Construct failure after open reduction and plate fixation of displaced midshaft clavicular fractures.

INTRODUCTION: Worldwide, implants mostly used for fixation of displaced midshaft clavicular fractures (DMCF) are the easily to bend reconstruction plate and the stiffer small fragment locking compression plate. Construct failure rates after plate fixation of DMCF are reported around 5 percent. Possible risk factors for construct failure are implant type and fracture type. However, little is known about the influence of fracture fixation method on construct failure. The aim of this study was to assess construct failure in plate fixation of DMCF and to identify possible risk factors. METHODS: All consecutive patients treated in a level 1 trauma centre with open reduction and fixation of DMCF using a 3.5-mm reconstruction plate or 3.5-mm small fragment locking compression plate between 2007 and 2015 were evaluated. Potential risk factors for construct failure were analysed using univariate analysis. RESULTS: Two hundred and fifty-nine patients were analysed. Fifty DMCF (19%) were fixated with a reconstruction plate and 209 (81%) with a small fragment locking compression plate. Construct failure was seen in 18 patients (6.9%), including 5 broken plates and 13 with screw loosening. Eight percent of all reconstruction plates broke in contrast to 0.5 percent of all small fragment locking compression plates (p=0.001). All broken implants were used as a bridging plate. Loosening of screws was seen in older patients and when the plate was fixated with less than three bicortical screws on one side of the fracture (p=0.002). CONCLUSIONS: Overall construct failure after open reduction and plate fixation of DMCF occurred in 6.9 percent. Risk factors for plate breakage were the use of a reconstruction plate and a bridging method for fracture fixation. Risk factors for screw loosening were an increasing patient age and plate fixation with less than three bicortical screws on one side of the fracture. RECOMMENDATIONS: Based on the results of this study our recommendation is to use a small fragment locking compression plate for open reduction and internal fixation of DMCF. The surgeon should always strive to fixate the plate on both sides of the fracture with at least three bicortical screws.

[Management of blunt renal trauma in paediatric patients]. / Behandeling van stomp nierletsel bij kinderen.

- In 90% of children, blunt abdominal trauma is the cause of renal, splenic or hepatic injury or an injury affecting a combination of these organs.- Because children's kidneys are anatomically less protected than those of adults, potential renal injury following direct trauma affecting the child's flank, for example by a handlebar or knee should be considered.- Symptoms of renal trauma include excoriations or haematoma on the flank, a 'seatbelt-sign', macroscopic haematuria and fractures of the ribs and vertebra.- As haematuria does not correlate with the severity of renal injury, all children with persistent haematuria should undergo renal imaging.- Children without abnormalities on Doppler ultrasound examination and without macroscopic haematuria can be discharged from the emergency room.- Conservative management of blunt renal trauma is indicated for all haemodynamically stable children. However, haemodynamically unstable children need to undergo an urgent laparotomy. The routine use of bed rest is only indicated for grade V renal injuries.- A DMSA scan is recommended 6-12 weeks after trauma for grade IV-V renal injury.

Technical errors and complications in orthopaedic trauma surgery.

INTRODUCTION: Adverse events and associated morbidity and subsequent costs receive increasing attention in clinical practice and research. As opposed to complications, errors are not described or analysed in literature on fracture surgery. The aim of this study was to provide a description of errors and complications in relation to fracture surgery, as well as the circumstances in which they occur, for example urgency, type of surgeon, and type of fracture. METHODS: All errors and complications were recorded prospectively in our hospital's complication registry, which forms an integral part of the electronic medical patient file. All recorded errors and complications in the complication registry linked to fracture surgery between 1 January, 2000 and 31 December, 2010 were analysed. RESULTS: During the study period 4310 osteosynthesis procedures were performed. In 78 (1.8 %) procedures an error in osteosynthesis was registered. The number of procedures in which an error occurred was significantly lower (OR = 0.53; p = 0.007) when an orthopaedic trauma surgeon was part of the operating team. Of all 3758 patients who were admitted to the surgical ward for osteosynthesis, 745 (19.8 %) had one or more postoperative complications registered. There was no significant difference in the number of postoperative complications after osteosynthesis procedures in which an orthopaedic trauma surgeon was present or absent (16.7 vs. 19.1 %; p = 0.088; OR 0.85). DISCUSSION: In the present study the true error rate after osteosynthesis may have been higher than the rate found. Errors that had no significant consequence may be especially susceptible to underreporting. CONCLUSION: The present study suggests that an osteosynthesis procedure performed by or actively assisted by an orthopaedic trauma surgeon decreases the probability of an error in osteosynthesis. Apart from errors in osteosynthesis, the involvement of an orthopaedic trauma surgeon did not lead to a significant reduction in the number of postoperative complications.

