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Background: A variety of diagnostic imaging techniques is available for excluding or confirming chronic osteomyelitis. Until now, an evidence-based algorithmic model for choosing the most suitable imaging technique has been lacking. The objective of this study was to determine the accuracy of current imaging modalities in the diagnosis of chronic osteomyelitis.Methods: A systematic review and meta-analysis of the literature was conducted with a comprehensive search of the MEDLINE, EMBASE, and Current Contents databases to identify clinical studies on chronic osteomyelitis that evaluated diagnostic imaging modalities. The value of each imaging technique was studied by determining its sensitivity and specificity compared with the results of histological analysis, findings on culture, and clinical follow-up of more than six months.Results: A total of twenty-three clinical studies in which the accuracy was described for radiography (two studies), magnetic resonance imaging (five), computed tomography (one), bone scintigraphy (seven), leukocyte scintigraphy (thirteen), gallium scintigraphy (one), combined bone and leukocyte scintigraphy (six), combined bone and gallium scintigraphy (three), and fluorodeoxyglucose positron emission tomography (four) were included in the review. No meta-analysis was performed with respect to computed tomography, gallium scintigraphy, and radiography. Pooled sensitivity demonstrated that fluorodeoxyglucose positron emission tomography was the most sensitive technique, with a sensitivity of 96% (95% confidence interval, 88% to 99%) compared with 82% (95% confidence interval, 70% to 89%) for bone scintigraphy, 61% (95% confidence interval, 43% to 76%) for leukocyte scintigraphy, 78% (95% confidence interval, 72% to 83%) for combined bone and leukocyte scintigraphy, and 84% (95% confidence interval, 69% to 92%) for magnetic resonance imaging. Pooled specificity demonstrated that bone scintigraphy had the lowest specificity, with a specificity of 25% (95% confidence interval, 16% to 36%) compared with 60% (95% confidence interval, 38% to 78%) for magnetic resonance imaging, 77% (95% confidence interval, 63% to 87%) for leukocyte scintigraphy, 84% (95% confidence interval, 75% to 90%) for combined bone and leukocyte scintigraphy, and 91% (95% confidence interval, 81% to 95%) for fluorodeoxyglucose positron emission tomography. The sensitivity of leukocyte scintigraphy in detecting chronic osteomyelitis in the peripheral skeleton was 84% (95% confidence interval, 72% to 91%) compared with 21% (95% confidence interval, 11% to 38%) for its detection of chronic osteomyelitis in the axial skeleton. The specificity of leukocyte scintigraphy in the axial skeleton was 60% (95% confidence interval, 39% to 78%) compared with 80% (95% confidence interval, 61% to 91%) for the peripheral skeleton.Conclusions: Fluorodeoxyglucose positron emission tomography has the highest diagnostic accuracy for confirming or excluding the diagnosis of chronic osteomyelitis. Leukocyte scintigraphy has an appropriate diagnostic accuracy in the peripheral skeleton, but fluorodeoxyglucose positron emission tomography is superior for detecting chronic osteomyelitis in the axial skeleton. [ABSTRACT FROM AUTHOR]

Objective: To cope with emergency departments (EDs) being progressively overcrowded, the concept of specialized emergency nurses (SENs) was conceived. In this study, the ability of SENs to treat ankle/foot injuries was assessed., Methods: Regular emergency nurses were trained in a 2-day session that addressed all aspects of ankle/foot injuries. A randomized controlled trial was set up in which the diagnostic accuracy of SENs was compared with that of house officers (HOs). Secondary outcome parameter was patient satisfaction measured by a standardized questionnaire., Results: In total, 512 consecutive patients were included. The sensitivity of SENs was 0.94 (95% confidence interval [CI], 0.78-0.99) compared with 0.78 (95% CI, 0.57-0.91) of HOs. Specificity was 0.94 (95% CI, 0.90-0.97) for SENs compared with 0.95 (95% CI, 0.91-0.98) for HOs. The delivered care by SENs was found to be significantly better and the median waiting time at the ED was significantly reduced (21 minutes for SENs vs 32 minutes for HOs)., Conclusions: Specialized emergency nurses are capable of assessing and treating ankle/foot injuries accurately with excellent patient satisfaction and with a reduction of waiting times. Other injury-specific courses are now developed for this approach.

Study Design: Multicenter prospective randomized trial., Objective: To test the hypotheses that thoracolumbar AO Type A spine fractures without neurologic deficit, managed with short-segment posterior stabilization will show an improved radiographic outcome and at least the same functional outcome as compared with nonsurgically treated thoracolumbar fractures., Summary of Background Data: There are various opinions regarding the ideal management of thoracolumbar Type A spine fractures without neurologic deficit. Both operative and nonsurgical approaches are advocated., Methods: Patients were randomized for operative or nonsurgical treatment. Data sampling involved demographics, fracture classifications, radiographic evaluation, and functional outcome., Results: Sixteen patients received nonsurgical therapy, and 18 received surgical treatment. Follow-up was completed for 32 (94%) of the patients after a mean of 4.3 years. At the end of follow-up, both local and regional kyphotic deformity was significantly less in the operatively treated group. All functional outcome scores (VAS Pain, VAS Spine Score, and RMDQ-24) showed significantly better results in the operative group. The percentage of patients returning to their original jobs was found to be significantly higher in the operative treated group., Conclusions: Patients with a Type A3 thoracolumbar spine fracture without neurologic deficit should be treated by short-segment posterior stabilization.

Study Design: Retrospective study and review of literature., Objectives: Study of demographic data concerning spinal fractures caused by horse riding, classification of fractures according to the AO and Load Sharing classifications, evaluation of mid-term radiological results and long-term functional results., Methods: A review of medical reports and radiological examinations of patients presented to our hospital with horse riding-related spine fractures over a 13-year period; long-term functional follow-up is performed using the Roland Morris Disability Questionnaire (RMDQ-24)., Results: Thirty-six spine fractures were found in 32 patients. Male to female ratio is 1:7. Average age is 33.7 years (8-58 years). The majority of the fractures (78%) are seen at the thoracolumbar junction Th11-L2. All but two patients have AO type A fractures. The average Load Sharing Classification score is 4.9 (range 3-9). Neurological examinations show ASIA/Frankel E status for all patients. Surgical treatment is performed on ten patients. Mean follow-up for radiological data is 15 months (range 3-63). Functional follow-up times range from 1 to 13 years with an average follow-up of 7.3 years. Mean RMDQ-24 score for all patients is 5.5 (range: 0-19), with significantly different scores for the non-operative and surgical group: 4.6 vs 8.1. Twenty-two percent of the patients have permanent occupational disabilities and there is a significant correlation between occupational disability and RMDQ-24 scores., Conclusions: Not only are short-term effects of spine fractures caused by horse riding substantial but these injuries can also lead to long-term disabilities.

