Major trauma: a district general hospital experience

A retrospective review of all patients with major trauma admitted to a busy suburban district hospital was conducted over a 1-year period. Outcome for each patient was assessed using the TRISS system which calculates the probability of survival based on anatomical extent of injury and degree of physiological disturbance at the time of admission. Thirty-nine patients were admitted following major trauma, of whom nine died. Seven of the deaths were in patients with a greater than 50 per cent chance of survival according to the TRISS system. In contrast, four patients survived who had a greater than 50 per cent chance of death. Details of these 11 cases are given. The numbers of patients who were referred to neurosurgeons and cardiothoracic surgeons in regional specialist centres were recorded, as was the relative contribution of general and orthopaedic surgeons in our own hospital. We conclude that, in the absence of specialized trauma centres, a reasonable standard of care for patients who have sustained major trauma can be delivered in a district general hospital.     

MRI of the knee: its cost-effective use in a district general hospital.

In the first year of magnetic resonance imaging (MRI) scanning of the knee in the East Berkshire Health District, 175 patients were scanned and 79 of these subsequently had an arthroscopy performed. We found that MRI accurately demonstrated the pathology present in the knee, particularly for meniscal lesions, although it was less accurate for anterior cruciate and cartilage lesions. The relative costs of MRI scanning, arthroscopy and conservative treatment are compared. On the basis of this analysis we have worked out a protocol for the cost-effective use of MRI in imaging the knee. This protocol has reduced the number of arthroscopies performed, allowing us to expend resources on patients who would definitely benefit from arthroscopic surgery.     

Magnetic resonance imaging of the knee

Magnetic resonance imaging (MRI) is gaining acceptance as the diagnostic imaging procedure of choice for the disorders of the knee. MRI can reliably display tears of the menisci and ligaments. It also has an unmatched capability of detecting and assessing a wide spectrum of knee disorders that may be present as nonspecific knee pain: osteonecrosis, osteochondritis dissecans, stress fracture, bone and soft-tissue tumors, and vascular abnormalities. Practicing orthopedists should become better acquainted with this powerful diagnostic tool that can be an invaluable asset to their clinical practices.     

Amputation in the diabetic: ten years experience in a district general hospital.

Over a period of 10 years, 149 amputations were performed for lower limb ischaemia in 119 diabetic patients. Thirty patients required amputation of the second limb. Ninety per cent of the patients were over the age of 60 years. Sixty four ischaemic limbs were treated by primary local amputation or debridement--29 healed successfully, 30 proceeded to a higher amputation. The incidence of multiple local operations was high. A below knee amputation was performed in 56 limbs--7 failed to heal and required a more proximal amputation. Seventy five patients in the series have died; 58 of these survived less than 3 years from their first amputation. The hospital stay for all patients was long; for an unsuccessful local amputation the average stay was 109 days. Conservative management with the Scotchcast boot has been shown to be satisfactory. This must be compared with the significant costs to the patient of early operative intervention.     

Magnetic resonance imaging of the knee

MRI has been in widespread clinical use since 1985 and in this short time has dramatically altered musculoskeletal imaging. The technology continues to become increasingly sophisticated; as both clinicians and radiologists become more familiar with its possibilities, further elucidation of pathologic processes affecting the knee will occur. In addition, advanced computer software has allowed a decrease in imaging time, which will allow a decrease in cost of this once-expensive technique. At this time, in many centers, MRI has essentially replaced arthrography for evaluation of disorders of the knee. The advantages of MRI include its inherent contrast sensitivity that allows visualization of a wide variety of tissues, multiplanar capabilities, lack of ionizing radiation, noninvasiveness, rapidity of imaging, and acceptability to patients.     

Necrotizing fasciitis: 10 years' experience in a district general hospital

Of 14 patients with necrotizing fasciitis who presented between 1979 and 1988, six (43 per cent) died. The deaths were associated with delays in diagnosis, poor surgical technique and diabetes. Prompt diagnosis, resuscitation and early radical surgery are essential to the successful management of necrotizing fasciitis.     

Orthopaedic audit: one year's experience in a district general hospital

In 1982 a prospective Audit of complications and mortality and a quarterly retrospective analysis of work done were undertaken on the orthopaedic unit of Southmead Hospital, Bristol. Since no account has been presented of Orthopaedic Audit it was felt that a discussion of the method, results and whether the aims had been achieved and at what cost would be of interest to other surgeons, and to orthopaedic surgeons in particular. Two orthopaedic surgeons treated 1811 inpatients during the year; 73.7% of the patients undergoing surgery at Southmead Hospital were emergencies. Mortality, excluding fractures of the neck of femur, was 0.22% and total mortality 1.8%; 16.7% of patients had a recorded complication of which the largest group was technical failure (2.7%) followed by wound infection (2.4%).     

