C. van der Werken

A dutch approach to methicillin-resistant Staphylococcus aureus

C. van der Werken Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands Methicillin-resistant Staphylococcus aureus (MRSA), first reported in 1962, has now emerged as a major cause of nosocomial infections [1]. Strains of MRSA are efficient colonizers of the skin and mucous membranes and can cause outbreaks that are difficult to control [1–3]. In addition, they have demonstrated remarkable ability to become resistant to other antibiotics. Numerous MRSA strains are now resistant to many antibiotics, including erythromycin, tetracycline, gentamicin and the fluoroquinolones [1, 2, 4]. In centers with high incidence rates of MRSA, however, the only therapeutic option for patients with MRSA infections is treatment with vancomycin or teicoplanin. It is therefore alarming that vancomycin intermediatesusceptible MRSA strains (VISA) are being isolated with increasing frequency [5]. VISA strains have also been reported from several centers in the USA. A recent editorial describing this phenomenon was titled “Vancomycin resistant Staphylococcus aureus: apocalypse now?” [6].

POSTOPERATIVE TREATMENT OF INTERNALLY FIXED ANKLE FRACTURES: A PROSPECTIVE RANDOMISED STUDY

In a prospective, randomised trial of 81 patients with fractures of the ankle of AO types A, B and C we compared two regimes of postoperative management after internal fixation. The patients were mobilised either non-weight-bearing with crutches or weight-bearing in a below-knee walking plaster. We found a temporary benefit in subjective evaluation only (65 v 50 points, Mann-Whitney test, cft, p=0.02) for those with a below-knee walking plaster. There were no significant differences between the groups in the loaded dorsal range of movement (25 degrees v 23 degrees, Mann-Whitney test, cft, p = 0.16) or in the overall clinical result. Both treatments were considered to be satisfactory and their choice depends on the ability to mobilise non-weight-bearing, wound healing, the type of work and personal preference.

Rauchen ist nachteilig für die Heilung von Knochen und Weichteilen

ZusammenfassungDiese Literaturübersicht zeigt den heutigen Kenntnisstand über nachteilige Effekte des Rauchens auf die Heilung von Knochen und Weichtteile, hauptsächlich am Beispiel der drittgradig offenen Unterschenkelfraktur dargestellt.Die pathophysiologischen Effekte des Rauchens sind u. a. Vasokonstriktion der Arteriolen, Hypoxie auf Zellniveau, Knochendemineralisation und verzögerte Revaskularisation. Sowohl in klinischen als auch in experimentellen Studien wird deutlich, dass bei Rauchern die klinische Frakturheilung länger dauert als bei Nichtrauchern und dass die Inzidenz der Pseudarthrosen höher liegt. Insbesondere in der plastischen und mikrovaskulären Chirurgie sind die negativen Effekte des Rauchens, z. B. die höhere Rate an Gewebenekrose und Hämatomen, schon lange bekannt.Vor allem Rauchern mit offenen Unterschenkelfrakturen drohen alle nachteiligen Effekte ihrer Sucht, da gerade diese Frakturen mit einem gravierenden Weichteilschaden, also auch längerer Heilungsperiode und einer höheren Anzahl von Pseudarthrosen, einhergehen. Werden mikrochirurgische Techniken eingesetzt, führt das Weiterrauchen zu einer erheblich höheren Rate von Wundinfekten, muskulären Verschiebelappennekrosen und Spalthautverlusten. Das sofortige Einstellen des Rauchens dagegen hat sowohl kurz- als auch langfristig günstige Einflüsse. Das sofortige Beenden des Rauchens bei Patienten mit offener Unterschenkelfraktur verbessert die Heilungschancen und verringert die Morbidität.Im Falle einer elektiven Rekonstruktionsoperation sollte der Patient zumindest 4 Wochen vor der Operation das Rauchen einstellen. Für beide Fälle gilt, dass das Rauchen während der ganzen Rehabilitationsperiode eingestellt werden muss.AbstractThis article reviews the current body of knowledge on the adverse effects of smoking on soft-tissue and bone healing, with emphasis on tibial fractures in combination with severe soft-tissue injury.The pathophysiological effects are multidimensional, including arteriolar vasoconstriction, cellular hypoxia, demineralisation of bone, and delayed revascularisation. Several animal and clinical studies have been published about the negative effects of smoking on bone metabolism and fracture healing. These studies show that smokers have a significantly longer time to clinical union than non-smokers and a higher incidence of non-union. The negative effects of smoking gained increased interest among plastic and microvascular surgeons, because smokers have been shown to suffer higher rates of flap failure, tissue necrosis, and haematoma formation.Especially smokers presenting with an open tibial fracture will suffer the negative effects of their smoking behaviour, because these fractures are inextricably bound up with soft-tissue injury. Their fractures will need a significantly longer time to heal than in non-smokers, and will have a higher incidence of non-union. If microvascular surgery is to be performed, persistent smoking significantly increases the rate of postoperative complications, with wound infection, partial flap necrosis, and skin graft loss being more common. Cessation of smoking has both short- and long-term beneficial effects. Nowadays, there is strong evidence to be very insistent that patients presenting with a (open) tibial fracture should refrain from smoking immediately to promote bone healing and to lower the complication rate.In case of elective reconstructive procedures, patients should refrain from smoking at least 4 weeks before surgery. In both situations, cessation should continue during the full rehabilitation period.

