Does circumferential casting prevent fracture redisplacement in reduced distal radius fractures? A retrospective multicentre study.

BACKGROUND: This study evaluates whether a circumferential cast compared to a plaster splint leads to less fracture redisplacement in reduced extra-articular distal radius fractures (DRFs). METHODS: This retrospective multicentre study was performed in four hospitals (two teaching hospitals and two academic hospitals). Adult patients with a displaced extra-articular DRF, treated with closed reduction, were included. Patients were included from a 5-year period (January 2012-January 2017). According to the hospital protocol, fractures were immobilized with a below elbow circumferential cast (CC) or a plaster splint (PS). The primary outcome concerned the difference in the occurrence of fracture redisplacement at one-week follow-up. RESULTS: A total of 500 patients were included in this study (PS n = 184, CC n = 316). At one-week follow-up, fracture redisplacement occurred in 52 patients (17%) treated with a CC compared to 53 patients (29%) treated with a PS. This difference was statistically significant (p = 0.001). CONCLUSION: This study suggests that treatment of reduced DRFs with a circumferential cast might cause less fracture redisplacement at 1-week follow-up compared to treatment with a plaster splint. Level of Evidence Level III, Retrospective study.

Long-term follow-up of distal radius fractures, an evaluation of the current guideline: the relation between malunion, osteoarthritis and functional outcome.

BACKGROUND: Last decades there is an increased tendency of performing surgery on displaced distal radius fractures. However, it is unclear whether this affects the development of osteoarthritis. This study aims to determine the relation between anatomical position, radiological osteoarthritis and functional outcome of the elderly wrist, 10-15 years after a distal radius fracture. PATIENTS AND METHODS: 173 patients between the age of 50 and 70 at time of trauma were included in this retrospective cohort study with a 10-15-year follow-up. Based on the reassessed initial X-rays, the patients were placed into 4 groups (1: anatomical, 2a: acceptable, 2b: current operative indication but treated conservative, 2c: operative indication and operated). Functional outcome was measured, questionnaires were answered, and new bilateral X-rays of the wrist were obtained. Factors influencing osteoarthritis, the difference in osteoarthritis between the groups and the difference between the fractured and non-fractured wrists were studied. RESULTS: Group 2b showed a significantly higher degree of osteoarthritis in comparison with the contralateral wrist. In the other groups, this difference was not observed. We found no significant difference in OA and functional outcomes between the groups. The degree of osteoarthritis of the non-fractured wrist appeared to be highly associated with osteoarthritis of the fractured wrist. CONCLUSION: The results of this study showed that the degree of radiocarpal osteoarthritis is higher in conservatively treated patients that should have been operated on according to current guidelines in comparison with patients without an indication for surgery. This might suggest that our current guidelines can be effective in prevention of posttraumatic osteoarthritis. However, the effect on the functional outcome is very limited. Since the degree of radiocarpal osteoarthritis of the non-fractured wrist appeared to be highly associated with the degree of osteoarthritis of the fractured wrist, future studies should always assess osteoarthritis of both wrists in order to study the real posttraumatic effect of a fracture.

Case Report: SPECT/CT as the New Diagnostic Tool for Specific Wrist Pathology.

Introduction: Single photon emission computed tomography has been introduced as a promising new diagnostic tool in orthopaedic pathology since the early 90'. Computed tomography, the combined with SPECT, gives insight in the specific sight of wrist pathology. Literature already supports introduction of SPECT/CT in wrist pathology, but clinical application is lagging. Case Report: A 40yr old patient reported first in 2004 with persisting pain after a right distal radius fracture. Several diagnostics and operative interventions were performed, all unsuccessful. Because of the persisting pain a SPECT-CT was performed which showed a cyst in the hamate bone, which was successfully enucleated. The patient was finally pain free at recent follow-up. With a QDash-score of 43 and a PRW (H) E-DLV-score of 58/150. Discussion: In this case report, SPECT/CT proved a very sensitive diagnostic tool for specific pathology of the wrist. It offered precise localisation and thereby the clinically suspected diagnosis was confirmed and the patient successfully treated.

Model-based roentgen stereophotogrammetric analysis of the surface replacement trapeziometacarpal total joint arthroplasty.

