WITHDRAWN: Bioresorbable fixation devices for musculoskeletal injuries in adults.

BACKGROUND: Bioresorbable implants for musculoskeletal injuries involving bone and ligaments in adults might have significant advantages compared to the conventionally used non-resorbable metal implants because they lead to a gradual transfer of the mechanical load from the implant to the healing bone and do not require a secondary removal operation. Tissue reactions may present a problem and bioresorbable screws are mechanically not as strong as their metal counterparts. OBJECTIVES: To compare bioresorbable implants to non-resorbable implants with respect to functional outcome, wound infections, other complications and reoperation rate,in the fixation of bone fractures or re-attachment of soft tissue to bone. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (March 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2004), MEDLINE (1966 to February 2004), EMBASE (1988 to February 2004), BL Inside (to February 2004), SIGLE (to February 2004), the metaRegister of Controlled Trials at http//:controlled-trials.com/, and reference lists of articles. SELECTION CRITERIA: Randomised controlled trials (RCTs) and quasi-randomised trials, comparing bioresorbable osteosynthesis with metal osteosynthesis (including titanium and stainless steel implants) were included. DATA COLLECTION AND ANALYSIS: Review authors independently assessed trial quality and extracted data. Data were pooled where relevant and possible. Sub-analyses for specific type of fractures and for specific type of tissue reactions were performed. Requests for more information were sent to trialists. MAIN RESULTS: No significant difference between the bioresorbable and other implants could be demonstrated with respect to functional outcome, infections and other complications. Reoperation rates were lower in some of the groups of people treated with bioresorbable implants. AUTHORS' CONCLUSIONS: In a selected group of compliant patients with simple fractures, the use of bioresorbable fixation devices might be advantageous.

Predictors of Death in Trauma Patients who are Alive on Arrival at Hospital.

OBJECTIVE: To determine which factors predict death occurring in trauma patients who are alive on arrival at hospital Design Prospective cohort study Method Data were collected from 507 trauma patients with multiple injuries, with a Hospital Trauma Index-Injury Severity Score of 16 or more, who were initially delivered by the Emergency Medical Services to the Emergency Department of the University Medical Centre Utrecht (UMCU) during the period 1999-2000. RESULTS: Univariate analysis showed that every year of age increase resulted in a 2% greater risk of death. If the patient had been intubated at the scene of the accident, this risk was increased 4.3-fold. Every point of increase in the Triage Revised Trauma Score (T-RTS) reduced the risk of death by 30%. A similar (but inverse) tendency was found for the HTI-ISS score, with every point of increase resulting in a 5% greater risk of death. There was a clear relationship between the base excess (BE) and hemoglobin (Hb) levels and the risk of death, the latter being increased by 8% for each mmol/l drop in BE, and reduced by 22% for each mmol/l increase in Hb. The risk of death occurring was 2.6 times higher in cases with isolated neurotrauma. These associations hardly changed in the multivariate analysis; only the relation with having been intubated at the scene disappeared. CONCLUSION: The risk of severely injured accident patients dying after arriving in hospital is mainly determined by the T-RTS, age, presence of isolated neurological damage, BE and Hb level. Skull/brain damage and hemorrhage appear to be the most important causes of death in the first 24 h after the accident. The time interval between the accident and arrival at the hospital does not appear to affect the risk of death.

Erratum to Predictors of Death in Trauma Patients who are Alive on Arrival at Hospital.

OBJECTIVE: To determine which factors predict death occurring in trauma patients who are alive on arrival at hospital Design Prospective cohort study Method Data were collected from 507 trauma patients with multiple injuries, with a Hospital Trauma Index-Injury Severity Score of 16 or more, who were initially delivered by the Emergency Medical Services to the Emergency Department of the University Medical Centre Utrecht (UMCU) during the period 1999-2000. RESULTS: Univariate analysis showed that every year of age increase resulted in a 2% greater risk of death. If the patient had been intubated at the scene of the accident, this risk was increased 4.3-fold. Every point of increase in the Triage Revised Trauma Score (T-RTS) reduced the risk of death by 30%. A similar (but inverse) tendency was found for the HTI-ISS score, with every point of increase resulting in a 5% greater risk of death. There was a clear relationship between the base excess (BE) and hemoglobin (Hb) levels and the risk of death, the latter being increased by 8% for each mmol/l drop in BE, and reduced by 22% for each mmol/l increase in Hb. The risk of death occurring was 2.6 times higher in cases with isolated neurotrauma. These associations hardly changed in the multivariate analysis; only the relation with having been intubated at the scene disappeared. CONCLUSION: The risk of severely injured accident patients dying after arriving in hospital is mainly determined by the T-RTS, age, presence of isolated neurological damage, BE and Hb level. Skull/brain damage and hemorrhage appear to be the most important causes of death in the first 24 h after the accident. The time interval between the accident and arrival at the hospital does not appear to affect the risk of death.

