Dutch Guideline on Knee Arthroscopy Part 2: non-meniscus intra-articular knee injury: a multidisciplinary review by the Dutch Orthopaedic Association.

Background and purpose - A guideline committee of medical specialists and a physiotherapist was formed on the initiative of the Dutch Orthopedic Association (NOV) to update the Guideline Arthroscopy of the Knee: Indications and Treatment 2010. This next Guideline was developed between June 2017 and December 2019. In part 1 we focused on the meniscus; this part 2 addresses all other aspects of knee arthroscopy.Methods - The guideline was developed in accordance with the criteria of the AGREE instrument (AGREE II: Appraisal of Guidelines for Research and Evaluation II) with support of a professional methodologist from the Dutch Knowledge Institute of Medical Specialists. The scientific literature was searched and systematically analyzed. Conclusions and recommendations were formulated according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. Recommendations were developed considering the balance of benefits and harms, the type and quality of evidence, the values and preferences of the people involved, and the costs.

Dutch Guideline on Knee Arthroscopy Part 1, the meniscus: a multidisciplinary review by the Dutch Orthopaedic Association.

Background and purpose - A guideline committee of medical specialists and a physiotherapist was formed on the initiative of the Dutch Orthopedic Association (NOV) to update the guideline Arthroscopy of the Knee: Indications and Treatment 2010. This next guideline was developed between June 2017 and December 2019. In this Part 1 we focus on the meniscus, in Part 2 on all other aspects of knee arthroscopy.Methods - The guideline was developed in accordance with the criteria of the AGREE instrument (AGREE II: Appraisal of Guidelines for Research and Evaluation II) with support of a professional methodologist from the Dutch Knowledge Institute of Medical Specialists. The scientific literature was searched and systematically analyzed. Conclusions and recommendations were formulated according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. Recommendations were developed considering the balance of benefits and harms, the type and quality of evidence, the values and preferences of the people involved, and the costs.

Association of pre-treatment radiographic characteristics of calcaneal fractures on patient-reported outcomes.

PURPOSES: Calcaneal fractures are known to influence patients' quality of life negatively. The type of calcaneal fracture might have a relation with the patient outcome. To inform patients in an early stage on how their calcaneal fracture may affect their lives, knowledge of the fracture characteristics is necessary. This study evaluates the association of type of calcaneal fracture, measurement of conventional radiograph angles, and the Sanders classification with patient-reported outcomes. MATERIAL AND METHODS: This is a retrospective study based on a prospective trauma database including all patients aged 16 years or older with a calcaneal fracture admitted in one of the participating trauma level I or II hospitals. Patients, trauma, and fracture characteristics were collected. The conventional radiographs were evaluated in which type of fracture, and Böhler's, Gissane's, and calcaneal compression angles were determined. Also, the CT images were classified according to Sanders. In addition, displaced intra-articular calcaneal fractures were separately analyzed. A questionnaire was sent to the included patients that consisted of the EQ-6D, patient-specific characteristics, satisfaction with foot appearance and wearable shoe range, complications, and capability to work. RESULTS: A total of 396 patients with 442 calcaneal fractures were eligible for follow-up. Two hundred fifteen patients with 246 calcaneal fractures participated. Patients with a calcaneal fracture into the talar surface reported a worse quality of life (p = 0.010), were less satisfied with their feet (p < 0.001), and had more complications (p = 0.001-0.006); extra-articular fractures had significantly opposite result. A negative Böhler's or calcaneal compression angle was related with unfavourable outcomes. Sanders classification was not related with any patient-reported outcome. CONCLUSION: Our study implies that patients with an intra-articular calcaneal fracture into the talar surface have a lower health-related quality of life, will be less satisfied with the outcome of their feet, and have more complications compared to patients with other type of calcaneal fractures. Furthermore, the Sanders classification was not associated with the patient-reported outcomes.

Weight-bearing and mobilization in the postoperative care of ankle fractures: a systematic review and meta-analysis of randomized controlled trials and cohort studies.

