[Show abstract][Hide abstract] ABSTRACT: The choice between operative or nonoperative treatment is questioned for partial articular fractures of the radial head that have at least 2 millimeters of articular step-off on at least one radiograph (defined as displaced), but less than 2 millimeter of gap between the fragments (defined as stable) and that are not associated with an elbow dislocation, interosseous ligament injury, or other fractures. These kinds of fractures are often classified as Mason type-2 fractures. Retrospective comparative studies suggest that operative treatment might be better than nonoperative treatment, but the long-term results of nonoperative treatment are very good. Most experts agree that problems like reduced range of motion, painful crepitation, nonunion or bony ankylosis are infrequent with both nonoperative and operative treatment of an isolated displaced partial articular fracture of the radial head, but determining which patients will have problems is difficult. A prospective, randomized comparison would help minimize bias and determine the balance between operative and nonoperative risks and benefits.
[Show abstract][Hide abstract] ABSTRACT: Fractures of the humeral shaft are associated with a profound temporary (and in the elderly sometimes even permanent) impairment of independence and quality of life. These fractures can be treated operatively or non-operatively, but the optimal tailored treatment is an unresolved problem. As no high-quality comparative randomized or observational studies are available, a recent Cochrane review concluded there is no evidence of sufficient scientific quality available to inform the decision to operate or not. Since randomized controlled trials for this injury have shown feasibility issues, this study is designed to provide the best achievable evidence to answer this unresolved problem. The primary aim of this study is to evaluate functional recovery after operative versus non-operative treatment in adult patients who sustained a humeral shaft fracture. Secondary aims include the effect of treatment on pain, complications, generic health-related quality of life, time to resumption of activities of daily living and work, and cost-effectiveness. The main hypothesis is that operative treatment will result in faster recovery.Methods/design: The design of the study will be a multicenter prospective observational study of 400 patients who have sustained a humeral shaft fracture, AO type 12A or 12B. Treatment decision (i.e., operative or non-operative) will be left to the discretion of the treating surgeon. Critical elements of treatment will be registered and outcome will be monitored at regular intervals over the subsequent 12 months. The primary outcome measure is the Disabilities of the Arm, Shoulder, and Hand score. Secondary outcome measures are the Constant score, pain level at both sides, range of motion of the elbow and shoulder joint at both sides, radiographic healing, rate of complications and (secondary) interventions, health-related quality of life (Short-Form 36 and EuroQol-5D), time to resumption of ADL/work, and cost-effectiveness. Data will be analyzed using univariate and multivariable analyses (including mixed effects regression analysis). The cost-effectiveness analysis will be performed from a societal perspective.
Successful completion of this trial will provide evidence on the effectiveness of operative versus non-operative treatment of patients with a humeral shaft fracture.Trial registration: The trial is registered at the Netherlands Trial Register (NTR3617).
[Show abstract][Hide abstract] ABSTRACT: Hip fractures in the elderly population are associated with high morbidity and mortality. However, there is still a lack of information on mortality and loss of independence in extremely elderly people with a hip fracture.
To study functional outcomes and mortality after osteosynthesis of hip fractures in very old patients in our clinic.
Hospital charts of all patients over 90 years old who were operated for a hip fracture between January 2007 and December 2011 were reviewed. Outcome measures were mortality, preoperative and postoperative mobility, and loss of independence.
A total of 149 patients were included; 132 (89%) women, median age 93.5±2.45 years. Thirty-six (24%) patients were classified as American Society of Anesthesiologists (ASA) grade 2, 104 (70%) as ASA grade 3, and nine (6%) as ASA grade 4. The Charlson comorbidity index (CCI) score was 2 or less in 115 (77%) patients and 34 (23%) patients scored 3 or more points. Short-term survival was 91% and 77% at 30 days and 3 months, respectively. Long-term survival was 64%, 42%, and 18% at 1, 3, and 5 years after surgery, respectively. Survival was significantly better in patients with lower ASA scores (P=0.005). No significant difference in survival was measured between patients according to CCI score (P=0.13). Fifty-one percent of patients had to be accommodated in an institution with more care following treatment, and 57% were less mobile after osteosynthesis of a hip fracture.
Our study shows that short-term mortality rates in very elderly patients with a hip fracture are high and there is no clear predictive value for mortality. ASA classification is the best predictive value for overall mortality. A large proportion of these patients lost their independence after osteosynthesis of a hip fracture.
