Association between Rift Valley fever virus seroprevalences in livestock and humans and their respective intra-cluster correlation coefficients, Tana River County, Kenya.

We implemented a cross-sectional study in Tana River County, Kenya, a Rift Valley fever (RVF)-endemic area, to quantify the strength of association between RVF virus (RVFv) seroprevalences in livestock and humans, and their respective intra-cluster correlation coefficients (ICCs). The study involved 1932 livestock from 152 households and 552 humans from 170 households. Serum samples were collected and screened for anti-RVFv immunoglobulin G (IgG) antibodies using inhibition IgG enzyme-linked immunosorbent assay (ELISA). Data collected were analysed using generalised linear mixed effects models, with herd/household and village being fitted as random variables. The overall RVFv seroprevalences in livestock and humans were 25.41% (95% confidence interval (CI) 23.49-27.42%) and 21.20% (17.86-24.85%), respectively. The presence of at least one seropositive animal in a household was associated with an increased odds of exposure in people of 2.23 (95% CI 1.03-4.84). The ICCs associated with RVF virus seroprevalence in livestock were 0.30 (95% CI 0.19-0.44) and 0.22 (95% CI 0.12-0.38) within and between herds, respectively. These findings suggest that there is a greater variability of RVF virus exposure between than within herds. We discuss ways of using these ICC estimates in observational surveys for RVF in endemic areas and postulate that the design of the sentinel herd surveillance should consider patterns of RVF clustering to enhance its effectiveness as an early warning system for RVF epidemics.

Inter-epidemic Rift Valley fever virus seroconversions in an irrigation scheme in Bura, south-east Kenya.

Rift Valley fever (RVF) is an acute mosquito-borne viral zoonosis whose outbreaks are often associated with prolonged rainfall and flooding, during which large numbers of vectors emerge. Recent studies into the inter-epidemic maintenance of RVF virus (RVFV) suggest that both vertical transmission in vectors and direct transmission between hosts act in combination with predisposing factors for persistence of the virus. A comparative longitudinal survey was carried out in Tana River County, Kenya, in irrigated, riverine and pastoral ecosystems from September 2014-June 2015. The objectives were to investigate the possibility of low-level RVFV transmission in these ecosystems during an inter-epidemic period (IEP), examine variations in RVFV seroprevalence in sheep and goats and determine the risk factors for transmission. Three hundred and sixteen small ruminants were selected and tested for immunoglobulin G antibodies against RVFV nucleoprotein using a competitive ELISA during six visits. Data on potential risk factors were also captured. Inter-epidemic RVFV transmission was evidenced by 15 seroconversions within the irrigated and riverine villages. The number of seroconversions was not significantly different (OR = 0.66, CI = 0.19-2.17, p = .59) between irrigated and riverine areas. No seroconversions were detected in the pastoral ecosystem. This study highlights the increased risk of inter-epidemic RVFV transmission posed by irrigation, through provision of necessary environmental conditions that enable vectors access to more breeding grounds, resting places and shade, which favour their breeding and survival.

Outcomes in Pancreas Transplantation With Exocrine Drainage Through a Duodenoduodenostomy Versus Duodenojejunostomy.

Until recently, pancreas transplantation has mostly been performed with exocrine drainage via duodenojejunostomy (DJ). Since 2012, DJ was substituted with duodenoduodenostomy (DD) in our hospital, allowing endoscopic access for biopsies. This study assessed safety profiles with DD versus DJ procedures and clinical outcomes with the DD technique in pancreas transplantation. DD patients (n = 117; 62 simultaneous pancreas-kidney [SPKDD ] and 55 pancreas transplantation alone [PTADD ] with median follow-up 2.2 years) were compared with DJ patients (n = 179; 167 SPKDJ and 12 PTADJ ) transplanted in the period 1998-2012 (pre-DD era). Postoperative bleeding and pancreas graft vein thrombosis requiring relaparotomy occurred in 17% and 9% of DD patients versus 10% (p = 0.077) and 6% (p = 0.21) in DJ patients, respectively. Pancreas graft rejection rates were still higher in PTADD patients versus SPKDD patients (p = 0.003). Hazard ratio (HR) for graft loss was 2.25 (95% CI 1.00, 5.05; p = 0.049) in PTADD versus SPKDD recipients. In conclusion, compared with the DJ procedure, the DD procedure did not reduce postoperative surgical complications requiring relaparatomy or improve clinical outcomes after pancreas transplantation despite serial pancreatic biopsies for rejection surveillance. It remains to be seen whether better rejection monitoring in DD patients translates into improved long-term pancreas graft survival.

