Identifying the severely injured benefitting from a specific level of trauma care in an inclusive network: A multicentre retrospective study

INTRODUCTION

Defining major trauma (MT) with an Injury Severity Score (ISS) > 15 has limitations. This threshold is used for concentrating MT care in networks with multiple levels of trauma care.

OBJECTIVE

This study aims to identify subgroups of severely injured patients benefiting on in-hospital mortality and non-fatal clinical outcome measures in an optimal level of trauma care.

METHODS

A multicentre retrospective cohort study on data of the Dutch National Trauma Registry, region South West, from January 1, 2015 until December 31, 2019 was conducted. Patients ≥ 16 years admitted within 48 h after trauma transported with (H)EMS to a level I trauma centre (TC) or a non-level I trauma facility with a Maximum Abbreviated Injury Scale (MAIS) ≥ 3 were included. Patients with burns or patients of ≥ 65 years with an isolated hip fracture were excluded. Logistic regression models were used for comparing level I with non-level I. Subgroup analysis were done for MT patients (ISS > 15) and non-MT patients (ISS 9-14).

RESULTS

A total of 7,493 records were included. In-hospital mortality of patients admitted to a non-level I trauma facility did not differ significantly from patients admitted to the level I TC (adjusted Odds Ratio (OR): 0.94; 95% confidence interval (CI) 0.68-1.30). This was also applicable for MT patients (OR: 1.06; 95% CI 0.73-1.53) and non-MT patients (OR: 1.30; 95% CI (0.56-3.03). Hospital and ICU LOS were significantly shorter for patients admitted to a non-level I trauma facilities, and patients admitted to a non-level I trauma facility were more likely to be discharged home. Findings were confirmed for MT and non-MT patients, per injured body region.

CONCLUSION

All levels of trauma care performed equally on in-hospital mortality among severely injured patients (MAIS ≥ 3), although patients admitted to the level I TC were more severely injured. Subgroups of patients by body region or ISS, with a survival benefit or more favorable clinical outcome measures were not identified. Subgroups analysis on clinical outcome measures across different levels of trauma care in an inclusive trauma network is too simplistic if subgroups are based on injuries in specific body region or ISS only.

Trends in incidence, health care consumption, and costs for proximal femoral fractures in the Netherlands between 2000 and 2019: a nationwide study

This study evaluated the incidence rates and societal burden of hip fractures in The Netherlands. Although incidence in the elderly population is decreasing and hospital stay is at an all-time low, the burden of medical costs and crude numbers of proximal femoral fractures are still rising in our aging population.

PURPOSE

The aim of this nationwide study was to provide an overview of the incidence rate and economic burden of acute femoral neck and trochanteric fractures in The Netherlands.

METHODS

Data of patients who sustained acute proximal femoral fractures in the period January 1, 2000, to December 31, 2019, were extracted from the National Medical Registration of the Dutch Hospital Database. The incidence rate, hospital length of stay (HLOS), health care and lost productivity costs, and years lived with disability (YLD) were calculated for age- and sex-specific groups.

RESULTS

A total of 357,073 patients were included. The overall incidence rate increased by 22% over the 20-year study period from 16.4 to 27.1/100,000 person-years (py). The age-specific incidence rate in elderly > 65 years decreased by 16% (from 649.1 to 547.6/100,000 py). The incidence rate in men aged > 90 has surpassed the incidence rate in women. HLOS decreased in all age groups, hip fracture subtypes, and sexes from a mean of 18.5 to 7.2 days. The mean health care costs, over the 2015-2019 period, were lower for men (€17,723) than for women (€23,351) and increased with age to €26,639 in women aged > 80. Annual cumulative costs reached €425M, of which 73% was spent on women.

CONCLUSION

The total incidence of hip fractures in The Netherlands has increased by 22%. Although incidence in the elderly population is decreasing and HLOS is at an all-time low, the burden of medical costs and crude numbers of proximal femoral fractures are still rising in our aging population.

Prognosis and institutionalization of frail community-dwelling older patients following a proximal femoral fracture: a multicenter retrospective cohort study

Hip fractures are a serious public health issue with major consequences, especially for frail community dwellers. This study found a poor prognosis at 6 months post-trauma with regard to life expectancy and rehabilitation to pre-fracture independency levels. It should be realized that recovery to pre-trauma functioning is not a certainty for frail community-dwelling patients.

