Endofibrosis of the External Iliac Artery in Sportsmen Clinical Review and Four New Cases

Endofibrosis of the external iliac artery is an unusual condition associated with competition cyclists. There seems to be a good prognosis after surgical therapy, consisting of endarterectomy and vein patching in combination with resection if the artery is lengthened. However, absence of well-documented long-term follow-up studies makes surgical treatment controversial. The authors describe four new patients with endofibrosis of the external iliac artery (EIA) with a review of relevant literature.

Reliability, validity, and responsiveness of the Western Ontario and McMaster Universities Osteoarthritis Index for elderly patients with a femoral neck fracture

BACKGROUND

The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) has been extensively evaluated in groups of patients with osteoarthritis, yet not in patients with a femoral neck fracture. This study aimed to determine the reliability, construct validity, and responsiveness of the WOMAC compared with the Short Form-12 (SF-12) and the EuroQol 5D (EQ-5D) questionnaires for the assessment of elderly patients with a femoral neck fracture.

METHODS

Reliability was tested by assessing the Cronbach alpha. Construct validity was determined with the Pearson correlation coefficient. Change scores were calculated from ten weeks to twelve months of follow-up. Standardized response means and floor and ceiling effects were determined. Analyses were performed to compare the results for patients less than eighty years old with those for patients eighty years of age or older.

RESULTS

The mean WOMAC total score was 89 points before the fracture in the younger patients and increased from 70 points at ten weeks to 81 points at two years postoperatively. In the older age group, these scores were 86, 75, and 78 points. The mean WOMAC pain scores before the fracture and at ten weeks and two years postoperatively were 92, 76, and 87 points, respectively, in the younger age group and 92, 84, and 93 points in the older age group. Function scores were 89, 68, and 79 points for the younger age group and 84, 71, and 73 points for the older age group. The Cronbach alpha for pain, stiffness, function, and the total scale ranged from 0.83 to 0.98 for the younger age group and from 0.79 to 0.97 for the older age group. Construct validity was good, with 82% and 79% of predefined hypotheses confirmed in the younger and older age groups, respectively. Responsiveness was moderate. No floor effects were found. Moderate to large ceiling effects were found for pain and stiffness scales at ten weeks and twelve months in younger patients (18% to 36%) and in the older age group (38% to 53%).

CONCLUSIONS

The WOMAC showed good reliability, construct validity, and responsiveness in both age groups of elderly patients with a femoral neck fracture who had been physically and mentally fit before the fracture. The instrument is suitable for use in future clinical studies in these populations.

CLINICAL RELEVANCE

The results are based on two clinical trials. The questionnaires used concern pure, clinically relevant issues (ability to walk, climb stairs, etc.). Moreover, the results can be used for future research comparing clinical outcomes (or treatments) for populations with a femoral neck fracture.

Operative treatment of dislocated midshaft clavicular fractures: plate or intramedullary nail fixation? A randomized controlled trial

BACKGROUND

Over the past decades, the operative treatment of displaced midshaft clavicular fractures has increased. The aim of this study was to compare short and midterm results of open reduction and plate fixation with those of intramedullary nailing for displaced midshaft clavicular fractures.

METHODS

A multicenter, randomized controlled trial was performed in four different hospitals. The study included 120 patients, eighteen to sixty-five years of age, treated with either open reduction and plate fixation (n = 58) or intramedullary nailing (n = 62). Preoperative and postoperative shoulder function scores and complications were documented until one year postoperatively. Significance was set at p < 0.05.

RESULTS

No significant differences in the Disabilities of the Arm, Shoulder and Hand (DASH) or Constant-Murley score (3.0 and 96.0 points for the plate group and 5.6 and 95.5 points for the nailing group) were noted between the two surgical interventions at six months postoperatively. Until six months after the surgery, the plate-fixation group experienced less disability than the nailing group as indicated by the area under the curve of the DASH scores for this time period (p = 0.02). The mean numbers of complications per patient, irrespective of their severity, were similar between the plate-fixation (0.67) and nailing (0.74) groups (p = 0.65).

