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Background: The clinical results of removal of metal implants after fracture healing are unknown and the question whether to remove or to leave them in is part of discussion worldwide. We present the design of a prospective clinical multicentre cohort study to determine the main indications for and expectations of implant removal, the influence on complaints, the incidence of surgery related complications and the socio-economic consequences of implant removal., Methods/design: In a prospective multicentre clinical cohort study at least 200 patients with a healed fracture after osteosynthesis with a metal implant are included for analyzing the outcome after removal. Six hospitals in the Netherlands are participating. Special questionnaires are designed. The follow up after surgery will be at least six months. The primary endpoint is the incidence of surgery related complications. Secondary endpoints are the influence of removal on preoperative symptoms and complaints and the socio-economic consequences., Discussion: By performing this study we hope to find profound arguments to remove or not to remove metal implants after fracture healing that can help to develop clear guidelines for daily practice., Trial Registration: NTR1297, http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1297.

Purpose: In a level 1 university trauma center, an explorative randomized controlled study was performed to compare soft tissue damage and functional outcome after antegrade femoral nailing through a trochanteric fossa (also known as piriform fossa) entry point to a greater trochanter entry point in patients with a femoral shaft fracture., Materials and Methods: Nineteen patients were enrolled and randomly assigned to two nail insertion groups; ten patients were treated with an Unreamed Femoral Nail(®) (UFN, Synthes(®), Solothurn, Switzerland) inserted at the trochanteric fossa and nine patients were treated with an Antegrade Femoral Nail(®) (AFN, Synthes(®), Solothurn, Switzerland) inserted at the tip of the greater trochanter. The main outcome measures were pain, gait, nerve and muscle function, along with endurance. Magnetic resonance imaging (MRI), electromyography (EMG), and Cybex isokinetic testings were performed at, respectively, 2 and 6 weeks and at a minimum of 12 months after surgery., Results: The MRI and EMG showed, in both groups, signs of iatrogenic abductor musculature lesions (four in the UFN group and four in the AFN group) and superior gluteal nerve injury (five in the UFN group and four in the AFN group). The isokinetic measurements and the patient-reported outcomes showed moderate reduction in abduction strength and endurance, as well as functional impairment with slight to moderate interference with daily life in both groups, with no appreciable differences between the groups., Conclusions: Anatomical localization of the entry point seems to be important for per-operative soft tissue damage and subsequent functional impairment. However, the results of this study did not show appreciable differences between femoral nailing through the greater trochanter tip and nailing through the trochanteric fossa.

Rerupture after treatment of acute Achilles tendon rupture is considered a serious complication. Yet data on long-term outcome after rerupture are limited. This study evaluated outcome after rerupture and compares it to a reference of uncomplicated cases. Thirteen patients with a rerupture following minimally invasive surgical Achilles tendon rupture repair were evaluated using Leppilahti score and resumption of work and sport. Mean follow-up was 8.7 years. Results were compared with a reference group of 23 uncomplicated cases with a follow-up of at least 1 year. The study was designed as a follow-up study. The relative risk for a fair/poor outcome by Leppilahti score after a rerupture when compared with uncomplicated cases is 2.83 (95% confidence interval=1.17-6.87; P=.0185). Although rerupture did not affect ultimate resumption of professional life, the relative risk for quitting sport or resuming sport at a lower level after a rerupture is 3.33 (95% confidence interval=1.71-6.51; P=.0001). In contrast, the plantar flexion strength deficit is 5% to 10% in the rerupture group and up to 20% in the reference group. Despite sufficient recovery of calf muscle strength, rerupture after acute Achilles tendon rupture treatment results in significant long-term functional disabilities., (Copyright © 2011 The Author(s))

Background: Complications of acute Achilles tendon rupture treatment are considered to negatively influence outcome, but the relevance of these effects is largely unknown., Purpose: The Achilles Tendon Total Rupture Score (ATRS) was used to determine level of disability in patients with minimally invasive surgical Achilles tendon rupture repair with a complicated postoperative course., Study Design: Case series; Level of evidence, 4., Methods: The charts of 340 consecutive patients treated for an acute Achilles tendon rupture by minimally invasive surgical repair were reviewed. Complications were categorized as rerupture, severe wound infection, sural nerve injury, and other. Level of disability was evaluated by the 10-item ATRS with a sum score of minimum 0 to maximum 100 points., Results: A total of 211 patients returned a completed questionnaire: mean follow-up was 6.2 years (range, 3-10 years). Mean ATRS for all 211 patients was 84 (95% confidence interval: 82, 87). The mean ATRS for the 135 (64%) uncomplicated cases was 89 of 100 points, 71 points for the 17 (8%) patients with a rerupture (95% confidence interval: 63, 79; P < .0001), 79 points for the 41 patients (19%) with a sural nerve injury (95% confidence interval: 74, 85; P = .0008), and 75 points for the 17 patients (8%) with another complication (95% confidence interval: 67, 83; P = .001). Of these other complications, 13 patients (6%) suffered a wound-healing complication considered minor. Their average ATRS score was 80 points (95% confidence interval: 71, 88.7; P = .0445). One patient suffered a severe wound infection as well, scoring 28 of 100 points. Rerupture significantly increased the risk of quitting or changing sport participation on the long term., Conclusion: Long-term outcome after minimally invasive Achilles tendon rupture repair is excellent. Rerupture and severe wound infection are the most important complications with lasting negative effect on outcome. It justifies the use of rerupture as a relevant outcome measure in treatment evaluation.

Objectives: This study was performed to explore the relationship between entry point-related soft tissue damage in antegrade femoral nailing and the functional outcome in patients with a proximal third femoral shaft fracture., Design: Retrospective clinical trial., Setting: Level I university trauma center., Patients: Seventeen patients with a high femoral shaft fracture treated with an antegrade femoral nail joined the study., Intervention: Nine patients with an Unreamed Femoral Nail (UFN; Synthes, Bettlach, Switzerland) inserted at the trochanteric fossa and eight patients with a long Proximal Femoral Nail (PFN; Synthes) inserted at the tip of the greater trochanter., Main Outcome Measurements: Pain, gait, nerve, and muscle function along with endurance., Results: Five patients with a UFN had a positive Trendelenburg sign and a reinnervated superior gluteal nerve after initial injury of the nerve at operation. None of these findings occurred in the long PFN group (P = 0.01). Isokinetic measurements showed diminished abduction as well as external rotator function in the UFN group rather than in the long PFN group. Leg endurance was significantly lower in patients with a UFN., Conclusions: Compared with the trochanteric fossa, femoral nailing through the greater trochanter tip may decrease the risk of damage to the superior gluteal nerve and intraoperative damage to the muscular apparatus of the hip region, resulting in some improved muscle function. Therefore, a lateral entry point may be a rational alternative for conventional nailing through the trochanteric fossa.

