Purpose of the study: Wounds of the calcaneal tendon are common, but less well documented compared with tears of the same tendon. We performed a retrospective analysis of the epidemiological, therapeutic and prognostic features of this injury. Material and method: The series included 70 patients collected from 1992 to 2002; 56 male and 14 female. Mean age was 22 years (range 4–70 years). The right ankle was involved in 42 cases. Causes were broken glass injury (44%), automobile accidents (22%), aggressions (18%) and motorcycle wheel injuries (10%). Results: The diagnosis was obvious at admission. A surgical exploration was systematic to determine the partial or complete nature of the injury. Surgical treatment involved tendon repair with a cage or frame in 65 patients. A plantar plasty was needed in three patients. Bosworth tendinoplasty was performed in two other patients. The three cases with skin loss were treated by directed wound healing (n=2) and MacFarlane flap (n=1). Postoperative complications were: infection (n=11) and functional (n=10, shoe conflict). The scar remained disgraceful in 20 patients. Outcome was good or very good according to the Schmitt criteria in 92% of patients. Discussion: Wounds of the calcaneal tendon are common, and are generally observed in young male patients. The diagnosis is clinical. The goal of treatment, either by simple suture or by pasty, is to restore normal ankle function. Because of the risk of infection, as well as the risk of a poorly healed scar preventing proper use of shoes, any surgical procedure must be as minimally traumatic as possible and performed under rigorous conditions. Adequate immobilisation and rehabilitation are required for good outcome. The prognosis is generally good

Aim. Persistent wound drainage has been recognized as one of the major risk factors of periprosthetic joint infection (PJI). Currently, there is no consensus on the management protocol for patients who develop wound drainage after total joint arthroplasty (TJA). The objective of our study was to describe a multimodal protocol for managing draining wounds after TJA and assess the outcomes. Methods. We conducted a retrospective study of 4,873 primary TJAs performed between 2008 and 2015. Using an institutional database, patients with persistent wound drainage (>48 hours) were identified. A review of the medical records was then performed to confirm persistent drainage. Draining wounds were first managed by instituting local wound care measures. In patients that drainage persisted over 7 days, a superficial irrigation and debridement (I&D) was performed if the fascia was intact, and if the fascia was not intact modular parts were exchanged. TJAs that underwent subsequent I&D, revision surgery, or developed PJI within one year were identified. Results. Draining wounds were identified in 6.2% (302/4,873) of all TJAs. Overall, 65% (196/302) of patients with draining wounds did not require any surgical procedures. Of the patients with persistent drainage, 9.8% underwent I&D, 25.0% underwent revision arthroplasty. Moreover, 15.9% of these patients developed PJI within one year. Compared to those without wound drainage, TJAs complicated by wound drainage demonstrated an odds ratio of 16.9 (95% CI: 9.1–31.6) for developing PJI, and 18.0 (95% CI: 11.3–28.7) for undergoing subsequent surgery. Conclusions. Wound drainage after TJA is a major risk factor for subsequent PJI and its proper management has paramount importance. Our results demonstrated that drainage ceased spontaneously in 65% of the patients with local wound care measures alone. Wounds with persistent drainage were at substantially higher risk for PJI than those that healed uneventfully

Carpal tunnel decompression is one of the most commonly performed orthopaedic operations. Last year 160 patients attended our department for surgery. There have been reports in the literature of good results and improved patient satisfaction for wound closure with Vicryl Rapide following Dupuytren's surgery. We looked at 200 consecutive patients who underwent carpal tunnel decompression. Wounds were closed using either non-absorbable monofilament sutures (first 97 patients) or interrupted Vicryl Rapide (next 103 patients). We compared the incidence of wound problems in the early post operative period, scar sensitivity and the number of patients requiring a further outpatient appointment because of ongoing problems associated with these issues. There was a higher incidence of early wound problems (p=0.0359) in patients whose wounds were closed with nylon. There was no difference in the rates of scar tenderness (p=1) or in the number of patients requiring further clinic appointments (p=0.356). There are also potential cost savings in using absorbable sutures as they require fewer sundry items at the dressings clinic. In conclusion there were fewer problems associated with wound closure with interrupted Vicryl Rapide sutures than with nylon in patients undergoing carpal tunnel decompression

