Long-term outcomes after high-energy open tibial fractures: Is a salvaged limb superior to prosthesis in terms of physical function and quality of life?

PURPOSE: The aim of this study was to describe complication rates and long-term functional outcomes among patients with amputated versus reconstructed limb after high-energy open tibial fractures. METHODS: Patients treated operatively for a high-energy open tibial fracture, classified as Gustilo-Anderson (GA) grade 3, at our hospital in the time period 2004-2013 were invited to a clinical and radiographic follow-up at minimum 2 years after injury. Eighty-two patients with 87 GA grade 3 fractures were included. There were 39 type GA 3A, 34 GA 3B, and 14 GA 3C. RESULTS: The GA 3A reconstruction group had the lowest complication rate and the best long-term outcome scores at mean 5 years (range 2-8 years) after injury. Within the group of GA 3B and 3C fractures, we found no significant differences in long-term outcomes among patients with reconstructed versus amputated limbs. The mean physical component summary score of the SF-36 in the reconstruction versus amputation group was 54.2 (95% CI 46.3-62.1) versus 47.7 (95% CI 32.6-62.2), respectively (p = 0.524), while the mean mental component summary score was 63.7 (95% CI 50.6-71.8) versus 59.2 (95% CI 48.8-68.0), respectively (p = 0.603). On the 6-minute walk test, the reconstruction group walked on average 493 m (95% CI 447-535 m) versus 449 m (95% CI 384-518 m) in the amputation group. The return to work rate was 73% (16 of 22) in the reconstruction group versus 50% (7 of 14) in the amputation group (p = 0.166). The mean patient satisfaction score (VAS 0-100) was 67 (95% CI 67-77) in the reconstruction group versus 65 (95% CI 51-76) in the amputation group (p = 0.795). Regardless of the treatment strategy, the complication rate was high. CONCLUSIONS: Amputation should be considered as a viable treatment option, equal to limb salvage, after high-energy open tibial fracture with severe vascular damage or soft tissue loss.

[Surgery of femoral neck fractures--higher rate of osteosynthesis failure with the use of 4,5 mm screws compared to 6,5 mm screws]. / Operasjon for lårhalsbrudd--hyppigere osteosyntesesvikt med bruk av 4,5 mm skruer enn med 6,5 mm.

BACKGROUND: Displaced femoral neck fractures are usually treated with screw osteosynthesis or primary hip replacement (unipolar or bipolar). MATERIAL AND METHOD: In this retrospective study we compared the rate of early failure during two consecutive years using two different screw implants each year. The patient groups were demographically similar, and the relationships between the use of hip replacement and screws as primary treatment were similar in the two groups. In the first group (group A), two screws with a shaft and outer thread diameter both of 6.5 mm were used. In the second group (group B), two screws with shaft diameter of 4.5 mm and outer thread diameter of 7.3 mm were used. The number of patients operated with screws were 191 the first year and 177 the following year. RESULTS: The number of patients reoperated with a hip replacement within the first 100 days was 16 (8%) in group A and 29 (16%) in group B (risk difference 0.08; 95% CI 0.013-0.147). INTERPRETATION: We recommend that when two screws are used for fixation of femoral neck fractures, they should have a shaft diameter of at least 6.5 mm.

[Clinical diagnosis of deep venous thrombosis after hip replacement surgery]. / Klinisk diagnostikk av dyp venetrombose etter hofteprotesekirurgi.

Hip replacement surgery is associated with a high frequency of postoperative deep vein thrombosis. This prospective study was performed in order to investigate if routine bedside questioning and examination by the visiting doctor could reveal deep vein thrombosis in the legs of patients who had received a hip replacement. 258 patients were evaluated. Thromboprophylaxis (dextran-70, low molecular weight heparin and graded elastic stockings) was given during the first week after operation. Bilateral venography was performed in all patients on day seven after operation, and showed an overall deep vein thrombosis incidence of 16%. The visiting doctors had not suspected deep vein thrombosis in any of the patients. This may have been because postoperative painful and swollen legs effectively masked any signs and symptoms of deep vein thrombosis. Our results show that deep vein thrombosis during the first week after hip replacement surgery cannot be discovered by clinical diagnostics. The high subclinical frequency of deep vein thrombosis indicates the importance of improving thromboprophylaxis in order to further minimise the occurrence of deep vein thrombosis and the risk of thromboembolic complications.

[Follow-up of Souter elbow prostheses]. / Etterundersøkelse av Souters albueproteser.

