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Background: The scaphoid bone is the most commonly fractured of the carpal bones. In the Netherlands 90% of all carpal fractures is a fracture of the scaphoid bone. The scaphoid has an essential role in functionality of the wrist, acting as a pivot. Complications in healing can result in poor functional outcome. The scaphoid fracture is a troublesome fracture and failure of treatment can result in avascular necrosis (up to 40%), non-union (5-21%) and early osteo-arthritis (up to 32%) which may seriously impair wrist function. Impaired consolidation of scaphoid fractures results in longer immobilization and more days lost at work with significant psychosocial and financial consequences.Initially Pulsed Electromagnetic Fields was used in the treatment of tibial pseudoarthrosis and non-union. More recently there is evidence that physical forces can also be used in the treatment of fresh fractures, showing accelerated healing by 30% and 71% reduction in nonunion within 12 weeks after initiation of therapy. Until now no double blind randomized, placebo controlled trial has been conducted to investigate the effect of this treatment on the healing of fresh fractures of the scaphoid., Methods/design: This is a multi center, prospective, double blind, placebo controlled, randomized trial. Study population consists of all patients with unilateral acute scaphoid fracture. Pregnant women, patients having a life supporting implanted electronic device, patients with additional fractures of wrist, carpal or metacarpal bones and pre-existing impairment in wrist function are excluded. The scaphoid fracture is diagnosed by a combination of physical and radiographic examination (CT-scanning).Proven scaphoid fractures are treated with cast immobilization and a small Pulsed Electromagnetic Fields bone growth stimulating device placed on the cast. Half of the devices will be disabled at random in the factory.Study parameters are clinical consolidation, radiological consolidation evaluated by CT-scanning, functional status of the wrist, including assessment by means of the patient rated wrist evaluation (PRWE) questionnaire and quality of life using SF-36 health survey questionnaire.Primary endpoint is number of scaphoid unions at six weeks, secondary endpoints are time interval to clinical and radiological consolidation, number of non-unions, functional status at 52 weeks and non-adherence to the treatment protocol., Trial Registration: Netherlands Trial Register (NTR): NTR2064., (© 2011 Hannemann et al; licensee BioMed Central Ltd.)

Objectives: In 2006, an intramedullar titanium osteosynthesis for the stabilization of distal radius fractures was introduced in The Netherlands: the Micronail®. The Micronail® can be used in approximately 30% of distal radius fracture treatments. This article presents the introduction of this new treatment, and first clinical results., Methods: In the first year after introduction of the Micronail® in our clinic, 10 patients have been treated with 11 Micronails® (eight 23-A2 radius fractures and three distal 22-A3 forearm fractures). Our patients were mainly woman (n=9) and had a mean age of 81 years (range 69-88 years). After re-alignment of the fracture, the Micronail® was placed into the medulla through a small incision over the styloid process of the radius. By using a guidance system, three locking buttress screws were placed in the distal radial fragment and two locking bolts were placed in the proximal radius. Postoperative treatment consisted of a splint for 5 days, after which full loadcarrying exercises can be started., Results: After 6 weeks, six patients had a full range of motion. Two patients were still in a cast because of secondary dislocation and CTS, respectively. One patient had a cast because of newly sustained trauma, which resulted in a peri-osteosynthetic fracture. Pain was not recorded in these patients. All fractures healed without major loss of alignment. Patients experienced good to excellent results on an analog scale showing the wrist function. At 4 months, all patients had a good range of motion in the operated wrist; the difference between the two wrists was a maximum of 10 °., Conclusion: The first results of Micronail® are promising. It has the advantages of other operative techniques (minimally invasive, stable, intramedullar) without their known disadvantages. Short immobilization is sufficient, after which full load-carrying exercises are indicated.

OBJECTIVE: The purpose of this study is to determine the efficacy of the open reduction and fixation of a dislocated proximal humerus fracture with a locking plate, also evaluating the incidence of complications and functional recovery of the shoulder. A retrospective study focusing on patients who had suffered a fracture of the proximal humerus and were treated by means of an open reduction and internal fixation with a locking plate, using either the Philos or the LPHP plate. We have also included a comparison of these two plates. METHOD: Ninety-two patients were found to be eligible and were included in our study. These patients had all been treated for a proximal humerus fracture between 2002 and 2008. We included those patients who could be classified as a class 2, 3, or 4 according to the Neer classification. Demographic data, surgical technique, and peri/post-operative complications were collected from medical records. Patients were followed-up and the Oxford Shoulder Score (OSS) was filled in by phone. The mean age of our patient population was 66.2 (15-97), with a male: female ratio of 1:5 (15:77). (The median follow-up was 2.4 years (0.2-5.8). Fourteen of our patients died during follow-up, while 25 patients were otherwise lost to follow-up. For this study, out of the original 131 patients, this finally resulted in 92 patients whom we followed-up post-operatively. RESULTS: Ninety-two patients (70%, 92/131) were interviewed. The mean Oxford Shoulder Score (OSS) was 19.76 (11-54). The overall complication rate was 39.1% (36/92). The most frequently occurring complications in our patient population were hemorrhage 3.3%; dislocation of the caput humeri and/or tuberculum majus 2.2%; persistent pain 3.3%; Avascular necrosis (AVN) of the humeral head 0%; Loss of reduction and screw cutout 6.5%; Plate breakout 6.5%; Subacromial Impingement 11.9%; Frozen shoulder 3.3%; rotator cuff rupture 1.1%, and infection 1.1%. Of the entire group of patients originally included in this study, 29% was re-operated due to one of the above-mentioned complications. CONCLUSION: In conclusion, the locking plate provides satisfactory functional outcomes after a mid-term follow-up in patients with displaced proximal humerus fractures. The incidence of complications and subsequent re-operation is relatively high, however, comparable to or slightly better when compared to data found in literature. Subacromial Impingement seems to occur more frequently when a Philos plate is implemented. We therefore suggest that randomized clinical trials determining the possible superiority of one specific type of plate in patients with a displaced proximal humerus fracture are to be performed in future.

