Acute burn care in resource-limited settings: A cohort study on treatment and outcomes in a rural regional referral hospital in Tanzania.

BACKGROUND: Only a few papers are published on the safety and effectiveness of acute burn care in low-income countries. A cohort study was therefore carried out to determine such outcomes. METHODS: The study was conducted in a rural Tanzanian hospital in 2017-2018. All patients admitted with burns were eligible. Complications were scored during admission as an indication for safety. Survivors of severe burn injuries were evaluated for time of reepithelialization, graft take, disability (WHODAS2.0) and quality of life (EQ5D-3L) up to 3 months post-injury, as an indication of effectiveness. RESULTS: Patients presented on average at 5 days after injury (SD 11, median 1, IQR 0-4). Three patients died at admission. The remaining 79 were included in the cohort. Their median age was 3 years (IQR 2-9, range 0.5-49), mean TBSA burned 12% (SD10%) and mortality rate 11.4%. No surgery-related mortality or life-threatening complications were observed. Skin grafting was performed on 29 patients at a delayed stage (median 23 days, IQR 15-47). Complications of skin grafts included partial (25% of procedures) and complete graft necrosis (8% of procedures). The mean time to reepithelialization was 52 (SD 42) days after admission. Disability and quality of life improved from admission to 3 months after injury (p<0.001, p<0.001, respectively). CONCLUSION: In this resource-limited setting patients presented after a delay and with multiple complications. The mortality during the first two weeks after admission was high. Surgery was found to be safe and effective. A significant improvement in disability and quality of life was observed.

The development of burn scar contractures and impact on joint function, disability and quality of life in low- and middle-income countries: A prospective cohort study with one-year follow-up.

OBJECTIVE: The aim of this study was to assess the development of burn scar contractures and their impact on joint function, disability and quality of life in a low-income country. METHODS: Patients with severe burns were eligible. Passive range of motion (ROM) was assessed using lateral goniometry. To assess the development of contractures, the measured ROM was compared to the normal ROM. To determine joint function, the normal ROM was compared to the functional ROM. In addition, disability and quality of life (QoL) were assessed. Assessments were from admission up to 12 months after injury. RESULTS: Thirty-six patients were enrolled, with a total of 124 affected joints. The follow-up rate was 83%. Limited ROM compared to normal ROM values was observed in 26/104 joints (25%) at 12 months. Limited functional ROM was observed in 55/115 joints (48%) at discharge and decreased to 22/98 joints (22%) at 12 months. Patients who had a contracture at 12 months reported more disability and lower QoL, compared to patients without a contracture (median disability 0.28 versus 0.17 (p = 0.01); QoL median 0.60 versus 0.76 (p = 0.001)). Significant predictors of developing joint contractures were patient delay and the percentage of TBSA deep burns. CONCLUSION: The prevalence of burn scar contractures was high in a low-income country. The joints with burn scar contracture were frequently limited in function. Patients who developed a contracture reported significantly more disability and lower QoL. To limit the development of burn scar contractures, timely access to safe burn care should be improved in low-income countries.

Patient-Reported Long-Term Outcomes After Free Vascularized Fibula Graft in Spinal Reconstruction: a 24-year Cohort.

PURPOSE: The use of free vascularized fibula grafts (FVFG) in complex spinal deformity surgery intends to allow for life-long stability of the spine with good long-term clinical outcome. However, these long-term outcomes of this technique are still lacking. The objective of this study is to report the long-term postoperative outcomes and establish the long-term viability of this method for spinal reconstruction. METHODS: A retrospective cohort study was conducted in all patients who underwent spinal reconstructive surgery utilizing a FVFG at a tertiary medical centre. Questionnaires taken from the participants were the Numeric Pain Rating Scale (NPRS), Oswestry Low Back Pain Disability (also known as Oswestry Disability Index (ODI)), Scoliosis Research Society 22r (SRS-22), the EQ-5D-5L and a self-assembled questionnaire regarding donor site comorbidities and patient satisfaction. RESULTS: Over a period of 24 years (1995-2019), we used FVFG for spinal reconstruction in 31 patients. A total of 25 patients were included in this study, 8 patients were deceased at the time of this study, and sixteen patients responded to the questionnaires. Patient satisfaction was rated 6.8 out of 10, the average SRS-22r score was 3.6, EQ-5D-5L score was 0.725, and the ODI score showed a minimal disability (0-20%) postoperatively. Overall complication-free survival was 8.9 years. Nine patients underwent a re-operation in the spinal area; five for the removal of the spinal instrumentation. CONCLUSION: Patients reported satisfied and good long-term outcomes following FVFG surgical procedure for complex spinal deformities. Therefore, considering the alternatives, this procedure provides a good long-term solution for complex spinal deformity surgery.