Twelve years'' experience of computer-aided diagnosis in a district general hospital.

This paper describes experience in a modern district general hospital with a small desktop system for computer-aided diagnosis of acute abdominal pain, over a 12-year period involving 5512 cases. When compared with a baseline year (1973) in which unaided performance was monitored, during an initial study period (1974-76) the diagnostic accuracy of junior staff rose by between 10 and 15%. This higher performance level was then maintained for a decade (1976-86) despite changes in staff. The perforation rate among appendicitis cases fell from 27% to 12.5%, accompanied by a smaller fall in negative laparotomy rates. The saving in surgical bednights devoted to acute abdominal pain was approximately 15%, and the notional cost of resources saved during the first 6 years of operation was 120,000 pounds. Other hospitals have shown--in the short term--benefits similar to those obtained at Airedale District General Hospital. The long-term benefits of the system at Airedale reinforce the conclusions of the earlier short-term trials that a comparable system should probably be offered to all DGHs in the UK, not as an exercise in 'artificial intelligence' but as an effective continuing stimulus to good clinical practice.     

Amputation for peripheral vascular disease: experience of a district general hospital.

Two hundred and ninety major lower-limb amputations were performed on 286 patients during the period 1969-79. The early mortality rate was 6.9%. The mean age of the amputees was 70.2 (range 35-91) years. The commonest site for amputation was above the knee (77.2%). Failure to obtain immediate satisfactory healing of the stump occurred in 18.4% and reamputation was required in 5.6%. The hospital mortality rate was 25.5%. Routine prophylactic penicillin was not given. One patient developed gas gangrene.     

Infantile hypertrophic pyloric stenosis: experience in a district general hospital

One hundred and twenty-nine infants with infantile hypertrophic pyloric stenosis were referred to one consultant surgeon over a 13-year period. In all cases general anaesthesia was used and a standardized surgical technique followed. No mortality was recorded. Twenty-seven infants had postoperative complications, excluding vomiting. Wound infections developed in 3% of cases and required treatment; there was no abdominal wound dehiscence. Prophylactic antibiotic treatment was not indicated. Postoperative vomiting occurred in 69% of the infants; in 15% this was severe and required an alteration in clinical management and a lengthened hospital stay. Attention to the severity rather than the incidence of postoperative vomiting will reduce morbidity further. Low morbidity and zero mortality can be achieved in non-specialist centres.     

Karydakis operation for sacrococcygeal pilonidal sinus disease: experience in a district general hospital.

Asymmetrical excision of sacrococcygeal pilonidal sinus has been shown to be associated with low recurrence rates. We report our experience with an asymmetric technique--the Karydakis operation. Of 28 patients who had the operation over a 4-year period, no recurrences were observed in 27 patients available for follow-up (median follow-up 3 years). Three patients had complications requiring surgical intervention. The operation is easy to teach and learn and is worth considering by both specialist and non-specialist surgeons.     

Magnetic resonance imaging of the multiple-ligament injured knee

OBJECTIVE: To evaluate magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) in detecting soft tissue, neurovascular, and bony injury after multiple ligament knee injury, including knee dislocation. MATERIALS AND METHODS: A retrospective search was performed for patients presenting with reported knee dislocation from May 1993 through May 2000 who underwent both MRI and surgical reconstruction. Twenty-one patients met these criteria (15 men and six women; age range 14 to 75 years; mean 32.6 years). Magnetic resonance diagnoses of soft tissue and bony injury were compared with the patients' operative findings. MRA of the popliteal vessels was performed in seventeen of our twenty-one patients, and the results of these studies are described. RESULTS: Multiple ligamentous, tendinous, meniscal, chondral, osseous, and neural injuries were seen. There was excellent correlation (kappa > 0.8) between the magnetic resonance and operative findings with regard to the size and location of tears. Regarding meniscal tears, the type (e.g., bucket, radial split, meniscocapsular separation) and location correlated well with surgery. All ten nerve injuries noted on magnetic resonance were confirmed at surgery. Six of our patients had both conventional angiograms and MRAs with 100 percent agreement between the studies. In one patient an intimal flap in the popliteal artery was seen on MRA and confirmed on conventional angiographic images. CONCLUSION: MRI is an accurate method of assessing soft tissue, osseous, and neural damage after knee dislocation. Our early experience with popliteal fossa MRA is encouraging with complete agreement between the MRA and conventional angiography in patients who had both studies.     

