Volar Plate Fixation Versus Cast Immobilization in Acceptably Reduced Intra-Articular Distal Radial Fractures: A Randomized Controlled Trial.

BACKGROUND: The evidence for the treatment of acceptably reduced intra-articular distal radial fractures remains inconclusive. We therefore compared the functional outcomes of cast immobilization (nonoperative) and volar plate fixation (operative) for patients with these fractures. METHODS: This multicenter randomized controlled trial enrolled patients between 18 and 75 years old with an acceptably reduced intra-articular distal radial fracture. Patients were randomized to nonoperative treatment or to operative treatment. The primary outcome measure was the Patient-Rated Wrist Evaluation (PRWE) score after 12 months. Secondary outcome measures were the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire; the Short Form-36 (SF-36) questionnaire; a visual analog scale for pain; range of motion; grip strength; radiographic parameters; and complications. Analyses followed the intention-to-treat principle. RESULTS: A total of 96 patients were randomized, and 90 (46 in the nonoperative group and 44 in the operative group) were included in the analysis. Patients treated in the operative group had significantly better functional outcomes measured with the PRWE at 6 weeks, 3 months, 6 months, and 1 year. Additionally, a 28% rate of subsequent surgery was identified in the nonoperative group. CONCLUSIONS: Adult patients with an acceptably reduced intra-articular distal radial fracture have better functional outcomes for 12 months when treated operatively instead of nonoperatively. We therefore recommend surgical treatment for patients with these fractures. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Z-effect after intramedullary nailing systems for trochanteric femur fractures.

PURPOSE: The aim of this study was to investigate the incidence of Z-effect after dual lag screw intramedullary nailing systems and risk factors contributing to this effect. We hypothesized that long nails provide more neck strength due to a longer lever than short nails and are therefore less likely to develop a misbalance of a higher head compressive strength than neck compressive strength. METHODS: In this retrospective cohort study 103 patients treated operatively with a dual lag screw intramedullary nailing device for (sub)trochanteric hip fracture were included. We analysed patient charts regarding patient and operation characteristics. Furthermore we conducted radiologic measurements within the 2-year follow-up period to investigate the quality of fracture fixation, implant failure and predictors for Z-effect. The re-operation risk was investigated with multivariate regression analysis. RESULTS: The incidence of (reversed) Z-effect in this study was 9% (n = 80); 6 out of 7 Z-effects occurred in the short nail group, which was not significant. Patients who were treated with a long nail had a significant larger number of complications in comparison with the short nail group (median 2 vs 0.5, p = 0.001). The long nail group received more often erythrocytes blood transfusions (82% vs 31%, p < 0.01) and had a longer hospital stay (13 vs 21 days, p < 0.05). Migration of lag screws (p <0.05) and unstable fracture type (p < 0.05), were risk factors for re-operation. The re-operation rate within 2 year after surgery was 21%, of which one fourth was due to a Z-effect. CONCLUSION: The nail length was not associated with the development of a Z-effect. Migration of lag screws after intramedullary nailing is common and a risk factor for re-operation.

Non-operative treatment of displaced distal radius fractures leads to acceptable functional outcomes, however at the expense of 40% subsequent surgeries.

BACKGROUND: Although secondary displacement following closed reduction and plaster immobilisation is high, several guidelines still recommend non-operative treatment for displaced distal radius fractures with an adequate closed reduction. PURPOSE: The purpose of this study was to evaluate functional outcomes, measured with the Disability of the Arm, Shoulder and Hand (DASH) questionnaire, in non-operative treated patients with displaced distal radius fractures and an adequate closed reduction confirmed on radiograph. MATERIALS AND METHODS: From a retrospective database, we reviewed non-operative treated adult patients with an unilateral displaced distal radius fracture and adequate closed reduction confirmed on radiograph. The primary outcome was the DASH score at 12months. DASH scores were prospectively collected pre-trauma and at three, six and 12months. Secondary outcome was the number of subsequent surgeries due to secondary displacement or a symptomatic malunion, and their possible predictors. Additionally, the difference in DASH scores between patients who were treated due to secondary displacement and asymptomatic malunion was compared. RESULTS: One-hundred and sixteen patients were included. The median age was 62 years and 79% was female. Fractures were classified according to the AO/OTA classification as follows: AO/OTA type A (49%), AO/OTA type B (3%), AO/OTA type C (48%). After 12months the median DASH score was 15. Forty-six (40%) patients underwent subsequent surgery due to a secondary displacement or symptomatic malunion. No significant differences in DASH scores between patients who were treated non-operatively and patients who received subsequent surgery were found. Younger patients were more likely to undergo subsequent surgery. Patients with a symptomatic malunion had significant higher DASH scores compared to patients with secondary displacement. DISCUSSION: Non-operative treatment of displaced distal radius fractures after adequate closed reduction confirmed on radiograph leads to acceptable functional outcomes after 12months, however, at the expense of 40% subsequent surgeries. LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

[Chronic neuralgia after knee surgery]. / Chronische zenuwpijn na een operatie aan de knie.