Objectives: In the quest for a cost-effective and quality-preserving solution to manage crowding in the emergency department, the possibility of deploying regular emergency nurses for the treatment of acute ankle injuries was investigated. The aim of this study is to compare the diagnostic accuracy of emergency nurses with that of senior house officers in interpreting ankle and foot radiographs., Methods: A prospective study comparing the assessment of 60 radiographs (30 feet and 30 ankles) by 16 emergency nurses before and after an educational session was performed. Each subset of 30 radiographs contained 12 fractures, hand-picked by a radiologist to represent everyday traumatology in the emergency department. The control group consisted of eight senior house officers representing everyday expertise. The outcome of the diagnostic assessment, represented as the pooled sensitivity and specificity for both groups, was compared using Z-statistics., Results: Before the training session, the specialized emergency nurse group showed a sensitivity of 0.87 (confidence interval 0.83-0.91) compared with 0.93 (confidence interval 0.88-0.96) for the control group (P = 0.05). The specificity of specialized emergency nurses was 0.87 (confidence interval 0.81-0.92) compared with 0.93 (confidence interval 0.89-0.95) for the senior house officers (P < 0.05). After the training session, specialized emergency nurse diagnostic parameters did not differ significantly from the control group, displaying a sensitivity of 0.89 (confidence interval 0.86-0.92) and specificity of 0.92 (confidence interval 0.87-0.95)., Conclusion: Before the training session, the specialized emergency nurse group showed a significantly lower accuracy than the SHO group. After training, however, the diagnostic accuracy did not differ significantly between groups. Therefore, we conclude that emergency nurses are able to accurately interpret foot and ankle radiographs after a short educational session.

Objectives: The ED is often confronted with long waiting periods. Because of the progressive shortage in general practitioners, further growth is expected in the number of patients visiting the ED without consulting a general practitioner first. These patients mainly present with minor injuries suitable for a standardized diagnostic protocol. The question was raised whether these injuries can be treated by trained ED nurses (specialized emergency nurses [SENs]). The aim of this study was to evaluate the diagnostic accuracy and reproducibility of SENs in assessing ankle sprains by applying the Ottawa Ankle Rules (OAR) and Ottawa Foot Rules (OFR)., Methods: In a prospective study, all ankle sprains presented in the ED from April to July 2004 were assessed by both a SEN and a junior doctor (house officer [HO]) randomized for first observer. Before the study, SENs were trained in applying OAR and OFR. In all patients, radiography was performed (gold standard). The diagnostic accuracy for the application of OAR and OFR was calculated for both groups and was compared using z statistics. Furthermore, from the paired results, reproducibility was calculated using kappa statistics., Results: In total, 106 injuries were assessed in pairs, of which 14 were ultimately found to concern acute fractures (prevalence, 13%). The sensitivity for the SEN group was 0.93 (95% confidence interval [CI], 0.64-1.00) compared with 0.93 (95% CI, 0.64-1.00) for the HO group (no significance [ns]). The specificity of the nurses was 0.49 (95% CI, 0.38-0.60) compared with 0.39 (95% CI, 0.29-0.50) for the doctors (ns). The positive predictive value for the SEN group was 0.22 (95% CI, 0.13-0.35) compared with 0.19 (95% CI, 0.11-0.31) for the HO group (ns). The negative predictive value for the nurses was 0.98 (95% CI, 0.87-1.00) compared with 0.97 (95% CI, 0.84-1.00) for the doctors (ns). The interobserver agreement for the OAR and OFR subsets was kappa = 0.38 for the lateral malleolus; kappa = 0.30, medial malleolus; kappa = 0.50, navicular; kappa = 0.45, metatarsal V base; and kappa = 0.43, weight-bearing. The overall interobserver agreement for the OAR was kappa = 0.41 and kappa = 0.77 for the OFR., Conclusion: Specialized emergency nurses are able to assess ankle and foot injuries in an accurate manner with regard to the detection of acute fractures after a short, inexpensive course.

Introduction: The Clinical Teaching Effectiveness Instrument (CTEI) was developed to evaluate the quality of the clinical teaching of educators. Its authors reported evidence supporting content and criterion validity and found favourable reliability findings. We tested the validity and reliability of this instrument in a European context and investigated its reliability as an instrument to evaluate the quality of clinical teaching at group level rather than at the level of the individual teacher., Methods: Students participating in a surgical clerkship were asked to fill in a questionnaire reflecting a student-teacher encounter with a staff member or a resident. We calculated variance components using the urgenova program. For individual score interpretation of the quality of clinical teaching the standard error of estimate was calculated. For group interpretation we calculated the root mean square error., Results: The results did not differ statistically between staff and residents. The average score was 3.42. The largest variance component was associated with rater variance. For individual score interpretation a reliability of > 0.80 was reached with 7 ratings or more. To reach reliable outcomes at group level, 15 educators or more were needed with a single rater per educator., Discussion: The required sample size for appraisal of individual teaching is easily achievable. Reliable findings can also be obtained at group level with a feasible sample size. The results provide additional evidence of the reliability of the CTEI in undergraduate medical education in a European setting. The results also showed that the instrument can be used to measure the quality of teaching at group level.

The discovery of bone morphogenetic proteins marks a major step forward in the understanding of bone physiology and in the development of advanced methods in skeletal surgery. The cornerstones for successful growth-factor therapy in skeletal surgery remain biomechanical stability and biological vitality of the bone providing an adequate environment for new bone formation. Knowledge of the biological characteristics, mechanisms of action, and methods of delivery of growth factors will become essential for skeletal surgeons. The current clinical application of bone morphogenetic proteins is safe and efficacious as a result of a well-regulated cascade of events leading to bone formation. Clinical trials have not yet determined whether different clinical indications each require a specific bone-tissue-engineering format or if a single pathway for stimulating bone-healing with growth factors is sufficient.

To analyze the effect of intramedullary reaming on fracture healing, we investigated whether or not cortical reamings contain viable bone cells. There are several tissue components contained in medullary reamings including blood, bone marrow and cortical bone. This study is focused on the cortical reamings, which are produced during reaming of the medullary cavity. They may stimulate fracture healing but it is still unclear if they contain vital bone cells. We tested the hypothesis that these cortical reamings are a source of viable bone cells and compared cell cultures with cultivated cells from iliac crest biopsies. Responses of protein content and ALP activity to vitD stimulation in the cells were considered as properties of viability. Ten in tact living sheep femora were fully reamed and the cortical reamings were cultivated in a standard manner and compared with cultivated cells from ipsi-lateral iliac crest biopsies from the same animals. Cells started to grow from the reamings as well as the iliac crest within 2-5 days, and covered the entire culture flask within 9-13 days. Protein content and ALP activity in cells from both reamings and iliac crest were significantly responsive to vitD stimulation. Cortical reamings from intramedullary nailing have osteoblastic potential and contain living bone cells similar to bone cells from the iliac crest. These findings may further explain the superior healing of fractures, treated with reamed nailing.

