Can near infrared spectroscopy measure the effect of pressure on oxygenation of sacral soft tissue?

OBJECTIVE: To test whether near infrared spectroscopy (NIRS) is applicable for the examination of the influence of external pressure on oxygenation of the soft tissues in the sacral area. METHOD: Tissue oxygenation was measured in 33 healthy volunteers in the prone position. A NIRS probe was positioned over the sacrum and external pressure was applied in 10 mmHg increments, from 20 mmHg to 200 mmHg and then decreased. At each level, tissue oxygen saturation (StO2) was measured. To test reproducibility, the protocol was repeated in six volunteers, in whom the thickness of the soft-tissue envelope at different levels of external pressure was assessed using ultrasound. RESULTS: There was wide variability in StO2 courses between the 33 subjects, with a non-linear relationship between pressure and StO2. The only consistent finding was that the StO2 was significantly higher after decreasing pressure than at the initial pressure of 20 mmHg, which is indicative of reactive hyperaemia. Despite the application of high external pressures, reasonable tissue oxygenation was maintained in 19 of 33 subjects. Reproducibility of the measurements was poor. Comparison of soft-tissue thickness with corresponding StO2 values showed that, with increasing pressure, the percentage decrease in tissue thickness was higher than the decrease in tissue oxygenation. CONCLUSION: This study confirms that NIRS is not useful for assessing tissue oxygenation in pressure ulcer research due to unacceptable inter-individual variability and poor reproducibility of measurements.

Bioresorbable fixation devices for musculoskeletal injuries in adults.

BACKGROUND: Bioresorbable implants for musculoskeletal injuries involving bone and ligaments in adults might have significant advantages compared to the conventionally used non-resorbable metal implants because they lead to a gradual transfer of the mechanical load from the implant to the healing bone and do not require a secondary removal operation. Tissue reactions may present a problem and bioresorbable screws are mechanically not as strong as their metal counterparts. OBJECTIVES: To compare bioresorbable implants to non-resorbable implants with respect to functional outcome, wound infections, other complications and reoperation rate,in the fixation of bone fractures or re-attachment of soft tissue to bone. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group Specialised Register (March 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2004), MEDLINE (1966 to February 2004), EMBASE (1988 to February 2004), BL Inside (to February 2004), SIGLE (to February 2004), the metaRegister of Controlled Trials at http//:controlled-trials.com/, and reference lists of articles. SELECTION CRITERIA: Randomised controlled trials (RCTs) and quasi-randomised trials, comparing bioresorbable osteosynthesis with metal osteosynthesis (including titanium and stainless steel implants) were included. DATA COLLECTION AND ANALYSIS: Review authors independently assessed trial quality and extracted data. Data were pooled where relevant and possible. Sub-analyses for specific type of fractures and for specific type of tissue reactions were performed. Requests for more information were sent to trialists. MAIN RESULTS: No significant difference between the bioresorbable and other implants could be demonstrated with respect to functional outcome, infections and other complications. Reoperation rates were lower in some of the groups of people treated with bioresorbable implants. AUTHORS' CONCLUSIONS: In a selected group of compliant patients with simple fractures, the use of bioresorbable fixation devices might be advantageous.

Percutaneous endoscopic gastrostomy as a standard procedure in head and neck surgery.

Adequate nutritional support is essential in patients with head and neck cancer, especially if extended oropharyngeal surgery is indicated. Enteral nutrition is an effective and safe alternative to parenteral nutrition, but the use of nasogastric tubes has several disadvantages in these patients. We describe our experience with percutaneous endoscopic gastrostomy as a standard procedure prior to surgical resection in patients with head and neck cancer.

Manual robot assisted endoscopic suturing: time-action analysis in an experimental model.

BACKGROUND: Robotic surgery systems were introduced to overcome the disadvantages of endoscopic surgery. The goal of this study was to assess whether robot assistance could support endoscopic surgeons in performing a complex endoscopic task. METHODS: Five experienced endoscopic surgeons performed end-to-end anastomosis on post-mortem porcine small intestine. The procedure was performed both with standard endoscopic techniques and with robotic assistance (da Vinci system, Intuitive Surgical, Sunny vale, CA). It was performed in three different working directions with a horizontal, vertical, and diagonal position of the bowel. Anastomosis time, number of stitches, knots, time per stitch, suture ruptures, and the number of stitch errors were recorded. Also, an action analysis was performed. RESULTS: Anastomosis time, number of stitches, and the number of knots did not differ significantly between the two groups. The time needed per stitch was significantly shorter with robot assistance (81.4 sec/stitch vs 95.9 sec/stitch, p = 0.005). More suture ruptures occurred in the robot group (0 (0-2) vs 0 (0-0), p = 0.003). In the standard group more stitch errors were found (2 (0-5) vs 0 (0-3), p = 0.017). These results were comparable for three different working directions. The action analysis, however, showed significant benefits of robotic assistance. The benefits were greatest in a vertical bowel position. CONCLUSION: Robot assistance might offer added value to experienced endoscopic surgeons in the performance of a small-bowel anastomosis in an experimental setup, even though total anastomosis time could not be demonstrated to be shorter and some suture tears occurred due to the lack of force feedback.