Clinical Interventions in Aging 01/2014; 9:41-9. · 2.65 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Over 75 % of patients presenting with a proximal humerus fracture are 70 years or older. Very little is known about the outcome after operative treatment of these fractures in very old patients. This study was performed to gain more insight in safety and functional outcome of surgical treatment of proximal humerus fractures in the elderly.
In this observational study, we analyzed all operatively treated patients, aged 75 or older, with a proximal humerus fracture between January 2003 and December 2008 in our center. Patient selection was on clinical grounds, based on physical, mental, and social criteria. Complications were evaluated. We used the DASH Questionnaire to investigate functional outcome, pain, and ADL limitations.
Sixty-four patients were treated surgically for a displaced proximal fracture of the humerus: 15 two-part, 32 three-part, and 17 four-part fractures. Mean DASH scores were 37.5, 36.9, and 48.6, respectively. Regarding the operative methods, overall good results were obtained with the modern locked plate osteosynthesis (mean DASH 34.4). Prosthetic treatment, mostly used in highly comminuted fractures, often resulted in poor function (mean DASH 72.9). Persistent pain and ADL limitations were more present in more comminuted fractures (64 and 50 % in patients with 4-part fractures vs. 14 % in 2-part fractures). There were no postoperative deaths within 3 months of surgery, and fracture-related and non-fracture-related complication rates were low (non-union 3 %; 1 myocardial infarction).
This study shows that it is safe and justifiable to consider surgical treatment of a severely dislocated proximal humerus fracture in selected patients aged 75 and older.
According to OCEBM Working Group, Level IV.
[Show abstract][Hide abstract] ABSTRACT: Identifying radial head fractures as fragility fractures may improve case-findings for osteoporosis and thus be an indicator other fragility fractures.
Thirty-five women aged ≥50 years with a radial head fracture and 57 controls were retrospectively selected and matched for age in strata of 5 years. Peripheral bone mineral density (BMD) measurement was performed at the calcaneus. A T score of less than -2.7 was considered osteoporosis. If the T value was between -1.4 and -2.7, an additional dual energy X-ray (DXA) scan was performed.
The patients were a median age of 60 years compared with 58 years for the control patients (P = .33). The mean T score of the patients was -1.8 (standard deviation [SD], 1.0; range, -2.2 to -0.3) compared with -1.2 (SD, 1.2; range, -4.0 to 1.3) for the control patients (P = .04). Osteoporosis was diagnosed in 11 patients and in 5 control patients. The patients had an increased risk of osteoporosis compared with the control patients (odds ratio, 3.4; P = .027).
This study confirms that radial head fractures in women aged ≥50 years are potentially osteoporotic fractures. Offering these patients a BMD measurement may prevent future osteoporotic fractures, such as hip and spine fractures.
Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.] 06/2012; 21(11):1555-8. · 1.93 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Recent studies report that magnetic resonance imaging (MRI) shows a high incidence of associated injuries in patients with a radial head fracture. This retrospective study describes the clinical relevance of these injuries.
Forty patients with 42 radial head fractures underwent a MRI scan after a mean of 7.0 days after trauma and were reviewed after a mean of 13.3 months.
MRI showed 24 of 42 elbows had a lateral collateral ligament (LCL) lesion, 1 had a medial collateral ligament (MCL) and LCL lesion, 16 had an injury of the capitellum, 1 had a coronoid fracture, and 2 had loose osteochondral fragments. Clinical evaluation after a mean of 13.3 months showed that 3 elbows had clinical MCL or LCL laxity, of which 2 elbows had no ligamentous injuries diagnosed with MRI. One elbow with a loose osteochondral fragment showed infrequent elbow locking. The mean Mayo Elbow Performance Scale was 97.5 (range, 80-100) after a mean of 13.3 months after trauma, with no significant difference between patients with and without associated injuries (P = .8).
Most injuries found with MRI in patients with radial head fractures are not symptomatic or of clinical importance in short-term follow-up.
Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.] 09/2011; 20(8):1282-8. · 1.93 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The major challenge in the management of patients with an infected open abdomen (OA) is to control septic peritonitis and intra-abdominal fluid secretion, and to facilitate repeated abdominal exploration, while preserving the fascia for delayed primary closure. We here present a novel method for closure of the infected OA, based on continuous dynamic tension, in order to achieve re-approximation of the fascial edges of the abdominal wall.
Eighteen cases with severe peritonitis of various origin (e.g., gastrointestinal perforations, anastomotic leakage) were primarily stabilized by laparostomy, sealed with either the vacuum-assisted closure abdominal dressing or the Bogotá bag. After hemodynamic stabilization and control of the sepsis, the Abdominal Re-approximation Anchor System (ABRA; Canica Design, Almonte, Ontario, Canada) was applied. This system approximates the wound margins through dynamic traction exerted by transfascial elastomers. Before ABRA application, 5/18 patients had a grade 2B, 2/18 a grade 3, and 11/18 a grade or 4 status according to the open abdomen classification of Björck.
