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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.

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.

This study evaluates the safety and results of surgery usingTaraKlamp Circumcision Device during a group circumcision. Atotal of 64 circumcisions of Muslim boys were performed by Medical Assistants supervised by Medical Doctors in a hall in Kuala Lumpur, Malaysia. A new type disposable clamp was used, which was removed 4 days after the operation. No major complications occurred and the boys experienced in general mild pain postoperatively. Mostly good cosmetic results were obtained and 90% of the parents would recommend this new clamp to others. Group circumcisions withTaraKlamp Circumcision Device (Kuala Lumpur, Malaysia) are safe, although proper patient selection and adequate training in using the device are mandatory.

The purpose of this study was to assess the long-term functional outcome and the quality of life of patients who were treated for a (Gustilo) Grade III open tibial fracture. We included 43 patients with successful limb salvage (group A) and 21 amputees (group B). The groups were similar with regard to age, sex, and Injury Severity Score (ISS). The functional outcome was scored using the "Guides to the Evaluation of Permanent Impairment". To compare quality of life we used the Nottingham Health Profile (NHP), the SF-36, and a questionnaire especially designed for this study. The mean lower extremity impairment (AMA) of patients in group A was 17.6%, compared to 73.5% for patients in group B. The results with both NHP and SF-36 show that patients in both groups have more problems in most categories than a healthy reference group. With the NHP, the difference in score was largest for the categories of pain, mobility, energy and sleep. The SF-36 scores correlated well with the NHP scores. No significant difference was found between the two groups. This type of injury has an enormous impact on every aspect of life--irrespective of the chosen treatment. A significant difference in lower extremity impairment is found between patients with a successful reconstruction and those who are amputees. However, the quality of life was shown to be the same.

Objective: To find out which factors influence outcome after a fractured hip, so that the optimum treatment may be chosen for each patient., Design: Prospective cohort study., Setting: 3 teaching and 2 rural hospitals, The Netherlands., Subjects: 215 patients aged 55-102 years (median 82) who presented with a fractured hip during 1994., Interventions: Interviews shortly after the injury and 4 and 12 months later, study of radiographs, and evaluation of casenotes., Main Outcome Measures: Mobility and functional recovery., Results: 38 patients had died by the 4-month follow up, at which time 64/177 (36%) had regained the level of mobility that they had before the injury. At 12 months the figure was 58/148 (39%). The corresponding figures for functional recovery were 52/177 (29%) and 36/148 (24%). Factors that militated against recovery were increasing age, coexisting diseases, general complications and local complications., Conclusions: The chance of a patient with a hip fracture making any further recovery after 4 months is minimal. Local complications are the most important risk factor.

The cultures of two patients of the Surgical Intensive Care Unit (IC) of the Medical Centre of Utrecht University were found positive for methicillin-resistant Staphylococcus aureus (MRSA). A male nurse turned out to be the source, 4 months after his return from working in an English hospital. Cultures were, by mistake, not taken directly on arrival from abroad. Pulsed-field gel electrophoresis proved MRSA strains from both source and the 2 patients to be identical to a strain which was epidemic in Great Britain but had never occurred in the Netherlands. The IC has meanwhile been closed; at source investigation, 14 other patients and six staff members were found MRSA-positive. The policy in the hospital is to screen health care workers for MRSA carriership on return from an hospital abroad. The success of the policy depends strongly on the cooperation of health care workers in this matter.

We report a case of a recurrent traumatic dislocation of the hip joint in a young man at the age of 13 and 17. The patient had retroversion of the femoral neck, instead of a physiological anteversion. We found no consensus about the management of a recurrent traumatic dislocation of the hip joint in the literature. The various therapeutic options are discussed. We advised posterior capsulorraphy with femoral rotation osteotomy. The patient refused surgery.

Operative fracture repair in trauma surgery is currently performed using metal implants. These metal implants often are removed during a second, retrieval operation. Biodegradable fracture fixation devices have been used clinically since the late seventies. Most bioresorbable implants are manufactured from polymers. The polylactides, polyglycolides and co-polymers slowly degrade into small components that are excreted from the human body via natural pathways and removal operations after fracture surgery are not necessary. Due to the limited mechanical properties, the polymer screws and pins are mostly used in the treatment of non weight-baring simple fractures of the ankle, elbow, hand and foot. In view of the progressing technical developments, new materials will be developed and tested for clinical use in the coming decades.