The aim of this study was to measure the effect of treatment of acute Achilles tendon ruptures on calf muscle strength recovery. Eighty-three patients with acute Achilles tendon rupture were randomly allocated to either minimally invasive surgery with functional after-treatment or conservative treatment by functional bracing. Calf muscle strength using isokinetic testing was evaluated at 3 months and after 6 or more months posttreatment. To exclusively investigate the effect of treatment on outcome, the authors excluded patients with major complications from the analysis. In 31 of 39 patients in the surgical treatment group and 25 of 34 patients in the conservative treatment group, isokinetic strength tests were performed. In the analysis of differences in mean peak torque, no statistically significant differences were found between surgery and conservative treatment, except for plantar flexion strength at 90 degrees per second at the second measurement, favoring conservative treatment. After 8 to 10 months follow- up, loss of plantar flexion strength was still present in the injured leg in both treatment groups. In conclusion, isokinetic muscle strength testing did not detect a statistically significant difference between minimally invasive surgical treatment with functional after-treatment and conservative treatment by functional bracing of acute Achilles tendon ruptures.

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 Bone, Joint and Muscle Trauma 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.

Background: Several randomised trials have been published on the effect of low-intensity pulsed ultrasound (LIPUS) on fracture healing in both distal radius and tibia fractures. Most studies showed a positive effect on time to clinical and radiological healing. We hypothesised that LIPUS has a beneficial effect on the healing of fresh clavicle fractures as well and studied its effect in non-operatively treated shaft fractures., Methods: We conducted a randomised double blind, placebo-controlled multi-centre trial in 101 adult patients with a non-operatively treated fresh clavicle shaft fracture. Of these patients, 49 used a placebo transducer and 52 patients had an active transducer with ultrasound stimulation (Exogen 2000). Data were analysed on intention to treat basis. Baseline parameters of both groups were not significantly different., Results: There were no differences in time to subjective clinical fracture healing, resumption of daily activities, sports or professional work, Visual Analogue pain Scores (VAS) and use of pain medication., Conclusion: Our findings did not confirm that LIPUS accelerates clinical healing time of fresh clavicle shaft fractures., Level of Evidence: Level 1 evidence that low-intensity pulsed ultrasound does not accelerate clinical fracture healing in non-operatively treated fresh midshaft clavicle fractures.

Objectives: Insertion of rigid uniplane bent femoral nails through the piriform fossa has been reported to cause neurovascular complications. New nails were designed for more lateral entry points. However, these may be associated with a higher risk of iatrogenic fractures. This study investigated if two differently bent nails with more lateral entry points induce higher cortical bone strains than a uniplane bent nail introduced through the piriform fossa., Methods: Three groups of 8 cadaveric femurs were instrumented using the following nail systems and entry points: Cannulated Femoral Nail, piriform fossa; Antegrade Femoral Nail, trochanteric tip; and helical nail, lateral of the trochanteric tip. During insertion, the maximum principal bone strains were recorded at 9 locations at the proximal femur and the diaphysis. The occurrence of iatrogenic fractures or fissures was documented., Results: The highest strains recorded were between 2000 and 4500 mum/m and mainly located at the posterior aspect of the greater trochanter and at the medial side of the entry point. In most of these cases fissures or fractures occurred, the number of which was higher for the trochanteric tip group as compared with the other groups. This was thought to be due to the thin cortical walls as a result of the larger reamer diameter in this group. Low strains (below 2000 microm/m) occurred at the medial cortex where the laterally inserted nails were expected to impinge., Conclusions: Bone strains at the medial impingement location were low for all nails. Entry portals with thin cortical walls due to, for example, larger reamer diameters and a small greater trochanter seem to be more susceptible to insertion accuracy, which may influence strain and fissure or fracture occurrence. Furthermore, we do not recommend determination of the entry point of laterally inserted nails based solely on anatomic landmarks of the greater trochanter because this may influence insertion accuracy. This implies that biplanar imaging is important for accurate and safe insertion of laterally started nails.

Antegrade intramedullary nailing is an accepted method of treatment for femoral shaft fractures. Entrance of the nail through the trochanteric fossa is currently recommended by some surgeons. This approach results in some cases, however, in loss of abduction strength and persistent pain. Nail insertion at the tip of the greater trochanter may be more favorable. In this study the anatomical relationships of the trochanteric fossa and of the tip of the greater trochanter were explored. Dissection was carried out in 10 fresh human cadaver femurs. The risks and safety of the two entry points with respect to the adjacent soft tissues were assessed. Abductor muscles and tendons, branches of the medial circumflex femoral artery and the hip joint capsule were at risk during nail insertion through the trochanteric fossa. These structures were not endangered during insertion through the trochanteric tip. The reported clinical morbidity after nailing through the trochanteric fossa may result from direct soft tissue injury and may be reduced by choosing the route through the greater trochanter., ((c) 2008 Wiley-Liss, Inc.)

Background: Surgical repair of acute Achilles tendon ruptures is considered superior to nonoperative treatment, but complications other than rerupture range up to 34%. Nonoperative treatment by functional bracing seems a promising alternative., Hypothesis: Nonoperative treatment of acute Achilles tendon rupture with functional bracing reduces the number of complications compared with surgical treatment with a minimally invasive technique., Study Design: Randomized controlled clinical trial; Level of evidence, 2., Method: Using concealed random allocation, 83 patients with acute Achilles tendon rupture were assigned to nonoperative treatment by functional bracing or minimally invasive surgical treatment followed by tape bandage. Patients were allowed full weightbearing, and follow-up was 1 year., Results: Complications risk other than rerupture by intention-to-treat basis was 9 in 42 patients (21%) for surgical treatment and 15 in 41 patients (36%) for nonoperative treatment (risk ratio, 0.59; 95% confidence interval, 0.29-1.19). Reruptures risk was 5 in 41 patients after nonoperative treatment and 3 in 42 patients for surgical treatment (risk ratio, 0.59; 95% confidence interval, 0.15-2.29). The mean time to work was 59 days (SD, 82) after surgical treatment and 108 days (SD, 115) after nonoperative treatment (difference, 49 days; 95% confidence interval, 4-94; P < .05). The difference between treatments for return to sports (risk ratio, 0.55; 95% confidence interval, 0.23-1.29), pain, and treatment satisfaction did not reach statistical significance., Conclusion: There appears to be a clinically important difference in the risk of complications between minimally invasive surgical treatment and nonoperative treatment for acute Achilles tendon ruptures, but this was not statistically significant.

Background: The routine removal of orthopaedic fixation devices after fracture healing remains an issue of debate. There are no evidence-based guidelines on this matter, and little is known on surgeons' practice and perceived effectiveness of implant removal in different clinical settings., Methods: A 41-item questionnaire was distributed to 730 attendees of the AO Principles and Masters Courses of Operative Fracture Treatment in Davos, Switzerland, to assess their attitudes towards removal of different types of implants, and perceived benefits and risks with this common procedure., Results: The response rate was 655/730 (89.7%), representing 54.6% of all 1199 course attendees. Surgeons from 65 countries (571 males and 84 females, mean age 39 +/- SD 9 years) took part in the survey. Fifty-eight percent of the participants did not agree that routine implant removal is necessary, and 49% and 58% did not agree that indwelling implants pose an excess risk for fractures or general adverse effects. Forty-eight percent felt that removal is riskier than leaving the implant in situ. Implant removal in symptomatic patients was rated to be moderately effective (mean rating on a 10-point-scale, 5.8, 95% confidence interval 5.7-6.0). Eighty-five percent of all participants agreed that implant removal poses a burden to hospital resources. Surgeons were undetermined whether implant removal is adequately reimbursed by payers of health care services (44% "I-don't-know"-answers)., Conclusion: Many surgeons refuse a routine implant removal policy, and do not believe in clinically significant adverse effects of retained metal implants. Given the frequency of the procedure in orthopaedic departments worldwide, there is an urgent need for a large randomized trial to determine the efficacy and effectiveness of implant removal with regard to patient-centred outcomes.