Brachial plexus injury in multitraumatized patients.

The majority of patients presenting with a brachial plexus traction injury suffer from multisystem trauma. The consequences are discussed. Occlusion of the axillary artery is an associated lesion which rarely produces ischaemia of the upper limb. Repair may preferentially be carried out together with elective plexus reconstructive surgery.

The floating shoulder. A multicentre study.

The aim of this retrospective study was to review a series of patients with ipsilateral fractures of the neck of the scapula and of the clavicle. Between 1991 and 1996 a total of 79 general and orthopaedic surgeons treated 46 patients with a floating shoulder in The Netherlands. The records and radiographs of these patients were studied. Of the 35 patients available for follow-up, 31 had initially been treated conservatively and four by operation; three underwent secondary reconstructive surgery. The mean Constant score for the 28 patients treated conservatively was 76 and for the seven treated operatively it was 71 at a mean follow-up of 35 months. In six of the 28 patients treated conservatively the glenoid was dislocated caudally at the end of treatment; they had a score of 42. In the 22 patients without this dislocation the score was 85. We conclude that this rare injury is not inherently unstable and, in the absence of caudal dislocation of the glenoid, conservative treatment gives a good functional outcome.

Evaluation of the Singh index for measuring osteoporosis.

We studied the reliability of the Singh classification of trabecular bone structure in the proximal femur as a measure of osteoporosis, using kappa statistics. Radiographs of fractures of the femoral neck or trochanteric region in 80 consecutive patients were assessed by six observers. The interobserver variation was large; only three of 72 radiographs were given the same classification by all six observers and the kappa values ranged from 0.15 to 0.54. the intraobserver variation showed substantial strength of agreement; kappa values ranged from 0.63 to 0.88. In 77 patients dual-energy X-ray absorptiometry was used to measure bone mineral density. The results were compared with those of the Singh classification: we found no correlation.

Subfascial plate fixation of comminuted diaphyseal femoral fractures: a report of three cases utilizing biological osteosynthesis.

Internal fixation with preservation of tissues and vascularization, as in intramedullary fixation and bridging plate osteosynthesis, so-called biological osteosynthesis, has become increasingly popular. Our experiences, in three patients, using a technique of internal fixation of comminuted diaphyseal femoral fractures with an AO plate in subfascial position without exposure of the fracture site is presented. Though based on unorthodox mechanical principles, the safety and efficacy of bridging plates, even when applied in unusual situations, are illustrated.

[Fournier's gangrene]. / Gangreen van Fournier.

Two patients with a necrotizing soft tissue infection of the scrotum and perineum are described. The etiology was found to be a gram negative synergistic gangrene. Patients were managed with extensive necrotectomy with a planned second look operation and supportive antibiotics (aminoglycosides, amoxicillin, metronidazole). Despite this aggressive approach one of the patients died of ongoing necrosis. The therapeutic management for necrotizing soft tissue infection comprises early surgical intervention with supportive antibiotic treatment. Nevertheless the disease is associated with a high mortality rate.

[Swallowed foreign body with perforation of the gastrointestinal system]. / Doorgeslikte corpora aliena met perforatie van het maagdarmkanaal.

A report on five cases, having had a laparotomy for perforation of the intestine by swallowed "radiolucent corpora aliena".

[Tissue decompression for the prevention of complications in fractures of the lower leg. A prospective study]. / Weefseldecompressie ter preventie van ischaemische complicaties bij fracturen van het onderbeen. Een prospectief onderzoek.

Short foot syndrome, a form of Volkmann contracture is a not so rare complication after fractures of the lower leg. Retrospectively we found this complication in 5.1% of our patients. This severe complication is prevented by early fasciotomy for decompression of tissues. Prospectively we studied the results of prophylactic fasciotomy of all 4 muscle compartments of the lower leg in patients with tibial or crural fractures at risk. In the three year period from 1981 to 1983 inclusive we treated 145 patients with 147 fractures of the lower leg. Fasciotomy was performed in 32 cases. In this period we saw only one patient with late sequellae of compartment syndrome. The technique of fasciotomy of all 4 compartments by one parafibular incision is described. Morbidity and postoperative complications are minor.

