Prospective randomized controlled trial: early weight bearing after conservative treatment of Weber B ankle fractures (pancake trial)

PURPOSE

Different studies have shown that weightbearing is safe in stable transsyndesmotic, isolated lateral simple ankle fractures. Despite this evidence, AO guidelines still recommend immobilization with above-the-knee cast for 4-6 weeks for these fractures. The objective of this study was to compare the outcomes of mobilization and weightbearing to those of immobilization and non-weightbearing in patients with stable transsyndesmotic, lateral isolated simple ankle fractures.

METHODS

Fifty patients were randomly assigned to permissive weightbearing in a walking boot or non-weightbearing immobilization using a below-the-knee cast. Primary outcome was ankle functionality as scored by the Olerud-Molander Ankle Score (OMAS). Secondary outcomes were radiological displacement of fracture, range of motion (ROM), calf circumference, and RAND 36-item health survey. Patients were in follow-up for 24 months.

RESULTS

Ankle functionality after six and twelve weeks was significantly higher for the intervention group, with respectively 30 points (p = 0.001) and 10 points (p = 0.015) of difference. ROM improved significantly in the intervention group after six weeks. All fractures showed radiological progression of fracture healing. RAND 36-item showed differences in both physical (60.3 vs. 46.3, p = 0.017) and mental (78.5 vs. 58.2, p = 0.034) components in favor of the intervention group. In 16% of patients who initially showed stable fractures on radiographic imaging, joint dislocation was identified on weightbearing radiographs prior to randomization, leading to exclusion.

CONCLUSION

Weightbearing and mobilization using a walking boot may be a safe treatment for patients with stable Weber B fractures.

The first experience with the Dextile anatomical mesh in laparoscopic inguinal hernia repair

BACKGROUND

The Dextile Anatomical mesh (Medtronic) is a polypropylene heavyweight mesh and has a 3D patented anatomical shape which adapts to the contours of the extra-peritoneal inguinal region without the need for fixation, potentially reducing the risk of hernia recurrence and chronic post-operative pain. This retrospective study will be the first study to assess the outcomes of the Dextile Anatomical mesh compared to another three-dimensional mesh, the 3DMax mesh (Bard).

METHODS

Between 2019 and 2022, all patients who underwent an elective unilateral inguinal hernia repair were assessed. 416 patients in the Dextile Anatomical mesh group and 540 patients in the 3DMax mesh group were included. Outcomes were intra- and post-operative complications, inguinal hernia recurrence and chronic post-operative inguinal pain.

RESULTS

No significant differences were found between the two groups regarding intra- and post-operative complications including wound infection, antibiotic use, hematoma, seroma, urinary retention and delayed wound healing. 1-year recurrence rate was comparable for the Dextile Anatomical mesh group and the 3DMax mesh group, respectively, 3.8% and 3.0%, P = 0.45. Chronic post-operative inguinal pain was similar for the Dextile Anatomical mesh (3.4%) and the 3DMax mesh (3.0%), P = 0.72.

CONCLUSION

This retrospective study comparing the relatively new Dextile Anatomical mesh (Medtronic) with the 3D Max mesh (Bard) in unilateral inguinal hernia repair showed that both meshes are safe and effective to use. There were no significant differences in intra-operative outcomes, recurrence rates and chronic post-operative inguinal pain.

Using an E-Health Application for Post-operative Monitoring After Inguinal Hernia Repair: A Feasibility Study

BACKGROUND

E-Health care is already well established in some (non-) surgical specialties and is considered as a means of improving patient-centred care. Considering the demand of remote health care changes, especially in the COVID-19 pandemic, it is essential to investigate the feasibility of e-Health care within one of the most performed surgery procedures: inguinal hernia repair.

METHODS

A total of 60 patients used the e-Health application in this study compliant. Primary objectives were to investigate the accuracy of the "deviating post-operative course" alerting by the e-Health application. Secondary objectives included patient perspective and e-Health costs analysis.

RESULTS

Forty-four patients reported no deviation in the post-operative course using the e-Health application of which 93.2% (n = 41) was in concordance with the findings during standard follow-up. Within 16 patients reporting a deviating post-operative course, a true complication was found in 25% (n = 4). Based on in-hospital costs, a hypothetical e-Health follow-up scenario was more expensive (€59.5 per patient) than current standard follow-up care (€28.2 per patient). Usage of the e-Health application showed a high perceived overall patient satisfaction: 4.2 (on a Likert-scale of 1-5).