Objective: To assess among seriously injured accident victims whether change of the Triage Revised Trauma Score (T-RTS) between first assessment and arrival at the hospital independently predicts mortality., Design: Prospective cohort study., Methods: The study analysed data on 507 trauma patients with multiple injuries and with a Hospital Trauma Index-Injury Severity Score (HTI-ISS) of 16 or higher, who were presented directly by ambulance services to the Accident & Emergency Department of the University Medical Centre Utrecht (the Netherlands) in 1999 and 2000., Results: Compared to non-intubated patients whose T-RTS remained unchanged (reference category), the mortality risk was 3.1 times higher [95% confidence interval (CI): 1.5-6.3, p = 0.001] for patients with deteriorating T-RTS, 2.9 times higher (95% CI: 1.3-6.5, p < 0.001) for patients who had an initially good T-RTS but were nevertheless intubated and 5.7 times higher (95% CI: 3.6-9.0, p < 0.001) for patients who had an initially poor T-RTS and were intubated. These associations were independent of factors that could be assumed to have a direct effect on T-RTS, that is intravenous therapy, oxygen administration and being attended to by a mobile medical team at the scene of the accident. Along with T-RTS change, more advanced age was associated with a higher mortality risk., Conclusion: Intubation and a deteriorating T-RTS between the time of the accident and patient's arrival at the hospital are powerful independent predictors of mortality after hospitalisation. Together with advanced age, a deteriorating T-RTS should be the main aspect guiding the preclinical procedures.

Objective: To assess the impact of major trauma on individual and population health., Methods: Data from a regional trauma registry were used, including all trauma fatalities and nonfatal severely injured patients (injury severity score >15) in 1999 and 2000. The impact of fatalities was expressed in terms of years of life lost (YLL). The impact of severe injury on survivors was expressed in terms of years lived with disability (YLD). Disability weights were based on quality of life at 15 months after injury, measured with EuroQol-5D. Disability-adjusted life years (DALYs) were calculated as the sum of YLLs and YLDs., Findings: There were 567 fatalities and 335 survivors. At the individual level, trauma fatalities (32 YLLs per patient) and nonfatal cases of major trauma (12 YLDs per patient) both led to a substantial loss of healthy life years. Each victim of major trauma contributed an average of 25 DALYs to the burden of disease. At the population level, major trauma caused 10 DALYs per 1000 inhabitants. Road-traffic injury was the main contributor to the population burden of major trauma., Conclusion: Both at individual and population levels, major trauma has a massive impact on health. Most severely injured victims of road-traffic crashes reach the hospital and have good chances of survival. Injury prevention and trauma care policies should aim at further reduction of both fatalities and permanent consequences among survivors.

Objective: To quantify the prevalence of return to work after major trauma, and to investigate the determinants of postinjury work status., Design: Prospective cohort study., Setting: University Medical Centre Utrecht, a level 1 trauma centre in the Netherlands., Method: All severely injured (ISS > 16) adult (age = 16+) trauma survivors admitted from January 1999 to December 2000 who were full-time employed at the time of the injury were selected for follow-up (n = 214). Response rate was 93%. Outcome was assessed at a mean of 15 months (SD = 1.5) after injury. Multivariate logistic regression analyses identified determinants at hospital discharge and at follow-up., Results: Following injury 58.4% of the patients (n = 125) were able to return to full-time employment, 21.5% had a part-time job, and 20.1% did not return to work. Univariate analysis yielded the following significant determinants of postinjury work status: age, comorbidity, injury severity score, brain injury, spinal cord injury, length of stay in an intensive care unit, hospital stay, discharge destination, percentage of permanent impairment (according to the fourth American Medical Association guide (AMA)), limitations in activities of daily living and cognitive complaints. Logistic regression analyses (23% explained variance) identified spinal cord injury, duration of hospital stay, discharge destination and age as determinants of return to work at hospital discharge. At follow-up, determinants of return to work included AMA, activities of daily living, cognitive complaints and being discharged home (51% explained variance)., Conclusions: Around 60% of the patients returned to their pre-injury work status after major trauma. The return to work rate was only partly explained by disability at follow-up. Independent determinants of return to work differ with the time of assessment.

Objective: To determine which factors predict death occurring in trauma patients who are alive on arrival at hospital Design Prospective cohort study Method Data were collected from 507 trauma patients with multiple injuries, with a Hospital Trauma Index-Injury Severity Score of 16 or more, who were initially delivered by the Emergency Medical Services to the Emergency Department of the University Medical Centre Utrecht (UMCU) during the period 1999-2000., Results: Univariate analysis showed that every year of age increase resulted in a 2% greater risk of death. If the patient had been intubated at the scene of the accident, this risk was increased 4.3-fold. Every point of increase in the Triage Revised Trauma Score (T-RTS) reduced the risk of death by 30%. A similar (but inverse) tendency was found for the HTI-ISS score, with every point of increase resulting in a 5% greater risk of death. There was a clear relationship between the base excess (BE) and hemoglobin (Hb) levels and the risk of death, the latter being increased by 8% for each mmol/l drop in BE, and reduced by 22% for each mmol/l increase in Hb. The risk of death occurring was 2.6 times higher in cases with isolated neurotrauma. These associations hardly changed in the multivariate analysis; only the relation with having been intubated at the scene disappeared., Conclusion: The risk of severely injured accident patients dying after arriving in hospital is mainly determined by the T-RTS, age, presence of isolated neurological damage, BE and Hb level. Skull/brain damage and hemorrhage appear to be the most important causes of death in the first 24 h after the accident. The time interval between the accident and arrival at the hospital does not appear to affect the risk of death.

Background: Studies of the consequences of major trauma have traditionally focused on mortality rates. The aims of this study were, firstly, to investigate the long-term functional health status in a large, unselected group of severely injured patients and to compare this with normative data, and secondly, to explore relations between functional health status and personal and injury characteristics., Methods: A prospective cohort study was performed at the University Medical Centre Utrecht (a level-1 trauma centre) in The Netherlands. Consecutive survivors of major trauma (ISS>or=16; >16 years of age) were included from January 1999 until December 2000. After an average of 15 months (range 12-18 months), 335 of the 359 eligible persons (response rate 93%) participated. Demographic and injury characteristics were retrieved from a hospital-based registration system. Functional health status was measured using the 136-item Sickness impact profile (SIP). Co-morbidity was assessed at the follow-up examination using a standard list of 26 conditions., Results: Subjects were 249 men and 86 women, mean age 37.7 years, mean ISS was 24.9 (S.D.=10.6). Almost, three quarters were traffic victims. Mean hospital stay was 25 days (S.D.=23.4). Discharge destination was home in 70% of all subjects. At follow-up, the mean overall SIP score was 9.3 (S.D.=10.1), which means mild to moderate disability. The mean score on the physical function dimension was 7.2 (S.D.=9.8) and that on psychosocial function was 8.7 (S.D.=12.0). Most problems were experienced in the categories of Work, Ambulation, Home Management, Recreation and Pastimes, and Alertness Behaviour. Scores of younger subjects deviated more strongly from the norm scores than those of elderly patients. Type of injury, especially lesions of traumatic brain and spinal cord and extremity injuries, was a predictor of both psychosocial and physical functioning after more than 1 year. The most important predictors, however, were age and co-morbidity.