Effects of climate change on the occurrence and distribution of livestock diseases.

The planet's mean air and ocean temperatures have been rising over the last century because of increasing greenhouse gas (GHG) emissions. These changes have substantial effects on the epidemiology of infectious diseases. We describe direct and indirect processes linking climate change and infectious diseases in livestock with reference to specific case studies. Some of the studies are used to show a positive association between temperature and expansion of the geographical ranges of arthropod vectors (e.g. Culicoides imicola, which transmits bluetongue virus) while others are used to illustrate an opposite trend (e.g. tsetse flies that transmit a range of trypanosome parasites in sub-Saharan Africa). We further describe a positive association between extreme events: droughts and El Niño/southern oscillation (ENSO) weather patterns and Rift Valley fever outbreaks in East Africa and some adaptation practices used to mitigate the impacts of climate change that may increase risk of exposure to infectious pathogens. We conclude by outlining mitigation and adaptation measures that can be used specifically in the livestock sector to minimize the impacts of climate change-associated livestock diseases.

Effects of Irrigation and Rainfall on the Population Dynamics of Rift Valley Fever and Other Arbovirus Mosquito Vectors in the Epidemic-Prone Tana River County, Kenya.

Rift Valley fever (RVF) is a mosquito-borne viral zoonosis that is found in most regions of sub-Saharan Africa, and it affects humans, livestock, and some wild ungulates. Outbreaks are precipitated by an abundance of mosquito vectors associated with heavy persistent rainfall with flooding. We determined the impact of flood-irrigation farming and the effect of environmental parameters on the ecology and densities of primary and secondary vectors of the RVF virus (RVFV) in an RVF-epidemic hotspot in the Tana River Basin, Kenya. Mosquito sampling was conducted in farms and villages (settlements) in an irrigated and a neighboring nonirrigated site (Murukani). Overall, a significantly higher number of mosquitoes were collected in farms in the irrigation scheme compared with villages in the same area (P < 0.001), or farms (P < 0.001), and villages (P = 0.03) in Murukani. In particular, key primary vectors of RVFV, Aedes mcintoshi Marks and Aedes ochraceous Theobald, were more prevalent in the farms compared with villages in the irrigation scheme (P = 0.001) both during the dry and the wet seasons. Similarly, there was a greater abundance of secondary vectors, particularly Culex univittatus Theobald and Culex pipiens (L.) in the irrigation scheme than in the Murukani area. Rainfall and humidity were positively correlated with mosquito densities, particularly the primary vectors. Adult floodwater mosquitoes and Mansonia spp. were collected indoors; immatures of Ae. mcintoshi and secondary vectors were collected in the irrigation drainage canals, whereas those of Ae. ochraceous and Aedes sudanensis Theobald were missing from these water bodies. In conclusion, irrigation in RVF endemic areas provides conducive resting and breeding conditions for vectors of RVFV and other endemic arboviruses.

Standard Approaches to the Acetabulum Part 3: Intrapelvic Approach.

Introduction The intrapelvic approach was originally described by Hirvensalo et al. from Finland in the early 90ies (8) and a further comparable description was published shortly thereafter by Cole et al. (5). Since then, various modifications have been described. Whereas the ilioinguinal approach was used until then to treat acetabular fractures with relevant anterior column involvement from an extrapelvic view, the intrapelvic approach was developed to address the often accompanied central hip dislocation in these fracture types with relevant fractures of the quadrilateral surface. With this approach a complete different view to the antero-medial acetabular pathology was possible. The view from more medial allows a better direct access to joint structures "below" the pelvic brim in the true pelvis (intrapelvic) in contrast to the extrapelvic access with the ilioinguibnal approach. Meanwhile, the surgical technique has been described in detail and some modifications and tricks have been published (5, 8, 10, 13, 19). The intrapelvic approach offers several advantages compared to the ilioinguinal approach: • lower invasiveness without substantial muscle detachment, • direct view of the superior pubic rami from superior and medial, the inferior anterior column and the quadrilateral surface up to the posterior border of the posterior column at the greater sciatic notch, • reduction and fixation of the anterior column and the quadrilateral surface under direct visualization, • reduction of antero-superior marginal impactions under direct visualization, • low risk of heterotopic ossification, • low risk of lesions to the lateral cutaneous femoral nerve. The aim of the third part of "standard approaches of the acetabulum" is to report on the special topics indication, positioning, exposure, incision, dissection, the anatomical basis of osteosynthesis and present results using the via the intrapelvic approach.