Treatment of unstable trochanteric fractures. Randomised comparison of the gamma nail and the proximal femoral nail.

The proximal femoral nail (PFN) is a recently introduced intramedullary system, designed to improve treatment of unstable trochanteric fractures of the hip. In a multicentre prospective clinical study, the intra-operative use, complications and outcome of treatment using the PFN (n = 211) were compared with those using the gamma nail (GN) (n = 213). The intra-operative blood loss was lower with the PFN (220 ml v 287 ml, p = 0.001). Post-operatively, more lateral protrusion of the hip screws of the PFN (7.6%) was documented, compared with the gamma nail (1.6%, p = 0.02). Most local complications were related to suboptimal reduction of the fracture and/or positioning of the implant. Functional outcome and consolidation were equal for both implants. Generally, the results of treatment of unstable trochanteric fractures were comparable for the PFN and GN. The pitfalls and complications were similar, and mainly surgeon- or fracture-related, rather than implant-related.

Impact of ultrasonographic duplex scanning on therapeutic decision making in lower-limb arterial disease.

Ultrasonographic duplex scanning has become a valuable diagnostic technique in detecting and grading stenoses and occlusions of the aortoiliac and femoropopliteal arteries. However, the question remains as to whether a treatment strategy can be designed without diagnostic angiography. This prospective study evaluated the impact of duplex scanning on therapeutic decision making. Patients with intermittent claudication, rest pain or ischaemic ulceration of the lower limb who were eligible for invasive treatment were studied. If treatment was considered necessary, a duplex scan was performed instead of diagnostic angiography. The surgeon made a therapeutic decision based on clinical assessment and information obtained from the duplex scan. If it was felt that duplex scanning gave insufficient information, diagnostic angiography was then performed. A group of 112 consecutive patients were studied prospectively; 12 were excluded for logistical reasons. The 100 remaining patients (intermittent claudication in 69, rest pain in 16, ischaemic ulceration in 15) were evaluated. Based on non-invasive tests 22 patients were treated conservatively, 36 were scheduled for percutaneous transluminal angioplasty (PTA) and 32 were scheduled for surgery. Angiography was requested to determine the definitive treatment policy in 28 patients: four of the 22 were scheduled for conservative treatment and 24 of the 32 were scheduled for surgery. All PTAs were performed without prior diagnostic angiography. Angiography was considered necessary in a further ten patients to formulate a therapeutic strategy. In 62 patients the treatment strategy could be determined without diagnostic angiography. Twenty-three of the 39 angiograms performed did not give additional information on treatment strategy. Integrated use of duplex scanning for the investigation of patients with arterial occlusive disease of the lower limb can reduce the need for diagnostic angiography.

The results of denatured homologous vein grafts as conduits for secondary haemodialysis access surgery.

OBJECTIVES: To determine the value of denatured homologous vein grafts as a conduit for secondary haemodialysis access. DESIGN: Retrospective clinical study. SETTING: 2 University Hospitals. MATERIALS AND METHODS: One-hundred-and-twenty-five patients received 195 grafts over a period of five years. Fifty-six first grafts (45%) functioned without complications throughout the study period of 5.8 years. MAIN RESULTS: Primary patency was 57% after 1 year and 25% after 3 years of follow-up. Of the initial grafts, 69 (55%) needed 161 interventions, for thrombosis (n = 59), stenosis (n = 43), failure beyond repair (n = 40), aneurysm (n = 12), infection (n = 4), steal syndrome (n = 1), and other causes (n = 2). Secondary patency was 76% at 1 year and 52% at 3 years of follow-up. A major advantage of these grafts was the low rate (2.6%) of infection. Aneurysm formation occurred 17 times in 195 grafts (8.7%). CONCLUSIONS: Denatured homologous vein graft is a good alternative in secondary access surgery.

The cleavage plane in semi-closed endarterectomy of the superficial femoral artery: a histologic study.

