The Value of Intraoperative 3-Dimensional Fluoroscopy in the Treatment of Distal Radius Fractures: A Randomized Clinical Trial.

PURPOSE: This study attempted to determine the clinical effectiveness of the intraoperative use of 3-dimensional fluoroscopy compared with conventional 2-dimensional fluoroscopy in patients with distal radius fractures. METHODS: We performed a multicenter randomized clinical trial in which 206 patients were randomized between the use of 3-dimensional fluoroscopy or not during operative treatment of the distal radius fracture. The primary outcome was the quality of fracture reduction and fixation assessed on a postoperative computed tomography scan with a dichotomous outcome: indication for revision, yes or no. RESULTS: There was no significant difference in whether the fracture required revision surgery: 31% (2-dimensional group) versus 24% (3-dimensional group). In 11% of distal radius fractures allocated to the 3-dimensional group, additional intraoperative corrections (screw replacements) were performed. CONCLUSIONS: Compared with 2-dimensional fluoroscopy, the use of intraoperative 3-dimensional fluoroscopy does not appear to improve the quality of reduction and fixation in the management of patients with a distal radius fracture. However, the use of 3-dimensional fluoroscopy appears to have advantages such as more intraoperative revisions and less revision surgeries that this study could not clearly demonstrate. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

A prospective cohort study comparing the VAS spine score and Roland-Morris disability questionnaire in patients with a type A traumatic thoracolumbar spinal fracture.

The Roland Morris Disability Questionnaire (RMDQ-24) and the VAS spine score have been regularly used to measure functional outcome in patients with back pain. The RMDQ-24 is primarily used in degenerative disease of the spine and the VAS Spine is used in trauma patients. The aim of this study is to compare these scores and to see if there is a correlation in patients with a traumatic thoracolumbar spinal fracture. Prospective cohort study comparing the RMDQ-24 and the VAS spine score in patients with a traumatic type A fracture thoracolumbar spine fracture. Fifteen non-operatively patients (group one) completed 118 questionnaires and 17 operatively treated patients (group two) completed 140 questionnaires. Group one scored an average of 6.6 and 65.9 for the RMDQ-24 and VAS Spine, in group two this was 5.1 and 82.9. Spearman's correlation test showed a significant correlation, in group one 0.83 and for the second group 0.87. RMDQ-24 and VAS Spine have a strong positive correlation in measuring disability in a group of patients with back pain because of a spinal fracture. In both non-operatively and operatively treated groups this correlation is significant.

Intimal hyperplasia in reversed and in situ vein grafts: an intra-individual canine study.

The apparent superiority of the in situ vein graft over the reversed vein graft in long arterial reconstructions has been explained by a superior hemodynamic performance and a reduction of intimal hyperplasia in the in situ graft. To examine this, an intracomparative canine study was performed with respect to the progression of intimal and medial changes in both in situ and reversed vein grafts. Paired femoropopliteal artery grafts were inserted in six dogs using the in situ technique in the right leg and the reversed technique in the left leg. The grafts were excised at 1 day, 3 months, and 6 months after operation. Substantial changes were shown both in histologic structure and in absolute intimal and medial thickness, without a significant intra-individual difference between in situ and reversed grafts. The intima-to-media ratio increased in the first 3 months and stabilized in the 3- to 6-month interval. In this intra-individual canine study preservation of adventitia and vasa vasorum had no biologic effect on the development of the same intimal changes in the midsection of reversed and in situ vein grafts.

[Three patients with accidental hypothermia: customized rewarming]. / Drie patiënten met accidentele hypothermie; opwarmen op maat.

Three patients, two men aged 47 and 33 years and a woman aged 33 years, became hypothermic after an accident with body temperatures of 34.5, 26.2 and 23.1 degrees C, respectively. Two of them developed circulatory disorders, for which reanimation was performed. All three patients recovered after active external heating using among other things warmed infusion fluids, a warmed waterbed, continuous arteriovenous rewarming and rewarming with the heart-lung machine. For the treatment to be successful, the type of rewarming selected should be guided by the degree of hypothermia, the circulatory situation and the severity of the accessory injuries.

Internal fixation of fractures of the proximal humerus with the MultiLoc nail.

OBJECTIVE: Anatomical reduction of two- to four-part fractures of the proximal humerus using indirect reduction techniques. Intramedullary fixation with a short humerus nail. Restoration of a stable bone-implant construct that enables early functional after-treatment. INDICATIONS: Displaced and unstable two- to four-part fractures of the proximal humerus. Fractures of the proximal humerus extending in the humeral diaphysis (use a long nail). Ipsilateral combined lesions of the proximal humerus and the humeral diaphysis (use a long nail). CONTRAINDICATIONS: Poor physical and/or mental status. Critical soft tissue conditions in the area near the surgical site. Local soft tissue infection. Pre-existing severe osteoarthritis of the shoulder joint; severe shoulder stiffness. Head-split fractures of the humerus head that cannot be reduced. SURGICAL TECHNIQUE: Exposure of the fracture using an anterior acromial approach and determination of the correct nail entrance point. Anatomic fracture reduction using indirect reduction techniques. Stable fixation using an intramedullary MultiLoc® nail. Determination of the proximal locking configuration depending on the fracture morphology. Distal locking with angle-stable option. POST-OPERATIVE TREATMENT: Post-operative radiographs for documentation of the surgical result and implant position. Use of an arm sling for 7-10 days. Active and passive exercises of the shoulder joint starting on day 1. Shoulder abduction limited to 60° for 2 weeks. Subsequent abduction to 90° until the 4th week. Subsequent active mobilisation without restrictions. Weight bearing and sporting activities after 3 months. Radiological evaluation after 2, 6 and 12 weeks. RESULTS: During a 6-month period, 160 patients were documented in a prospective clinical multicentre study. According to the AO classification, there were 36% A-type fractures, 41% B- and 23% C-type injuries. A 6-month follow-up was available for 17 patients. The mean age of these patients was 67 years. One patient had an A-type fracture. There were ten B- and six C-type fractures. At the time of follow-up, the mean Constant score was 66 points. Radiographically, all fractures had healed. Intra-articular screw penetration and loss of reduction were both observed once.

