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.

Hiatal hernia recurrences after laparoscopic surgery: exploring the optimal technique

INTRODUCTION

The recurrence rate of hiatal hernia (HH) after laparoscopic surgery with crural repair and Nissen or Toupet fundoplication is high (< 25-42%). HH repair can be reinforced with additional anterior sutures, vertical mesh strips (VMS) or mesh placement but the effect in the long-term (> 1 year) is still unclear. We determined the recurrence rate of HH after surgery and established whether the use of reinforcement techniques could reduce long-term recurrence rates.

METHODS

In this retrospective cohort study patients were included if they underwent a laparoscopic fundoplication in this hospital between 2012 and 2019. HH was measured with computed tomography and baseline patient characteristics and surgical details were collected. Primary outcomes were recurrence of symptoms and re-intervention, secondary outcome was effect of surgical reinforcement techniques. Statistical analyses comprised chi-square tests, Mann-Whitney U tests and uni- and multivariable logistic regression analyses.

RESULTS

In total, 307 patients were included, 206 women and 101 men. During primary surgery, 208 patients underwent a Toupet fundoplication and 97 patients underwent a Nissen fundoplication. Reinforcements consisted of anterior sutures in 132 patients, VMS in 89 patients and mesh in 17 patients. After primary surgery, recurrence of HH was diagnostically confirmed in 64 patients (20.8%). Use of VMS during primary surgery was significantly associated with fewer recurrences (OR = 0.34, p = 0.048), corrected for confounding factors. Secondary surgery was performed in 54 patients (17.6%) and tertiary surgery in five patients (1.6%). Mesh and VMS were used more during secondary and tertiary surgery.

CONCLUSION

The recurrence rate among HH patients in this cohort study was 20.8% with a mean follow-up time of 6 years. Secondary surgery was performed in 17.6% of the patients. In future, the use of VMS might lead to fewer recurrences after primary laparoscopic repair of HH.

OC-067 HIATAL HERNIA RECURRENCES AFTER LAPAROSCOPIC SURGERY: EXPLORING CONTRIBUTING SURGICAL FACTORS

Aim

The recurrence rate of hiatus hernia (HH) is high after laparascopic surgery (25–42%). HH repair can be reinforced by means of additional ventral sutures, pledgets or mesh placement. We determined the recurrence rate of HH after surgery and established whether lower long-term recurrence rates can be achieved with reinforcement techniques.

Methods

Patients were included in this retrospective cohort study if they underwent a laparoscopic fundoplication in our hospital between 2012–2019. HH was measured on CT scans and patient files were reviewed.

Results

In total, 307 patients were included, 206 women and 101 men. Pre-operatively, 102 patients were diagnosed with type III HH and 68 patients with type IV HH. The median transverse diameter of the HH was 3.2 cm. 208 patients underwent a Toupet fundoplication and 97 patients underwent a Nissen fundoplication. Reinforcements consisted of ventral sutures in 132 patients, pledgets in 89 patients and mesh in 17 patients. After primary surgery, recurrence of HH was diagnostically confirmed in 64 patients (20.8%). Secondary surgery was performed in 54 patients (17.6%) and tertiary surgery in 5 patients (1.6%). Use of pledgets during primary surgery (OR=0.34, p=0.048) was significantly associated with fewer recurrences, corrected for confounding factors. Use of ventral sutures and mesh were not significantly associated with reduced recurrence rates.

Conclusions

The recurrence rate among HH patients in our hospital was 20.8% with a mean follow-up time of 6 years. In future, the use of pledgets might lead to fewer recurrences after primary laparoscopic repair of HH.

VATS-assisted surgical stabilization of rib fractures in flail chest: 1-year follow-up of 105 cases

OBJECTIVES

Early surgical stabilization of flail chest has been shown to improve chest wall stability and diminish respiratory complications. The addition of video‑assisted thoracoscopic surgery (VATS) can diagnose and manage intrathoracic injuries and evacuate hemothorax. This study analyzed the outcome of our 7-year experience with VATS-assisted surgical stabilization of rib fractures (SSRF) for flail chest.

METHODS

From January 2013 to December 2019, all trauma patients undergoing VATS-assisted SSRF for flail chest were included. Patient characteristics and complications during 1-year follow-up were reported.