CONCLUSIONS

The patients in the plate-fixation group recovered faster than the patients in the intramedullary nailing group, but the groups had similar results at six months postoperatively and the time of final follow-up. The rate of complications requiring revision surgery was low. Implant-related complications occurred frequently and could often be treated by implant removal.

A randomized controlled trial of nonoperative treatment versus open reduction and internal fixation for stable, displaced, partial articular fractures of the radial head: the RAMBO trial

Background

The choice between operative or nonoperative treatment is questioned for partial articular fractures of the radial head that have at least 2 millimeters of articular step-off on at least one radiograph (defined as displaced), but less than 2 millimeter of gap between the fragments (defined as stable) and that are not associated with an elbow dislocation, interosseous ligament injury, or other fractures. These kinds of fractures are often classified as Mason type-2 fractures. Retrospective comparative studies suggest that operative treatment might be better than nonoperative treatment, but the long-term results of nonoperative treatment are very good. Most experts agree that problems like reduced range of motion, painful crepitation, nonunion or bony ankylosis are infrequent with both nonoperative and operative treatment of an isolated displaced partial articular fracture of the radial head, but determining which patients will have problems is difficult. A prospective, randomized comparison would help minimize bias and determine the balance between operative and nonoperative risks and benefits.

Methods/Design

The RAMBO trial (Radial Head – Amsterdam – Amphia – Boston - Others) is an international prospective, randomized, multicenter trial. The primary objective of this study is to compare patient related outcome defined by the ‘Disabilities of Arm, Shoulder and Hand (DASH) score’ twelve months after injury between operative and nonoperative treated patients. Adult patients with partial articular fractures of the radial head that comprise at least 1/3^rd of the articular surface, have ≥ 2 millimeters of articular step-off but less than 2 millimeter of gap between the fragments will be enrolled. Secondary outcome measures will be the Mayo Elbow Performance Index (MEPI), the Oxford Elbow Score (OES), pain intensity through the ‘Numeric Rating Scale’, range of motion (flexion arc and rotational arc), radiographic appearance of the fracture (heterotopic ossification, radiocapitellar and ulnohumeral arthrosis, fracture healing, and signs of implant loosening or breakage) and adverse events (infection, nerve injury, secondary interventions) after one year.

Discussion

The successful completion of this trial will provide evidence on the best treatment for stable, displaced, partial articular fractures of the radial head.

Trial registration

The trial is registered at the Dutch Trial Register: NTR3413.

Extension test and ossal point tenderness cannot accurately exclude significant injury in acute elbow trauma

STUDY OBJECTIVE

Elbow injury is a common presentation at the emergency department (ED). There are no guidelines indicating which of these patients require radiography, whereas clinical decision rules for other limb injuries are widely accepted and resulted in less radiography and reduced waiting times. We aim to identify clinical signs that can be used to predict the need for radiography in elbow injury.

METHODS

A prospective observational study at 2 ED locations in the Netherlands was performed. For every eligible patient with acute elbow injury, elbow extension and addition of point tenderness at the olecranon, epicondyles, and radial head were evaluated for predicting the need for radiography (primary endpoint). A subgroup of patients was assessed by a blinded second investigator to analyze interobserver variability (secondary endpoint). All patients received anterior-posterior and lateral elbow radiographs. Fractures were treated according to current guidelines and patients were followed at outpatient clinics.

RESULTS

In total, 587 patients were included. Normal extension was observed in 174 patients (30%). Normal extension predicted absence of a fracture or isolated fat pad with 88% sensitivity and 55% specificity. Five patients with normal extension had a fracture that required surgery. Absence of point tenderness in patients with normal extension was observed in only 24 patients, of whom 3 showed a fracture and 1 required surgery. Addition of point tenderness to the extension test to predict absence of a fracture or isolated fat pad resulted in 98% sensitivity and 11% specificity. Interobserver analysis for extension and palpation of olecranon, epicondyles, and radial head resulted in κ values between 0.6 and 0.7.

CONCLUSION

In contrast with previous studies, ours shows that in acute elbow injury, the extension test alone or in combination with point tenderness assessment does not safely rule out clinically significant injury. Interobserver variability was substantial. We would not recommend the use of the extension test (+/- point tenderness assessment) as a clinical decision rule to guide radiologic diagnostics in acute elbow trauma.