Introduction: Various measures have been introduced to enhance learning experiences in clerkships, generally with limited success. This study evaluated the impact of a multifaceted approach on the effectiveness of learning in a surgical clerkship. In accordance with results obtained in continuing medical education, several interventions were introduced simultaneously. We compared students' evaluations of the traditional surgical clerkship with those of the restructured clerkship., Methods: Two consecutive cohorts of students were asked to complete a questionnaire about the quality and quantity of their learning experiences. Cohort 1 (n = 28) undertook the traditional clerkship and cohort 2 (n = 72) the restructured clerkship. A Mann-Whitney test was used to compare outcomes between the 2 cohorts., Results: There were few statistically significant differences between cohorts 1 and 2. Overall, quality indicators did not differ between the 2 cohorts., Discussion: A short-term multifaceted intervention led to a slight increase in the performance of clinical skills and a slight decrease in time spent on activities of limited educational value. The intervention may have been too brief to produce substantial effects. Future interventions should also target teachers, including trainees, in order to assess their opinions and address their educational needs.

Background & Aims: Severe trauma leads to an immune suppression, characterized by a Type 2 T-lymphocyte response, contributing to the susceptibility of infectious complications. Plasma concentrations of glutamine (GLN), the preferred fuel for immunocompetent cells, severely decrease after trauma. Since administering glutamine-enriched enteral nutrition (EN) reduces infectious complications in trauma patients, we compared the effect of glutamine-enriched EN with an isocaloric, isonitrogenous enteral control (Con) feeding, on the Type 1 and 2 T-lymphocyte responses., Methods: Thirty-eight trauma patients (Injury Severity Score >20) were sensitized with Keyhole Limpet Hemocyanin (KLH) within 12 h after trauma (17 GLN group). Healthy volunteers served as controls (HV, n=17). In vitro interferon-gamma (IFN-gamma), IL-4 and IL-10 productions of phytohemagglutinin (PHA)-stimulated PBMCs were determined by ELISA technique. KLH-specific IgG, IgM, IgA, IgG1, IgG2, IgG3, IgG4 and IgE were measured in serum., Results: Both patient groups had a low in vitro (IFN-) production of stimulated PBMCs on d1. On d14, the IFN-gamma production increased significantly in the glutamine group as compared to the controls. IL-4 production was not different between the groups on day 1 (d1). On d14, IL-4 decreased in the control group as compared to the glutamine group. KLH-specific antibodies reached comparable levels in both patients groups and healthy volunteers at d14., Conclusions: In conclusion, trauma caused a suppressed in vitro cellular immune response presented by a low IFN-gamma production and depressed the IgG and IgM response to KLH directly after trauma. Glutamine increased IFN-gamma production (d14), maintained a normal IL-4 production, but was not acquired for the development of KLH-specific humoral response on d14, in sync suggesting that dietary glutamine supports the restoration of the Type-1 T-lymphocyte responsiveness.

Severe trauma can lead to a compromised immune response, thereby increasing susceptibility to infections. Here we will study to what extent these early changes in the immune status upon trauma affect a primary immune response to keyhole limpet haemocyanin (KLH). Because glutamine is the preferred respiratory substrate for immune competent cells and known to be depleted after trauma, we studied the immune status and the primary sensitization in relation to the glutamine plasma concentration in a group of severe trauma patients [injury severity score (ISS) >17]. Trauma patients (n = 31) were sensitized with KLH within 12 h after trauma; plasma glutamine concentrations and immune parameters were determined, after which KLH-specific immune responsiveness was evaluated on days 9 and 14. Low plasma glutamine concentrations were found after trauma. Significantly elevated numbers of granulocytes and CD14-positive leucocytes were found, whereas the HLA-DR expression on CD14-positive cells was significantly lower in trauma patients than in healthy controls. Trauma did not change the in vitro proliferative capacity of lymphocytes when cultured with glutamine; however, when lymphocytes were cultured without glutamine, trauma resulted in lower proliferation than healthy controls. Phytohaemagglutinin-(PHA)-induced interferon (IFN)-gamma and interleukin (IL)-10 production was significantly lower after trauma, whereas IL-4 production was not affected. KLH sensitization following trauma resulted in poor skin test reactivity and low in vitro KLH-induced lymphocyte proliferation compared to controls. In contrast, the development of anti-KLH IgM, IgG, IgA, IgG1, IgG2, IgG3 and IgG4 production on days 9 and 14 following trauma was not different from that in healthy controls. Major trauma was associated with a reduced cell-mediated immune response, correlating with low plasma glutamine concentrations, while no effects of trauma were found on the development of a primary humoral immune response.

Autologous bone grafting is currently considered the treatment of choice for correction of large bone defects. However, to avoid morbidity associated with autologous bone harvesting many artificial bone-substitute materials have been developed over the years. A new generation of resorbable materials is emerging, with promising results so far. In order to investigate the possibility to use one of these new materials as an alternative with better results than hydroxyapatite, an experimental study was performed. A new resorbable calcium phosphate particles and paste forms, the latter of which hardens in situ after application. In 28 sheep, a 3-cm segmental tibial defect was made and intramedullary fixed by an interlocking nail. Twelve weeks after defect filling, radiological, biomechanical, and histological examinations were performed. Mean radiographic and biomechanical tests results were compared with the Mann-Whitney test. Significance was set at p<0.05. Radiographically, the resorbable paste group performed better than all other groups. Biomechanical investigations showed a higher torsional stiffness (p=0.049) for the resorbable calcium-phosphate paste group in comparison with autologous bone. On histological examination, no adverse effects were observed in the calcium-phosphate groups. Resorption by osteoclasts was seen in the resorbable implants. In conclusion, the current study shows an advantageous radiological and mechanical outcome for resorbable calcium phosphates. This indicates that these new materials might be a potential alternative for autologous bone grafting in humans., (Copyright 2003 Wiley Periodicals, Inc.)