Pancreas transplantation with enteroanastomosis to native duodenum poses technical challenges--but offers improved endoscopic access for scheduled biopsies and therapeutic interventions.

To facilitate endoscopic access for rejection surveillance and stenting of the pancreas, we have abandoned the duodenojejunostomy (DJ) in favor of duodenoduodenostomy (DD) in pancreas transplantation (PTx). From September 2012 to September 2013 we performed 40 PTx with DD; 20 solitary-PTx (S-PTx) and 20 simultaneous pancreas and kidney transplantation (SPK). We compared the outcomes with results from 40 PTx-DJ (10 S-PTx and 30 SPK) from the preceding era. The DD-enteroanastomoses were performed successfully. Endoscopic pancreas biopsies (endoscopic ultrasound examination [EUS]) yielded representative material in half of the cases. One exocrine fistula was treated by endoscopic stenting. PTxs-DD were associated with a higher rate of thrombosis compared to PTx-DJ (23% vs. 5%) and reoperations (48% vs. 30%), as well as inferior graft survival (80% vs. 88%). Time on waiting list, HLA A + B mismatches and reoperations were associated with graft loss. Only recipient age remained an independent predictor of patient death in multivariate analysis. PTx-DD showed a higher rate of thrombosis and inferior results, but facilitated a protocol biopsy program by EUS that was feasible and safe. Given that technical difficulties can be solved, the improved endoscopic access might confer long-term benefits, yet this remains to be proven.

The usefulness of MRI and arthroscopy in the diagnosis and treatment of soft-tissue injuries associated with split-depression fractures of the lateral tibial condyle.

The role of arthroscopy in the treatment of soft-tissue injuries associated with proximal tibial fractures remains debatable. Our hypothesis was that MRI over-diagnoses clinically relevant associated soft-tissue injuries. This prospective study involved 50 consecutive patients who underwent surgical treatment for a split-depression fracture of the lateral tibial condyle (AO/OTA type B3.1). The mean age of patients was 50 years (23 to 86) and 27 (54%) were female. All patients had MRI and arthroscopy. Arthroscopy identified 12 tears of the lateral meniscus, including eight bucket-handle tears that were sutured and four that were resected, as well as six tears of the medial meniscus, of which five were resected. Lateral meniscal injuries were diagnosed on MRI in four of 12 patients, yielding an overall sensitivity of 33% (95% confidence interval (CI) 11 to 65). Specificity was 76% (95% CI 59 to 88), with nine tears diagnosed among 38 menisci that did not contain a tear. MRI identified medial meniscal injuries in four of six patients, yielding an overall sensitivity of 67% (95% CI 24 to 94). Specificity was 66% (95% CI 50 to 79), with 15 tears diagnosed in 44 menisci that did not contain tears. MRI appears to offer only a marginal benefit as the specificity and sensitivity for diagnosing meniscal injuries are poor in patients with a fracture. There were fewer arthroscopically-confirmed associated lesions than reported previously in MRI studies.

Husbandry factors and the resumption of luteal activity in open and zero-grazed dairy cows in urban and peri-urban kampala, Uganda.