Guideline on anterior cruciate ligament injury

The Dutch Orthopaedic Association has a long tradition of development of practical clinical guidelines. Here we present the recommendations from the multidisciplinary clinical guideline working group for anterior cruciate ligament injury. The following 8 clinical questions were formulated by a steering group of the Dutch Orthopaedic Association. What is the role of physical examination and additional diagnostic tools? Which patient-related outcome measures should be used? What are the relevant parameters that influence the indication for an ACL reconstruction? Which findings or complaints are predictive of a bad result of an ACL injury treatment? What is the optimal timing for surgery for an ACL injury? What is the outcome of different conservative treatment modalities? Which kind of graft gives the best result in an ACL reconstruction? What is the optimal postoperative treatment concerning rehabilitation, resumption of sports, and physiotherapy? These 8 questions were answered and recommendations were made, using the "Appraisal of Guidelines for Research and Evaluation" instrument. This instrument seeks to improve the quality and effectiveness of clinical practical guidelines by establishing a shared framework to develop, report, and assess. The steering group has also developed 7 internal indicators to aid in measuring and enhancing the quality of the treatment of patients with an ACL injury, for use in a hospital or practice.

Surfer wipe out by predator fish

Needlefish injuries, commonly reported in the Indo-Pacific region, have not been previously reported along the European coastlines. This case report describes a penetrating injury to the heel of a professional surfer during competition off the Portuguese coast. Diagnostic as well as therapeutic recommendations are made.

Recognising vascular causes of leg complaints in endurance athletes. Part 1: validation of a decision algorithm

Flow limitations in the iliac arteries of endurance athletes during exercise were previously ascribed solely to intravascular lesions. We postulate that functional kinking of the arteries can also result in flow limitations. However, the diagnostic tools in routine practice are not effective in diagnosing such flow limitations in a substantial proportion of athletes, mainly because these diagnostic tools do not measure in the provocative situations. Ninety-two symptomatic legs in 80 endurance athletes were examined with newly developed, sports-specific vascular tests. Thirty-five asymptomatic cyclists matched for working capacity served as the control subjects. Legs were classified as vascular or non-vascular following a decision algorithm, based upon the results of these diagnostic tests, excluding orthopaedic causes by the effects of specific treatment. Independently of this clinical classification, an alternative method was applied to find stable characteristics in the total patient group using factor analysis. This characterisation was based on scores on 14 test variables deriving from diagnostic tests that were not used in the decision algorithm, thus avoiding dependency between the clinical categorisation and the statistical categorisation. The hypothesis was that these characteristics were sufficiently sensitive to classify patients with vascular and non-vascular complaints. If so, these characteristics should correspond with the one derived from the decision algorithm. Following the decision algorithm, 58 legs (63%) were classified as vascular, 29 (32%) as non-vascular and 5 (5%) as inconclusive. The latter were considered non-vascular. In a substantial proportion of the vascular patients, kinking of the iliac arteries was identified as the major cause of flow limitation. The characteristics derived from factor analysis proved to classify 87% in agreement with the decision algorithm (kappa 0.56). The agreement is sufficient for validation of the clinical classification. The algorithm can therefore be applied in clinical situations to diagnose endurance athletes with flow limitations due to both intravascular lesions and kinking of the arteries.

Recognising vascular causes of leg complaints in endurance athletes. Part 2: the value of patient history, physical examination, cycling exercise test and echo-Doppler examination

Leg complaints at maximal exercise in endurance athletes may have many causes, including arterial flow limitations in the iliac arteries. Such flow limitations can evolve into serious health problems due to increasing intravascular obstruction or even complete obstruction as a result of dissection or thrombosis. Early detection is therefore of clinical importance, but conventional diagnostic tools often prove inadequate. In the current study simple sports-specific tests are examined for their diagnostic power. Test variables derived from patient history, physical examination, cycling exercise testing followed by arterial pressure measurements at the ankle, and echo-Doppler examination with provocative manoeuvres were tested in 92 symptomatic legs (80 patients). A validated clinical classification acted as a reference. Several test variables proved useful. However, no single test variable combined a high sensitivity with a high specificity. Multivariate testing resulted in the correct classification of 91 % of patients, reaching a sensitivity of 0.90 and specificity of 0.93 (kappa 0.76). Four patients wrongly classified as non-vascular suffered from kinking in the common iliac artery that could not be visualised using the diagnostic tools currently available in this study.

