Outcomes of a standardized surgical and rehabilitation program in transtibial amputation for peripheral vascular disease: a prospective cohort study.

OBJECTIVE: To study the outcomes of a new surgical and rehabilitation program for initial unilateral transtibial amputation in patients with peripheral vascular disease. The program consists of sagittal incision, rigid dressing, compression therapy using silicone liner, and direct manufacturing prosthetic technique. DESIGN: A prospective cohort study with 1-yr follow-up. RESULTS: Of the 217 consecutive patients with peripheral vascular disease who underwent transtibial amputation (mean age, 77 yrs; 51% diabetic; 116 could walk before amputation), 119 (55%) were fitted with a prosthesis at a median time of 41 (range, 12-147) days after amputation. Of the prosthetic recipients, 76 (64%) obtained good function with the prosthesis within 6 mos. Within 1 yr, reamputation was performed on 8.2%, and contralateral amputation was performed on 5.5%. The 90-day mortality was 24% (53 patients). The total 1-yr mortality was 40% (86 patients): 17% among patients who received a prosthesis and 67% among those who did not receive a prosthesis or had undergone reamputation. CONCLUSIONS: Following this standardized surgical and rehabilitation program, prosthetic fitting was achieved in more than half of transtibial amputees, almost two-thirds of prosthetic recipients obtained good function, and the reamputation rate was low. Comparison with outcomes of alternative strategies is needed.

Pneumatic wound compression after hip fracture surgery did not reduce postoperative blood transfusion: A randomized controlled trial involving 292 fractures.

BACKGROUND AND PURPOSE: Patients with fracture of the proximal femur often undergo blood transfusion. A pneumatic compression bandage has been shown to reduce transfusion after primary hip arthroplasty for osteoarthritis. In this randomized trial, we evaluated the efficacy of this bandage following surgery for hip fracture. PATIENTS AND METHODS: 288 patients, 50 years or older with 292 fractured hips treated with hemiarthroplasty or internal fixation (except pinning), were randomized to an experimental group with pneumatic wound compression applied after surgery (n = 138) and a control group with the same dressing but no compression (n = 154). Transfusion threshold was blood hemoglobin below 100 g/L. The primary outcome measures were the number of blood units and the proportion of patients transfused after surgery. RESULTS: The primary outcome measures were similar in both groups. The mean number of postoperatively transfused blood units was 1.3 in the compression group and 1.1 in the non-compression group. Blood transfusion was given to 84 patients (62%) in the compression group and to 85 patients (55%) in the non-compression group. INTERPRETATION: Pneumatic wound compression does not reduce the need for transfusion after hip fracture surgery.

Open compared with 2-portal endoscopic carpal tunnel release: a 5-year follow-up of a randomized controlled trial.

PURPOSE: The purpose of this investigation was to extend the previously reported short-term randomized trial of open and endoscopic carpal tunnel release in patients with carpal tunnel syndrome (CTS) to compare outcomes 5 years after surgery. METHODS: In a single-center randomized controlled trial, 128 patients (25 to 60 years) with clinically diagnosed and electrophysiologically confirmed idiopathic CTS were randomized immediately before surgery to open or 2-portal endoscopic release. The outcome measures included the validated CTS questionnaire's symptom severity and functional status scales (scored from 1 to 5) completed at baseline and 1 year postoperatively. At the extended follow-up of the trial 5 years after surgery, 2 patients had died and the other 126 participants (63 patients in each group) completed the CTS questionnaire. RESULTS: At the 5-year follow-up no difference between the groups was found in the CTS symptom severity score. The mean (SD) score in the open group was 1.42 (0.7) and in the endoscopic group was 1.45 (0.7), and the mean difference in score change from baseline was 0.03 (95% confidence interval, -0.21 to 0.27). Between 1 year and 5 years postoperatively, the CTS symptom severity score had deteriorated by at least 0.4 point in 9 patients in the open group and in 10 patients in the endoscopic group. The mean (SD) CTS functional status score was 1.29 (0.5) in the open group and 1.30 (0.5) in the endoscopic group. At 5 years, 11 patients in the open group and 10 patients in the endoscopic group reported persistent pain in the scar or proximal palm. Three patients in each group had repeat surgery on the operated hand because of persistent or recurrent symptoms. CONCLUSIONS: The improvements in symptoms of CTS and hand-related disability 5 years after open and 2-portal endoscopic carpal tunnel release were equivalent. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Incidence of lower-limb amputation in the diabetic and nondiabetic general population: a 10-year population-based cohort study of initial unilateral and contralateral amputations and reamputations.