CONCLUSION

An e-Health application is a promising tool for identifying patients who require in-person or phone follow-up assessment. Patients' perspectives surveys revealed high potential and willingness of using this application. A hypothetical e-Health follow-up scenario showed to be more expensive compared to current standard follow-up. If the identified (dis)advantages can be improved, e-Health follow-up care appears to be promising in terms of safety and feasibility. Future studies can leverage on this study and further investigate the use of e-Health within the field of general surgery.

Two cases of near-fatal gamma-butyrolactone (GBL) ingestion and intoxication

We present two cases of GBL intoxication. Patient A is a 45-year old man who lost consciousness after drinking a clear unknown liquid. He was brought to the Emergency Departement (ED) after he was intubated. His partner notified the liquid could be GBL, a prodrug for GHB. He regained consciousness 16 hours later in the intensive care unit (ICU) where he could be successfully extubated. Patient B is a 25-year old man who was found unconscious at home with next to him an empty bottle of GBL. He was intubated in the intensive care unit. He could be extubated after 12 hours. GBL intoxication is becoming a more frequent problem and overdosage of GBL can rapidly occur because of its rapid onset and high potency when compared to GHB. We discuss the clinical course and complications after GBL ingestion and intoxication.

Fatal cerebral oedema in adult diabetic ketoacidosis

In this report, a case of adult onset fatal cerebral oedema as a rare complication of diabetic ketoacidosis (DKA) is described and confirmed at post-mortem pathological examination. The pathogenesis of cerebral oedema due to DKA is still unknown. Potential mechanisms include the administration of sodium bicarbonate leading to intracellular acidosis, excessive fluid infusion causing swelling of brain tissue, or reduction of plasma osmolarity by a rapid fall in glucose levels causing osmotic swelling.

Treatment of dilated venous bypass grafts with an expanded polytetrafluoroethylene-covered nitinol endoprosthesis

An above-knee femoropopliteal bypass graft constructed of great saphenous vein became dilated in 2 patients 12 and 25 years after surgery. Both patients had several concomitant disorders. The dilations were treated by insertion of an expanded polytetrafluoroethylene-covered nitinol endoprosthesis. There were no major procedural complications. One minor endoleak that developed immediately after endograft placement resolved within 6 weeks. The leg swelling subsided, and the endoprostheses have remained patent for 18 and 24 months, respectively. To our knowledge, these were the first cases in which an endoprosthesis was used to treat dilation of a venous bypass graft.

Unexpected fatal neurological deterioration after successful cardio-pulmonary resuscitation and therapeutic hypothermia

A 77-year-old woman was admitted to the intensive care unit after successful cardiopulmonary resuscitation for out-of-hospital cardiac arrest due to pulseless electrical activity. She was treated with mild therapeutic hypothermia to minimise secondary anoxic brain damage. After a 24 h period of therapeutic hypothermia with a temperature of 32.5 degrees C, the patient was rewarmed and sedation discontinued. Neurological evaluation after 24 h revealed a maximum Glasgow Coma Score of E4M4Vt with spontaneous breathing. However the patient developed a fever reaching 39 degrees C for several hours that was unresponsive to conventional cooling methods. In the subsequent 24 h patient developed apnoea, hypotension and bradycardia with deterioration of the coma score. Diabetes insipidus was confirmed. Cerebral CT was performed which showed diffuse brain oedema with herniation and brainstem compression. The patient died within hours. Autopsy showed massive brain swelling and tentorial herniation. Hyperthermia possibly played a pivotal role in the development of this fatal insult to this vulnerable brain after cardiac arrest and therapeutic hypothermia treatment. The acute histopathological alterations in the brain, possibly caused by the deleterious effects of fever after cardiac arrest in human brain, may be considered a new observation.

[Isolated orchidodynia as the initial symptom of aneurysm of the abdominal aorta]

A 67-year-old man presented with isolated pain of the right testicle. He was admitted and treated for epididymitis. His symptoms did not improve and lower abdominal pain developed. After hypotension and severe anaemia (Hb 2.1 mmol/l) had developed, abdominal echography was carried out, revealing a ruptured abdominal aortic aneurysm. The patient underwent surgical repair with an aortic-bifemoral prosthesis and was ultimately discharged without further complications. This is the fourth report in the literature of orchidodynia as referred pain from an aneurysm of the abdominal aorta.