IN CONCLUSION

simple sports-specific tests accurately diagnose iliac artery obstruction in endurance athletes.

Recurrent traumatic dislocation of the hip joint at the age of 13 and 17 years. A case report

We report a case of a recurrent traumatic dislocation of the hip joint in a young man at the age of 13 and 17. The patient had retroversion of the femoral neck, instead of a physiological anteversion. We found no consensus about the management of a recurrent traumatic dislocation of the hip joint in the literature. The various therapeutic options are discussed. We advised posterior capsulorraphy with femoral rotation osteotomy. The patient refused surgery.

[Patients without referral treated in the emergency room: patient characteristics and motives]

OBJECTIVES

To determine the motives of patients to directly visit the Emergency Department for medical treatment without seeing their family practitioner first and to establish the characteristics of this group.

DESIGN

Prospective, descriptive.

METHOD

Of the surgical patients attending the Emergency Room (ER) of Utrecht University Hospital, the Netherlands, between 1st April and 25th June 1997, the demographic and diagnostic data of the non-referred patients were compared with those of patients referred by the general practitioner (GP). The non-referred patients were asked about their reasons to attend without referral.

RESULTS

A total of 1026 patients visited the ER at their own initiative: 603 males and 423 females. The most frequent reasons for the direct visits were 'had not thought of their family practitioner' (48%) and 'wants help that can only be provided in a hospital' (30%). The self-referring patients differed from the 962 referred patients in severity of the trauma: 76% versus 39% had a relatively minor trauma; sort of trauma: 19% versus 4% had a sport trauma; place of residence: 57% versus 45% lived in the near vicinity of the hospital. Of the self-referring patients 57% visited the hospital out of office hours, versus 39% of the referred patients.

CONCLUSION

A large part of the non-referred patients visited the ER unnecessarily and should actually have consulted their GP. These were mainly young adults with minor injuries or sports injuries who lived close to the hospital. Important factors were unfamiliarity with or lack of understanding of the existing regulations.

[Injuries missed in diagnosing severely injured accident victims in the emergency room]

OBJECTIVE

To determine the incidence of injuries missed in the emergency room (ER) and the factors involved.

DESIGN

Retrospective.

METHOD

Of patients with an Hospital trauma index-injury severity score (HTI-ISS) > or = 14 who were treated in 1996 in the ER of the Academic Hospital Utrecht, the Netherlands, it was studied in the computerized database whether injuries had been missed. A missed injury was defined as an injury not identified during assessment in the Emergency department, but identified later in the hospital or rehabilitation centre. The groups of patients with and without missed injuries were compared with each other regarding possible risk factors for missing injuries.

RESULTS

Of 376 severely injured patients in 1996, 329 patients had sufficient follow-up documentation. In 37 patients (11%) of these 329 patients 47 injuries were missed. Fractures were the injuries most frequently missed (n = 25), followed by nerve tissue injuries (n = 14). There were consequences for the treatment in 13 of these patients (35%). Patients with missed injuries had a higher HTI-ISS, were more often primarily referred to the ER and arrived more often at night compared with patients without missed injuries. The two patient groups did not differ at to experience of the physicians.

Improved results in treatment of femoral shaft fractures with the unreamed femoral nail? A multicenter experience

OBJECTIVES

The first studies of intramedullary nailing with the Arbeidsgemeinschaft fur Osteosynthesefragen (AO) unreamed femoral nail in selected clinics showed favorable results. Daily practice, however, is that femoral fractures are treated in a variety of clinics by a mixture of surgeons. To evaluate whether similar results could be obtained in general practice, a prospective multicenter trial was undertaken, involving a variety of university and general hospitals in one country.