Hydroxyapatite is a synthetic bone graft, which is used for the treatment of bone defects and nonunions. However, it is a rather inert material with no or little intrinsic osteoinductive activity. Recombinant human osteogenic protein-1 (rhOP-1) is a very potent biological agent, that enhances osteogenesis during bone repair. Bone marrow contains mesenchymal stem cells, which are capable of new bone formation. Biosynthetic bone grafts were created by the addition of rhOP-1 or bone marrow to granular porous hydroxyapatite. The performance of these grafts was tested in a sheep model and compared to the results of autograft, which is clinically the standard treatment of bone defects and nonunions. A 3 cm segmental bone defect was made in the tibia and fixed with an interlocking intramedullary nail. There were five treatment groups: no implant (n=6), autograft (n=8), hydroxyapatite alone (n=8), hydroxyapatite loaded with rhOP-1 (n=8), and hydroxyapatite loaded with autologous bone marrow (n=8). At 12 weeks, healing of the defect was evaluated with radiographs, a torsional test to failure, and histological examination of longitudinal sections through the defect. Torsional strength and stiffness of the healing tibiae were about two to three times higher for autograft and hydroxyapatite plus rhOP-1 or bone marrow compared to hydroxyapatite alone and empty defects. The mean values of both combination groups were comparable to those of autograft. There were more unions in defects with hydroxyapatite plus rhOP-1 than in defects with hydroxyapatite alone. Although the differences were not significant, histological examination revealed that there was more often bony bridging of the defect in both combination groups and the autograft group than in the group with hydroxyapatite alone. Healing of bone defects, treated with porous hydroxyapatite, can be enhanced by the addition of rhOP-1 or autologous bone marrow. The results of these composite biosynthetic grafts are equivalent to those of autograft.

Little is known about the effectiveness of clinical education. A more educational structure is considered to be potentially beneficial. The following structured components were added to a surgical clerkship: logbooks, an observed student-patient encounter, individual appraisals, feedback on patient notes, and (case) presentations by students. The authors organized two focus-group sessions in which 19 students participated to explore their perceptions about effective clinical learning experiences and the newly introduced structured components. The analysis of the transcripts showed that observation and constructive feedback are key features of clinical training. The structured activities were appreciated and the results show the direction to be taken for further improvement. Learning experiences depended vastly on individual clinicians' educational qualities. Students experienced being on call, assisting in theatre and time for self-study as instructive elements. Recommended clerkship components are: active involvement of students, direct observation, selection of teachers, a positive learning environment and time for self-study.

Background: Taurine is a unique amino acid with antioxidant and osmolytic properties. Glutamine serves as the preferred fuel for the gut, liver, and immune cells and as a precursor for antioxidants. Trauma patients have low glutamine concentrations., Objectives: We investigated the effect of glutamine-enriched enteral nutrition on plasma taurine concentrations in patients with severe trauma (injury severity score >20). Additionally, plasma taurine concentrations and organ fluxes were studied in a stressed rat model., Design: Twenty-nine patients with multiple trauma received glutamine-enriched nutrition and 31 patients received isocaloric, isonitrogenous control solution for 5 d. Plasma taurine and glutamine concentrations were measured. Male Wistar rats (250-300 g) received a glutamine-enriched diet (12%, by wt) or a control solution for 2 wk. Plasma taurine concentrations were measured. Taurine fluxes and fractional extraction rates in the liver, kidneys, and gut were assessed with a radioactive microsphere technique., Results: Both patient groups had low taurine concentrations on day 1. From day 3 onward, the glutamine-fed patients had significantly higher taurine concentrations. Rats fed a glutamine-enriched diet had significantly higher plasma taurine concentrations than did the controls. A high taurine uptake was found in the liver, kidneys, and gut of the glutamine-fed rats. Fractional extraction rates were not significantly different between the rat groups., Conclusions: Glutamine enrichment increases plasma taurine in trauma patients and in stressed rats. Because of increased availability, organ fluxes showed a higher taurine uptake in the liver, kidneys, and gut. The reduction in morbidity with glutamine enrichment could be explained in part by increased taurine availability.

The aim of this study was to investigate the effect of glutamine-(Gln)-enriched enteral nutrition (EN) on human leukocyte antigen (HLA)-DR and FcgammaR1/CD64 expression on monocytes and plasma glutamine concentrations in multi-trauma patients. HLA-DR expression on monocytes is crucial in the presentation of foreign antigen to the immune system and is severely reduced in trauma patients. In vitro monocyte HLA-DR and FcgammaRI/CD64 expression is dependent on glutamine availability. To study the effect of glutamine supplemented enteral nutrition on HLA-DR and FcgammaRI/CD64 expression on CD14(+) monocytes, 55 multi-trauma patients were studied in a randomized, double-blinded, controlled trial. Trauma patients received either a Gln-enriched EN (glutamine group, n = 28) or an isocaloric, isonitrogenous control EN (control group, n = 27) and were compared with a group of age-matched healthy volunteers (healthy volunteers, n = 53). On d 1, 5, 9 and 14 after trauma, expressions of HLA-DR and FcgammaRI/CD64 were determined on CD14(+) monocytes using FACS analysis. Plasma glutamine levels were measured using HPLC. Plasma glutamine was lower in both trauma patient groups compared with healthy volunteers and from d 3 to d 5; glutamine was higher in the glutamine group than in the control group. On d 1, HLA-DR expression was much lower in both trauma patient groups than in healthy volunteers. HLA-DR expression was greater on d 5, 9 and 14 in the glutamine group than in the control group. FcgammaRI/CD64 expression on monocytes of trauma patients was not different than the expression of healthy volunteers. This study showed that glutamine-enriched enteral nutrition was associated with a higher HLA-DR expression on CD14(+) monocytes of trauma patients. No difference in monocyte FcgammaRI/CD64 expression was detected between patients that received the two enteral diets and between trauma patients and the healthy volunteers. Increased HLA-DR expression may improve cellular immune function and may be involved in the beneficial effect of glutamine on the occurrence of infections in trauma patients.

