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The transition of hospital care to primary care is one of the mainstays of national health care policy in the Netherlands. This paper presents the results of a successful initiative to establish a regional community-based wound care network in the Zwolle region of the Netherlands.

Background: Surgical site infections (SSI) after vascular surgery are related to substantial morbidity. Restriction of bacterial access to the site of surgery with a cyanoacrylate sealant is a new concept. We performed a randomized clinical trial to assess the effect of the sealing of skin with a cyanoacrylate preparation at the site of surgery on the incidence of SSI after arterial reconstruction.Methods: Patients scheduled for vascular reconstruction in or distal to the groin were randomized into a treatment and a control group. Standard measures for preventing contamination of the surgical field were taken in the control group, whereas cyanoacrylate was used as a skin sealant at the surgical site in the patients in the treatment group. We hypothesized that the incidence of SSI with the use of cyanoacrylate would be two-thirds (67%) lower than that with standard preparation of the surgical site, and performed an interim analysis of 50 patients to assess this.Results: Risk factors among the 50 patients in the study included smoking (28%), hypertension (77%), diabetes mellitus (36%), and hypercholesterolemia (74%). Indications for surgery were invalidating claudication (Fontaine IIb), pain at rest, or tissue necrosis. The overall incidence of SSI was 3/47 (6%), without differences between groups; 9% SSIs in the control group versus 4% SSIs in the intervention group.Conclusion: We could not confirm a reduction in the incidence of SSI after inguinal vascular surgery with theuse of a cyanoacrylate skin sealant as compared with conventional means for preparing the surgical site.

This retrospective study found that use of autologous platelet-rich fibrin on a range of hard-to-heal wounds achieved full healing or a significant reduction in wound diameter with no adverse effects. Prospective studies are now needed

Despite antibiotic treatment and other measures, many chronic ulcers do not heal. Infection and bacterial colonisation is one of the factors delaying wound healing. As a result, a revival of maggots in treatment of such wounds has been seen in the last decades, for maggots may produce unknown factors that promote wound healing. Maggot debridement therapy (MDT) has been used for centuries and in many different cultures.1 After witnessing the benefits of maggot-infested wounds in the battlefields of World War I, the orthopaedic surgeon William Baer successfully applied maggots to children with severe osteomyelitis.2 By 1934, more than 1000 surgeons were using maggot therapy, the Surgical Maggots™ were available commercially from Lederle Corporation.3 With the introduction of antibiotics, the use of maggots reduced. The appearance of antibiotic-resistant bacteria in the 1980s and 1990s, such as methicillin-resistant Staphylococcus aureus (MRSA), and the finding that modern wound treatment not always seems to be the answer to severely infected ulcers, gave rise to a strong ‘maggot comeback’.4,5 Although the mechanism of MDT has not been clarified completely, it is known that: (i) there are mechanical effects;6 (ii) there are tissue growth effects;7 (iii) direct killing of bacteria in the alimentary tract of the maggot takes place;8–10 and (iv) maggots produce antibacterial factors.11–16 Clinical observations indicate that maggots are more effective in the treatment of Gram-positive infected wounds, compared to Gram-negative infected wounds.17–20 In January 2004, the US Food and Drug Administration (FDA) issued 510(k)#33391, thereby allowing production and marketing of maggots as a medical device. Based on the literature, there seem to be no clear indications or contra-indications for MDT, but patients with open wounds and ulcers that contain gangrenous or necrotic tissue with infection seem suited for MDT.21 Success rates of MDT, reported in the literature, vary, but seem to be around 80–90%.18,19,22 The present study discusses the observations of MDT in patients with complex and chronic wounds in whom major limb amputation or sepsis was the only alternative, if no MDT would be performed. In total, 101 patients with 117 wounds, seen in our surgical department, were treated. Patient characteristics, wound characteristics and treatment characteristics are described. Moreover, factors are identified that significantly influence MDT outcome. On the basis of these factors, patient selection for MDT could be improved.