INTRODUCTION

Proximal femoral fractures are a serious public health issue in the older patient. Although a significant rise in frail community-dwelling elderly is expected because of progressive aging, a clear overview of the outcomes in these patients sustaining a proximal femoral fracture is lacking. This study assessed the prognosis of frail community-dwelling patients who sustained a proximal femoral fracture.

METHODS

A multicenter retrospective cohort study was performed on frail community-dwelling patients with a proximal femoral fracture who aged over 70 years. Patients were considered frail if they were classified as American Society of Anesthesiologists score ≥ 4 and/or a BMI < 18.5 kg/m² and/or Functional Ambulation Category ≤ 2 pre-trauma. The primary outcome was 6-month mortality. Secondary outcomes were adverse events, health care consumption, rate of institutionalization, and functional recovery.

RESULTS

A total of 140 out of 2045 patients matched the inclusion criteria with a median age of 85 (P₂₅-P₇₅ 80-89) years. The 6-month mortality was 58 out of 140 patients (41%). A total of 102 (73%) patients experienced adverse events. At 6 months post-trauma, 29 out of 120 (24%) were readmitted to the hospital. Out of the 82 surviving patients after 6 months, 41 (50%) were unable the return to their home, and only 32 (39%) were able to achieve outdoor ambulation.

CONCLUSION

Frail community-dwelling older patients with a proximal femoral fracture have a high risk of death, adverse events, and institutionalization and often do not reobtain their pre-trauma level of independence. Foremost, the results can be used for realistic expectation management.

Cost-effectiveness of immediate total-body CT in patients with severe trauma (REACT-2 trial)

BACKGROUND

The effect of immediate total-body CT (iTBCT) on health economic aspects in patients with severe trauma is an underreported issue. This study determined the cost-effectiveness of iTBCT compared with conventional radiological imaging with selective CT (standard work-up (STWU)) during the initial trauma evaluation.

METHODS

In this multicentre RCT, adult patients with a high suspicion of severe injury were randomized in-hospital to iTBCT or STWU. Hospital healthcare costs were determined for the first 6 months after the injury. The probability of iTBCT being cost-effective was calculated for various levels of willingness-to-pay per extra patient alive.

RESULTS

A total of 928 Dutch patients with complete clinical follow-up were included. Mean costs of hospital care were €25 809 (95 per cent bias-corrected and accelerated (bca) c.i. €22 617 to €29 137) for the iTBCT group and €26 155 (€23 050 to €29 344) for the STWU group, a difference per patient in favour of iTBCT of €346 (€4987 to €4328) (P = 0.876). Proportions of patients alive at 6 months were not different. The proportion of patients alive without serious morbidity was 61.6 per cent in the iTBCT group versus 66.7 per cent in the STWU group (difference -5.1 per cent; P = 0.104). The probability of iTBCT being cost-effective in keeping patients alive remained below 0.56 for the whole group, but was higher in patients with multiple trauma (0.8-0.9) and in those with traumatic brain injury (more than 0.9).

CONCLUSION

Economically, from a hospital healthcare provider perspective, iTBCT should be the diagnostic strategy of first choice in patients with multiple trauma or traumatic brain injury.

Treatment of dorsally dislocated distal radius fractures with individualized 3D printed bracing: an exploratory study

Background

The aim of this work was to develop a three-dimensionally (3D) printed brace for the acute treatment of dorsally dislocated and correctly reduced distal radius fractures (DRF). The hypothesis was that a brace shaped to the mirror image of the contralateral (non-fractured) wrist will have an optimal anatomical fit, resulting in improved comfort and lower rates of secondary fracture displacement.

Method

Validation: the circumference of both wrists and comfort of the brace were studied in healthy volunteers and effectiveness of the brace was evaluated in an ex vivo fracture model.

Clinical study: the brace was tested for comfort and effectiveness in patients with a well reduced unstable DRF.

Results

Validation: the circumference of both wrists may be different, the brace retained the reduction in the ex vivo fracture model and was well tolerated in the volunteers.