PURPOSE: The purpose of this study was to determine the cleavage plane in semiclosed endarterectomy of the superficial femoral artery, a histologic study of endarterectomy cores of 10 consecutive patients was performed. Superficial femoral artery occlusive disease consisted of multiple stenoses in one and an occlusion in the other cases. METHODS: Microscopic paraffin cross-sections were made every half centimeter of the endarterectomy core. The sections were stained with hematoxylin-eosin and with elastica van Gieson. Microscopic studies were conducted of a total of 484 sections. Intima, internal elastic membrane, media, external elastic membrane, and adventitia were identified, if present. RESULTS: When the procedure of separating the diseased intima from the remainder of the arterial wall was commenced, the cleavage plane was located between the internal elastic membrane and the media in most cases. In two cases the cleavage plane was located inside the intima, and in one case parts of the media were removed as well. During passage of the ring stripper through the artery, the location of the cleavage plane changes and extends into the media. In one patient a residual stenosis was located in the segment of the core in which only the intima and internal elastic membrane were removed. In two patients the endarterectomy core contained parts of the external plastic membrane as well. During passage of the ring stripper through the artery, the location of the cleavage plane changes. In some segments the media is left intact, whereas in other segments the media is partially or totally removed. The reason for the variability of the cleavage plane rests in the nature of the pathologic behavior of the atheroma. The tissue necrosis that is part of the atheromatous complex frequently dips beyond the internal elastic membrane into the media and even into the external elastic membrane and adventitia. CONCLUSIONS: The question remains as to whether the location of the cleavage plane has an influence on the long-term results of endarterectomy. Long-term follow-up studies are required to supply us with the answer.

Management of superficial femoral artery occlusive disease.

The prevalence of intermittent claudication in men aged 55-74 years is 4.5 per cent and a common cause of such claudication is superficial femoral artery (SFA) occlusive disease. The preferred management of patients with this condition remains a subject of discussion. Therapeutic options range from conservative treatment to endovascular intervention and surgical bypass or endarterectomy. Conservative therapy is the primary treatment of choice. However, if this fails and an endovascular technique is chosen, percutaneous transluminal angioplasty (PTA) is the best option; other endovascular methods have failed to achieve higher rates of technical success or patency. PTA should be considered only for short lesions (< or = 10 cm). The usual surgical option for SFA occlusive disease is femoropopliteal bypass using autogenous vein, which has an expected 5-year patency rate of 56-76 per cent. Patency rates decrease if other types of graft are used. An alternative to vein bypass is endarterectomy, with an expected 5-year patency rate of 35-71 per cent. A multicentre randomized trial should be conducted to determine the optimal management of claudication caused by SFA occlusive disease.

Long-term results of semiclosed endarterectomy of the superficial femoral artery and the outcome of failed reconstructions.

PURPOSE: The optimal method of treatment of superficial femoral artery occlusive disease has yet to be established. Therapeutic options include percutaneous transluminal angioplasty for short lesions and reversed or in situ autologous saphenous vein bypass for long lesions. Currently, staged revascularization with polytetrafluoroethylene as an initial conduit and autologous vein for secondary procedures is suggested. An alternative to these procedures is endarterectomy of the occluded superficial femoral artery, followed by a femoropopliteal bypass in cases of endarterectomy failure. Our results with this procedure are reviewed in this article. METHODS: From 1980 until 1990, 259 endarterectomies of the superficial femoral artery were attempted, 231 of which were successfully performed in 197 patients (145 men and 52 women), with an average age of 64 years (range 40 to 82 years). The indication for successfully performed endarterectomy was claudication in 186 patients (80%), rest pain in 21 (9%), and gangrene in 24 (11%). The postoperative mortality rate was 0.8% with a complication rate of 10%. RESULTS: Eighty-two failures occurred during follow-up, of which 33 were treated with peripheral bypass. Five additional bypasses were performed because of occlusions distal from the endarterectomized segment. The 5-year primary overall patency rate of successfully performed endarterectomy was 71% (SE 3.6). The 5-year overall secondary bypass patency rate was 61% (SE 11.3). The combined endarterectomy and bypass patency rate (tertiary patency) was 79% (SE 3.3) after 5 years and 45% (SE 7.6) after 10 years. The overall amputation rate was 5.6% and the amputation rate was 1.6% in patients treated for claudication. CONCLUSIONS: The combination of endarterectomy and peripheral bypass provides a valuable alternative to the current treatment of superficial femoral artery occlusive disease.