RESULTS

VATS‑assisted SSRF for flail chest was performed in 105 patients. Median age was 65 years (range 21-92). Median injury severity score was 16 (range 9-49). Hemothorax was evacuated with VATS in 80 patients (median volume 200 ml, range 25-2500). In 3 patients entrapped lung was freed from the fracture site and in 2 patients a diaphragm rupture was repaired. Median postoperative ICU admission was 2 days (range 1-41). Thirty-two patients (30%) had a post‑operative complication during admission and six patients (6%) a complication within 1 year. In-hospital mortality rate was 1%. Six patients (6%) died after discharge, due to causes unrelated to the original injury.

CONCLUSIONS

Addition of VATS to SSRF for flail chest seems helpful to diagnose and manage intrathoracic injuries and adequately evacuate hemothorax. The majority of complications are low grade and occur during admission. Further prospective research needs to be conducted to identify potential risk factors for complications and better selection for addition of VATS to improve care in the future.

Addition of Video-Assisted Thoracoscopic Surgery to the Treatment of Flail Chest

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) is increasingly used in chest trauma for diagnostic and therapeutic purposes. In this report we describe our single-institutional experience with VATS in the surgical treatment of patients with flail chest after high-energy trauma.

METHODS

From January 2013 to July 2014, 15 patients with flail chest after high-energy trauma were treated in our hospital. The Injury Severity Score (ISS) ranged from 16 to 44. Rib fixation was performed with precontoured plates or intramedullary splints. In all, patients we additionally used VATS to explore the thoracic cavity and evacuate any hemothorax.

RESULTS

In 10 patients a prominent hemothorax was present, which needed evacuation. The median operative time was 120 minutes (range, 60 to 180 minutes), with a median blood loss of 150 mL (range, <100 to 400 mL). The mean stay in the intensive care unit was 5.27 days (SD 6.79). Ten patients were extubated directly after operation in the operating room. The other 5 patients were extubated after 1 to 13 days. The mean duration of mechanical ventilation was 2 days (SD 4.17). No patient required a tracheostomy. Three patients had minor postoperative adverse events. All patients were discharged after 6 to 44 days (mean, 11.9 hospitalization days) (SD 9.57).

CONCLUSIONS

We believe VATS is effective and safe and can be of additional value by providing the possibility to adjust the planned incision for rib fixation and decrease the area of muscle destruction. Additional pulmonary or mediastinal pathologic conditions can be identified and complete evacuation of hemothorax can be achieved simultaneously.

[A young man with a painful knee]

A 23-year-old man injured his left knee. A CT scan showed a dislocation of the proximal tibiofibular joint. Closed reduction of the dislocation was done successfully under procedural sedation and analgesia. Afterwards he was treated with a pressure bandage and immobilisation of the knee for 2 weeks.

Acute thrombosis of an abdominal aortic aneurysm: a short report

INTRODUCTION

Sudden thrombosis of an abdominal aortic aneurysm is a rare condition with a high mortality rate.

REPORT

We present a patient with acute neurological deficits in both legs based on a thrombosis of a nine centimetre infrarenal abdominal aortic aneurysm. Successful iliac thrombectomy with aortic tube graft reconstruction was performed.

DISCUSSION

Sudden thrombosis of an abdominal aortic aneurysm is a rare condition, but should be taken into consideration in patients with acute neurological deficits of the lower extremities. Prompt diagnosis and surgical management can lead to a successful outcome. A review of the literature is presented.

Metastasis in a benign duodenal stromal tumour

Gastro-intestinal stromal tumour (GIST) is increasingly recognized as a distinct entity within the group of soft tissue tumours. Mostly, GIST arises from the muscular components of the stromal layer, but the tumour may also originate from the autonomic nerve system, recently designated as gastro-intestinal autonomic nerve tumour (GANT). The majority of GIST is located in the stomach and small intestine; only 4% of GIST is found in the duodenum. Clinical and pathological criteria to differentiate benign from malignant GIST are not well established. Tumour size and mitotic activity are commonly considered as important features, predicting biological behaviour and outcome. It has been suggested that the clinical course of the GANT-type tumours may be more aggressive. We present a case of a radically resected duodenal stromal tumour with benign features, in a young woman, with metastases to the liver and peritoneum occurring 8 years after the initial diagnosis.