METHODS

Between August of 1994 and June of 1996, 122 patients with 129 traumatic femoral shaft fractures treated with the unreamed femoral nail in eight hospitals were included in this study. Patients who had a reoperation with an unreamed femoral nail or patients with a pathologic fracture of the femur were excluded from this part of the study. Of these patients, 58 patients had multiple injuries, and 33 of the fractures had open soft-tissue injury.

RESULTS

Postoperative infection occurred in four patients; the nail broke in one patient. In total, nine patients (6.6 %) sustained general complications, five of which developed adult respiratory distress syndrome (3.6%). Non-union occurred in seven patients (5.1%) and delayed union occurred in four cases (2.9%) with a reintervention rate of 6.6%.

CONCLUSION

In this study, a decrease in the number of patients who develop adult respiratory distress syndrome through the use of a thin unreamed nail could not be demonstrated. The promising early callus formation and good consolidation mentioned in previous studies could not be confirmed. We find that the technical and clinical results in this study of unreamed femoral nailing in a mixture of clinics and by a variety of surgeons are comparable to the results of reamed nailing in the literature and are not as favorable as in the previous reports.

[Reasonably good results of Hansson's pins in elderly patients with a medial femoral neck fracture]

OBJECTIVE

To establish the result of treatment of medial femoral neck fractures in patients aged 70 years and older using Hansson pins introduced percutaneously.

DESIGN

Descriptive.

SETTING

Department of Surgery, University Hospital Utrecht, the Netherlands.

METHOD

Ninety-two patients aged 70 years and older with a medial femoral neck fracture were treated in the period 1986-1994 with osteosynthesis using Hansson pins. The case histories and X-rays of these patients were analysed. All fractures were classified according to Garden and Pauwels, with Singh classification of bone quality. The result of the operation was evaluated with the aid of postoperative X-rays.

RESULTS

The patients' mean age was 80 years. There were 16 non-dislocated Garden grades I or II and 71 dislocated Garden III and IV fractures. Four patients died within 30 days after the operation. At the time of the follow-up (after an average of 4.5 years), 45 patients had died. Thirty-three patients in all developed a fracture-related complication; 27 of them underwent reoperations during which 19 (21%) were fitted with a head-neck prosthesis or a total hip prosthesis. All reoperations which included implantation of a prosthesis were performed in dislocated Garden grades III and IV fractures. In fractures of this type in which postoperative repositioning proved inadequate, more reoperations were performed than in the Garden grades III and IV fractures with correct posture.

CONCLUSION

Treatment of a medial femoral neck fracture in elderly patients by means of internal fixation with percutaneously introduced Hansson pins gives results similar to those of other types of internal fixation. This is a good operation for Garden grades I and II fractures, whereas in Garden grades III and IV fractures in which repositioning is impossible, internal fixation should be refrained from and a head-neck prosthesis should be implanted in one session.

[Outpatient sports clinic, first impressions]

OBJECTIVE

To review the first year of the outpatient sports clinic in Utrecht University Hospital (AZU), and to demonstrate the feasibility of such a sports clinic.

DESIGN

Retrospective study (period: April 1993-March 1994).

SETTING

University Hospital Utrecht, the Netherlands.

METHODS

The patients attended the sports clinic either on referral or on their own initiative. The specialist directly entered the patients' data onto a registration form.

RESULTS

Over a period of one year 461 consultations where given to 271 patients. The patients' average age was 31 years. The commonest sports were soccer, running and tennis. The lower limb was the commonest site of injury (79%) and overuse injuries predominated. For 57% of the patients therapy was instituted, which consisted in 67% of the cases of physiotherapy and in 13% of operative intervention.

CONCLUSION

The outpatient sports clinic appears to be visited in particular by senior athletes with chronic complaints caused by surmenage injuries or with residual complaints following acute injuries. Future intramural sports medicine will have to deal not only with treatment of injuries as presented at the sports clinic, but also with prevention of chronic complaints resulting from acute injuries in this group of athletes.