Objective: To determine which factors predict death occurring in trauma patients who are alive on arrival at hospital Design Prospective cohort study Method Data were collected from 507 trauma patients with multiple injuries, with a Hospital Trauma Index-Injury Severity Score of 16 or more, who were initially delivered by the Emergency Medical Services to the Emergency Department of the University Medical Centre Utrecht (UMCU) during the period 1999-2000., Results: Univariate analysis showed that every year of age increase resulted in a 2% greater risk of death. If the patient had been intubated at the scene of the accident, this risk was increased 4.3-fold. Every point of increase in the Triage Revised Trauma Score (T-RTS) reduced the risk of death by 30%. A similar (but inverse) tendency was found for the HTI-ISS score, with every point of increase resulting in a 5% greater risk of death. There was a clear relationship between the base excess (BE) and hemoglobin (Hb) levels and the risk of death, the latter being increased by 8% for each mmol/l drop in BE, and reduced by 22% for each mmol/l increase in Hb. The risk of death occurring was 2.6 times higher in cases with isolated neurotrauma. These associations hardly changed in the multivariate analysis; only the relation with having been intubated at the scene disappeared., Conclusion: The risk of severely injured accident patients dying after arriving in hospital is mainly determined by the T-RTS, age, presence of isolated neurological damage, BE and Hb level. Skull/brain damage and hemorrhage appear to be the most important causes of death in the first 24 h after the accident. The time interval between the accident and arrival at the hospital does not appear to affect the risk of death.

Objective: To determine the background and consequences of failing to diagnose injuries in prehospital care., Design: Prospective cohort study., Method: Data were collected from 507 trauma patients with multiple injuries, and a Hospital trauma index-injury severity score of 16 or higher, who were delivered by the emergency ambulance service to the emergency department of the University Medical Centre Utrecht, the Netherlands, in 1999-2000., Results: The percentage of missed injuries varied from 9-55. For every additional year of age the risk of missing thoracic injuries was 2% higher. The risk of missing head injuries was 84% lower in people with a Triage revised trauma score (T-RTS) < 11. Initially missing an injury had no consequences for duration of stay in the ICU except in those patients with injuries to the lower extremities. A difference in quality of life was only reported for patients in whom injuries ofthe ribs, shoulder or clavicle had been missed. For every year of age, there was a 2% greater risk of dying within 1.5 years. A T-RTS < 11 resulted in a 5.6-fold greater risk of death. Failing to diagnose an injury did not in itself increase the risk of death., Conclusion: Frequently missing an injury prior to hospitalization did not result in a poorer chance of survival or lesser quality of life. The risk of dying was mainly related to a higher age and a poorer general condition at the scene of the accident. According to these findings there is no reason to adapt the current policy with regard to initial care and transport of trauma patients.

Purpose: Acute compartment syndrome is known to develop after trauma or after postischemic revascularization. It also can occur when a patient has been lying in the lithotomy position during prolonged surgery. Methods were searched for the prevention of this iatrogenic complication after a series of seven patients who developed compartment syndrome after surgery at our hospital., Methods: A series of seven consecutive patients who developed compartment syndrome of the lower leg(s) after abdominoperineal surgical procedures from 1997 to 2002 is presented and so are the lessons learned to prevent this problem., Results: When comparing our experiences with data from literature, the seven patients had the usual risk factors for development of a compartment syndrome: lengthy procedure (>5 hours); decreased perfusion of the lower leg because of Trendelenburg positioning combined with the lithotomy position; and external compression of the lower legs (because of positioning, stirrups, or antiembolism stockings). Measures have been taken to prevent compartment syndrome from developing after prolonged surgery in the lithotomy position. This complication has not occurred again after the introduction of these measures two years ago., Conclusions: Acute compartment syndrome can be prevented if adequate measures are taken, but after lengthy surgery, maximum alertness for emerging acute compartment syndrome remains indicated. Early diagnosis and treatment by four-compartment fasciotomy is still the only way to prevent irreversible damage.

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.

Ipsilateral scapular neck and clavicular shaft fractures comprise the so-called "floating shoulder". This rare injury, which is, in general, caused by a high-energy trauma, is perceived to be an unstable injury with the considerable risk of significant displacement of scapular neck and/or the clavicular fracture. An understanding of the patho-anatomy is important in identifying a floating shoulder and to offer rational treatment for this injury. The current status of the anatomical, biomechanical and clinical aspects of a floating shoulder is reviewed in this article. Recommendations for treatment of particularly displaced ipsilateral fractures of the scapular neck and clavicular shaft cannot be derived from the reported clinical studies. The possible correlation between functional outcome and malunion of the scapular neck is called into doubt.

Objective: To compare the pressure-reducing and pressure-redistributing characteristics of four operating room (OR) table mattresses using interface pressure measurements, in two positions adopted for surgical procedures., Method: Support surfaces were randomly assigned to 80 patients. These were: an overlay pad filled with fibres (the standard OR mattress), a custom-made viscoelastic polyurethane foam mattress, an inflatable mattress with air-filled cells and a fluid mattress. An XSENSOR full-body pressure-mapping pad was used to record interface pressures of 40 patients in the supine position and 40 patients in the lithotomy position. Measurements were analysed for peak pressure, peak pressure index, total contact surface area and the occurrence of a significant increase in interface pressure during the surgical procedure., Results: The highest interface pressures were measured on the standard mattress, in both the supine and lithotomy position. Overall, the fluid mattress showed the best pressure-reducing and pressure-redistributing capacities., Conclusion: As long as no reference values are available for interface pressures under which no pressure-related damage will occur, clinical testing of OR table surfaces is still necessary.

Intramedullary nailing through the piriform fossa results in some cases in loss of abduction strength and persistent pain. Nail insertion at the tip of the greater trochanter may be favourable. The aim of this study was to assess (possible) iatrogenic injury to the abductor and external rotator musculature, branches of the superior gluteal nerve and branches of the MFCA in relation to the two different entry points. In 10 fresh human cadaver femurs, five unreamed femoral nails (UFN) were inserted through the piriform fossa and five AO prototype nails (AFN) through the trochanteric tip. The iatrogenic injury at each nailing procedure was assessed. Various muscles and tendons, branches of the MFCA along with the hip joint capsule were injured or largely at risk during nail insertion through the piriform fossa. Most of these structures were not exposed during insertion through the trochanteric tip. The reported clinical morbidity after nailing through the piriform fossa may find its origin in direct soft tissue injury and may be reduced by choosing a lateral nail entry point.

