Shared decision-making for non-operative management versus operative management of hip fractures in selected frail older adults with a limited life expectancy: a protocol for a nationwide implementation study.

BACKGROUND AND PURPOSE: Recent research has highlighted non-operative management (NOM) as a viable alternative for frail older adults with hip fractures in the final phase of life. This study aims to guide Dutch physicians and hospitals nationwide in a standardised implementation of shared decision-making regarding surgery or NOM in selected frail older adults with a hip fracture. METHODS AND ANALYSIS: The patient population for implementation includes frail older adults aged ≥70 years with an acute proximal femoral fracture, nursing home care or a similar level of care elsewhere and at least one additional criterion (ie, malnutrition, severe mobility impairment or ASA≥4). The 2-year implementation study will be conducted in four phases. In phases 1 and 2, barriers and facilitators for implementation will be identified and an implementation protocol, educational materials and patient information will be developed. Phase 3 will involve an implementation pilot in 14 hospitals across the Netherlands. The protocol and educational material will be improved based on healthcare provider and patient experiences gathered through interviews. Phase 4 will focus on upscaling to nationwide implementation and the effect of the implementation on NOM rate will be measured using data from the Dutch Hip Fracture Audit. ETHICS AND DISSEMINATION: The study was exempted by the local Medical Research Ethics Committee (MEC-2023-0270, 10 May 2023) and Medical Ethics Committee United (W23.083, 26 April 2023). The study's results will be submitted to an open access international peer-reviewed journal. Its protocols, tools and results will be presented at several national and international academic conferences of relevant orthogeriatric (scientific) associations. TRIAL REGISTRATION NUMBER: NCT06079905 .

Clinically relevant bleeding risk in low-energy fragility fractures of the pelvis in elderly patients.

INTRODUCTION: Low-energy fragility fractures of the pelvis (FFP) are an underestimated entity, yet increasing in incidence. The bleeding risk for pelvic fractures in high-energy trauma is well known, resulting in adequate treatment guidelines and clear protocols. This is not the case for FFPs but this risk is presumably low. This study aims to investigate the clinically relevant bleeding risk, in patients older than 50 years with a fragility fracture of the pelvis admitted to the emergency department (ED). METHOD: A retrospective cohort study was conducted of consecutive patients aged over 50 years with a FFP due to low-energy trauma (LET) presented to the ED of a single trauma center (North-West Clinics in Alkmaar, The Netherlands) between January 2018 and August 2022. The primary outcome was the percentage of patients requiring blood transfusion, or invasive procedures such as coiling by the interventional radiologists or damage control surgery, due to bleeding. Secondary outcomes were the mean decrease of hemoglobin and mortality. RESULTS: In total, 322 consecutive patients with a mean age of 80 years of which 84% female were included. In total 66% was admitted to the hospital and seven patients underwent surgical intervention. Three cases (0.9%) of potentially clinically relevant bleeding were observed. These three cases needed a blood transfusion, without other interventions, and were all admitted with a low hemoglobin level without signs of hemodynamic instability. No invasive interventions were noted. CONCLUSION: The risk of bleeding in FFP's is very low with very few patients requiring blood transfusions (< 1%) and with no invasive interventions due to bleeding. Since the risk of clinically relevant bleeding is low, the significance of repeated Hb checks and CECT may be questionable. The effect of these diagnostics in case of absence of hemodynamic instability and above borderline normal Hb levels needs to be investigated in further studies.

The value of preoperative diagnostic testing and geriatric assessment in frail institutionalized elderly with a hip fracture; a secondary analysis of the FRAIL-HIP study.

PURPOSE: The aim of this study was to provide a comprehensive overview of (preoperative and geriatric) diagnostic testing, abnormal diagnostic tests and their subsequent interventions, and clinical relevance in frail older adults with a hip fracture. METHODS: Data on clinical consultations, radiological, laboratory, and microbiological diagnostics were extracted from the medical files of all patients included in the FRAIL-HIP study (inclusion criteria: hip fracture, > 70 years, living in a nursing home with malnourishment/cachexia and/or impaired mobility and/or severe co-morbidity). Data were evaluated until hospital discharge in nonoperatively treated patients and until surgery in operatively treated patients. RESULTS: A total of 172 patients (88 nonoperative and 84 operative) were included, of whom 156 (91%) underwent laboratory diagnostics, 126 (73%) chest X-rays, and 23 (13%) CT-scans. In 153/156 (98%) patients at least one abnormal result was found in laboratory diagnostics. In 82/153 (50%) patients this did not result in any additional diagnostics or (pharmacological) intervention. Abnormal test results were mentioned as one of the deciding arguments for operative delay (> 24 h) for 10/84 (12%) patients and as a factor in the decision between nonoperative and operative treatment in 7/172 (4%) patients. CONCLUSION: A large number and variety of diagnostics were performed in this patient population. Abnormal test results in laboratory diagnostics were found for almost all patients and, in majority, appear to have no direct clinical consequences. To prevent unnecessary diagnostics, prospective research is required to evaluate the clinical consequences and added value of the separate elements of preoperative diagnostic testing and geriatric assessment in frail hip fracture patients.