Objective: To assess the results of twelfth rib resection as a direct posterior surgical approach to subphrenic abscesses in case of failure of percutaneous drainage, abandonment of percutaneous drainage in view of a too high risk of perforation of adjacent organs, or contamination of the pleural space, or an inaccessible abdomen., Design: Retrospective study., Setting: University hospital, The Netherlands., Patients: 17 patients who required rib resection for subphrenic abscesses that developed after infected necrotising pancreatitis, splenectomy, or anastomotic disruption., Interventions: 18 rib resections., Main Outcome Measures: Outcome and morbidity., Results: Twelfth rib resection was successfully in 13 of 17 patients. Four patients died from multiple organ failure despite subsequent (re) laparotomies for additional surgical drainage., Conclusion: Twelfth rib resection can be useful for the treatment of subphrenic abscesses in selected patients.

Advances in computer technology will revolutionize surgical techniques in the next decade. The operating room (OR) of the future will be connected with a laboratory where clinical specialists and researchers prepare image-guided interventions and explore the possibilities of these techniques. The virtual reality is linked to the actual situation in the OR with the aid of navigation instruments. During complicated operations the images prepared preoperatively will be corrected during the operation on the basis of the information obtained peroperatively. MRI currently offers maximal possibilities for image-guided surgery of soft tissues. Simpler techniques such as fluoroscopy and echography will become increasingly integrated in computer-assisted peroperative navigation. The development of medical robot systems will make possible microsurgical procedures by the endoscopic route. Tele-manipulation systems will also play a part in the training of surgeons. Design and construction of the OR will be adapted to the surgical technology, and include an information and control unit where preoperative and peroperative data come together and from where the surgeon operates the instruments. Concepts for the future OR should be regularly adjusted to allow for new surgical technology.

Objective: To determine whether it is possible to decrease the number of X-rays in acute ankle injury while keeping the health care constant, using a scoring system., Design: Prospective., Method: Patients presenting in the emergency department of the University Hospital Utrecht (AZU), the Netherlands, over a one-year period of time with acute ankle injuries were subjected to a thorough physical examination based on a scoring system developed at Leiden University Hospital. The score was calculated and X-ray examination was indicated when this score was > or = 8 points. Radiological investigation or telephone interviews six weeks after injury achieved verification of the clinically relevant ankle fractures. Specificity and sensitivity were calculated from every possible cut-off point and drawn in a 'receiver operating characteristics' (ROC) curve., Results: Of the 514 patients included 81 patients had a score of 8 or higher and 24 of them had a clinically relevant fracture. In 34 patients an ankle X-ray was made although their score was < 8 points. The positive and negative predictive values of the system were 30% (95% confidence interval (95% CI): 20-41) and 99% (95% CI: 97-100) respectively. The score yielded an area under the ROC curve of 91% (95% CI: 84-98). A cut-off point of 8 led to a reduction of X-rays by 60% (using the 'Ottawa ankle rules' the decrease in this population would have been 28%). On the other hand, 5 clinically relevant fractures were missed., Conclusion: Radiological examination in patients wit acute ankle complaints was reduced while health care remained almost constant. In the AZU, a decision was made for a major reduction in X-rays while accepting that some fractures would be missed.

Objective: To assess the results of open management of the abdomen and planned re-operations in severe bacterial peritonitis after perforation or anastomotic disruption of the digestive tract., Design: Retrospective study., Setting: University Hospital, The Netherlands., Subjects: 67 consecutive patients., Interventions: Open management of the abdomen and planned reoperations., Main Outcome Measures: Hospital morbidity and mortality, long-term follow-up., Results: 38 patients developed multiple organ failure (MOF), but 29 needed only ventilatory and inotropic support. The mean number of re-operations was nine. 16 patients developed severe bleeding and 16 fistulas. In-hospital mortality was 42% (n = 28). Long-term morbidity, particularly the number of abdominal wall defects (n = 10), was considerable., Conclusion: Despite open management of the abdomen and planned re-operations, mortality of severe bacterial peritonitis still continues to be too high, and both short and long-term morbidity are appreciable. The value of open management of the abdomen and planned re-operations rests only on the clinical observation that other conventional surgical treatments of severe bacterial peritonitis often fail.