Background: Repair of a large, severely contaminated abdominal wall defect is a challenging problem. Most patients are currently treated with a multistaged procedure, which is time consuming, carries a high complication rate, and is often not finalized., Study Design: In this study, our experience with a one-stage repair of contaminated abdominal wall defects using the Components Separation Method was evaluated with respect to morbidity and recurrence. Medical records of patients with contaminated abdominal wall defects, treated with the Components Separation Method from 1996 to 2000, were studied. Patients were invited to visit the outpatient clinic for a physical examination., Results: Twenty-six patients with a median age of 49 years and a mean defect size of 267 cm2 were treated. Intraoperative contamination, graded according to the National Research Council (NRC), showed 22 National Research Council III patients and 4 National Research Council IV patients. Postoperatively, five superficial wound infections, three cases of pneumonia, three instances of recurrent enterocutaneous fistulation, and two cases of sepsis were observed. One of the patients with sepsis died after anastomotic disruption led to peritonitis and multiple organ failure. Two asymptomatic recurrences were diagnosed (8%) after a median followup of 27 months., Conclusions: Large contaminated abdominal wall hernias can be closed by the Components Separation Method, with a low recurrence rate but considerable morbidity.

Background and Objective: At the University Medical Center Utrecht (UMCU), follow-up implies an inventory of risk factors and screening for MRSA colonization among all MRSA-positive patients for at least 6 months. If risk factors or positive cultures persist or re-emerge, longer follow-up is indicated and isolation at readmission. This study investigated how long MRSA-positive patients remained colonized after hospital discharge and which risk factors were important. Furthermore, the results of eradication therapy were evaluated., Design: All patients who were positive for MRSA at the UMCU between January 1991 and January 2001 were analyzed regarding carriage state, presence of risk factors for prolonged carriage of Staphylococcus aureus, and eradication treatment., Results: A total of 135 patients were included in the study. The median follow-up time was 1.2 years. Eighteen percent of the patients were dismissed from follow-up 1 year after discharge. Only 5 patients were dismissed after 6 months. Among patients with no risk factors, eradication treatment was effective for 95% within 1 year. Among patients with persistent risk factors, treatment was effective for 89% within 2 years., Conclusions: Based on these findings, eradication therapy should be prescribed for all MRSA carriers, independent of the presence of risk factors. MRSA-positive patients should be evaluated for 6 months for the presence of risk factors and MRSA carriage. Screening for risk factors is important because intermittent MRSA carriage was found in a significant number of our patients. Patients with negative MRSA cultures and without risk factors for 12 months can be safely dismissed from follow-up.

Background: Patients with chronic exertional compartment syndrome have pain during exercise that usually subsides at rest. History and physical examination may raise suspicion of the syndrome; diagnosis is usually confirmed with intracompartmental pressure measurement after exercise. Studies have shown that magnetic resonance imaging and near-infrared spectroscopy have diagnostic ability in this syndrome., Hypothesis: Magnetic resonance imaging and near-infrared spectroscopy can be used to diagnose chronic exertional compartment syndrome., Study Design: Cohort study (diagnosis); Level of evidence, 2., Methods: Patients were enrolled if there was clinical suspicion of chronic exertional compartment syndrome, and a fasciotomy was performed based on this suspicion. Before fasciotomy, intracompartmental pressure, near-infrared spectroscopy, and magnetic resonance imaging data were collected during and after exercise on a treadmill. Near-infrared spectroscopy and intracompartmental pressure values were recorded in the same manner after fasciotomy. Retrospective proof that diagnosis of the syndrome had been correct was the absence of exertional complaints from the preoperative examination during exercise at postfasciotomy visit., Results: Fifty patients (100 legs) participated in the prefasciotomy visit; 3 refused fasciotomy; 2 were lost to follow-up. Of 45 patients who completed the postfasciotomy visit, the diagnosis of chronic exertional compartment syndrome was retrospectively confirmed in 42 patients and discarded in 3 patients. The sensitivity for intracompartmental pressure (cutoff point, 35 mmHg) found in this study was 77% (67%-86%, exact 95% confidence interval), lower than estimates from the literature (93%). The sensitivity (previously defined cutoff) for near-infrared spectroscopy was 85% (76%-92%, exact 95% confidence interval), validating the estimate found in the literature (85%). Sensitivity of magnetic resonance imaging was comparable to that of intracompartmental pressure and near-infrared spectroscopy; associated specificity at a given sensitivity appeared to be lower with magnetic resonance imaging., Conclusion: This study validates the sensitivity of near-infrared spectroscopy and provides estimates for the sensitivity and specificity of magnetic resonance imaging in chronic exertional compartment syndrome in a large group of patients. The sensitivity of noninvasive near-infrared spectroscopy is clinically equivalent to that of invasive intracompartmental pressure measurements.

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.

Introduction: The Less Invasive Stabilization System (LISS) is an internal fixator that can be inserted percutaneously by means of a minimally invasive surgical approach. This paper presents the use of this system exclusively in patients with AO33 distal femoral fractures, a group in which fracture management is often complicated by multiple trauma and soft-tissue damage., Materials and Methods: A series of 62 patients (mean age 52 years) with 66 AO33A or C fractures received the LISS implant and were followed prospectively for 12 months. Assessments included the radiographic evaluation of implant placement and healing, measurement of valgus/varus and sagittal joint malalignment, and the assessment of weight-bearing capacity and range of motion., Results: The mean duration of surgery was 85 min (range 40-135 min) for 33A fractures and 149 min (range 50-300 min) for 33C fractures. Postoperative radiographic assessments showed that the LISS implant was positioned correctly in 59 cases (89%). Assessment of valgus/varus alignment showed correct axial alignment in 49 cases (74%), a deviation of 5-10 degrees in 13 cases, and a 10-20 degrees deviation in 1 case. Correct sagittal alignment was observed in 56 cases (85%), 5-10 degrees malalignment in 5 cases, and 10-20 degrees in 2 cases. During the course of the 1-year follow-up, 8 patients (9 fractures) died; 2 other patients were not available for follow-up. Complete fracture healing was achieved in 85% of the followed-up patients. Forty-eight patients were capable of full weight-bearing. After fracture healing, maximum flexion of the injured limb was on average 80% of the range of the uninjured limb. An extension deficit of more than 5 degrees was measured in 3 cases. Of the 62 patients, 14 underwent further operations during the course of follow-up. Of these, 6 required bone grafting and 3 refixation of the implant due to implant loosening. Deep infections requiring several debridements occurred in 2 patients. No complications relating solely to the implant were observed., Conclusion: The LISS showed good overall results in the treatment of these difficult fractures. It is a good alternative to conventional extramedullary and intramedullary stabilizing techniques, especially in more complex fracture situations.