Clinical study: in DRF patients comfort scores were lower and pain scores higher compared to the healthy volunteers. After 3 and 5 weeks all patients were independent in ADL according to the Katz-index. Posttraumatic swelling subsided in the first week. In two of the five patients secondary fracture dislocation occurred.

Conclusions

Treatment of a dislocated DRF in the acute setting (day one) with a custom-made 3D printed brace, anatomically modelled from a 3D scan of the contralateral wrist, is possible. Difference between both wrists and posttraumatic swelling must be adapted for. The high rate of secondary fracture displacement led to early discontinuation of the study and a small sample size.

Trial registration

Name of the registry: ClinicalTrials.Gov

Trial registration number: NCT03848702

Date of registration: 02/21/2019, retrospectively registered

Rib fractures after blunt thoracic trauma in patients with normal versus diminished bone mineral density: a retrospective cohort study

This study aimed to evaluate rib fracture rate as well as rib fracture characteristics after thoracic trauma in patients with normal versus diminished bone mineral density (BMD). A retrospective cohort study of persons aged 50 years or older presenting to the Emergency Department after sustaining blunt thoracic trauma between July 1, 2014, and December 31, 2017, was performed. Patient and trauma characteristics and DXA scan results were collected. Rib fracture rate and characteristics were evaluated on a radiograph and/or CT scan of the thorax. In total, 119 patients were included for analysis. Fifty-eight of them (49%) had a diminished BMD. In the remaining 61, the BMD was normal. The diminished BMD group experienced rib fractures more often than the normal BMD group (n = 43 (74%) versus n = 31 (51%); p = 0.014). Patients with diminished BMD suffered low-energy trauma more frequently than the normal BMD group (21 (36%) versus 11 patients (15%), respectively (p = 0.011)). Rib fracture characteristics such as the median number of rib fractures, concomitant intrathoracic injury rate, and rib fracture type distribution were not different between the groups. The rate of rib fractures after blunt thoracic trauma was significantly higher in patients with diminished BMD than in patients with a normal BMD. Differences in number and location of rib fractures between groups could not be proven. When assessing patients aged 50 years or older presenting to the hospital after substantial blunt thoracic trauma, the presence of diminished BMD should be taken into account and the presence of rib fractures should be investigated with appropriate diagnostic procedures. Diminished bone mineral density (i.e., osteopenia or osteoporosis) is associated with increased fracture risk. This study evaluated if diminished BMD increases the rib fracture risk. Patients with diminished BMD have a higher risk of sustaining rib fractures after substantial blunt thoracic trauma, which implicates a lower threshold for CT imaging of the chest.

Early detection of severe injuries after major trauma by immediate total-body CT scouts

INTRODUCTION

Evaluation of immediate total-body CT (iTBCT) scouts during primary trauma care could be clinically relevant for early detection and treatment of specific major injuries. The aim of this study was to determine the diagnostic usefulness of TBCT scouts in detecting life-threatening chest and pelvic injuries.

METHODS

All patients who underwent an iTBCT during their primary trauma assessment in one trauma center between April 2011 and November 2014 were retrospectively included. Two experienced trauma surgeons and two emergency radiologists evaluated iTBCT scouts with structured questionnaires. Inter-observer agreement and diagnostic properties were calculated for endotracheal tube position and identification of pneumo- and/or hemothorax and pelvic fractures. Diagnostic properties of iTBCT scouts for indication for chest tube placement and pelvic binder application were calculated in comparison to decision based on iTBCT.

RESULTS

In total 220 patients with a median age of 37 years (IQR 26-59) were selected with a median Injury Severity Score of 18 (IQR 9-27). There was moderate to substantial inter-observer agreement and low false positive rates for pneumo- and/or hemothorax and for severe pelvic fractures by iTBCT scouts. For 19.8%-22.5% of the endotracheal intubated patients trauma surgeons stated that repositioning of the tube was indicated. Positive predictive value and sensitivity were respectively 100% (95%CI 52%-100%) and 50% (95%CI 22%-78%) for decisions on chest tube placement by trauma surgeon 1 and 67% (95%CI 13%-98%) and 22% (95%CI 4%-60%) for decisions by trauma surgeon 2. Only in one of 14 patients the pelvic binder was applied after iTBCT acquisition.