Extramedullary versus intramedullary fixation of unstable trochanteric femoral fractures (AO type 31-A2): a systematic review and meta-analysis.

OBJECTIVE: The aim of this systematic review was to compare extramedullary fixation and intramedullary fixation for AO type 31-A2 trochanteric fractures in the elderly, with regard to functional outcomes, complications, surgical outcomes, and costs. METHODS: Embase, Medline, Web of Science, Cochrane Central Register of Controlled Trials, and Google Scholar were searched for randomized controlled trials (RCTs) and observational studies. Effect estimates were pooled across studies using random effects models. Results are presented as weighted risk ratio (RR) or weighted mean difference (MD) with corresponding 95% confidence interval (95% CI). RESULTS: Fourteen RCTs (2039 patients) and 13 observational studies (22,123 patients) were included. Statistically superior results in favor of intramedullary fixation were found for Harris Hip Score (MD 4.09, 95% CI 0.91-7.26, p = 0.04), Parker mobility score (MD - 0.67 95% CI - 1.2 to - 0.17, p = 0.009), lower extremity measure (MD - 4.07 95% CI - 7.4 to - 0.8, p = 0.02), time to full weight bearing (MD 1.14 weeks CI 0.92-1.35, p < 0.001), superficial infection (RR 2.06, 95% CI 1.18-3.58, p = 0.01), nonunion (RR 3.67, 95% CI 1.03-13.10, p = 0.05), fixation failure (RR 2.26, 95% CI 1.16-4.44, p = 0.02), leg shortening (MD 2.23 mm, 95% CI 0.81-3.65, p = 0.002), time to radiological bone healing (MD 2.19 months, 95% CI 0.56-3.83, p = 0.009), surgery duration (MD 11.63 min, 95% CI 2.63-20.62, p = 0.01), operative blood loss (MD 134.5 mL, 95% CI 51-218, p = 0.002), and tip-apex distance > 25 mm (RR 1.73, 95% CI 1.10-2.74, p = 0.02). No comparable cost/costs-effectiveness data were available. CONCLUSION: Current literature shows that several functional outcomes, complications, and surgical outcomes were statistically in favor of intramedullary fixation when compared with extramedullary fixation of AO/OTA 31-A2 fractures. However, as several of the differences found appear not to be clinically relevant and for many outcomes data remains sparse or heterogeneous, complete superiority of IM fixation for AO type 31-A2 fractures remains to be confirmed in a detailed cost-effectiveness analysis.

The Quality of Dying in Frail Institutionalized Older Patients After Nonoperative and Operative Management of a Proximal Femoral Fracture: An In-Depth Analysis.

Proximal femoral fractures in frail patients have a poor prognosis. Despite the high mortality, little is known about the quality of dying (QoD) while this is an integral part of palliative care and could influence decision making on nonoperative- (NOM) or operative management (OM). To identify the QoD in frail patients with a proximal femoral fracture. Data from the prospective FRAIL-HIP study, that studied the outcomes of NOM and OM in institutionalized older patients ≥70 years with a limited life expectancy who sustained a proximal femoral fracture, was analyzed. This study included patients who died within the 6-month study period and whose proxies evaluated the QoD. The QoD was evaluated with the Quality of Dying and Death (QODD) questionnaire resulting in an overall score and 4 subcategory scores (Symptom control, Preparation, Connectedness, and Transcendence). In total 52 (64% of NOM) and 21 (53% of OM) of the proxies responded to the QODD. The overall QODD score was 6.8 (P25-P75 5.7-7.7) (intermediate), with 34 (47%) of the proxies rating the QODD 'good to almost perfect'. Significant differences in the QODD scores between groups were not noted (NOM; 7.0 (P25-P75 5.7-7.8) vs OM; 6.6 (P25-P75 6.1-7.2), P = .73). Symptom control was the lowest rated subcategory in both groups. The QoD in frail older nursing home patients with a proximal femoral fracture is good and humane. QODD scores after NOM are at least as good as OM. Improving symptom control would further increase the QoD.