Burn scar contracture release surgery effectively improves functional range of motion, disability and quality of life: A pre/post cohort study with long-term follow-up in a Low- and Middle-Income Country.

OBJECTIVE: Burn scar contractures limit range of motion (ROM) of joints and have substantial impact on disability and the quality of life (QoL) of patients, particularly in a Low- and Middle-Income Country (LMIC) setting. Studies on the long-term outcome are lacking globally; this study describes the long-term impact of contracture release surgery performed in an LMIC. METHODS: This is a pre-post cohort study, conducted in a referral hospital in Tanzania. Patients who underwent burn scar contracture release surgery in 2017-2018 were eligible. ROM (goniometry), disability (WHODAS 2.0) and QoL (EQ-5D) were assessed. The ROM data were compared to the ROM that is required to perform activities of daily living without compensation, i.e. functional ROM. Assessments were performed preoperatively and at 1, 3, 6 and 12 months postoperatively. RESULTS: In total, 44 patients underwent surgery on 115 affected joints. At 12 months, the follow-up rate was 86%. The mean preoperative ROM was 37.3% of functional ROM (SD 31.2). This improved up to 108.7% at 12 months postoperatively (SD 42.0, p < 0.001). Disability-free survival improved from 55% preoperatively to 97% at 12 months (p < 0.001) postoperatively. QoL improved from 0.69 preoperatively, to 0.93 (max 1.0) at 12 months postoperatively (p < 0.001). Patients who regained functional ROM in all affected joints reported significantly less disability (p < 0.001) and higher QoL (p < 0.001) compared to patients without functional ROM. CONCLUSIONS: Contracture release surgery performed in an LMIC significantly improved functional ROM, disability and QoL. Results showed that regaining a functional joint is associated with less disability and higher QoL.

Short-term cost-effectiveness of one-stage implant-based breast reconstruction with an acellular dermal matrix versus two-stage expander-implant reconstruction from a multicentre randomized clinical trial.

BACKGROUND: Implant-based breast reconstruction (IBBR) is the most commonly performed reconstructive procedure and its economic impact is significant. This study aimed to analyse whether a direct one-stage IBBR with use of an acellular dermal matrix (ADM) is more cost-effective than two-stage (expander-implant) breast reconstruction. METHODS: The BRIOS (Breast Reconstruction In One Stage) study was an open-label multicentre RCT in which women scheduled for skin-sparing mastectomy and immediate IBBR were randomized between one-stage IBBR with ADM or two-stage IBBR. Duration of surgery and hospital stay, and visits for the primary surgery, unplanned and cosmetic procedures were recorded. Costs were estimated at an institutional level. Health status was assessed by means of the EuroQol Five Dimensions 5L questionnaire. RESULTS: Fifty-nine patients (91 breasts) underwent one-stage IBBR with ADM and 62 patients (92 breasts) two-stage IBBR. The mean(s.d.) duration of surgery in the one-stage group was significantly longer than that for two-stage IBBR for unilateral (2·52(0·55) versus 2·02(0·35) h; P < 0·001) and bilateral (4·03(1·00) versus 3·25(0·58) h; P = 0·017) reconstructions. Costs were higher for one-stage compared with two-stage IBBR for both unilateral (€12 448 (95 per cent c.i. 10 722 to 14 387) versus €9871 (9373 to 10 445) respectively; P = 0·025) and bilateral (€16 939 (14 887 to 19 360) versus €13 383 (12 414 to 14 669); P = 0·002) reconstructions. This was partly related to the use of relatively expensive ADM. There was no difference in postoperative health status between the groups. CONCLUSION: One-stage IBBR with ADM was associated with higher costs, but similar health status, compared with conventional two-stage IBBR. Registration number: NTR5446 ( http://www.trialregister.nl).