CONCLUSIONS

iTBCT scouts can be useful for early detection of pneumo- and/or hemothorax and severe pelvic fractures. Decision for chest tube placement based on iTBCT scouts alone is not recommended.

Open reduction and internal fixation versus closed reduction and percutaneous fixation in the treatment of Bennett fractures: A systematic review

PURPOSE

Open reduction and internal fixation (ORIF) of Bennett fractures is increasingly preferred over closed reduction and percutaneous fixation (CRIF) in an attempt to prevent the development of post-traumatic arthrosis. The aim of this systematic review was to determine whether the preference for ORIF is justified based on the available literature regarding functional outcome and complications after surgery.

METHODS

A systematic review was performed in Medline, Embase, Cochrane CENTRAL, Web of science, and Google scholar. Duplicates were removed and title and abstract were screened after which full text articles were analysed. The reference lists of selected articles were screened for additional relevant studies. Study characteristics were recorded and methodological qualities were assessed after which data was extracted from the included articles. The Eaton-Littler score for post-traumatic arthrosis (primary outcome) on follow-up X-rays was used as primary outcome. Secondary outcomes were Grip strength, Pinch strength, persistent pain, fixation failure, functional impairment, infection and surgery time.

RESULTS

Ten studies were included; three retrospective comparative studies and seven retrospective case series. Of the 215 patients in these studies, 138 had been treated using an open technique and 77 by a closed percutaneous technique. The pooled rate of post-traumatic arthrosis was 57.5% (26.6-85.5) in the ORIF group versus 26.1% (3.9-59.0) in the CRIF group. Mean surgical operation time was 71.9 min for ORIF and 30.2 min for percutaneous patients. Fixation failure was significantly more often seen in the ORIF patients, 8.2% (0.7-22.8) vs. 2.9% (0.8-9.1), Risk Ratio 1.132 (0.01-176.745); p = 0.048. Infection was only seen in 5 CRIF patients. Persistent pain was seen in 32.9% (0.6-83.1) in ORIF patients versus 22.3% (8.1-41.1) in the CRIF patients. The pooled means Grip strength was 48.3 kg (95% CI; 39.7-56.9) versus 43.4 kg (95% CI; 22.9-63.8) for ORIF and CRPF, respectively. Functional impairment was similar between the two groups, 1.4% (0.1-4.4) vs 1.8% (0.1-5.7) respectively.

CONCLUSION

The analysed data do not confirm ORIF to prevent post-traumatic arthrosis, secondly more fixation failure and pain was seen in the ORIF group. The pooled data show percutaneous fixation to be preferable over ORIF in the surgical treatment of Bennett fractures.

Bennett's fracture: Comparative study between open and closed surgical techniques

The aim of this study was to assess long-term outcomes of surgically treated Bennett fractures, while comparing open reduction and internal fixation (ORIF) with closed reduction and percutaneous fixation (CRPF). Patients treated between 1994 and 2010 were assessed retrospectively during an outpatient visit using a validated questionnaire (i.e. DASH, pain assessed through VAS), sensory testing, grip- and pinch-strength and radiographic analysis for post-traumatic arthritis. Fifty patients were included. Mean follow-up was 10 years. Mean age at trauma was 34 years. ORIF was used in 35 patients. CRPF was used in 15 patients. No differences in grip- and pinch-strength were found. Re-operations were needed in five ORIF-treated patients. Higher Pain Scores (VAS) were seen in the ORIF-treated patients. No correlation was found between surgical technique and functional outcomes. A persistent step-off or gap larger than 2 mm after surgical fixation was significantly correlated with post-traumatic arthritis at 10 years' follow-up. The need to perform ORIF for anatomical reduction seems to be less important in preventing post-traumatic arthritis as a persistent step-off or gap of more than 2 mm was found to be significantly correlated with the development of post-traumatic arthritis. Secondly, both techniques lead to good functional outcomes, although persistent pain was seen in the ORIF-treated patients. Bennett fractures can therefore be safely treated with CRPF when the persistent step-off and gap after fixation do not exceed 2 mm. LEVEL OF EVIDENCE: Therapeutic study, Level III.