Fracture-dislocations of the tarsometatarsal joint, a combined anatomical and computed tomographic study

Based on anatomical and computed tomographic data as well as experience with the treatment of 30 patients with fracture-dislocation of the tarsometatarsal (Lisfranc) joint, a pathophysiological model is described in which the shape of the foot and ligamentous configuration in combination with applied forces are of pivotal importance. CT imaging helps to elucidate the extent of the lesions, easily overlooked in straight radiographs. In the transverse plane we discern three grades of dislocation. Grade 1, virtually no displacement; grade 2, dislocation of half of the shaft; grade 3, total displacement. Treatment is generally dictated by the severity of the lesion and ranges from plaster application to open reduction and internal fixation. Quality of reduction is easily visualized with CT imaging.

The posterior antiglide plate for fixation of fractures of the lateral malleolus.

Anatomical reduction and internal fixation of displaced lateral malleolar fractures are the cornerstone of the operative treatment of ankle fractures. The classical method of fixation is the application of one-third tubular plates laterally to the distal fibula, a technique, however, that has several disadvantages. In exceptional cases and under special circumstances we prefer a dorsal approach with the use of an antiglide plate. Indications, technique and experiences are discussed.

Arthrodesis after osteosynthesis and infection of the ankle joint.

Nineteen patients with a severely infected ankle joint after previous osteosynthesis were treated with arthrodesis in our institution. Their notes and X-rays were reviewed. Goals of treatment were eradication of infection by aggressive débridement of infected tissues, obtaining adequate soft-tissue coverage, preservation/restoration of bonelength, and finally consolidation of the arthrodesis. Thirteen men and six women were treated, with a median age of 46 (17-69) years. Arthrodesis took place after a median of 6 months (0.5-40) post-accident, and after one to six earlier operative procedures. Primarily there had been four bimalleolar, five trimalleolar and ten pilon tibial fractures. Fifteen fractures were open with severe soft tissue damage. Seven free muscle transfers were performed, and ten cancellous bone graftings. Finally 29 attempts at arthrodesis were performed. Ultimately we had to perform two amputations. After a mean follow up of 3.5 years, one patient has an aseptic but asymptomatic pseudarthrosis, for which no further surgery is scheduled. Sixteen extremities are free from infection while full weightbearing is possible. The limb-threatening problem of deep infection after osteosynthesis of an ankle fracture can be resolved by consistent but prolonged treatment. After successful arthrodesis a weightbearing extremity without infection remains in the majority of cases.