To attain a better understanding of antibiotic cycling and its effects on the epidemiology of antibiotic resistance in gram-negative microorganisms, two different antibiotic classes (quinolone and beta-lactam) were cycled during four 4-month periods in a surgical intensive care unit. Respiratory aspirates and rectal swabs were obtained and DNA fingerprinting was performed. Primary endpoint of the study was the acquisition rate with gram-negative bacteria resistant to the antibiotic of choice during each cycle. Secondary endpoints were changes in endemic prevalence of resistant bacteria and the relative importance of cross-transmission. In all, 388 patients were included and 2,520 cultures analyzed. Adherence to antibiotic protocol was 96%. Overall antibiotic use increased with 24%. Acquisition rates with resistant bacteria were highest during levofloxacin exposure (relative risk [RR] 3.2; 95% confidence interval [CI]: 1.4-7.1) and piperacillin/tazobactam exposure (RR 2.4; 95% CI 1.2-4.8). The relative importance of cross-transmission decreased during the study. For individual patients, treatment with levofloxacin was the only independent risk factor for acquisition of levofloxacin-resistant bacteria (hazard ratio 12.6; 95% CI 3.8-41.6). Potential for selection of antibiotic-resistant gram-negative bacteria during periods of homogeneous exposure increased from cefpirome to piperacillin/tazobactam to levofloxacin. Cycling of homogeneous antibiotic exposure is unlikely to control the emergence of gram-negative antimicrobial resistance in intensive care units.

After some considerable delay, acute compartment syndrome of the lower leg was diagnosed in a 17-year-old man, a 32-year-old man and a 76-year-old woman. The first patient was an accident victim whose leg was continuously bandaged for three days following treatment of a complicated femur fracture and lower leg wounds, so that inspection was not possible. In the second patient who was also an accident victim, the haemodynamics and the neurological condition initially required so much attention that the compartment syndrome was only noticed after 48 hours. The woman presented with a cold, painful left foot. She had atrial fibrillations. A thrombus mass was removed endovascularly from the femoral artery. She controlled her own pain medication by means of an epidural catheter, but as a result of that a reperfusion compartment syndrome was only noticed at a later stage. These cases reveal that it can be very difficult to establish the diagnosis of acute compartment syndrome, especially if this is masked by the already quite subjective symptoms of the clinical picture. The consequences of a missed compartment syndrome are serious, with a considerable impairment of the limb concerned that often necessitates amputation. Awareness and healthy suspicion are the keys to a quick and timely diagnosis. Prophylactic fasciotomies must be carried out on the basis of several clear indications.

Bacterial spread between patients may contribute to the high prevalence of antibiotic-resistant pathogens within ICUs. The aim of this study was to evaluate the fate of Pseudomonas aeruginosa during the different antibiotic regimens. Susceptibility patterns and genotyping were performed to determine whether there was a predominant clone and to track the spread of resistant strains within the unit. Twenty-eight different ribotypes were found among 82 Pseudomonas isolates. Four ribotypes accounted for 42 (51%) isolates and were designated the "major clones" occurring throughout multiple cycles. The ribotypes with multiple occurrences were more resistant to antibiotics than ribotypes that appeared only once. The correlation of antibiotic use with antibiotic resistance and the finding of a large number of ribotypes suggested that de novo development of antibiotic resistance is a likely event in P. aeruginosa. In addition, ribotypes associated with antibiotic resistance appeared to have a survival advantage and can become frequent colonizers in the ICU.

The sliding hip screw is the implant of choice for the operative treatment of stable pertrochanteric femur fractures (AO classification 31-A.1). For this indication, a four-hole side plate with four bicortical screws is widely used to allow full weight bearing immediately after operation, but scientific support for the need of such a long side plate is not available. A shorter side plate is potentially less invasive. Therefore, we retrospectively evaluated all 148 consecutive patients (median age 80 years) with a stable pertrochanteric femur fracture who were treated between 1995 and 2001 with a dynamic hip screw (DHS) and a short (two-hole) side plate and immediate full weight bearing mobilisation. Although two wound hematomas and four wound infections occurred, 145 fractures healed radiologically without implant-related complications within 6 months. Two hip screws cut out of the femoral head due to a poor position. In one patient, the side plate broke out after a fall out of bed on the fifth postoperative day. Pull off of any two-hole side plate during early full weight bearing mobilisation without further trauma was not observed. We conclude that fixation of stable pertrochanteric femur fractures with a two-hole DHS is safe. The traditional use of a four-hole DHS plate for this indication is therefore 'over-treatment' since it is more invasive.

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.

Closure of large incisional hernias with the Components Separation Method (CSM) could be explained by medial-caudal rotation of the internal and transverse oblique muscles around their centres of origin. In eight human cadavers, the CSM was performed, and translation of the rectus abdominis muscle was measured. Mean unilateral translation of the rectus abdominis in the lateral-medial direction measured 2.2, 3.7, and 3.5 cm. This was 2.7, 4.5, and 4.0 cm after release of the posterior rectus sheath. Mean translation in a caudal direction was 0.5 cm, but seven cadavers showed a mean translation of 1 cm of the uppermost measuring point in a cranial direction. The hypothesis that rotation of separate tissue layers of the abdominal wall largely accounts for the translation effect of the CSM must be rejected. Release of the external oblique muscle produces more benefit to abdominal wall closure than release of the posterior rectus sheath.

This prospective study aims to describe the results of fasciotomy in patients with exercise-induced pain in the lower leg with suspected (chronic) exertional compartment syndrome. The diagnosis of (chronic) exertional compartment syndrome was made if pain in the lateral side of the lower leg after a standard physical load was accompanied by elevated tissue pressures in the anterior muscle compartment. Tissue measurements were performed in 114 patients. In 56 patients (106 compartments) increased tissue pressure was found (> 50 mmHg measured immediately after exercise, or > 30 mmHg if the pressure before exercise > 20 mmHg, or if the pressure five minutes after exercise is still > 30 mmHg). Two years after fasciotomy, (remaining) complaints were evaluated on the basis of a questionnaire: 87 % of the patients had significant reduction in complaints. Patients who were not found to have increased tissue pressure were also asked to report developments through the questionnaire. In 18 patients a fasciotomy was performed on the basis of the typical history, despite normal or slightly increased intramuscular pressures. Twelve of these patients (24 compartments) were asymptomatic after surgery. Fasciotomy in patients with a (chronic) exercise-induced compartment syndrome in the anterior compartment of the lower leg, based on our criteria, gave a marked reduction in symptoms in 87 % of the patients. Further research has to be done for the minimum tissue pressures above which fasciotomy may be successful in terms of reducing complaints.

Background: Patients with chronic exertional compartment syndrome (CECS) experience pain during exercise. An abnormal increase in intracompartmental pressure (ICP) leads to impaired local tissue perfusion resulting in ischemia and pain. At cessation of exercise, pain subsides. Diagnosis is confirmed through postexercise ICP. Near infrared spectroscopy (NIRS) can measure tissue oxygen saturation (StO(2)) noninvasively., Hypothesis: NIRS can diagnose CECS by showing tissue deoxygenation., Study Design: Prospective, nonrandomized clinical trial., Method: Volunteers completed a standardized exercise protocol. Those suspected of CECS did so preoperatively and postoperatively. StO(2) and ICP were monitored. Data were compared between volunteers and patients and prefasciotomy and postfasciotomy., Results: Significant differences between the StO(2) values of volunteers and patients with CECS were found. Average peak exercise StO(2) value for those with CECS was lower than for the healthy (27 versus 56, P <.05). Patients showed more absolute and percentage change between baseline and peak exercise StO(2) (absolute: 60 versus 35, P <.05; percentage: 67 versus 38, P <.05). StO(2) values in legs with confirmed CECS returned to normal range postfasciotomy. All changes differed significantly with preoperative values., Conclusion: StO(2) can distinguish healthy from diseased legs. This study provides evidence supporting NIRS as a noninvasive, painless alternative to ICP in the diagnosis of CECS.

