Although it is widely accepted that grade IIIB open tibial fractures require combined specialised orthopaedic and plastic surgery, the majority of patients in the UK initially present to local hospitals without access to specialised trauma facilities. The aim of this study was to compare the outcome of patients presenting directly to a specialist centre (primary group) with that of patients initially managed at local centres (tertiary group). We reviewed 73 consecutive grade IIIB open tibial shaft fractures with a mean follow-up of 14 months (8 to 48). There were 26 fractures in the primary and 47 in the tertiary group. The initial skeletal fixation required revision in 22 (47%) of the tertiary patients. Although there was no statistically-significant relationship between flap timing and flap failure, all the failures (6 of 63; 9.5%) occurred in the tertiary group. The overall mean time to union of 28 weeks was not influenced by the type of skeletal fixation. Deep infection occurred in 8.5% of patients, but there were no persistently infected fractures. The infection rate was not increased in those patients debrided more than six hours after injury. The limb salvage rate was 93%. The mean limb functional score was 74% of that of the normal limb. At review, 67% of patients had returned to employment, with a further 10% considering a return after rehabilitation. The times to union, infection rates and Enneking limb reconstruction scores were not statistically different between the primary and tertiary groups. The increased complications and revision surgery encountered in the tertiary group suggest that severe open tibial fractures should be referred directly to specialist centres for simultaneous combined management by orthopaedic and plastic surgeons.

Rapid prototype models are directly integrated into nonengineering applications such as medicine. Medical models are used to plan complex procedures prior to surgery with potential to optimise patient treatment in the operating theatre. This paper presents results following a 12 month National Health Service Executive research project to assess the feasibility of using rapid prototype medical models. A total of 16 medical models were created. Nine anatomical sites were reconstructed from patient data acquired from five London hospitals. The purpose of the models is described and the commissioning surgeons as part of a questionnaire assessed their usefulness. Future developments are discussed and conclusions about the use of medical models are made.

This study demonstrates that a systemised trauma network combined with evidence based practice can lead to improvements in patient care.

A prospective randomized trial was undertaken to compare the influence of absorbable and non-absorbable sutures on pillar pain, scar tenderness, extent of wound inflammation and overall outcome of the surgery following open carpal tunnel release. Forty hands in 33 patients (mean age, 51 years; range, 31-74 years) were randomized into group A (absorbable sutures) or group B (non-absorbable sutures). Clinical assessment was done at 2, 6 and 12 weeks follow-up. The outcome of surgery in terms of improvement of severity of symptoms and functional status of patients was assessed using a self-administered Boston Questionnaire. There was no significant difference between the two groups for any of our outcome measures at the final follow-up.

Although scoliosis found in the orangutan has features similar to idiopathic scoliosis, there also are some dissimilar features, making this diagnosis unlikely. The features observed in this spine suggest that erect posture is important in the morphology of human idiopathic scoliosis.