[Post-COVID-19 rehabilitation; a matter of customisation]. / Nazorg voor covid-19-patiënten.

In the early phase of the COVID-19 pandemic, knowledge about the natural course of recovery of COVID-19 is limited. We therefore describe - based on generic knowledge of post IC syndrome (PICS) and (pulmonary) rehabilitation - the possibilities to organize personalized rehabilitation programs in several care settings. To illustrate variety in need for rehabilitation, we described three cases of critical COVID-19 disease survivors after treatment in the intensive care unit. Some patients require immediate rehabilitation following hospitalization, but rehabilitation may also be initiated in the home environment. For the latter population monitoring of progress and recovery should be organized to assess whether a more intensified multidisciplinary rehabilitation program is needed. This may be initiated in one of the medical rehabilitation centers or in pulmonary rehabilitation centers. Post-COVID-19 rehabilitation, regardless of the specific form, should be patient-centered and multidisciplinary organized.

Efficacy of a novel intradermal Lawsonia intracellularis vaccine in pigs against experimental infection and under field conditions.

BACKGROUND: The efficacy of a novel inactivated intradermal Lawsonia intracellularis vaccine, Porcilis® Lawsonia ID, was evaluated in two experimental vaccination-challenge studies and under field conditions on a farm with a history of recurrent acute ileitis. In addition, the efficacy of the vaccine was compared to that of a commercially available live attenuated vaccine. The novel inactivated vaccine consists of a freeze-dried antigen fraction that is dissolved just prior to use in either the adjuvant or in Porcilis® PCV ID; an existing intradermal vaccine against porcine Circovirus type 2. In the two experimental vaccination-challenge studies, groups of 25 piglets were vaccinated once at 3 weeks of age or left unvaccinated as challenge control. Vaccines tested were Porcilis® Lawsonia ID as standalone (study 1) or in associated mixed use with Porcilis® PCV ID (study 2) and an orally administered commercially available live vaccine (study 1). The pigs were challenged with virulent L. intracellularis at 4 weeks (study 1) or 21 weeks (study 2) after vaccination. Post-challenge, the pigs were evaluated for clinical signs, average daily weight gain, shedding and macroscopic as well as microscopic immuno-histological ileum lesion scores. In the field study, the mortality and key performance parameters were evaluated over a period of 8 months. RESULTS: The results of the two experimental vaccination-challenge studies showed that Porcilis® Lawsonia ID as single vaccine or in associated mixed use with Porcilis® PCV ID, induced statistically significant protection against experimental L. intracellularis infection, 4 weeks or 21 weeks after vaccination. This was demonstrated by lower clinical scores, improved weight gain, reduction of L. intracellularis shedding and reduction of macroscopic as well as microscopic ileum lesion scores when compared to the controls. The protection induced was superior to that of the commercially available live vaccine. In the field study Porcilis® Lawsonia ID was highly efficacious in reducing L. intracellularis associated mortality and improving key production parameters. CONCLUSION: The results support that this new intradermal vaccine is efficacious against L. intracellularis and may be used in associated mixed use with Porcilis® PCV ID.

Correction to: Routine versus on demand removal of the syndesmotic screw; a protocol for an international randomised controlled trial (RODEO-trial).

An amendment to this paper has been published and can be accessed via the original article.

Treating open lower limb fractures successfully; thoughts and current practice on therapy and centralization in The Netherlands.