For operative treatment of unstable trochanteric fractures two options exist: extramedullary or intramedullary stabilisation. A review of 18 international papers that compared two different treatment methods for trochanteric fractures, in prospective randomised clinical trials, is presented. In view of the overall results, routine use of intramedullary fixation devices is not to be recommended for stable trochanteric fractures. For these fractures one of the sliding hip screw systems provides a safe and simple alternative. For unstable fractures intramedullary implants are (biomechanically) superior. The review shows that clinical advantages of both treatment methods are suggested and advocated, but still remain to be demonstrated on evidence base.

In the late 1980s the Dutch trauma surgeons (Dutch Trauma Society) expressed their concern about the quality of care to the (multi) trauma patients, in the prehospital as well as the in-hospital setting. The following intensive debate with the public health inspectorate and the government became the start point for major improvements in teaching and training (a.o. ATLS), reorganization, regionalization and implementation in which all partners in trauma care were involved. The regionalization of ambulance care, the introduction of mobile medical teams, the availability of trauma helicopters, the categorization of hospitals, the designation of trauma centres, the given responsibility of these centres in the regionalization of trauma care will and already have resulted in an important quality improvement, not only of the individual organizations but for all of the entire chain of trauma care. It has become a major step forward in the philosophy: get the individual trauma patient at the right time at the right hospital. Besides, initiatives have been taken to design a nationwide trauma registration data base in which all in-hospital trauma patients will be included. However serious concerns remain: shortage of intensive care beds, the impossibility to use the helicopter service at night, the shortage in the number of mobile medical teams at night and the slowness in executions of agreements between contracting parties. Many of the remaining problems are a matter of money. Not only (para) medical partners and hospitals but for all government and insurance companies should take their responsibility in this.

In recent years computer technologies have become more and more integrated in surgical procedures. The potential advantages of computer assisted surgery (CAS) are: increase of accuracy of surgical interventions, less invasive operations, better planning and simulation and reduction of radiation exposure for both patient and surgeon. After introduction of CAS in neurosurgery, the clinical applications of this technique expanded also into trauma and orthopaedic surgery. The first application of this new technique in orthopaedic and trauma surgery was for placement of lumbar pedicle screws. After its introduction into spine surgery, CAS was applied in other fields of orthopaedic surgery like hip, knee and skeletal trauma surgery. In this article the technical background and the various clinical applications and future perspectives of computer assisted orthopaedic and trauma surgery are outlined.

The standard AO-plate was used as an external fixator in 31 patients with an infected nonunion or open fracture mainly of the upper extremity. With the use of this technique, good stability can be achieved with an inexpensive and relatively simple construction. The low profile of the frame is an advantage for the patient.

Although the Dutch policy to eradicate methicillin-resistant Staphylococcus aureus (MRSA) is very strict compared to policies employed in other countries, it has proven to be successful epidemiologically (incidence of MRSA in the Netherlands, <0.5%). The present study was performed to investigate both the financial and the logistical consequences of this strict, so-called "search and destroy" policy in the Netherlands. The data were based on a 10-year survey (1991-2000) of screening, surveillance, and outbreaks at the University Medical Center Utrecht. The consequences of the policy were determined by a panel comprising physicians from the Department of Surgery, the Department of Medical Microbiology, Subdivision Hospital Hygiene and Infection Prevention, the Department of Pharmacy, and Household Services. The costs associated with the policy were also calculated, including those for additional (disposable) material, cultures, specific medication, decontamination, and closing of the wards. Over the course of the 10 years, implementation of the MRSA policy resulted in more than 2,265 lost hospitalization days. In addition, the wards had to be closed 48 times, 29 healthcare workers had to temporarily discontinue working, and 78,000 additional cultures had to be performed. The total cost reached 6 million Dutch guilders (euro 2,800,000). The financial and logistical consequences were then compared to those in a hypothetical situation without the "search and destroy" policy. In such a situation, the hospital would be faced with an increased incidence of MRSA, vancomycin intermediate-susceptible Staphylococcus aureus, and vancomycin-resistant enterococci. The costs associated with the use of alternative antibiotics, required in a scenario of high endemic-level MRSA, would be at least twice as high as the costs expended in the actual situation, thus demonstrating that a strict MRSA policy is financially worthwhile.

Objective: Review of the literature concerning pressure ulcers in the intensive care setting. DATA SOURCE AND STUDY SELECTIONS: Computerized databases (Medline from 1980 until 1999 and CINAHL from 1982 until 1999). The indexing terms for article retrieval were: "pressure ulcers", "pressure sores", "decubitus", and "intensive care". Nineteen articles met the selection criteria, and seven more were found from the references of these articles. One thesis was also analyzed., Results: Data on prevention, incidence, and costs of pressure ulcers in ICU patients are scarce. Overall there are no conclusive studies on the identification of pressure ulcer risk factors. None of the existing risk-assessment scales was developed especially for use in ICU patients. It is highly questionable to what extent these scales can be used in this setting as they are not even reliable in "standard care". The following risk factors might play a role in pressure ulcer development: duration of surgery and number of operations, fecal incontinence and/or diarrhea, low preoperative protein and albumin concentrations, disturbed sensory perception, moisture of the skin, impaired circulation, use of inotropic drugs, diabetes mellitus, too unstable to turn, decreased mobility, and high APACHE II score. The number of patients per study ranged from 5 from 638. The definition of "pressure ulcer" varied widely between authors or was not mentioned., Conclusions: Meaningful comparison cannot be made between the various studies because of the use of different grading systems for pressure ulcers, different methods of data collection, different (or lack of) population characteristics, unreported preventive measures, and the use of different inclusion and exclusion criteria. There is a need for well-conducted studies covering all these aspects.

Background and Objective: In the Netherlands, the prevalence of methicillin resistance among Staphylococcus aureus isolates has been kept to less than 1% by using active screening programs and isolation. At the University Medical Center Utrecht (UMCU), an active screening program for methicillin-resistant S. aureus (MRSA) in the surgical intensive care unit (ICU) was implemented in 1986. Between 1992 and 2001, only 6 patients with MRSA were admitted to the surgical ICU. However, 4 of these 6 strains were able to spread to 23 other patients and 15 healthcare workers (HCWs). We were surprised by the epidemic behavior of these strains and wondered whether this was exceptional for S. aureus or whether methicillin-susceptible S. aureus (MSSA) was also spreading in the ICU., Design: A 2-month, prospective, observational study to investigate the incidence and spread of MSSA in the surgical ICU of UMCU and historical data collected during a 10-year period regarding MRSA., Setting: A 10-bed surgical ICU in a 1,042-bed teaching hospital., Results: Weekly swabs revealed the presence of MSSA in 11 (24%) of 45 patients and 16 (22%) of 72 HCWs. Of all 4,105 patient-HCW contacts, there were only 21 episodes in which both the patient and the HCW were found to carry MSSA. With the use of pulsed-field gel electrophoresis, no identical strains could be identified., Conclusion: In our surgical ICU, MRSA seems to spread more easily than MSSA, probably because of selection under antibiotic pressure or a still unknown intrinsic factor within MRSA.