Predictors of complications after direct-to-implant breast reconstruction with an acellular dermal matrix from a multicentre randomized clinical trial.

BACKGROUND: In the multicentre randomized trial BRIOS (Breast Reconstruction In One Stage), direct-to-implant (DTI) breast reconstruction with an acellular dermal matrix (ADM) was associated with a markedly higher postoperative complication rate compared with two-stage tissue expander/implant breast reconstruction. This study aimed to identify factors that contribute to the occurrence of complications after DTI ADM-assisted breast reconstruction. METHODS: Data were obtained from the BRIOS study, including all patients treated with DTI ADM-assisted breast reconstruction. Logistic regression analyses were performed to identify factors predictive of postoperative complications. RESULTS: Fifty-nine patients (91 breasts) were included, of whom 27 (35 breasts) developed a surgical complication. Reoperations were performed in 29 breasts (32 per cent), with prosthesis removal in 22 (24 per cent). In multivariable analyses, mastectomy weight was associated with complications (odds ratio (OR) 1·94, 95 per cent c.i. 1·33 to 2·83), reoperations (OR 1·70, 1·12 to 2·59) and removal of the implant (OR 1·55, 1·11 to 2·17). Younger patients (OR 1·07, 1·01 to 1·13) and those who received adjuvant chemotherapy (OR 4·83, 1·15 to 20·24) more frequently required reoperation. In univariable analyses, adjuvant radiotherapy showed a trend towards more complications (OR 7·23, 0·75 to 69·95) and removal of the implant (OR 5·12, 0·76 to 34·44), without reaching statistical significance. CONCLUSION: Breast size appeared to be the most significant predictor of complications in DTI ADM-assisted breast reconstruction. The technique should preferably be performed in patients with small to moderate sized breasts. Registration number: NTR5446 ( http://www.trialregister.nl).

The risk of recurrent IgA nephropathy in a steroid-free protocol and other modifying immunosuppression.

Recurrent glomerulonephritis is an important cause of kidney allograft failure. The effect of immunosuppression on recurrent IgA nephropathy (IgAN) is unclear. We analyzed the impact of steroids and other immunosuppression on the risk of recurrent IgAN post-kidney transplantation. Between June 1989 and November 2008, 3311 kidney transplants were performed at our center. IgAN was the primary disease in 124 patients; of these, 75 (60.5%) patients received steroid-based immunosuppression (15 undergoing late steroid withdrawal), and 49 (39.5%) were maintained on steroid-free immunosuppression. Recurrent IgAN was diagnosed in 27 of 124 (22%) patients in clinically indicated kidney allograft biopsies over a median follow-up of 6.86 ± 5.4 yr. On cox proportional hazards model multivariate analysis, the hazard risk (HR) of IgAN recurrence was significantly higher in patients managed with steroid-free (HR 8.59: 3.03, 24.38, p < 0.001) and sirolimus-based (HR = 3.00:1.16, 7.75, p = 0.024) immunosuppression without antilymphocyte globulin induction (HR = 4.5: 1.77, 11.73, p = 0.002). Mycophenolate use was associated with a lower risk (HR = 0.42: 0.19, 0.95, p = 0.036), whereas cyclosporine did not have a significant impact on the risk of IgAN recurrence (p = 0.61). These results warrant future prospective studies regarding the role of steroids and other immunosuppression drugs in reducing recurrence of IgAN and other glomerulonephritis post-transplant.

Spinal reconstruction with free vascularised bone grafts; approaches and selection of acceptor vessels.

