Complications following the extended lateral approach for calcaneal fractures do not influence mid- to long-term outcome.

BACKGROUND AND AIM: Open reduction and internal fixation (ORIF) of intra-articular calcaneal fractures through an extended lateral approach is frequently accompanied by a high complication rate. However, ORIF currently provides the best long-term clinical results. The aim of this study was twofold: (1) to evaluate both mid- to long-term clinical and radiological results of a consecutive series treated by ORIF and (2) to determine the influence of short-term complications on long-term clinical outcome. METHODS: Patients with a displaced intra-articular calcaneal fracture, treated with ORIF, through an extended lateral approach, in a level-2 trauma centre between 1995 and 2008 were evaluated for the study. The long-term functional outcome (American Orthopaedic Foot & Ankle Society (AOFAS), 36-Item Short-Form Health Survey (SF-36) and Visual Analogue Scale (VAS)) and radiographic results (e.g., Böhler and Gissane angle, height, width and joint reduction) were determined. Short- and long-term complications were documented. RESULTS: A total of 57 patients matched the inclusion criteria, from which 39 patients agreed to participate in this study (68%). The median follow-up was 6.5 years (range 2-16 years). Based on the AOFAS hindfoot score, 74% of the patients had a good-to-excellent long-term clinical result. Radiological results were satisfying with a median postoperative Böhler angle of 26° and 25° at follow-up. Complications occurred in 32% of all patients; mainly wound-healing problems were noted. Short-term complications did not influence mid- to long-term clinical results (p>0.05). Anatomic reconstruction of the calcaneus was associated with improved long-term clinical results (p<0.05). CONCLUSION: Despite the high complication rate following ORIF of a calcaneal fracture, complications do not affect mid- to long-term clinical outcome. Surgical treatment should focus on restoring the anatomy. LEVEL OF EVIDENCE: Therapeutic level IV.

[Removal of a massive broken tibial intramedullary nail]. / Entfernung eines gebrochenen massiven Tibiamarknagels.

A problem arose when the reamed tibia nail was replaced by a massive unreamed tibia nail. Of the nail fractures, it is difficult to remove the distal fragment from the medullary cavity. It may also happen that the connecting screw between the insertion handle and the nail breaks off at the edge of the implant, which complicates removal of the nail. The authors have developed a technique for removing the implant without having to saw a fissure in the marrow. A concave instrument is slid over the part of the nail left behind after which the two are connected by means of a K wire. This method has been successfully applied in two patients.

[Removal of a broken massive tibial intramedullary nail]. / Entfernung eines gebrochenen massiven Tibiamarknagels.

A problem has arisen when replacing the reamed tibia nail by the massive unreamed tibia nail. In case of nail fracture it is difficult to remove the distal fragment from the medullary cavity. It may also occur that the connecting screw between the insertion handle and the nail breaks off at the edge of the implant, which much complicates removal of the nail. The authors have developed a technique to remove the implant without having to saw a fissure in the marrow. A concave instrument is slid over the part of the nail left behind after which the two are connected by means of a K wire. This method has been successfully applied in 2 patients.

Corrective osteotomy for malunion of the distal radius: the effect of concomitant ulnar shortening osteotomy.

Positive ulnar variance due to inadequate correction of radial length is a common disorder after radial corrective osteotomy. To avoid this complication we performed a combination of ulnar-shortening osteotomy and radial corrective osteotomy in 6 of 22 radial corrections. The indication for the combined procedure was a relative ulnar length of minimally 6 mm. The functional outcome was fair in 1 and good in 5 cases with combined osteotomy. Overall, the functional results were good in 17 cases, and pain in the distal radioulnar joint was observed in 3 of 22 patients. Positive ulnar variance was the reason for pain in only 1 patient. Eventually, 2 hemiresections of the ulnar head (Bower's arthroplasty) were performed. It appears that a combination of ulnar shortening and radial osteotomy is a reliable technique, which can reduce symptoms and need for secondary operations on the ulnar side of the wrist.

Association between haematoma after inguinal hernia repair and site of heparin injection.

OBJECTIVE: To see if subcutaneous heparin prophylaxis against deep vein thrombosis and pulmonary embolism given into the abdominal wall caused more haematomas after repair of inguinal hernia than the same dose given into the shoulder. DESIGN: Random control trial. SETTING: District hospital. SUBJECTS: 101 consecutive patients admitted for elective inguinal hernia repair. INTERVENTIONS: Four injections of sodium heparin 5,000 IU given either into the abdominal wall or the shoulder, the first two hours, before, and the last 24 hours after operation. MAIN OUTCOME MEASURE: Incidence of haematoma after operation. RESULTS: There was no significant difference in the incidence of haematoma between the groups. Haematoma formation was associated with a fall in systolic blood pressure of more than 25% (p = 0.055), which in turn was significantly associated with age over 60 years (p less than 0.0003). CONCLUSION: Injection of heparin subcutaneously into the abdominal wall does not lead to more wound haematomas than injection into the shoulder. Haematoma formation seems to be associated with a drop in systolic blood pressure of 25% or more, and thus requires further investigation.

Torsion of the gallbladder.

Two patients are presented with torsion of the gallbladder, a rare disorder mainly seen in elderly women. The postoperative course was uneventful in both patients. The anatomic abnormalities which allow torsion of the gallbladder are discussed together with some etiological factors. The prognosis of this disorder is favorable when cholecystectomy is performed without delay.

Patellar dislocation and osteochondral fractures.

Follow-up study of nine patients with patellar dislocation in combination with osteochondral fractures. Three of these patients with special problems in relation to knee pathology are discussed in detail. This group of knee injuries is often overlooked because of frequent spontaneous reposition. Etiology, diagnosis and treatment are discussed. Arthroscopy is recommended to visualize chondral defects. Results are presented in combination with follow-up. Four patients still complain of instability of the knee after surgery. Reconstruction is the treatment of choice. The kind of fixation depends on the size of the osteochondral fragment, and consists of either screws or fibrin, in future possibly resorbable pins. Continuous passive motion is to be recommended after operation. Factors predisposing to recurrence are an indication for correction.