27 patients (30 elbows) treated with Souter elbow prosthesis replacement were examined at a follow-up study. 26 patients had rheumatic arthritis. The mean observation time was five years (2-10 years). The indication for surgery was severe pain and reduced elbow function. Preoperative radiological examination revealed considerable pathological changes in all the elbows. Six of the elbows underwent revision with new prosthesis replacement. The indications for the re-operations were fractures, loosening of the prosthesis and luxations. 19 elbows (26%) had deteriorated and three patients had no definite opinion. Four of the six elbows replaced by a new prosthesis, became worse than before the first operation. Follow-up radiological examination showed that 80% of the humerus components showed varying degrees of radiological loosening and more than half of the humerus components showed cranial migration. All patients who suffered fractures during the operation have been, or will be, re-operated. Radiological loosening of the prosthesis makes the prognosis uncertain for the majority of the patients. Re-operation with a new prosthesis is unsatisfactory. As a consequence of the poor results, this prosthesis is no longer used at our hospital.

Prolonged thromboprophylaxis following hip replacement surgery--results of a double-blind, prospective, randomised, placebo-controlled study with dalteparin (Fragmin)

Discontinuation of thromboprophylaxis a few days after surgery may unmask delayed hypercoagulability and contribute to late formation of deep venous thrombosis (DVT). To investigate whether thromboprophylaxis should be prolonged beyond the hospital stay, a prospective, double-blind randomised study was conducted in 308 patients. All patients received initial thromboprophylaxis with dalteparin, dextran and graded elastic stockings. On day 7, patients were randomised to receive dalteparin (Fragmin) 5000 i.u. once daily, or placebo, for 4 weeks. All patients were subjected to bilateral venography, perfusion ventilation scintigraphy and chest X-ray on days 7 and 35. Patients with venographically verified proximal DVT on day 7 were withdrawn from the randomised study to receive anticoagulant treatment. The overall prevalence of DVT on day 7 was 15.9%. On day 35, the prevalence of DVT was 31.7% in placebo-treated patients compared with 19.3% in dalteparin-treated patients (p = 0.034). The incidence of DVT from day 7 to day 35 was 25.8% in the placebo-treated group versus 11.8% in the dalteparin-treated group (p = 0.017). The incidence of symptomatic pulmonary embolism (PE) from day 7 to day 35 was 2.8% in the placebo-treated group compared with zero in the dalteparin-treated group. This included one patient who died from PE. No patients experienced serious complications related to the injections of dalteparin or placebo. This study shows that prolonged thromboprophylaxis with dalteparin. 5000 IU, once daily for 35 days significantly reduces the frequency of DVT and should be recommended for 5 weeks after hip replacement surgery.

[Activities of the Norwegian field hospital in Bosnia-Herzegovina. Survey of a 3-year material]. / Virksomheten ved det norske feltsykehuset i Bosnia-Hercegovina. Gjennomgang av et treårsmateriale.

In November, 1993 the UN opened a Norwegian field hospital in Bosnia-Herzegovina. The hospital was handed over to the American IFOR forces in November, 1996. In the present study, we analyse the activities at the hospital and the results achieved by the Norwegian management. While under Norwegian supervision 2,593 patients were admitted, and 67% of them were civilians. Almost two thirds of military personnel admitted were non-surgical cases. The war-related surgical activity was low, corresponding to the low number of war-related injuries. In the period in question 135 emergency operations were performed on military persons. There was considerable out-patient activity at the hospital, covering both military personnel and civilians. Altogether, 12,921 out-patients were treated, 40% of which were civilians. The hospital was well-equipped and well-run. This experience will be helpful in planning future Norwegian task forces abroad.

[Pseudomyxoma peritonei]. / Pseudomyoxoma peritonei.

The article describes a case of pseudomyxoma peritonei. The disease is uncommon. The origin is usually a malignant process in the ovary or appendix. The disease spreads to the peritoneal surface, which becomes studded with mucinous bulks. The patient suffered from abdominal discomfort and distension. 80-85% of persons with this disease die within ten years. The disease must be treated with extensive surgery. The case demonstrates the effect of adjuvant chemotherapy. The treatment of pseudomyxoma peritonei must involve co-operation between surgery and oncology.

[Pseudolymphoma of the stomach]. / Pseudolymfom i ventrikkelen.

The article reports a case of pseudolymphoma of the stomach. The histological hallmark is lymphoid hyperplasia, with formation of reactive follicles. Most authors believe that this is a benign disorder. The exuberance of the lymphoid reaction may be misinterpreted, however, as malignant lymphoma, which may possibly explain the unduly good prognosis reported in some earlier studies of malignant lymphoma of the stomach.