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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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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 endoseopic 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. [ABSTRACT FROM AUTHOR]

Abstract 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

Abstract 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.

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. [ABSTRACT FROM AUTHOR]

Focuses on the cosmetic results of closed and open healing after abdominal surgery. Patients who had open-wound management after contaminated abdominal surgery compared with matched controls having a similar operation with primary skin closure; Chart showing cosmetic results of abdominal scars for appendicectomies and median laparotomies.

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.

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.