Results of group-circumcision of Muslim boys in Malaysia with a new type of disposable clamp.

This study evaluates the safety and results of surgery usingTaraKlamp Circumcision Device during a group circumcision. Atotal of 64 circumcisions of Muslim boys were performed by Medical Assistants supervised by Medical Doctors in a hall in Kuala Lumpur, Malaysia. A new type disposable clamp was used, which was removed 4 days after the operation. No major complications occurred and the boys experienced in general mild pain postoperatively. Mostly good cosmetic results were obtained and 90% of the parents would recommend this new clamp to others. Group circumcisions withTaraKlamp Circumcision Device (Kuala Lumpur, Malaysia) are safe, although proper patient selection and adequate training in using the device are mandatory.

[Treatment of septic arthritis of the hand using temporary intermittent immobilization with an external fixator]. / Behandeling van purulente artritis van de hand door tijdelijke intermitterende immobilisatie met een externe fixateur.

OBJECTIVE: To evaluate the treatment of a bacterial infection of a finger joint with incision, drainage and intermittent immobilization using external fixation apparatus. DESIGN: Retrospective, descriptive. SETTING: Department of Surgery, St Elisabeth Hospital, Tilburg. METHOD: In eight males and two females (median age 37 years) with acute bacterial arthritis of a finger joint, this joint was opened surgically, washed out and then immobilized using mini-external fixation equipment, for about 3 weeks. The fixator was unscrewed daily so that the patient could move the finger in water, with the purpose of mechanical cleansing of the joint; the intermittent pressure that occurs in the cartilage during movement is supposed to promote the removal of debris. Subsequently, the finger was fixed in alternating positions to prevent adhesions. Mean duration of follow-up was 48 months (11-78). RESULTS: Arthrodesis had to be carried out in one patient because of persistent arthritis and tissue necrosis, while in one other, part of the finger was amputated. The other eight patients showed good final results, without symptoms. CONCLUSION: In bacterial arthritis of a finger joint, temporary intermittent immobilization using external fixation equipment is certainly worth consideration.

[Rupture of the biceps tendon]. / Bicepspeesrupturen.

Ruptures of the tendon of the biceps muscle usually occur spontaneously because of degeneration and almost always in the proximal tendon of the long head. Experiences of 13 patients with a rupture of the long head are described. Ten patients were treated by operation, the results of simple transposition of the tendon are excellent as long as ruptures have not existed for more than 6 weeks. The indication to operate ruptures of the long head is relative.

[Registration of postoperative complications to improve the results of surgery]. / Registratie van postoperatieve complicaties om de resultaten van chirurgie te verbeteren.

OBJECTIVE: To analyse the consequences of postoperative complications in 1418 surgical patients. DESIGN: Prospective descriptive study. SETTING: St. Elisabeth Hospital in Tilburg, The Netherlands. METHOD: In the period 1986-1992 all postoperative complications and their consequences occurring during or after the clinical treatment of surgical patients were registered. RESULTS: In 5% of the 28,485 surgical procedures (= 1418 patients) postoperative complications were found. To treat these complications, 577 patients had to be reoperated on, 233 patients several times, and generally because of postoperative infections. Readmission after discharge was necessary in 310 patients for treatment of their complications. Mean hospital stay for all patients was 10 days, as against 21 days in patients with postoperative complications. On the basis of the figures recorded, quality enhancing measures were taken, e.g. regarding antibiotic prophylaxis and wound treatment. CONCLUSION: The consequences of postoperative complications are considerable. With respect to quality control in health care it is important to develop national registration and documentation of surgical complications.

[Surgical treatment of toxic megacolon]. / Chirurgische behandeling van het toxisch megacolon.

From 1978 to 1989, 11 patients suffering from toxic megacolon were treated. In eight patients it was based on ulcerative colitis, while Crohns' disease, infectious colitis and pseudomembranous colitis were seen once each. Patients were initially treated with intravenous fluids and corticosteroids. They were closely followed both clinically and radiologically. The plain abdominal X-ray was of great help. Conservative regimen was successful in 3 patients, the remaining had to be operated on in due course. Three patients proved to have a perforation of the bowel at the time of operation. The initial operations performed were one proctocolectomy, four times a subtotal colectomy, twice a partial colectomy and in one instance a diverting colostomy. Two patients had to undergo an additional colon resection. Postoperative complications consisted mainly of intra-abdominal abscesses. Two of the operated patients died. Follow-up is between 2 and 9 years. None of the patients had a recurrence of the toxic megacolon. Four patients had a recurrence of their underlying disease, which however could be resolved in most cases by medical means. In one patient total colectomy is being considered.