The study investigated the influence of selected husbandry factors on interval to resumption of post-partum cyclicity among dairy cows in urban and peri-urban Kampala. A prospective study of 85 day post-partum period of 59 dairy cows in open (n = 38) and zero grazing (n = 21) systems was conducted on 24 farms. Cows of parity 1-6 were recruited starting 15-30 days post-partum. Progesterone (P4) content in milk taken at 10-12 day intervals was analysed using ELISA. The cow P4 profiles were classified into 'normal' (< 56 days), 'delayed' (> 56 days), 'ceased' or 'prolonged' (if started < 56 days but with abnormal P4 displays) resumption of luteal activity and tested for association with husbandry and cow factors. Of the 59 cows, luteal activity in 81.4% resumed normally and in 18.6%, delayed. Only 23.7% maintained regular luteal activity, while the others had ceased (10.2%), prolonged (37.3%) or unclear luteal activity (20.3%). There were no differences between open and zero-grazed cows. Milk production was higher (p < 0.05) in zero than open grazing, in urban than peri-urban and in cows fed on brew waste (p < 0.001) compared with mill products and banana peels. Results suggest that luteal activity resumes normally in a majority of cows, although only a minority experienced continued normal cyclicity once ovulation had occurred, in the two farming systems irrespective of feed supplements or water, and that supplementing with brew waste is beneficial for milk production.

Factors predicting the development of early osteoarthritis following lateral tibial plateau fractures: mid-term clinical and radiographic outcomes of 73 operatively treated patients.

BACKGROUND AND AIMS: The indications for operative treatment of lateral tibial plateau fractures are still controversial. The objective of this study was to determine whether residual articular surface depression and valgus malalignment of plated lateral tibial plateau fractures at medium-term follow-up affect the clinical and radiographic outcomes. MATERIAL AND METHODS: A chart review of patients with operatively treated (AO type B3.1) tibial plateau fractures that were admitted to our level I trauma center between 2002 and 2008 was performed. Out of 123 patients, 73 were available to participate in a clinical and radiographic follow-up examination. The mean follow-up time was 54 months. Patients were clinically assessed and completed the Lysholm knee score and Western Ontario and McMaster Universities Osteoarthritis Index. Maximal articular surface depression, radiological mechanical axis, and degree of posttraumatic osteoarthritis were evaluated from standing radiographs. RESULTS: Patients with valgus malalignment of 5° or greater at follow-up developed more advanced osteoarthritis (Kellgren-Lawrence grade 3-4) than patients with a normal mechanical axis (p = 0.006). Similarly, patients with articular depression greater than 2 mm at follow-up also developed more advanced osteoarthritis compared to patients with a depression of 2 mm or less (p = 0.001). The degree of valgus malalignment or articular depression had no effect on the Western Ontario and McMaster Universities Osteoarthritis Index or Lysholm scores. CONCLUSIONS: The postoperative articular congruity and normal mechanical axis of the lower leg after plate fixation in lateral tibial plateau fractures seem to have a role in prevention of posttraumatic osteoarthritis but does not appear to predict clinical outcome at medium-term follow-up. The role of initial dislocation and associated cartilage damage in the development of osteoarthritis following these fractures is still unknown.

Improved patient survival with simultaneous pancreas and kidney transplantation in recipients with diabetic end-stage renal disease.

AIMS/HYPOTHESIS: We aimed to determine whether simultaneous pancreas and kidney (SPK) transplantation would improve patient and kidney graft survival in diabetic end-stage renal disease (ESRD) compared with kidney transplantation alone (KTA). METHODS: Follow-up data were retrieved for all 630 patients with diabetic ESRD who had received SPK or KTA at our centre from 1983 to the end of 2010. Recipients younger than 55 years of age received either an SPK (n = 222) or, if available, a single live donor kidney (LDK; n = 171). Older recipients and recipients with greater comorbidity received a single deceased donor kidney (DDK; n = 237). Survival was analysed by the Kaplan-Meier method and in multivariate Cox regression analysis adjusting for recipient and donor characteristics. RESULTS: Patient survival was superior in SPK compared with both LDK and DDK recipients in univariate analysis. Follow-up time (mean ± SD) after transplantation was 7.1 ± 5.7 years. Median actuarial patient survival was 14.0 years for SPK, 11.5 years for LDK and 6.7 years for DDK recipients. In multivariate analyses including recipient age, sex, treatment modality, time on dialysis and era, SPK transplantation was protective for all-cause mortality compared with both LDK (p = 0.02) and DDK (p = 0.029) transplantation. After the year 2000, overall patient survival improved compared with previous years (HR 0.40, 95% CI 0.30, 0.55; p < 0.001). Pancreas graft survival also improved after 2000, with a 5 year graft survival rate of 78% vs 61% in previous years (1988-1999). CONCLUSIONS/INTERPRETATION: Recipients of SPK transplants have superior patient survival compared with both LDK and DDK recipients, with improved results seen over the last decade.

