Does intraoperative fluoroscopic 3D imaging provide extra information for fracture surgery?

Fracture surgery of the extremities using 2D fluoroscopy frequently fails to detect the suboptimal positioning of implants and joint incongruities. The use of intraoperative 3D-rotational X-ray (3D-RX) imaging with a new X-ray device potentially reveals these failures. We compared 50 intraoperative (2D) results of surgery and certainty about the effectiveness of different aspects of fracture reduction as interpreted from conventional (2D) methods versus intraoperative 3D-RX in 42 distal extremity fractures by means of a surgery questionnaire. In addition, we investigated the need for revision surgery based on postoperative radiological findings in 81 patients. After fracture reduction, just before a 3D-RX scan, the surgeon preoperatively assessed the result of surgery. Three months after surgery, the 3D-RX scan was judged by three experienced surgeons independently. Intraoperative 3D-RX showed significantly more information as to screw positioning and rotation of the fracture reduction than the conventional method (p < 0.005). None of the 81 patients in whom 3D-RX was performed needed surgical revision based on postoperative radiological examinations. Intraoperative 3D-RX with this new device scanning offers additional information about extremity fracture reduction as compared to conventional intraoperative 2D imaging, and may reduce the need for revision surgery. The value of 3D-RX on functional outcomes still needs to be assessed.

Cost-effectiveness of identifying aortoiliac and femoropopliteal arterial disease with angiography or duplex scanning.

OBJECTIVES: Cost-effectiveness analysis of three diagnostic imaging strategies for the assessment of aortoiliac and femoropopliteal arteries in patients with peripheral arterial occlusive disease. The strategies were: angiography as the reference strategy, duplex scanning (DS) plus supplementary angiography (S1) and DS plus confirmative angiography (S2). DESIGN, MATERIALS AND METHODS: A decision model was built with sensitivity and specificity data from literature, supplemented with prospective hospital cost data in Euro (euro). The probability of correctly identifying the status of a lesion was taken as the primary outcome. We compared strategies by assessing the extra costs per additional correctly identified case. RESULTS: Assuming no false positive or false negative results, angiography is the most effective strategy if the prevalence of significant obstructive lesions in the aortoiliac and femoropopliteal tract exceeds 70%, or if the sensitivity of duplex scanning is lower than 83%. In case of lower prevalence, strategy S1 becomes equally or even more effective than angiography. At a prevalence of 75%, performing angiography costs euro 8443 per extra correctly identified case compared with strategy S1. CONCLUSIONS: In most situations angiography is more effective than diagnostic strategy S1. However, if society is unwilling to pay more than euro 8443 for knowing a patient's disease status, diagnostic strategy S1 is a cost-effective alternative to angiography, especially at lower prevalence values.

[Local wound care: evidence-based treatments and dressings]. / Lokale wondzorg: evidence-based behandelingen en verbandmaterialen.

Patients with open wounds require specific local-wound care. There is huge variety in methods of local-wound care. This is due not only to the many different types of wounds but also to the widely varying preferences of doctors and nurses, and to the lack of strong evidence and relevant guidelines regarding the most appropriate form of local-wound care. In 19 systematic literature reviews from the Cochrane Collaboration on surgical and traumatic wounds and ulcers (venous, arterial and diabetic) information can be found on local-wound treatment. Eleven of these reviews were limited to strong evidence for the use of: tissue adhesives for surgical and traumatic wounds; foam dressings in surgical wounds healing by secondary intention; (intermittent) compression, bilayer artificial skin and lidocaine-prilocaine cream for venous ulcers; hydrogel and in-shoe orthotics for diabetic-foot ulcers; negative pressure for chronic wounds, and cleansing of acute wounds with clean tap water.

Toe blood pressure measurements in patients suspected of leg ischaemia: a new laser Doppler device compared with photoplethysmography.