Radial head fractures: operative or conservative treatment? The Greek temple model

An important point in any communication on fracture treatment is agreement on classification of the fracture to be discussed. for fractures of the radial head there are several useful classification systems. The well-recognized Mason classification is particularly useful in the treatment of radial head fractures. It is however important to realize that the usefulness of this classification system is limited to radial head fractures without associated injury. In deciding on operative or conservative treatment it is therefore essential to subdivide fractures of the radial head into simple or complex fractures. As stated, the Mason classification system is most useful in deciding on treatment of simple fractures, that is to say fractures without an additional fracture or ligamentous injury. Type I fractures should be treated conservatively because of their excellent prognosis. The treatment of type II fractures is still controversial. The decision for osteosynthesis is not only based on the fracture configuration but certainly also on the talent of the surgeon involved. Immediate resection is not considered acceptable in this type of fracture. In type III fractures however, immediate excision is an acceptable method of treatment as long as there is no associated fracture or ligamentous injury. In deciding whether or not there is a complex injury the "Greek Temple" model is very useful. In this model the ulna and radius are seen as two "pillars" which support the "roof" of the distal humerus. The connection between the roof and the pillar on the ulnar side is formed by a ligament, on the radial side there is only the tension of the muscles. With this model it is easy to memorize which associated injuries form the basis of a complex injury, in which excision of the radial head or conservative treatment can cause ulnohumeral subluxation or late radioulnar instability. Treatment in these complex injuries should therefore in principle consist of reconstruction or temporary fixation of the radial pillar, and if necessary temporary stabilization of the ulnar pillar.

Brachial artery lesions after cardiac catheterisation

In a prospective study the incidence of brachial artery injury after cardiac catheterisation and the factors involved were examined. The main aim of the study however was to determine whether immediately after the injury it was possible to predict if long-term ischaemic symptoms would occur if conservative treatment was used. Five-hundred and two patients were seen pre- and post-catheterisation. Examination included inspection, palpation, segmental blood pressure measurements before and after exercise, Doppler score evaluation and in selected cases, angiography. Twenty-nine patients (5.8%) had postcatheterisation complaints of pain, pallor, hypoaesthesia or paraesthesia. A postcatheterisation wrist blood pressure index of less than 0.85, was found in 97 patients (19%). This included 22 occlusions confirmed by angiography (4.5%). Cardiac valve disease and previous catheterisations were a risk factor. All brachial artery injuries, that is to say those patients with a postcatheterisation wrist index of less than 0.85, were treated conservatively and reviewed at 6 months. Nineteen of the 72 patients seen at follow-up still had ischaemic symptoms on effort. Postinjury complaints of pain and paraesthesia had no value in predicting whether or not ischaemic symptoms would persist, whilst angiography, wrist pulse palpation, capillary refill time and the wrist pressure index at rest had very little predictive value. The Doppler score, pallor and coldness of the hand all had some value. The best predictor of long-term ischaemic symptoms was the wrist pressure index after exercise. Brachial artery injury occurs frequently after cardiac catheterisation and ischaemic symptoms thereafter are usually mild.(ABSTRACT TRUNCATED AT 250 WORDS)

Minimal osteosynthesis of lateral malleolar fractures

An oblique fracture of the lateral malleolus caused by a supination-external rotation injury (Danis-Weber type B) is the most common ankle fracture and is preferably treated operatively. Interfragmentary compression and lateral plating are generally used as the method of osteosynthesis. As an alternative two posteriorly inserted lag screws in the antero-posterior direction were used in 18 patients. In all but one good to excellent results as regards pain, function and radiographic appearance were achieved. The advantages of less extensive dissection, smaller amounts of foreign material and shorter operation time tend to make this the technique of choice for this type of fracture.

Surgical treatment of patients with a carotid artery occlusion and a contralateral stenosis

Patients with a carotid artery occlusion and a haemodynamically significant contralateral stenosis have an increased risk of incurring a stroke. Based on the results of a series of 33 patients our conclusion is that the surgical therapy of choice should be endarterectomy of the stenotic artery irrespective of which side the symptoms are located on. Only those patients who continue to have TIA's on the side of the occlusion after endarterectomy of the stenotic side should be considered for an ECIC bypass.