Introduction

Diabetic foot disease is a major public health problem with an annual NHS expenditure in excess of £1 billion. Infection increases risk of major amputation fivefold. Due to the polymicrobial nature of diabetic foot infections, it is often difficult to isolate the correct organism with conventional culture techniques, to deliver appropriate narrow spectrum antibiotics. Rapid DNA-based technology using multi-channel arrays presents a quicker alternative and has previously been used effectively in intensive care and respiratory medicine.

We present the first systematic review conducted by the UK Defence Medical Services in conjunction with the Cochrane Collaboration. Irrigation fluids are used to remove contamination during the surgical treatment of traumatic wounds in order to prevent infection. This review aims to determine whether there is evidence that one wound irrigation fluid is superior to another at reducing infection. A pre-published methodology was used and two reviewers independently assessed the search results. The search produced 917 studies, of which three met the inclusion criteria. All were studies in open fractures, incorporating a total of 2,903 patients. Each RCT involved a distinct comparison, precluding meta-analysis: i) sterile saline vs. distilled/boiled water; ii) antibiotic solution vs. soap solution; iii) saline vs. soap solution. The odds ratios of infection following irrigation with various fluids was as follows: i) saline vs. distilled or boiled water 0.25 (95%CI 0.08–0.73); ii) antibiotic solution vs. soap 1.42 (95%CI 0.82–2.46); iii) saline vs. soap solution 1.00 (95%CI 0.80–1.26). These results suggest that neither soap nor antibiotic solution is superior to saline and that saline is inferior to distilled or boiled water.

1. Six cases of infection of wounds with actinomyces are described alld tile cultural characteristics of tile organisms are discussed.

2. In three patients the infecting organism was an unusual aerobic form.

3. Possible sources of infection are considered.

4. The chronicity of the condition and the difficulty in treatment are stressed.

5. Penicillin and X-radiation hold out most hope of cure.

Purpose: Nail punctures of the foot initially appear deceptively mild. Most reported series relate to injuries in children mostly complicated by pseudomonas infection. The study aimed at reviewing our experience of managing plantar puncture injuries.

Methods and Patients: The medical charts of 350 patients treated and followed between 1995 and 2000 were reviewed. Data collected included wound classification according to Alson, wound location, management, isolated pathogens, and complications.

Results: 151 patients had superficial wounds (Alson I) treated with oral antibiotics. Of the 199 patients who were admitted (Alson II– IV), 74% were construction workers, average age was 24.5 years, 35% presented within 24 hours after injury, 68% of wounds were located at forefoot (23% and 21% at first and second MTPJs areas respectively), 21% were in midfoot, and 11% in hindfoot. 44% were treated with intravenous antibiotics, 30% had plantar incision and drainage, 14% had plantar and dorsal incision and drainage, and in 12% arthrotomy or bone debridement were also needed. Different pathogens were isolated mainly staphylococcus (36%). Retained foreign bodies were identified in 14 cases. Septic arthritis and osteomyelitis developed in 11% and 4% of cases respectively.

Conclusions: Adult and children puncture injuries seem to behave differently, including risk for complications, and bacteriology. Clinical vigilance and early treatment are crucial. Forefoot injuries occur at the heel-off stage of the stance phase, and the nail is pushed with a high ground reaction force. The injury is therefore deeper, usually involving an MTPJ space and consequently more liable to complications.

Despite long-standing dogma, a clear relationship between the timing of surgical irrigation and the development of subsequent deep infection has not been established in the literature. Traditionally, irrigation of an open fracture has been recommended within six-hours of injury based on animal studies from the 1970s, however the clinical basis for this remains unclear. Using data from a multi-centre randomized controlled trial of 2,447 open fracture patients, the primary objective of this secondary analysis is to determine if a relationship exists between timing of wound irrigation (within six hours of injury versus beyond six hours) and subsequent reoperation rate for infection or healing complications within one year for patients with open extremity fractures requiring surgical treatment.

