[Treatment of tibial shaft fractures in Denmark]. / Behandling af crusfrakturer i Danmark.

INTRODUCTION: Only a few randomised studies have been published on the treatment of tibial shaft fractures. We therefore expected a great diversity in the choice of treatment methods in Denmark. In order to analyse this, we carried out a questionnaire investigation. MATERIAL AND METHODS: In autumn 1997, a questionnaire was sent to all departments in Denmark where tibial fractures are treated. The fractures were classified according to stability, amount of energy, and the degree of soft tissue injury. RESULTS: Ninety-three per cent of the departments answered the questionnaire. We present here the results with respect to the use of antibiotics, thrombosis prophylaxis, invasive pressure measuring, and the choice of treatment: conservative or operative methods and techniques. DISCUSSION: As expected, we found a significant variation in the choice of treatment of tibial shaft fractures in Denmark. This is consistent with the recommendations in the literature, which vary somewhat and are mostly based on non-randomised studies.

Results after surgery for severe Dupuytren's contracture: does a dynamic extension splint influence outcome?

Seventy-six consecutive patients were operated on for advanced Dupuytren's contracture and the results evaluated after nine months with special reference to the use of a dynamic extension splint. The patients were separated into three groups: those in whom the splint was used according to our guidelines (n = 15); those in whom the splint was used, but inadequately (n = 15); and those who did not require splinting (n = 24). Our results nine months postoperatively were similar to those of other studies in showing that the fifth proximal interphalangeal joint constituted the greatest problem. Comparison of the three groups indicated that splinting the way we used it did not influence the natural course of the disease after operation.

Level of amputation following failed arterial reconstruction compared to primary amputation--a meta-analysis.

OBJECTIVES: To determine if the level of amputation after failed vascular reconstruction was comparable to the level of amputation after primary amputation. DESIGN AND METHODS: Medline literature search (1975-1996), meta-analysis. RESULTS: The odds ratio of transtibial to transfemoral (TT/TF) amputations was 927/657 = 1.41 (95% confidence limits: 1.278-1.561) in postrevascularisation amputation (PRVA) and 1590/1162 = 1.37 (95% confidence limits: 1.269-1.477) in primary amputation (PA) (p = 0.65). The pooled data show that the number of conversions from transtibial (TT) to transfemoral (TF) amputations due to amputation stump complications were 85/369 (23%) in PRVA against 93/752 (12.4%) in PA (p < 0.01). CONCLUSIONS: We could not detect any difference in TT/TF ratio between PRVA and PA. However, the risk of conversion i.e. reamputation to a higher level is higher after PRVA compared to PA. The chance of having a successful transtibial amputation is approximately 58% for postrevascularisation amputation as well as for primary amputations. An aggressive approach towards vascular reconstruction seems justified.

Pituitary adenylate cyclase activating polypeptide (PACAP) is localized in human dermal neurons and causes histamine release from skin mast cells.

OBJECTIVE AND DESIGN: Pituitary adenylate cyclase activating polypeptide (PACAP) is a neuropeptide homologous with vasoactive intestinal polypeptide (VIP) which is known to induce histamine release in human skin mast cells. PACAP has not been detected in human skin. The purposes of the study were to investigate the occurrence of PACAP in human skin and to evaluate the histamine releasing activity of the two common pro-PACAP products, PACAP-27 and PACAP-38. MATERIAL: Fourteen human surgical skin samples were obtained. PACAP and VIP were visualized by immunohistochemistry. A microdialysis technique was used to measure histamine release in intact skin samples following intradermal injections of the peptides. RESULTS: PACAP and VIP were localized in dermal nerves in connection with sweat glands. Intradermal injection of 3 or 10 microm PACAP significantly released histamine. Kinetics of histamine release showed peak release 2-4 min after skin challenge. Ten microm of PACAP-27, VIP and somatostatin caused histamine release with similar efficacy, whereas PACAP-38 was less effective. Substance P was twice as efficient as PACAP-27, whereas calcitonin gene-related peptide did not release histamine. CONCLUSIONS: PACAP is found in human skin and is capable of releasing histamine from skin mast cells.

Day care surgery for advanced Dupuytren's contracture.

Seventy-six consecutive patients suffering from advanced Dupuytren's contracture were analysed in order to evaluate the safety of day care surgery. The complication rates for haematoma, necrosis, infection and reflex sympathetic dystrophy were acceptable, but we found an unacceptably high percentage of nerve lesions. Day care treatment was achieved in all but seven cases. We concluded that advanced Dupuytren's contracture can be treated by day care surgery but the operations should be performed by surgeons who are skilled in hand surgery, and individual selection of patients with recurrence seems advisable.