The primary aim of this clinical and radiostereometric study was to study the migration pattern of the surface replacement trapeziometacarpal joint prosthesis (SRTMTMC, Avanta®, San Diego, CA). The secondary aims were to assess patient-related outcomes and prosthesis survival 5 years after surgery. Ten patients received the prosthesis. Radiostereometric radiographs were obtained 6 weeks, 6 months, 1 year and 5 years post-operatively and were analysed using model-based software. All patients completed DASH and Nelson Hospital scores at these follow-ups. Mean translations varied between 0.0 and 0.5 mm after 5 years. Rotation values could be calculated in six patients and mean rotations varied between -0.3 and 2.3°, although the precision of rotation values seems to be poor. The 5-year survival rate was 80%. Mean pre-operative DASH and Nelson Hospital scores were 53 (SD 14) and 51 (SD 13), respectively. Six months post-operatively, the DASH and Nelson Hospital scores had both significantly improved to 25 (SD 20) and 74 (SD 18) and remained high after 5 years. Implant stability was good 5 years post-operatively, and early migration did not predict implant failure in this study. LEVEL OF EVIDENCE: IV.

Feasibility of model-based Roentgen Stereophotogrammetric Analysis to evaluate early migration of the trapeziometacarpal joint prosthesis.

BACKGROUND: The purpose of this study was to determine the feasibility of Roentgen Stereophotogrammetric Analysis (RSA) in total joint arthroplasty of the trapeziometacarpal (TMC) joint of the thumb. METHODS: In five cadaveric hands the TMC-joint was replaced by the Surface Replacement Trapeziometacarpal prosthesis (SR™ TMC prosthesis; Avanta, San Diego, CA) and tantalum beads of 0.8 mm were implanted for RSA. RSA radiographs in two directions were made in ten positions to calculate the measurement error. Migration values from zero are indicative for the measurement error. The number of detected markers was recorded. RESULTS: The accuracy analysis showed that for the translations the mean measurement error varied between 0.003 mm (SD 0.057) and 0.055 mm (SD 0.133). For the rotations values ranged from 0.034° (SD 1.759) to 0.502° (SD 1.617). CONCLUSIONS: RSA analysis of the SR™ TMC prosthesis is feasible. The measurement error is good for the translations but high for the rotations. The latter is due to the close position of the markers relative to each other. Level of evidence III.

Lumbar extraforaminal ligaments act as a traction relief and prevent spinal nerve compression.

BACKGROUND: In a previous study, ligaments that connect the extraforaminal lumbar spinal nerves with the fibrous capsule of the facet joints and the dorsolateral side of the intervertebral disc were described. This anatomical configuration suggests a mechanical role in transferring extraforaminal spinal nerve traction. METHODS: One embalmed human lumbar spine was dissected from the twelfth thoracic vertebra to the first sacral vertebra to isolate the twelfth thoracic to the fourth lumbar spinal nerves. The spinal nerves from L1 to L4 were pulled at different angles with respect to the axis of the spine. Forces of 1-6N were applied. The displacements of reflective markers glued to the proximal and distal ends of the adjoining ligaments were recorded with a video system. FINDINGS: The spinal nerve proximal of the extraforaminal ligaments stays centred in the intervertebral foramen when pulling at an angle. At levels L1-L4 strain reduction by the extraforaminal ligaments was largest when pulling at a wider angle to the spinal axis in the sagittal plane. Proximal to the extraforaminal ligaments less displacement was seen compared to the displacement distal of the extraforaminal ligaments when pulling in longitudinal direction. A graded decrease in the displacement proximal to the extraforaminal ligaments was seen from the levels L1-L4. INTERPRETATION: Extraforaminal ligaments play an important role in the prevention of damage due to spinal nerve traction. The proximal attachments secure a spinal nerve position central in the intervertebral foramen and also reduce longitudinal tension.

Extraforaminal ligament attachments of the thoracic spinal nerves in humans.