The use of free vascularised bone grafts is an infrequently performed surgical technique for the reconstruction of spinal defects. This field of surgery brings many challenges concerning the choice of free vascularised bone graft, planning of the operative procedure and selection of recipient vessels. This study aims to report our experience with free vascularised bone grafts, with special emphasis on the surgical approach and the selection of recipient vessels. Over a period of 17 years (1994-2011), we used these grafts for anterior spinal reconstruction in 30 patients. In 28 patients, a free vascularised fibular graft was used, and in two cases a free vascularised iliac crest graft was used. The spinal segments reconstructed involved the cervical or cervicothoracic spine (6 cases), the thoracic spine (11 cases) and the thoracolumbar and lumbosacral spine (13 cases). Revascularisation of the free vascularised bone graft proved to be technically feasible in 30 patients, but failed in one fibular graft due to difficulties with recipient vessels in the lumbar region. Technical challenges were met with respect to the choice of the recipient vessel at various anatomical sites. Availability of acceptor vessels was highly de-pendant of the type of surgery (resection or stabilisation) and the selected surgical approach. Based on these findings, a preferred approach is given for each region. The use of free vascularised bone grafts is a valuable technique for the reconstruction of complex spinal disorders. Successful execution requires microvascular expertise with respect to graft harvesting and appropriate choice of recipient vessels. Adequate preoperative planning in a multidisciplinary setting and adherence to the basic principles for spinal reconstruction are required.

Periosteal ossification of the vascular pedicle after reconstruction of continuity defects of the mandible and the maxilla with fibular free flaps: a retrospective study.

Periosteal ossification of the vascular pedicle of a fibular free flap after reconstruction of mandibular and maxillary continuity defects has been thought to be rare. The purpose of this study was to evaluate its incidence and contributory factors to its development.

Women with silicone breast implants and unexplained systemic symptoms: a descriptive cohort study.

BACKGROUND: Since their introduction, the safety of silicone breast implants has been under debate. Although an association with systemic diseases was never established, women continuously blamed implants for their unexplained systemic symptoms. In 2011, a pattern of symptoms caused by systemic reactions to adjuvants (e.g. vaccines, silicone) was identified: 'autoimmune syndrome induced by adjuvants' (ASIA). Our aim was to collect a cohort of women with silicone breast implants and unexplained systemic symptoms to identify a possible pattern and compare this with ASIA. METHODS: Women with silicone breast implants and unexplained systemic symptoms were invited through national media to visit a special outpatient clinic in Amsterdam. All were examined by experienced consultant physicians and interviewed. Chest X-ray and laboratory tests were performed. RESULTS: Between March 2012 and 2013, 80 women were included, of which 75% reported pre-existent allergies. After a symptom-free period of years, a pattern of systemic symptoms developed, which included fatique, neurasthenia, myalgia, arthralgia and morning stiffness in more than 65% of women. All had at least two major ASIA criteria and 79% fulfilled ≥ 3 typical clinical ASIA manifestations. After explantation, 36 out of 52 women experienced a significant reduction of symptoms. CONCLUSIONS: After excluding alternative explanations, a clear pattern of signs and symptoms was recognised. Most women had pre-existent allergies, suggesting that intolerance to silicone or other substances in the implants might cause their symptoms. In 69% of women, explantation of implants reduced symptoms. Therefore, physicians should recognise this pattern and consider referring patients for explantation.

The use of free vascularised bone grafts in spinal reconstruction.

The use of free vascularised bone grafts (FVBGs) is an infrequently performed surgical technique for the reconstruction of spinal defects. This field of surgery brings many challenges concerning choice of FVBG, planning of the operative procedure and selection of recipient vessels. This study aims to report our experience with FVBGs, with special emphasis on the planning and surgical technique. Over a period of 10 years (1994-2004), we used FVBG for anterior spinal reconstruction in 23 patients. In 21 patients, a free vascularised fibular graft was used, and in two cases a free vascularised iliac crest graft was used. The spinal segments reconstructed involved the cervical spine (4 cases), the thoracic spine (13 cases) and the thoraco-lumbar and lumbo-sacral spine (6 cases). Re-vascularisation of the FVBG proved to be technically feasible in 22 patients, but failed in one fibular graft due to difficulties with recipient vessels in the lumbar spine. When necessary, the fibula was osteotomized and folded in a double-, triple- or quadruple-barrel construction to increase the strength of the reconstruction. Technical challenges were met with respect to the choice of the recipient vessel at various anatomical sites. The use of FVBG is a valuable technique for the reconstruction of complex spinal disorders. Successful execution requires microvascular expertise with respect to graft harvesting and appropriate choice of recipient vessels. Adequate preoperative planning in a multidisciplinary setting and adherence to the basic principles for spinal reconstruction are required.

[Reconstruction after surgical treatment of head and neck cancer: surgical and prosthetic possibilities]. / Reconstructie na chirurgische tumorbehandeling in het hoofd-halsgebied. Chirurgische en prothetische mogelijkheden.

