Surgical treatment of trochanteric fractures of the femur]

The authors present the results of studies of etiology of acute group intestinal diseases in neonates from whom escherichia of serological group 0128ac:K67 possessing the following characteristics were isolated: of the same (with the H12 antigen) serological and enzymatic type (nonfermenting sucrose and raffinose, fermenting dulcit and sorbit the first 24 hours, and slowly fermenting ramnose). All the cultures isolated were resistant to the majority of antibiotics used at present, and were only weakly sensitive to erythromycin. Difficulties (agglutination of live cultures with production sera in the absence of low agglutinability of heated cultures) in serological typing of the cultures were due to different partial O-antigen composition of the cultures isolated and of the production strain used in the preparation of commercial sera of the given serological group (0128ab:K67). Because circulation of escherichia of serological 0128ac variant was revealed in the USSR there occurred a necessity of their identification in practical laboratories; for this purpose organization of industrial production of the corresponding serum is necessary.     

Evaluation of the direct cost of trochanteric fractures in the elderly

PURPOSE OF THE STUDY: The cost effectiveness of trochanteric hip fractures in 1995 at Pitié-Salpétrière Hospital in Paris has been thoroughly analysed. The aim of this retrospective study was to identify the factors responsible for the variation in the treatment cost of those fractures. MATERIAL AND METHODS: Cost, Hospital stay, functional status, ASA score, mental status and surgical treatment were analysed in 74 patients aged over 60 years old. RESULTS: The mean cost per patient was 23,901 FF divided as follows: 8.5 per cent for preoperative care, 40.5 per cent for surgical procedures, 51 per cent for post-operative care. The mean hospital stay was 18 days. The cost of hospital personnel (44 per cent) and medical materiel (26 per cent) were the two main sources of hospital expenses beside medical investigations (11 per cent), hostelry (8 per cent), blood transfusion (6 per cent) and drugs (5 per cent). DISCUSSION: The duration of hospital stay was the only factor that affected statistically the mean cost per patient. Furthermore, factors related to the patient as age, sex, place of residence prior to admission, functional status, ASA score, mental status, had no influence on cost variation. CONCLUSION: Therefore, the best way to reduce the cost of trochanteric fractures treatment is to develop convalescence structures to avoid a lengthy and costly hospital stay and to minimize the abuse utilization of medical materials.     

The treatment of middle-aged and elderly patients suffering from trochanteric fractures of the femur

Treatment of 198 elderly patients with trochanteric fractures included different conservative and operative therapy methods. For the first time in Russia a new approach of extrafocus osteosynthesis was recommended for "decompensated" patients. It is proved, that for this category of the injured, active surgery tactics results in a considerable improvement of treatment outcome.     

Therapeutic management of hypercholesterolemia

FUNDAMENTAL PRINCIPLES: Therapeutic management of hypercholesterolemia requires information on two fundamental aspects: the patient's lipid profile and his/her risk of coronary artery disease. RISK EVALUATION: The latest therapeutic trials have partially confirmed the LDL-cholesterol levels retained for the different guidelines, including those proposed by the ANDEM. It is clear however, that the assessment of the individual beneficial effect of primary prevention must be based on a multifactorial evaluation of risk. But there is no standardization of methodologies currently used to evaluate risk. Briefly, these methodologies use mathematical equations deducted from statistical models or noninvasive quantification of preclinical atherosclerosis. PERSPECTIVES: In the future, this strategy based on quantification of cardiovascular risk should be evaluated in a prospective study.     

Clinical management of crown fractures

Contemporary treatment of uncomplicated and complicated crown fractures is presented in this article. New concepts and approaches are discussed in relation to modern research and new restorative materials. Practical suggestions for the recognition and clinical management of various types of crown fractures are described.     

Nurse-aid management of fractures: 1

Fractures occur in the bones of any age group, even the newborn, and are caused in any number of different ways. This article is the first in a three-part series that will examine the causes and types of fractures, the symptoms and presenting factors, nurse-aid intervention and the healing process.     

Pneumonia and pleural effusion. Therapeutic management

The pleural effusion with pneumonia is a common complication. Early diagnosis and adequate handling are required, being based fundamentally on the characteristics of pleural liquid. Antibiotic therapy and pleural drainage are, in most cases, the main basis for very best outcome. Un specific circumstances administration of intrapleural fibrinolysis is increased, giving up surgery for those difficult cases which are not resolved with the previous treatment. The clinical case and the therapeutical different choices are revised, and finally a guideline that helps to the best management of parapneumonic effusion, is suggested.     

