Learning the lessons from conflict: Pre-hospital cervical spine stabilisation following ballistic neck trauma

Background

Current ATLS protocols dictate that spinal precautions should be in place when a casualty has sustained trauma from a significant mechanism of injury likely to damage the cervical spine. In hostile environments, the application of these precautions can place pre-hospital medical teams at considerable personal risk. It may also prevent or delay the identification of airway problems. In today's global threat from terrorism, this hostile environment is no longer restricted to conflict zones. The aim of this study was to ascertain the incidence of cervical spine injury following penetrating ballistic neck trauma in order to evaluate the need for pre-hospital cervical immobilisation in these casualties.

Methods

We retrospectively reviewed the medical records of British military casualties of combat, from Iraq and Afghanistan presenting with a penetrating neck injury during the last 5.5 years. For each patient, the mechanism of injury, neurological state on admission, medical and surgical intervention was recorded.

Results

During the study period, 90 casualties sustained a penetrating neck injury. The mechanism of injury was by explosion in 66 (73%) and from gunshot wounds in 24 (27%). Cervical spine injuries (either cervical spine fracture or cervical spinal cord injury) were present in 20 of the 90 (22%) casualties, but only 6 of these (7%) actually survived to reach hospital. Four of this six subsequently died from injuries within 72 h. Only 1 (1.8%) of the 56 survivors to reach a surgical facility sustained an unstable cervical spine injury that required surgical stabilisation. This patient later died as result of a co-existing head injury.

Conclusions

Penetrating ballistic trauma to the neck is associated with a high mortality rate. Our data suggests that it is very unlikely that penetrating ballistic trauma to the neck will result in an unstable cervical spine in survivors. In a hazardous environment (e.g. shooting incidents or terrorist bombings), the risk/benefit ratio of mandatory spinal immobilisation is unfavourable and may place medical teams at prolonged risk. In addition cervical collars may hide potential life-threatening conditions.     

Biophysical stimulation in osteonecrosis of the femoral head

Osteonecrosis of the femoral head is the endpoint of a disease process that results from insufficient blood flow and bone-tissue necrosis, leading to joint instability, collapse of the femoral head, arthritis of the joint, and total hip replacement. Pain is the most frequent clinical symptom. Both bone tissue and cartilage suffer when osteonecrosis of the femoral head develops. Stimulation with pulsed electromagnetic fields (PEMFs) has been shown to be useful for enhancing bone repair and for exerting a chondroprotective effect on articular cartilage. Two Italian studies on the treatment of avascular necrosis of the femoral head with PEMFs were presented in this review. In the first study, 68 patients suffering from avascular necrosis of the femoral head were treated with PEMFs in combination with core decompression and autologous bone grafts. The second one is a retrospective analysis of the results of treatment with PEMFs of 76 hips in 66 patients with osteonecrosis of the femoral head. In both studies clinical information and diagnostic imaging were collected at the beginning of the treatment and at the time of follow up. Statistical analysis was performed using chi-square test. Both authors hypothesize that the short-term effect of PEMF stimulation may be to protect the articular cartilage from the catabolic effect of inflammation and subchondral bone-marrow edema. The long-term effect of PEMF stimulation may be to promote osteogenic activity at the necrotic area and prevent trabecular fracture and subchondral bone collapse. PEMF stimulation represents an important therapeutic opportunity to resolve the Ficat stage-I or II disease or at least to delay the time until joint replacement becomes necessary.     

Stress Fracture of the Proximal Fibula in Military Recruits

Background

We wanted to report on stress fracture of the proximal fibula and to suggest the pathomechanism of this fracture.

Methods

Between April 2004 through April 2005, the military recruits who complained of leg pain during the 6 weeks basic training in the Republic of Korea Marine Corps education and training group were evaluated according to their clinical manifestations and plain radiographs.