OBJECTIVE: The purpose of this study was to compare the incidence of vascular lower-limb amputation (LLA) in the diabetic and nondiabetic general population. RESEARCH DESIGN AND METHODS: A population-based cohort study was conducted in a representative Swedish region. All vascular LLAs (at or proximal to the transmetatarsal level) performed from 1997 through 2006 were consecutively registered and classified into initial unilateral amputation, contralateral amputation, or reamputation. The incidence rates were estimated in the diabetic and nondiabetic general population aged > or =45 years. RESULTS: During the 10-year period, LLA was performed on 62 women and 71 men with diabetes and on 79 women and 78 men without diabetes. The incidence of initial unilateral amputation per 100,000 person-years was 192 (95% CI 145-241) for diabetic women, 197 (152-244) for diabetic men, 22 (17-26) for nondiabetic women, and 24 (19-29) for nondiabetic men. The incidence increased from the age of 75 years. Of all amputations, 74% were transtibial. The incidences of contralateral amputation and of reamputation per 100 amputee-years in diabetic women amputees were 15 (7-27) and 16 (8-28), respectively; in diabetic men amputees 18 (10-29) and 21 (12-32); in nondiabetic women amputees 14 (7-24) and 18 (10-28); and in nondiabetic men amputees 13 (6-22) and 24 (15-35). CONCLUSIONS: In the general population aged > or =45 years, the incidence of vascular LLA at or proximal to the transmetatarsal level is eight times higher in diabetic than in nondiabetic individuals. One in four amputees may require contralateral amputation and/or reamputation.

Comparison of vacuum-formed removable rigid dressing with conventional rigid dressing after transtibial amputation: similar outcome in a randomized controlled trial involving 27 patients.

BACKGROUND AND PURPOSE: Following transtibial amputation, a rigid dressing of plaster of Paris has been reported to have advantages over a soft dressing regarding wound healing and reduction of edema, but use of the former may be limited by difficulties in application and in gaining access to the wound. An easily applicable and removable vacuum-formed rigid dressing (ORD) has recently been introduced. We compared the ORD with a conventional rigid plaster of Paris dressing with regard to wound healing, time to fitting of a prosthesis, and function with the prosthesis. METHOD: Patients undergoing transtibial amputation for peripheral vascular disease were randomized at surgery to receive ORD (O) or conventional rigid dressing (C) for 5 to 7 days, followed by compression therapy using silicone liner. The primary outcome measure was time to prosthetic fitting and secondary outcome measures included function with the prosthesis 3 months after amputation, measured with the Locomotor Capability Index (LCI) and the Timed "Up and Go" (TUG) test. All patients received prostheses with a total surface-bearing socket. RESULTS: Of 27 patients randomized to one or other dressing (15 O and 12 C), prosthetic fitting was achieved in 23 patients (mean age 76 (43-91) years; 13 (9 men) in the O group and 10 (5 men) in the C group). Wound healing was similar in both groups. Mean time to prosthetic fitting was 37 (26-54) days in the O group and 34 (21-47) days in the C group (adjusted mean difference 3, 95% CI: -3-9). At 3 months, mean LCI was 28 (6-42) in the O group and 25 (2-41) in the C group (mean difference -0.1, 95% CI: -8.5-8.2). Mean TUG was 41 (10-92) seconds and 29 (10-47) seconds, respectively (mean difference 14, 95% CI:-2-30). INTERPRETATION: The vacuum-formed rigid dressing appears to give results similar to those of the conventional rigid dressing regarding time to prosthetic fitting and patient's function with prosthesis.

