Intra-articulaire calcaneusfracturen

ABSTRACT About 0.6% of all fractures is an intra-articular calcaneal fracture. Patients often have additional injuries, and returning to work can take up to one year. The diagnostics consist of plain, lateral and axial, radiographs of the calcaneus. In addition a CT-scan is performed in three planes. Because of the lack of a standardised classification and disease specific outcome-scores there is no agreement on the best treatment modality. More randomised controlled trials are mandatory in the future to determine the best treatment modality for the different types of intra-articular calcaneal fractures

Behandeling van proximale humerusfracturen bij volwassenen

Samenvatting. Achtergrond: Fracturen van de proximale humerus zijn veel voorkomende letsels. De behandeling van deze fracturen, inclusief chirurgische interventies, varieert sterk. Doel: In kaart brengen van bewijs voor verschillende therapeutische interventies en revalidatie voor fracturen van de proximale humerus. Zoekstrategie: Onderzocht werden the Cochrane Bone, Joint and Muscle Trauma Group Specialized Register, the Cochrane Central Register of Controlled Trails, MEDLINE, EMBASE en andere registers en bibliografische weergave van rapporten van trials. Deze zoekactie werd in maart 2010 beëindigd. Selectie: Alle Randomised Controlled Trials (RCT’s) die betrekking hebben op de behandeling van de fracturen van de proximale humerus bij volwassenen werden geselecteerd. Dataverzameling en analyse: Twee personen verrichtten onafhankelijk van elkaar de studieselectie, risicoinventarisatie op bias en dataverzameling. Door de heterogeniteit van de trials bleken de gegevens niet geschikt te zijn voor een meta-analyse. Resultaten: Zestien kleine gerandomiseerde trials met 801 patiënten werden geïncludeerd. Het was niet mogelijk om de bias in deze studies uit te sluiten. Acht onderzoeken evalueerden conservatieve therapie. In één studie blijkt een armsling in het algemeen meer comfortabel dan de minder gebruikte lichaamsfixatie/bandage van de arm. Er was enig bewijs dat vroege fysiotherapeutische behandeling, in vergelijking met fysiotherapie starten na drie weken van immobilisatie, resulteert in minder pijn en mogelijk een beter herstel bij patiënten met een niet gedisloceerde of een stabiele fractuur. Vergelijkbaar was er bewijs voor vermindering van pijn op korte termijn zonder negatieve gevolgen voor een resultaat op langere termijn in geval van een vroege mobilisatie in de eerste week in vergelijking met de mobilisatie na drie weken. Twee onderzoeken leverden enig bewijs voor een in het algemeen redelijk resultaat bij patiënten die, zonder medische supervisie maar wel met een adequate instructie voor een fysiotherapeutisch programma behandeld werden. Operatieve interventie verbeterde het herstel van de anatomie van de fractuurfragmenten in twee onderzoeken maar dit leidde tot meer complicaties in een van deze onderzoeken en resulteerde niet in een verbetering van de schouderfunctie. De voorlopige gegevens uit een ander onderzoek leverden geen significant verschil in complicaties, kwaliteit van het leven en kosten tussen plaatosteosynthesen conservatieve therapie. In één onderzoek leidde een hemiarthroplastiek tot een betere functie op korte termijn met minder pijn en invaliditeit in vergelijking met conservatieve behandeling van ernstige letsels. Een tension band fixatie bij ernstige letsels ging gepaard met een hoog reoperatie aantal in vergelijking met een hemiarthroplastiek in één studie. In één ander onderzoek werden betere functionele resultaten voor één type hemiarthroplastiek gevonden. Slechts zeer beperkt bewijs suggereerde vergelijkbare resultaten van vroege versus uitgestelde schoudermobilisatie na hetzij een operatieve fractuurfixatie (één onderzoek) of een hemiarthroplastiek (één onderzoek). Conclusie van de auteurs: Er is onvoldoende bewijs voor adequate informatie over de behandeling van proximale humerusfracturen bij volwassenen. Vroege fysiotherapie, zonder immobilisatie, lijkt adequaat voor de behandeling van sommige niet gedisloceerde fracturen. Het is onduidelijk of de operatieve therapie, zelfs voor specifieke fractuurtypen, zal leiden tot een consistent beter lange termijn resultaat