Operative treatment of carpal tunnel syndrome in Denmark. Results of a questionnaire.

The aim of our study was to determine the incidence of operative treatment for carpal tunnel syndrome in Denmark and to see whether there was a consensus about the place of preoperative electromyography and nerve conduction studies. A questionnaire was mailed to all surgical departments (n = 70) and all registered private surgical practices (n = 214) in Denmark. The incidence of operation was about 0.61 per 1,000 population. Most surgeons used preoperative electromyograms and nerve conduction studies in less than 50% of cases. The use of preoperative testing was related to the surgical speciality.

Relative mortality in lower limb amputees with diabetes mellitus.

A nationwide epidemiological study included 3516 primary major lower limb amputations in diabetic patients, during the period 1982 to 1992. On this well defined diabetic amputee population the relative mortality (Standard Mortality Ratio, SMR) has been analysed. The mortality rate was found to be 8 times the expected during the first year following amputation. The relative mortality is higher for females than males. An inverse relation between age and SMR was found, and the SMR was significantly related to the level of amputation. No significant difference could be detected when analysing SMR in relation to subdiagnosis (NIDDM vs IDDM) or SMR in relation to the period of treatment 1982-87 versus 1988-92.

[Posture-related injuries and patient insurance]. / Lejringsbetingede nerveskader og patientforsikring.

The Danish Patient Insurance Society (Patientforsikringsforeningen) was established by law in July 1992. The aim was to provide a just system of compensation for complications following medical treatment, that are not caused by culpous actions or omissions. The first 34 case records concerning position-related nerve injury were reviewed. The material has national coverage. The exact incidence of position related nerve injury in Denmark is unknown, but transitory neurological symptoms after otherwise uncomplicated surgical procedures are probably not infrequent complications. The material includes 17 males and 17 females. Position-related injury most often affects the peroneal nerve, followed by the ulnar nerve and lesions to the brachial plexus. The etiology is often difficult to establish precisely, and may often be multifactorial. In our material the main reason is believed to be direct pressure to the nerve in 76% of cases. Predisposition (e.g. subclinical neuropathy or diabetes) often complicates the case, but neurophysiological examination and the relation in time between an operation and the onset of neurological symptoms often clarifies the etiology.

Functional and social long-term results after free tissue transfer to the lower extremity.

We report the long-term social and functional results in 53 patients receiving free tissue transfer after trauma to the lower extremity. The results are compared with those of a matched group of patients receiving primary amputation. The microsurgically treated patients had significantly more complaints over pain during walk (p = 0.02) and edema (p < 0.00005). Regarding social results, no significant differences between the two groups were found. Time until surgery, infection, or bone defect before free flap surgery did not alter the overall results significantly. It is concluded that the long-term functional and social results after free tissue transfer are almost the same as those achieved after simple amputation. Because the median time until free flap surgery in this series was 158 days, early limb-saving procedures could possibly improve the long-term results.

Epidemiology of leg amputation: the influence of vascular surgery.

The number of amputations performed for vascular disease in Denmark has decreased from 1777 (34.5 per 100,000 population) in 1983 to 1288 (25.0 per 100,000) in 1990, a reduction of 28 per cent. This decline coincided with an increase in vascular surgical activity of up to 100 per cent, including a marked rise in the rate of femorodistal reconstruction. Moreover, regional variation in vascular surgical activity correlated with percentage reduction in amputation rate (rS = 0.65, P < 0.01). The relative number of above-knee amputations also decreased in favour of more distal levels during the period studied. These findings suggest that vascular surgery may be responsible for the lower amputation rate.

[Salvage of extremities or amputation in severe traumas]. / Ekstremitetsbevarelse eller amputation ved svaere traumer.

The decision whether a severely traumatized limb should undergo primary amputation or be exposed to limb salvage procedures is often extremely difficult. A large number of clinical parameters should be evaluated and some specific damages should lead to primary amputation. Four limb salvage indexes are evaluated.

Trauma-related major lower limb amputations: an epidemiologic study.

