The tertiary management of pretibial lacerations

Pretibial lacerations remain one of the commonest yet most neglected conditions facing emergency departments and plastic surgeons alike. Furthermore, these injuries afflict the most vulnerable groups of adults - the elderly and the infirm. It is essential therefore to have an approach to pretibial lacerations based on best available evidence, in order to optimize wound outcomes, but perhaps more importantly, to safeguard the general health of the vulnerable individual. We present an evidence-based approach to the tertiary management of these injuries and propose a treatment algorithm that we have utilized in our unit to successfully manage 40% of tertiary referrals of pretibial lacerations in a conservative manner.     

Grafting without a donor site: an easy approach to pretibial lacerations

Pretibial lacerations are a common soft tissue injury especially amongst elderly women. An alternative repair approach to this problem is described. The traumatized and often necrosed-looking flap of skin from the injured area is made into a full thickness 'fenestrated' skin graft to cover the defect. Experience of 30 cases shows the method to be useful for accident and emergency departments as well as surgical units. The healing time is shorter than in conservative methods and similar to 'meshed split skin grafting' as an out-patient procedure, but the great advantage is the absence of a donor site.     

Bumping to a rollator walker: How pretibial hematomas create more costs than pretibial lacerations

Pretibial lacerations (PL) and pretibial hematomas (PH) are debilitating traumas among the elderly and infirm. The injuries are frequently grouped together despite differences in treatment and symptoms. Patients are known to have multiple contacts in health care, perhaps because of inadequate treatment. Despite the burden, financial costs have not been assessed. Calculate and compare the treatment costs of PLs and PHs for differences and provide economic incentives to treat and diagnose patients optimally. From linkage to ICD10 diagnoses, we analysed NordDRG product invoices generated by the treatment of the patients. We calculated and compared the costs of treatment in both cohorts from the invoices. This method has not been previously used for analysing wound care costs. Mean treatment costs were 1800€ (PL) and 3300€ (PH). The total costs, emergency room, surgical treatment, and inpatient care of PHs were higher than PLs (P = .0486, P = .0002, P = .0058, P = .6526). PLs generate more costs from the outpatient clinic but were not statistically significant (P = .6533). PHs cause a higher economic burden than PLs. Costs arise from repeat ER visits and the need for surgeries because of delayed treatment. PLs have multiple contacts in the wound clinic. Improvement in the diagnosis and treatment of both injuries is needed.     

Wound healing and infection in pretibial lacerations

Eighty-eight patients with pretibial lacerations were entered into a study to analyze bacteriological and wound-healing profiles. Fifty-four patients were followed to complete wound healing. A complete photographic record of wounds from time of presentation to healing was available for analysis in 49 of these patients. Staphylococcus aureus was the most common pathogen, but the correlation between clinical wound infection and growth of pathogenic bacteria was poor. Flucloxacillin alone was found to be significantly more effective in controlling wound infection than in combination with metronidazole. Computerized image analysis of the photographic records was performed. There was no significant difference in the healing times of the various classic surgical wound types, and image analysis confirmed that the rates of wound healing were generally similar in all the types of pretibial wounds.     

A new method of treating pretibial myxoedema

Pretibial myxoedema is a well recognized complication of Graves disease and occurs in approximately 5% of patients [8]. Many forms of treatment have been proposed, ranging from topical steroids under occlusive dressings [12] to plasmapheresis [7], but none has been universally successful. A simple shave excision without skin grafting was performed on a severe case of pretibial myxoedema and a good cosmetic result was achieved with no recurrence to date.     

A new approach in the management of incarcerated hernia

The authors describe the case of a 74-year-old male presenting with an incarcerated epigastric hernia. An algorithm for successful management of such a case is proposed. Received: 18 November 1996/Accepted: 26 December 1996     

A new approach to the management of malignant esophageal obstruction and esophagorespiratory fistula

Successful palliation of 6 patients with total or nearly total malignant esophageal obstruction is reported. In 5 of the patients, laser vaporization, dilation, and placement of an endoesophageal prosthesis resulted in an esophageal lumen that allowed adequate swallowing of soft food. In 1 patient with an esophagorespiratory fistula, the prosthesis successfully occluded the fistula and prevented aspiration or pulmonary infection until the patient's death. This rapidly achieved endoscopic palliation represents a major advance in the management of a serious medical problem.     

A new surgical approach to the management of symptomatic aberrant right subclavian artery

Aberrant right subclavian artery is a rare congenital anomaly that usually does not produce symptoms. Symptomatic patients require surgical intervention. Ligation of the aberrant artery through a left thoracotomy has been advocated as the operation of choice. If development of vertebrobasilar insufficiency is anticipated, division and ligation of the aberrant artery and its anastomosis to the right common carotid artery or aortic arch are performed at a second operation. In the procedure advocated here, both ligation and anastomosis of the aberrant artery are performed simultaneously through midsternotomy. Normal blood flow is thereby established to the right upper extremity, which obviates any early or late complications.     