Wrist-bridging versus non-bridging external fixation for displaced distal radius fractures: a randomized assessor-blind clinical trial of 38 patients followed for 1 year.

BACKGROUND: Non-bridging external fixation has been introduced to achieve better fracture fixation and functional outcomes in distal radius fractures, but has not been specifically evaluated in a randomized study in the elderly. The purpose of this trial was to compare wrist-bridging and non-bridging external fixation for displaced distal radius fractures. METHOD: The inclusion criteria were women >/= 50 or men >/= 60 years, acute extraarticular or intraarticular fracture, and dorsal angulation of >/=20 degrees or ulnar variance >/= 5 mm. The patients completed the disabilities of the arm, shoulder and hand (DASH) questionnaire before and at 10, 26 and 52 weeks after surgery. Pain (visual analog scale), range of motion and grip strength were measured by a blinded assessor. RESULTS: 38 patients (mean age 71 years, 31 women) were randomized at surgery (19 to each group). Mean operating time was shorter for wrist-bridging fixation by 10 (95% CI 3-17) min. There was no significant difference in DASH scores between the groups. No statistically significant differences in pain score, range of motion, grip strength, or patient satisfaction were found. The non-bridging group had a significantly better radial length at 52 weeks; mean difference in change in ulnar variance from baseline was 1.4 (95% CI 0.1-2.7) mm (p = 0.04). Volar tilt and radial inclination were similar in both groups. INTERPRETATION: For moderately or severely displaced distal radius fractures in the elderly, non-bridging external fixation had no clinically relevant advantage over wrist-bridging fixation but was more effective in maintaining radial length.

Outcomes of endoscopic surgery compared with open surgery for carpal tunnel syndrome among employed patients: randomised controlled trial.

OBJECTIVES: To compare endoscopic and open carpal tunnel release surgery among employed patients with carpal tunnel syndrome. DESIGN AND SETTING: Randomised controlled trial at a single orthopaedic department. PARTICIPANTS: 128 employed patients aged 25-60 years with clinically diagnosed and electrophysiologically confirmed idiopathic carpal tunnel syndrome. MAIN OUTCOME MEASURES: The primary outcome was severity of postoperative pain in the scar or proximal palm and the degree to which pain or tenderness limits activities, each rated on a 4 point scale, transformed into a combined score of 0 (none) to 100 (severe pain or tenderness causing severe activity limitation). The secondary outcomes were length of postoperative work absence, severity of symptoms of carpal tunnel syndrome and functional status scores, SF-12 quality of life score, and hand sensation and strength (blinded examiner); follow-up at three and six weeks and three and 12 months. RESULTS: 63 patients were allocated to endoscopic surgery and 65 patients to open surgery, with no withdrawals or dropouts. Pain in the scar or proximal palm was less prevalent or severe after endoscopic surgery than after open surgery but the differences were generally small. At three months, pain in the scar or palm was reported by 33 patients (52%) in the endoscopic group and 53 patients (82%) in the open group (number needed to treat 3.4, 95% confidence interval 2.3 to 7.7) and the mean score difference for severity of pain in scar or palm and limitation of activity was 13.3 (5.3 to 21.3). No differences between the groups were found in the other outcomes. The median length of work absence after surgery was 28 days in both groups. Quality of life measures improved substantially. CONCLUSIONS: In carpal tunnel syndrome, endoscopic surgery was associated with less postoperative pain than open surgery, but the small size of the benefit and similarity in other outcomes make its cost effectiveness uncertain.