To adjust for the influence of patient and injury characteristics on the timing of irrigation, a propensity score was developed from the data set. Propensity-adjusted regression allowed for a matched cohort analysis within the study population to determine if early irrigation put patients independently at risk for reoperation, while controlling for confounding factors. Results were reported as odds ratios (ORs), 95% Confidence Intervals (CIs), and p-values. All analyses were conducted using STATA 14 (StataCorp LP, College Station, TX, USA).

Two thousand, two hundred eighty-six of 2,447 patients randomized to the trial from 41 orthopaedic trauma centers across five countries had complete data regarding time to irrigation. Prior to matching, the patients managed with early irrigation had a higher proportion requiring reoperation for infection or healing complications (17% versus 12.8%, p=0.02), however this does not account for selection bias of more severe injuries preferentially being treated earlier. After the propensity score-matching algorithm was applied, there were 373 matched pairs of patients available for comparison. In the matched cohort, reoperation rates did not differ between early and late groups (16.1% vs 16.6%, p=0.84). When accounting for propensity matching in a logistic regression analysis, early irrigation was not associated with reoperation (OR 0.93, 95% CI 0.62 to 1.40, p=0.73).

When accounting for other variables, late irrigation does not independently increase risk of reoperation.

1. In the first 1600 of the series of peripheral nerve injuries treated during the years 1940-45 at the Peripheral Nerve Injuries Unit, Oxford, 52 per cent. were due to penetrating wounds, and 6 per cent. of these involved the brachial plexus.

2. A specific method of grouping and grading recovery is described: Group I—lesions of the roots and trunk of C.5, 6; Group II—lesions of the posterior cord; Group III—lesions of C.8, T.1, and the medial cord.

3. The recovery of cases in Group I was good, in Group II fair, and in Group III poor.

4. The brachial plexus was explored on twenty-two occasions. Only in four instances was there interruption of continuity—which is in striking contrast with the frequency in more distal degenerative nerve lesions in open wounds.

5. There is no evidence to suggest that neurolysis influenced motor or sensory recovery, but on one occasion it relieved persistent pain in the limb. In general the correlation between operative findings and prognosis was not precise.

6. With one exception, no recovery of consequence took place in the small muscles of the hand after a lesion in continuity, although galvanic stimulation to all paralysed muscles had been given regularly.

7. There is evidence to suggest that innervation of the biceps may not always be limited to C.5 and 6 and that in a proportion of cases C.7 may make a substantial contribution.

8. In five cases (12 per cent.) Horner's syndrome was present; the causation is discussed.

9. In every case of damage to a main vessel there was a marked tendency to joint stiffness, particularly in the hand, but on one occasion only was there evidence of ischaemic changes in the muscles and nerves.

10. The good spontaneous recovery which occurred in Groups I and II; the poor recovery in Group III even in cases where there was an apparently favourable lesion in continuity; the rarity with which division of nerves was found at operation; and the discouraging results of repair in three cases; make it necessary to conclude that routine exploration of open wounds of the brachial plexus is neither profitable nor justifiable.

A patient with a chronic discharging sinus or an extensive adherent scar is never safe from the risk of malignant change. Examples are still occurring more than thirty years after the end of the first world war. The possibility should be kept in mind by those concerned with the long-term treatment of wounds of this kind. Reasonable prophylactic measures would be: excision of adherent or unstable scars with, if necessary, their replacement by suitable pedicle flaps having a good blood supply; and earlier amputation if a osteomyelitic sinus persists for several years and does not yield to treatment. Supervision of doubtful cases should be frequent and should not be relaxed with the passage of the years. Warty changes or indolent ulceration of scars should be regarded with grave suspicion and investigated by biopsy. Any increase in pain or discharge in association with a sinus should receive prompt attention. Finally, if malignant change supervenes, treatment should be as speedy and as radical as with any other cancer. At least thirteen of our twenty-four patients have died of cancer.