BACKGROUND: Chronic knee symptoms after surgery around the knee may be neuropathic. These symptoms are often described after intramedullary osteosynthesis of the lower leg, placement of total knee prosthesis and arthroscopy. This neuropathic pain may be caused by partial damage to the infrapatellar nerve. CASE DESCRIPTION: An 18-year-old patient had chronic neuropathic symptoms after intramedullary osteosynthesis of the lower leg. The diagnosis was made through physical examination and injection of lidocaine 1%. After surgical removal of the infrapatellar nerve, the patient became symptom-free for a long time. CONCLUSION: In case of chronic pain around the knee, neuropathic pain resulting from infrapatellar nerve damage should be part of the differential diagnosis. Neurectomy of the patellar nerve is a good treatment if conservative therapy did not lead to improvement of the symptoms.

Surgical options after a failed neurectomy in anterior cutaneous nerve entrapment syndrome.

BACKGROUND: Injection treatment followed by an anterior neurectomy in patients insufficiently responding to an injection regimen is successful long term in three-quarters of patients with anterior cutaneous nerve entrapment syndrome (ACNES). The efficacy of secondary surgery, including re-exploration or a posterior neurectomy in patients reporting recurrent pain after initially successful surgery or following an immediately failed anterior neurectomy is unknown. METHODS: A database of ACNES patients receiving surgery between 2004 and 2012 in the SolviMáx institution was analysed. Adult patients with residual pain after an anterior neurectomy (failures) or with recurrent pain after initially successful surgery (recurrences) were selected. Following a re-exploration or a posterior neurectomy, pain was scored using a pain intensity numeric rating scale (PI-NRS 0-10) and a six-point verbal category rating scale (VRS). Success was defined as a ≥50 % PI-NRS reduction and/or ≥2 point VRS reduction. RESULTS: ACNES patients undergoing an anterior neurectomy (n = 181) were analysed during the 8-year study period. At follow-up, 51 patients reported unacceptable pain levels following an anterior neurectomy, whereas 20 developed recurrent abdominal wall pain. Of these 71 unsuccessful patients, 41 underwent secondary surgery, including a re-exploration (n = 10), or a posterior neurectomy (n = 31). After a 25-month median follow-up, secondary surgical treatment regimens proved successful in 66 % (27/41). Patients with recurrent pain did better (14/15) than patients who were immediate failures after the anterior neurectomy (13/26, p = 0.01). CONCLUSIONS: Secondary surgery including re-explorations and posterior neurectomies are successful in two-thirds of ACNES patients with persistent pain or recurrence of pain after an anterior neurectomy.

Bio-resorbable versus metal implants in wrist fractures: a randomised trial.

BACKGROUND: Distal radius fractures are often surgically treated if insufficient reduction has been achieved or after conservative treatment has failed. Treatment using metal implants often demands a secondary operation to remove the implant. A bio-resorbable implant (in this study the Reunite osteosynthesis plate by Biomet Inc) should obviate the need for a secondary operation with equal functional results. MATERIALS AND METHODS: Thirty-two patients with a distal radius fracture were assigned to treatment with either a bio-resorbable implant (N = 19) or a metal implant (N = 13). Both groups received the same postoperative care and were followed for 52 weeks in the outpatient clinic. The hypothesis of this study was a decrease in re-operation rate in the experimental group with equal functional results. RESULTS: Five out of 19 patients treated with the Reunite plate were re-operated and four out of 13 treated with metal implants needed a secondary operation. In both implants, equal functional results in Range of Motion and DASH scores were found. CONCLUSION: There were no significant differences between the experimental and control group with respect to re-operations, DASH scores and Range of Motion. Because of the higher initial costs and equal results, the use of bio-resorbable implants must be considered carefully.

An X-ray template assessment for distal radial fractures.