Results

Twelve recruits of 635 recruits who complained leg pain were diagnosed as having fibular stress fracture. Eleven cases (10 recruits) appeared at the junction of the proximal and middle 1/3 of the fibula and 2 cases (2 recruits) were in the middle 1/3 of the fibula, as assessed radiologically. Tenderness was the most reliable clinical manifestation. All the fractures occurred after repetitive walking or jumping in a squatting position. Conservative treatments that included bed rest, immobilization and non-steroidal anti-inflammatory drugs administration according to the symptom severity were satisfactory.

Conclusions

Proximal fibular stress fracture is not rare in military recruits. The shearing force on the proximal fibula and the repetitive stress by walking or jumping in a squatting position contribute to the stress fracture of the proximal fibula.     

Retrograde Intramedullary Nailing for Periprosthetic Supracondylar Fractures of the Femur after Total Knee Arthroplasty

Background

Periprosthetic supracondylar fractures of the femur after total knee arthroplasty are not common but are usually difficult to treat due to the advanced age of patients and frequently accompanying osteoporosis. Retrograde intramedullary nailing can be effective in promoting healing of these fractures by providing sufficient stability, but the number of beneficiaries is small due to its limited applicability and the postoperative function has rarely been assessed. This study evaluated the efficacy of retrograde intramedullary nailing for the treatment of periprosthetic supracondylar fractures of the femur using the clinical outcomes.

Methods

Between January 2000 and May 2006, 9 patients (10 knees) with periprosthetic supracondylar fractures of the femur underwent retrograde intramedullary nailing. An open reduction and additional fixation using a shape memory alloy ring were used in 3 of them in whom a closed reduction was not successful. The clinical and radiographic findings were reviewed retrospectively in 7 patients (8 knees), excluding 2 who were unavailable for a follow-up assessment due to death. The mean follow-up period was 39 months (range, 24 to 82 months). The union and alignment of the fracture were assessed radiographically. The postoperative function was evaluated using Sanders'' criteria.

Results

Radiographic union was obtained in all patients after an average of 13 weeks (range, 12 to 15 weeks) postoperatively. No postoperative infection, heterotopic ossification and component loosening were observed. After union, the coronal alignment averaged 0.1° valgus (range, 3.6° varus to 2.6° valgus) and the mean sagittal alignment was 1.9° of extension (range, 0.9° of flexion to 6.3° of extension). The mean range of motion was 103° (range, 90° to 120°) postoperatively. At the last follow up, there were 1 excellent, 5 good and 2 fair results according to Sanders'' criteria.

Conclusions

With retrograde intramedullary nailing, excellent fracture union and good functional recovery were obtained in patients with periprosthetic supracondylar fractures.     

Subintimal placement of covered stent versus subintimal balloon angioplasty in the treatment of long-segment superficial femoral artery occlusion

Background

Subintimal endovascular intervention has been used widely in the treatment of symptomatic superficial femoral artery (SFA) occlusion. The relative effectiveness of subintimal placement of a covered stent (CS) versus balloon-only subintimal angioplasty (SIA) remains uncertain.

Methods

We performed a retrospective cohort study of consecutive patients with symptomatic SFA occlusions (>15 cm) who underwent subintimal endovascular intervention, either CS or SIA, in a single institution. Primary patency was the primary outcome. Secondary outcomes included complication rates, freedom from re-intervention, and limb salvage rates. Patency was ascertained with followup duplex or clinically.

Results

We evaluated 57 patients in the SIA group and 31 patients in the CS group. At 1 year the SFA primary patency for the SIA and CS groups was 28% versus 75% (P < .001), whereas the primary assisted patency was 37% versus 84% (P < .001), respectively. Need for bypass was 13% versus 0% (P = .05) in the SIA and CS groups, respectively.

Conclusions

Placement of a covered stent improves patency after subintimal intervention for long SFA occlusion.     

Open acute segmental tibial fracture fixation using the Less Invasive Stabilisation System (LISS): Study of 23 consecutive cases

Aim

To evaluate the Less Invasive Stabilisation System (LISS) in the treatment of segmental tibial fractures.

Methods

A prospective series of 23 consecutive open acute segmental tibial fractures were treated with a long LISS plate, in a university hospital. All but three fractures were temporarily fixed with a unilateral external frame. The minimal follow-up was 2 years.