Hypothermie bei Traumapatienten

ZusammenfassungEine akzidentelle Hypothermie (AH) kann als unbeabsichtigtes Absinken der Körperkerntemperatur unter 35° C bei einer Kälteexposition von Personen ohne intrinisische Störung der Wärmeregulation definiert werden. Die pathophysiologischen Veränderungen sind vom Schweregrad der Hypothermie sowie von den pathologischen Begleitfaktoren wie Trauma, Kältewasserimmersion, Intoxikation und Grunderkrankungen abhängig. Bei Traumaopfern, die nach dem Injury Severity Score (Score des Schweregrades der Verletzung) stratifiziert werden, gilt der Faktor Hypothermie als prognostisch ungünstiges Zeichen für das Überleben. Bei diesen Patienten ist die Wiedererwärmung so bald wie möglich einzuleiten. In der Universitätsklinik von Utrecht werden erwachsene Patienten mit AH entsprechend einem auf der vorliegenden hämodynamischen Situation basierenden Behandlungsalgorithmus therapiert. Patienten mit aufrechterhaltener Herztätigkeit und einem systolischen Blutdruck über 80 mmHg erhalten eine kontinuierliche arteriovenöse Wiedererwärmung (CAVR). Bei Patienten mit Kreislauf- und Atemstillstand und hämodynamischer Instabilität wird ein kardiopulmonaler Bypass (CPB) gelegt. In einem Zeitraum von 3 Jahren wurden 22 Patienten mit AH in die Notaufnahme eingeliefert. Bei 14 Patienten war die Ursache der Hypothermie ein Trauma. Zwanzig Patienten wurden entsprechend diesem Behandlungsalgorithmus (CAVR: n = 18, CPB: n = 2) und zwei Patienten alternativ behandelt. Die Letalität betrug 28 % in der CAVR-Gruppe, die Gesamtletalität erreichte 32 %. Komplikationen der CAVR sind mit der Plazierung und der Entfernung von Gefäßkathetern assoziiert und können bei Patienten mit beeinträchtigter Blutgerinnung schwerwiegend sein. Die CAVR ermöglicht einen guten Zugang zum (Trauma-) Patienten. Die Wiedererwärmung kann zeitgleich zur Diagnosestellung und der Behandlung verschiedener Verletzungen fortgeführt werden.SummaryAccidental hypothermia (AH) can be defined as an unintentional decrease in core temperature below 35 °C during cold exposure by individuals without intrinsic thermoregulatory dysfunction. Pathophysiological changes can be attributed both to the severity of hypothermia and to co-morbid factors such as trauma, submersion, intoxication and underlying diseases. In trauma victims stratified according to the Injury Severity Score, the factor hypothermia is considered to be a poor prognostic sign for survival. In these patients rewarming therapy should be applied as soon as possible. In the Utrecht University Hospital, adult patients with AH are managed according to an algorithm based on their presenting hemodynamic conditions. Patients with perfusing cardiac rhythms and systolic pressures over 80 mmHg will receive continuous arteriovenous rewarming (CAVR). Arrested and hemodynamically instable patients are treated with cardiopulmonary bypass (CPB). In a 3-year period, 22 patients with AH were admitted to the emergency department. Fourteen patients had a trauma as the cause of hypothermia. Twenty patients were treated according to the algorithm (CAVR n = 18, CPB n = 2) and two patients were alternatively managed. Mortality in the CAVR group was 28 % and total mortality reached 32 %. Complications of CAVR are related to placement and removal of vascular catheters and may be severe in these patients with impaired coagulation. CAVR permits a good access to the (trauma-) patient and rewarming can be continued synchronously with diagnosis and treatment of various injuries.

Comparison of two surveillance methods for detecting nosocomial infections in surgical patients.

Abstract.Nosocomial infections play a role in quality and cost control in health care. Surveillance of these infections is the only way to gain more insight into their frequency and causes. Since the results of surveillance may lead to changes in both patient and hospital management, which are sometimes major, it is necessary that all healthcare workers involved agree on the criteria used for the diagnosis and surveillance of these complications. In order to compare the efficacy of two surveillance methods, nosocomial infections in surgical patients were registered by both the Department of Surgery (complication surveillance [CS]) and the Department of Infection Control (nosocomial infection surveillance [NIS]) at the University Medical Center Utrecht, The Netherlands, over a 2-month period. The CS team used the national criteria of the Association of Surgeons of the Netherlands and the NIS team used the international criteria of the Centers for Disease Control and Prevention, USA, to define cases of nosocomial infection. A total of 515 patients were included in both arms of the study. The CS team diagnosed 69 infections in 49 patients, and the NIS team diagnosed 64 infections in 45 patients. Of 104 total infections, 39 were diagnosed by the CS team exclusively, 35 by the NIS team exclusively and only 30 by both. The main reasons for the inconsistent results were as follows: (i) the lack of follow-up after discharge in the NIS arm, (ii) the use of clinical criteria for the definition of a nosocomial infection in the CS arm, and (iii) the use of positive cultures as part of the criteria in the NIS arm. From the perspective of infection control, the CS system cannot be recommended for the surveillance of nosocomial infections.

Resorbierbare Implantate für Frakturfixierungen, aktueller Stand

: Operative fracture repair in trauma surgery is currently performed using metal implants. These metal implants often are removed during a second, retrieval operation. Biodegradable fracture fixation devices have been used clinically since the late seventies. Most bioresorbable implants are manufactured from polymers. The polylactides, polyglycolides and co-polymers slowly degrade into small components that are excreted from the human body via natural pathways and removal operations after fracture surgery are not necessary. Due to the limited mechanical properties, the polymer screws and pins are mostly used in the treatment of non weight-baring simple fractures of the ankle, elbow, hand and foot. In view of the progressing technical developments, new materials will be developed and tested for clinical use in the coming decades.

‘Quadriplane’ fracture of the distal tibia: a tripiane fracture with a double metaphyseal fragment

employed as opposed to partial gravitational equinus (Carden et al., 1987). Proponents of surgical repair comment on the higher incidence of rerupture if non-operative management is employed (Inglis et al., 1976). However, these reports do not make it clear whether or not full equinus was employed where cast immobilization was used. Although full equinus does not necessarily produce end-to-end tendon apposition, a good functional result may be achieved. It is interesting to note that, in a discussion on ossified Achilles tendons Lotke (1970) suggested that pain is indicative of fracture of the ossified mass and an indication for surgery to prevent complete tendon rupture and persistence of symptoms. This is not borne out by this case.