INTRODUCTION: The British Orthopedic Association (BOA) and British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) updated the evidence-based guidelines for the treatment and care of open lower limb fractures (BOAST 4). Following this, a Dutch version has been developed. The main points are multidisciplinary care, planning, and treatment of these injuries. Early osteosynthesis (within 7-14 days) combined with soft-tissue coverage results in more efficient care and less complications. AIM: To study the variation in treatment and thoughts among trauma, orthopedic, and plastic surgeons. MATERIALS AND METHODS: In this cross-sectional study 94 surgeons (57 trauma, 23 plastic, and 14 orthopedic surgeons) working at 46 centers completed an online questionnaire, consisting of 5 demographic, 14 hospital-related, 8 BOAST 4-related, and 2 centralization-related questions. RESULTS: There was a strong agreement among surgeons about the best moment for multidisciplinary consultation, which was before initial debridement, while in practice, this often does not occur. All surgeons agreed that the initial debridement should be performed immediately by any surgeon, but not solely by trainees. Plastic surgeons responded that the definitive stabilization and wound cover should not exceed 7 days, while half of the trauma and orthopedic surgeons agreed that it should not exceed 14 days. Finally, most surgeons agreed that Gustilo 3 fractures should be centralized. However, there was disagreement on the need for centralization of Gustilo 2 fractures. DISCUSSION: Surgeons agree on better and earlier multidisciplinary treatment of open lower limb fractures and the centralization of Gustilo 3 fractures.

Routine versus on demand removal of the syndesmotic screw; a protocol for an international randomised controlled trial (RODEO-trial).

BACKGROUND: Syndesmotic injuries are common and their incidence is rising. In case of surgical fixation of the syndesmosis a metal syndesmotic screw is used most often. It is however unclear whether this screw needs to be removed routinely after the syndesmosis has healed. Traditionally the screw is removed after six to 12 weeks as it is thought to hamper ankle functional and to be a source of pain. Some studies however suggest this is only the case in a minority of patients. We therefore aim to investigate the effect of retaining the syndesmotic screw on functional outcome. DESIGN: This is a pragmatic international multicentre randomised controlled trial in patients with an acute syndesmotic injury for which a metallic syndesmotic screw was placed. Patients will be randomised to either routine removal of the syndesmotic screw or removal on demand. Primary outcome is functional recovery at 12 months measured with the Olerud-Molander Score. Secondary outcomes are quality of life, pain and costs. In total 194 patients will be needed to demonstrate non-inferiority between the two interventions at 80% power and a significance level of 0.025 including 15% loss to follow-up. DISCUSSION: If removal on demand of the syndesmotic screw is non-inferior to routine removal in terms of functional outcome, this will offer a strong argument to adopt this as standard practice of care. This means that patients will not have to undergo a secondary procedure, leading to less complications and subsequent lower costs. TRIAL REGISTRATION: This study was registered at the Netherlands Trial Register (NTR5965), Clinicaltrials.gov ( NCT02896998 ) on July 15th 2016.

[The effects of severe and very severe injuries]. / Gevolgen van ernstige en zeer ernstige letsels.

- The effects of severe injuries can be charted using the International Classification of Functioning, Disability and Health (ICF) model and the burden of disease model, in which the burden of disease is expressed in 'disability-adjusted life years' (DALYs). - Severe accidents cause 10 DALYs per 1000 people, which is comparable with the burden of disease of mood disorders and lung cancer.- In the Netherlands, severe injury victims are often males aged < 40 years, who are often injured in road traffic accidents. - The average hospital stay after a severe injury is one month, after which almost 75% of the patients are discharged home, while one quarter subsequently stay in rehabilitation facilities for 3-6 months. More than half return to their original employment. - Patients with thoracic and abdominal injuries recover relatively well, whereas injuries of the lower extremities, brain and spinal cord give a relatively poor prognosis. Comorbidity increases the chance of a less good recovery. Older people who survive an accident recover relatively well.

Evidence for and cost-effectiveness of physiotherapy in haemophilia: a Dutch perspective.

INTRODUCTION: Musculoskeletal impact of haemophilia justifies physiotherapy throughout life. Recently the Dutch Health Care Institute constrained their 'list of chronic conditions', and withdrew financial coverage of physiotherapy for elderly persons with haemophilia (PWH). This decision was based on lack of scientific evidence and not being in accordance with 'state of science and practice'. METHODS: In general, evidence regarding physiotherapy is limited, and especially in rare diseases like haemophilia. 'Evidence based medicine' classifies and recommends evidence based on meta-analyses, systematic reviews and randomized controlled trials, but also means integrating evidence with individual clinical expertise. For the evaluation of physiotherapy - usually individualized treatment - case studies, observational studies and Case Based Reasoning may be more beneficial. RESULTS: Overall annual treatment costs for haemophilia care in the Netherlands are estimated over 100 million Euros, of which 95% is covered by clotting factor concentrates. The cost for physiotherapy assessments in all seven Dutch HTCs (seven centres for adult PWH and seven centres for children) is limited at approximately 500 000 Euros annually. Costs of the actual physiotherapy sessions, carried out in our Dutch first-line care system, will also not exceed 500 000 Euros. Thus, implementation of physiotherapy in haemophilia care the Netherlands in a most optimal way would cost less than 1% of the total budget. AIM: The present paper describes the role of physiotherapy in haemophilia care including available evidence and providing suggestions regarding generation of evidence. Establishing the effectiveness and cost-effectiveness of physiotherapy in haemophilia care is a major topic for the next decennium.