Background: Despite advances in diagnosis, surgery, antimicrobial therapy and intensive care support, the mortality rate associated with severe secondary peritonitis remains unacceptably high. This article presents various surgical treatment strategies for severe secondary peritonitis, emphasizing the role of open management of the abdomen and planned relaparotomies., Methods: Material was identified from previous review articles, references cited in original papers and a Medline search of the literature., Results and Conclusion: Surgical treatment of severe secondary peritonitis is highly demanding and very complex. The combination of improved surgical techniques, antimicrobial therapy and intensive care support has improved the outcome of such peritonitis following perforation or anastomotic disruption of the digestive tract, or infected necrotizing pancreatitis. However, aggressive surgical treatment strategies, such as open management of the abdomen and planned relaparotomies, may have reached their limits.

Objective: To describe the results of free vascularized muscle transfer for treatment of complications of severe open fractures of the distal tibia and ankle region., Design: Retrospective., Methods: In 1994-1998, 32 patients underwent free muscle transfer for soft tissue reconstruction after high energy injury to the distal tibia and ankle region. In six patients reconstruction took place within one week after the injury (group 1); 13 patients underwent free muscle transfer in combination with (re)osteosynthesis and cancellous bone grafting for treatment of infected (defect) pseudarthrosis (group 2); chronic posttraumatic osteitis existed for an average of 12 years in six patients (group 3); in seven patients the indication was determined by unstable scar tissue, cosmetic reasons, or as preparation for corrective osteotomy (group 4)., Results: Three haematomas and two thrombembolic complications were encountered. Amputation could not be avoided in three patients. Consolidation of the fracture, pseudarthrosis or arthrodesis and/or eradication of infection was accomplished in all remaining 29 patients. An average of 2.2 (range: 0-7) reinterventions were additionally needed in groups 1-3, including reosteosynthesis, sequestrectomy, cancellous bone grafting and/or arthrodesis., Conclusion: In case of severe open fracture of the distal tibia and/or ankle region, free vascularized muscle transfer provided cover of the fracture or pseudarthrosis region, thereby improving local vascularisation. This treatment protects the underlying bone, enhances osteogenesis and improves resistance to infection.

Currently available intramedullary devices for the treatment of unstable pertrochanteric femoral fractures are technically demanding and show a considerable failure rate due to their massiveness and the persistent rotational instability of the head-neck fragment. The Arbeitsgemeinschaft für Osteosynthesefragen (AO/ASIF) therefore designed a new intramedullary device, the proximal femoral nail (PFN), which during a handling study was tested in 4 European clinics. Within one year 191 proximal femoral fractures were treated with the PFN. After a follow up period of at least 4 months technical failures (poor reduction, malrotation or wrong choice of screws) were seen in just 4.6% of the cases. One patient showed a cut-out of the implant but there were no mechanical failures (bending, breaking of the implant) or ipsilateral fractures of the femoral shaft at the tip of the implant. It is therefore concluded that the results of this new implant compare favourably to the currently available implants for the treatment of the unstable pertrochanteric femoral fracture.

A 59-year-old woman had persistent sepsis after abdominal operations because of a volvulus and subsequently a retroperitoneal abscess, in spite of antibiotic treatment against Klebsiella pneumoniae, which grew in blood cultures. During abscess drainage, a haemorrhage from the infrarenal part of the aorta had occurred; in view of a presumed aortitis this part had been replaced by a bifemoral bypass. Computer tomography revealed intraosseous formation of gas in vertebrae and pelvis. At operation, abscesses were drained and necrotomy and sequestrotomy of the bone were performed. Cultures of the pus from the iliac crests showed K. pneumoniae. The antibiotic management was changed; the wounds were flushed regularly. After exposure of the wounds still draining after 6 months and vascular surgery because of occlusion of the bypass after 7 months, the patient recovered well. She died 2 years later from a cerebral haemorrhage.

This case demonstrates once again the potential and serious complications of pelvic fractures, especially when associated urogenital injuries are missed. Missing the bladder rupture proved almost fatal to our patient. Second, it was confirmed that in very unstable pelvic fractures, external fixation alone does not provide enough stability. Local stability is the cornerstone in the treatment of (bone) infection, and in these cases, maximal stability is only obtainable with internal fixation. The advantages of metal implants in infected areas outweigh the disadvantages by far. For the bladder-rupture, we chose a two-stage approach. First, we performed a urinary diversion, to avoid surgical closure of the infiltrated bladder wall. All cavities, including the open bladder, were packed with omentum to fill the dead space with highly vital tissue to offer stout resistance to infection. Two years later, with the patient in excellent physical condition, urinary undiversion was carried out. Ultimately physical and social recovery was complete.