Compartment syndrome of the lower leg after surgery in the modified lithotomy position: report of seven cases.

PURPOSE: Acute compartment syndrome is known to develop after trauma or after postischemic revascularization. It also can occur when a patient has been lying in the lithotomy position during prolonged surgery. Methods were searched for the prevention of this iatrogenic complication after a series of seven patients who developed compartment syndrome after surgery at our hospital. METHODS: A series of seven consecutive patients who developed compartment syndrome of the lower leg(s) after abdominoperineal surgical procedures from 1997 to 2002 is presented and so are the lessons learned to prevent this problem. RESULTS: When comparing our experiences with data from literature, the seven patients had the usual risk factors for development of a compartment syndrome: lengthy procedure (>5 hours); decreased perfusion of the lower leg because of Trendelenburg positioning combined with the lithotomy position; and external compression of the lower legs (because of positioning, stirrups, or antiembolism stockings). Measures have been taken to prevent compartment syndrome from developing after prolonged surgery in the lithotomy position. This complication has not occurred again after the introduction of these measures two years ago. CONCLUSIONS: Acute compartment syndrome can be prevented if adequate measures are taken, but after lengthy surgery, maximum alertness for emerging acute compartment syndrome remains indicated. Early diagnosis and treatment by four-compartment fasciotomy is still the only way to prevent irreversible damage.

Use of the less invasive stabilization system (LISS) in patients with distal femoral (AO33) fractures: a prospective multicenter study.

INTRODUCTION: The Less Invasive Stabilization System (LISS) is an internal fixator that can be inserted percutaneously by means of a minimally invasive surgical approach. This paper presents the use of this system exclusively in patients with AO33 distal femoral fractures, a group in which fracture management is often complicated by multiple trauma and soft-tissue damage. MATERIALS AND METHODS: A series of 62 patients (mean age 52 years) with 66 AO33A or C fractures received the LISS implant and were followed prospectively for 12 months. Assessments included the radiographic evaluation of implant placement and healing, measurement of valgus/varus and sagittal joint malalignment, and the assessment of weight-bearing capacity and range of motion. RESULTS: The mean duration of surgery was 85 min (range 40-135 min) for 33A fractures and 149 min (range 50-300 min) for 33C fractures. Postoperative radiographic assessments showed that the LISS implant was positioned correctly in 59 cases (89%). Assessment of valgus/varus alignment showed correct axial alignment in 49 cases (74%), a deviation of 5-10 degrees in 13 cases, and a 10-20 degrees deviation in 1 case. Correct sagittal alignment was observed in 56 cases (85%), 5-10 degrees malalignment in 5 cases, and 10-20 degrees in 2 cases. During the course of the 1-year follow-up, 8 patients (9 fractures) died; 2 other patients were not available for follow-up. Complete fracture healing was achieved in 85% of the followed-up patients. Forty-eight patients were capable of full weight-bearing. After fracture healing, maximum flexion of the injured limb was on average 80% of the range of the uninjured limb. An extension deficit of more than 5 degrees was measured in 3 cases. Of the 62 patients, 14 underwent further operations during the course of follow-up. Of these, 6 required bone grafting and 3 refixation of the implant due to implant loosening. Deep infections requiring several debridements occurred in 2 patients. No complications relating solely to the implant were observed. CONCLUSION: The LISS showed good overall results in the treatment of these difficult fractures. It is a good alternative to conventional extramedullary and intramedullary stabilizing techniques, especially in more complex fracture situations.

The diagnostic value of intracompartmental pressure measurement, magnetic resonance imaging, and near-infrared spectroscopy in chronic exertional compartment syndrome: a prospective study in 50 patients.