Osteogenic protein-1 (OP-1), or bone morphogenetic protein-7, is an osteoinductive morphogen that is involved in embryonic skeletogenesis and in bone repair. In bone defect models without spontaneous healing, local administration of recombinant human OP-1 (rhOP-1) induces complete healing. To investigate the ability of rhOP-1 to accelerate normal physiologic fracture healing, an experimental study was performed. In 40 adult female goats a closed tibial fracture was made, stabilized with an external fixator, and treated as follows: (1) no injection; (2) injection of 1 mg rhOP-1 dissolved in aqueous buffer; (3) injection of collagen matrix; and (4) injection of 1 mg rhOP-1 bound to collagen matrix. The test substances were injected in the fracture gap under fluoroscopic control. At 2 and 4 weeks, fracture healing was evaluated with radiographs, three-dimensional computed tomography (CT), dual-energy X-ray absorptiometry, biomechanical tests, and histology. At 2 weeks, callus diameter, callus volume, and bone mineral content at the fracture site were significantly increased in both rhOP-1 groups compared with the no-injection group. As signs of accelerated callus maturation, bending and torsional stiffness were higher and bony bridging of the fracture gap was observed more often in the group with rhOP-1 dissolved in aqueous buffer than in uninjected fractures. Treatment with rhOP-1 plus collagen matrix did not result in improved biomechanical properties or bony bridging of the fracture gap at 2 weeks. At 4 weeks there were no differences between groups, except for a larger callus volume in the rhOP-1 plus collagen matrix group compared with the control groups. All fractures showed an advanced stage of healing at 4 weeks. In conclusion, the healing of a closed fracture in a goat model can be accelerated by a single local administration of rhOP-1. The use of a carrier material does not seem to be crucial in this application of rhOP-1.

Background: This experimental study was designed to compare different in vitro methods of measuring the cortical temperature when reaming the medullary cavity. This was done to validate an approved mathematical model which can be used to determine the temperature gradient in cortical bone in the presence or absence of sensors., Methods: Artificial bone was used with an intramedullary heat source instead of a reamer. Temperatures were measured with thermocouples placed radially and axially in the cortical wall. This method with these two measurement positions were compared and used to validate an approved mathematical model. This model was used to determine the temperature gradient in cortical bone in the absence of sensors., Results: The measurement of the cortical temperature with the thermocouples in a radial position only reflects maximally 14% of the temperature of the reamer (calculated 55%). The measurement with the thermocouples in axial position reflects maximally 65% (calculated 70%) of the reamer temperature, which is similar to undisturbed bone., Conclusion: The measuring method with the thermocouples in a radial position cannot be recommended. It is likely that a much higher temperature is generated and conducted through reaming than has been assumed until now.

To assess the educational quality of a traditional clerkship, a questionnaire was administered to 28 students at the end of their 10-week surgical clerkship. The questionnaire contained 116 items on learning objectives, patient problems encountered by students, clinical skills performed, feedback received and amounts of time spent on various activities. The students indicated that they had adequate ability to correctly analyse and manage patient problems. However, the standard deviations and ranges show that individual students' exposure to various patient problems was insufficient. Students generally saw too few emergency patients. The frequencies of performance of diagnostic and therapeutic skills varied widely among students. Most of the feedback received by students was given by residents rather than faculty physicians. Students spent considerable time on activities of limited educational value. It appears that learning during a clerkship occurs rather haphazardly. There are indications that the 'educational exposure' varies substantially from student to student.

Fracture healing could be stimulated with osteoinductive bone morphogenetic proteins (bmp's), such as osteogenic protein-1 (OP-1), but little is known about its effectiveness in stimulation of fracture healing. In this study, biomechanical and histological aspects of fracture healing after an injection of OP-1 in the fracture gap were investigated. In 40 goats, a closed fracture was created in the left tibia. The fractures were stabilized with an external fixator and the animals were assigned to four different groups: no injection, injection of 1 mg OP-1, injection of 1 mg OP-1 with collagenous carrier material, and injection of carrier material alone. Twenty-one animals were sacrificed after 2 weeks and 19 after 4 weeks. Biomechanical testing was perfomed on both explanted tibiae. Four longitudinal samples of the fracture were sawn, processed for histology, and examined by two observers. Biomechanical evaluation showed a higher stiffness and strength at 2 weeks after injection of OP-1. Histological evaluation showed normal fracture healing patterns in all animals without adverse effects of the given injections. These data show that fracture healing can be accelerated with a single injection of OP-1, eventually resulting in normally healed bone.

Survival of patients with traumatic rupture of the thoracic aorta (TRTA) depends on early surgical repair. Six cases of TRTA were treated at our institution in 7 years. Time to diagnosis was 1.5, 3, 4, 36, 91 and 140 hours (mean = 46 hours). Diagnosis was made by computed tomography in one and by angiography in five cases. Time from arrival to treatment was 3, 9, 5, 46, 117 and 152 hours (mean = 55 hours). All six patients were treated by clamp and suture technique, with a mean cross clamp time of 48 minutes. Significant delay in diagnosis and treatment occurred in three patients. The reasons for delay were unrecognized signs for TRTA on the initial chest X-ray, a false-negative result of transoesophageal echography and not considering the diagnosis of TRTA. The diagnosis of TRTA requires a high index of suspicion and should always be considered in victims of high impact trauma.

Objective: To investigate the reliability of radiographs in the evaluation of healing of closed fractures., Design: A closed midshaft tibial fracture was created in 40 goats and stabilized with an external fixator. The animals were assigned to four groups: no injection, injection of 1 mg osteogenic protein-1 (OP-1), 1 mg OP-1 with collagenous carrier, or carrier alone. Radiographs were performed weekly until the animals were killed after 2 and 4 weeks. Healing was evaluated using radiographs, biomechanical testing, and histological examination. All radiographs were examined by two independent observers. Interobserver agreement was calculated and radiographic scores were compared with mechanical and histological scores using regression analysis., Results: Regression analysis showed poor correlation between radiographic scores and biomechanical and histological data. Correlation coefficients varied between 0.39 and 0.63. Good agreement between the observers was seen in only three parameters: visibility of the fracture line, weightbearing ability, and a combined healing parameter., Conclusion: Plain radiography provides poor parameters for monitoring the fracture healing process.

Background: Reamed nailing gives better fracture healing than unreamed nailing in operative treatment of fractures and nonunions. This study investigates the effect of isolated reaming debris on fracture healing in an animal model., Methods: Thirty sheep were treated with an osteotomy of the tibia with 5-mm distraction. In one group, the osteotomy gap was left empty; in the second group, the gap was packed with reaming debris from the ipsilateral femur; and in the third group, the gap was packed with cancellous bone from the iliac crest. At follow-up, callus volume was measured on standard radiographs., Results: After 3 weeks, callus volume from the reaming debris group as well as the iliac crest group had increased significantly compared with the empty group., Conclusion: This study shows that isolated reaming debris supports callus building as much as conventional bone grafting, which might explain why fractures heal with more callus formation when treated with reamed nailing compared with unreamed nailing.