[Treatment of isolated ulnar shaft fractures using Sarmiento's method]. / Behandeling van geïsoleerde fracturen van de ulnaschacht volgens Sarmiento.

Twenty-three patients with an isolated fracture of the ulnar shaft were treated by functional bracing as proposed by Sarmiento. Complete functional recovery was achieved quickly in all cases. No pseudarthroses occurred. In those cases in which the ulna had healed with some angulation, no clear restriction of rotation of the forearm was observed. The patients tolerated the treatment well. It is concluded that functional bracing of isolated fractures of the ulnar shaft is an elegant method of treatment with a minimal risk of complications. It is important that associated dislocation of the head of the radius is excluded before the treatment is instituted.

[Differentiated protocol for the conservative/surgical treatment of ankle fractures in children]. / Gedifferentieerd protocol voor de conservatieve/chirurgische behandeling van enkelfracturen bij kinderen.

OBJECTIVE: Evaluation of the long-term results of protocolled treatment of ankle fractures in childhood. SETTING: St Elisabeth Hospital, Tilburg, the Netherlands. DESIGN: Retrospective long-term follow-up study. METHOD: All 78 children with an ankle fracture and an open epiphyseal plate in the period 1985-1989 were treated according to a protocol which specified the indications for conservative or surgical therapy depending on the particular fracture type according to Salter and Harris. After a median follow-up period of 3.42 years (range: 2.08-7.67 years) in 48 patients the treatment results could be evaluated in 92% of these patients. Thirty patients had an isolated fracture of the distal part of the fibula. RESULTS: A clinically 'good' or 'excellent' result was achieved in 100% of the patients, and an 'excellent' result in 68%. CONCLUSIONS: Growth disturbances after an ankle fracture in children with an open epiphyseal plate can now be restricted to the very rare fractures with severe damage to the germinative layer of the epiphyseal plate. In general, conservative treatment should be used in Salter and Harris I and II fractures and operative treatment in displaced Salter and Harris III and IV fractures.

[Differentiated protocol for the conservative/surgical treatment of ankle fractures in adults]. / Gedifferentieerd protocol voor de conservatieve/chirurgische behandeling van enkelfracturen bij volwassenen.

OBJECTIVE: Evaluation of the long-term results of protocol treatment of adult patients with ankle fractures. SETTING: St Elisabeth Hospital, Tilburg, the Netherlands. DESIGN: Retrospective long-term follow-up study. METHOD: All patients (n = 579) with an ankle fracture (580 fractures) in the period 1985-1989, who had not died soon after the injury and in whom the morbidity was not caused mainly by other conditions (n = 30) were treated according to a protocol which specified the indications for conservative or surgical therapy depending on the particular fracture type. After a median follow-up period of 5 years (range: 2.25-8.17 years) the treatment results could be evaluated in 92% of the patients. RESULTS: Clinically "good' or "excellent' results ranging from 79-90.5% types A, B and C fractures (according to the Swiss Arbeitsgemeinschaft für Osteosynthesefragen) were achieved. CONCLUSIONS: A broad indication for conservative, even functional (tape bandaging) treatment and restricted use of implants during osteosynthesis appear justified considering the results obtained.

[Clenched fist injuries from teeth: not to be disregarded]. / Hand-tandletsel: onderschat het niet.

During the delivery of a blow to the jaw, two men, 33 and 34 years of age, suffered an injury at the level of the right metacarpophalangeal joint in, respectively, the 4th and 3rd digit. In both cases, purulent arthritis and destruction of the MCP-joint developed. Clenched-fist injuries are known for their severe complications such as septic arthritis, osteomyelitis and persistent infection leading to amputation. These complications are due to the easy perforation of the MCP-joint capsule and the fact that the patients do not seek medical treatment until a significant inflammatory process has developed. Exploration of the wound on a flexed hand is crucial to exclude perforation of tendon, joint and bone. The wound should be left open to avoid infections. In case of infections, which can be caused by a variety of aerobic and anaerobic bacteria, the recommended treatment is immediate debridement and administration of broad-spectrum antibiotics.