Angiographic embolization in the treatment of arterial pelvic hemorrhage: evaluation of prognostic mortality-related factors.

PURPOSE: The control of arterial bleeding associated with pelvic ring and acetabular fractures (PRAF) remains a challenge for emergency trauma care. The aim of the present study was to uncover early prognostic mortality-related factors in PRAF-related arterial bleedings treated with transcatheter angiographic embolization (TAE). METHODS: Forty-nine PRAF patients (46 pelvic ring and three acetabular fractures) with arterial pelvic bleeding controlled with TAE (within 24 h) were evaluated. RESULTS: All large arterial disruptions (n = 7) were seen in type C pelvic ring injuries. The 30-day mortality in large vessel (iliac artery) bleeding was higher (57 %) than in medium- or small-size artery bleeding (24 %). Overall 30-day mortality was 29 %. No statistically significant difference in the first laboratory values between the survivors and nonsurvivors was found. However, after excluding patients dying of head injuries (n = 5), a reasonable cut-off value was identified for the base excess (BE; lower than -10 mmol/l) obtained on admission. CONCLUSIONS: PRAF patients with exsanguinating bleeding from the large pelvic artery have the worst prognosis. Very low BE values (<-10.0 mmol/l) on admission for exsanguinating patients have a negative predictive value for survival, thus anticipating a poor outcome in bleeding controlled with TAE only and an increased risk of death. In critical cases, an aggressive bleeding control protocol prompts extraperitoneal pelvic packing prior to TAE. PRAF-related rupture of the external iliac artery is rare and indicates surgical techniques in controlling and restoring blood supply to the lower leg.

Evaluation tools and outcomes after osteosynthesis of unstable type B and C pelvic ring injuries.

The evaluation of present long-term studies on results after surgical stabilization of the pelvic ring is difficult, as different treatment concepts are used and the majority of these studies are not comparable regarding selected evaluation parameters. Additionally, no standardized measurement instrument exists to analyze the clinical and radiological result after pelvic ring injuries. Only short-term evaluations with a mandatorily recommended minimum follow-up time of one year are available. Medium-term analyses or real long-term analyses are missing. Present data show an increase of long-term sequelae from stable type A injuries to completely unstable type C injuries. Concomitant injuries of other injury regions around the body as well as additional injuries to the pelvic region (complex pelvic trauma) seem to influence the overall results. Therefore, in the future it is necessary to develop a sufficient pelvic outcome instrument which addresses these parameters. Additionally, results of treatment of specific fracture types depend on the chosen stabilization method. Overall, as single centres have only "limited" experience in treating pelvic ring injuries within a short period of time, and there is a wide range of completely different injury types and different treatment concepts, for future evaluation of long-term results after pelvic ring injuries prospective, multicenter outcome studies are recommended.

Severe pelvic fracture-related bleeding in pediatric patients: does it occur?

PURPOSE: Pediatric pelvic fractures are rare and less likely to cause hemodynamic instability than similar injuries in adult patients. The associated injuries are common, and they have a major impact on mortality. The aim of the present study was to evaluate the risk of life-threatening hemorrhage associated with unstable pelvic fractures in children. METHODS: We identified retrospectively all pediatric pelvic fractures (ring and acetabulum) treated at Helsinki University Central Hospital during a 10-year period (1998-2007). Stable A-type fractures (fractures not involving the pelvic ring) were excluded. All available pre- and in-hospital medical records were reviewed. The collected data consisted of patient characteristics, mechanisms of injury, vital signs, laboratory tests, care given, other injuries diagnosed, and the 30-day survival rate. RESULTS: There were 71 (40 males) pediatric patients (median age 14, range 1-16 years) with unstable pelvic fractures; 66 pelvic ring and 5 acetabulum fractures. The most common mechanism of injury was traffic accident (69%). Four patients had life-threatening bleeding. All had fracture of a mature pelvic ring, but the source of massive bleeding was pelvic ring fracture in only two patients (2.8% of all patients). No acetabulum fracture-related major pelvic bleeding was observed. One patient (age 16 years) required emergency surgery and angioembolization for pelvic bleeding. No life-threatening pelvic bleeding was seen among patients with immature bony pelvis. Pelvic ring fractures were surgically treated in 25 patients. Two patients died from head injuries (overall mortality 2.8%), but there were no bleeding-related deaths. CONCLUSIONS: We conclude that life-threatening bleeding from pelvic or acetabular fractures in pediatric patients is rare (2.8%), and does not contribute to the overall mortality.