Dual energy xray absorptiometry was investigated as a method for evaluation of the strength of closed tibial fractures. In 40 goats, a closed midshaft fracture was created in the left tibia. The fractures were stabilized with an external fixator. After 2 weeks (n = 21) and after 4 weeks (n = 19), both tibias were explanted and, using dual energy xray absorptiometry, bone mineral density and bone mineral content were measured in a 1 cm region. With nondestructive bending tests, area ratio and stiffness index were determined and torsional strength and torsional stiffness were determined with a torsional test to failure. Linear regression analysis was used to calculate the squared correlation coefficients for the relations between dual energy xray absorptiometry and the outcome of the mechanical tests. The squared correlation coefficients for the relation between bone mineral density and torsional strength, torsional stiffness, and area ratio and stiffness index were 0.72, 0.76, 0.64, and 0.72, respectively. The squared correlation coefficients for the relation between bone mineral content and these mechanical parameters were 0.72, 0.77, 0.63, and 0.77, respectively. The results using dual energy xray absorptiometry indicate the strength of healing closed fractures. Additional research is required to investigate specific aspects of this technique.

This study was designed to further explain the better fracture healing in fractures treated with a reamed nail. It investigates the location and quantity of the reaming debris in an ex vivo animal model to test the autograft theory. In 10 cadaveric sheep femurs, a 5-mm semicircular gap was created at the midshaft. The medullary cavity was opened and the reaming debris that dropped from the gap during reaming and the debris from the proximal opening were collected and weighed separately. The mean harvest of reaming debris at the gap was 0.99 g +/- 0.12 g (24%) and from the proximal opening at the medullary cavity 3.08 g +/- 0.31 g (76%) (total 4.07 +/- 0.34 g). This study proves that a significant amount of reaming debris collects at an artificial fracture gap during reaming of the medullary cavity. This finding supports the theory of bone autografting.

Resorbable calcium phosphate ceramics are only osteoconductive; therefore, their combination with osteogenic substances may lead to stimulation of bone healing. In the present study this combination, using autologous bone marrow, was investigated. In 31 sheep, a 3-cm tibial segmental defect was created and stabilized with an intramedullary nail. The animals were divided into four groups: empty defects (group 1, n = 7), and defects filled with 10-mL dense resorbable calcium phosphate particles (group 2, n = 8), with 10-mL particles soaked in bone marrow (group 3, n = 8), or with 10-mL autologous bone (group 4, n = 8). On evaluation after 12 weeks, significantly higher values were seen in group 3 than in group 2 for callus volume (p = .016), bone mineral density ratio (p = .03), bone mineral content ratio (p = .04), torsional strength (p = .005), and torsional stiffness (p = .01). For all end points, the outcome of group 3 was lower than that of group 4. In the histology, there was direct contact between newly formed bone and remnants of the particles. There were no signs of inflammatory reactions. Although a stimulatory effect of bone marrow was seen, the combination of resorbable calcium phosphate particles with bone marrow does not provide an alternative for autologous bone grafting., (Copyright 2000 John Wiley & Sons, Inc.)

Isolated sternal fractures are seen with an increasing frequency in traffic road accidents especially after the introduction of the seatbelt legislation. In most cases, the victims are young, otherwise healthy individuals. The medical records of all patients who were treated with a diagnosis of sternal fracture over the past 10 years were retrospectively reviewed. All patients with a radiologic diagnosis of sternal fracture were admitted for cardiac monitoring for at least 24 hours. ECG, determinations of cardiac enzyme levels CK (creatinephosphokinase) and CK-MB and evaluation by a cardiologist were routinely performed. An echocardiography was performed when indicated by the cardiologist. A total of 86 patients had sustained a sternal fracture during the 10-year study period. There were 39 males and 47 females with a mean age of 50 years (range 15-97 years). Serial 12-lead electrocardiograms, which were performed in 83 (97%) patients, revealed no information about myocardial contusion or cardiac arrhythmias with consequent therapy. In eight patients, a significant elevation in cardiac enzyme levels (elevation of CK-MB fraction above 10% of CK) was observed. All were normalized within 24 hours without development of any arrhythmias. Echocardiography was performed in 31 patients. In two patients, dyskinesia of the right ventricle (without enzyme elevations or arrhythmias) was observed. Within 24 hours these abnormalities resolved. The cardiac rhythm was monitored in 61 (71%) patients for a total of 1550 hours. No arrhythmias were observed. The cardiac enzyme studies, ECG and echocardiography revealed no consequent information about arrhythmias. In case of a sternal fracture, we recommend a chest X-ray to exclude other associated intrathoracic injuries. If no abnormalities are identified, admission to hospital is not necessary.

An appropriate animal model is required for the study of treatments that enhance bone healing. A new segmental long bone defect model was developed for this purpose, and dual energy x-ray absorptiometry was used to quantify healing of this bone defect. In 15 sheep, a 3-cm segmental defect was created in the left tibia and fixed with an interlocking intramedullary nail. In seven animals, the defect was left empty for the assessment of the spontaneous healing response. In eight animals serving as a positive control, autologous bone grafting was performed. After 12 weeks, healing was evaluated with radiographs, a torsional test to failure, and dual energy x-ray absorptiometry. The mechanical test results were used for the assessment of unions and nonunions. Radiographic determination of nonunion was not reliably accomplished in this model. By means of dual energy x-ray absorptiometry, bone mineral density and content were measured in the middle of the defect. Bone mineral density was 91+/-7% (mean +/- SEM) and 72+/-6% that of the contralateral intact tibia in, respectively, the autologous bone-grafting and empty defect groups (p = 0.04). For bone mineral content, the values were, respectively, 117+/-18 and 82+/-9% (p = 0.07). Torsional strength and stiffness were also higher, although not significantly, in the group with autologous bone grafting than in that with the empty defect. Bone mineral density and content were closely related to the torsional properties (r2 ranged from 0.76 to 0.85, p < or = 0.0001). Because interlocking intramedullary nailing is a very common fixation method in patients, the newly developed segmental defect model has clinical relevance. The interlocking intramedullary nail provided adequate stability without implant failure. This model may be useful for the study of treatments that affect bone healing, and dual energy x-ray absorptiometry may be somewhat helpful in the analysis of healing of this bone defect.

Since the degradability of the synthetic polymers used for fracture fixation is still unclear, a research project with biodegradable interlocking nails with a longterm implantation period has been started. In 21 female sheep a complete mid-shaft osteotomy of the left femur was performed to mimic a fracture of the femoral shaft. For the fixation, an intramedullary stainless-steel interlocking nail, a PLA rod or a PLA/PGA rod was used. After 30 months of implantation the histological results of these three materials were examined. In contrast to most reports the degradation rate of both polymers was much lower than the suggested ultimate period of two years. Even the tissue response was more pronounced than expected and this reaction can imply certain risks for repulsion. One can conclude that the volume quantity of polymeric implant in the bony tissue must be reduced if possible to avoid severe foreign body responses. The immunologic responses and the clinical consequences need more studies. The degradation behavior of the polymer is still not under control.