Objective: To describe the experience with circumcision of Moslem boys under local anaesthesia outside the hospital., Design: Prospective, descriptive., Method: A total of 94 circumcisions under local anaesthesia were performed from April through November 1997 in a Health Centre of the Municipal Health Service, Utrecht, the Netherlands. Pain and unrest of the boys were scored on a scale from 1 to 10 by the operating surgeon (1 = no pain/patient fully calm; 10 = unbearable pain/patient in panic). Postoperative follow-up was only done on request of the parents/fosterers. The reasons for these follow-ups were recorded. One week after the circumcision the parents/fosterers were asked if there were any complications and whether they were satisfied with this method., Results: The median age was 3 years (range: 2-24). The pain during the operation was scored by the surgeon with a median of 1 (1-6) while unrest scored a median of 3 (1-9). Thirteen children were seen again because of bleeding (n = 4), haematoma (n = 2), swelling (n = 7). One week after the operation 89% of 70 parents/fosterers interviewed by telephone were content with the treatment. The social aspect of this way of circumcision was much appreciated., Conclusion: Circumcisions under local anaesthesia outside the hospital are feasible. Complications were according to published figures and most parents were content. With this procedure a cost reduction of 70% may be achieved in comparison with clinically performed circumcision under general anaesthesia.

Objective: To assess a scoring system for predicting recurrence of fulminant bacterial peritonitis after discontinuation of antimicrobial treatment in patients being treated by open management of the abdomen for persistent bacterial peritonitis after perforation of the digestive tract, anastomotic disruption, or necrotising pancreatitis., Design: Retrospective study., Setting: University Hospital, The Netherlands., Subjects: 58 consecutive patients., Main Outcome Measurements: Recurrence of fulminant bacterial peritonitis and survival., Results: 13 of the 58 patients (22%) died during the initial course of antimicrobial drugs. 14 of the remaining 45 patients had a recurrence of fulminant bacterial peritonitis after discontinuation of antimicrobial drugs, 4 of whom died. Predictive criteria included raised white cell count (WCC) (p = 0.02), duration of initial antibiotic treatment (p = 0.05), and deterioration in Simplified Acute Physiology Score (p = 0.05). Using the WCC and the duration of initial antimicrobial treatment together with other variables that showed a predictive trend (body temperature, percentage band cells, underlying disease, and use of inotropic agents), in a new scoring system (0-12), fulminant bacterial peritonitis did not recur when the score was 0-3, but in 9 of 11 patients with a score of 6 or more it did (p < 0.001)., Conclusion: Patients at increased risk of recurrence of fulminant bacterial peritonitis during open management of the abdomen can be identified at the time of discontinuation of antimicrobial treatment by a new scoring system; antimicrobial treatment should not be discontinued in patients with a score of 6 or more.

Accidental hypothermia (AH) can be defined as an unintentional decrease in core temperature below 35 degrees C during cold exposure by individuals without intrinsic thermoregulatory dysfunction. Pathophysiological changes can be attributed both to the severity of hypothermia and to co-morbid factors such as trauma, submersion, intoxication and underlying diseases. In trauma victims stratified according to the Injury Severity Score, the factor hypothermia is considered to be a poor prognostic sign for survival. In these patients rewarming therapy should be applied as soon as possible. In the Utrecht University Hospital, adult patients with AH are managed according to an algorithm based on their presenting hemodynamic conditions. Patients with perfusing cardiac rhythms and systolic pressures over 80 mmHg will receive continuous arteriovenous rewarming (CAVR). Arrested and hemodynamically instable patients are treated with cardiopulmonary bypass (CPB). In a 3-year period, 22 patients with AH were admitted to the emergency department. Fourteen patients had a trauma as the cause of hypothermia. Twenty patients were treated according to the algorithm (CAVR n = 18, CPB n = 2) and two patients were alternatively managed. Mortality in the CAVR group was 28% and total mortality reached 32%. Complications of CAVR are related to placement and removal of vascular catheters and may be severe in these patients with impaired coagulation. CAVR permits a good access to the (trauma-) patient and rewarming can be continued synchronously with diagnosis and treatment of various injuries.