Introduction: The Micronail(®) is a minimally invasive intramedullar titanium locking screw fixation for two-part dislocated extra-articular fractures and average displaced intra-articular fractures., Patients and Methods: In a retrospective study we analyzed the outcome of 20 distal radius fractures in 18 patients (17 female, mean age 78 years), which were treated by Micronail(®). Average follow-up time was 4 months. We describe the operative technique. All fractures were classified according to AO guidelines. We studied the radiologic and clinical outcome., Results: According to the AO classification there were 12 A2, 3 A3, 1 B1, and 1 B3 fracture. Three patients had an antebrachii fracture. Mean American Society of Anesthesiologists (ASA) score was 2.4. Eight patients had associated lesions. Average operative time was 58 min. All fractures healed without major loss of alignment. There were two major complications: one patient developed a carpal tunnel syndrome and one device secondary dislocated. With the use of the Micronail(®), we found no infections or complications due to the insertion of the osteosynthesis materials. Patients experienced good to excellent results, on an analogue scale, in function of their wrist from the procedure. All patients had a good range of motion of the operated wrist; the difference between their two wrists was maximal 10° in all directions., Conclusion: This intramedullary implant intends to minimize some of the disadvantages of other surgical options in the treatment of distal radius fracture; the Micronail(®) causes less tissue damage and has early load-carrying capacity. This minimally invasive technique seems suitable in selected, two-part dislocated extra-articular and average displaced intra-articular, distal radius fractures.

Objective: To assess the efficacy of isosorbide dinitrate in healing anal fissures., Design: Randomised, prospective, double blind, placebo controlled trial., Setting: Teaching hospital, The Netherlands., Subjects: 37 consecutive subjects with anal fissure diagnosed in the surgical outpatient department., Interventions: After randomisation, 20 patients were given isosorbide dinitrate, and 17 patients placebo., Main Outcome Measures: Healing of anal fissure, recurrence, and tolerance., Results: Both groups were treated for a median (range) of 5 weeks (range 1-10). After this period, 17 in the isosorbide group had healed compared with 6 controls (p < 0.003). The fissure recurred in 2 patients who had had an initial good response to isosorbide, and in 2 in the control group. Side effects (particularly headache) were more common after isosorbide dinitrate, but not significantly so (9/20 compared with 3/17)., Conclusions: Isosorbide dinitrate is an effective treatment for anal fissure, and is significantly better than placebo.

Constipation following routine hysterectomy seems to occur more frequently than originally thought. Treatment depends on whether the patient is referred and to whom. Physical examination seems of limited value. Proper protocols for evaluation of complaints after hysterectomy are mandatory. Colonic transit studies and dynamic rectal examination could be useful. We found an overrepresentation of enteroceles in the hysterectomy group. Management of these abnormalities seems much more complicated than was previously thought. Prospective studies are needed to investigate anorectal disorders after hysterectomy.

We determined maximal exercise capacity and measured hemodynamics in 10 6-wk-old lambs with an aortopulmonary left-to-right shunt [S, 57 +/- 11%, (SD)] and in 9 control lambs (C) during a graded treadmill test 8 days after surgery. Maximal exercise capacity (3.7 +/- 0.2 km/h and 10 +/- 5% inclination vs. 4.0 +/- 0.9 km/h and 15 +/- 0% inclination, P less than 0.02) and peak oxygen consumption (25 +/- 7 vs. 34 +/- 8 ml O2.min-1.kg-1, P less than 0.02) were both lower in the shunt than in the control lambs. This was due to a lower maximal systemic blood flow in the shunt lambs (271 +/- 38 vs. 359 +/- 71 ml.min-1.kg-1, P less than 0.01). Despite their high maximal left ventricular output, which was higher than in the control lambs (448 +/- 87 vs. 359 +/- 71 ml.min-1.kg-1, P less than 0.05), the left-to-right shunt could not be compensated for during maximal exercise because of a decreased reserve in heart rate (S: 183 +/- 22 to 277 +/- 38 beats/min; C: 136 +/- 25 to 287 +/- 29 beats/min) and in left ventricular stroke volume (S: 1.8 +/- 0.3 to 1.6 +/- 0.4 ml/kg; C: 1.0 +/- 0.3 to 1.3 +/- 0.2 ml/kg). We conclude that exercise capacity of shunt lambs is lower than that of control lambs, despite a good left ventricular performance, because a part of the reserves for increasing the left ventricular output is already utilized at rest.