Background. In the authors' experience re-epithelialization after successful debridement and granulation can be the most difficult part of the wound closure process. Extracellular matrix products represent a possible solution. However, in studies discussing the effectiveness of extracellular wound matrix (porcine-derived small intestine submucosa [SIS], [OASIS® Wound Matrix, Healthpoint Ltd, Fort Worth, Tex]), a long list of exclusion criteria has been presented. The present study was designed to explore the contraindications of OASIS Wound Matrix.In this study, 32 patients in whom the wounds were fully debrided and granulated were treated with weekly applications of the wound matrix. The exclusion criteria formulated in the reported literature were followed. Seven different outcomes were defined. Various patient and wound characteristics that might influence outcome were recorded.Beneficial outcomes were seen in 80.6 % (n = 25) of the patients. The two main complications seen were infection and hypergranulation tissue. Infection was seen in 7 patients (22.6%). Four patients (57.1%) had an unsuccessful outcome. Hypergranulation tissue occurred in another 7 patients (22.6%) after a couple of applications. They all had a beneficial outcome.Much of the exclusion criteria used in previous reports are too strict. Infection should be the only absolute contraindication for starting treatment with OASIS, and it is a good reason to discontinue treatment with an ECM. Hypergranulation tissue (22.6%) is an easily treatable complication that has no negative influence on outcome. Some wounds (77.4%) had no complications, or had easily treatable complications that did not negatively influence the outcome.

Objective: Pain as a complication of maggot debridement therapy (MDT) has been a topic of some controversy. This study set out to determine pain levels in patients treated with MDT. Method: A retrospective analysis using a visual analogue scale (VAS) was performed: 41 patients were treated with MDT for non-healing wounds (22 men and 19 women; average age: 67 years). Average wound duration was 14 months (range: two weeks to 132 months). Maggots were applied using the contained or the free-range techniques. Paracetamol (1g three times daily) and Durogesic plaster (25µg every three days and 50µg the day before the maggot change) were given for pain relief in the outpatient clinic. Results: Diabetic patients experienced the same amount of pain before and during MDT. Eight out of 20 non-diabetic patients experienced more pain during MDT than before; the remaining non-diabetic patients had the same amount of pain before and during the therapy. The difference between diabetic and non-diabetic patients was statistically significant (pConclusion: In 78% of patients (29/37) pain can be adequately treated with analgesic therapy. However, if pain is unmanageable in the outpatient department, we believe that options include hospital admission, using the contained method of application or, in the worst case scenario, cessation of treatment. A standardised but individually tailored pain management protocol is mandatory. Declaration of interest: None

OBJECTIVE To determine which method of maggot debridement therapy--free-range or contained--is more effective for wound healing. METHODS In vivo study of 64 patients with 69 chronic wounds that showed signs of gangrenous or necrotic tissue. Patients were treated with either free-range or contained maggot debridement therapy according to maggot availability, dressing difficulty, and physician preference. RESULTS Significantly better outcomes were achieved with the free-range technique versus the contained technique (P = .028). With the free-range technique, the mean number of maggot applications and the total number of maggots per treatment were significantly lower than with the contained application technique (P = .028 and P < .001, respectively). CONCLUSION This clinical in vivo study supports in vitro studies in which containment of maggots was found to reduce the effectiveness of maggot debridement therapy.

Background— Granulocyte-macrophage colony-stimulating factor (GM-CSF) was recently shown to increase collateral flow index in patients with coronary artery disease. Experimental models showed beneficial effects of GM-CSF on collateral artery growth in the peripheral circulation. Thus, in the present study, we evaluated the effects of GM-CSF in patients with peripheral artery disease. Methods and Results— A double-blinded, randomized, placebo-controlled study was performed in 40 patients with moderate or severe intermittent claudication. Patients were treated with placebo or subcutaneously applied GM-CSF (10 μg/kg) for a period of 14 days (total of 7 injections). GM-CSF treatment led to a strong increase in total white blood cell count and C-reactive protein. Monocyte fraction initially increased but thereafter decreased significantly as compared with baseline. Both the placebo group and the treatment group showed a significant increase in walking distance at day 14 (placebo: 127±67 versus 184±87 meters, P =0.03, GM-CSF: 126±66 versus 189±141 meters, P =0.04) and at day 90. Change in walking time, the primary end point of the study, was not different between groups. No change in ankle-brachial index was found on GM-CSF treatment at day 14 or at day 90. Laser Doppler flowmetry measurements showed a significant decrease in microcirculatory flow reserve in the control group ( P =0.03) and no change in the GM-CSF group. Conclusions— The present study does not support the use of GM-CSF for treatment of patients with moderate or severe intermittent claudication. Issues that need to be addressed are dosing, the selection of patients, and potential differences between GM-CSF effects in the coronary and the peripheral circulation.