Anterior instrumentation in the management of thoracolumbar burst fractures

Anterior instrumentation in the treatment of thoracolumbar fractures has progressed significantly during the past 2 decades. These fixation systems have evolved to meet the anatomic, biomechanical, and imaging challenges associated with internal fixation of the thoracolumbar spine. The evolution of these devices will be reviewed, and from this, the indications and surgical techniques necessary for the safe and effective use of the device will be discussed. This study also reports the authors' initial clinical experience using the Z plate anterior thoracolumbar plating system in the treatment of thoracolumbar burst fractures. The study consists of 12 consecutive adult patients who underwent a 1-stage anterolateral decompressive and stabilization procedure for burst fractures from T9-L3. The indications for surgery included neurologic deficits, deformity, progressive kyphosis, and late pain. Ten of the 12 patients maintained their postoperative sagittal alignment or a significant portion of their kyphosis reduction. Two patients with severe kyphotic deformities greater than 50 degrees lost 10 degrees and 20 degrees of their reduction at last followup. All 3 patients with neurologic deficits recovered. There were no neurologic or perioperative complications. Eleven of the 12 patients obtained a good or excellent functional outcome. Anterior arthrodesis using instrumentation stabilization after a 1-stage anterolateral decompression and reduction procedure can yield successful clinical results in the treatment of thoracolumbar burst fractures.     

Portable fluoroscopy in the management of zygomatic arch fractures

There is no "gold standard" for diagnosing thoracic outlet compression syndrome (TOS), however, anesthetic blocks of the anterior scalene muscle (ASM) have been used as a means of predicting which patients may benefit from surgical decompression. The standard technique of using surface landmarks often results in inadvertent somatic block and sympathetic block because there is no reliable verification of needle tip localization. The present study was undertaken to determine if needle tip localization can be improved by using electrophysiological guidance. ASM blocks were performed for patients with a diagnosis of possible TOS. An insulated hypodermic needle was inserted into the ASM which was identified during electromyogram (EMG) activation maneuvers. Stimulation was performed to make sure that the needle tip was not in the brachial plexus. Local anesthetic was instilled and the intensity of pain induced by TOS stress maneuvers was compared to pain ratings obtained after control injections. The ASM could be identified electromyographically in all 122 cases. There were no instances of inadvertent somatic block nor sympathetic block. Of 38 patients who underwent surgical decompression of the thoracic outlet, 30 of 32 (94%) with a positive block had a good outcome compared with 3 of 6 (50%) who underwent surgery in spite of a negative block. Electrophysiological guidance facilitates accurate needle tip placement in the performance of ASM blocks; the results of these blocks appear to correlate with surgical outcomes.     

Monocondylar fractures of the femur. Therapeutic strategy and clinical outcome]

Two groups of 3 120-160-kg Holstein steers were fed a diet high in carbohydrate and low in long fiber and either with or without added sodium sulfate. Prior to and during the course of feeding the experimental diet, the concentrations of rumen hydrogen sulfide gas and rumen fluid sulfide were determined by a simple sulfide detector tube method and by sulfide-selective electrode, respectively. Other measurements included rumen fluid pH, blood creatine kinase, and blood sulfhemoglobin. Two of the 3 steers fed the high-sulfate diet developed signs and lesions of polioencephalomalacia. Clinical signs included episodic ataxia and blunted or absent menace reaction. Increased ruminal H2S gas concentrations occurred in all 3 steers consuming the diet with added sulfate. The onset of clinical signs coincided with the onset of elevated H2S concentrations. These increases were 40-60 times the values measured in the steers consuming the diet without added sulfate. In contrast, increases in rumen fluid sulfide concentrations usually rose to 4 times that of control steers. The steers fed an identical diet but without added sulfate exhibited no signs or lesions of polioencephalomalacia and no elevations of sulfide in rumen gas or fluid. All steers had a modest decrease in rumen fluid pH associated with the transition to the concentrate diet. No significant changes were observed in any of the blood measurements of any of the steers. An additional pair of steers was fed the experimental diet with or without added sulfate to compare the ruminal H2S gas concentrations estimated by H2S detector tubes with those estimated by a different method of analysis utilizing charcoal trapping of H2S, conversion to sulfate, and measurement of the sulfate. Both methods yielded comparable estimates of H2S concentration. Overall, these data indicate that changes in rumen gas cap H2S concentrations are larger than changes in rumen fluid sulfide concentration and the estimation of rumen gas cap H2S concentration may be a practical approach to detecting pathologic increases in ruminal H2S gas. This simple, rapid, minimally invasive method should be useful for estimating the H2S content of ruminal gas under field conditions.     

Therapeutic benefit of touch-massage in the overall management of demented elderly