The annual number of major lower limb amputations in Denmark as a consequence of trauma was constant during the period 1978 through 1990, with about 70 (1.4 per 100,000 population) per year. The mean age of the amputation population was 49.4 years (males, 44.8 years; females, 58.8 years). Analysis of the age distribution shows characteristic differences between male and female patients. The average hospital stay was 49 days, and 56% of patients were discharged to their homes. The most prevalent amputation levels were transtibial and above-knee, which accounted for about 80% of all amputations. The only systematic change during the period under study was the increase in the number of through-knee amputations. The in-hospital mortality was related to sex, level of amputation, and age. The relative number of amputations varied in the different counties of Denmark and a positive correlation between population density and rate of amputation was found.

Halving the number of leg amputations: the influence of infrapopliteal bypass.

A retrospective review of amputations in patients with vascular disease during 10 years in Bispebjerg Hospital was undertaken. There were 1383 amputations leading to 1167 final level amputations. In previously independent patients there were 482 below knee amputations (BKA), 476 above knee amputations (AKA) and 43 had disarticulations in the ankle, knee or hip. During the period studied the number of final level amputations in independent patients were halved from 122 in 1981 to 58 in 1990. A similar reduction was also found in the total number of amputations: from 171 to 90, and in the number of reamputations: from 35 to 21. However, amputations in patients from long stay institutions remained at a constant level by on average 17 per year. The decrease in amputation rate took place synchronously with an increasing use of bypass to crural and pedal arteries as well as an overall increase in vascular reconstructions and angioplasties of more than 100%. However, the BKA/AKA ratio decreased from 1.12 to 0.67 (p < 0.005).

Major amputation for malignant melanoma: an epidemiological study.

The annual number of amputations in Denmark as a consequence of malignant melanoma on the limbs has been constant during the period 1978-1987. In contrast, the number of malignant melanoma localized to the extremities increases. For lower limb amputation the mean age is 58 y for males and for females, 72 y. The sex ratio, male to female is 1:2.2. Of the 13 male amputees 7 (54%) had died after 18 mo, of the 28 female amputees 20 (74%) had died after 19 mo. An analysis (Kaplan-Meier) shows a 5-y survival rate of about 28%. The mortality is found to be related to sex and level of amputation. Six cases of upper extremity amputation are presented. A review of the literature in order to compare the demographic factors and to outline the indications for amputation reveals a number of differences, most significantly the higher mean age at time of amputation (about 65 y) in Denmark than the figures earlier published (about 45 y). The consensus seems to be that amputation is rarely indicated except as a form of palliation.

Level of lower limb amputation in relation to etiology: an epidemiological study.

The Danish Amputation Register and the nationwide National Patient Register are presented. Based upon the code numbers in the WHO classification system (ICD), 4 etiology groups i.e. vascular insufficiency, diabetes mellitus, malignant neoplasma and trauma were extracted. The purpose was to analyse the relationship between level of amputation (i.e. foot, below-knee, through-knee, above-knee and hip) and etiology (cause of amputation). The material represents all such amputations in Denmark during the period 1978 to 1989 (n = 25.767). The number of amputations because of vascular insufficiency with and without diabetes mellitus decreased over the period studied. The number of tumour and trauma amputations seemed unchanged. There was a significant reduction in the number of amputations at proximal levels (above-knee) for vascular insufficiency with and without diabetes mellitus and in the trauma group. No such change was found regarding tumour amputations. There was a characteristic pattern in the distribution of level respectively of etiological factors for each etiology group and for each level of amputation.

[Inter-nosocomial variations in amputations for vascular insufficiency]. / Internosocomielle forskelle ved vaskuloer insufficiensamputationer.

A study has been made of 18,225 admissions to Danish hospitals for lower limb amputation in cases of diabetic or non-diabetic vascular insufficiency. Clear correlations were found between the type of department and the level of amputation, mortality and duration of hospitalisation, orthopaedic departments being characterized by lower levels of amputation, lower mortality, and shorter hospitalisation than general surgery or mixed departments.

Epidemiology of lower limb amputations in diabetics in Denmark (1980 to 1989).

From 1980 to 1989, 4852 diabetic patients in Denmark underwent 5642 lower limb amputations. Records of the Danish Amputation Register and the National Patient Register indicate a decrease of amputations in diabetics from 681 to 463 per year in this time. There has also been a decrease in above knee amputations in diabetics from 30 to 20 percent of all amputations with a corresponding increase of amputations at or below the knee. Demographic factors and possible reasons for these changes are reviewed. There seems to be a relationship between the improvement of diabetic foot care by the free service of trained podiatrists and the reduction of amputations in diabetics in Denmark.