PURPOSE To describe the successful endovascular treatment of an iatrogenic anterior tibial artery pseudoaneurysm with a polytetrafluoroethylene-covered stent-graft. CASE REPORT A 58-year-old man was admitted to our hospital with pseudoarthrosis and malunion of the right distal tibia. Fibulotomy and intramedullary fixation were performed, which was complicated by a pseudoaneurysm of the anterior tibial artery. Under local anesthesia, a 4x31-mm Symbiot covered stent was successfully placed over the origin of the pseudoaneurysm. At 12 months, the pseudoaneurysm remained excluded, and the anterior tibial artery was patent. CONCLUSIONS Endovascular treatment of a crural artery pseudoaneurysm seems to be a feasible treatment option. Further experience with this technique is needed to validate its safety and long-term patency.

e Abstract: Peripheral arterial disease (PAD) affects a large percentage of the elderly population. Standard invasive treatment, apart from risk factor modulation, consists of bypass surgery or percutaneous transluminal angioplasty. However, symptomatic recurrence rates are high for both procedures and a substantial part of the patient population with PAD is not a candidate for invasive revascularization due to complexity of the lesion and/or co-morbidity. Therapeutic arteriogenesis has been proposed as an alternative treatment option. The present paper describes the design of the START-trial. This trial aims to determine the potential of the pro- arteriogenic substance granulocyte/macrophage colony stimulating factor (GM-CSF) to increase maximal walking distance in patients with intermittent claudication. A double-blinded, ran- domized, placebo-controlled study will be performed in 40 patients with peripheral obstructive arterial disease Rutherford grade I, category 2 or 3, that are candidates for bypass surgery or percutaneous transluminal angioplasty. Based on pharmacokinetic and toxicologic studies, a dose of 10 mg/kg will be used. Patients will be treated for a period of 14 days on each consecu- tive day, with the last injection applied on day 12. The primary endpoint will be the change in walking distance from day 0 to day 14 as assessed by an exercise treadmill test. Secondary endpoints will be the ankle- brachial index at rest and after exercise, the pain-free walking dis- tance and cutaneous microcirculatory alterations as assessed by laser Doppler e uxmetry. Iliac e ow reserve and conductance will be measured by magnetic resonance imaging.

Because quality of care for patients with end-stage renal disease (ESRD) has improved, they require long-term vascular access for hemodialysis. Construction of a native vein arteriovenous fistula (AVF) on the arm is considered best practice; a prosthetic graft (PG) AVF on the arm is a good alternative, although insertion of a central venous catheter (CVC), the third choice, is sometimes necessary. A quality improvement project was initiated at the dialysis unit of Rijnland Hospital (The Netherlands) to improve quality of vascular access care.Seventy-four patients were treated from January 2001 through June 2002. The list of preferred access operations was adapted from evidence-based guidelines. The percentages of CVCs and PGs were chosen as quality indicators.Twelve of 19 patients (34%) appeared to be using CVCs unnecessarily. Actions were taken, and the CVC indicator decreased by 11%. The PG indicator decreased gradually from 24% to 8%.Reductions in the use of CVCs and PGs suggest that the vascular access improvement project resulted in improvement of long-term vascular access for hemodialysis patients. A considerable decrease in the use of PGs and CVCs was achieved in 2001. However, a decrease of CVCs to20% has still not been realized, perhaps because new hemodialysis patients referred to the dialysis unit have already had CVCs inserted.Considerable improvement, as reflected in the number of hemodialysis patients with CVCs or PGs, can be achieved with a minimum of costs.

Man has lived together with microbes for so long that we have become completely dependent on their presence. Most microbes reside in biofilms; structured communities encased in a protective matrix of biopolymers. Under healthy conditions, the microbial biofilm is in balance with itself (endo-balance) and with the host (exo-balance). Integrity of the skin is an important immunological function. Wounds go through a well-orchestrated series of healing steps. However, if for some reason healing times are extended, serious problems related to infection and homeostasis can develop. Based on recent advances in biofilm research and microbiological identification we discuss two hypotheses describing the role of microbial biofilms in chronic wound biology. The first hypothesis describes microbial biofilms as the cause of extended healing times. The second hypothesis is based on the host as cause of extended healing times and basically treats microbial biofilms as a logical consequence of failure to re-build the integrity of the skin.

