External fixation for unstable intra-articular distal radial fractures in women older than 55 years. Acceptable functional end results in the majority of the patients despite significant secondary displacement.

UNLABELLED: Unstable intra-articular distal radial fractures in women older than 55 years were treated by closed reduction and external fixation to achieve the best functional outcome. Sixteen women had radiographic and functional assessment. Despite initial good alignment secondary displacement occurred in 11 patients, probably due to the comminution of the fracture and possibly influenced by osteoporosis. Malunion of the distal radius was seen in two patients and intra-articular incongruity with an intra-articular step exceeding 1 mm was observed in two other patients. The functional outcome was excellent or good in 10 and fair in two patients. Four patients had a poor functional outcome. Two of these patients had a significant loss of reduction, one resulting in a malunion. The other two had an intra-articular incongruity of more than 1 mm. Three of the four patients with a poor functional outcome had clinical signs of reflex sympathetic dystrophy. CONCLUSION: Closed reduction and external fixation of "bad case" severely comminuted unstable distal radial fractures in the elderly may result in an acceptable functional outcome in the majority of the cases, although significant secondary displacement occurred in eleven of the sixteen patients.

The distal radial fracture in elderly women and the bone mineral density of the lumbar spine and hip.

The incidence of distal radial fractures in elderly women is high and is associated with osteoporosis and hip fracture. Osteoporosis can be detected by measuring the bone mineral density (BMD) of the lumbar spine or hip with dual energy X-ray absorptiometry. Low BMD of the lumbar spine or hip is a strong predictor for future vertebral deformities and hip fractures. At present, elderly women with a distal radial fracture are not investigated for osteoporosis on a routine basis. The BMD of the lumbar spine and hip were assessed in 94 women (mean age, 69 years) with a distal radial fracture. A low BMD was found in 85% of the patients, and osteoporosis was diagnosed in 51%. The mean BMD decreased by 0.04 SD per year and there was a significant relationship between post-menopausal status and decreased BMD of the hip. The BMD in patients treated with bisphosphonate medication increased significantly in 1 year. As more than half of the elderly women with a distal radial fracture have osteoporotic BMD values for the lumbar spine or hip, it is our opinion that such patients should be screened for osteoporosis.

[One hundred years of the Netherlands Association of Surgeons. II. The evolution of the Association]. / Honder jaar Nederlandse Vereniging voor Heelkunde. II. De ontwikkelingsgang van de Vereniging.

The Association of Surgeons in the Netherlands was founded 100 years ago with the objective to further surgery in general; from 1948 onward a separate objective was to further the interests of surgeons. The Association has developed into an active scientific society that ensures that quality of Dutch surgical practice, that stimulates the development of surgery and that organizes the training of surgeons. The number of operations has more than doubled in the past 25 years, despite the limited increase in the number of surgeons owing to a great leap in efficiency. This has led to a differentiation in the surgical discipline, with a number of sub-associations. The currents quality policy emphasizes certification of clinics, the development of guidelines, mandatory attendance to ongoing training programmes, a registry of complications, adequate patient information, visitation of clinics and a compulsory specialization course for all surgical residents.

Arthroscopically assisted osteosynthesis of tibial plateau fractures in patients older than 55 years.

PURPOSE: To evaluate the end results of arthroscopically assisted osteosynthesis of tibial plateau fractures in patients older than 55 years of age. TYPE OF STUDY: Case series. METHODS: Over a 5-year period, 201 consecutive patients presented with tibial plateau fracture; 131 of these patients were treated with arthroscopically assisted osteosynthesis of the tibial plateau. Inclusion in the retrospective analysis was limited to those patients older than 55 years at the time of injury and those who were available for follow-up at the time of the study. Thirty patients met these criteria. RESULTS: Secondary displacement occurred in 9 patients (30%) within 12 weeks after surgery. After a median follow-up of 3 years, 24 of 30 patients (80%) had an excellent or good clinical result according to the modified Rasmussen criteria. There was no difference in clinical outcome between the patients with or without secondary displacement of the fracture. CONCLUSIONS: Given the good clinical results, arthroscopically assisted osteosynthesis has been shown to be highly efficient in the treatment of tibial plateau fractures in the elderly.

[Local and regional in-hospital trauma care following fireworks depot explosion in Enschede]. / De lokale en regionale intramurale traumaopvang bij de Enschedese vuurwerkramp.