During the delivery of a blow to the jaw, two men, 33 and 34 years of age, suffered an injury at the level of the right metacarpophalangeal joint in, respectively, the 4th and 3rd digit. In both cases, purulent arthritis and destruction of the MCP-joint developed. Clenched-fist injuries are known for their severe complications such as septic arthritis, osteomyelitis and persistent infection leading to amputation. These complications are due to the easy perforation of the MCP-joint capsule and the fact that the patients do not seek medical treatment until a significant inflammatory process has developed. Exploration of the wound on a flexed hand is crucial to exclude perforation of tendon, joint and bone. The wound should be left open to avoid infections. In case of infections, which can be caused by a variety of aerobic and anaerobic bacteria, the recommended treatment is immediate debridement and administration of broad-spectrum antibiotics.

Several techniques are available for the provision of enteral nutritional support. Nasal tubes, gastrostomy tubes and jejunostomy tubes can be distinguised. Nasal tubes are used for short-term support, gastrostomy tubes (preferably via a percutaneous endoscopic gastrostomy) for long-term support (over 4 to 6 weeks), while (needle catheter) jejunostomy tubes are most often used to provide early enteral nutrition immediately after operations on the proximal gastrointestinal tract. The most frequent complications are: with the nasal tube dislodging, clogging and aspiration, with the gastrostomy tube peristomal infection and with the jejunostomy tube, obstruction. It should further be noted that the quantity of enteral nutrition prescribed and that actually administered may differ substantially so that patients with a feeding device may even become malnourished. With proper patient selection and secure control of the energy balance, feeding tubes are simple (temporary) devices that improve the patient's health and quality of life.

Early enteral nutrition improves the outcome of severely injured patients. To provide enteral nutrition, various methods are available. In a restrospective study we analysed the outcome of 24 severely traumatized patients (mean ISS = 44), in whom a percutaneous endoscopic gastrostomy (PEG) was used for enteral nutrition. All patients had been admitted to the intensive care unit with major cerebral injury. The mean duration of intensive care treatment and the in hospital stay were 28 and 71 days, respectively. PEG was introduced 14 days after hospital admittance. Enteral nutrition through the PEG was administered for 45 days. Four patients died, 8 patients were discharged from the hospital while being fed via the PEG and 12 patients resumed normal feeding and the PEG was removed. Three severe complications occurred; 1 patient aspirated massively and died; in 2 patients intra-abdominal leakage of the enteral nutrition occurred. Both patients recovered from this complication. We conclude that because of the advantages of early enteral nutrition on the one hand and the drawbacks of nasogastric feeding tubes on the other, in injured patients with severe cerebral damage, PEG placement is justified, despite the risk of complications.

Three patients, two men aged 47 and 33 years and a woman aged 33 years, became hypothermic after an accident with body temperatures of 34.5, 26.2 and 23.1 degrees C, respectively. Two of them developed circulatory disorders, for which reanimation was performed. All three patients recovered after active external heating using among other things warmed infusion fluids, a warmed waterbed, continuous arteriovenous rewarming and rewarming with the heart-lung machine. For the treatment to be successful, the type of rewarming selected should be guided by the degree of hypothermia, the circulatory situation and the severity of the accessory injuries.

Objective: To assess the results of fasciotomy in patients with a chronic compartmental syndrome., Design: Retrospective study., Setting: Department of Surgery, Central Military Hospital, Utrecht, the Netherlands., Method: Closed fasciotomy was performed in 81 patients (151 compartments) after standardized measurement of the pressure of the symptomatic compartment during exercise. The anterior compartment was affected 149 times and the lateral compartment twice. The pressure reading was repeated at least 3 months after the operation. All operated patients 6 months postoperatively were sent a written questionnaire inquiring about the results of the operation., Results: Postoperative complications included a neurinoma (3 times) and a seroma (once). The mean postoperative intramuscular pressures were lower than the preoperative ones: the pressure at rest fell from 22.1 to 14.0 mm Hg (p < 0.05), the exercise pressure from 57.5 to 25.4 mm Hg (p < 0.01) and the relaxation pressure from 34.4 to 25.2 mm Hg (p < 0.05). Ten patients had an unchanged increased pressure after the operation, for which a second fasciotomy was performed 4 times. Attenuation of symptoms was reported by 59 patients (76%). Nine patients with poor results had already had a combination with some other hyperpressure injury before the operation., Conclusion: Closed fasciotomy in a demonstrated chronic compartmental syndrome in most cases gave good results, viz. attenuation of symptoms and a decrease of the intramuscular pressure, especially after exercise.