Purpose: To evaluate the end results of arthroscopically assisted osteosynthesis of tibial plateau fractures in patients older than 55 years of age. Type of Study: Case series. Methods: Over a 5-year period, 201 consecutive patients presented with tibial plateau fracture; 131 of these patients were treated with arthroscopically assisted osteosynthesis of the tibial plateau. Inclusion in the retrospective analysis was limited to those patients older than 55 years at the time of injury and those who were available for follow-up at the time of the study. Thirty patients met these criteria. Results: Secondary displacement occurred in 9 patients (30%) within 12 weeks after surgery. After a median follow-up of 3 years, 24 of 30 patients (80%) had an excellent or good clinical result according to the modified Rasmussen criteria. There was no difference in clinical outcome between the patients with or without secondary displacement of the fracture. Conclusions: Given the good clinical results, arthroscopically assisted osteosynthesis has been shown to be highly efficient in the treatment of tibial plateau fractures in the elderly. Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 8 (October), 2001: pp 826–831

Success rates of Maggot Debridement Therapy (MDT) differ, but range from 70% to 80%. In this article it is argued that wound closure is not always feasible and is not always the aim of the treatment. A patient is described in whom the intent of MDT was not wound closure, but infection removal, reduction of odor, and eventually prevention of a below knee amputation. This succeeded: the pain was diminished, the odor reduced, and the wound showed signs of healing. Still the patient died. In maggot literature, as with other wound treatments, outcome is recorded as closed or as failed. In our opinion, MDT has other indications besides wound closure.

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

Definitive wound closure in large open wounds can be achieved by split-skin grafting. In our hospital large split-skin grafts are performed in the operating room. However, many patients in our wound clinic are at high risk of developing postoperative complications such as delirium, pneumonia, urinary tract infection and pressure ulceration. In such cases, hospital admission might not only result in higher morbidity but also increased mortality. 1 In addition, surgery is delayed if routine preoperative swabs identify bacterial colonisation with microorganisms such as Staphylococcus aureus, Streptococci and Pseudomonas. We are therefore constantly searching for alternative products to splitskin grafting that preferably can be used in the outpatient department. Such alternatives need to be effective, easy to use, pain-free, inexpensive and require infrequent dressing changes. Extracellular matrix products seem to be a possible option. They promote granulation and epithelialisation in dermal wounds, and effectively regulate evaporation of moisture and absorption of exudation.

Scaphoid fractures are the most common carpal fractures; their overall incidence is however low. Missing a scaphoid fracture may lead to a non-union with a possible disastrous outcome for the patient; for this reason, treatment of a suspected scaphoid fracture, even without a proven fracture on the first radiograph, has been conservative with plaster treatment. There are many clinical tests developed to diagnose a scaphoid fracture. However not all tests are equally practical, and their sensitivity and specificity are not always known, or are very low. In this study 18 clinical tests were evaluated and a subset of 7 tests remained, which were found to be practical and/or had a high enough sensitivity. A clinical decision protocol was developed using a combination of these seven tests, in order to improve diagnostic accuracy and at the same time reduce unnecessary plaster cast treatment of patients with a suspected scaphoid, who turn out to only have a sprained wrist.

In an earlier study we have proposed a scaphoid decision-protocol in order to improve diagnostic accuracy in case of suspected scaphoid fractures. This pilot study evaluated this protocol. In this pilot study (n = 31) most cases with clinical suspicion of scaphoid fractures reached a positive test result on the combined 7 clinical tests (93.5%). Using this test combination, no scaphoid fractures were missed (no false-negatives; sensitivity 100%), but it also included many patients with no scaphoid fracture. Many of these, however, were found to have another fracture. In total, 48% had a scaphoid fracture, 19% another fracture and 32% no fracture. In the pilot study the proposed protocol seems to be a safe protocol, without missing scaphoid fractures. It leads to a reduction of unnecessary plaster casting of sprained wrists and produces a marked reduction in plain radiographic examinations.