Slaughter pigs are commonly infected by closely related but distinct gastric ulcerative lesion-inducing gastrospirilla

An association between (unculturable) gastrospirillum-like organisms (GLO) and ulcerative lesions in the pars oesophagea in stomachs of swine has been claimed. In dogs GLO detected by microscopy may represent several Helicobacter species or subspecies. Therefore we investigated which Helicobacter spp. are present in stomachs of swine and their possible association with ulcerative lesions of the pars oesophagea. The presence of Helicobacter spp. in the antrum and pars oesophagea in 122 stomachs of slaughter swine was determined by microscopy (n = 122), by culture on selective and nonselective media (n = 112), and by a genus-specific 16S ribosomal DNA (rDNA) PCR (n = 80). GLO could not be cultured. Phylogenetic analysis of 43 16S rDNA fragments (out of 54 PCR-positive biopsy specimens) revealed the presence of Helicobacter heilmannii type 1 in 42 of them. This correlated with the presence of bacteria with GLO morphology. Helicobacter bilis 16S rDNA was amplified directly from one sample harboring bacteria with H. bilis morphology. The association between Helicobacter spp. and gastric lesions was investigated with a second group of 41 pigs with (n = 21 cases) or without (n = 20 controls) gastric lesions. Fifteen of the 21 cases were positive by PCR or microscopy, compared to 7 of 20 of the controls (P = 0.03). 16S rDNA sequence analysis of 7 of 14 PCR-positive cases revealed the presence of H. heilmannii type 1. Microscopy showed bacteria with GLO morphology. One sample (cases) was culture negative but PCR positive for Helicobacter pullorum-related 16S rDNA. In conclusion, our findings indicate that H. heilmannii type 1 is the predominant Helicobacter spp. in the stomachs of pigs and that its presence is associated with ulcerative lesions in the pars oesophagea.

A bacterial genome in flux: the twelve linear and nine circular extrachromosomal DNAs in an infectious isolate of the Lyme disease spirochete Borrelia burgdorferi

We have determined that Borrelia burgdorferi strain B31 MI carries 21 extrachromosomal DNA elements, the largest number known for any bacterium. Among these are 12 linear and nine circular plasmids, whose sequences total 610 694 bp. We report here the nucleotide sequence of three linear and seven circular plasmids (comprising 290 546 bp) in this infectious isolate. This completes the genome sequencing project for this organism; its genome size is 1 521 419 bp (plus about 2000 bp of undetermined telomeric sequences). Analysis of the sequence implies that there has been extensive and sometimes rather recent DNA rearrangement among a number of the linear plasmids. Many of these events appear to have been mediated by recombinational processes that formed duplications. These many regions of similarity are reflected in the fact that most plasmid genes are members of one of the genome's 161 paralogous gene families; 107 of these gene families, which vary in size from two to 41 members, contain at least one plasmid gene. These rearrangements appear to have contributed to a surprisingly large number of apparently non-functional pseudogenes, a very unusual feature for a prokaryotic genome. The presence of these damaged genes suggests that some of the plasmids may be in a period of rapid evolution. The sequence predicts 535 plasmid genes >/=300 bp in length that may be intact and 167 apparently mutationally damaged and/or unexpressed genes (pseudogenes). The large majority, over 90%, of genes on these plasmids have no convincing similarity to genes outside Borrelia, suggesting that they perform specialized functions.

Occurrence and characterization of gastric Helicobacter spp. in naturally infected dogs

Helicobacter-like organisms are frequently observed in the stomach of dogs but the relationship between these microorganisms and gastric pathology has not been clearly established. Different species of helicobacters are known to be present in the canine stomach but their specific prevalence in naturally infected dogs is unknown. The aims of this study were to isolate and characterize helicobacters in canine gastric biopsies, to compare the commonly used tests for the identification of Helicobacter spp. and to determine the occurrence of these species in dogs. Twenty-three out of 25 dogs (92%) were positive for Helicobacter-like organisms in cytological screening. Culture was successful from biopsies of 5/25 dogs. The isolates were analyzed by electron microscopy, biochemical and physiological tests, whole protein analysis and 16S rDNA sequencing. Helicobacter felis was identified in four samples and Helicobacter bizzozeronii in one sample. Only the whole protein analysis in combination with electron microscopy was able to clearly discriminate the two species. Compared to the high prevalence of Helicobacter-like organisms, the occurrence of H. felis and H. bizzozeronii, was low (17 and 4%, respectively). No Flexispira rappini-like organisms or H. salomonis were detected. Electron microscopy revealed that H. bizzozeronii-like microorganisms were present in three additional biopsies where we were unable to culture any Helicobacter-like organisms. These observations indicate that in the stomach of dogs not all helicobacters are culturable. The unculturable bacteria appeared to be the prevalent ones and may represent different spiral organisms. The presence of distinct helicobacters with different characteristics can reflect different roles in the pathogenesis of canine gastric disease.