Extramedullary versus intramedullary fixation of stable trochanteric femoral fractures: a systematic review and meta-analysis.

OBJECTIVE: This systematic review and meta-analysis compared extramedullary fixation and intramedullary fixation for stable two-part trochanteric femoral fractures (AO type 31-A1) with regards to functional outcomes, complications, and surgical outcomes. METHODS: Embase, Medline, Web of Science, Cochrane Central Register of Controlled Trials, and Google Scholar were searched for randomized controlled trials (RCTs) and observational studies. Effect estimates were pooled across studies using random effects models. Results were presented as weighted risk ratio (RR) or weighted mean difference (MD) with corresponding 95% confidence interval (95% CI). RESULTS: Five RCTs (397 patients) and 14 observational studies (21,396 patients) were included. No significant differences in functional outcomes, complications, or surgical outcomes were found between extramedullary and intramedullary fixation devices, except for a difference in duration of surgery (MD 14.1 min, CI 5.76-22.33, p < 0.001) and intra-operative blood loss (MD 92.30 mL, CI 13.49-171.12, p = 0.02), favoring intramedullary fixation. CONCLUSION: Current literature shows no meaningful differences in complications, surgical, or functional outcomes between extramedullary and intramedullary fixation of stable two-part trochanteric femoral fractures. Both treatment options result in good outcomes. This study implicates that, costs should be taken into account when considering implants or comparing fixation methods in future research.

Shared decision-making for the treatment of proximal femoral fractures in frail institutionalised older patients: healthcare providers' perceived barriers and facilitators.

INTRODUCTION: Proximal femoral fractures are common in frail institutionalised older patients. No convincing evidence exists regarding the optimal treatment strategy for those with a limited pre-fracture life expectancy, underpinning the importance of shared decision-making (SDM). This study investigated healthcare providers' barriers to and facilitators of the implementation of SDM. METHODS: Dutch healthcare providers completed an adapted version of the Measurement Instrument for Determinants of Innovations questionnaire to identify barriers and facilitators. If ≥20% of participants responded with 'totally disagree/disagree', items were considered barriers and, if ≥80% responded with 'agree/totally agree', items were considered facilitators. RESULTS: A total of 271 healthcare providers participated. Five barriers and 23 facilitators were identified. Barriers included the time required to both prepare for and hold SDM conversations, in addition to the reflective period required to allow patients/relatives to make their final decision, and the number of parties required to ensure optimal SDM. Facilitators were related to patients' values, wishes and satisfaction, the importance of SDM for patients/relatives and the fact that SDM is not considered complex by healthcare providers, is considered to be part of routine care and is believed to be associated with positive patient outcomes. CONCLUSION: Awareness of identified facilitators and barriers is an important step in expanding the use of SDM. Implementation strategies should be aimed at managing time constraints. High-quality evidence on outcomes of non-operative and operative management can enhance implementation of SDM to address current concerns around the outcomes.

Additional clinical value of routine CT imaging in fragility fractures of the pelvis: a prospective cohort study (ARTIFACT).

PURPOSE: Additional CT imaging for fragility fractures of the pelvis (FFP) has a high detection rate for concomitant posterior ring fractures (cPRFs). However, the clinical value of routine additional CT imaging is unknown. This study aimed to determine the additional clinical value of routine CT imaging by changes in treatment policy and to establish the predictive value of pain localized around the sacroiliac joint (SIJ) for cPRFs. METHODS: A prospective cohort study was conducted in a single teaching hospital in the Netherlands between November 2019 and November 2020. Patients were included if they were ≥ 65 years and had a (suspected) FFP on the pelvic radiograph. All patients underwent additional CT imaging. Changes in treatment policies ((possible) surgery, restrictive weight-bearing, hospital admission and outpatient follow-up) after CT imaging were registered. RESULTS: Fifty-one patients (44 female) were included with a mean age of 80.6 years. Routine CT imaging revealed an additional cPRF in 27 patients (53%). A change in treatment occurred in 29 patients (57%), of which 7 (12%) were managed either surgical or with restrictive weight-bearing. The presence of pain around the SIJ had a sensitivity of 89% and specificity of 61% for detecting a cPRF. CONCLUSION: Routine additional CT imaging has few direct therapeutic consequences with regards to surgical management or restrictive weight-bearing. These findings may be altered when considering a lower threshold for surgical intervention. The presence of pain around the SIJ was highly predictive for a clinically relevant cPRF. TRIAL REGISTRATION: NL8011 on 02-09-2019.

Evaluation of Quality of Life After Nonoperative or Operative Management of Proximal Femoral Fractures in Frail Institutionalized Patients: The FRAIL-HIP Study.

Importance: Decision-making on management of proximal femoral fractures in frail patients with limited life expectancy is challenging, but surgical overtreatment needs to be prevented. Current literature provides limited insight into the true outcomes of nonoperative management and operative management in this patient population. Objective: To investigate the outcomes of nonoperative management vs operative management of proximal femoral fractures in institutionalized frail older patients with limited life expectancy. Design, Setting, and Participants: This multicenter cohort study was conducted between September 1, 2018, and April 25, 2020, with a 6-month follow-up period at 25 hospitals across the Netherlands. Eligible patients were aged 70 years or older, frail, and institutionalized and sustained a femoral neck or pertrochanteric fracture. The term frail implied at least 1 of the following characteristics was present: malnutrition (body mass index [calculated as weight in kilograms divided by height in meters squared] <18.5) or cachexia, severe comorbidities (American Society of Anesthesiologists physical status class of IV or V), or severe mobility issues (Functional Ambulation Category ≤2). Exposures: Shared decision-making (SDM) followed by nonoperative or operative fracture management. Main Outcomes and Measures: The primary outcome was the EuroQol 5 Dimension 5 Level (EQ-5D) utility score by proxies and caregivers. Secondary outcome measures were QUALIDEM (a dementia-specific quality-of-life instrument for persons with dementia in residential settings) scores, pain level (assessed by the Pain Assessment Checklist for Seniors With Limited Ability to Communicate), adverse events (Clavien-Dindo classification), mortality, treatment satisfaction (numeric rating scale), and quality of dying (Quality of Dying and Death Questionnaire). Results: Of the 172 enrolled patients with proximal femoral fractures (median [25th and 75th percentile] age, 88 [85-92] years; 135 women [78%]), 88 opted for nonoperative management and 84 opted for operative management. The EQ-5D utility scores by proxies and caregivers in the nonoperative management group remained within the set 0.15 noninferiority limit of the operative management group (week 1: 0.17 [95% CI, 0.13-0.29] vs 0.26 [95% CI, 0.11-0.23]; week 2: 0.19 [95% CI, 0.10-0.27] vs 0.28 [95% CI, 0.22-0.35]; and week 4: 0.24 [95% CI, 0.15-0.33] vs 0.34 [95% CI, 0.28-0.41]). Adverse events were less frequent in the nonoperative management group vs the operative management group (67 vs 167). The 30-day mortality rate was 83% (n = 73) in the nonoperative management group and 25% (n = 21) in the operative management group, with 26 proxies and caregivers (51%) in the nonoperative management group rating the quality of dying as good-almost perfect. Treatment satisfaction was high in both groups, with a median numeric rating scale score of 8. Conclusions and Relevance: Results of this study indicated that nonoperative management of proximal femoral fractures (selected through an SDM process) was a viable option for frail institutionalized patients with limited life expectancy, suggesting that surgery should not be a foregone conclusion for this patient population.

Prognosis of nonoperative treatment in elderly patients with a hip fracture: A systematic review and meta-analysis.

OBJECTIVE: Hip fractures in frail elderly patients are associated with significant mortality and morbidity. Surgery remains the predominant treatment of choice, despite the poor prognosis. Limited research has been done with regards to nonoperative management of frail elderly patients with a hip fracture and therefore the natural course is relatively unknown. This systematic review aimed to provide an overview of the prognosis of nonoperative management in frail elderly patients with a hip fracture in terms of mortality, complications, mobility, and quality of life (QoL). DESIGN: A systematic review of the literature was conducted in PubMed, EMBASE, and Cochrane Central. In addition, a meta-analysis was performed. The primary outcome measurement was 30-days mortality. RESULTS: A total of 4,318 studies were screened. In total eighteen studies matched the eligibility criteria; with low to moderate quality. Approximately two-thirds of the patients were managed nonoperatively due to medical reasons and one-third due to non-medical reasons. Pooled mortality rates after 30 days, six months and one year were 36%, 46%, and 60%, respectively. 33% of the patients developed in-hospital complications. At six months post trauma, 9.6% of the patients were able to mobilize. Data on quality of life (QoL), functional outcome, pain, comfort during nursing care, and costs were not reported. CONCLUSION: Nonoperative management of frail elderly patients with a hip fracture is associated with a poor prognosis. Heterogenous study cohorts and limited outcomes were reported. Current literature shows a lack of evidence of the true prognosis of nonoperative management of frail elderly patient with a hip fracture and a limited life expectancy. Results of this review can be used to aid decision making and improve expectation management.

Tension Band Wiring Provides Excellent Patient-Reported Long-Term Results for Both Comminuted and Simple Displaced Olecranon Fractures.

OBJECTIVES: To assess the long-term functional results of both simple and comminuted olecranon fractures treated with tension band wiring (TBW). DESIGN: Retrospective. SETTING: Level 1 trauma center. PATIENTS & INTERVENTION: Between 2004 and 2014, 178 fractures in 178 patients >16 years of age were treated with TBW for a unilateral olecranon fracture. MAIN OUTCOME MEASUREMENTS: Subjective functionality was tested with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and the Mayo Elbow Performance Index (MEPI). RESULTS: Fifty percent of our cohort were lost to follow-up leaving 89 for review. A total of 51.7% had a comminuted fracture. Mean follow-up time was 7.1 years. Reoperation rate for implant removal was 84%. The total median DASH score was 0.83. Eighty-five patients (95.5%) were rated excellent using the MEPI score. No significant difference in either score was found between the simple (SF) and the comminuted (CF) group. Median range of motion was flexion/extension: 145/-2 degrees, supination/pronation: 90/90 degrees. No clinically relevant difference in range of motion was found between the 2 groups. CONCLUSIONS: We found no relevant differences in either subjective or objective functionality between patients with simple or comminuted olecranon fractures after fixation with TBW. Therefore, TBW seems to be an adequate and justifiable treatment modality for both simple and comminuted olecranon fractures. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The value of nonoperative versus operative treatment of frail institutionalized elderly patients with a proximal femoral fracture in the shade of life (FRAIL-HIP); protocol for a multicenter observational cohort study.

BACKGROUND: Proximal femoral fractures are strongly associated with morbidity and mortality in elderly patients. Mortality is highest among frail institutionalized elderly with both physical and cognitive comorbidities who consequently have a limited life expectancy. Evidence based guidelines on whether or not to operate on these patients in the case of a proximal femoral fracture are lacking. Practice variation occurs, and it remains unknown if nonoperative treatment would result in at least the same quality of life as operative treatment. This study aims to determine the effect of nonoperative management versus operative management of proximal femoral fractures in a selected group of frail institutionalized elderly on the quality of life, level of pain, rate of complications, time to death, satisfaction of the patient (or proxy) and the caregiver with the management strategy, and health care consumption. METHODS: This is a multicenter, observational cohort study. Frail institutionalized elderly (70 years or older with a body mass index < 18.5, a Functional Ambulation Category of 2 or lower pre-trauma, or an American Society of Anesthesiologists score of 4 or 5), who sustained a proximal femoral fracture are eligible to participate. Patients with a pathological or periprosthetic fractures and known metastatic oncological disease will be excluded. Treatment decision will be reached following a structured shared decision process. The primary outcome is quality of life (Euro-QoL; EQ-5D-5 L). Secondary outcome measures are quality of life measured with the QUALIDEM, pain level (PACSLAC), pain medication use, treatment satisfaction of patient (or proxy) and caregivers, quality of dying (QODD), time to death, and direct medical costs. A cost-utility and cost-effectiveness analysis will be done, using the EQ-5D utility score and QUALIDEM score, respectively. Non-inferiority of nonoperative treatment is assumed with a limit of 0.15 on the EQ-5D score. Data will be acquired at 7, 14, and 30 days and at 3 and 6 months after trauma. DISCUSSION: The results of this study will provide insight into the true value of nonoperative treatment of proximal femoral fractures in frail elderly with a limited life expectancy. The results may be used for updating (inter)national treatment guidelines. TRIAL REGISTRATION: The study is registered at the Netherlands Trial Register (NTR7245; date 10-06-2018).