In this severely ill population the mean time before ABRA system application was 12 days (range: 2-39 days). Two of 18 patients died of non-ABRA-related causes within three weeks. In 14 of the remaining 16 patients (88%) primary abdominal closure of the midline was accomplished in 15 days (range: 7-30 days). The other two patients needed a component separation technique according to Ramirez to reach closure. However, secondary wound dehiscence occurred in both these patients. Two thirds of patients (12/18) developed pressure sores to the skin and/or dermis, but all healed without further complications. During outpatient clinic follow-up, 4/14 successfully closed patients still developed a midline hernia.
Delayed primary closure of OA in septic patients could be achieved in 88% with this new approximation system. However, the risk of hernia development remained. We consider this system a useful tool in the treatment of septic patients with an open abdomen.
World Journal of Surgery 08/2011; 35(10):2348-55. · 2.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Elbow dislocations can be classified as simple or complex. Simple dislocations are characterized by the absence of fractures, while complex dislocations are associated with fractures of the radial head, olecranon, or coronoid process. The majority of patients with these complex dislocations are treated with open reduction and internal fixation (ORIF), or arthroplasty in case of a non-reconstructable radial head fracture. If the elbow joint remains unstable after fracture fixation, a hinged elbow fixator can be applied. The fixator provides stability to the elbow joint, and allows for early mobilization. The latter may be important for preventing stiffness of the joint. The aim of this study is to determine the effect of early mobilization with a hinged external elbow fixator on clinical outcome in patients with complex elbow dislocations with residual instability following fracture fixation.
The design of the study will be a multicenter prospective cohort study of 30 patients who have sustained a complex elbow dislocation and are treated with a hinged elbow fixator following fracture fixation because of residual instability. Early active motion exercises within the limits of pain will be started immediately after surgery under supervision of a physical therapist. Outcome will be evaluated at regular intervals over the subsequent 12 months. The primary outcome is the Quick Disabilities of the Arm, Shoulder, and Hand score. The secondary outcome measures are the Mayo Elbow Performance Index, Oxford Elbow Score, pain level at both sides, range of motion of the elbow joint at both sides, radiographic healing of the fractures and formation of periarticular ossifications, rate of secondary interventions and complications, and health-related quality of life (Short-Form 36).
The outcome of this study will yield quantitative data on the functional outcome in patients with a complex elbow dislocation and who are treated with ORIF and additional stabilization with a hinged elbow fixator.
The trial is registered at the Netherlands Trial Register (NTR1996).
[Show abstract][Hide abstract] ABSTRACT: Elbow dislocations can be classified as simple or complex. Simple dislocations are characterized by the absence of fractures, while complex dislocations are associated with fractures. After reduction of a simple dislocation, treatment options include immobilization in a static plaster for different periods of time or so-called functional treatment. Functional treatment is characterized by early active motion within the limits of pain with or without the use of a sling or hinged brace. Theoretically, functional treatment should prevent stiffness without introducing increased joint instability. The primary aim of this randomized controlled trial is to compare early functional treatment versus plaster immobilization following simple dislocations of the elbow.
The design of the study will be a multicenter randomized controlled trial of 100 patients who have sustained a simple elbow dislocation. After reduction of the dislocation, patients are randomized between a pressure bandage for 5-7 days and early functional treatment or a plaster in 90 degrees flexion, neutral position for pro-supination for a period of three weeks. In the functional group, treatment is started with early active motion within the limits of pain. Function, pain, and radiographic recovery will be evaluated at regular intervals over the subsequent 12 months. The primary outcome measure is the Quick Disabilities of the Arm, Shoulder, and Hand score. The secondary outcome measures are the Mayo Elbow Performance Index, Oxford elbow score, pain level at both sides, range of motion of the elbow joint at both sides, rate of secondary interventions and complication rates in both groups (secondary dislocation, instability, relaxation), health-related quality of life (Short-Form 36 and EuroQol-5D), radiographic appearance of the elbow joint (degenerative changes and heterotopic ossifications), costs, and cost-effectiveness.
The successful completion of this trial will provide evidence on the effectiveness of a functional treatment for the management of simple elbow dislocations.
The trial is registered at the Netherlands Trial Register (NTR2025).
