Postero-medio-anterior approach of the ankle for the pilon fracture

A good view of the operative field is important for better reduction and fixation in surgical treatment of fractures. The exposure of the ankle joint for the pilon fracture is commonly through the anterior approach, or combined with the medical approach. But sometimes it is still difficult to have complete viewing of the articular surface and to apply internal fixation by that approach. In recent years, we developed a "postero-medio-anterior" approach of the ankle joint by one incision. This approach provides an excellent exposure of the anterior, medial and posterior aspects of the ankle joint with a clear view of the articular surface. In our 45 cases of pilon fracture during 1991 to 1995, there was no incisional injury to the neurovascular bundle. Superficial wound edge necrosis was noted in two cases which healed later without further procedure. Therefore, we recommend this approach as a simple and reliable incision for open reduction of pilon fractures.     

Blunt hepatic injury: minimal intervention is the policy of treatment

BACKGROUND: Many publications recommend nonoperative treatment for stable blunt hepatic injury patients. Unstable hemodynamic status is the only indication for surgery. When operation is indicated, controversies exist regarding which operative procedure will be more beneficial to the patients. The purposes of this study are to compare the results of operative and nonoperative management of patients with blunt hepatic injuries and to identify the optimal surgical approach when surgery is indicated. METHODS: Different prospective protocols of treating adult blunt hepatic injuries were conducted. From 1992 to 1993 (group I), urgent surgery would be performed in the presence of hemoperitoneum. The policy shifted to aggressive nonoperative approach between 1996 and 1997 (group II). The patients from each period were divided into three subgroups. Group A included the patients who received nonoperative treatment in either period. Group B consisted of the patients who received surgery in the first period and nonoperative management in the second period. Group C included the patients who were operated on in either group. Comparisons were made between matched groups. RESULTS: Groups IA and IIA patients had minor injuries and could be successfully treated nonoperatively. The results of groups IB and IIB were similar concerning hospital stay, morbidity, and mortality. Transfusion requirements of group IIB patients were significantly higher (2.2 vs. 1.1 units,p = 0.01) than those of group IB. However, 25 (58%) celiotomies of group IB patients were nontherapeutic. When surgery was indicated, group IC patients had significantly higher liver-related mortality (14 of 49 vs. 3 of 55, p = 0.002). Anatomic resection was performed more frequently in that period. CONCLUSION: Nonoperative treatment significantly decreased the rate of nontherapeutic laparotomy but carried the risks of higher transfusion requirements and delaying operation. When surgery was indicated, the policy of minimal intervention positively affected the patients' outcomes. The goal of surgery should be hemorrhage control rather than resection of the injured liver tissues.     

The relative incidence of anterior cruciate ligament injury in men and women at the United States Naval Academy

The purpose of this study was to evaluate the relative risk of anterior cruciate ligament injury in female versus male midshipmen at the United States Naval Academy. From 1991 to 1997, we recorded the incidence of anterior cruciate ligament injury during intercollegiate athletics, intramural athletics, and military training. The subjects were male and female varsity athletes, coed intramural athletes, and participants in military training consisting of the obstacle course and instructional wrestling. All patient data were collected at the time of injury. Records filed at the intramural sports office, along with a questionnaire completed by coaches and trainers, were used to estimate midshipmen exposures. Results showed that in intercollegiate soccer, basketball, and rugby, women had a relative injury risk of 3.96 compared with men. In coed soccer, basketball, softball, and volleyball, the women's relative injury risk was 1.40 compared with men. In military training, women had a relative injury risk of 9.74 compared with men. In comparing overall annual anterior cruciate ligament injury rates among midshipmen, we found that women had a relative injury risk of 2.44 compared with men. We concluded that female midshipmen have an increased relative risk of anterior cruciate ligament injury as compared with men in intercollegiate athletics, basic military training, and throughout their service academy career. This increase was not statistically significant at the intramural level of athletics.     

Pyometra as a lower abdominal doughnut sign on a Ga-67 scan

A 77-year-old woman was referred for Ga-67 scan to evaluate intermittent fever and chills that had lasted more than 20 days. The Ga-67 whole-body scan revealed a doughnut-shaped Ga-67 accumulation in the lower abdominal region. Combined Ga-67 and Tc-99m MDP bone scan confirmed that this activity was in the uterus, because the shape of the urinary bladder on bone scan was different from that of the Ga-67-avid lesion. Pyometra was proved during operation, and pus culture was performed.     

Influence of the Addition of Dispersible Color Powder and Polyacrylic Emulsion on the Durability of Cement Mortar

Cement mortar can be colored using color additive technology to give colorful facades to the surfaces of buildings, and to beautify the environment. In this study, weight ratios of color powder/cement at 1:80, 1:40, and 1:27, and polyacrylic emulsion/cement at a ratio of 1:5 were added as pigments to cement mortar; the fresh properties, slump, slump flow, hardened properties, compressive strength, flexural strength, ultrasonic pulse velocity, durability, surface electrical resistivity and thermal conductivity of the colored cement mortar were then examined. The results showed that adding color powder/cement at 1:80 and polyacrylic emulsion/cement at 1:5 gives the best water/cement (W/C) ratio, which equals 0.5; this can effectively improve the hardness and durability of colored cement mortar. At 28 days of aging, the strength of the various colored cement mortars was maintained at 33.1–36.8 MPa. The acrylic-based emulsion significantly improved the flexural strength of the specimen. At 91 days of aging, all of the cement mortars exceeded the control group, with an anti-bay strength of 19.9–21.7 MPa, and the strength increased with aging. Adding appropriate amounts of inorganic color powder and mixing water can effectively enhance the fresh and hardened properties and durability of the colored cement mortar, while polyacrylic emulsion may significantly improve the test pieces and flexural strength, which increases with age. Moreover, natural α-Fe₂O₃ (rust layer) is formed on the surface of the colored cement mortar samples through the addition of inorganic color powder that contains Fe(III) ion; this prevents the intrusion of noxious ions and thus increases the durability. All of the test pieces of colored cement mortar in this study had a surface resistance of over 20 kΩ-cm on the seventh day of the test period, meaning good surface compactness. In addition, because the thermal conductivity of the added inorganic color powder was higher than that of cement, the thermal conductivity was significantly improved.