Effects of sequence variations in innate immune response genes on infectious outcome in trauma patients: A comprehensive review

Infectious complications, sepsis, and multiple organ dysfunction syndrome (MODS) remain important causes for morbidity and mortality in patients who survive the initial trauma. Increasing evidence suggests that genetic variants, particularly single nucleotide polymorphisms (SNPs), are critical determinants for interindividual differences in both inflammatory responses and clinical outcome in sepsis patients. Although the effect of SNPs on sepsis and MODS has been studied in many populations and diseases, this review aimed to summarize the current knowledge on the effect of SNPs on infectious complication specifically in trauma patients. A review of available literature was performed in PubMed database. The following genes have been studied in populations of trauma patients: CD14, HMGB1, IFNG, IL1A, IL1B, IL1RN, IL4, IL6, IL8, IL10, IL17F, IL18, MBL2, MASP2, FCN2, TLR1, TLR2, TLR4, TLR9, TNF, LTA, GR, MYLK, NLRP3, PRDX6, RAGE, HSPA1B, HSPA1L, HSP90, SERPINE1, IRAK1, IRAK3, VEGFA, LY96, ANGPT2, LBP, MicroRNA, and mtDNA. In this review, we discuss the genes of the Pattern Recognition Receptors, Signal Transducing Adaptor Proteins, and Inflammatory Cytokines of the innate immune system. A number of genetic variations have so far been studied in cohorts of trauma patients. Studies are often unique and numbers sometimes small. No definitive conclusions can be reached at this time about the influence of specific sequence variations on outcome in trauma patients

Multiple Infectious Complications in a Severely Injured Patient with Single Nucleotide Polymorphisms in Important Innate Immune Response Genes

Abstract Trauma is a major public health problem worldwide. Infectious complications, sepsis, and multiple organ dysfunction syndrome (MODS) remain important causes for morbidity and mortality in patients who survive the initial trauma. There is increasing evidence for the role of genetic variation in the innate immune system on infectious complications in severe trauma patients. We describe a trauma patient with multiple infectious complications caused by multiple micro-organisms leading to prolonged hospital stay with numerous treatments. This patient had multiple single nucleotide polymorphisms (SNPs) in the MBL2, MASP2, FCN2 and TLR2 genes, most likely contributing to increased susceptibility and severity of infectious diseas

Percutaneous reduction and fixation of intraarticular calcaneal fractures

Objective: Percutaneous reduction by distraction and subsequent percutaneous screw fixation to restore calcaneal and posterior talocalcaneal facet anatomy. The aim of this technique is to improve functional outcome and to diminish the rate of secondary posttraumatic arthrosis compared to conservative treatment and, secondly, to reduce infectious complications compared to open reduction and internal fixation (ORIF). Indications: Sanders type II-IV displaced intraarticular calcaneal fractures. Contraindications: Isolated centrally depressed fragment. Contraindications: Patients who are expected to be noncompliant. Surgical Technique: Four distractors (Synthes™) are positioned, two on each side of the foot, between the tuberosity of the calcaneus and talus and between the tuberosity and cuboid. A distracting force is given over all four distractors. A blunt drifter is then introduced from the plantar side to unlock and push up any remaining depressed parts of the subtalar joint surface of the calcaneus. The reduction is fixated with two or three screws inserted percutaneously. Postoperative Management: Directly postoperatively, full active range of motion exercises of the ankle joint can start, with the foot elevated in the 1st postoperative week. Stitches are removed after 14 days. Implant removal is necessary in 50-60% of patients. Results: Between 1999 and 2004, 59 patients with 71 fractures were treated by percutaneous skeletal triangular distraction and percutaneous fixation. A total of 50 patients with 61 fractures and a minimum follow-up of 1 year were available for follow-up. According to the American Orthopaedic Foot and Ankle Society Hindfoot Score, 72% had a good to excellent result. A secondary subtalar arthrodesis was performed in five patients and planned in four (total 15%). Böhler's angle increased by about 20° postoperatively. Sagittal motion was 90% andsubtalar motion 70% compared to the healthy foot