This detailed research tries out a "Touch-Massage" action about the studies of reflex and estimates the repercussion this action may have as regards the abnormal behaviour (either in connection with wandering and/or restlessness and/or shouting) of the Elderly who stay in a same place and show cognitive deficiency in connection with an Alzheimer's dementia. In order to check the "intra personal" consequences this action may have, 4 elderly people were chosen and an experimental estimate with different levels was made with them. Two sessions a week of 30 minutes each during 6 months (51 sessions) were suggested that is to say a total of 204 sessions. The effects of this approach regarding the different abnormal behaviour are estimated on one hand from a special clinical grid which assess the different reactions, verbal or not, which occurred during the session. On the other hand the effects are observed directly fifteen minutes after the session. The results are explained, first, for each person and compared between each other; then they are explained according to a collective way regarding the 4 old people. What emerges from all that is that for the whole sessions which were proposed, the activity was accepted at 95%. During the session, the signs showing physical relaxation (59%), sleepiness (34%), research of different manners to communicate with us (59%), stop or decrease of the abnormal behaviour (79%) prove the actual benefit the activity brings during thirty minutes. Fifteen minutes after the session, the signs showing physical relaxation (52%), sleepiness (42%), research of different manners to communicate with us (23%), stop or decrease of the abnormal behaviour (70%) are always significant. In view of the above results, we can stay this new approach using the activity of "Touch Massage" brings a further possibility of nursing care and can help to answer the question "how to take in charge every day an elderly demented patient".     

Editorial: Therapeutic management of the intermediate syndrome]

The ability of antibiotics to inhibit acetylcholinesterase was measured in homogenates of goldfish brain. Puromycin aminonucleoside was the most potent inhibitor followed by puromycin, cycloheximide and acetoxycycloheximide. Puromycin effectively impaired retention of active-avoidance learning in goldfish when injected either immediately before or after training, while puromycin aminonucleoside did not regardless of injection time. These results suggest that the known amnestic effects of puromycin, cycloheximide and acetoxycycloheximide are not a consequence of interference with acetylcholinesterase.     

An algorithm for the management of femoral neck fractures

The choice of total hip arthroplasty should probably be reserved for those rare patients with preexisting osteoarthritis of the hip in the setting of a subcapital hip fracture. Additionally, relative indications for total hip arthroplasty may include the presence of contralateral hip disease; the presence of metabolic bone disease, which may controvert internal fixation or reasonable results with endoprosthetic replacement; and those patients with high activity expectations or life expectancy greater than 5 years. Given the diminished performance of hemiarthroplasty with time and activity, it may be argued that the most cost effective solution to the subcapital hip fracture in the majority of patients may be the reduction and internal fixation pathway, with elective conversion, when necessary, of the approximately 25% of patients who suffer avascular necrosis to total hip arthroplasty. It appears that hemiarthroplasty is best suited for the elderly household ambulator, whereas total hip arthroplasty is the better alternative either as the elective solution to failed internal fixation of femoral neck fractures or in the occasional community ambulator with high activity expectations and irreducible femoral neck fractures. Younger patients, and those with minimally displaced fractures, should be treated with internal fixation in an attempt to preserve the natural hip joint.     

Assessment and management of three-and four-part proximal humeral fractures

Three-and four-part comminuted fractures of the proximal humerus are difficult and technically demanding to treat. The various treatment methods reported in the literature are reviewed. It is recommended that three-part fractures be treated with open reduction and internal fixation. Four-part fractures in the younger, active patient also can be treated successfully with open reduction and internal fixation. However, in the elderly and in the patient with osteoporosis, a hemiarthroplasty is the treatment of choice. There is a need for universal agreement on a scoring system for measuring outcome in these fractures to allow a meaningful comparison between reported treatment methods.     

The role of local antibiotic therapy in the management of compound fractures

Seven hundred four compound fractures (198 [28%] Grade I, 259 [37%] Grade II, and 247 [35%] Grade III) were treated during a seven-year period at the author's institution. One hundred fifty-seven open fractures (22%) (Group A) received systemic antibiotic prophylaxis only, whereas 547 compound fractures (78%) (Group B) were treated with local application of antibiotic beads (tobramycin) in addition to prophylaxis. Fracture grades, age, gender, fracture location, and length of follow-up period were not significantly different between the two groups. All fractures underwent timely irrigation, debridement, and skeletal stabilization. Forty-nine of 704 compound fractures (7%) developed an infection (acute wound infection or chronic osteomyelitis or both). Group A showed an infection rate of 17% (26/157); treatment in Group B resulted in 23 compound fracture infections (4.2%). The difference in the incidence of infection was statistically significant. Comparison of the infection rates in either wound infection or chronic osteomyelitis showed a trend toward decreased rates in Group B versus Group A throughout all fracture grades. However, by subdivision into the fracture grades, only the IIIB types had a statistically significant decrease of infection in Group B versus Group A; the wound infection rate was 39% (9/23) in Group A and 7.3% (7/96) in Group B. The rate of chronic osteomyelitis was 26% (6/23) in Group A and 6.3% (6/96) in Group B. Prophylactic use of antibiotic-laden PMMA beads in addition to systemic antibiotics was of benefit in preventing infectious complications in compound fractures, in particular in Type IIIB open fractures.     

The management of segmental bone loss associated with forearm fractures

Eighteen fractures of one or both bones of the forearm, including fourteen with segmental defects, were treated with an interposed corticocancellous iliac-bone graft. A plate and screws were used to fix the fracture fragments and graft. The technique allowed early motion of the extremity. Good results were achieved in all but six of the patients. The one poor result with non-union and five others with limited motion were related primarily to infection.