent) of those managed with enoxaparin and seventeen (1.1 percent) of those managed with warfarin (p = 0.0083), had venous thromboembolic disease during hospitalization. After discharge from the hospital, venous thromboembolic disease developed in ninety patients (3.0 percent): fifty-one (3.4 percent) of those managed with enoxaparin and thirty-nine (2.6 percent) of those managed with warfarin. One patient who had been managed with enoxaparin died because of a pulmonary embolism, which was confirmed at autopsy. Three additional patients (one who had been managed with enoxaparin and two who had been managed with warfarin) died, and the deaths were attributed to venous thromboembolic disease; however, no autopsies were performed. Twenty-six patients (0.9 percent) (eighteen managed with enoxaparin and eight managed with warfarin) had clinically important bleeding. CONCLUSIONS: Inpatient programs providing treatment with either enoxaparin (thirty milligrams every twelve hours) or adjusted-dose warfarin for a mean of 7.3 days afforded protection against venous thromboembolic disease, with overall rates of morbidity and mortality of 3.7 and 0.6 percent, respectively, and a very low rate of major bleeding complications (0.9 percent) for three months after total hip arthroplasty. During hospitalization, the patients managed with enoxaparin had a lower rate of venous thromboembolic disease than those managed with adjusted-dose warfarin (p = 0.0083). This benefit was lost after the medication was discontinued, with no difference in the prevalences of venous thromboembolic disease between the two groups at three months after discharge from the hospital.     

Outcomes of Interventional Management of Coronary Artery Disease in Kidney Transplant Recipients

BackgroundCardiovascular disease is the most common cause of death among kidney transplant (KT) recipients. Trials routinely exclude patients with end-stage renal disease when assessing the effect of coronary artery revascularization. We looked to compare long-term outcomes in patients who underwent percutaneous coronary intervention (PCI) before KT with those managed medically.MethodsWe identified all patients who underwent coronary artery catheterization before KT from January 2008 to November 2019 at the Cleveland Clinic. The primary endpoint was all-cause mortality.ResultsA total of 272 patients were included, of whom 52 (19.11%) underwent PCI, and the remaining 220 patients were managed medically. The median age in the PCI group was 57.4 years (interquartile range [IQR], 46.9-61.2 years), whereas it was 53.9 years (IQR, 44.6-61 years) in the group medically managed. Baseline characteristics including sex, race, hypertension, diabetes, smoking, and hyperlipidemia were comparable in both groups. The median time to KT was 2.4 years (IQR, 1-5 years) in the PCI group vs 1.2 years (IQR, 0.6-3.3 years) in the medically managed group (P = .001). Among patients who underwent PCI, 40.4% had single vessel disease and 59.6% had multivessel disease compared with 16.8% and 28.6%, respectively, in the medically managed group (P < .001). Overall, there was no difference in mortality in the PCI group compared with the medically managed group after 10 years of follow-up (P = .416).ConclusionsPatients with coronary artery disease can be safely treated with PCI before KT and have comparable outcomes to those who are managed medically.     

Complete duplication of male urethra. Two case reports

Complete urethral duplication is a rare anomaly in boys. About 60 cases have been reported in the literature, of which approximately one-third were managed with a surgical procedure of total excision of the accessory urethra. Another third were managed by partial excision, and the rest were managed conservatively. Here 2 cases are presented, and the surgical treatment is discussed.     

Weight-bearing in ankle fractures: An audit of UK practice

IntroductionThe purpose of this national study was to audit the weight-bearing practice of orthopaedic services in the National Health Service (NHS) in the treatment of operatively and non-operatively treated ankle fractures.MethodsA multicentre prospective two-week audit of all adult ankle fractures was conducted between July 3rd 2017 and July 17th 2017. Fractures were classified using the AO/OTA classification. Fractures fixed with syndesmosis screws or unstable fractures (>1 malleolus fractured or talar shift present) treated conservatively were excluded. No outcome data were collected. In line with NICE (The National Institute for Health and Care Excellence) criteria, “early” weight-bearing was defined as unrestricted weight-bearing on the affected leg within 3 weeks of injury or surgery and “delayed” weight-bearing as unrestricted weight-bearing permitted after 3 weeks.Results251 collaborators from 81 NHS hospitals collected data: 531 patients were managed non-operatively and 276 operatively. The mean age was 52.6 years and 50.5 respectively. 81% of non-operatively managed patients were instructed for early weight-bearing as recommended by NICE. In contrast, only 21% of operatively managed patients were instructed for early weight-bearing.DiscussionThe majority of patients with uni-malleolar ankle fractures which are managed non-operatively are treated in accordance with NICE guidance. There is notable variability amongst and within NHS hospitals in the weight-bearing instructions given to patients with operatively managed ankle fractures.ConclusionThis study demonstrates community equipoise and suggests that the randomized study to determine the most effective strategy for postoperative weight-bearing in ankle fractures described in the NICE research recommendation is feasible.     