OBJECTIVES: To study the usefulness of a new laser Doppler (LD) device as compared with photoplethysmography (PPG) to measure toe systolic blood pressures (TBP) in patients suspected of arterial insufficiency of the legs. DESIGN: Prospective comparative clinical study. MATERIALS AND METHODS: Seventy patients (121 legs) referred to our vascular laboratory for TBP measurements were investigated using a standard PPG and a new LD instrument, incorporating a cuff inflator and probe heater. RESULTS: Mean toe pressures with the PPG, unheated LD, and heated LD (37 degrees C) were 68.1, 67.2, and 75.5 mmHg, respectively. TBP with heated LD was systematically higher than with PPG (7.7 mmHg; p<0.001). Intra-class correlations between PPG vs. unheated LD and PPG vs. heated LD were good: 0.91 and 0.93, respectively. However, a considerable variation existed between PPG and LD (95% confidence interval: 45 mmHg), which were unrelated to the value of the TBP. Kappa values of agreement between PPG and unheated and heated LD to detect critical ischaemia (TBP below 30 mmHg) were good (kappa=0.77 and 0.63, respectively). CONCLUSIONS: The new LD device appears a good alternative to standard PPG measurements to assess TBP, despite a rather wide variation.

Spinal cord stimulation in the treatment of non-reconstructable stable critical leg ischaemia: results of the European Peripheral Vascular Disease Outcome Study (SCS-EPOS).

OBJECTIVE: To determine the effect of spinal cord stimulation (SCS) on limb survival in patients with non-reconstructable critical leg ischaemia, and the value of patient selection on the basis of transcutaneous oxygen pressure (TcpO2) measurements and trial screening. DESIGN: A prospective, controlled, European multicentre study. METHODS: Non-reconstructable patients with stable critical leg ischaemia were divided into three groups. The SCS-Match group comprised patients with a baseline forefoot TcpO2 of < 30 mmHg and both sufficient pain relief and sufficient paraesthesia coverage (> 75%) after a test stimulation period of at least 72 h. If baseline TcpO2 was < 10 mmHg, the TcpO2 should have exceeded 20 mmHg after test stimulation. The SCS-Match group was compared with patients not meeting these criteria, who were treated either with SCS (SCS-No-Match) or without SCS (No-SCS). RESULTS: At baseline, the mean (+/- SD) supine TcpO2 was 14.9 +/- 8.3 mmHg in the SCS-Match group (n = 41), 11.3 +/- 13.3 mmHg in the SCS-No-Match group (n = 32) and 15.3 +/- 17.1 mmHg in the No-SCS group (n = 39). In the SCS-Match group a significant improvement in pain relief (p < 0.005) and TcpO2 (p < 0.001) was seen. After 12 months, cumulative limb survival of patients treated with SCS was significantly better than that of patients not treated with SCS (p < 0.03), and limb survival in the SCS-Match group was significantly higher (p < 0.03) than that in the SCS-No-Match and No-SCS groups (78, 55 and 45%, respectively). CONCLUSION: SCS treatment of non-reconstructable critical leg ischaemia provides a significantly better limb survival rate compared with conservative treatment. Patient selection based on TcpO2 and the results of trial screening further increase the probability of limb survival after SCS therapy.

The best TcpO(2) parameters to predict the efficacy of spinal cord stimulation to improve limb salvage in patients with inoperable critical leg ischemia.

AIM: Spinal cord stimulation (SCS) is available as an alternative therapy for patients suffering from inoperable critical limb ischemia (CLI). Selection of patients is essential to achieve the best treatment effect. For this purpose transcutaneous oxygen (TcpO(2)) measurements have frequently been applied. So far, it is unclear which TcpO(2) parameters serve this purpose best. METHODS: Studies in which inoperable CLI patients were treated with conservative treatment with or without SCS, and in whom various TcpO(2) measurements were performed before and during treatment were pooled to investigate which TcpO(2) parameter(s) were best to detect patients who benefit most from SCS treatment as to limb salvage. RESULTS: TcpO(2) in the supine position increased significantly (p<0.001) in patients after a short period of SCS treatment (from 9 to 22 mmHg), but not in those treated conservatively (from 7 to 7 mmHg). Baseline supine TcpO(2) (using a cut-off value of 10 mmHg), the baseline sitting-supine TcpO(2) difference (cut-off value: 17 mmHg), and the difference in TcpO(2) before and after test stimulation (cut-off value: 4 mmHg) were related to a significantly increased limb salvage. SCS patients with a sitting-supine TcpO(2) difference of >17 mmHg had a 1-year limb salvage of 83% vs 68% in the whole SCS-treated group irrespective of TcpO(2) selection. CONCLUSION: The TcpO(2) parameters mentioned above are capable of detecting the effect of SCS treatment. Selection using (a combination of) TcpO(2) measurements substantially improves limb salvage of patients treated with SCS for inoperable CLI.