Reinsertion of an inverted osteochondral lesion of the talus: A case report

Osteochondral lesions of the talus (OLTs) occur infrequently and are missed at the initial presentation in up to 67% of cases. Probably more than 1500 OLTs have been reported in published studies, of which, thus far, only 5 cases have been an inverted anterolateral OLT. An anterolateral OLT results from a hypersupination trauma, in which the talar dome is caught behind the fibula. Apparently, if the forces are large enough a " flip of the coin" phenomenon occurs, causing the fragment to invert 180° upside down. We present the case of a young female patient with an inverted OLT that was treated with open reduction and internal fixation using bioabsorbable pins. Follow-up radiographs and computed tomography showed a congruent joint and complete healing of the osteochondral fragment. At the short-term follow-up visit, the functional outcome was promising

Botvervangende materialen

Abstract Bone substitutes – In trauma and orthopedic surgery the use of autograft is a first choice therapy for filling bone defects. Due to drawbacks in the use of autografts (for example donor site morbidity and limited amount of bone tissue) there is an increasing interest in the use of (artificial) bone substitutes. This article provides an overview of the basic science of bone substitution. For optimal ingrowth of bone a transplant should have osteogenic, osteoinductive and osteoconductive characteristics. Bone substitutes are mostly osteoconductive and provide a scaffold for bone regeneration. Osteoconductivity is mainly determined by pore size, porosity and cristallinity. Calcium phosphates represent a group of bone substitutes that is being used mostly, and this group of products has been extensively studied. In addition, calcium sulphates and bioactive glass are used also. New developments such as the addition of growth factors to bone substitutes are under extensive research

Inventarisatiestudie naar de behoefte aan assistentie door het Mobiel Medisch Team in de avond en nacht

Samenvatting Inleiding: Tot 2005 kon men uitsluitend gedurende de dag een beroep doen op professionele aanvullende prehospitale hulpverlening. In 2005 ontstond een voor Nederland unieke situatie waarbij het Mobiel Medisch Team (MMT) ook ’s nacht paraat inzetbaar was. Het doel van deze studie was inzicht te krijgen in de kwantitatieve en kwalitatieve aspecten van grondgebonden MMT inzetten in de nacht, tussen 19.00 en 7.00 uur. Methode: In een beschrijvend cohortonderzoek werden alle patiënten waarvoor in 2005 tussen 19.00 en 7.00 uur MMT-assistentie werd gevraagd in de regio Zuid West Nederland geïncludeerd. Van de geïncludeerde patiënten werden prospectief (pre)hospitale data gedocumenteerd, en na 1 jaar geanalyseerd. Resultaten: Gedurende de studieperiode werd in de avond en nacht 235 keer om assistentie gevraagd, waarvan 69 aanvragen werden geannuleerd. Zevenenzestig procent van deze nachtelijke inzetten vond plaats op basis van de inzetcriteria die gebaseerd zijn op de aard van het ongeval, en 33% op basis van de toestand van de patiënt. Drieënzestig procent van de inzetten vond plaats tussen 19.00 uur en middernacht. De mediane Injury Severity Score was 10 (4-25) met een mortaliteit van 16 %. Drieëntwintig procent van de patiënten werd geïntubeerd. Conclusie: Deze studie laat zien dat er ook gedurende de avond en nacht aanzienlijke behoefte is aan gespecialiseerde medische hulp ter aanvulling op de ambulancezorg. De kwalitatieve behoefte aan zorg is vergelijkbaar met de zorgvraag overdag. Het handelen van het nachtelijk grondgebonden MMT was potentieel levensreddend. Extrapolatie van deze regionale resultaten levert een behoefteraming op van jaarlijks 505 daadwerkelijke MMT assistenties in heel Nederland tussen 19.00 uur en 7.00 uur