One therapeutic alternative for redislocation of Colles' fractures is closed reduction and transstyloid Kirschner-wire fixation. We describe our results concerning 21 redislocations treated in this way. According to Older's classification, B fractures were type 3 and 13 fractures type 4. After a median follow-up period of 2 years, most patients had regained normal volar tilt, but significant loss of radial tilt and radial length was found in 11 patients. Malunion occurred in 8 wrists due to either fracture comminution or insufficient K-wire fixation. According to Gartland and Werley's point system, the end-results were poor in 2, fair in 11, good in 4, and excellent in 4 wrists. There was no statistically significant difference in secondary displacement and functional end-result between Older's type 3 and type 4 fractures. We conclude that K-wire fixation is frequently not firm enough and external fixation might be a better alternative for stabilizing redislocated distal radial fractures.

Isolated clavicle fractures are frequently encountered in the accident and emergency department. Complications of isolated clavicle fractures are rare. Pneumothorax as a complication of a clavicle fracture has only been reported five times in English literature. In all five cases the pneumothorax was treated by a thoracostomy and the clavicle fracture was treated conservatively. In our case, both pneumothorax and clavicle fracture were treated conservatively with good result. Although isolated clavicle fractures rarely present with complications and normally heal with routine immobilisation, we must be aware of the serious complications that may occur, which require urgent treatment. Thorough history, physical examination, with particular attention to the neurovascular and chest examinations and radiographs of the clavicle are necessary to prevent overlooking these potentially serious complications.

Wound infection after breast surgery is not uncommon and is not always simple to treat. This paper presents the case of a patient in whom the wound was successfully treated with larval debridement therapy after other methods failed

Wound infection rates after ilioinguinal node dissection are high; 9% to 16% have been reported. The authors report a patient who underwent an ilioinguinal node dissection for a regional metastasized melanoma. Unfortunately, a deep wound infection occurred with extensive skin necrosis and production of abundant wound fluid (750 cc daily). Despite 6-daily dressings, the wound deteriorated, necessitating further operative debridement. In theatre, the authors failed to identify the lymphatic fistula and therefore were unable to close it. In accordance with literature on treatment of groin infections after vascular prosthesis, vacuum-assisted closure (VAC) therapy was started. After 11 days of VAC therapy, the lymphatic leakage completely stopped. Concurrent successful management of the wound with split skin graft therapy led to a complete closure of the wound. The treatment was not painful, changes of the sponge could be done in the ward, and there were no complications.

Laparostomy is a technique in which the abdomen remains open after a laparotomy. It is indicated when initial treatment is followed by abdominal compartment syndrome, or when relaparotomies for other complications are expected. Laparostomy is also effective and practical in patients with severe intra-abdominal infection.

A 72-year-old male, with no medical history, presented with acute ischemia of the second and third digits of his left hand (acute limb ischemia classification 1) to our emergency department. Radial and ulnar arterial pulses were palpable at physical examination. Symptoms improved during his admission to the emergency department and the digits remained viable. The patient denied any history of trauma or use of crutches. Duplex ultrasound and a computed tomography angiogram showed a left axillary artery aneurysm containing a thrombus with a maximum diameter of 3.7 cm (Panel A; arrows) as the embolic source. Semi-elective surgical management of the symptomatic aneurysm was recommended to prevent further embolic complications of the distal arm. The aneurysm was considered unsuitable for endovascular intervention due to the artery’s tortuous course. Using an incision distal to the lateral clavicle, the aneurysm was exposed by splitting the major and division of the minor pectoral muscles. The aneurysm originated distally to the acromiothoracic artery (Panel B; arrow) and lay in close relation to the lateral cord of the brachial plexus. There were no signs of inflammation or infection. Following resection of the aneurysm, circulatory continuity was reestablished using a great saphenous vein interposition graft (Panel C; arrow). Two days after surgery the patient was

Dermacyn Wound Care (Oculus Innovative Sciences, California, US) is a superoxidised water proven capable of destroying bacteria, viruses, moulds and spores at an efficient rate in vitro, while studies undertaken by the manufacturer have found no toxic side-effects. The product’s promotional literature claims it can heal diabetic foot ulcers and facilitate faster hospital discharge of children with burn injuries.