BACKGROUND: The current method for radiological measurements on plain X-rays of distal radius fractures is unreliable. We examined the reproducibility of a new X-ray assessment technique-where the uninjured side is used as a template for the injured side-compared to the conventional assessment technique. METHODS: X-rays of 30 patients with a unilateral distal radial fracture were included reflecting the prevalence of AO fracture types in clinical practice. Eight experienced observers assessed these X-rays on two separated occasions (2-month interval) using the traditional measurement technique and the template technique. Reproducibility of the X-ray assessments was quantified by intraclass correlations and weighted kappa coefficients. RESULTS: The reproducibility of the radial length measurement did not improve nor did the volar angulation measurement. However, marked improvement in reproducibility was observed for the radial inclination measurement, the kappa increased from 0.36 (95 % CI; 0.30-0.41) to 0.49 (95 % CI; 0.43-0.55) in the template technique. As a result, the classification of the reduction results (Lidström score) greatly improved. The overall kappa for the Lidström score improved from 0.37 (95 % CI; 0.31/0.43) to 0.59 (0.52/0.63). CONCLUSION: The assessment technique using the uninjured side as a template for the injured side resulted only in an improved reproducibility of the radial inclination measurement which in turn resulted in an improved classification reproducibility of the reduction results.

[Sore throat and a swollen neck: Lemierre's syndrome until proven otherwise]. / Keelpijn en een gezwollen hals: syndroom van Lemierre totdat het tegendeel is bewezen.

Physicians seldom prescribe antibiotics to patients presenting with a combination of sore throat and feelings of malaise. However, this restrictive regimen may have a downside. Two patients, men aged 23 and 19 years, respectively, with pharyngitis developed a life-threatening syndrome following a Fusobacterium throat infection. They suffered from Lemierre's syndrome, referred to in recent literature as the 'forgotten disease'. The second patient recovered uneventfully after prompt intravenous antibiotic treatment. The first, however, succumbed following overwhelming multiple organ failure. A classical case of Lemierre's syndrome is characterised by bacterial embolisation from a clogged internal jugular vein following a sore throat. Spread of organisms may lead to sepsis and organ failure. The main pathogen is Fusobacterium necrophorum. Early recognition is essential, since prompt antibiotic treatment is usually effective. This syndrome should be suspected until proven otherwise in any patient with signs of pharyngitis, a painful swollen neck and pulmonary symptoms.

Minimally invasive femoral nail extraction.

INTRODUCTION: Case report about a minimally invasive technique for removal of a femoral antegrade nail (FAN). Femoral nails are introduced by minimally invasive techniques, but are often removed with more invasive surgery. MATERIALS AND METHODS: Four cases of young patients are described in whom the femoral nail was removed after consolidation by a minimally invasive extraction technique at the trochanteric site. By using a threaded wire for locating the proximal entrance of the femoral nail followed by reaming over the wire, the entrance of the nail in the trochanteric region is freed. Then the extraction bolt can be placed over the wire and the nail can be extracted through the same incision as it was inserted in, without enlarging the incision. DISCUSSION: This case report discusses a technique for minimally invasive femoral nail extraction, not the necessity of removing nails. Leaving out the endcap at the initial operation is the only preoperative condition, since the endcap blocks the entrance of the nail. This operation is done with fluoroscopic guidance. The difficult part is the reaming. The reamer must not be damaged when approaching the nail entrance. This minimally invasive femoral nail extraction technique is applicable for various types of femoral nails. CONCLUSION: Minimally invasive extraction of femoral nails is possible and needs more attention. The level of evidence is a level IV case series.

Los function and obesity: the impact of untreated obesity, weight loss, and chronic gastric balloon distension.

BACKGROUND/AIMS: In obesity, many gastro-oesophageal reflux promoting factors are present. Weight reduction is advised to symptomatic overweight subjects. The aim of the present study was to investigate the influences of untreated obesity, weight loss, and chronic gastric balloon distension on the lower oesophageal sphincter (LOS) function. METHODS: Patients entering a randomized, double-blind, sham-controlled study of balloon treatment, consisting of 4 months of either sham balloon or balloon treatment followed by 4 months of balloon treatment. Manometry and 24-hour pH measurements were performed at the start of the study and after 13 and 26 weeks. RESULTS: Before treatment, LOS dysfunction was present in 7 of 32 patients (21.9%). Increased upright and supine reflux was present in 8 patients (25%). Sham treatment resulted in a weight loss of 9.7% with improved LOS function (a significant 0.6-cm increase in LOS length and a non-significant 2.6 mm Hg higher LOS pressure) and in a significantly decreased upright reflux (acid reflux time decreasing from 8.0 to 5.5% and number of meal-related and postprandial reflux episodes decreasing from 49 to 32). These improved values deteriorated after 4 months of balloon placement, with significantly increasing total, upright, and supine reflux to 7.5, 7.6, and 6.7% of the time, respectively, with oesophageal lesions after an overall 17.8% weight loss. Four months of balloon treatment induced a similar weight loss (9.9%) with significantly increased supine reflux from 1.6 to 6.7% of the time. After a second 4-month balloon period and an overall 13.8% weight loss, LOS and reflux values returned towards baseline values. A comparison of both groups demonstrated the adverse effects of balloon positioning after a period of substantial sham-induced weight loss. CONCLUSIONS: Impaired LOS function and increased gastro-oesophageal reflux were observed in one quarter of the untreated obese subjects. Weight loss ameliorated manometry and pH values, but subsequent balloon positioning tended to counteract these beneficial changes. In patients on balloon treatment from the start, adverse effects seemed to wear off with prolonged treatment.