Insights into treatment and outcome of fracture-related infection: a systematic literature review

INTRODUCTION

Standardized guidelines for treatment of fracture-related infection (FRI) are lacking. Worldwide many treatment protocols are used with variable success rates. Awareness on the need of standardized, evidence-based guidelines has increased in recent years. This systematic literature review gives an overview of available diagnostic criteria, classifications, treatment protocols, and related outcome measurements for surgically treated FRI patients.

METHODS

A comprehensive search was performed in all scientific literature since 1990. Studies in English that described surgical patient series for treatment of FRI were included. Data were collected on diagnostic criteria for FRI, classifications used, surgical treatments, follow-up protocols, and overall outcome. A systematic review was performed according to the PRISMA statement. Proportions and weighted means were calculated.

RESULTS

The search yielded 2051 studies. Ninety-three studies were suitable for inclusion, describing 3701 patients (3711 fractures) with complex FRI. The population consisted predominantly of male patients (77%), with the tibia being the most commonly affected bone (64%), and a mean of three previous operations per patient. Forty-three (46%) studies described FRI at one specific location. Only one study (1%) used a standardized definition for infection. A total of nine different classifications were used to guide treatment protocols, of which Cierny and Mader was used most often (36%). Eighteen (19%) studies used a one-stage, 50 (54%) a two-stage, and seven (8%) a three-stage surgical treatment protocol. Ten studies (11%) used mixed protocols. Antibiotic protocols varied widely between studies. A multidisciplinary approach was mentioned in only 12 (13%) studies.

CONCLUSIONS

This extensive literature review shows a lack of standardized guidelines with respect to diagnosis and treatment of FRI, which mimics the situation for prosthetic joint infection identified many years ago. Internationally accepted guidelines are urgently required to improve the quality of care for patients suffering from this significant complication.

Total medical costs of treating femoral neck fracture patients with hemi- or total hip arthroplasty: a cost analysis of a multicenter prospective study

The aim of this study was to determine the total medical costs for treating displaced femoral neck fractures with hemi- or total hip arthroplasty in fit elderly patients. The mean total costs per patient at 2 years of follow-up were €26,399. These results contribute to cost awareness.

INTRODUCTION

The absolute number of hip fractures is rising and increases the already significant burden on society. The aim of this study was to determine the mean total medical costs per patient for treating displaced femoral neck fractures with hemi- or total hip arthroplasty in fit elderly patients.

METHODS

The population was the Dutch sample of an international randomized controlled trial consisting of femoral neck fracture patients treated with hemi- or total hip arthroplasty. Patient data and health care utilization were prospectively collected during a total follow-up period of 2 years. Costs were separated into costs for hospital care during primary stay, hospital costs for clinical follow-up, and costs generated outside the hospital during rehabilitation. Multiple imputations were used to account for missing data.

RESULTS

Data of 141 participants (mean age 81 years) were included in the analysis. The 2-year mortality rate was 19 %. The mean total cost per patient after 10 weeks of follow-up was €15,216. After 1 and 2 years of follow-up the mean total costs were €23,869 and €26,399, respectively. Rehabilitation was the main cost determinant, and accounted for 46 % of total costs. Primary hospital admission days accounted for 22 % of the total costs, index surgery for 11 %, and physical therapy for 7 %.

CONCLUSIONS

The main cost determinants for hemi- or total hip arthroplasty after treatment of displaced femoral neck fractures (€26,399 per patient until 2 years) were rehabilitation and nursing homes. Most of the costs were made in the first year. Reducing costs after hip fracture surgery should focus on improving the duration and efficiency of the rehabilitation phase.

The societal costs of femoral neck fracture patients treated with internal fixation

SUMMARY

The study rationale was to provide a detailed overview of the costs for femoral neck fracture treatment with internal fixation in the Netherlands. Mean total costs per patient at 2-years follow-up were <euro>19,425. Costs were higher for older, less healthy patients. Results are comparable to internationally published costs.

INTRODUCTION

The aim of this study was to provide a detailed overview of the cost and healthcare consumption of patients treated for a hip fracture with internal fixation. A secondary aim was to compare costs of patients who underwent a revision surgery with patients who did not.

METHODS

The study was performed alongside the Dutch sample of an international randomized controlled trial, concerning femoral neck fracture patients treated with internal fixation. Patient characteristics and healthcare consumption were collected. Total follow-up was 2 years. A societal perspective was adopted. Costs included hospital costs during primary stay and follow-up, and costs related to rehabilitation and changes in living situation. Costs were compared between non-revision surgery patients, implant removal patients, and revision arthroplasty patients.