Objective: Survey of the influence of smoking on the healing of open tibial fractures., Design: Retrospective., Method: During the period 1 January 1994 to 31 December 2000, 168 patients were treated at the Department of Surgery (University Medical Center Utrecht, the Netherlands) due to an open tibial fracture; 118 patients with 125 fractures were included in the study. On the basis of their smoking behaviour, patients were classified as 'non-smokers' or 'smokers'. For all of the patients it was ascertained whether or not complications had occurred during treatment. Whether the fracture had consolidated was determined on the basis of clinical and radiological criteria., Results: Seventy-two (61%) patients were non-smokers and 46 were smokers. The non-smokers had 77 open tibial fractures and the smokers 48. Initial therapy was identical and wound infections occurred with similar incidences in both groups. However, there was a statistically significant difference in the incidence of osteitis between both groups: 7 (9%) times in the non-smokers and 13 (27%) times in smokers (p = 0.04). The mean time to consolidation was 26 weeks for non-smokers and 33 weeks for smokers (p = 0.04). Smokers remained longer in hospital and underwent more re-operations., Conclusions: Smoking was negatively associated with the healing of open tibial fractures. In smoking patients, the time to consolidation was on average statistically significantly longer and they suffered more from osteitis.

Nosocomial infections play a role in quality and cost control in health care. Surveillance of these infections is the only way to gain more insight into their frequency and causes. Since the results of surveillance may lead to changes in both patient and hospital management, which are sometimes major, it is necessary that all healthcare workers involved agree on the criteria used for the diagnosis and surveillance of these complications. In order to compare the efficacy of two surveillance methods, nosocomial infections in surgical patients were registered by both the Department of Surgery (complication surveillance [CS]) and the Department of Infection Control (nosocomial infection surveillance [NIS]) at the University Medical Center Utrecht, The Netherlands, over a 2-month period. The CS team used the national criteria of the Association of Surgeons of the Netherlands and the NIS team used the international criteria of the Centers for Disease Control and Prevention, USA, to define cases of nosocomial infection. A total of 515 patients were included in both arms of the study. The CS team diagnosed 69 infections in 49 patients, and the NIS team diagnosed 64 infections in 45 patients. Of 104 total infections, 39 were diagnosed by the CS team exclusively, 35 by the NIS team exclusively and only 30 by both. The main reasons for the inconsistent results were as follows: (i) the lack of follow-up after discharge in the NIS arm, (ii) the use of clinical criteria for the definition of a nosocomial infection in the CS arm, and (iii) the use of positive cultures as part of the criteria in the NIS arm. From the perspective of infection control, the CS system cannot be recommended for the surveillance of nosocomial infections.

Fluoroscopy-based navigation systems can be used for internal fixation of intracapsular femoral neck fractures, with the object of optimizing positioning of the implant and reducing radiation exposure. With this technique, the virtual position and direction of a reamer can be simultaneously superimposed on anteroposterior (AP) and axial (AX) fluoroscopic images. However, surgeons have to rely on the accuracy of these systems, because the only intraoperative feedback on the true position of the reamer is the projection of a virtual reamer superimposed on two fluoroscopic images. The objective of this study was to evaluate the accuracy of the displayed position of the virtual reamer in relation to the true position of the instrument when using a fluoroscopy-based navigation system (medivision, Oberdorf, Switzerland). Secondary to this, the accuracy of the drill-channel measuring tool of the system was analyzed. The study was performed on 20 sawbones. To evaluate the position of the virtual reamer, an 8-mm Perspex bar was inserted in predefined drill channels in each sawbone. AP and AX fluoroscopic images of the sawbones with the Perspex bar were loaded into the workstation. The Perspex bar was then removed and exchanged for a navigated dynamic hip screw (DHS) reamer. The position of the Perspex bar in the images represented the true position of the reamer. Subsequently, the difference between the position of the virtual reamer and the Perspex bar was measured with a dedicated computer program. Drill-channel lengths measured with the system were compared with measurements obtained with a digital ruler. The mean difference in position of the Perspex bar and reamer at a predefined point was 0.90 mm (range: 0.00-3.21 mm) in 360 images. The mean difference in length measurements between the medivision system and the digital ruler was 1.00 mm (p = 0.01, SD =1.33). Reaming and measuring the screw channel of a DHS with a medivision fluoroscopy-based navigation system can be performed with an acceptable error margin., (Copyright 2003 Wiley-Liss, Inc.)

This article reviews the current body of knowledge on the adverse effects of smoking on soft-tissue and bone healing, with emphasis on tibial fractures in combination with severe soft-tissue injury. The pathophysiological effects are multidimensional, including arteriolar vasoconstriction, cellular hypoxia, demineralisation of bone, and delayed revascularisation. Several animal and clinical studies have been published about the negative effects of smoking on bone metabolism and fracture healing. These studies show that smokers have a significantly longer time to clinical union than non-smokers and a higher incidence of non-union. The negative effects of smoking gained increased interest among plastic and microvascular surgeons, because smokers have been shown to suffer higher rates of flap failure, tissue necrosis, and haematoma formation. Especially smokers presenting with an open tibial fracture will suffer the negative effects of their smoking behaviour, because these fractures are inextricably bound up with soft-tissue injury. Their fractures will need a significantly longer time to heal than in non-smokers, and will have a higher incidence of non-union. If microvascular surgery is to be performed, persistent smoking significantly increases the rate of postoperative complications, with wound infection, partial flap necrosis, and skin graft loss being more common. Cessation of smoking has both short- and long-term beneficial effects. Nowadays, there is strong evidence to be very insistent that patients presenting with a (open) tibial fracture should refrain from smoking immediately to promote bone healing and to lower the complication rate. In case of elective reconstructive procedures, patients should refrain from smoking at least 4 weeks before surgery. In both situations, cessation should continue during the full rehabilitation period.

Background: Prediction of complications is an essential part of risk management in surgery. Knowing which patients are at high risk of developing complications will contribute to the quality and cost reduction of surgery., Methods: All patients admitted to a general surgical ward during a 1-year interval were followed until 30 days after discharge. Complications and data on potential risk factors were recorded prospectively. Relative risks were calculated for each risk factor and predictive values for the development of a serious or minor complication were computed using logistic regression analysis. The predictive values of different combinations of variables were expressed as receiver operating characteristic curves., Results: Of 3075 patients, 375 suffered one or more serious complications and 319 experienced a minor complication. A model was developed for prediction of serious complications, consisting of 11 variables, with an area under the curve (AUC) of 0.79 (95 per cent confidence interval (c.i.) 0.76 to 0.81). The prognostic value of the model for minor complications (seven variables) was lower (AUC 0.68 (95 per cent c.i. 0.65 to 0.71))., Conclusion: Serious complications in patients admitted to a surgical ward can be predicted using a model consisting of 11 variables. The risk score can be used in the decision-making process before surgery.