We reviewed ninety-three civilian transpelvic gunshot wounds from 1998 to date. The patients were all recruited through our Trauma Unit. The first sixty were seen on a referral basis, yet for the subsequent patients we were informed on admission. Based on our earlier findings we promoted bullet tract washout, bullet removal when passed through hollow viscus, rectal stump washout and early removal of juxta-articular bullets. We review the nature of associated injuries and outcomes in relation to osteitis, osteoarthritis, nerve injuries and vascular injuries.

Fifty-seven patients had an entry wound in the buttock. This is associated with a high incidence of sciatic nerve damage (14%), extra peritoneal rectal injury (21%), juxta-articular bullets (73%) and osteitis (12%). There were fifty patients with hollow viscus injuries in various combinations. Thirteen patients overall developed osteitis (14%), of these twelve had hollow viscus injuries. Of these extra-peritoneal rectal injuries carry the highest proportion of osteitis (33%) as a complication, followed by colonic injuries (25%) and bladder (21%). Small bowel injuries (29) were not associated with any osteitis.

Peri and intra-articular injuries were grouped together totalling fifty-nine. Seven of these developed osteitis, leading to secondary osteoarthritis in all. The sciatic nerve was damaged in nine patients, and only three recovered fully. There were two femoral nerve injuries with no significant sequelae. In extra-peritoneal rectal injuries those who had early rectal stump wash-out (5/12) did not develop osteitis and yet of those not washed (5/12) three developed osteitis (60%). Tract washout has similar results. Of bullets that passed through a hollow viscus and were removed late 45% (8/18) were infected.

Our preliminary results suggest that all missile tracts should be washed out and debrided, that all bullets traversing a hollow viscus should be removed, that all peri-articular bullets be removed, and that the rectal stump be washed out in extra-peritoneal rectal injuries.

Between June 1998 and April 2006, 93 patients with trans-pelvic gunshot injuries were admitted to our hospital. Initially the management was done by general surgeons, without any orthopaedic consultation. Later a good working relationship between general surgeons and orthopaedic surgeons developed, and good co-operation was achieved.

We felt it was important to determine the direction of the bullet tract. A detailed history was taken to try and position the assailant, and the action taken by the victim. We tried to establish the number of shots that were fired, and whether any pervious gunshot injury had been sustained. We then drew an imaginary straight line between the entry and exit wound, in order to try and determine the anatomical structures that were likely to be injured by the bullet.

When x-rays were not helpful in identifying the bony injury, then a CT scan with 3D reconstruction was performed. Contrast studies such as a sinogram, a cystogram and intravenous pyelogram, combined with contrast CT, was also helpful in determining the bullet tract.

At laparotomy the entire bullet tract has to be debrided. All injured viscera are repaired, and the abdominal cavity thoroughly washed out. Any extra-peritoneal rectal injury requires a proximal colostomy, and rectal stump washout. All bullets lodged near or into a joint must be removed early, within 4 days of injury. We feel that using antibiotics alone for contaminated bullet tracts, without debriding the tract and removing the bullet from bone, does not prevent sepsis.

Purpose of the study: Unlike thoracic and abdominal stab wounds, little has been reported about blade wounds to the forearm. We report a serie of machete wounds to the forearm treated in the Caribbean island Martinique, between 1997 and 2004.

Material and methods: This study included 14 open fractures of the forearm caused by machete wounds. This retrospective analysis was based on the patient files. We studied the mechanism of the fracture, the type and level of the fractures, the associated lesions, the type of treatment given, and complications observed.

Results: Mean follow-up was seven months. Among the 14 patients studied, 14 presented an ulnar fracture, and five a radial fracture. Five patients suffered a complete amputation of the hand. Ten patients (71%) also had associated tendon injuries, all on the ulnar side. Three associated vascular injuries were noted (21%), two on the ulnar side. There were four nerve lesions (29%) involving the ulnar nerve alone (n=2),the ulnar and medial nerves (n=1) or all of the nerve trunks (n=1). The fractures involved the distal third of the forearm in nine patients (64%) and were comminutive for ten (71%). A complete fracture was noted in twelve patients (86%) with a partial fracture in two. Osteosynthesis was performed in all cases. There were nine complications: early infection (n=2, due to late referral), stiff joints (n=6, 43% including tendon retraction in five), nonunion (n=2, one repeated case) and one late healing at one year. Motor and sensorial sequelae were observed at last follow-up in all patients with an initial nervous lesion.