[Show abstract][Hide abstract] ABSTRACT: A case is presented of isolated scaphoid dislocation with carpal dissociation in the presence of a lunato-triquetral coalition. We present the treatment and follow-up of this case. In addition, the literature on scaphoid dislocation and its treatment is reviewed. We emphasize the need to reconstruct the carpal alignment and scapho-lunate linkage.
Strategies in Trauma and Limb Reconstruction 08/2010; 5(2):105-10.
[Show abstract][Hide abstract] ABSTRACT: Radial head fractures are common, and may be associated with other injuries of clinical importance. We present the results of a standard additional MRI scan for patients with a radial head fracture. PATIENTS AND METhods: 44 patients (mean age 47 years) with 46 radial head fractures underwent MRI. 17 elbows had a Mason type-I fracture, 23 a Mason type-II fracture, and 6 elbows had a Mason type-III fracture.
Associated injuries were found in 35 elbows: 28 elbows had a lateral collateral ligament lesion, 18 had capitellar injury, 1 had a coronoid fracture, and 1 elbow had medial collateral ligament injury.
The incidence of associated injuries with radial head fractures found with MRI was high. The clinical relevance should be investigated.
[Show abstract][Hide abstract] ABSTRACT: Recent literature shows an increased mean age of female patients with radial head fractures compared with male patients with radial head fractures. However, data on epidemiology of radial head fractures and specifically in relation to age distribution and male-female ratios of radial head fracture are scarce.
A retrospective database search was performed to identify all patients with a radial head fracture over a 3-year period.
A total of 328 radial head fractures were diagnosed in 322 patients. The incidence was 2.8 per 10,000 inhabitants per year. The male-female ratio was 2:3. The mean age was 48.0 years (range, 14-88 years; SD, 14.8). The mean age of female patients (52.8 years) was significantly higher than that of male patients (40.5 years) (P = .001). As the age increases above 50 years, the number of female patients becomes significantly higher than the number of male patients (P = .001). An associated osseous injury was present in 40 patients (12.4%).
Radial head fractures are common, and associated injuries are frequent.
Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.] 02/2010; 19(4):520-3. · 1.93 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In deze retrospectieve studie zijn de resultaten geëvalueerd van de eerste drie jaar chirurgische behandeling van proximale humerusfracturen met een hoekstabiele plaatosteosynthese. Tussen 2004 en 2006 werden 40 opeenvolgende patiënten behandeld met een hoekstabiele plaatosteosynthese; 28 patiënten konden worden getraceerd en onderzocht. Evaluatie vond plaats gemiddeld veertig maanden postoperatief. De gemiddelde consolidatietijd was drie maanden. Op de röntgenfoto werd bij drie schouders een avasculaire necrose van de schouderkop gezien, in twee gevallen partieel en in één geval volledig. Bij twee patiënten liet de röntgenfoto protrusie van schroeven door het caput zien. Er werden geen plaatbreuken of secundaire standsafwijkingen waargenomen. De gemiddelde constant-score van de geopereerde arm was 80, de score van de andere arm 95. Zes patiënten werden nogmaals geopereerd in verband met klachten van het osteosynthesemateriaal. Fixatie met hoekstabiele plaatosteosynthese is een goede operatieve behandeling van proximale humerusfracturen. Patiënten kunnen snel mobiliseren, de schouderfunctie op de middellange termijn is goed en de radiologische union-rate is hoog. Het risico op complicaties is klein.
Nederlands Tijdschrift Voor Traumatologie. 01/2010; 2010(6):162-166.
[Show abstract][Hide abstract] ABSTRACT: Radial head fractures are common injuries. In American publications, one-third of the patients with these fractures have been shown to have associated injuries. The aim of this retrospective study is to describe the epidemiology of radial head fractures and associated fractures of the ipsilateral upper extremity in a European population. This study describes the epidemiology of radial head and associated fractures of the upper extremity in a Dutch population by a retrospective radiographic review of all patients with a radial head fracture between 1 January 2006 and 1 July 2007. A total of 147 radial head fractures were diagnosed in 145 patients. The incidence in the general population was 2.5 per 10.000 per year. The average age was 45.9 (SD 17.3) years and male-female ratio was 2:3. The mean age of males was significantly lower (37.1, SD 14.2 years) than of women (53.9, SD 16.4 years). Associated fracture of the upper extremity was found in 10.2%. Coronoid fractures were most common (4.1%). Associated upper limb fractures in patients with a radial head fracture are common in the European population. It is of clinical importance to suspect associated lesions and to perform a thorough physical examination and additional radiological examination on demand.
Strategies in Trauma and Limb Reconstruction 08/2008; 3(2):71-4.