UNLABELLED: On Saturday 13 May, 2000 at about 15:30 h, the Dutch city of Enschede was struck by the explosion of a midtown firework depot. Twenty-two people were killed and almost 1,000 people were wounded. A complete district with 1,000 houses was destroyed. In total, 527 victims were treated in one of the regional hospitals, 76 (14%) of whom were admitted and 451 (84%) were treated as outpatients. Of the clinically treated victims, 11 patients were triaged as T1 and needed immediate intervention, 63 patients were triaged as T2 where treatment within six hours was indicated, and two T3 patients did not need urgent treatment. The outpatients mainly suffered secondary blast injuries to the head and extremities due to flying debris. Of the 11 T1 patients, 10 underwent acute surgery; intervention radiology was performed in one patient. The injuries of the severely wounded T1 patients consisted of penetrating thoracic, abdominal and skull injuries, as well as blunt abdominal trauma and compound fractures. Two patients from the disaster area underwent acute vascular surgery for acutely burst aortic aneurysms. The in-hospital trauma care was characterised by the spontaneous arrival of a large number of extra medical personnel. The regional distribution of the trauma patients was adequate. The regional capacity of the emergency rooms, IC-units and operating facilities proved to be sufficient. Routing of lightly-wounded patients was found to be important. The communication in all phases of the disaster management appeared to be poorly structured. CONCLUSION: During the initial trauma care, the routing of vast numbers of ambulant, lightly-wounded patient, as well as extra doctors and nurses, needs careful planning.

Primary reconstruction of the medial collateral ligament in combined injury of the medial collateral and anterior cruciate ligaments. Short-term results.

We describe our experiences with 22 patients who underwent acute surgical intervention for complete combined injury of the anterior cruciate ligament (ACL) and medial collateral ligament (MCL) in our hospital. In all patients, an arthroscopically guided repair of the MCL was performed, while the torn ACL was treated non-surgically. Primary reconstruction of the MCL in patients with complete disruptions of the MCL complex as well as the ACL reduces combined anteromedial instability to an isolated problem of the ACL. As a result of this treatment, the condition of 15 of 22 knees was improved, after an average duration of follow-up of 2 and a half years. In conclusion, our treatment strategy of an immediate repair of the MCL and reconstruction of the ACL when conservative treatment has failed seems safe and effective.

[Arthroscopic reconstruction using the Leeds-Keio ligament following anterior cruciate ligament lesions in 200 patients]. / Artroscopische reconstructie met het Leeds-Keio-ligament na voorste-kruisbandlaesie bij 200 patiënten.

OBJECTIVE: To establish the results of arthroscopic reconstruction of the anterior cruciate ligament with the Leeds-Keio ligament after a mean follow-up period of three years. DESIGN: Descriptive follow-up study. SETTING: Medisch Spectrum Twente in Enschede, the Netherlands. METHOD: The arthroscopic reconstruction has been carried out since 1988. Early in 1990 the prospective study was started. The patients were evaluated preoperatively according to a protocol. Postoperatively, follow-up consultations took place 3, 6 and 12 months after surgery and subsequently once every year. The results concerned the first 204 patients (205 knees); 200 patients attended all follow-up consultations. RESULTS: In the early postoperative phase there were few complications (2%). After a short period of hospitalisation (mean 3.5 days), most of the patients were able to handle full weight-bearing quite soon (average 4.8 weeks). A total of 98% returned to their original jobs after a mean of almost 12 weeks, while 94% participated again in sporting activities after a mean of more than 15 weeks. Rupture or elongation of the Leeds-Keio ligament occurred in 9% of the patients, on average 18 months after surgery (6-32), and a partial rupture in three cases (2%). In 62% the rupture or elongation occurred after a new evident trauma. Subjectively 85% of the patients no longer complained of instability, objectively stability was found in 90%. Functionally a marked improvement in comparison with the preoperative situation was achieved: 89% had a good to excellent functional score (Lysholm score). At the last follow-up 92% were satisfied with their knee functioning. CONCLUSION: Arthroscopic reconstruction with the Leeds-Keio ligament leads to promising objective, subjective and functional results after a mean follow-up of three years, with few complications.

Predictive value of the hip flexion test for fractures of the pelvis.

In 39 patients with pelvic injury, four clinical tests were performed during physical examination. Of these four tests, the positive and negative hip flexion test (active flexion of the hip with extension of the knee) had the highest predictive value for the presence (95 per cent) or the absence of pelvic fractures (90 per cent), respectively. The predictive values of the other three tests (downward compression on the pubic bone, compression on the iliac rings, and distraction pressure on the iliac crests) were considerably lower.

First experience and complications with the long Gamma nail.

Treatment of proximal femoral fractures is difficult. A retrospective analysis of 92 patients treated with a custom-made extended gamma nail with a mean follow up of 4 months is presented. The early results of this new method are promising. The indications for the use of the long gamma nail were intertrochanteric fractures with extension to the subtrochanteric region, imminent and pathologic fractures of the intertrochanteric and subtrochanteric region, mostly in elderly patients, proximal femoral fractures, and combination injuries in multiple trauma patients and delayed unions. In 67 cases the patients were primarily treated with a long Gamma nail. In 25 cases the nail was used after the failure of initial treatment. Complications occurred in 32 patients; however, 88 patients were able to walk at the end of the study. The advantage of this new method is that with a closed surgical technique full weight bearing directly after the operation is achieved. The long Gamma nail provides a procedure by which most complex fractures in the proximal femur can be managed.