We describe our experiences in 40 consecutive patients with subtrochanteric fractures treated with an AO 95 degrees condylar blade plate. Three patients died early due to multiple injuries. One patient developed a delayed union which ultimately resulted in repeated plate fractures due to fatigue. All other fractures heated despite deep postoperative wound infection in three cases. Based on our favourable results, we consider the condylar blade plate fixation of subtrochanteric fractures to be an excellent method, especially if an image intensifier and/or fracture table are not available.

Objective: Evaluation of the long-term results of protocolled treatment of ankle fractures in childhood., Setting: St Elisabeth Hospital, Tilburg, the Netherlands., Design: Retrospective long-term follow-up study., Method: All 78 children with an ankle fracture and an open epiphyseal plate in the period 1985-1989 were treated according to a protocol which specified the indications for conservative or surgical therapy depending on the particular fracture type according to Salter and Harris. After a median follow-up period of 3.42 years (range: 2.08-7.67 years) in 48 patients the treatment results could be evaluated in 92% of these patients. Thirty patients had an isolated fracture of the distal part of the fibula., Results: A clinically 'good' or 'excellent' result was achieved in 100% of the patients, and an 'excellent' result in 68%., Conclusions: Growth disturbances after an ankle fracture in children with an open epiphyseal plate can now be restricted to the very rare fractures with severe damage to the germinative layer of the epiphyseal plate. In general, conservative treatment should be used in Salter and Harris I and II fractures and operative treatment in displaced Salter and Harris III and IV fractures.

Objective: Evaluation of the long-term results of protocol treatment of adult patients with ankle fractures., Setting: St Elisabeth Hospital, Tilburg, the Netherlands., Design: Retrospective long-term follow-up study., Method: All patients (n = 579) with an ankle fracture (580 fractures) in the period 1985-1989, who had not died soon after the injury and in whom the morbidity was not caused mainly by other conditions (n = 30) were treated according to a protocol which specified the indications for conservative or surgical therapy depending on the particular fracture type. After a median follow-up period of 5 years (range: 2.25-8.17 years) the treatment results could be evaluated in 92% of the patients., Results: Clinically "good' or "excellent' results ranging from 79-90.5% types A, B and C fractures (according to the Swiss Arbeitsgemeinschaft für Osteosynthesefragen) were achieved., Conclusions: A broad indication for conservative, even functional (tape bandaging) treatment and restricted use of implants during osteosynthesis appear justified considering the results obtained.

We studied the reliability of the Singh classification of trabecular bone structure in the proximal femur as a measure of osteoporosis, using kappa statistics. Radiographs of fractures of the femoral neck or trochanteric region in 80 consecutive patients were assessed by six observers. The interobserver variation was large; only three of 72 radiographs were given the same classification by all six observers and the kappa values ranged from 0.15 to 0.54. the intraobserver variation showed substantial strength of agreement; kappa values ranged from 0.63 to 0.88. In 77 patients dual-energy X-ray absorptiometry was used to measure bone mineral density. The results were compared with those of the Singh classification: we found no correlation.

Objective: To establish the result of treatment of medial femoral neck fractures in patients aged 70 years and older using Hansson pins introduced percutaneously., Design: Descriptive., Setting: Department of Surgery, University Hospital Utrecht, the Netherlands., Method: Ninety-two patients aged 70 years and older with a medial femoral neck fracture were treated in the period 1986-1994 with osteosynthesis using Hansson pins. The case histories and X-rays of these patients were analysed. All fractures were classified according to Garden and Pauwels, with Singh classification of bone quality. The result of the operation was evaluated with the aid of postoperative X-rays., Results: The patients' mean age was 80 years. There were 16 non-dislocated Garden grades I or II and 71 dislocated Garden III and IV fractures. Four patients died within 30 days after the operation. At the time of the follow-up (after an average of 4.5 years), 45 patients had died. Thirty-three patients in all developed a fracture-related complication; 27 of them underwent reoperations during which 19 (21%) were fitted with a head-neck prosthesis or a total hip prosthesis. All reoperations which included implantation of a prosthesis were performed in dislocated Garden grades III and IV fractures. In fractures of this type in which postoperative repositioning proved inadequate, more reoperations were performed than in the Garden grades III and IV fractures with correct posture., Conclusion: Treatment of a medial femoral neck fracture in elderly patients by means of internal fixation with percutaneously introduced Hansson pins gives results similar to those of other types of internal fixation. This is a good operation for Garden grades I and II fractures, whereas in Garden grades III and IV fractures in which repositioning is impossible, internal fixation should be refrained from and a head-neck prosthesis should be implanted in one session.