Genomic sequence of a Lyme disease spirochaete, Borrelia burgdorferi

The genome of the bacterium Borrelia burgdorferi B31, the aetiologic agent of Lyme disease, contains a linear chromosome of 910,725 base pairs and at least 17 linear and circular plasmids with a combined size of more than 533,000 base pairs. The chromosome contains 853 genes encoding a basic set of proteins for DNA replication, transcription, translation, solute transport and energy metabolism, but, like Mycoplasma genitalium, it contains no genes for cellular biosynthetic reactions. Because B. burgdorferi and M. genitalium are distantly related eubacteria, we suggest that their limited metabolic capacities reflect convergent evolution by gene loss from more metabolically competent progenitors. Of 430 genes on 11 plasmids, most have no known biological function; 39% of plasmid genes are paralogues that form 47 gene families. The biological significance of the multiple plasmid-encoded genes is not clear, although they may be involved in antigenic variation or immune evasion.

Telomeres of the linear chromosomes of Lyme disease spirochaetes: nucleotide sequence and possible exchange with linear plasmid telomeres

Bacteria of the spirochaete genus Borrelia have linear chromosomes about 950 kbp in size. We report here that these linear chromosomes have covalently closed hairpin structures at their termini that are similar but not identical to those reported for linear plasmids carried by these organisms. Nucleotide sequence analysis of the chromosomal telomeric regions indicates that unique, apparently functional genes lie within a few hundred bp of each of the telomeres, and that there is an imperfect 26 bp inverted repeat at the two telomeres. In addition, we characterize a major chromosomal length polymorphism within the right telomeric regions of various Borrelia isolates, and show that sequences similar to those near the right telomere are often found on linear plasmids in B. burgdorferi (sensu stricto) isolates from nature. Sequences similar to a number of other regions of the chromosome, including those near the left telomere, were not found on B. burgdorferi plasmids. These observations suggest that there has been historical exchange of genetic information between the linear plasmids and the right end of the linear chromosome.

Characterization of cp18, a naturally truncated member of the cp32 family of Borrelia burgdorferi plasmids

We have mapped the genes encoding the antigenic lipoproteins OspE and OspF to an approximately 18-kb circular plasmid in Borrelia burgdorferi N40. Sequencing and restriction mapping have revealed that this plasmid, cp18, is homologous to an 18-kb region of the cp32 circular plasmids found in the Lyme disease spirochetes. Our data show that cp18 may have arisen from an ancestral cp32 plasmid by deletion of a 14-kb region of DNA, indicating that a significant portion of the cp32 plasmid is not essential in cis for plasmid maintenance. These findings suggest that a relatively small recombinant plasmid capable of being stably maintained in B. burgdorferi could be constructed from a cp32 plasmid.

Homology throughout the multiple 32-kilobase circular plasmids present in Lyme disease spirochetes

We have characterized seven different 32-kb circular plasmids carried by Borrelia burgdorferi isolate B31. Restriction endonuclease recognition site mapping and partial sequencing of these plasmids indicated that all seven are probably closely related to each other throughout their lengths and have substantial relationships to cp8.3, an 8.3-kb circular plasmid of B. burgdorferi sensu lato isolate Ip21. With the addition of the seven 32-kb plasmids, this bacterial strain is known to carry at least 10 linear and 9 circular plasmids. Variant cultures of B. burgdorferi B31 lacking one or more of the 32-kb circular plasmids are viable and, at least in some cases, infectious. We have examined a number of different natural isolates of Lyme disease borreliae and found that all of the B. burgdorferi sensu stricto isolates and most of the B. burgdorferi sensu lato isolates tested appear to carry multiple 32-kb circular plasmids related to those of B. burgdorferi B31. The ubiquity of these plasmids suggests that they may be important in the natural life cycle of these organisms. They may be highly conjugative plasmids or prophage genomes, which could prove to be useful in genetically manipulating B. burgdorferi.