RESULTS

A total of 248 patients were included (mean age 71 years). Mean total costs per patient at 2-years follow-up were <euro>19,425. In the non-revision surgery patients total costs were <euro>17,405 (N = 137), in the implant removal patients <euro>10,066 (N = 38), and in the revision arthroplasty patients <euro>26,733 (N = 67). The main contributing costs were related to the primary surgery, admission days, physical therapy, and revision surgeries.

CONCLUSIONS

The main determinant was the costs of admission to a rehabilitation center/nursing home. Costs were specifically high in elderly with comorbidity, who were less independent pre-fracture, and have a longer admission to the hospital and/or a nursing home. Costs were also higher in revision surgery patients. The 2-years follow-up costs in our study were comparable to published costs in other Western societies.

Immediate thoracotomy for penetrating injuries: ten years' experience at a Dutch level I trauma center

BACKGROUND

An emergency department thoracotomy (EDT) or an emergency thoracotomy (ET) in the operating theater are both beneficial in selected patients following thoracic penetrating injuries. Since outcome-descriptive European studies are lacking, the aim of this retrospective study was to evaluate ten years of experience at a Dutch level I trauma center.

METHOD

Data on patients who underwent an immediate thoracotomy after sustaining a penetrating thoracic injury between October 2000 and January 2011 were collected from the trauma registry and hospital files. Descriptive and univariate analyses were performed.

RESULTS

Among 56 patients, 12 underwent an EDT and 44 an ET. Forty-six patients sustained one or multiple stab wounds, versus ten with one or multiple gunshot wounds. Patients who had undergone an EDT had a lower GCS (p < 0.001), lower pre-hospital RTS and hospital triage RTS (p < 0.001 and p = 0.009, respectively), and a lower SBP (p = 0.038). A witnessed loss of signs of life generally occurred in EDT patients and was accompanied by 100 % mortality. Survival following EDT was 25 %, which was significantly lower than in the ET group (75 %; p = 0.002). Survivors had lower ISS (p = 0.011), lower rates of pre-hospital (p = 0.031) and hospital (p = 0.003) hemodynamic instability, and a lower prevalence of concomitant abdominal injury (p = 0.002).

CONCLUSION

The overall survival rate in our study was 64 %. The outcome of immediate thoracotomy performed in this level I trauma center was similar to those obtained in high-incidence regions like the US and South Africa. This suggests that trauma units where immediate thoracotomies are not part of the daily routine can achieve similar results, if properly trained.

Accuracy of an expanded early warning score for patients in general and trauma surgery wards

Background

Early warning scores (EWS) may aid the prediction of major adverse events in hospitalized patients. Recently, an expanded EWS was introduced in the Netherlands. The aim of this study was to assess the relationship between this EWS and the occurrence of major adverse clinical events during hospitalization of patients admitted to a general and trauma surgery ward.

Methods

This was a prospective cohort study of consecutive patients admitted to the general and trauma surgery ward of a university medical centre (March–September 2009). Follow-up was limited to the time the patient was hospitalized. Logistic regression analysis was used to assess the relationship between the EWS and the occurrence of the composite endpoint consisting of death, reanimation, unexpected intensive care unit admission, emergency surgery and severe complications. Performance of the EWS was analysed using sensitivity, specificity, predictive values and receiver operating characteristic (ROC) curves.

Results

A total of 572 patients were included. During a median follow-up of 4 days, 46 patients (8.0 per cent) reached the composite endpoint (two deaths, two reanimations, 17 intensive care unit admissions, 44 severe complications, one emergency operation). An EWS of at least 3, adjusted for baseline American Society of Anesthesiology classification, was associated with a significantly higher risk of reaching the composite endpoint (odds ratio 11·3, 95 per cent confidence interval (c.i.) 5·5 to 22·9). The area under the ROC curve was 0·87 (95 per cent c.i. 0·81 to 0·93). When considering an EWS of at least 3 to be a positive test result, sensitivity was 74 per cent and specificity was 82 per cent.

Conclusion

An EWS of 3 or more is an independent predictor of major adverse events in patients admitted to a general and trauma surgery ward.