An anatomical study of the extraforaminal attachments of the thoracic spinal nerves was performed using human spinal columns. The objectives of the study are to identify and describe the existence of ligamentous structures at each thoracic level that attach spinal nerves to structures at the extraforaminal region. During the last 120 years, several mechanisms have been described to protect the spinal nerve against traction. All the described structures were located inside the spinal canal proximal to the intervertebral foramen. Ligaments with a comparable function just outside the intervertebral foramen are mentioned ephemerally. No studies are available about ligamentous attachments of thoracic spinal nerves to the spine. Five embalmed human thoracic spines (Th2-Th11) were dissected. Bilaterally, the extraforaminal region was dissected to describe and measure anatomical structures and their relationships with the thoracic spinal nerves. Histology was done at the sites of attachment of the ligaments to the nerves and along the ligaments. The thoracic spinal nerves are attached to the transverse process of the vertebrae cranial and caudal to the intervertebral foramen. The ligaments consist mainly of collagenous fibers. In conclusion, at the thoracic level, direct ligamentous connections exist between extraforaminal thoracic spinal nerves and nearby structures. They may serve as a protective mechanism against traction and compression of the nerves by positioning the nerve in the intervertebral foramen.

Extraforaminal ligament attachments of human lumbar nerves.

STUDY DESIGN: An anatomic study of the extraforaminal attachments of the lumbar spinal nerves was performed using human lumbar spinal columns. OBJECTIVES: To identify and describe the existence of ligamentous structures at each lumbar level that attach lumbar spinal nerves to structures at the level of the extraforaminal region. SUMMARY OF BACKGROUND DATA: During the last 120 years, several mechanisms to protect the spinal nerve against traction have been described. All these structures involved are located in the spinal canal, proximal to the intervertebral foramen. METHODS: Five embalmed human lumbar spines (T12-S1) were used. Bilaterally, the extraforaminal region was dissected to describe and measure anatomic structures and their relationships. Histology was performed with staining on the sites of attachment and along the ligament. RESULTS: The levels T12-L2 show bilaterally 2 ligaments, a superior extraforaminal ligament and an inferior extraforaminal ligament. The superior extraforaminal ligament emerges from the joint capsule of the facet joints and inserts in both, the intervertebral disc and the ventral crista of the intervertebral foramen, passing the spinal nerve laterally. In one specimen on level L2-L3, the superior extraforaminal ligament is not attached to the spinal nerve. The inferior extraforaminal ligament emerges from the intervertebral disc, passing the nerve medially and attaching the spinal nerve. At the levels L2-L5, the inferior extraforaminal ligaments are only attached to the intervertebral disc, not to the joint capsule. Histologically, the ligaments consisted of mainly collagenous structures. CONCLUSION: Ligamentous connections exist between lumbar extraforaminal spinal nerves and nearby structures.

Starting from standing; why step backwards?

At push-off, the mass centre of gravity of the body must be positioned in front of the foot to prevent a somersault. When starting a sprint from out the standing position the use of a step backwards is necessary for maximal acceleration. The aim of the present study was to quantify the positive contribution to push off from a backward step of the leg, which seems to be counterproductive. Ten subjects were instructed to sprint start in three different ways: (a) starting from the standing position just in front of the force platform on the subject's own initiative, (b) starting from the standing position on the force platform with no step backward allowed, and (c) starting out of the starting position with one leg in front of the force platform and the push-off leg on the force platform. A step backwards was observed in 95% of the starts from the standing position. The push-off force was highest in starting type (a), which had the shortest time to build up the push-off force. The results indicate a positive contribution to the force and power from a step backwards. We advocate developing a training program with special attention to the phenomenon step backwards.

[Experiences of relatives of donors with the donation procedure; comparison between 1995 and 1998]. / Ervaringen van nabestaanden van donoren met de donatieprocedure; vergelijking tussen 1995 en 1998.

OBJECTIVE: To determine the experience of the relatives of organ and tissue donors, immediately before, during and soon after the donation procedure. DESIGN: Questionnaire. METHOD: At two national one-day meetings at which about 10% of the families of donors between 1991 and 1998 were represented, the participants completed a questionnaire with questions about their appreciation of the communication with the different health care professionals. The appreciation was scored on a 7-point scale. RESULTS: Most relatives looked back with satisfaction on the events in the hospital and soon thereafter; the appreciation was 'a little satisfied' to 'satisfied'. The relatives in non-heart-beating kidney transplantation were more satisfied compared to those confronted with the brain death transplantation, with regard to the conversation in which the death was announced as well as to the conversation regarding the donation procedure. Relatives in 1998 were more positive about some specific aspects than in 1995, notably concerning explanation of the phenomenon of brain death. Satisfaction was primarily influenced by the way in which the news of death was conveyed and the aftercare by the transplant coordinator. The moment donation was addressed and the moment the relatives said 'good-bye' to their beloved were the next important factors.