Distal radius and ulna fractures are the most common fractures seen in England, occurring at a rate of 22/10,000 person years. Kirschner (K)-wire fixation is a well-accepted method of treating these fractures. There is a surprising paucity of evidence on the subject of prophylactic antibiotics and the duration of K wires can be left in, as these relate to infection rates. We therefore present the results of our protocol for distal radius K-wire fixation for which: no antibiotic prophylaxis was given; we used a percutaneous (not buried) technique, where the K wires were removed after 4 weeks, and the patient has a total of 6 weeks in cast (last 2 wk without wires). The results of the last 100 consecutive patients who were treated with manipulation and K wiring of dorsally displaced distal radial fractures in a standard district general hospital over a 2-year period were analyzed retrospectively. A total of 100 patients had 176 K wires inserted. The mean age was 32.5 years. The mean time to pin removal was 29.4 days. The infection rate was 2%. These results illustrate a safe and clinically effective protocol for K-wire fixation in treating distal radius fractures. On the basis of this study, we do not advocate the use of prophylactic antibiotics, postulating that they do not affect infection rate and thereby eliminating potential antibiotic adverse effects. Furthermore, we do not bury the K wires, which allows for their removal in clinic, thus preventing risks of further operative procedures.
Objective To compare the intelligence and grip strength of orthopaedic surgeons and anaesthetists.
BackgroundVenous Thrombo-embolic disease is currently a hot topic especially in the UK. 25,000 patients per year die of Pulmonary Emboli (PE) in the United Kingdom (UK). Hip and knee arthroplasty surgery is associated with an increased rate of deep vein thrombosis (DVT) and pulmonary embolus (PE). The National Institute for Clinical Excellence (NICE) guidelines introduced in January 2010 recommended use of subcutaneous heparin or an oral anticoagulant (Dabigatran or Rivaroxiban) for 10-14 days post knee and 28-35 days post hip arthroplasty. In our unit we were keen on the advantages of an oral anticoagulant post arthroplasty in terms of patient compliance, and avoiding the need for self administered injection in the community.MethodsWe analysed all the notes, blood results and imaging of patients undergoing total hip or knee arthroplasty and present 1 year’s data using a regime of subcutaneous Dalteparin whilst an inpatient, followed by discharge on oral Dabigatran at a low dose (150 mg once daily).ResultsThere were 337 patients over 1 year with hip and knee arthroplasty, with a 1.19% rate of DVT with no PEs and 1 death due to an unrelated cause. There was a transfusion rate of 11.57% with 1.19% patients taken back to theatre for evacuation of haematomas. There were no reported adverse effects of Dabigatran.ConclusionOur treatment protocol is a novel practical approach for VTE prophylaxis in hip and knee replacement patients. This approach shows promising data but no definitive evidence to warrant wide-spread use of this new regime. This data can act as a foundation for larger randomised clinical trials.
We present, to our knowledge, the first reported case of necrotizing fasciitis following insertion of a cardiac permanent pacemaker (PPM).A 91-year-old gentleman was admitted with septic shock under the medical team. He had had a cardiac PPM inserted 10 days prior for complete heart block. He was initially treated by the GP for a postoperative superficial infection with a course of oral antibiotics at home but over the next few days he became systemically unwell. Preadmission, this patient was independent, living with his wife and had no other significant past medical history apart from the heart block.On admission he had suffered a ventricular tachycardia-related cardiac arrest and had been successfully resuscitated. He was subsequently managed in the coronary care unit (CCU) with a diagnosis of systemic sepsis from an infected pacemaker.While in CCU his condition deteriorated and he developed acute renal failure. It was noted that the cellulitis was becoming increasingly widespread around the pacemaker site, and was not responding to the intravenous antibiotics. There was an extremely high suspicion of necrotizing fasciitis, and the plastic surgeons were contacted for a review. The same day, he was expeditiously taken to theatre by the plastic surgical team.Perioperative findings included the presence of murky fluid, oedema of the subcutaneous tissue and necrotic muscle around the pacemaker. This gentleman then underwent a radical debridement of the infected tissues. The infected pacemaker was removed and the patient temporarily externally paced.Microbiology revealed the causative organisms to be Staphylococcus capitis, Streptococcus salivarius and Staphlococcus aureus. The histology from the samples gathered at the time of the procedure was consistent with a diagnosis of necrotizing fasciitis.Following treatment in the intensive care unit, the open chest wound was closed with a split thickness skin graft, five days post-debridement. He had re-implantation of a new PPM on the contralateral (right) side two days later.
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