Hybrid external fixation in treatment of proximal tibial fractures: a good outcome in AO/ASIF type-C fractures.

INTRODUCTION: The treatment of proximal tibial fractures is often challenging, and internal fixation is occasionally associated with problems in wound healing due to frequently co-existing soft tissue injuries. External fixation of these fractures have yielded satisfactory results, but some studies have reported problems in the achievement and maintenance of fracture reduction. The purpose of the present study was to evaluate the performance of a hybrid external fixator in the treatment of different types of proximal tibial fractures. MATERIALS AND METHODS: Thirty-three proximal tibial fractures, of which 20 were high energetic, were treated with a hybrid external fixator (Tenxor Strker-Howmedica) in the acute phase. Fracture categorisation was done according to AO/ASIF, and the reduction was performed most often by closed means or through mini-open reduction (26/78.8%). The patients were followed up to an average of 12.7 months (range 10-22) and were evaluated with radiographs and clinical examinations. RESULTS: Five AO/ASIF type-C intraarticular fractures had a poor postoperative reduction, and were thus treated with internal fixation in a second operation. Of the remaining 28 patients, local and transient pin tract infection was observed in seven patients, and one had septic arthritis of the knee. All 13 C1 and five of six C2/C3 fractures united in mean time of 15.1 weeks, whereas three of nine type-A fractures failed to unite, albeit an adequate reduction, and needed a second operation (odds ratio 11.4, 95% CI 1.0-143, compared with type-C fractures). For the remaining six type-A fractures, the mean healing time was 24 weeks (mean difference 8.9, 95% CI 6-12 weeks compared with type-C fractures). Age over 48 and the presence of an open fracture, but not fracture type, gender, or the level of injury energy, correlated to a poor subjective outcome. CONCLUSIONS: The hybrid external fixation method we have used is safe, and type-C1 fractures are particularly suitable to be treated with this method. However, even C2/C3 fractures may be candidates for this method, but a meticulous fracture reduction should be performed. Type-A fractures are liable to healing problems when the fixator is used as a rigid complex.

Clinical and MRI evaluation of meniscal tears repaired with bioabsorbable arrows.

BACKGROUND AND AIMS: Excision of meniscal tissue has been shown to increase the risk of degenerative changes of the knee joint. Whenever possible, meniscus repair has become the procedure of choice for treatment of meniscal tears. MATERIALS AND METHODS: The present retrospective study evaluated the healing results of 77 meniscal ruptures treated with the an all-inside technique (Biofix meniscus arrow). The study group consisted of 73 patients with 77 longitudinal, vertical meniscal ruptures treated at Helsinki University Hospital between the beginning of January 1997 and the end of March 2001. The patients who had not received secondary surgery for failed repair during the follow-up period were examined clinically and with MRI. RESULTS: Fifty-one out of 77 meniscal ruptures (66%) healed clinically. In repairs performed in conjunction with ligament reconstruction the healing rate was higher (79%) than in the isolated tears (56%). The poorest results were seen in the very long vertical tears with luxation of the meniscus (38% healing rate). CONCLUSIONS: Bioabsorbable arrows offer a good alternative for treatment of meniscal ruptures, but the arrows alone do not seem to be sufficient to provide a reliable long-lasting result in the repair of very unstable meniscal ruptures.

Lateral approach for fixation of the fractures of the distal tibia. Outcome of 20 patients. Technical note.