We present two patients in whom abnormal masses in the groin caused diagnostic difficulty. Synovial cysts and iliopsoas bursa enlargement may be more common than previously reported and should be considered in patients with unexplained hip pain and unusual ilioinguinal swelling.

Objective: To analyse the consequences of postoperative complications in 1418 surgical patients., Design: Prospective descriptive study., Setting: St. Elisabeth Hospital in Tilburg, The Netherlands., Method: In the period 1986-1992 all postoperative complications and their consequences occurring during or after the clinical treatment of surgical patients were registered., Results: In 5% of the 28,485 surgical procedures (= 1418 patients) postoperative complications were found. To treat these complications, 577 patients had to be reoperated on, 233 patients several times, and generally because of postoperative infections. Readmission after discharge was necessary in 310 patients for treatment of their complications. Mean hospital stay for all patients was 10 days, as against 21 days in patients with postoperative complications. On the basis of the figures recorded, quality enhancing measures were taken, e.g. regarding antibiotic prophylaxis and wound treatment., Conclusion: The consequences of postoperative complications are considerable. With respect to quality control in health care it is important to develop national registration and documentation of surgical complications.

A case of a complicated postoperative course after laparoscopic cholecystectomy in which, ultimately, gallbladder duplication was suspected and confirmed at laparotomy is described. The diagnostic tools, differential diagnosis, and therapy are discussed. After open cholecystectomy patients' complaints dissolved. Awareness of the possibility of a double gallbladder in case of persisting symptoms after laparoscopic cholecystectomy can lead to diagnosis of this condition at an earlier stage.

An important point in any communication on fracture treatment is agreement on classification of the fracture to be discussed. for fractures of the radial head there are several useful classification systems. The well-recognized Mason classification is particularly useful in the treatment of radial head fractures. It is however important to realize that the usefulness of this classification system is limited to radial head fractures without associated injury. In deciding on operative or conservative treatment it is therefore essential to subdivide fractures of the radial head into simple or complex fractures. As stated, the Mason classification system is most useful in deciding on treatment of simple fractures, that is to say fractures without an additional fracture or ligamentous injury. Type I fractures should be treated conservatively because of their excellent prognosis. The treatment of type II fractures is still controversial. The decision for osteosynthesis is not only based on the fracture configuration but certainly also on the talent of the surgeon involved. Immediate resection is not considered acceptable in this type of fracture. In type III fractures however, immediate excision is an acceptable method of treatment as long as there is no associated fracture or ligamentous injury. In deciding whether or not there is a complex injury the "Greek Temple" model is very useful. In this model the ulna and radius are seen as two "pillars" which support the "roof" of the distal humerus. The connection between the roof and the pillar on the ulnar side is formed by a ligament, on the radial side there is only the tension of the muscles. With this model it is easy to memorize which associated injuries form the basis of a complex injury, in which excision of the radial head or conservative treatment can cause ulnohumeral subluxation or late radioulnar instability. Treatment in these complex injuries should therefore in principle consist of reconstruction or temporary fixation of the radial pillar, and if necessary temporary stabilization of the ulnar pillar.

Triplane fractures of the distal tibia are relatively rare and usually occur during adolescence. A classification of the various types of triplane fractures, based on a survey of the literature and the material in this study, is presented. The authors' treatment principles are discussed and the results of a consecutive group of 20 patients, including long-term follow-up (median 6 1/12 years) are described.