Discussion: The mean follow-up in our patients was short because of the specific context (homelessness, drug addiction). Most of our patients refused medical follow-up. The strong predominance of bony or soft tissue injuries observed on the ulnar side of the forearm corresponds to the mechanism of defense used by the victims. Despite the fact that the wounds were soiled and that the patients failed to comply with medical advice, the rate of early and secondary infection was low. Stiff joints due to tendon retractions and motor deficits were however frequent and compromised the functional outcome.

Conclusion: Fractures of the forearm by machete wounds generally occur in a typical situation of self defense. The characteristic injury to the ulnar side of the forearm results from this mechanism. Tendon and nervous complications are common and cause invalidating sequelae. Secondary infection is exceptional. Prolonged regular follow-up could probably improve the functional outcome of these particular injuries.

Over 200 high-velocity missile injuries treated in a low-technology environment were audited under the aegis of the International Committee of the Red Cross Hospitals in Afghanistan and Northern Kenya.

Femoral fractures were treated either by traction or external fixation using a uniaxial frame. The results showed that patients treated by external fixation remained in hospital longer than those treated on traction. The positional outcome was identical in both groups. In tibial fractures the external fixator was only of extra benefit in those of the lower third when compared with simple plaster slabs unless more complex procedures such as flaps or vascular repair were to be performed. In complex humeral fractures, external fixation resulted in long stays in hospital and a large number of interventions when compared with simple treatment in a sling.

We conclude therefore that in an environment where facilities are limited and surgeons have only general experience very careful initial wound excision is the most important factor determining outcome. The application of complex holding techniques was generally inappropriate.

Many studies report the incidence and prevalence of surgical site infections (SSIs) following open fractures; however, there is limited information on the treatment and subsequent outcomes of superficial SSIs in open fracture patients. There is also a lack of clinical studies describing the prognostic factors that are associated with failure of antibiotic treatment (non-operative) for superficial SSI. To address this gap, we used data from the FLOW (Fluid Lavage in Open Fracture Wounds) trial to determine how successful antibiotic treatment was for superficial SSIs and to identify prognostic factors that could be predictive of antibiotic treatment failure.

This is a secondary analysis of the FLOW trial dataset. The FLOW trial included 2,445 operatively managed open fracture patients. FLOW participants who had a non-operatively managed superficial SSI diagnosed in the 12 months post-fracture were included in this analysis. Participants were grouped into two categories: 1) participants whose superficial SSI resolved with antibiotics alone and 2) participants whose SSI did not resolve with antibiotics alone (defined as requiring surgical management or SSI being unresolved at final follow-up (12-months post-fracture for the FLOW trial)). Antibiotic treatment success and the date when this occurred was defined by the treating surgeon. A logistic binary regression analysis was conducted to identify factors associated with superficial SSI antibiotic success. Based on biologic rationale and previous literature, a priori we identified 13 (corresponding to 14 levels) potential factors to be included in the regression model.

Superficial SSIs were diagnosed in168 participants within 12 months of their fracture. Of these, 139 (82.7%) had their superficial SSI treated with antibiotics alone. The antibiotic treatment was successful in resolving the superficial SSI in 97 participants (69.8%) and unsuccessful in resolving the SSI in 42 participants (30.2%). We found that superficial SSIs that were diagnosed later in follow-up were associated with failure of treatment with antibiotic alone (Odds ratio 1.05 for every week in diagnosis delay, 95% Confidence Interval 1.004–1.099; p=0.03). Age, sex, fracture severity, fracture pattern, wound size, time from injury to initial surgical irrigation and debridement were not associated with antibiotic treatment failure.