INTRODUCTION: The treatment of fractures of the distal third of the tibia remains still controversial. It is often difficult to get and retain good reduction by non-operative or nailing methods. Open reduction and plate fixation offers good reduction and retention of the achieved position. However, increased soft tissue damage and high complication rate has led to search less invasive surgical methods such as minimal invasive plating technique. MATERIAL AND METHODS: Lateral approach for the distal tibia allows to reduce and to plate both the fibula and the tibia using only one skin incision. We have used lateral approach for 20 consecutive tibia fracture patients and report clinical and radiological results after an average follow-up of 31 months. RESULTS: All fractures united, but two malunions were developed after good primary reduction. Seventeen patients achieved excellent or good subjective result while one had moderate and two poor results. Four superficial wound infections were noticed and they were treated conservatively. CONCLUSION: We conclude that lateral approach for the distal tibia is a demanding, but useful surgical method for treatment of the distal tibia fractures especially in cases where no medial comminution of the tibia is present and when the fibula has to be fixed, too.

Finnish Trauma Audit 2004: current state of trauma management in Finnish hospitals.

There is great variation in the organisation of trauma care in European countries. The state of trauma care in Finnish hospitals has not been appropriately reviewed in the past. The aim of the present study conducted by the Finnish Trauma Association (FTA) was to assess the number of Finnish hospitals admitting severe trauma patients, and to evaluate the organisation and training of trauma care in those hospitals. In 2004, a telephone survey to all the Finnish hospitals was conducted, and information on the number of severe trauma patients treated per month, the organisation of acute trauma care, and the existence of multidisciplinary trauma care training was collected. Thirty-six Finnish hospitals admitted trauma patients. The range of estimated number of severely injured trauma patients treated in individual hospitals per month varied from 0.5 to 12, resulting in an estimated number of 1000-1300 patients with severe trauma treated in Finland every year (19-25/100.000 inhabitants). About 20% of the hospitals had a trauma team, and 25% had a systematic trauma education program. Only one hospital had established multidisciplinary and systematic trauma team training. The case load of severe trauma patients is low in most Finnish hospitals making it difficult to obtain and maintain sufficient experience. Too many hospitals admit too few patients, and only a few hospitals have been working on updating their trauma management protocols and education. There is an obvious need for leadership, discussion, legislation and initiatives by the professional organisations and the government to establish a modern trauma system in Finland.

Pertrochanteric femoral fractures treated with a dynamic hip screw or a proximal femoral nail. A randomised study comparing post-operative rehabilitation.

We treated 108 patients with a pertrochanteric femoral fracture using either the dynamic hip screw or the proximal femoral nail in this prospective, randomised series. We compared walking ability before fracture, intra-operative variables and return to their residence. Patients treated with the proximal femoral nail (n = 42) had regained their pre-operative walking ability significantly (p = 0.04) more often by the four-month review than those treated with the dynamic hip screw (n = 41). Peri-operative or immediate post-operative measures of outcome did not differ between the groups, with the exception of operation time. The dynamic hip screw allowed a significantly greater compression of the fracture during the four-month follow-up, but consolidation of the fracture was comparable between the two groups. Two major losses of reduction were observed in each group, resulting in a total of four revision operations. Our results suggest that the use of the proximal femoral nail may allow a faster post-operative restoration of walking ability, when compared with the dynamic hip screw.

Femoral shaft medialisation and neck-shaft angle in unstable pertrochanteric femoral fractures.

We analysed the time-dependent mean changes in the femoral neck length, neck-shaft angle and hip offset in a randomised study comprising 48 patients who were treated with the dynamic hip screw (DHS) or the proximal femoral nail (PFN) for an unstable intertrochanteric femoral fracture. As a consequence of fracture compression, the mean post-operative neck length was significantly shorter in patients treated with the DHS. During the first 6 weeks after the operation, a mean decrease of 4.6 degrees was observed in the neck-shaft angle, but there was not a significant difference between the treatment groups. The radiographic measures remained virtually unaffected during the interval from 6 weeks to 4 months in both groups. When the operated hip was compared to the opposite hip, patients who had received the DHS showed significantly greater medialisation of the femoral shaft at 4 months than those treated with the PFN. We thus recommend that unstable intertrochanteric fractures should be initially reduced in a slight valgus position in order to achieve an outcome after healing that is as normal as possible. As a result of differences in operative technique and implant stability, the PFN may be superior to the DHS in retaining the anatomical relations in the hip region in unstable intertrochanteric fractures.