PURPOSE: To determine the effectiveness and safety of interventions used for rehabilitation after open reduction and internal fixation of ankle fractures. METHODS: A systematic review and meta-analysis was performed using both randomized trials and cohort studies. The effect of mobilization, weight-bearing, and unprotected weight-bearing as tolerated on postoperative recovery was compared using the Olerud Molander score, return to work/daily activities, and the rate of complications. RESULTS: A total of 25 articles were included. Ankle exercises resulted in earlier return to work and/or daily activities compared to immobilization (mean difference (MD) -20.76 days; 95% confidence interval (CI) -40.02 to -1.50). There was no difference in the rate of complications between exercises and immobilization (risk ratio (RR) 1.22; 95% CI 0.60 to 2.45) or between early and late weight-bearing (RR 1.26; 95%CI 0.56 to 2.85). INTERPRETATION: Results of this meta-analysis show that following ankle surgery, 1) active exercises accelerate return to work and daily activities compared to immobilization, 2) early weight-bearing tends to accelerate return to work and daily activities compared to late weight-bearing. Active exercises in combination with immediate weight-bearing may be a safe option.

Treatment of torus fractures in the forearm in children using bandage therapy.

BACKGROUND: In a torus fracture, there is an intact cortex at the side of the fracture which gives more intrinsic stability than in greenstick fractures, where one side of the cortex is disrupted. Two previously done studies compared soft bandage therapy (BT) with cast therapy in the treatment of torus forearm fractures in children and showed this is safe and does not cause any complications. The aim of our study was to validate these studies by treating all patients presenting to emergency department with a torus fracture with BT and investigate whether any complications occur. METHODS: At a single-center from January 2009 to June 2009, all patients with an impacted greenstick fracture of the distal radius and/or ulna without exception were treated using BT. Primary endpoint was secondary angulation; secondary endpoint was pain on Visual Analog Score. RESULTS: Seven patients were misdiagnosed as torus fractures but were actually greenstick fractures and had to be excluded. A total of 49 patients with a torus fracture were included in statistical analysis. No fracture displacement was seen. Four patients needed an additional nonsteroidal antiinflammatory drug or an antalgic plaster cast. The overall Visual Analog Score of the patients was lower than in previous studies. CONCLUSIONS: Soft BT is safe in all children without risk of further angulation and with a pain score equal to cast therapy. Important is that misdiagnosis of the torus fracture at initial presentation should be minimized.

The proximal femur nail antirotation: an identifiable improvement in the treatment of unstable pertrochanteric fractures?

BACKGROUND: The optimal surgical treatment of patients with an unstable extracapsular proximal femoral fracture is yet to be found. From the biomechanical point of view, the use of an intramedullary device in combination with a dynamic femoral head/neck stabilization implant seems an optimal technique. One of these intramedullary devices, the Proximal Femoral Nail (PFN), has several drawbacks in practice. The Proximal Femur Nail Antirotation (PFNA) has been designed to address these. We hypothesized that the placement of one femoral head/neck fixation device in the PFNA would improve positioning of the implant in the femoral head compared with the PFN and reduce the number of reoperations in both short and long term. METHODS: We followed 157 consecutive patients with unstable trochanteric fractures (Arbeitsgemeinschaft für Osteosynthesefragen classification 31.A.2 and A.3) treated with a PFN or a PFNA for 1 year. The radiologic position of the implant was evaluated, and the postoperative local and systemic complications were registered. RESULTS: The position of the femoral head/neck stabilization implant was "good" in 39 (44.8%) patients in the PFN group and 23 (32.9%) patients in the PFNA group; the position was "acceptable" in 30 (34.5%) versus 33 (47.1%) patients, and in 18 (20.7%) versus 14 (20%) patients, the position was "poor" (p = 0.277). Because of implant-related complications, three patients in the PFN group and four patients in the PFNA group needed an early reoperation (p = 0.136). A late reoperation because of implant-related complications was performed in 13 patients in the PFN group and in three in the PFNA group (p = 0.016). CONCLUSIONS: This study shows that osteosynthesis with the PFNA does not improve the position of the implant in the femoral head compared with the PFN. However, the risk of a secondary complication and the necessity of a late reoperation are significantly higher in patients treated with a PFN compared with patients treated with a PFNA.

Treatment of impacted greenstick forearm fractures in children using bandage or cast therapy: a prospective randomized trial.