Serious problems such as stress shielding, allergic reactions, and corrosion are associated with the use of metallic fracture fixation devices in fractured long bones. Metal implants often are removed during a second retrieval operation after fracture healing has completed. A biocompatible implant that degrades slowly during implantation would obviate the need for a second operation and save the patient from considerable physical, psychologic, and financial discomfort. The biodegradable implant must provide the fractured limb sufficient support for a certain time, allowing early loading. A gradual transfer of load from the biodegradable implant to the bone would result in a better product of bone healing and avoid stress shielding. In an animal model using adult sheep, two types of biodegradable polymer interlocking nails were tested in comparison with a stainless steel interlocking nail. Fracture healing, mechanical properties of the bones, degradation behavior in vivo and in vitro, and tissue response were monitored during a 2 1/2-year followup study. To detect shifts in acid base relations caused by the release of acid compounds, pH measurements were performed. Fracture healing was unimpaired, and the mechanical test results of all three groups were excellent. Histologic analysis showed a mild inflammatory response, but no pH shifts were observed. The results of this study justify additional research on these promising materials.

Background: Infections are an important cause of morbidity and mortality in patients with multiple trauma. Studies in both animals and human beings have suggested that glutamine-enriched nutrition decreases the number of infections., Methods: Patients with multiple trauma with an expected survival of more than 48 h, and who had an Injury Severity Score of 20 or more, were randomly allocated glutamine supplemented enteral nutrition or a balanced, isonitrogenous, isocaloric enteral-feeding regimen along with usual care. Each patient was assessed every 8 h for infection, the primary endpoint. Data were analysed both per protocol, which included enteral feeding for at least 5 days, and by intention to treat., Findings: 72 patients were enrolled and 60 received enteral feeding (29 glutamine-supplemented) for at least 5 days. Five (17%) of 29 patients in the glutamine-supplemented group had pneumonia compared with 14 (45%) of 31 patients in the control group (p<0.02). Bacteraemia occurred in two (7%) patients in glutamine group and 13 (42%) in the control group (p<0.005). One patient in the glutamine group had sepsis compared with eight (26%) patients in the control group (p<0.02)., Interpretation: There was a low frequency of pneumonia, sepsis, and bacteraemia in patients with multiple trauma who received glutamine-supplemented enteral nutrition. Larger studies are needed to investigate whether glutamine-supplemented enteral nutrition reduces mortality.

Whole bone bending tests are commonly used in mechanical evaluation of long bones. Reliable information about the midshaft can only be obtained if the bending moment is uniformly distributed along the shaft, and if the distribution of the bending stress is not adversely influenced by rigid clamping of the bone ends. A testing device was developed to determine bending stiffness of long bones in 24 directions, perpendicular to the bone axis. For optimal distribution of bending moment and stress, four-point bending was performed, and bone ends were simply supported, not rigidly clamped. The method was validated by repeated testing of a stainless steel rod, and a sheep femur. Left-right ratios were assessed twice in 2 groups of 5 sheep: one control group, and one group in which the left femur was stabilized with a stainless steel interlocking nail for 2.5 yr, after a midshaft osteotomy. Test results obtained with the steel rod reproducibly were close to predicted values. Measurements with the sheep femurs were reproducible and precise for 3 of the 4 parameters of the bending test. Stiffness parameters were significantly higher in the operated sheep than in the control group. We conclude that the method described here provides accurate and reproducible information, which is representative for the long bone shaft.

Quantitative methods are necessary for an objective evaluation of fracture healing. Three-dimensional computed tomography (CT) for the measurement of callus volume and density could be such a method and was investigated in an animal model. In 23 goats a closed tibial fracture was created and stabilized with a cast. The animals were killed at 2, 4 and 6 weeks for radiographical, CT and biomechanical analysis. From the CT scans a three-dimensional reconstruction of the callus was made to measure its volume and mean density. At 2 weeks the callus volume had already reached its maximum. In contrast, callus density, torsional strength and torsional stiffness increased over time (P < 0.0001, analysis of variance, ANOVA). Multiple regression analysis showed that the callus volume was not related to the torsional properties. However, callus density was a significant explanatory variable for both torsional strength (R2 = 0.72, P < 0.0001) and torsional stiffness (R2 = 0.82, P < 0.0001). Therefore, callus density as measured by three-dimensional CT is a predictor of the extent of fracture consolidation. CT with three-dimensional reconstruction of the callus seems a valid technique for the quantification of fracture healing.

A previous study has shown bone formation around poly-L-lactic acid (PLLA) wire in vivo. However, it is still unknown how bone cells are stimulated to form bone around PLLA wire. The effect of PLLA on primary bone cells in vitro is the subject of this study. Osteoprogenitor and osteoblastic cells derived from neonatal mouse calvaria were cultured after addition of PLLA wire or L-lactide to the culture medium. Alkaline phosphatase (AP) activity, as a parameter of bone cell differentiation, and DNA content, to assess cell growth were measured. In osteoblast-enriched cell cultures PLLA wire did not affect DNA content, but AP activity was increased by 28%. In osteoprogenitor-enriched cell cultures PLLA wire decreased DNA content by 10%, but AP activity of the cells was not affected. L-Lactide enhanced the DNA content of osteoblastic cell cultures at 0.1 mM by 19%, but not at higher concentrations, and did not affect cell differentiation. In osteoprogenitor cell cultures, L-lactide had no effect at all. These results indicate that the proliferation and differentiation of bone cells in vitro can be modulated by PLLA, dependent on their stage of differentiation. L-Lactide at concentrations up to 10 mM did not adversely affect cell growth or differentiation, while PLLA wire upregulated the expression of the osteoblastic phenotype. These data support the observation of newly formed bone around poly-lactic acid wire in vivo in other the studies.

In this in vivo study, low-molecular-weight as-polymerized PLLA powder was placed in the medullary cavity of a porcine femur in order to study the tissue reaction on predegradated PLLA. An attempt was made to simulate the long-term degradation of a large PLLA implant. This phase can be characterized by the release of PLLA particles and acid compounds from a heterogeneously degrading PLLA implant into the surrounding tissues. The clinical consequences and tissue response were studied. The clinical recovery of the experimental animals was favorable. No signs of clinical inflammation could be detected during the eight-week follow-up period. Histological analysis of the bone/PLLA interface showed signs of a mild inflammatory tissue response.

The combination of traumatic aortic rupture and spine fracture is rare. We describe the treatment of both injuries in a one-stage procedure with good results in a 47-year-old woman.