Soft and hard tissue defects in the head and neck region after benign or malignant tumour resection, can be reconstructed by surgical techniques, such as tissue transplantation, and/or prostheses. The aim of reconstruction is to restore the original esthetics and functions of the bone and soft tissues that have been resected. The introduction of free vascularized osteomyocutaneous fibula and iliac crest flaps improved the surgical possibilities of reconstructing the mandible and the maxilla. With respect to oral rehabilitation, a reconstruction of the mandible and the maxilla should be carried out in such a way that it provides an adequate base for inserting endosseous implants, which will retain a removable or fixed prosthesis This requires good interdisciplinary planning, in which the plan for prosthetic treatment determines, in part, the choice of reconstruction method.

Metastasizing ameloblastoma.

Ameloblastomas are locally invasive tumours of odontogenic origin with a high propensity for local recurrence. Regional and distant metastases are extremely rare. Here is presented a case of a 26-year-old woman with a recurrent ameloblastoma of the mandible and a metastatic lymph node in the homolateral neck.

[A swelling in the midline of the mandible caused by a ossifying fibroma]. / Een zwelling in het onderfront: berustend op een ossificerend fibroom.

A 34-year-old woman complained of a swelling in the midline of the mandible, present for about six months and diagnosed as ossifying fibroma. Because of the rapid development and the extent of the tumour, treatment consisted of a partial mandibulectomy, followed by immediate reconstruction with a free vascularized fibula transplant.

Recurrent osteoblastoma of the hamate bone. A two-stage reconstruction with a free vascularized iliac crest flap.

An osteoblastoma in a carpal bone is very rare and presents a problem of reconstruction after wide tumour excision. We report a case of recurrent osteoblastoma of the right hamate bone with involvement of the ulnar carpal bones and soft tissues that was successfully treated by en bloc resection, temporary interposition of bone cement and fixation with K-wires, followed by reconstruction with a free vascularized iliac crest flap, tailored to the exact size of the defect, in a second procedure. Rapid fusion was achieved and hand function preserved with no evidence of recurrence 3 years postoperatively.

Free vascularized bone graft in spinal surgery: indications and outcome in eight cases.

In selected spinal deformities the use of a vascularized graft to establish fusion may be considered: compared to a non-vascularized graft it has superior mechanical properties, resulting in greater graft strength and stiffness, and greater effectiveness in facilitating union. Eight patients with a progressive spinal deformity (four cases) and malignancy (four cases) were treated with resection and/or correction and stabilization. To facilitate (multi)level fusion vascularized fibular grafts were used in two cervical and two thoracolumbar deformities. Fibular (two cases) or iliac grafts (two cases) were used in four cases of spinal reconstruction after vertebrectomy for malignancy. In all patients complete incorporation of the graft was obtained within 5 weeks to 8 months postoperatively. Complications occurred in three cases: one patient had a transient laryngeal edema and laryngeal nerve palsy. Another patient had a non-fatal deep vein thrombosis with pulmonary embolisms, successfully treated with anticoagulants. A third patient developed a lung infection and subsequently a deep infection around the dorsal instrumentation; after hardware removal the infection was controlled. At the latest follow-up (mean 30 months, range 24-48 months) six out of eight patients are alive. One patient died 2.5 years after the intervention due to widespread metastases, while another patient died in the postoperative period due to unknown reasons. Vascularized bone graft in spinal surgery facilitates primary mechanical stability and rapid fusion, and it has higher resistance to infection. The variety of applications of a vascularized graft may extend the range of indications for the use of grafts in spinal surgery.

Severe progressive osteoporotic spine deformity with cardiopulmonary impairment in a young patient. A case report.

