[Infection of a hip prosthesis after dry needling]. / Infectie van een heupprothese na 'dry needling'.

A 57-year-old patient presented to the orthopaedic department with hip pain 7 months after hip replacement and two weeks after dry needling by a physiotherapist. Dry needling is used by physiotherapists to treat pain and stiffness. In the Netherlands, there are no clear guidelines or contra-indications described for this treatment. The surgical scar of our patient showed signs of inflammation for which debridement and irrigation were performed. Tissue samples showed positive bacterial cultures and the patient was treated with antibiotics. One week after completing this treatment, the infection returned. Debridement and irrigation were repeated and antibiotic treatment was recommenced. Three months later, the patient showed no signs of infection with the prosthesis still in situ. Although there is no strong evidence for a causal relationship between dry needling and the infection, dry needling should be used carefully in patients with a joint replacement, due to the increased risk of infection.

Long-term results of ankle fractures with a posterior malleolar fragment.

The aim of this study was to evaluate 1) long-term results of ankle fractures with a posterior malleolar fragment, and 2) the need for fixation of fragments smaller than 25%. Forty-five patients with ankle fractures and a posterior malleolar fragment were evaluated. Mean follow-up was 13 years (range, 2-24). The size and fixation of the fragment were registered. Outcome was assessed using an Ankle Fracture Scoring System (maximum: 150 points), a 10-point Numeric Scale for Pain (1 = no pain, 10 = unbearable pain) and an OsteoArthritis Score (0 = no osteoarthritis, 3 = severe osteoarthritis). The mean Ankle Fracture Scoring System, Numeric Scale for Pain and Osteoarthritis-score were 124, 2.5, and 1.2, respectively. The mean size of fixated fragments was significantly larger than that of nonfixated fragments (30% versus 16%). Those patients in which the posterior malleolar fragment was fixated did not have a statistically significant better outcome than those patients in which the fragments were not fixated (Ankle Fracture Scoring System: 119 versus 126, Numeric Scale for Pain: 2.6 versus 2.4, Osteoarthritis-score: 1.0 versus 1.2). There was no significant correlation between outcome and size of unfixated fragments. Fracture-dislocation was seen more often in combination with larger fragments (24% versus 15%) and resulted in statistically significant worse long-term outcome than nondislocated fractures, except for pain (Ankle Fracture Scoring System: 115 versus 134, Osteoarthritis-score: 1.7 versus 0.8). In conclusion, patients showed good results after 13 years follow-up and there was no evidence for the need for fixation of fragments smaller than 25%.

Open reduction and internal fixation of three and four-part fractures of the proximal part of the humerus.

BACKGROUND: Controversy persists concerning the preferred treatment of displaced fractures of the proximal part of the humerus. The present study was undertaken to evaluate the results of open reduction and internal fixation of three and four-part fractures of the proximal part of the humerus and the functional limitations of patients in whom avascular necrosis of the humeral head develops as a complication of this fracture. METHODS: We assessed the intermediate and long-term results for sixty patients with a three or four-part fracture of the proximal part of the humerus who had undergone open reduction and internal fixation with cerclage wires or a T-plate. The Constant score and a visual analog score for pain were calculated, and radiographs of the proximal part of the humerus were evaluated. RESULTS: After an average of ten years of follow-up, fifty-two patients (87%) had a good or excellent result on the basis of the Constant score whereas eight patients (13%) had a poor result. Fifty-one patients (85%) were satisfied with the result at the time of the most recent examination. Twenty-two patients (37%) had development of avascular necrosis of the humeral head, and seventeen (77%) of these twenty-two patients had a good or excellent Constant score. CONCLUSIONS: Open reduction and internal fixation with cerclage wires or a T-plate yields good functional results in most patients. This option should be considered even for patients with fracture-dislocation patterns that are associated with a high risk for avascular necrosis of the humeral head, as this complication did not preclude a good result.

[No positive effect of preoperative exercise therapy and teaching in patients to be subjected to hip arthroplasty]. / Geen positief effect van preoperatieve oefentherapie en instructie bij patiënten die heupartroplastiek zullen ondergaan.

OBJECTIVE: To evaluate the benefits of preoperative physical therapy and instruction of patients with primary coxarthrosis to be subjected to a total hip arthroplasty. SETTING: University Hospital Maastricht. DESIGN: Controlled trial. MATERIAL AND METHOD: During 14 months the effects were measured of preoperative physical therapy and instruction of 64 patients divided into two populations; one group (n = 31) received preoperative instruction and physical therapy, the other did not (n = 33). Effects were measured with the Visual Analog Scale, the Harris Hip Score and the days patients could stand, walk, climb a stair and be discharged. RESULTS: The Harris Hip Score showed a significant difference (p < 0.05) favouring the instructed group on day 14 after the operation and at the moment the patients were discharged. The other parameters showed no significant differences between the groups. Differentiation by age, gender and type of arthroplasty showed the same results. CONCLUSION: Preoperative exercise and instruction is not useful for patients who in the near future will be treated with a total hip arthroplasty for primary coxarthrosis.