Increased rates of wound complications with locking plates in distal fibular fractures

INTRODUCTION

There is a growing use of locking compression plates in fracture surgery. The current study was undertaken to investigate the wound complication rates of locking versus non-locking plates in distal fibular fractures.

PATIENTS AND METHODS

During a 6-year study period all consecutive, closed distal fibular fractures treated with either a locking or a non-locking plate were included and retrospectively analysed for complication related to the fibula.

RESULTS

A total of 165 patients received a one-third tubular plate and 40 patients were treated with a locking plate. The two groups were comparable with respect to patient characteristics (age, gender, smokers and diabetics), injury characteristics (affected side, fracture dislocations, number of fractured malleoli and classification) and operation characteristics (surgical delay and duration, use of a tourniquet and plate length). The wound complication rate was 5.5% in the conventional plating group, and 17.5% in the locking plate group (p=0.019). This difference was largely due to an increase in major complications, for which removal of the plate was necessary (p=0.008).

CONCLUSION

There is a significant increase in wound complications in distal fibular fractures treated with a locking compression plate. In light of the current study, we would caution against the application of the currently used locking compression plates in the treatment of distal fibular fractures.

Real-time PCR of host DNA in feces to study differential exfoliation of colonocytes between rats and humans

BACKGROUND

Colonic mucosa has a high turnover rate. At the end of their lifespan, colonocytes become senescent and die. Histological studies indicate that senescent colonocytes are shed (exfoliated) into the fecal stream in rats, but phagocytosed by mucosal macrophages in humans. We study whether quantification of host DNA in feces can be used as a non-invasive marker for this differential disposal of colonocytes.

METHODS

Selective primers and probes for the rat and human beta-globin genes were designed and used in real-time PCR reactions.

RESULTS

Host DNA was quantitatively extracted and detected in fecal samples of both species. Feces of rats fed a humanized diet contained approximately 100 microg rat DNA per g freeze-dried feces. In human feces, however, only 5 out of 12 samples contained detectable, though very low (less than 0.35 microg/g), levels of host DNA. This about 300-fold difference could not be attributed to differences in DNase activities in the fecal stream.

CONCLUSION

Our results indicate that there is considerable luminal shedding of senescent colonocytes in rats, whereas mucosal phagocytosis is the main route of colonocyte disposal in humans. Thus, real-time PCR of host DNA in feces can be applied as a non-invasive method for studying the differential exfoliation of colonocytes.

Delayed peripheral nerve regeneration and central nervous system collateral sprouting in leucocyte common antigen-related protein tyrosine phosphatase-deficient mice

Cell adhesion molecule-like receptor-type protein tyrosine phosphatases have been shown to be important for neurite outgrowth and neural development in several animal models. We have previously reported that in leucocyte common antigen-related (LAR) phosphatase deficient (LAR-deltaP) mice the number and size of basal forebrain cholinergic neurons, and their innervation of the hippocampal area, is reduced. In this study we compared the sprouting response of LAR-deficient and wildtype neurons in a peripheral and a central nervous system lesion model. Following sciatic nerve crush lesion, LAR-deltaP mice showed a delayed recovery of sensory, but not of motor, nerve function. In line with this, neurofilament-200 immunostaining revealed a significant reduction in the number of newly outgrowing nerve sprouts in LAR-deltaP animals. Morphometric analysis indicated decreased axonal areas in regenerating LAR-deltaP nerves when compared to wildtypes. Nonlesioned nerves in wildtype and LAR-deltaP mice did not differ regarding myelin and axon areas. Entorhinal cortex lesion resulted in collateral sprouting of septohippocampal cholinergic fibres into the dentate gyrus outer molecular layer in both genotype groups. However, LAR-deltaP mice demonstrated less increase in acetylcholinesterase density and fibre number at several time points following the lesion, indicating a delayed collateral sprouting response. Interestingly, a lesion-induced reduction in number of (septo-entorhinal) basal forebrain choline acetyltransferase-positive neurons occurred in both groups, whereas in LAR-deltaP mice the average cell body size was reduced as well. Thus, regenerative and collateral sprouting is significantly delayed in LAR-deficient mice, reflecting an important facilitative role for LAR in peripheral and central nervous system axonal outgrowth.