Results

Mean age of the casualties was 34 (17-72) years, all but two were male and all were involved in high-energy accidents, had multiple injuries and open fractures. Of the fractures, 4 were grade IIIA, 16 grade IIIB and 3 grade IIIC. It was possible to span the distal fracture with the LISS plate in 20 cases; of these, 3 developed compartment syndrome. Two people with trifocal fractures required additional distal plates, one of which became loose and infected, resulting in a malunion of 8°. Dermatofasciotomy was performed in 13 cases, in 10 of these as a preventive measure and in 3 because of impending compartment syndrome. In five cases a post-fixation neural palsy of the extensor hallucis longus was observed. All except three fractures healed; mean time for union for the proximal fractures was 16 (10-24) weeks and for the distal fractures was 22 (16-44) weeks.

Conclusion

Use of the LISS plate in fixing these difficult fractures is commended, but immediate fixation should be avoided. A staged sequential procedure with a temporary spanning external fixation and definitive treatment after soft-tissue healing is preferred.     

A double-blind, prospective, randomised, controlled clinical trial of minimally invasive dynamic hip screw fixation of intertrochanteric fractures

Objective

To compare minimally invasive dynamic hip screw (MIDHS) fixation with conventional dynamic hip screw (CDHS) fixation for treatment of intertrochanteric femoral fracture.

Methods

Of the 66 participants in this double-blind study, 35 were randomised to MIDHS and 31 to CDHS fixation. Main outcome measurements were wound size, haemoglobin decrease, blood transfusion rate, pain score, analgesic consumption, Elderly Mobility Scale score, hip screw position, tip-apex distance, union rate, time to healing and complication rate.

Results

The groups had similar preoperative clinical data. Postoperatively the MIDHS group had significantly smaller wound size, less blood loss, lower blood transfusion rates, pain scores and rates of analgesic consumption, and higher early Elderly Mobility Scale scores. There were no significant differences in fracture alignment, hip screw position, tip-apex distance, union rate, time to healing or complication rate.

Conclusion

MIDHS fixation of intertrochanteric fractures is effective and safe and significantly reduces blood loss, pain and rehabilitation period, without sacrificing reduction alignment, screw position, fixation stability or bone healing.     

经尿道电切术治疗女性膀胱颈梗阻12例

目的探讨经尿道电切治疗女性膀胱颈梗阻的疗效。方法对12例女性膀胱梗阻患者行径尿道膀胱颈电切术治疗,年龄51±13岁,病程3个月-5年,尿流率3.8±11.4ml／s,残余尿200-800ml术后随诊6个月以上。结果手术均获成功,手术时间15-50min,平均25min,术中出血〈20ml。12例患者排尿症状评分,最大尿流率平均18ml／s,残余尿均〈50ml。最大尿流率、残余尿量等均较术前显著改善,随访无尿失禁、尿瘘发生。结论经尿道电切术治疗女性膀胱颈梗阻疗效显著,并发症少。     

50例股疝疗效分析

目的评估股疝术后患者发病率和死亡率的影响因素。方法对2005年6月到2008年6月50例股疝修补术后患者进行回顾性分析。手术方法为McVay疝修补术和Lichtenstein无张力疝修补术。研究性别,年龄,修补技术,嵌顿／绞窄的情况,嵌顿／绞窄的器官,术后并发症,住院时间,复发率,影响发病率和死亡率的因素。结果50例股疝患者中,年龄范围23岁至77岁（平均年龄48．74岁）,其中女性患者占72％。20例（40％）患者因嵌顿／绞窄行急诊手术,其中16例疝内容物为大网膜,4例发生小肠绞窄行肠切除。30例（60％）患者行择期手术。所有患者中44例行Lichtenstein无张力疝修补术,6例行McVay疝修补术,1例急诊手术术后伤口感染,无死亡病例,无复发病例。结论股疝容易发生嵌顿／绞窄,对老年患者而言,急诊手术增加手术风险和死亡率,因此股疝患者应尽早手术治疗。