Conservative management of aortic lacerations due to blunt trauma

Three patients with angiographically documented thoracic aortic lacerations were managed conservatively over 8 years due to the nonthreatening appearance of the injuries in two and the presence of an associated major closed head injury in a third. The lesion(s) resolved in one, diminished in another, and remained unchanged in the third. At least ten other cases managed similarly are recorded in the literature. In certain selected circumstances this approach may represent a viable alternative to the current standard of immediate surgical correction of aortic injuries.     

A new approach to scoliosis

Despite the advantages that new derotation-based systems have brought to the treatment of scoliosis, the debate continues, especially regarding adolescent idiopathic scoliosis. Problems like decompensation, junctional kyphosis, and insufficient sagittal plane alignment are met with new proposals. We now are using a technique and system, the Ibn-I Sina Spinal System (IBS), that we think is able to overcome these problems. It makes use of sublaminar wires, hooks, screws, and rods for correction. The main innovation is that the major corrective force is a controlled translation force acting simultaneously on all segments of the curve. A retrospective assessment of 25 patients treated with this system showed that besides dealing well with decompensation and junctional kyphosis problems, the technique was superior in sagittal plane adjustments, mainly in that it carried the normal kyphosis to its physiologic location. IBS has proved easy and successful in scoliosis treatment, especially with lordotic rigid curves. We encountered no neurologic injury or instrument failure. In addition to these advantages, ease of preoperative planning and application, decreased operation time, easy removal or revision, and versatility and safety of the system has made the Ibn-I Sina Spinal System (IBS) a treatment of choice, especially for adolescent idiopathic scoliosis cases, in some centers in Turkey. Received: 4 March 1998 Revised: 10 August 1998 Accepted: 26 October 1998     

A new transtrochanteric approach to the hip

Summary This transtrochanteric approach to the hip maintains continuity between the greater trochanter and the vastus lateralis muscle, thereby preventing the gross displacement of the greater trochanter and preserving the branches of the lateral circumflex vessles to it. The procedure offers the advantages of easy exposure and a high rate of bony union between trochanter and femur. We have used the procedure in 189 consecutive operations; in only four cases did union between the bones not occur. The trochanter was never cranially displaced more than three cm, and even in the cases of non-union abductor power was good. Although we do not recommend trochanteric osteotomy for every case of total hip replacement, we suggest that the approach be used for cases where technical problems are anticipated.

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Résumé Cette voie d'abord trans-trochantérienne respecte la continuité entre grand trochanter et muscle vaste externe, permettant ainsi de prévenir les déplacements importants du grand trochanter et de respecter les branches des vaisseaux circonflexes qui lui sont destinées. Cette technique assure à la fois une bonne exposition et un risque minimum de non-consolidation: sur nos 189 patients, seuls 4 n'ont pas consolidé. Ces 4 patients, malgré leur pseudarthrose, ont une force d'abduction satisfaisante. Le déplacement du grand trochanter vers l'avant n'a jamais excédé trois cm. Bien que nous ne conseillions pas cette voie d'abord dans tous les cas, nous la préconisons chaque fois que des difficultés techniques paraissent à redouter.

     

A conservative approach to major blunt renal lacerations with urinary extravasation and devitalized renal segments

OBJECTIVES: To determine the feasibility of a conservative (expectant) approach to major blunt renal laceration with urinary extravasation and devitalized renal segments. PATIENTS AND METHODS: All patients treated conservatively who presented between 1990 and 1999 with major renal laceration (grade 4 and 5) were retrospectively reviewed to determine whether urinary extravasation and devitalized segments adversely affected the outcome. For each patient the data collected included the initial emergency department evaluation, findings on computed tomography, associated injuries, duration of hospital stay, transfusion requirements, complications and follow-up imaging. RESULTS: Of 20 patients who sustained blunt trauma resulting in a major renal laceration (five grade 5 and 15 grade 4) with urinary extravasation, 11 had coexisting devitalized segments. There was a statistically significant difference in the length of hospital stay (16.3 vs 7.3 days), blood transfusions (six vs two patients, P < 0.08) and the need for delayed surgical intervention (nine vs two, P < 0.01) between patients with and with no devitalized segments, respectively. Urinary extravasation spontaneously resolved in two of 11 patients with and in seven of nine with no devitalized segment, respectively (P < 0.05) CONCLUSIONS: Urinary extravasation will resolve spontaneously in most patients with blunt renal trauma, and expectant treatment does not adversely affect the outcome or prolong hospitalization. In patients who present with a major renal laceration associated with devascularized segments, conservative management is feasible in those who are clinically stable with blunt trauma. However, the physician must be especially aware of the probable complications within this subset of patients.     

A new approach to the treatment of osteoporosis

Osteoporosis remains a significant clinical problem despite the availability of effective therapies. The main therapy still needed is an anabolic agent for the treatment of osteoporosis. This study examined the in vivo effect of the enzyme 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor simvastatin, which controls the first step in the biosynthesis of cholesterol, on bone formation in rats. Histologic specimens were collected 7, 14, and 21 days after administration of 1 mg of simvastatin for 5 days and compared with control specimens for changes in bone tissue. The observed effects on the bone in a healthy animal model included advancement of the blood supply, acceleration of the proliferation and differentiation of osteoprogenitor cells, and formation of osteoid tissue.