[The dynamic hip screw in medial fractures of the femoral neck: results in 51 patients]. / De dynamische heupschroef bij mediale fracturen van het collum femoris: resultaten bij 51 patiënten.

Femoral neck fractures are common in the elderly, especially in female patients. Pseudarthrosis and femoral head necrosis were complications with a high incidence in earlier days, when the femoral neck fracture was treated by obsolete osteosynthesis techniques. Replacement of the femoral head by an endoprosthesis was introduced in the seventies because of these complications. This hemiarthroplasty also causes many postoperative complications. With the development of the dynamic hip screw for trochanteric and subtrochanteric fractures a new technique for stabilising femoral neck fractures has been introduced. In a retrospective study (average follow-up: 3.4 years; 3 months-6 years; median: 3.6 years) of 51 patients with a femoral neck fracture who were treated with a DHS the short- and long-term postoperative complications (femoral head necrosis and pseudarthrosis) were determined. The most frequent short-term complications were bleeding (10 patients), the need for blood transfusion (10), decubitus (6), wound infection (5), urinary tract infection (5). Femoral head necrosis was seen in two patients more than 30 days after the operation. Pseudarthrosis was not observed. Because of the low complication rate, we can conclude that DHS osteosynthesis, on a correct indication, can be used as first choice in femoral neck fractures.

[Reconstruction of the tibial plateau fracture with arthroscopic monitoring without arthrotomy]. / Reconstructie van de tibiaplateaufractuur onder artroscopische controle zonder artrotomie.

In the period from October 1986 to November 1988 in the Medisch Spectrum Twente of Enschede, 25 patients were treated for a tibial plateau fracture by means of arthroscopic surgery. The mean hospital stay was 18 days. Active movement of the leg was prescribed from the fifth day. The results were very good in 23 and poor in 2 patients. Complications such as wound infections and skin necrosis were not seen. Additional meniscal lesions could be diagnosed and treated better using this surgical technique. In addition, the limited incisions and consequently the avoidance of extensive arthrotomy allowed faster rehabilitation and a higher probability of healing the chondral tissue.

Graded stress radiography in acute injury to the lateral ligaments of the ankle.

The diagnostic accuracy of graded stress radiography in 26 patients with acute injury to the lateral ankle ligaments has been compared with findings at arthrography and surgery. Measuring talar tilt angles and anterior talar displacement over a range of pressures applied to the distal tibia using a commercially available stress device allows diagnostic distinction between isolated anterior talofibular ligament injury and a combined lesion that involves the calcaneofibular ligament. The results compare well with arthrographic and surgical findings.

Injury to the lateral ankle ligaments of athletes. A posttraumatic followup.

Twenty of 26 original athletes with injuries to the lateral ligaments of the ankle were reexamined 2 to 5 years following treatment. The functional quality of their anterior talofibular (TF) and calcaneofibular (CF) ligaments was tested by stress examination, using a commercially available stress device, and was compared with the results of stress examination, arthrography, and surgery at the time of injury. Surgically treated patients showed a 70% to 100% recovery of the functional properties of the lateral ankle ligaments on comparison with the contralateral, uninjured ankle. Of the six patients treated conservatively with elastic bandages and rest, only one had regained normal function, whereas the others showed minimal or no improvement. Isolated lesions of the anterior TF ligaments, when treated conservatively, may have only a slightly better prognosis than a combined lesion of both anterior TF and CF ligaments in the athletic population.

Stress examination of traumatized lateral ligaments of the ankle.

In the diagnostic analysis of acute injury to the lateral ankle ligaments, ankle arthrography and plain film stress examination play an important role. Inasmuch as the treatment of choice, whether conservative or surgery, and insofar as the therapeutic results may be determined by the extent of injury, it is important to have access to quantitative information on the functional properties of the involved ligaments at the time of the initial diagnostic studies. This can be obtained by measuring the strain on the anterior talofibular (tf) and calcaneofibular (cf) ligaments as a function of pressure applied to the distal tibia. Any device that ensures that the externally applied pressure is proportionally carried through to the ligaments can be used for this purpose. The results of 25 quantitative stress examinations using a Telos stress device are compared with arthrography findings and findings at surgery. Stress examination correlates well with both arthrographic and operative findings. The method is also useful for the evaluation of chronic ankle instability, follow-up examinations, and for the detection of vestiges of previous trauma of the contralateral ankle. The procedure is straightforward and noninvasive and can be performed within 15 minutes.