Early proximal row carpectomy after severe carpal trauma.

Complex fracture dislocations of the wrist often result in post-traumatic arthrosis. In these cases, patients can experience severe pain and loss of function of the wrist and as a result many of them end up having a total arthrodesis. In trying to avoid the disadvantages of a total arthrodesis, alternative treatment strategies have been investigated, amongst which proximal row carpectomy (PRC). Basic conditions for a good outcome of PRC are an intact cartilage of the lunate fossa of the distal radius and an intact surface of the head of the capitate for the new radiocapitate joint (, schematic drawing post-PRC). Also, an intact (volar) radioscaphocapitate (RSC) ligament is necessary because it plays an essential role in stabilizing the new joint and preventing volar dislocation and ulnar translocation of the distal carpal row. Acute post-traumatic PRC can be indicated, but is rarely reported in literature. In this article, we present four patients whom we have treated with early PRC after severe trauma of the wrist. Three patients had a good outcome. In the patient with the bad outcome, the before-mentioned prerequisites were not met, which is discussed.

[Anxiety self-rating and myocardial infarction (author's transl)]. / Auto-évaluation de l'anxiété et infarctus du myocarde.

This study addresses to critical issues related to the role of anxiety in myocardial infarct. Is the predictive value of the Anxiety Scale Questionnaire (ASQ) to be found in content of items and its self-rating by the subject or in response style to the questionnaire? Would anxiety play in certain circumstances a positive role in that it drives the individual to seek early medical treatment? Differences in anxiety scores, response style indices and factorial structures of the ASQ items reveal : 1. myocardial infarction subjects have higher, but not significantly higher, anxiety scores relative to healthy volunteers to an atherosclerosis screening test and healthy control individuals matched for age, sex and socio-economic status, 2. healthy volunteers are characterized by extreme response style that could reveal their involvement in the testing situation; 3. control individuals show a tendency to intermediate response; 4. the lack of invariance of factorial structure across the three groups suggests that each of them has a specific organization of anxiety. Scale-checking style, though strongly associated with the content of items, could have a predictive value since, anxiety levels being equal, subjects may be differently involved in their answers. The assumption is supported by the specific organization of anxiety evidenced in each group considered. A relation between such organization and preventive behaviour is not infirmed by the present data and ought to be further analyzed.

The basilic vein as an in situ bypass for occlusion of the brachial artery.

The use of the basilic vein as an in situ bypass in upper extremity revascularisation has not as yet been reported. Two patients with an occlusion of the brachial artery and disabling arm claudication in whom the basilic vein was a suitable vascular conduit are discussed.

Bicycle-spoke injuries: a prospective study.

A prospective study of bicycle-spoke injuries was undertaken to assess the severity of soft tissue damage and the incidence of skeletal injuries. During a 12 month period, 59 children with spoke injuries were examined. Soft tissue damage was divided into three categories: bruising without laceration (four), bruising and superficial abrasions (49) and full thickness skin defects (six). Seventeen children had skeletal injuries: nine tibial fractures (five greenstick fractures and four spiral fractures) and eight epiphyseal injuries of the distal fibula. All fractures were treated non-operatively. The mean time for soft tissue healing was 16.5 days and the mean time for regaining full weight-bearing was 8.5 days. Soft tissue damage is the most important prognostic factor in the healing of a bicycle-spoke injury.

Hypothermia in trauma patients.

Accidental hypothermia (AH) can be defined as an unintentional decrease in core temperature below 35 degrees C during cold exposure by individuals without intrinsic thermoregulatory dysfunction. Pathophysiological changes can be attributed both to the severity of hypothermia and to co-morbid factors such as trauma, submersion, intoxication and underlying diseases. In trauma victims stratified according to the Injury Severity Score, the factor hypothermia is considered to be a poor prognostic sign for survival. In these patients rewarming therapy should be applied as soon as possible. In the Utrecht University Hospital, adult patients with AH are managed according to an algorithm based on their presenting hemodynamic conditions. Patients with perfusing cardiac rhythms and systolic pressures over 80 mmHg will receive continuous arteriovenous rewarming (CAVR). Arrested and hemodynamically instable patients are treated with cardiopulmonary bypass (CPB). In a 3-year period, 22 patients with AH were admitted to the emergency department. Fourteen patients had a trauma as the cause of hypothermia. Twenty patients were treated according to the algorithm (CAVR n = 18, CPB n = 2) and two patients were alternatively managed. Mortality in the CAVR group was 28% and total mortality reached 32%. Complications of CAVR are related to placement and removal of vascular catheters and may be severe in these patients with impaired coagulation. CAVR permits a good access to the (trauma-) patient and rewarming can be continued synchronously with diagnosis and treatment of various injuries.