Magnetic resonance imaging of the knee: correlation with arthroscopy

Magnetic resonance imaging (MRI) was used to diagnose acute and chronic intraarticular knee pathology in 23 knees. The results were compared with arthroscopic findings of meniscal, ligamentous, and articular cartilaginous pathology using a double-blind prospective protocol. The overall accuracy for meniscal tears was 78%, with a sensitivity of 88% and a specificity of 72%; for cruciate ligaments, MRI was 82% accurate, with a sensitivity of 67% [anterior cruciate ligament (ACL) only] and a specificity of 86%. In select clinical situations, MRI of the knee is a useful diagnostic tool.     

Magnetic resonance imaging of total knee arthroplasty

Evaluation of painful total knee arthroplasty can be clinically difficult, and traditional imaging techniques such as conventional radiographs, arthrography, and bone scintigraphy are limited by poor contrast resolution and specificity. Traditional magnetic resonance imaging techniques often are nondiagnostic because of significant metal artifact. Forty-one patients (46 knees) had magnetic resonance imaging, tailored to reduce metallic susceptibility artifact, after total knee arthroplasty, and the findings and clinical and surgical followup were reviewed. All studies consistently showed the integrity of the periprosthetic soft tissues. Magnetic resonance imaging findings led to surgical or other therapeutic interventional procedures in 20 patients, and influenced clinical treatment in all patients. Optimized magnetic resonance imaging, in which the metallic artifact is diminished, is a clinically useful adjunct to traditional imaging techniques in evaluation of patients with painful total knee arthroplasty.     

Serum CEA in the follow-up of colorectal carcinoma: experience in a district general hospital

Serum CEA was measured at 6-monthly intervals, over a 3-year period, in 102 patients being followed up after apparently complete excision of colorectal carcinoma. Residual disease was identified in 27 patients and was preceded by a CEA rise in 22 of these patients (81.5%). The CEA was initially normal in 68% of patients with residual disease in whom it subsequently rose. Rise in CEA was not detected until a median of 14 weeks before recurrence was diagnosed clinically. CEA-instigated second-look laparotomy was performed in 7 patients (31.5% of cases with CEA-associated residual disease). Despite a high resectability rate, no patient was cured. The results might have been improved by more frequent CEA measurement and more immediate second-look laparotomy, but in this study, CEA rise was not associated with surgically curable residual disease.     

Abdominal aortic aneurysm surgery in a district general hospital: a 15-years experience

The incidence of patients presenting with both ruptured abdominal aortic aneurysm (RAAA) and elective abdominal aortic aneurysm (EAAA) increases with age. The aim of our study was to find out the incidence of RAAA, age and sex groups of patients at risk, and 30-day all-cause perioperative mortality associated with RAAA as well as EAAA repair in a busy district general hospital over a 15-year time period. All patients operated for AAA during 1989-2003, both elective and ruptured, were included in the study. Patients who died in the community from RAAA were also included. The data were collected from the hospital information system, theater logbooks, intensive therapy unit records, postmortem register, and patients' medical notes. We divided the data for RAAA into two groups of 7.5 years each to see if there was any improvement over time in 30-day postoperative mortality. There were 816 cases of AAA, which included 468 RAAAs (57%) and 348 EAAAs (43%). Out of 468 RAAAs, 243 patients had emergency repair, of whom 213 were males. There were 201 patients who had RAAA postmortem (43%). Median age (range) was 73 (54-94) years in males and 77 (52-99) years in females, with a male-to-female ratio of 7:1. The peak incidence of RAAA was over 60 years of age in males and 70 years in females. Incidence of RAAA was 7.3/100,000/year in males and 5/100,000/year in females. For RAAA, 30-day perioperative mortality was 43% (105/243) while overall mortality was 70% (330/468), which includes deaths in the community. There was no improvement in 30-day mortality over time after comparing data for the first 7.5 years (50/115, 43.5%) with those for the second set of 7.5 years (55/128, 43%). There were 348 patients who had EAAA repair over the same period, comprising 282 males, with a male:female ratio of 4.3:1. The 30-day mortality in the elective group was 7.75%. Incidence and mortality of RAAA remain high. A high proportion of patients with AAA remain undiagnosed and die in the community. More lives may be saved if a screening program is started for AAA.