Long-term followup of endoscopic management of urethral strictures in children

The long-term followup of 31 children with urethral strictures managed by an endoscopic technique was reviewed. Four children could not be managed endoscopically and required urethroplasty, yielding an over-all success rate of 87 per cent. Repeat endoscopic procedures were needed in approximately a third of the patients and intralesional steroids enhanced the change of success. The initial favorable short-term results with endoscopic management of urethral strictures in children are confirmed in this expanded series.     

Displaced hip fractures in children and adolescents

The results of ten acute, displaced proximal femoral fractures in patients 14 years and under are reported. These high-risk fractures were managed with urgent open reduction and pin or screw fixation with supplemental spica casting. The exception to this protocol was in two Delbet's type IV (intertrochanteric) fractures which were managed by closed reduction and spica casting. There was a case of partial avascular necrosis of the femoral head in a type I transepiphyseal fracture. At a minimum followup of 2 years the patients were asymptomatic with no significant limitation of hip motion.     

Management of low velocity gunshot-induced fractures

Bullets fired from civilian weapons are usually of low velocity, resulting in minimal tissue cavitation as compared to high-velocity weapons. A prospective protocol was initiated for patients sustaining a low-velocity gunshot to the extremity resulting in a stable, nonoperative fracture configuration. Treatment consisted of local irrigation and débridement, tetanus prophylaxis as required, a long acting cephalosporin intramuscularly, and splinting or casting of the fractured extremity. Twenty-five patients were managed by this protocol. This patient population was compared to a random retrospective sample of 25 patients with similar ballistic induced fractures and wounds managed by local débridement and 48 h of intravenous antibiotics. One infection occurred in each group, requiring further therapy. We conclude that the patient with a low-velocity gunshot induced fracture can be managed without the use of short-term intravenous antibiotics with no increased risk of infection.     

Intramedullary fixation for congenital pseudarthrosis of the tibia.

Eighteen consecutively seen patients who had a congenital pseudarthrosis of the tibia were treated operatively. The mean age when the patients were first seen was four years. Seventeen previous procedures had failed: six patients had had one previous procedure; three, two previous procedures; and one, five previous procedures. At an average follow-up interval of ten years (range, three to nineteen years), healing with re-formation of the medullary canal was seen in thirteen of the eighteen tibiae, including one tibia that had united after a Boyd amputation. Five patients did not have healing of the tibia: four of them had a below-the-knee amputation, and one declined additional treatment. The average residual angulation was 12 degrees in the sagittal plane and 5 degrees in the coronal plane. Union occurred in ten of the thirteen patients who had been managed with intramedullary fixation. Of these thirteen, eight had been managed with intramedullary fixation, bone-grafting, and implantation of an electrical stimulator, and seven of them had union. Five of the thirteen patients had been managed with intramedullary fixation and bone-grafting, and three of them had union. Union occurred in one of two patients who had been managed with vascularized free fibular transfer, one who had been managed with delayed bone-grafting, and one who had been managed with a Boyd amputation. Four of the five patients who did not have union were subsequently managed with a below-the-knee amputation, and one patient refused additional treatment.     

Tibial periprosthetic fractures in Total Knee Arthroplasty – A scoping review

BackgroundPeriprosthetic tibial fractures in Total Knee Arthroplasty are much less commonly seen than femoral fractures, and there is a paucity of available literature and management recommendation for these fractures. We aimed to identify the relevant and up-to-date literature on this subject to analyse the incidence, risk factors, and management recommendations.MethodsA literature search was done on the databases of PubMed and SCOPUS using appropriate keywords. All the published literature in the English language was included for this review.ResultsWe included 21 studies comprising 260 tibial periprosthetic fractures (91 intra-operative (35%) and 169 (65%) post-operative or delayed fractures). Only 5.9% of these fractures were managed conservatively. Whereas 98 cases (58%) were managed with open reduction and internal fixation (ORIF) with plating, 19 (11.2%) were managed with revision TKA. Seventeen cases (10%) were managed with minimally invasive percutaneous plate osteosynthesis (MIPPO), and 8 (4.7%) were managed with intramedullary nailing. Less than 6% of cases were managed with other means, viz. megaprosthesis (n = 4), arthrodesis (n = 5), amputation (n = 1), and external fixator (n = 1).ConclusionIntraoperative fractures accounted for one-third of the fractures in our review. A majority of the delayed periprosthetic fractures were treated with surgical intervention. The most preferred surgical treatment method was ORIF of fractures using locking plates (either open or MIPPO). Revision TKA or megaprosthesis was used in cases with the loosened implants in association with the fracture.Level of evidenceIV