Vaginal delivery after hemipelvectomy and pelvic radiotherapy for chondrosarcoma.

Chondosarcoma of the proximal femur is a rare malignant disorder in women of (pre-) childbearing age, for which a radical resection through a hemipelvectomy could be indicated. We describe a case of a 36-year-old primigravida with a hemipelvectomy (2004) who had a history of radiotherapy of the pelvic and uterine regions after an atypical cartilaginous tumour. After an uncomplicated pregnancy, she had a spontaneous rupture of the membranes at 41+2 weeks and an uncomplicated vaginal delivery with physiological development of the infant. On the basis of the literature review, vaginal delivery after hemipelvectomy should be advocated and discussed with the patient and involved care providers. Women with radiotherapy in the pelvic and uterine areas have an increased risk of stillbirth, placental attachment disorders, impaired fetal growth, fetal malposition and preterm labour, but no association with prolonged rupture of the membranes has been described.

[Serious foot injury: consider partial amputation designed to preserve leg-length and a weight-bearing stump]. / Ernstig letsel van de voet: overweeg partiële amputatie op maat met behoud van beenlengte en een eindbelastbare stomp.

Three patients with physically demanding jobs, a 25-year-old farmer, a 22-year-old market trader and a 32-year-old house painter, each suffered a traumatic injury of one foot. All three underwent amputation in which part of their foot was salvaged and were able to return to their physically demanding jobs. The first patient underwent a Syme's amputation, the second a Pirogoff's amputation and the third a Chopart's amputation. A partial amputation of the foot has several advantages: patients are able to walk without walking aids, particularly in and around the house, due to the presence of a direct weight-bearing stump. With a prosthesis patients may be able to resume their physically demanding jobs, there are fewer problems of functional restraint of the knee and phantom pain is rare. Although these amputations can be technically demanding, an amputation at this level in young as well as older patients with an adequate blood supply to the hind foot is worthwhile and to be recommended for several reasons.

Long-term functional health status of severely injured patients.

BACKGROUND: Studies of the consequences of major trauma have traditionally focused on mortality rates. The aims of this study were, firstly, to investigate the long-term functional health status in a large, unselected group of severely injured patients and to compare this with normative data, and secondly, to explore relations between functional health status and personal and injury characteristics. METHODS: A prospective cohort study was performed at the University Medical Centre Utrecht (a level-1 trauma centre) in The Netherlands. Consecutive survivors of major trauma (ISS>or=16; >16 years of age) were included from January 1999 until December 2000. After an average of 15 months (range 12-18 months), 335 of the 359 eligible persons (response rate 93%) participated. Demographic and injury characteristics were retrieved from a hospital-based registration system. Functional health status was measured using the 136-item Sickness impact profile (SIP). Co-morbidity was assessed at the follow-up examination using a standard list of 26 conditions. RESULTS: Subjects were 249 men and 86 women, mean age 37.7 years, mean ISS was 24.9 (S.D.=10.6). Almost, three quarters were traffic victims. Mean hospital stay was 25 days (S.D.=23.4). Discharge destination was home in 70% of all subjects. At follow-up, the mean overall SIP score was 9.3 (S.D.=10.1), which means mild to moderate disability. The mean score on the physical function dimension was 7.2 (S.D.=9.8) and that on psychosocial function was 8.7 (S.D.=12.0). Most problems were experienced in the categories of Work, Ambulation, Home Management, Recreation and Pastimes, and Alertness Behaviour. Scores of younger subjects deviated more strongly from the norm scores than those of elderly patients. Type of injury, especially lesions of traumatic brain and spinal cord and extremity injuries, was a predictor of both psychosocial and physical functioning after more than 1 year. The most important predictors, however, were age and co-morbidity.