BACKGROUND: Patients with chronic exertional compartment syndrome have pain during exercise that usually subsides at rest. History and physical examination may raise suspicion of the syndrome; diagnosis is usually confirmed with intracompartmental pressure measurement after exercise. Studies have shown that magnetic resonance imaging and near-infrared spectroscopy have diagnostic ability in this syndrome. HYPOTHESIS: Magnetic resonance imaging and near-infrared spectroscopy can be used to diagnose chronic exertional compartment syndrome. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: Patients were enrolled if there was clinical suspicion of chronic exertional compartment syndrome, and a fasciotomy was performed based on this suspicion. Before fasciotomy, intracompartmental pressure, near-infrared spectroscopy, and magnetic resonance imaging data were collected during and after exercise on a treadmill. Near-infrared spectroscopy and intracompartmental pressure values were recorded in the same manner after fasciotomy. Retrospective proof that diagnosis of the syndrome had been correct was the absence of exertional complaints from the preoperative examination during exercise at postfasciotomy visit. RESULTS: Fifty patients (100 legs) participated in the prefasciotomy visit; 3 refused fasciotomy; 2 were lost to follow-up. Of 45 patients who completed the postfasciotomy visit, the diagnosis of chronic exertional compartment syndrome was retrospectively confirmed in 42 patients and discarded in 3 patients. The sensitivity for intracompartmental pressure (cutoff point, 35 mmHg) found in this study was 77% (67%-86%, exact 95% confidence interval), lower than estimates from the literature (93%). The sensitivity (previously defined cutoff) for near-infrared spectroscopy was 85% (76%-92%, exact 95% confidence interval), validating the estimate found in the literature (85%). Sensitivity of magnetic resonance imaging was comparable to that of intracompartmental pressure and near-infrared spectroscopy; associated specificity at a given sensitivity appeared to be lower with magnetic resonance imaging. CONCLUSION: This study validates the sensitivity of near-infrared spectroscopy and provides estimates for the sensitivity and specificity of magnetic resonance imaging in chronic exertional compartment syndrome in a large group of patients. The sensitivity of noninvasive near-infrared spectroscopy is clinically equivalent to that of invasive intracompartmental pressure measurements.

Near infrared spectroscopy in the diagnosis of chronic exertional compartment syndrome.

BACKGROUND: Patients with chronic exertional compartment syndrome (CECS) experience pain during exercise. An abnormal increase in intracompartmental pressure (ICP) leads to impaired local tissue perfusion resulting in ischemia and pain. At cessation of exercise, pain subsides. Diagnosis is confirmed through postexercise ICP. Near infrared spectroscopy (NIRS) can measure tissue oxygen saturation (StO(2)) noninvasively. HYPOTHESIS: NIRS can diagnose CECS by showing tissue deoxygenation. STUDY DESIGN: Prospective, nonrandomized clinical trial. METHOD: Volunteers completed a standardized exercise protocol. Those suspected of CECS did so preoperatively and postoperatively. StO(2) and ICP were monitored. Data were compared between volunteers and patients and prefasciotomy and postfasciotomy. RESULTS: Significant differences between the StO(2) values of volunteers and patients with CECS were found. Average peak exercise StO(2) value for those with CECS was lower than for the healthy (27 versus 56, P <.05). Patients showed more absolute and percentage change between baseline and peak exercise StO(2) (absolute: 60 versus 35, P <.05; percentage: 67 versus 38, P <.05). StO(2) values in legs with confirmed CECS returned to normal range postfasciotomy. All changes differed significantly with preoperative values. CONCLUSION: StO(2) can distinguish healthy from diseased legs. This study provides evidence supporting NIRS as a noninvasive, painless alternative to ICP in the diagnosis of CECS.

Pressure ulcers in intensive care patients: a review of risks and prevention.

OBJECTIVE: Review of the literature concerning pressure ulcers in the intensive care setting. DATA SOURCE AND STUDY SELECTIONS: Computerized databases (Medline from 1980 until 1999 and CINAHL from 1982 until 1999). The indexing terms for article retrieval were: "pressure ulcers", "pressure sores", "decubitus", and "intensive care". Nineteen articles met the selection criteria, and seven more were found from the references of these articles. One thesis was also analyzed. RESULTS: Data on prevention, incidence, and costs of pressure ulcers in ICU patients are scarce. Overall there are no conclusive studies on the identification of pressure ulcer risk factors. None of the existing risk-assessment scales was developed especially for use in ICU patients. It is highly questionable to what extent these scales can be used in this setting as they are not even reliable in "standard care". The following risk factors might play a role in pressure ulcer development: duration of surgery and number of operations, fecal incontinence and/or diarrhea, low preoperative protein and albumin concentrations, disturbed sensory perception, moisture of the skin, impaired circulation, use of inotropic drugs, diabetes mellitus, too unstable to turn, decreased mobility, and high APACHE II score. The number of patients per study ranged from 5 from 638. The definition of "pressure ulcer" varied widely between authors or was not mentioned. CONCLUSIONS: Meaningful comparison cannot be made between the various studies because of the use of different grading systems for pressure ulcers, different methods of data collection, different (or lack of) population characteristics, unreported preventive measures, and the use of different inclusion and exclusion criteria. There is a need for well-conducted studies covering all these aspects.