Intraosseous devices: A randomized controlled trial comparing three intraosseous devices

Introduction. Access to the circulation is mandatory for adequate treatment in medical emergency situations. Intraosseous (IO) infusion is a safe, fast, and effective alternative for gaining access to the circulation, if intravenous access fails. In the last decade, the IO method gained renewed interest. New devices have been developed, such as the Bone Injection Gun (BIG) 15G/18G and the First Access for Shock and Trauma 1 (FAST1). Objective. To determine which IO needle is preferable for gaining IO access in patients requiring acute administration of fluids or medication in a prehospital setting. Methods. In this single-blind prospective randomized trial, the IO needles were added to the equipment of the helicopter emergency medical services (HEMS) system. The HEMS nurses received training in proper use of all needles. Children (113 years) were randomized to the Jamshidi 15G or the BIG 18G, and adults (≥ 14 years) were randomized to the Jamshidi 15G, the BIG 15G, or the FAST1. All patients requiring acute administration of fluids or medication, without successful insertion of an intravenous (IV) catheter, were included. The IO needles were compared in terms of insertion time, success rate, bone marrow aspiration, adverse events during placement, and user satisfaction. Results. Sixty-five adult and 22 pediatric patients were included. The treatment groups were similar with respect to age, gender, mortality, and trauma mechanism (p ≥ 0.05). The median insertion times ranged from 38 seconds for the Jamshidi 15G to 49 seconds for the BIG 15G and 62 seconds for the FAST1 (p 0.004). The devices did not differ with respect to success rates (adults overall 80 and children overall 86), complication rates, and user satisfaction. Conclusions. The Jamshidi 15G needle could be placed significantly faster than the FAST1. The devices had similar success rates, complication rates, and user-friendliness. Intraosseous devices provide a safe, simple, and fast method for gaining access to the circulation in emergency situations

Implant removal after internal fixation of a femoral neck fracture: Effects on physical functioning

Objectives: The effect of implant removal after internal fixation of a femoral neck fracture on physical functioning was analyzed. Characteristics of patients who had their implant removed were studied, as it is currently unknown from which type of patients implants are removed and what effect removal has on function. Design: Secondary cohort study alongside a randomized controlled trial. Setting: Multicenter study in 14 hospitals. Patients and Intervention: Patients who had their implant removed after internal fixation of a femoral neck fracture are compared with patients who did not. Main outcome measurements: Patient characteristics and quality of life (Short Form 12, Western Ontario McMaster Osteoarthritis Index) were compared. Matched pairs were selected based on patient/fracture characteristics and prefracture physical functioning. Results: Of 162 patients, 37 (23%) had their implant removed. These patients were younger (median age: 67 vs. 72 years, P 0.024) and more often independently ambulatory prefracture (100% vs. 84%, P 0.008) than patients who did not. They more often had evident implant back-out on x-rays (54% vs. 34%, P 0.035), possibly related to a higher rate of Pauwels 3 fractures (41% vs. 22%, P 0.032). In time, quality of life improved more in implant removal patients [+2 vs. -4 points, Short Form 12 (physical component), P 0.024; +9 vs. 0 points, Western Ontario McMaster Osteoarthritis Index, P 0.019]. Conclusions: Implant removal after internal fixation of a femoral neck fracture positively influenced quality of life. Implant removal patients were younger and more often independently ambulatory prefracture, more often had a Pauwels 3 fracture, and an evident implant back-out. Implant removal should be considered liberally for these patients if pain persists or functional recovery is unsatisfactory. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence