Publications by authors named "Taco J Blokhuis"

36 Publications

MAS: Standalone Microwave Resonator to Assess Muscle Quality.

Sensors (Basel) 2021 Aug 14;21(16). Epub 2021 Aug 14.

Ångström Laboratory, Division of Solid State Electronics, Department of Electrical Engineering, Uppsala University, SE-75121 Uppsala, Sweden.

Microwave-based sensing for tissue analysis is recently gaining interest due to advantages such as non-ionizing radiation and non-invasiveness. We have developed a set of transmission sensors for microwave-based real-time sensing to quantify muscle mass and quality. In connection, we verified the sensors by 3D simulations, tested them in a laboratory on a homogeneous three-layer tissue model, and collected pilot clinical data in 20 patients and 25 healthy volunteers. This report focuses on initial sensor designs for the Muscle Analyzer System (MAS), their simulation, laboratory trials and clinical trials followed by developing three new sensors and their performance comparison. In the clinical studies, correlation studies were done to compare MAS performance with other clinical standards, specifically the skeletal muscle index, for muscle mass quantification. The results showed limited signal penetration depth for the Split Ring Resonator (SRR) sensor. New sensors were designed incorporating Substrate Integrated Waveguides (SIW) and a bandstop filter to overcome this problem. The sensors were validated through 3D simulations in which they showed increased penetration depth through tissue when compared to the SRR. The second-generation sensors offer higher penetration depth which will improve clinical data collection and validation. The bandstop filter is fabricated and studied in a group of volunteers, showing more reliable data that warrants further continuation of this development.
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http://dx.doi.org/10.3390/s21165485DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8399157PMC
August 2021

Deep Learning Automated Segmentation for Muscle and Adipose Tissue from Abdominal Computed Tomography in Polytrauma Patients.

Sensors (Basel) 2021 Mar 16;21(6). Epub 2021 Mar 16.

Department of Traumatology, Maastricht University Medical Centre+, 6229 HX Maastricht, The Netherlands.

Manual segmentation of muscle and adipose compartments from computed tomography (CT) axial images is a potential bottleneck in early rapid detection and quantification of sarcopenia. A prototype deep learning neural network was trained on a multi-center collection of 3413 abdominal cancer surgery subjects to automatically segment truncal muscle, subcutaneous adipose tissue and visceral adipose tissue at the L3 lumbar vertebral level. Segmentations were externally tested on 233 polytrauma subjects. Although after severe trauma abdominal CT scans are quickly and robustly delivered, with often motion or scatter artefacts, incomplete vertebral bodies or arms that influence image quality, the concordance was generally very good for the body composition indices of Skeletal Muscle Radiation Attenuation (SMRA) (Concordance Correlation Coefficient (CCC) = 0.92), Visceral Adipose Tissue index (VATI) (CCC = 0.99) and Subcutaneous Adipose Tissue Index (SATI) (CCC = 0.99). In conclusion, this article showed an automated and accurate segmentation system to segment the cross-sectional muscle and adipose area L3 lumbar spine level on abdominal CT. Future perspectives will include fine-tuning the algorithm and minimizing the outliers.
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http://dx.doi.org/10.3390/s21062083DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8002279PMC
March 2021

Feasibility and validity of ambulant biofeedback devices to improve weight-bearing compliance in trauma patients with lower extremity fractures: A narrative review.

J Rehabil Med 2020 Aug 31;52(8):jrm00092. Epub 2020 Aug 31.

Dept. of Trauma Surgery, Maastricht University Medical Centre, , 6229HX Maastricht, The Netherlands. E-mail:

Background: Ambulant biofeedback devices can be used to provide real-time feedback for trauma patients on weight-bearing regimes. The devices also enable prescribing clinicians to monitor and train patients' level of weight-bearing. However, there is limited evidence regarding the feasibility of use of such devices in controlling weight-bearing, and their full potential remains to be elucidated.

Objective: To investigate the feasibility of using ambulant biofeedback training devices to improve compliance with weight-bearing regimes in trauma patients with lower extremity fractures.

Methods: A literature review of the feasibility and clinical validity of ambulant biofeedback devices.

Results: Three clinically validated biofeedback devices were found feasible for use in monitoring the compliance of patients who have lower extremity fractures with different weight-bearing regimes.

Conclusion: Further information about the feasibility and clinical validity of biofeedback training devices is nee-ded in order to optimize weight-bearing instructions for patients.
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http://dx.doi.org/10.2340/16501977-2721DOI Listing
August 2020

High Prevalence of Sarcopenia in Older Trauma Patients: A Pilot Study.

J Clin Med 2020 06 29;9(7). Epub 2020 Jun 29.

Department of Traumatology, Maastricht University Medical Centre+, 6229HX Maastricht, The Netherlands.

Sarcopenia is related to adverse outcomes in various populations. However, little is known about the prevalence of sarcopenia in polytrauma patients. Identifying the number of patients at risk of adverse outcome will increase awareness to prevent further loss of muscle mass. We utilized data from a regional prospective trauma registry of all polytrauma patients presented between 2015 and 2019 at a single level-I trauma center. Subjects were screened for availability of computed tomography (CT)-abdomen and height in order to calculate skeletal mass index, which was used to estimate sarcopenia. Additional parameters regarding clinical outcome were assessed. Univariate analysis was performed to identify parameters related adverse outcome and, if identified, entered in a multivariate regression analysis. Prevalence of sarcopenia was 33.5% in the total population but was even higher in older age groups (range 60-79 years), reaching 82 % in patients over 80 years old. Sarcopenia was related to 30-day or in-hospital mortality ( = 0.032), as well as age ( < 0.0001), injury severity score ( = 0.026), and Charlson comorbidity index ( = 0.001). Log rank analysis identified sarcopenia as an independent predictor of 30-day mortality ( = 0.032). In conclusion, we observed a high prevalence of sarcopenia among polytrauma patients, further increasing in older patients. In addition, sarcopenia was identified as a predictor for 30-day mortality, underlining the clinical significance of identification of low muscle mass on a CT scan that is already routinely obtained in most trauma patients.
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http://dx.doi.org/10.3390/jcm9072046DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7408833PMC
June 2020

Are current wireless monitoring systems capable of detecting adverse events in high-risk surgical patients? A descriptive study.

Injury 2020 May 17;51 Suppl 2:S97-S105. Epub 2019 Nov 17.

Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands.

Background: Adverse events are common in high-risk surgical patients, but early detection is difficult. Recent innovations have resulted in wireless and 'wearable' sensors, which may capture patient deterioration at an early stage, but little is known regarding their ability to timely detect events. The objective of this study is to describe the ability of currently available wireless sensors to detect adverse events in high-risk patients.

Methods: A descriptive analysis was performed of all vital signs trend data obtained during an observational comparison study of wearable sensors for vital signs monitoring in high-risk surgical patients during the initial days of recovery at a surgical step-down unit (SDU) and subsequent traumatology or surgical oncology ward. Heart rate (HR), respiratory rate (RR) and oxygen saturation (SpO) were continuously recorded. Vital sign trend patterns of patients that developed adverse events were described and compared to vital sign recordings of patients without occurrence of adverse events. Two wearable patch sensors were used (SensiumVitals and HealthPatch), a bed-based mattress sensor (EarlySense) and a patient-worn monitor (Masimo Radius-7).

Results: Twenty adverse events occurred in 11 of the 31 patients included. Atrial fibrillation (AF) was most common (20%). The onset of AF was recognizable as a sudden increase in HR in all recordings, and all patients with new-onset AF after esophagectomy developed other postoperative complications. Patients who developed respiratory insufficiency showed an increase in RR and a decrease in SpO, but an increase in HR was not always visible. In patients without adverse events, temporary periods of high HR and RR are observed as well, but these were transient and less frequent.

Conclusions: Current systems for remote wireless patient monitoring on the ward are capable of detecting abnormalities in vital sign patterns in patients who develop adverse events. Remote patient monitoring may have potential to improve patient safety by generating early warnings for deterioration to nursing staff.
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http://dx.doi.org/10.1016/j.injury.2019.11.018DOI Listing
May 2020

Vital Signs Monitoring with Wearable Sensors in High-risk Surgical Patients: A Clinical Validation Study.

Anesthesiology 2020 03;132(3):424-439

From the Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (M.J.M.B., E.J.K., K.v.L., C.J.K.) FocusCura, Driebergen-Rijsenburg, The Netherlands (M.J.M.B., D.A.J.D.) Department of Technical Medicine, University of Twente, Enschede, The Netherlands (E.J.K.) Department of Trauma Surgery (L.P.H.L.) Department of Gastrointestinal and Oncologic Surgery (R.v.H., J.P.R.) University Medical Center Utrecht, Utrecht, The Netherlands (L.P.H.L.) Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands (T.J.B.).

Background: Vital signs are usually recorded once every 8 h in patients at the hospital ward. Early signs of deterioration may therefore be missed. Wireless sensors have been developed that may capture patient deterioration earlier. The objective of this study was to determine whether two wearable patch sensors (SensiumVitals [Sensium Healthcare Ltd., United Kingdom] and HealthPatch [VitalConnect, USA]), a bed-based system (EarlySense [EarlySense Ltd., Israel]), and a patient-worn monitor (Masimo Radius-7 [Masimo Corporation, USA]) can reliably measure heart rate (HR) and respiratory rate (RR) continuously in patients recovering from major surgery.

Methods: In an observational method comparison study, HR and RR of high-risk surgical patients admitted to a step-down unit were simultaneously recorded with the devices under test and compared with an intensive care unit-grade monitoring system (XPREZZON [Spacelabs Healthcare, USA]) until transition to the ward. Outcome measures were 95% limits of agreement and bias. Clarke Error Grid analysis was performed to assess the ability to assist with correct treatment decisions. In addition, data loss and duration of data gaps were analyzed.

Results: Twenty-five high-risk surgical patients were included. More than 700 h of data were available for analysis. For HR, bias and limits of agreement were 1.0 (-6.3, 8.4), 1.3 (-0.5, 3.3), -1.4 (-5.1, 2.3), and -0.4 (-4.0, 3.1) for SensiumVitals, HealthPatch, EarlySense, and Masimo, respectively. For RR, these values were -0.8 (-7.4, 5.6), 0.4 (-3.9, 4.7), and 0.2 (-4.7, 4.4) respectively. HealthPatch overestimated RR, with a bias of 4.4 (limits: -4.4 to 13.3) breaths/minute. Data loss from wireless transmission varied from 13% (83 of 633 h) to 34% (122 of 360 h) for RR and 6% (47 of 727 h) to 27% (182 of 664 h) for HR.

Conclusions: All sensors were highly accurate for HR. For RR, the EarlySense, SensiumVitals sensor, and Masimo Radius-7 were reasonably accurate for RR. The accuracy for RR of the HealthPatch sensor was outside acceptable limits. Trend monitoring with wearable sensors could be valuable to timely detect patient deterioration.
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http://dx.doi.org/10.1097/ALN.0000000000003029DOI Listing
March 2020

Early fixation versus conservative therapy of multiple, simple rib fractures (FixCon): protocol for a multicenter randomized controlled trial.

World J Emerg Surg 2019 30;14:38. Epub 2019 Jul 30.

1Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands.

Background: Multiple rib fractures are common injuries in both the young and elderly. Rib fractures account for 10% of all trauma admissions and are seen in up to 39% of patients after thoracic trauma. With morbidity and mortality rates increasing with the number of rib fractures as well as poor quality of life at long-term follow-up, multiple rib fractures pose a serious health hazard. Operative fixation of flail chest is beneficial over nonoperative treatment regarding, among others, pneumonia and both intensive care unit (ICU) and hospital length of stay. With no high-quality evidence on the effects of multiple simple rib fracture treatment, the optimal treatment modality remains unknown. This study sets out to investigate outcome of operative fixation versus nonoperative treatment of multiple simple rib fractures.

Methods: The proposed study is a multicenter randomized controlled trial. Patients will be eligible if they have three or more multiple simple rib fractures of which at least one is dislocated over one shaft width or with unbearable pain (visual analog scale (VAS) or numeric rating scale (NRS) > 6). Patients in the intervention group will be treated with open reduction and internal fixation. Pre- and postoperative care equals treatment in the control group. The control group will receive nonoperative treatment, consisting of pain management, bronchodilator inhalers, oxygen support or mechanical ventilation if needed, and pulmonary physical therapy. The primary outcome measure will be occurrence of pneumonia within 30 days after trauma. Secondary outcome measures are the need and duration of mechanical ventilation, thoracic pain and analgesics use, (recovery of) pulmonary function, hospital and ICU length of stay, thoracic injury-related and surgery-related complications and mortality, secondary interventions, quality of life, and cost-effectiveness comprising health care consumption and productivity loss. Follow-up visits will be standardized and daily during hospital admission, at 14 days and 1, 3, 6, and 12 months.

Discussion: With favorable results in flail chest patients, operative treatment may also be beneficial in patients with multiple simple rib fractures. The FixCon trial will be the first study to compare clinical, functional, and economic outcome between operative fixation and nonoperative treatment for multiple simple rib fractures.

Trial Registration: www.trialregister.nl, NTR7248. Registered May 31, 2018.
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http://dx.doi.org/10.1186/s13017-019-0258-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6668138PMC
April 2020

Long-term functional outcome after a low-energy hip fracture in elderly patients.

J Orthop Traumatol 2019 04 11;20(1):20. Epub 2019 Apr 11.

Department of Trauma Surgery, Maastricht University Medical Center+, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands.

Background: The incidence of hip fractures is increasing. Elderly patients with a hip fracture frequently present with comorbidities, which are associated with higher mortality rates. Clinical studies regarding long-term functional outcome and mortality in hip fractures are rare. The aim of this study was to analyse the functional outcome and the mortality rate after a follow-up of 5 years in elderly patients with a hip fracture.

Materials And Methods: This combined retrospective and cross-sectional study included patients aged 65 years or older with a low energy hip fracture who underwent surgery in the Maastricht University Medical Center+, the Netherlands. Data such as demographics and mortality rates were retrospectively collected and functional outcome (i.e. mobility, pain, housing conditions and quality of life) was assessed by a questionnaire.

Results: Two hundred and sixteen patients were included in this study (mean age 82.2, SD ± 7.5). No significant differences were found in pain before hip fracture and after 1-year and 5-year follow-ups. Long-term functional outcome deteriorated after a hip fracture, with a significant increase in the use of walking aids (p < 0.001), a significant decrease of patients living in a private home (p < 0.001), and a low physical quality of life (SF-12 PCS = 27.1). The mortality incidences after 30-day, 1-year and 5-year follow-ups were 7.9%, 37.0% and 69.4%, respectively.

Conclusion: Long-term functional outcome in elderly patients with hip fractures significantly deteriorated, with an increased dependency for mobility and housing conditions and a decreased physical quality of life. In addition, hip fractures are associated with high mortality rates at the 5-year follow-up.

Level Of Evidence: Level III, a retrospective cohort study.
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http://dx.doi.org/10.1186/s10195-019-0529-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6459450PMC
April 2019

Perioperative nutritional supplementation and skeletal muscle mass in older hip-fracture patients.

Nutr Rev 2019 04;77(4):254-266

Department of Surgery, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, The Netherlands.

Older people with hip fractures are often malnourished at the time of fracture, which can have substantial influence on mortality and clinical outcomes, as well as functional outcome and quality of life. A close relationship between protein intake and muscle maintenance has been demonstrated. Skeletal muscle weakness is an independent risk factor for falls and fall-related injuries in the elderly and is an independent marker of prognosis. However, the effect of perioperative nutritional interventions on outcomes in elderly hip-fracture patients remains controversial. In this narrative review, an overview is presented of the existing literature on nutritional status and sarcopenia in elderly hip-fracture patients, clinical outcomes, and the effects of nutritional intervention on outcome and rehabilitation in this patient group.
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http://dx.doi.org/10.1093/nutrit/nuy055DOI Listing
April 2019

Characterization of the Fat Channel for Intra-Body Communication at R-Band Frequencies.

Sensors (Basel) 2018 Aug 21;18(9). Epub 2018 Aug 21.

Microwaves in Medical Engineering Group, Solid State Electronics, Department of Engineering Sciences, Ångström Laboratory, Uppsala University, P.O. Box 534, 751 21 Uppsala, Sweden.

In this paper, we investigate the use of fat tissue as a communication channel between in-body, implanted devices at R-band frequencies (1.7⁻2.6 GHz). The proposed fat channel is based on an anatomical model of the human body. We propose a novel probe that is optimized to efficiently radiate the R-band frequencies into the fat tissue. We use our probe to evaluate the path loss of the fat channel by studying the channel transmission coefficient over the R-band frequencies. We conduct extensive simulation studies and validate our results by experimentation on phantom and ex-vivo porcine tissue, with good agreement between simulations and experiments. We demonstrate a performance comparison between the fat channel and similar waveguide structures. Our characterization of the fat channel reveals propagation path loss of ∼0.7 dB and ∼1.9 dB per cm for phantom and ex-vivo porcine tissue, respectively. These results demonstrate that fat tissue can be used as a communication channel for high data rate intra-body networks.
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http://dx.doi.org/10.3390/s18092752DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6165426PMC
August 2018

Neutrophils Inhibit Synthesis of Mineralized Extracellular Matrix by Human Bone Marrow-Derived Stromal Cells .

Front Immunol 2018 1;9:945. Epub 2018 May 1.

Department of Surgery, University Medical Center Utrecht, Utrecht, Netherlands.

Although controlled local inflammation is essential for adequate bone regeneration, several studies have shown that hyper-inflammatory conditions after major trauma are associated with impaired fracture healing. These hyper-inflammatory conditions include the trauma-induced systemic inflammatory response to major injury, open fractures, and significant injury to the surrounding soft tissues. The current literature suggests that increased or prolonged influx of neutrophils into the fracture hematoma may mediate impairment of bone regeneration after hyper-inflammatory conditions. The underlying mechanism remains unclear. We hypothesize that high neutrophil numbers inhibit synthesis of mineralized extracellular matrix (ECM) by bone marrow stromal cells (BMSCs). We therefore studied the effect of increasing concentrations of neutrophils on ECM synthesis by human BMSCs . Moreover, we determined how high neutrophil concentrations affect BMSC cell counts, as well as BMSC osteogenic activity determined by alkaline phosphatase (ALP) expression and ALP activity. Co-culture of BMSCs with neutrophils induced a 52% decrease in BMSC cell count ( < 0.01), a 64% decrease in the percentage of ALP+ cells ( < 0.001), a 28% decrease in total ALP activity ( < 0.01), and a significant decrease in the amount of mineralized ECM [38% decrease after 4 weeks ( < 0.05)]. Co-cultures with peripheral blood mononuclear cells and neutrophils within transwells did not induce a significant decrease in ALP activity. In conclusion, our data shows that a decreased amount of mineralized ECM became synthesized by BMSCs, when they were co-cultured with high neutrophil concentrations. Moreover, high neutrophil concentrations induced a decrease in BMSC cell counts and decreased ALP activity. Clarifying the underlying mechanism may contribute to development of therapies that augment bone regeneration or prevent impaired fracture healing after hyper-inflammatory conditions.
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http://dx.doi.org/10.3389/fimmu.2018.00945DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5938347PMC
July 2019

Serum from the Human Fracture Hematoma Contains a Potent Inducer of Neutrophil Chemotaxis.

Inflammation 2018 Jun;41(3):1084-1092

Department of Traumatology, Maastricht University Medical Center, Maastricht, The Netherlands.

A controlled local inflammatory response is essential for adequate fracture healing. However, the current literature suggests that local and systemic hyper-inflammatory conditions after major trauma induce increased influx of neutrophils into the fracture hematoma (FH) and impair bone regeneration. Inhibiting neutrophil chemotaxis towards the FH without compromising the hosts' defense may therefore be a target of future therapies that prevent impairment of fracture healing after major trauma. We investigated whether chemotaxis of neutrophils towards the FH could be studied in vitro. Moreover, we determined whether chemotaxis of neutrophils towards the FH was mediated by the CXCR1, CXCR2, FPR, and C5aR receptors. Human FHs were isolated during an open reduction internal fixation (ORIF) procedure within 3 days after trauma and spun down to obtain the fracture hematoma serum. Neutrophil migration towards the FH was studied using Ibidi™ Chemotaxis μ-Slides and image analysis of individual neutrophil tracks was performed. Our study showed that the human FH induces significant neutrophil chemotaxis, which was not affected by blocking CXCR1 and CXCR2. In contrast, neutrophil chemotaxis towards the FH was significantly inhibited by chemotaxis inhibitory protein of Staphylococcus aureus (CHIPS), which blocks FPR and C5aR. Blocking only C5aR with CHIPSΔ1F also significantly inhibited neutrophil chemotaxis towards the FH. Our finding that neutrophil chemotaxis towards the human FH can be blocked in vitro using CHIPS may aid the development of therapies that prevent impairment of fracture healing after major trauma.
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http://dx.doi.org/10.1007/s10753-018-0760-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5982450PMC
June 2018

Reliability of wireless monitoring using a wearable patch sensor in high-risk surgical patients at a step-down unit in the Netherlands: a clinical validation study.

BMJ Open 2018 02 27;8(2):e020162. Epub 2018 Feb 27.

Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.

Background And Objectives: Intermittent vital signs measurements are the current standard on hospital wards, typically recorded once every 8 hours. Early signs of deterioration may therefore be missed. Recent innovations have resulted in 'wearable' sensors, which may capture patient deterioration at an earlier stage. The objective of this study was to determine whether a wireless 'patch' sensor is able to reliably measure respiratory and heart rate continuously in high-risk surgical patients. The secondary objective was to explore the potential of the wireless sensor to serve as a safety monitor.

Design: In an observational methods comparisons study, patients were measured with both the wireless sensor and bedside routine standard for at least 24 hours.

Setting: University teaching hospital, single centre.

Participants: Twenty-five postoperative surgical patients admitted to a step-down unit.

Outcome Measures: Primary outcome measures were limits of agreement and bias of heart rate and respiratory rate. Secondary outcome measures were sensor reliability, defined as time until first occurrence of data loss.

Results: 1568 hours of vital signs data were analysed. Bias and 95% limits of agreement for heart rate were -1.1 (-8.8 to 6.5) beats per minute. For respiration rate, bias was -2.3 breaths per minute with wide limits of agreement (-15.8 to 11.2 breaths per minute). Median filtering over a 15 min period improved limits of agreement of both respiration and heart rate. 63% of the measurements were performed without data loss greater than 2 min. Overall data loss was limited (6% of time).

Conclusions: The wireless sensor is capable of accurately measuring heart rate, but accuracy for respiratory rate was outside acceptable limits. Remote monitoring has the potential to contribute to early recognition of physiological decline in high-risk patients. Future studies should focus on the ability to detect patient deterioration on low care environments and at home after discharge.
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http://dx.doi.org/10.1136/bmjopen-2017-020162DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5855309PMC
February 2018

Split-Ring Resonator Sensor Penetration Depth Assessment Using In Vivo Microwave Reflectivity and Ultrasound Measurements for Lower Extremity Trauma Rehabilitation.

Sensors (Basel) 2018 Feb 21;18(2). Epub 2018 Feb 21.

Microwaves in Medical Engineering Group, Solid State Electronics, Department of Engineering Sciences, Angstrom Laboratory, Uppsala University, Box 534, SE 75121 Uppsala, Sweden.

In recent research, microwave sensors have been used to follow up the recovery of lower extremity trauma patients. This is done mainly by monitoring the changes of dielectric properties of lower limb tissues such as skin, fat, muscle, and bone. As part of the characterization of the microwave sensor, it is crucial to assess the signal penetration in in vivo tissues. This work presents a new approach for investigating the penetration depth of planar microwave sensors based on the Split-Ring Resonator in the in vivo context of the femoral area. This approach is based on the optimization of a 3D simulation model using the platform of CST Microwave Studio and consisting of a sensor of the considered type and a multilayered material representing the femoral area. The geometry of the layered material is built based on information from ultrasound images and includes mainly the thicknesses of skin, fat, and muscle tissues. The optimization target is the measured S parameters at the sensor connector and the fitting parameters are the permittivity of each layer of the material. Four positions in the femoral area (two at distal and two at thigh) in four volunteers are considered for the in vivo study. The penetration depths are finally calculated with the help of the electric field distribution in simulations of the optimized model for each one of the 16 considered positions. The numerical results show that positions at the thigh contribute the highest penetration values of up to 17.5 mm. This finding has a high significance in planning in vitro penetration depth measurements and other tests that are going to be performed in the future.
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http://dx.doi.org/10.3390/s18020636DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5855979PMC
February 2018

Real-time visual biofeedback to improve therapy compliance after total hip arthroplasty: A pilot randomized controlled trial.

Gait Posture 2018 Mar 31;61:306-310. Epub 2018 Jan 31.

Department of Surgery, Maastricht University Medical Center+, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands.

Background: Previous studies have shown limited therapy compliance in weight-bearing in patients following total hip arthroplasty.

Research Question: The purpose of this pilot RCT is to determine the immediate and late effect of real-time, visual biofeedback on weight-bearing during rehabilitation after THA in elderly.

Methods: 24 participants who underwent THA were randomized to either the control or the intervention group. The intervention group received real-time, visual biofeedback on weight-bearing during training with the physical therapist during hospitalization and at twelve weeks follow up.

Results: Without biofeedback, therapy compliance was limited. Significant improvement in peak load was found in the intervention group in the early postoperative phase. In contrast to the control group, the peak load at twelve weeks was significantly higher in the intervention group compared to the pre-operative peak load, indicating a lasting effect of early biofeedback. Other gait parameters were not significantly different in the early postoperative phase. In the intervention group a longer walking distance was observed and the use of walking aids was reduced at twelve weeks.

Significance: Biofeedback systems could be promising to improve outcomes and reduce costs in future rehabilitation programs after THA.
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http://dx.doi.org/10.1016/j.gaitpost.2018.01.038DOI Listing
March 2018

Permissive weight bearing in trauma patients with fracture of the lower extremities: prospective multicenter comparative cohort study.

BMC Surg 2018 Feb 2;18(1). Epub 2018 Feb 2.

Department of Traumatology, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands.

Background: The standard aftercare treatment in surgically treated trauma patients with fractures around or in a joint, known as (peri)- or intra-articular fractures of the lower extremities, is either non-weight bearing or partial weight bearing. We have developed an early permissive weight bearing post-surgery rehabilitation protocol in surgically treated patients with fractures of the lower extremities. In this proposal we want to compare our early permissive weight bearing protocol to the existing current non-weight bearing guidelines in a prospective comparative cohort study.

Methods/design: The study is a prospective multicenter comparative cohort study in which two rehabilitation aftercare treatments will be contrasted, i.e. permissive weight bearing and non-weight bearing according to the AO-guideline. The study population consists of patients with a surgically treated fracture of the pelvis/acetabulum or a surgically treated (peri)- or intra-articular fracture of the lower extremities. The inclusion period is 12 months. The duration of follow up is 6 months, with measurements taken at baseline, 2,6,12 and 26 weeks post-surgery.

Primary Outcome Measure: ADL with Lower Extremity Functional Scale. Outcome variables for compliance, as measured with an insole pressure measurement system, encompass peak load and step duration.

Discussion: This study will investigate the (cost-) effectiveness of a permissive weight bearing aftercare protocol. The results will provide evidence whether a permissive weight bearing protocol is more effective than the current non-weight bearing protocol.

Trial Registration: The study is registered in the Dutch Trial Register ( NTR6077 ). Date of registration: 01-09-2016.
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http://dx.doi.org/10.1186/s12893-018-0341-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5796499PMC
February 2018

Real-time visual biofeedback during weight bearing improves therapy compliance in patients following lower extremity fractures.

Gait Posture 2018 01 20;59:206-210. Epub 2017 Oct 20.

Department of Surgery, Maastricht University Medical Center+, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands.

Background: Individuals with lower extremity fractures are often instructed on how much weight to bear on the affected extremity. Previous studies have shown limited therapy compliance in weight bearing during rehabilitation. In this study we investigated the effect of real-time visual biofeedback on weight bearing in individuals with lower extremity fractures in two conditions: full weight bearing and touch-down weight bearing.

Methods: 11 participants with full weight bearing and 12 participants with touch-down weight bearing after lower extremity fractures have been measured with an ambulatory biofeedback system. The participants first walked 15m and the biofeedback system was only used to register the weight bearing. The same protocol was then repeated with real-time visual feedback during weight bearing. The participants could thereby adapt their loading to the desired level and improve therapy compliance.

Results: In participants with full weight bearing, real-time visual biofeedback resulted in a significant increase in loading from 50.9±7.51% bodyweight (BW) without feedback to 63.2±6.74%BW with feedback (P=0.0016). In participants with touch-down weight bearing, the exerted lower extremity load decreased from 16.7±9.77kg without feedback to 10.27±4.56kg with feedback (P=0.0718). More important, the variance between individual steps significantly decreased after feedback (P=0.018).

Conclusions: Ambulatory monitoring weight bearing after lower extremity fractures showed that therapy compliance is low, both in full and touch-down weight bearing. Real-time visual biofeedback resulted in significantly higher peak loads in full weight bearing and increased accuracy of individual steps in touch-down weight bearing. Real-time visual biofeedback therefore results in improved therapy compliance after lower extremity fractures.
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http://dx.doi.org/10.1016/j.gaitpost.2017.10.022DOI Listing
January 2018

Intra-body microwave communication through adipose tissue.

Healthc Technol Lett 2017 Aug 23;4(4):115-121. Epub 2017 May 23.

Department of Engineering Sciences, Solid State Electronics, Uppsala University, SE-751 21 Uppsala, Sweden.

The human body can act as a medium for the transmission of electromagnetic waves in the wireless body sensor networks context. However, there are transmission losses in biological tissues due to the presence of water and salts. This Letter focuses on lateral intra-body microwave communication through different biological tissue layers and demonstrates the effect of the tissue thicknesses by comparing signal coupling in the channel. For this work, the authors utilise the R-band frequencies since it overlaps the industrial, scientific and medical radio (ISM) band. The channel model in human tissues is proposed based on electromagnetic simulations, validated using equivalent phantom and measurements. The phantom and measurements are compared with simulation modelling. The results show that electromagnetic communication is feasible in the adipose tissue layer with a low attenuation of ∼2 dB per 20 mm for phantom measurements and 4 dB per 20 mm for measurements at 2 GHz. Since the dielectric losses of human adipose tissues are almost half of tissue, an attenuation of around 3 dB per 20 mm is expected. The results show that human adipose tissue can be used as an intra-body communication channel.
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http://dx.doi.org/10.1049/htl.2016.0104DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5569712PMC
August 2017

Timing of definitive fixation of major long bone fractures: Can fat embolism syndrome be prevented?

Injury 2017 Jun 24;48 Suppl 1:S3-S6. Epub 2017 Apr 24.

Department of Surgery, Universitair Medisch Centrum Radboud, Nijmegen, The Netherlands.

Fat embolism is common in patients with major fractures, but leads to devastating consequences, named fat embolism syndrome (FES) in some. Despite advances in treatment strategies regarding the timing of definitive fixation of major fractures, FES still occurs in patients. In this overview, current literature is reviewed and optimal treatment strategies for patients with multiple traumatic injuries, including major fractures, are discussed. Considering the multifactorial etiology of FES, including mechanical and biochemical pathways, FES cannot be prevented in all patients. However, screening for symptoms of FES should be standard in the pre-operative work-up of these patients, prior to definitive fixation of major fractures.
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http://dx.doi.org/10.1016/j.injury.2017.04.015DOI Listing
June 2017

Management of traumatic bone defects: Metaphyseal versus diaphyseal defects.

Authors:
Taco J Blokhuis

Injury 2017 Jun 24;48 Suppl 1:S91-S93. Epub 2017 Apr 24.

Department of Surgery, Maastricht University Medical Center +, Postbus 5800, 6202 AZ Maastricht, The Netherlands. Electronic address:

Although bone defects after trauma appear in different locations and forms, many clinicians have adopted a single strategy to deal with any defect. In this overview, a distinction is made between metaphyseal, or cancellous defects, and diaphyseal, or cortical defects. The treatment goals and background of these two types of defects are discussed in order to describe the difference in strategy and hence the difference in treatment method.
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http://dx.doi.org/10.1016/j.injury.2017.04.021DOI Listing
June 2017

Technical Aspects and Validation of a New Biofeedback System for Measuring Lower Limb Loading in the Dynamic Situation.

Sensors (Basel) 2017 Mar 22;17(3). Epub 2017 Mar 22.

Department of Surgery, Maastricht University Medical Center+, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands.

Background: A variety of techniques for measuring lower limb loading exists, each with their own limitations. A new ambulatory biofeedback system was developed to overcome these limitations. In this study, we described the technical aspects and validated the accuracy of this system.

Methods: A bench press was used to validate the system in the static situation. Ten healthy volunteers were measured by the new biofeedback system and a dual-belt instrumented treadmill to validate the system in the dynamic situation.

Results: Bench press results showed that the sensor accurately measured peak loads up to 1000 N in the static situation. In the healthy volunteers, the load curves measured by the biofeedback system were similar to the treadmill. However, the peak loads and loading rates were lower in the biofeedback system in all participants at all speeds.

Conclusions: Advanced sensor technologies used in the new biofeedback system resulted in highly accurate measurements in the static situation. The position of the sensor and the design of the biofeedback system should be optimized to improve results in the dynamic situation.
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http://dx.doi.org/10.3390/s17030658DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5375944PMC
March 2017

Impaired bone healing in multitrauma patients is associated with altered leukocyte kinetics after major trauma.

J Inflamm Res 2016 18;9:69-78. Epub 2016 May 18.

Department of Traumatology, Julius center, Utrecht, the netherlands.

Animal studies have shown that the systemic inflammatory response to major injury impairs bone regeneration. It remains unclear whether the systemic immune response contributes to impairment of fracture healing in multitrauma patients. It is well known that systemic inflammatory changes after major trauma affect leukocyte kinetics. We therefore retrospectively compared the cellular composition of peripheral blood during the first 2 weeks after injury between multitrauma patients with normal (n=48) and impaired (n=32) fracture healing of the tibia. The peripheral blood-count curves of leukocytes, neutrophils, monocytes, and thrombocytes differed significantly between patients with normal and impaired fracture healing during the first 2 weeks after trauma (P-values were 0.0122, 0.0083, 0.0204, and <0.0001, respectively). Mean myeloid cell counts were above reference values during the second week after injury. Our data indicate that leukocyte kinetics differ significantly between patients with normal and impaired fracture healing during the first 2 weeks after major injury. This finding suggests that the systemic immune response to major trauma can disturb tissue regeneration.
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http://dx.doi.org/10.2147/JIR.S101064DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4876940PMC
June 2016

Neutrophils contribute to fracture healing by synthesizing fibronectin+ extracellular matrix rapidly after injury.

Clin Immunol 2016 Mar 12;164:78-84. Epub 2016 Feb 12.

Department of Traumatology, University Medical Center Utrecht, Heidelberglaan 100, HP G04. 228, 3508, GA, Utrecht, The Netherlands. Electronic address:

The role of inflammatory cells in bone regeneration remains unclear. We hypothesize that leukocytes contribute to fracture healing by rapidly synthesizing an "emergency extracellular matrix (ECM)" before stromal cells infiltrate the fracture hematoma (FH) and synthesize the eventual collagenous bone tissue. 53 human FHs were isolated at different time points after injury, ranging from day 0 until day 23 after trauma and stained using (immuno)histochemistry. FHs isolated within 48 h after injury contained fibronectin(+) ECM, which increased over time. Neutrophils within the early FHs stained positive for cellular fibronectin and neutrophil derived particles were visible within the fibronectin(+) ECM. Stromal cells appeared at day 5 after injury or later and collagen type I birefringent fibrils could be identified during the second week after injury. Our study suggests that neutrophils contribute to bone regeneration by synthesizing an "emergency ECM" before stromal cells infiltrate the FH and synthesize the eventual bone tissue.
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http://dx.doi.org/10.1016/j.clim.2016.02.001DOI Listing
March 2016

Proinflammatory T cells and IL-17 stimulate osteoblast differentiation.

Bone 2016 Mar 11;84:262-270. Epub 2016 Jan 11.

Department of Orthopedics, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, The Netherlands. Electronic address:

The local immune response is important to consider when the aim is to improve bone regeneration. Recently T lymphocytes and their associated cytokines have been identified as regulators in fracture callus formation, but it is not known whether T cells affect bone progenitor cells directly. The goal of this in vitro study was to investigate the role of different T cell subsets and their secreted factors on the osteogenic differentiation of human mesenchymal stem cells (MSCs). Significant increases in the alkaline phosphatase activity and the subsequent matrix mineralization by MSCs were found after their exposure to activated T cells or activated T cell-derived conditioned medium. Blocking IFN-γ in the conditioned medium abolished its pro-osteogenic effect, while blocking TGF-β further enhanced osteogenesis. The relative contribution of an anti- or proinflammatory T cell phenotype in MSC osteogenic differentiation was studied next. Enrichment of the fraction of anti-inflammatory regulatory T cells had no beneficial osteogenic effect. In contrast, soluble factors derived from enriched T helper 17 cells upregulated the expression of osteogenic markers by MSCs. IL-17A, and IL-17F, their main proinflammatory cytokines, similarly exhibited strong osteogenic effects when exposed directly to MSCs. IL-17A in particular showed a synergistic action together with bone morphogenetic protein 2. These results indicate that individual T cell subsets, following their activation, affect osteoblast maturation in a different manner through the production of soluble factors. From all T cells, the proinflammatory T cells, including the T helper 17 cells, are most stimulatory for osteogenesis.
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http://dx.doi.org/10.1016/j.bone.2016.01.010DOI Listing
March 2016

Proinflammatory Mediators Enhance the Osteogenesis of Human Mesenchymal Stem Cells after Lineage Commitment.

PLoS One 2015 15;10(7):e0132781. Epub 2015 Jul 15.

Department of Orthopedics, University Medical Center Utrecht, Utrecht, the Netherlands.

Several inflammatory processes underlie excessive bone formation, including chronic inflammation of the spine, acute infections, or periarticular ossifications after trauma. This suggests that local factors in these conditions have osteogenic properties. Mesenchymal stem cells (MSCs) and their differentiated progeny contribute to bone healing by synthesizing extracellular matrix and inducing mineralization. Due to the variation in experimental designs used in vitro, there is controversy about the osteogenic potential of proinflammatory factors on MSCs. Our goal was to determine the specific conditions allowing the pro-osteogenic effects of distinct inflammatory stimuli. Human bone marrow MSCs were exposed to tumor necrosis factor alpha (TNF-α) and lipopolysaccharide (LPS). Cells were cultured in growth medium or osteogenic differentiation medium. Alternatively, bone morphogenetic protein 2 (BMP-2) was used as osteogenic supplement to simulate the conditions in vivo. Alkaline phosphatase activity and calcium deposition were indicators of osteogenicity. To elucidate lineage commitment-dependent effects, MSCs were pre-differentiated prior treatment. Our results show that TNF-α and LPS do not affect the expression of osteogenic markers by MSCs in the absence of an osteogenic supplement. In osteogenic differentiation medium or together with BMP-2 however, these mediators highly stimulated their alkaline phosphatase activity and subsequent matrix mineralization. In pre-osteoblasts, matrix mineralization was significantly increased by these mediators, but irrespective of the culture conditions. Our study shows that inflammatory factors potently enhance the osteogenic capacity of MSCs. These properties may be harnessed in bone regenerative strategies. Importantly, the commitment of MSCs to the osteogenic lineage greatly enhances their responsiveness to inflammatory signals.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0132781PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4503569PMC
April 2016

Increased osteogenic capacity of Reamer/Irrigator/Aspirator derived mesenchymal stem cells.

Injury 2014 Dec;45(12):2060-4

Introduction: Donor-site morbidity, complications and availability remain concerns in autologous bone grafting today. The Reamer/Irrigator/Aspirator system (RIA) provides an alternative method to overcome these problems. According to literature, RIA graft possesses a higher osteogenic potency. This study compares iliac crest and RIA graft performance by determining their in vitro osteogenic capacity in a porcine model.

Methods: Osteogenic capacity and cell content was determined in RIA and iliac crest bone grafts harvested from six female domestic white pigs. Cells initially washed off, and cells harvested with collagenase were analysed separately and in combination. Alkaline phosphatase expression (ALP) and cell numbers were evaluated after 7 and 14 days of culture. Matrix mineralisation was quantified after 14 days.

Results: Cell cultures showed a significant increase of matrix mineralisation by RIA-derived cells compared to iliac crest bone graft (p = 0.0313). The yield of collagenase derived cells was increased in the RIA group and a synergy between washed off and collagenase derived cells was observed. Cell proliferation was similar in both groups.

Discussion: The osteogenic differentiation capacity of cell populations isolated from the RIA derived bone graft surpasses that of iliac crest derived cells. It is proposed that the observed effect can be attributed to the origin of the cells and to the specific action of the RIA system. This study provides further evidence indicating that RIA bone graft provides superior osteogenic properties compared to iliac crest bone graft.
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http://dx.doi.org/10.1016/j.injury.2014.10.009DOI Listing
December 2014

Dynamic weight loading in older people with hip fracture.

J Rehabil Med 2014 Jul;46(7):708-11

Department of Surgery , University Medical Centre Utrecht, The Netherlands.

Objective: Hip fractures have a high morbidity and mortality in elderly patients. Improving mobility outcomes is crucial in order to decrease the burden of this injury. The objective of this study was to investigate dynamic weight loading in older people with hip fractures using a new device.

Design: In an observational study, low-energy hip fracture patients were monitored one day per week with the [email protected] system during their admission. Pain, gait and balance scores were noted. Outcome measures of the [email protected] system are steps, walking bouts and loading rate.

Results: A total of 21 patients with hip fracture were included in the study (mean age 80.3 years (standard deviation 8.3 years)). The number of steps, walking bouts and loading rate had a positive linear relationship with rehabilitation (i.e. gait and balance scores) (p < 0.05). These parameters also differed significantly between patients with short (less than 8 weeks, n = 7), intermediate (between 8 and 12 weeks, n = 8) and long (longer than 12 weeks, n = 6) of rehabilitation (p < 0.01).

Conclusion: The loading rate is a sensitive weight loading parameter for analysis of dynamic weight loading during rehabilitation in elderly hip fracture patients. This parameter correlates with clinical improvement and can differentiate between fast and slow rehabilitation.
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http://dx.doi.org/10.2340/16501977-1793DOI Listing
July 2014

Intramedullary nailing without interlocking screws for femoral and tibial shaft fractures.

Arch Orthop Trauma Surg 2013 Aug 23;133(8):1109-13. Epub 2013 May 23.

Department of Surgery, University Medical Center Utrecht (UMCU), HP G04.228, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands.

Background: Intramedullary fixation is the treatment of choice for diaphyseal fractures of the femur and tibia. Locking the implant can sometimes be cumbersome and time consuming. In our institution, fractures with axial and rotational stability are treated with intramedullary nailing without interlocking.

Methods: All consecutive patients presented in the University Medical Center Utrecht from October 2003 to August 2009 with acute traumatic diaphyseal fractures of the tibia or femur that were considered axial and rotational stable were included. They underwent internal fixation using intramedullary nails without interlocking. Patient records were evaluated for duration of surgery, perioperative complications, consolidation time and re-operations.

Results: Twenty-nine long bone fractures were treated in 27 patients: 20 men and 7 women, with an average age of 28.9 years (range 15.6-54.4). There were 12 femoral fractures and 17 tibial fractures. Sixteen fractures were closed and 13 were open (10 Gustilo 1, 3 Gustilo 2). The mean operating time was 43 min (range 18-68 min) for tibial fractures and 55 min (range 47-150 min) for femoral fractures. Postoperative complications occurred in six patients. Two patients (three fractures) were lost to follow-up. Healing occurred in 25 of the 26 remaining fractures (96 %) without additional interventions. One tibia was secondarily converted to a standard locked nail because of axial and rotational instability. All patients returned to their pre-injury level of activity.

Conclusion: The use of intramedullary nailing without interlocking is associated with minimal complications in selected fractures. The advantages include a short operating time and the simplicity of its application.
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http://dx.doi.org/10.1007/s00402-013-1775-9DOI Listing
August 2013

Autograft versus BMPs for the treatment of non-unions: what is the evidence?

Injury 2013 Jan;44 Suppl 1:S40-2

Department of Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands.

Autograft is considered the gold standard in non-union treatment. However, it is associated with significant morbidity and limited biological activity. The introduction of bone morphogenetic proteins (BMPs) has added a valuable tool to the surgeon's possibilities. The initial expectations of the effectiveness of BMPs were high, but over the years the union rate of BMPs was shown to be comparable with autograft. In this overview, both treatment modalities are compared. The off-label use of BMPs, the combination of BMPs and autograft, and the economic perspective of BMP use are summarized. In their current formulation, BMPs are an effective alternative for autograft in selected cases. The beneficial effect outweighs the economic costs. Widening of the indication to other long bone non-unions and new formulations are expected in the nearby future.
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http://dx.doi.org/10.1016/S0020-1383(13)70009-3DOI Listing
January 2013

Segmental tibial fractures: an infrequent but demanding injury.

Clin Orthop Relat Res 2013 Sep;471(9):2790-6

Department of Surgery, University Medical Center Utrecht, PO Box 85500, Suite G04.228, 3508 GA, Utrecht, The Netherlands.

Background: Segmental tibial fractures are considered to be a special injury type associated with high complication rates. However, it is unclear whether healing of these fractures truly differs from that of nonsegmental fractures.

Questions/purposes: We therefore asked (1) does the time to union in segmental tibial fractures differ from that of nonsegmental fractures; and (2) does the complication rate of segmental fractures differ from that of nonsegmental fractures?

Methods: We retrospectively studied 30 patients with segmental tibial fractures treated at a Level I trauma center from January 2000 to December 2008 and compared healing and complications with a matched control group of 30 nonsegmental tibial fractures. In followup we determined time to union, delayed and nonunion, and overall complication rates. Patients were followed at least until union was attained. The minimum followup was 5 months (median, 15 months; range, 5-54 months).

Results: Median time to union was 34 weeks (range, 12-122 weeks). Segmental fractures took longer to heal than nonsegmental fractures (median, 34 weeks; range, 12-122 weeks and median, 24 weeks; range, 11-39 weeks, respectively). The overall rate of complications was higher in segmental fractures as was the necessity for reoperation to attain healing.

Conclusions: Healing of segmental tibial fractures is characterized by substantially more complications and longer healing times than nonsegmental fractures and should be considered as a special type of injury. We believe these should be treated in specialized trauma centers.
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http://dx.doi.org/10.1007/s11999-012-2739-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3734401PMC
September 2013
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