Anthrax is extremely rare in the western world but is endemic to areas of south and central Asia. In early 2010 an outbreak was identified in heroin-injecting intravenous drug users in the United Kingdom and Europe. Afghanistan is currently the principal source of heroin which reaches the United Kingdom. When anthrax occurs, cutaneous disease accounts for over 95% of cases. At least 47 cases with 13 deaths have been confirmed so far. We present three cases presenting during this time with marked swelling, one resulting in compartment syndrome but all with an absence of the expected cutaneous appearances.

We suggest that rather than cutaneous anthrax, these patients represent a new subcutaneous presentation of anthrax.

Background: Massive bone loss from the proximal femur is a complex problem, occurring in multiple-revision hip arthroplasties, and malignancy. Allograft prosthetic composites (APCs) are used to restore bone loss and provide better function of the limb.

Material and Methods: Between 1986 and 1999, 94 patients (96 hips) including 31 male and 63 female (mean age 59.5 years), with massive bone loss due to an average of 2 previous revisions, had a revision hip arthroplasty using an allograft-prosthesis composite (APC). A previous history of infection was present in 21 of these cases.

Results: At an average follow-up of 11 years (range, 8 to 20 years), 72 patients were alive, 21 patients died, and 1 patient was lost to follow-up. Major complications occurred in 33 cases: femoral stem loosening (12); dislocation (15); periprosthetic fracture (10); and infection (7). Minor complications occurred in 13 other cases. Further revision surgery was performed in 21 of the 96 cases including revision of the acetabular component (3), femoral APC (16) or both (2). The 10 year survival of the APCs was 68.8% (95% CI 58.6%–79%, 26 cases remaining at risk). There was no statistically significant difference in survival time between gender, age, indication for APC (including infection), surgical approach and APC technique. Statistically significant factors negatively impacting APC survival included two or more prior revisions, severity of preoperative bone loss (Paprosky type IV) and use of plates and screws (p< 0.05). Statistically significant improvement in APC survival was identified in those reconstructions in which cement was used for proximal fixation of the femoral component within the allograft (p< 0.05).

Conclusion: Reconstruction of massive proximal femoral bone loss with an allograft-implant composite is a demanding procedure. Preservation of bone stock is a great advantage of this biologic means of reconstruction. Specific technical issues should be known and followed so to avoid failure and need for early re-revision

The inhibition of neural input by infiltration of local anaesthetic around the operation site prior to the trauma of an operation may reduce subsequent pain post-operatively. Prevention of the normal phenomenon of central and peripheral sensitisation in the nervous system stops the post operative hypersensitivity state that manifests as a decrease in the pain threshold at the site of injury. The underlying clinical principle is for therapeutic intervention to be made in advance of the pain rather than as a reaction to it ¹. We performed a prospective double blind randomised clinical trial to measure the effect of pre operative infiltration of local anaesthetic around arthroscopy wounds compared to post-operative infiltration on post operative pain relief.

Thirty six patients undergoing day case unilateral knee arthroscopy between October 2000 and March 2001 were studied. All patients gave written informed consent. They were randomised into 2 groups using block randomisation to ensure equal group sizes. The sealed envelope technique was used. The pre-operative group had 10ml 0.25% bupivicaine infiltrated around the arthroscopy portal site following induction of general anaesthesia (G.A.), the post-operative group received 10ml 0.25% bupivicaine after the procedure but before reversal of the G.A. The injection technique and G.A. used were standardised. Pain was assessed using a 10cm Visual Analogue Score (VAS) at pre-operative, 1, 2 and 24h post-operative. At each assessment the patients were blinded to the previous scores that they had submitted. Oral analgesic use in the post-operative 24 hours was also recorded.

There were 18 patients in each group. Demographic details did not differ between the 2 groups. One patient in the post-operative group was excluded, as intravenous sedation was required in recovery due to an extreme anxiety state. The mean Visual Acuity Pain Scores (VAS) were lower in the post-operative group (1.3) compared to the pre-operative group (1.58) at pre-operative assessment. However this difference was not statistically significant (p =0.5607). At 1h post op the mean VAS in the post op group was 1.58 and in the pre op group 2.59 (p =0.18). The mean VAS at 2h post op in the pre op group was 1.76 compared to 1.82 in the post op group (p =0.9932).

At 24h the pre op group had a lower mean VAS (2.25) than the post op group (2.4). This difference was however not statistically significant (p =0.7418).

Analysis of the postoperative analgesia requirement in both groups failed to reveal a statistically significant difference (p =0.3965). In day case knee arthroscopy under general anaesthesia there is no beneficial role in the use of pre-emptive local anaesthetic infiltration around the arthroscopy portal sites as compared to post-operative infiltration.