Objective: To evaluate the treatment of a bacterial infection of a finger joint with incision, drainage and intermittent immobilization using external fixation apparatus., Design: Retrospective, descriptive., Setting: Department of Surgery, St Elisabeth Hospital, Tilburg., Method: In eight males and two females (median age 37 years) with acute bacterial arthritis of a finger joint, this joint was opened surgically, washed out and then immobilized using mini-external fixation equipment, for about 3 weeks. The fixator was unscrewed daily so that the patient could move the finger in water, with the purpose of mechanical cleansing of the joint; the intermittent pressure that occurs in the cartilage during movement is supposed to promote the removal of debris. Subsequently, the finger was fixed in alternating positions to prevent adhesions. Mean duration of follow-up was 48 months (11-78)., Results: Arthrodesis had to be carried out in one patient because of persistent arthritis and tissue necrosis, while in one other, part of the finger was amputated. The other eight patients showed good final results, without symptoms., Conclusion: In bacterial arthritis of a finger joint, temporary intermittent immobilization using external fixation equipment is certainly worth consideration.

Objective: Evaluation of incidence, treatment and outcome of multiple injuries in children and adults., Method: All patients aged 16 years or under with an Injury Severity Score of 18 or more admitted to the Intensive Care Unit between 1984 and 1991, were retrospectively studied. Type and severity of injuries, treatment, complications and outcome were noted. The severity of injuries was scored using both the Injury Severity Score and the Paediatric Trauma Score., Results: Children are more likely to be run over by motor vehicles. Rib fractures are rare in childhood. Compared with adults, children stay relatively shortly in the Intensive Care Unit. None of the children studied developed a Respiratory Distress Syndrome (RDS) or Multi-Organ Failure (MOF). External fixation of fractures is a common treatment in children., Conclusions: I. Outcome of multiple injuries in children is relatively good. This can partly be attributed to the low incidence of RDS and MOF, but also to the more common diffuse brain injury in children compared with adults, with better outcome and lower mortality. 2. External fixation of fractures appears to be a first rate treatment in children. 3. Scoring of multiple injuries in children with the Paediatric Trauma Score instead of the Injury Severity Score offers no advantages.

Twenty-seven patients with 28 open femoral shaft fractures were treated by intramedullary nailing. Ten fractures were Grade I, nine Grade II and nine Grade III according to Gustilo. After debridement and irrigation of the wounds, 26 fractures were nailed immediately, whilst two fractures were stabilized at an early stage. Two infections developed. One occurred before intramedullary nailing during a period of femoral traction. Both infections were treated successfully. The authors conclude that primary intramedullary nailing is safe in open femoral fractures of all grades. If a thorough debridement and irrigation are performed, the postoperative infection rate is low.

Treatment of severely comminuted unstable intra-articular finger fractures has three goals: reconstruction of the articular surfaces, prevention of redislocation of those surfaces, and proper healing of the capsuloligamentous apparatus. Dynamic circle traction (DCT), as described by Schenck (1986), is based on these principles and is the first method of treatment combining traction with intermittent or continuous passive motion. In order to improve on this method we applied continuous, instead of intermittent, passive motion in a newly developed DCT-device (continuous dynamic circle-traction = CDCT). Its first clinical use is discussed below. Our results with DCT, in eight patients, and CDCT, in four patients, are encouraging. Full function was regained at follow-up, in both groups, in three-quarters of the metacarpophalangeal (MCP) and half of the proximal interphalangeal (PIP) joints involved. Average loss of range of motion of the other MCP and PIP joints was 3.7 degrees and 5.6 degrees respectively. Treatment with CDCT may yield better results than DCT; the small number of patients treated and the relatively short period of follow-up does not justify comparison of both methods.

From 1980 through 1990 14 patients with severely complicated unstable fractures of the pelvis were treated. There were 13 men and one women (mean age, 28 years). Eight fractures also involved the acetabulum. The injuries were accompanied by anorectal (nine), urogenital (eight), vascular (three), and nerve (three) injuries. After resuscitation, fractures were stabilized immediately, preferably using internal fixation, notwithstanding fecal contamination in certain cases. Anorectal ruptures were treated with lavage of the distal colon and a divergent stoma. The urogenital lesions also were treated primarily. Two patients died early after treatment of accompanying injuries. Infectious complications were seen seven times. In one patient internal fixation broke down. All fractures healed with good functional results. At last follow-up examination all patients were continent for feces. It is concluded that early internal stabilization of these complex injuries achieves a low mortality rate and good functional results. Immediate repair of urogenital and sphincter lesions, with concomitant divergent stoma and lavage of the distal colon, gives good results notwithstanding the risk of infectious complications.