Post-traumatic osteitis (PTO) still constitutes a medical and surgical problem. Although different treatment regimes have been tested, controversial results have been obtained. Taurolin-gel® 4% and Taurolin®-collagen are broad spectrum synthetic antibacterial agents used for the local treatment of PTO. This study was designed to evaluate Taurolin under standardised conditions using an animal model for experimentally induced PTOIn 21 rabbits a PTO was induced in the left femur and they were assigned into three groups. Four weeks after this operation the second operation followed: in group A (n=5) the intramedullairy rod was removed and the marrow cavity flushed with Ringer lactate solution. In groups B and C (n=16) Taurolin®-gel 4% or Taurolin®-collagen was installed into the marrow cavity after the same debridement. The disease was monitored by hematologic, roentgenografic and bacteriological parameters.After 4 weeks all animals showed signs of an osteitis. At obduction the marrow flush and bone cultures of group A all consisted S. aureus. In group B three out of eight and in group C two out of eight cultures showed bacterial grows.Treatment of an animal PTO is more difficult than the human disease for thorough debridement is difficult. Even though we achieved a succespercentage of 69%. This is a number which is also described in clinical studies. Further investigations with Taurolin® are necessary to develop an optimal treatment regime and to determine to what extent it can be integrated in everyday clinical practise.

Uncontrollable bleeding remains a life-threatening problem in severe liver injury. The application of an absorbable mesh has been reported in a small number of patients. To evaluate an absorbable mesh wrap in standardized conditions, we performed an experimental study in 14 female pigs. A standard liver laceration imitating a blunt injury grade IV (Liver Injury Scale of the American Association for the Surgery of Trauma) was made in all animals. Heparin was administered to mimic coagulopathy. After randomization, seven animals received a polyglycolic acid (Vicryl) mesh wrap to control bleeding. Seven animals served as controls. Six of seven animals with a mesh wrap survived. Six of seven animals in the control group died (p = 0.02, Fisher's exact test). Intrahepatic pressures in the treated group varied from 3 to 55 mm Hg. Liver function tests in surviving animals were temporarily elevated. Necropsy at 2 weeks demonstrated adhesions to the wrapped lobe, but no hematoma, free bile, or abscess. Histologic examination showed a foreign-body reaction to the mesh and necrotic parts in the liver. It is concluded that an absorbable mesh wrap can effectively control bleeding from severe liver injury and improve survival in an animal model, although it may cause some damage to liver tissue.

A rat model for the study of closed fracture healing is described. Standard closed tibial fractures were produced with specially designed pliers in 24 rats. All fractures were located in the middle third of the tibia and healed without complications as delayed union, infection or soft tissue problems. The average angle of the fracture line with the axis of the tibia on lateral view was 80 +/- 2 degrees (SEM). The model is considered to be suited for the study of closed fracture healing processes. Closed intramedullary fracture fixation, can also be evaluated in this model.

In order to develop a biodegradable interlocking nail for fracture fixation, polylactic acid (PLLA) rods were implanted in the femoral bone of young pigs. A midshaft osteotomy was performed in order to mimic a fracture. The tissue response to PLLA rods versus stainless steel rods was studied after 1 and 3 months of implantation. Fracture-healing characteristics and chemical and mechanical properties of the PLLA rods were studied after explantation. Mechanical properties deteriorated during implantation and chemical properties changed significantly in 1 and 3 months of implantation. PLLA and stainless steel induced a similar tissue reaction during the studied implantation time of 3 months.

A new animal model for posttraumatic osteomyelitis was designed. This model mimics the pathogenesis of the human disease more accurately than models presently available. Femora of New Zealand white rabbits were exposed at the greater trochanter and a stainless steel rod was inserted into the marrow cavity. A Staphylococcus aureus suspension was placed in and around a bone defect, which was drilled midshaft. The disease was evaluated by clinical observation and roentgenographic, hematologic, bacteriologic, and histologic parameters. Osteomyelitis developed in all 24 infected rabbits. None of the five rabbits receiving only an intramedullary rod developed an osteomyelitis. This model proves that an experimental posttraumatic osteomyelitis associated with a foreign body can be reliably induced, even when no infection-promoting chemical agents, small inoculum of bacteria, or minimal bone trauma is present.

We evaluated the subsequent loss of bone from the proximal part of the ipsilateral and contralateral femora and from the lumbar spine of seven men and nine women who had a fracture of the tibia. The average age was sixty years. All of the fractures were unstable, and the involved leg bore no weight for an average of eight weeks. The bone mineral density was measured with dual-energy x-ray absorptiometry of the lumbar spine and of the femoral neck and the trochanteric region of both hips immediately after the fracture, after the period of immobilization, and at approximately three, six, and twelve months after the fracture. During the period of immobilization, the bone mineral density of the trochanteric region decreased an average of 9 +/- 7 per cent on the side of the fracture, compared with the value immediately after the fracture, but there was no change on the contralateral side (p < 0.01). At twelve months, the average decrease in the trochanteric area was 15 +/- 10 per cent on the side of the fracture, compared with the value immediately after the fracture, but again there had been no change on the uninjured side (p < 0.01). The bone mineral density of the femoral neck on the side of the fracture had decreased 6 +/- 6 per cent at twelve months, compared with a decrease of 2 +/- 4 per cent on the uninjured side (p < 0.05). The bone mineral density of the lumbar spine decreased only during the period of unloading of the fractured leg (1 +/- 2 per cent, p = 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

The purpose of this study was to evaluate the results of patients with an unstable fracture in the trochanteric region who were treated by hemiarthroplasty. During a 10-year period, 154 of the 308 patients with a trochanteric fracture treated in our hospital had an unstable fracture. In patients with severe comminution and osteoporosis an endoprosthesis was inserted: 5 patients with a subtrochanteric and 17 with a pertrochanteric fracture. Ten patients suffered from central nervous system diseases, and in 10 patients cardiovascular or pulmonary disorders were diagnosed. Pre- and postoperative ambulation levels were classified. Seventeen patients (77%) achieved full weight-bearing mobilization. Five patients never walked again (23%): 2 patients died in the first month (9%). It is concluded that for elderly and debilitated patients with an unstable trochanteric fracture, hemiarthroplasty is an acceptable alternative to osteosynthesis.

Cardiac luxation caused by blunt thoracic trauma carries a high mortality rate. We present a case of traumatic diaphragmatic rupture, in combination with herniation of the stomach into the pericardial sac, pericardial rupture, and cardiac luxation. The recent literature is reviewed and diagnostic difficulties and procedures are discussed.

In a randomized study 43 patients with fracture-dislocations of the ankle joint were treated by open reduction and fixation with either steel or biodegradable implants. Results in both groups were favorable and the biodegradable material appears to be useful for some fracture-dislocations to obviate the need for a second operation.