BACKGROUND: To evaluate the relative risks and advantages of using soft bandage therapy (BT) for impacted greenstick fractures of the distal forearm compared with cast therapy (CT). METHODS: At a single center from September 2005 to October 2006 all patients with an impacted greenstick fracture were randomized to BT or CT. RESULTS: A total of 92 patients were randomized and assigned. No fracture displacement was seen. Three patients from the BT group were converted to standard treatment. A significant difference in pain was seen between both groups after 1 week in favor of the CT group. Discomfort was significantly less in the BT group compared with the CT group. After 4 weeks, the wrist function was significantly better in the BT group. After 6 weeks, the wrist functions of both the groups were comparable. CONCLUSIONS: BT for impacted greenstick fractures of the distal forearm is a safe technique, patients treated with bandage suffer greater pain at the start of the treatment, are able to return to normal activities sooner, and have less discomfort when compared with the standard CT.

Surgical repair of a gunshot injury to the left carotid artery: case report and review of literature.

We present a case of a 37-year-old man who sustained a single gunshot wound (penetrating zones I and II) and internal carotid artery injury. Optimal evaluation and management of vascular injury remains controversial. Literature on the operative techniques of carotid artery injuries is reviewed.

Treatment of traumatic thoracolumbar spine fractures: a multicenter prospective randomized study of operative versus nonsurgical treatment.

STUDY DESIGN: Multicenter prospective randomized trial. OBJECTIVE: To test the hypotheses that thoracolumbar AO Type A spine fractures without neurologic deficit, managed with short-segment posterior stabilization will show an improved radiographic outcome and at least the same functional outcome as compared with nonsurgically treated thoracolumbar fractures. SUMMARY OF BACKGROUND DATA: There are various opinions regarding the ideal management of thoracolumbar Type A spine fractures without neurologic deficit. Both operative and nonsurgical approaches are advocated. METHODS: Patients were randomized for operative or nonsurgical treatment. Data sampling involved demographics, fracture classifications, radiographic evaluation, and functional outcome. RESULTS: Sixteen patients received nonsurgical therapy, and 18 received surgical treatment. Follow-up was completed for 32 (94%) of the patients after a mean of 4.3 years. At the end of follow-up, both local and regional kyphotic deformity was significantly less in the operatively treated group. All functional outcome scores (VAS Pain, VAS Spine Score, and RMDQ-24) showed significantly better results in the operative group. The percentage of patients returning to their original jobs was found to be significantly higher in the operative treated group. CONCLUSIONS: Patients with a Type A3 thoracolumbar spine fracture without neurologic deficit should be treated by short-segment posterior stabilization.

Spine fractures caused by horse riding.

STUDY DESIGN: Retrospective study and review of literature. OBJECTIVES: Study of demographic data concerning spinal fractures caused by horse riding, classification of fractures according to the AO and Load Sharing classifications, evaluation of mid-term radiological results and long-term functional results. METHODS: A review of medical reports and radiological examinations of patients presented to our hospital with horse riding-related spine fractures over a 13-year period; long-term functional follow-up is performed using the Roland Morris Disability Questionnaire (RMDQ-24). RESULTS: Thirty-six spine fractures were found in 32 patients. Male to female ratio is 1:7. Average age is 33.7 years (8-58 years). The majority of the fractures (78%) are seen at the thoracolumbar junction Th11-L2. All but two patients have AO type A fractures. The average Load Sharing Classification score is 4.9 (range 3-9). Neurological examinations show ASIA/Frankel E status for all patients. Surgical treatment is performed on ten patients. Mean follow-up for radiological data is 15 months (range 3-63). Functional follow-up times range from 1 to 13 years with an average follow-up of 7.3 years. Mean RMDQ-24 score for all patients is 5.5 (range: 0-19), with significantly different scores for the non-operative and surgical group: 4.6 vs 8.1. Twenty-two percent of the patients have permanent occupational disabilities and there is a significant correlation between occupational disability and RMDQ-24 scores. CONCLUSIONS: Not only are short-term effects of spine fractures caused by horse riding substantial but these injuries can also lead to long-term disabilities.