Our secondary analysis of prospectively collected FLOW data found antibiotics alone resolved superficial SSIs in 69.8% of patients diagnosed with superficial SSIs. We also found that superficial SSIs that were diagnosed earlier in follow-up were associated with successful treatment with antibiotics alone. This suggests that if superficial SSIs are diagnosed and treated promptly, there is a higher probability that they will resolve with antibiotic treatment.

Purpose: The correlation of surgical wounds for total hip and knee replacements with the presentation or recurrence of skin disorders.

Materials-method: In 9 patients, 5 men and 4 women, operated for total knee replacement and 1 patient, a female, operated for total hip replacement, skin disorders appeared around their surgical wounds. The female patient with the THR sustained a herpes zoster in the operated buttock 8 months after surgery. 1 patient with leuke had an exaltation of symptoms the wounds of both operated knees. 6 patients, 2 men and 4 women, had increased growth of hair on both sides of the wound some months after the TKR, in contrast with the rest of their skin. 1 patient with psoriasis had increased local symptoms after a TKR compared with the non-operated side. Finally, 1 patient, 25 days after a TKR, sustained an exanthema around his wound.

Conclusion: Total joint replacement may rarely be the cause for the presentation or recurrence of skin disorders around the surgical wounds.

1. The background to the work of Australian medical teams in South Vietnam is described.

2. The types of limb wounds seen among the Vietnamese civilian population are classified and described, and the methods of treatment used are reported.

Purpose: To assess the outcome of patients with an infected TKA who developed complex wounds requiring surgical intervention in our institution.

Methods: The computerised local database was searched for patients recorded as having complex knee wounds associated with an infected TKA. Fifteen patients operated on between 1997 and 2007 were retrospectively reviewed. Data including the limb salvage rate, type of soft tissue surgery performed, local wound complications, and re-implantation rate were recorded. Average follow up was 3.2 years. Three patients had died at the time of review.

Results: Eleven out of 15 patients had been referred to our centre from other hospitals with an infected TKA. Fourteen patients were treated with two stage revision surgery. The remaining patient had direct exchange of the infected implant. Mean age at the time of surgery to address the soft tissue defect was 69.6 years.

Nine patients required a medial gastrocnemius flap. Three patients received fasciocutaneous flaps (one bipedicle); one patient was managed with a tissue expander pre-operatively; one with a split skin graft, and one patient required perforating skin incisions in order to close the wound. 60% of patients developed local wound complications and 27% required further soft tissue procedures.

The overall limb salvage rate was 73.3% (four patients required an above knee amputation for persistent infection). Five patients had successful re-implantation surgery. Four patients had arthrodesis surgery with successful eradication of infection. Two patients developed chronic infection.

Conclusions: Intensive specialist input from plastic and orthopaedic surgeons is required with such difficult cases. Contrary to recent literature, the risk of failure may be higher than previously thought. Patients should be fully counselled pre-operatively about the risks of such procedures.

Background: A subcuticular suture is an ideal closure method of a surgical wound, in patients undergoing foot & ankle surgery, when the aim is healing by primary intention. However, the addition of adhesive strips over the subcuticular suture has become an accepted method of closure despite being based on anecdotal, rather than experimental evidence.

Methods: We performed a prospective study to compare the postoperative wound complications of combination closure (3/0 Monocryl & steri strips) with subcuticular closure alone (3/0 Monocryl). Patients undergoing foot & ankle surgery were allocated to either group on an alternate basis. The wounds of sixty consecutive patients were assessed clinically for wound complications at one-week post op.

Results: Patients who had a combined closure were more likely to develop a wound discharge (23% vs 7%), friable skin (53% vs 3%) and were more likely to have non-opposed wound edges (60% vs 23%). They were also twice as likely to return to clinic for a further wound check (20% vs 10%).

Discussion: Adhesive strips were originally developed as wound dressings and offer no improvement in the tensile strength of the subcuticular closure. Instead their addition exposes the surgical wound to the possibility of epidermal injury from the adhesive in the tape and increases the likelihood of developing wound complications. We recommend meticulous closure of surgical wounds of the foot and ankle with continuous, absorbable, subcuticular suture without adhesive strips, for an optimal outcome.