Selective use of diagnostic laparoscopy in patients with suspected appendicitis.

BACKGROUND: Diagnostic laparoscopy has been introduced as a new diagnostic tool for patients with acute appendicitis. We performed diagnostic laparoscopy when the clinical diagnosis of appendicitis was in doubt. The aims of this study were to evaluate this strategy and to analyze the efficacy of diagnostic laparoscopy in patients with suspected appendicitis. PATIENTS AND METHODS: All patients referred to our hospital with suspected appendicitis during the period 1994-1997 were evaluated prospectively. The clinical diagnosis was determined by the surgeon or resident on call based on the patient's history, physical examination, and leukocyte count. The patients were divided into three groups: group 1: appendicitis not likely. These patients were observed for 24 h or discharged. When they showed signs of appendicitis in 24 h, they were transferred to either group 2 or 3; group 2: doubt concerning diagnosis. These patients underwent diagnostic laparoscopy, and appendectomy was performed if indicated; group 3: In these patients the diagnosis appendicitis was felt to be certain. They were treated by primary appendectomy by an open procedure. In this study, 1,050 patients, 531 women (51%), 389 men (37%), and 130 children (12%) <11 yrs, were evaluated. RESULTS: Altogether, 377 diagnostic laparoscopies were performed, leaving 109 healthy-looking appendices in place. This reduced the negative appendectomy rate from 25% to 14% in all surgically managed patients. The negative appendectomy rate for the women in group 2 was reduced from 49% to 14%, and for the men from 22% to 11%, so it also seemed worthwhile to perform diagnostic laparoscopy in men. Because the appendix sana was left in place in only three children, the benefit from laparoscopy is relatively small for children. In 48% of these patients a second diagnosis was obtained, most of them gynecologic in nature. There were no false-negative laparoscopies and no complications resulting from the laparoscopic procedure. CONCLUSIONS: Diagnostic laparoscopy is a safe procedure that reduced the appendix sana rate without increasing the total number of operations. It is a useful method for obtaining other, mostly gynecologic, diagnoses. To further reduce the appendix sana rate, better criteria for laparoscopic assessment of the appendix are needed.

Operative treatment of meralgia paresthetica: transection versus neurolysis.

The question of the superior operative technique for meralgia paresthetica is unsettled. Operative treatment by either neurolysis or transection of the lateral femoral cutaneous nerve was performed in 21 patients with meralgia paresthetica after complete failure of conservative treatment; neurolysis in 10 patients and transection in 11 patients were performed by five neurosurgeons. The average follow-up period was 74 months (+/- 52 mo). The results were scored as complete relief, partial relief, or failure. Direct comparison of neurolysis and transection confirmed the superiority of transection as a treatment for meralgia paresthetica (Mann-Whitney-U test, P = 0.022; one-sample sign test, P = 0.0020).

[Bariatric surgery using an adjustable gastric band for morbid obesity: initial 30 patients in The Netherlands]. / Bariatrische chirurgie met een variabele maagband voor morbide obesitas: eerste 30 patiënten in Nederland.

OBJECTIVE: Early evaluation of efficacy and safety of Adjustable Silicone Gastric Banding (ASGB) in the treatment of morbid obesity. DESIGN: Descriptive. SETTING: Red Cross Hospital, Beverwijk, the Netherlands. METHOD: In the period September 1991-September 1993, 30 eligible patients (5 men and 25 women, median age 37 years (range 22-60), median excessive weight 63 kg (18-94), median body mass index (BMI) 43 kg/m2 (28-53)) were operated. A horizontal gastroplasty was performed resulting in a pouch of 25 ml and a new stomach outlet with a diameter of 12 mm. The volume of the band may be increased in order to diminish the diameter of the outlet according to clinical needs postoperatively. RESULTS: The follow-up was 10 months in 13 of the 30 patients. After 6 months median BMI was 33 kg/m2 (23-38) and median loss of excessive weight 53% (27-94), after 10 months these 28 kg/m2 (23-38) and 67% (27-98) respectively. No patients died perioperatively; 52 gastric band adjustments were necessary in 17 patients. Complications consisted of: band dislocation (1 patient), functional stenosis (2), gastric perforation (2) and wound infection (1). Four patients needed reoperation. CONCLUSION: In this short term follow-up ASGB gave a good weight reduction. Advantages of ASGB are the reversibility of the operation and the adjustable outlet.