STUDY DESIGN: This report describes a young patient with a rapidly progressive kyphosis caused by collapse of a severely osteoporotic thoracolumbar spine, which led to impairment of cardiopulmonary function. OBJECTIVES: To highlight the treatment strategy, difficulty of diagnosis, operative stabilization, and outcome. SUMMARY OF BACKGROUND DATA: Little is known about natural history, treatment options, and results of this condition. METHODS: The magnitude of bone loss was measured by dual-energy x-ray absorptiometry, and the deformity was visualized by computed tomography and magnetic resonance imaging. Laboratory investigations also were performed before and during halotraction in an attempt to establish a diagnosis. These data constituted the preoperation information required to assess later results of medical and surgical intervention. RESULTS: An extensive evaluation of possible underlying etiologies failed to identify a specific etiology. Before and during halotraction, bone mineral substitutes were given, partially correcting the bone mineral content as measured on repeated dual-energy x-ray absorptiometry scans. In addition, the thoracic kyphosis was partially corrected, from 100 degrees to 70 degrees Cobb's angle. Subsequently, a combined anterior and posterior stabilization was performed from C7 to S1 using a vascularized fibula graft, a double Isola rod system (AcroMed, Cleveland, OH), and a carbonate apatite cancellous bone cement to reinforce the pedicle screws. At follow-up assessment 40 months surgery, the patient was asymptomatic and fully mobilized, with radiographs showing complete incorporation of the grafts and no loosening of the fixation device. CONCLUSIONS: The diagnostic and therapeutic difficulties of progressive spine deformity caused by severe osteoporosis in young patients emphasizes the importance of a thoroughly planned treatment strategy. Halotraction is recommended to stop progression of the deformity, or even partially correct it, and to allow time to search for the diagnosis and bone mineral substitution. Surgical treatment using vascularized fibular strut grafts and a strong fixation device was successful. Biocompatible carbonated apatite cancellous bone cement was successfully used to reinforce pedicle screw fixation.

Reliability of the proximal skin paddle of the osteocutaneous free fibula flap: a prospective clinical study.

The vascularization of the skin paddle of 20 osteocutaneous fibula free flaps in 20 patients was studied. All skin paddles were designed over the proximal and middle third of the fibula. A parallel vascularization of the skin was found in 10 cases. In these cases, an axial (septo)musculocutaneous perforator was found to originate high in the peroneal artery or even in the popliteal artery. This branch runs parallel to the peroneal artery without any further connections with it. In 5 of these 10 cases, no other skin perforators were located within the boundaries of the skin paddle. Harvesting such a flap in the traditional way by blind inclusion of a muscle cuff results in ligation of the supplying vessel of the skin paddle and subsequent loss of the skin. In this series, this would have been the case in 5 of the 20 patients (25 percent). This might explain the bad reputation of the skin paddle of this flap. The high prevalence of the described vascular configuration in a proximally designed skin paddle justifies à vue dissection of all musculocutaneous perforators up to their origin, unless one or more septocutaneous perforators are found within the boundaries of the flap.

Stimulation of cartilage differentiation by osteogenic protein-1 in cultures of human perichondrium.

Exposure of progenitor cells with chondrogenic potential to recombinant human osteogenic protein-1 [rhOP-1, or bone morphogenetic protein-7 (BMP-7] may be of therapeutic interest in the regeneration of articular cartilage. Therefore, in this study, we examined the influence of rhOP-1 on cartilage formation by human perichondrium tissue containing progenitor cells with chondrogenic potential in vitro. Fragments of outer ear perichondrium tissue were embedded in clotting autologous blood to which rhOP-1 had been added or not (controls), and the resulting explant was cultured for 3 weeks without further addition of rhOP-1. Cartilage formation was monitored biochemically by measuring [³5;S]sulfate incorporation into proteoglycans and histologically by monitoring the presence of metachromatic matrix with cells in nests. The presence of rhOP-1 in the explant at the beginning of culture stimulated [³5;S]sulfate incorporation into proteoglycans in a dose-dependent manner after 3 weeks of culture. Maximal stimulation was reached at 40 microgram/ml. Histology revealed that explants treated with 20-200 microgram/ml rhOP-1, but not untreated control explants, contained areas of metachromatic-staining matrix with chondrocytes in cell nests. These results suggest that rhOP-1 stimulates differentiation of cartilage from perichondrium tissue. The direct actions of rhOP-1 on perichondrium cells to stimulate chondrocytic differentiation and production of cartilage matrix in vitro provide a cellular mechanism for the induction of cartilage formation by rhOP-1 in vivo. Thus, rhOP-1 may promote early steps in the cascade of events leading to cartilage formation. Therefore, rhOP-1 could be an interesting factor for regeneration of cartilage in articular cartilage defects.