[Show abstract][Hide abstract] ABSTRACT: Forty-one (impending) fractures were reviewed in 39 patients with metastatic bone disease. Thirty-one lesions were located in the femur, and the remaining ten lesions were located in the humerus. In 22 cases there were multiple lesions in the affected bone. All patients were treated with intramedullary nailing, 21 times because of a pathologic fracture and 20 times because of an impending pathologic fracture. There was no mortality related to the surgical procedures. In nine patients the postoperative course was complicated (four technical and five systemic complications). Pain relief was achieved in 29 patients. Ambulatory status was improved in 27 patients. A pathologic refracture in the same bone occurred in five cases, all located in the femoral neck. Intramedullary nailing is useful in the treatment of metastatic bone disease. This technique facilitates stabilization of the whole bone, which in our view, with respect to the presented data, is mandatory.
The Journal of trauma 03/1994; 36(2):211-5. · 2.35 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The growing success in renal transplantation has resulted in an increase in the need for donor organs. Procurement of kidneys from heart-beating (HB) donors is unlikely ever to meet this demand. Non-heart-beating (NHB) donors offer a yet untapped source of renal grafts. Cadaver kidneys from patients who have sustained cardiac standstill are often considered unsuitable for transplantation due to prolonged warm ischemia time. Using an emergency in situ perfusion technique it is possible to limit warm ischemic damage and to salvage these kidneys for transplantation. The procedure requires prompt action and cooperation of emergency service personnel. This report presents a protocol for the emergency in situ preservation procedure that can be practiced in most hospitals. At the University Hospital of Maastricht, The Netherlands, implementation of this procedure resulted in 20% more kidneys available for transplantation. Although NHB donor kidneys showed a higher rate of delayed function compared with a matched HB donor kidney population, there was no significant difference in long-term graft survival between the two groups.
[Show abstract][Hide abstract] ABSTRACT: Immobilization of the knee as part of the treatment in bone or joint lesions leads to atrophy and consequently loss of functionally. In patients this atrophy and loss of functionality is difficult to quantify because of interfering symptoms and missing baseline data. In the present study structural and functional changes in thigh muscles were examined in eight healthy volunteers of whom one leg was immobilized in a cast for four weeks. Quadriceps cross-sectional area determined with computed tomography was 21% +/- 7% diminished after four weeks immobilization (p < 0.05). Muscle biopsies from the musculus vastus lateralis revealed an 16% decreased fiber diameter (p < 0.05) and no significant shift in fiber types. Isokinetic strength measurements of knee extensors and flexors demonstrated a fall in peak torque of 53% +/- 9% and 26% +/- 13% at an angular velocity of 60 deg.s-1 (p < 0.01). Aerobic power in one-leg-cycling exercise was not significantly affected, but isokinetic quadriceps endurance work decreased from 9.1 kJ to 5.6 kJ (p < 0.05). Despite the fall in quadriceps performance the subjects had only minor functional complaints for a few days. It is concluded that immobilization of the knee is an important factor in the development of thigh muscle atrophy in patients and should therefore be diminished as much as possible.
International Journal of Sports Medicine 07/1993; 14(5):283-7. · 2.27 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The cytokinetic behavior of isolated hepatocytes transplanted into the spleen of syngenic normal Wistar rats was studied. Hepatocyte transplantation (HTX) was performed by the intrasplenic injection of 10(7) isolated hepatocytes. The proliferation index (PI) of intrasplenic donor hepatocytes was assessed by immunocytochemical visualization of DNA-synthesizing cells after pulse-labeling with bromodeoxyuridine (BrdU), a thymidine analogue. A method for determination of intrasplenic liver mass based on tissue glutamate dehydrogenase content was developed. The spontaneous PI of donor hepatocytes at 12 and at 20 weeks post-HTX amounted to around 3%. A significant increase of intrasplenic liver mass was demonstrated between the 12th and 20th week post-HTX (from 8.1 +/- 0.8% to 10.8 +/- 0.8% of spleen weight, P less than 0.05). After partial hepatectomy (PH) at 12 weeks post-HTX, the PI of liver cells in the spleen showed a transient increase up to about 10%, which rapidly declined to the "spontaneous" level of 3%. However, PH did not cause an additional increase in intrasplenic liver mass. This study shows that continuous mitotic activity of intrasplenic hepatocytes results in an actual increase of liver mass in spleen. Although a short-lived increase of proliferative activity of ectopically grafted hepatocytes was shown to occur after PH in the HTX-treated rat, this procedure did not result in an additional increase of intrasplenic liver tissue.