Preoperative colour-coded duplex scanning in varicose veins of the lower extremity.

OBJECTIVE: To evaluate the role of colour-coded duplex scanning in the preoperative assessment of varicose veins of the lower extremity. DESIGN: Open study. SETTING: District hospital. SUBJECTS: 48 patients who were due to be operated on for varicose veins (20 bilateral); 10 were being operated on for the second time. MAIN OUTCOME MEASURES: The planned operation was changed according to the results of the colour-coded duplex scan if they differed from those of physical examination and continuous wave Doppler flow, and its accuracy was verified at operation. RESULTS: The use of colour-coded duplex scanning resulted in a change in the plan of operation in 18 of the 68 legs. Escape points between the superficial and deep venous system would have been left intact in 14, the long saphenous vein would have been stripped unnecessarily in three, and one exploration to find an incompetent perforating vein would have been unnecessary. In 6 of the 10 having reoperations colour-coded duplex scanning showed that the recurrences were caused by incompetent perforating veins; this indicated that ligation of perforating veins had been inadequate at the first operation. In the remaining four the duplex scan showed that the recurrence was caused either by a patent incompetent long saphenous vein (n = 2) or by an incompetent saphenofemoral junction (n = 2). CONCLUSION: Colour-coded duplex scanning is more accurate than physical examination and continuous wave Doppler flow studies in the preoperative assessment of varicose veins of the lower limb.

Value of Duplex scanning in the selection of patients for percutaneous transluminal angioplasty.

Duplex scanning is becoming increasingly important in the diagnosis and follow-up of arterial lesions, though most surgeons and radiologists currently still prefer diagnostic angiography prior to percutaneous transluminal angioplasty (PTA). We performed PTA based on Duplex scanning alone in 31 selected patients during the last 6 months of 1991. Seventeen patients were treated for lower extremity ischemia and 14 for (a)-symptomatic stenosis in a peripheral bypass. Results of Duplex scanning were compared to the finding of PTA to assess the value of Duplex scanning done prior to PTA. Duplex scanning showed 51 lesions eligible for PTA, in 48 of 51 lesions (94%) the location as found with Duplex scanning was in agreement with the findings of the angiogram during PTA. Of a total of 31 patients scheduled for PTA, Duplex scanning predicted the indication for PTA adequately in 26 patients (84%). No complications were seen. Duplex scanning proved to be a valuable tool in the detection of lesions suitable for PTA. Furthermore, puncture site and route can be determined by means of Duplex scanning.

Endarterectomy of the superficial femoral artery: a procedure worth reconsidering.

The preferred management of superficial femoral artery occlusive disease remains unresolved. The oldest technique for restoring vascular continuity, endarterectomy, has been largely replaced by bypass operations and percutaneous transluminal angioplasty. We have continued to perform semi-closed endarterectomy in selected cases and review here a series of 231 consecutive cases in 197 patients treated during the last 10 years. The indication for the endarterectomy was disabling claudication in 186 operations (80%), rest pain in 21 (9%) and gangrene in 24 (11%). The superficial femoral artery abnormality consisted of 1-10 cm occlusion in 52 cases (23%), > 10 cm occlusion in 96 (41%), single stenosis in 21 (9%), multiple stenoses in 28 (12%) and it was unknown in 34 cases (15%). Postoperative mortality was 0.8% with a complication rate of 10%. Five year cumulative primary patency was 71% overall, 75% in patients with disabling claudication, 61% in those with rest pain and 46% in those with gangrene. Eight year patency was 55% (S.E. 5.4%). No difference in 5-year cumulative patency was seen between treatment for stenosis or occlusion (74 and 70%, respectively). The results of earlier studies and the current study raise the question of whether endarterectomy should be the first treatment of choice in obstructive lesions of the superficial femoral artery. The results of endarterectomy are better than can be achieved with angioplasty and compare well with the results of femoropopliteal bypass. Endarterectomy has specific advantages above femoro-popliteal bypass: the autologous saphenous vein is spared for future use and in case of failure of the endarterectomy, femoro-popliteal bypass remains possible.(ABSTRACT TRUNCATED AT 250 WORDS)