[Background and consequences of injuries missed when diagnosing severely injured accident victims in prehospital care in patients transported by ambulance to the University Medical Centre in Utrecht, 1999-2000]. / Achtergronden en gevolgen van het missen van letsels in de ambulancezorg bij ernstig gewonde ongevalspatiënten die vervoerd werden naar het Universitair Medisch Centrum Utrecht, 1999-2000.

OBJECTIVE: To determine the background and consequences of failing to diagnose injuries in prehospital care. DESIGN: Prospective cohort study. METHOD: Data were collected from 507 trauma patients with multiple injuries, and a Hospital trauma index-injury severity score of 16 or higher, who were delivered by the emergency ambulance service to the emergency department of the University Medical Centre Utrecht, the Netherlands, in 1999-2000. RESULTS: The percentage of missed injuries varied from 9-55. For every additional year of age the risk of missing thoracic injuries was 2% higher. The risk of missing head injuries was 84% lower in people with a Triage revised trauma score (T-RTS) < 11. Initially missing an injury had no consequences for duration of stay in the ICU except in those patients with injuries to the lower extremities. A difference in quality of life was only reported for patients in whom injuries ofthe ribs, shoulder or clavicle had been missed. For every year of age, there was a 2% greater risk of dying within 1.5 years. A T-RTS < 11 resulted in a 5.6-fold greater risk of death. Failing to diagnose an injury did not in itself increase the risk of death. CONCLUSION: Frequently missing an injury prior to hospitalization did not result in a poorer chance of survival or lesser quality of life. The risk of dying was mainly related to a higher age and a poorer general condition at the scene of the accident. According to these findings there is no reason to adapt the current policy with regard to initial care and transport of trauma patients.

Instability of the distal radio-ulnar joint: stabilization by a Gore-Tex ligament.

Diagnosis and treatment of problems caused by instability of the distal radio-ulnar joint are complex. In this retrospective study, the results of a uniform procedure by using a Gore-Tex ligament for stabilization of the distal radio-ulnar joint are presented. In eight patients, nine wrists were operated on. The mean age of the patients was 35 years. The dominant side was involved in six patients. The mean follow-up was 3.4 years. Three of nine wrist problems were of spontaneous onset. In these wrists, the final results were excellent. The other six wrists were operated on for problems after trauma: four patients after soft-tissue injury, one patient after distal radius fracture, and one patient after forearm fracture. Among these cases, one result was excellent, four were good, and another one was fair.

[Satisfactory results of surgical reconstruction of rotator cuff ruptures, 1984-1990]. / Bevredigende resultaten van operatieve reconstructie van 'rotator cuff'-rupturen, 1984-1990.

OBJECTIVE: Evaluation of the middle-long term results of open surgical treatment of rotator cuff tears and identification of pre- and peroperative parameters with predictive value for the final result. DESIGN: Retrospective study (1984-1990). SETTING: Department of orthopaedics of the Sint Antonius Hospital, Nieuwegein, the Netherlands. METHOD: All patients were asked to cooperate on an extensive standard anamnesis and physical examination. Re-evaluation of the X-rays, arthrograms and operation reports took place. There were three stragglers. RESULTS: The follow-up concerned 41 shoulders in 40 patients (21 women, 19 men). The average age was 61 years (37-77). The average postoperative period was 5 years (2.5-9.2). The subjective final result was satisfactory in 80% as judged by persistent complaints and function of the operated shoulder. Young and active patients were less satisfied with the final result than older, female patients. More persistent complaints were seen in larger and longer existing cuff tears. CONCLUSIONS: Open surgical treatment of rotator cuff tears gave a satisfying result, as described in literature. Sex, age, level of activity and size of the tear appeared to be predictive parameters for the subjective final result.