Outcome of pubic rami fractures with or without concomitant involvement of the posterior ring in elderly patients.

INTRODUCTION: Pubic rami fractures are common fractures in a growing osteoporotic geriatric population. Concomitant posterior ring fractures (cPRF) are often found when properly looked for. The pain and consequent immobilization leaves this vulnerable patient group at risk for complications. Conservative therapy is usually sufficient, but with cPRF's surgery can be indicated. Although previous studies have pointed out that mortality rates are high, longer term morbidity outcomes are lacking. This study aims to further establish the longer term consequences of these fractures. Risk factors will be identified for complications, also addressing the possible differences between patients with or without a cPRF. METHOD: Retrospective analysis of patients aged over 65 years sustaining a pubic rami fracture in the North-West Hospital Group Alkmaar combined with a survey to establish risk factors for morbidity and mortality after 6 months' post trauma. Multiple logistic regression analysis was used to identify risk factors. RESULTS: 117 patients matched inclusion criteria with a median age of 83 and of which 86% was female. 23 cPRF's were identified. Significant deterioration in ambulation and independency was found. 34% was institutionalized at discharge. 49% lost their independent mobility status and 40% of the patients did not experience a full recovery. One-year mortality rate was 23%. Patients with a cPRF had a significant higher complication rate (44 vs 18% p = 0.02), but mortality and other morbidity outcomes did not statistically differ. The strongest predictor for 1-year mortality was complications during admission and a dependent ambulatory status (OR 5.2 and 4.1 respectively). CONCLUSION: Pubic fractures with or without involvement of the posterior pelvic ring in patients aged over 65 have a significant impact on mobility and independency. Mortality rates are similar to hip fracture patients. Careful evaluation of every patient's mobility status is necessary to identify patients at risk for complications and determine their future health care needs. Future studies are needed to achieve consensus on diagnostic and treatment protocols and identify ways to decrease the significant impact of this injury.

Effect of Antibiotic Prophylaxis on Surgical Site Infections Following Removal of Orthopedic Implants Used for Treatment of Foot, Ankle, and Lower Leg Fractures: A Randomized Clinical Trial.

Importance: Following clean (class I, not contaminated) surgical procedures, the rate of surgical site infection (SSI) should be less than approximately 2%. However, an infection rate of 12.2% has been reported following removal of orthopedic implants used for treatment of fractures below the knee. Objective: To evaluate the effect of a single dose of preoperative antibiotic prophylaxis on the incidence of SSIs following removal of orthopedic implants used for treatment of fractures below the knee. Design, Setting, and Participants: Multicenter, double-blind, randomized clinical trial including 500 patients aged 18 to 75 years with previous surgical treatment for fractures below the knee who were undergoing removal of orthopedic implants from 19 hospitals (17 teaching and 2 academic) in the Netherlands (November 2014-September 2016), with a follow-up of 6 months (final follow-up, March 28, 2017). Exclusion criteria were an active infection or fistula, antibiotic treatment, reimplantation of osteosynthesis material in the same session, allergy for cephalosporins, known kidney disease, immunosuppressant use, or pregnancy. Interventions: A single preoperative intravenous dose of 1000 mg of cefazolin (cefazolin group, n = 228) or sodium chloride (0.9%; saline group, n = 242). Main Outcomes and Measures: Primary outcome was SSI within 30 days as measured by the criteria from the US Centers for Disease Control and Prevention. Secondary outcome measures were functional outcome, health-related quality of life, and patient satisfaction. Results: Among 477 randomized patients (mean age, 44 years [SD, 15]; women, 274 [57%]; median time from orthopedic implant placement, 11 months [interquartile range, 7-16]), 470 patients completed the study. Sixty-six patients developed an SSI (14.0%): 30 patients (13.2%) in the cefazolin group vs 36 in the saline group (14.9%) (absolute risk difference, -1.7 [95% CI, -8.0 to 4.6], P = .60). Conclusions and Relevance: Among patients undergoing surgery for removal of orthopedic implants used for treatment of fractures below the knee, a single preoperative dose of intravenous cefazolin compared with saline did not reduce the risk of surgical site infection within 30 days following implant removal. Trial Registration: clinicaltrials.gov Identifier: NCT02225821.

Are routine preoperative liver function tests in patients with uncomplicated symptomatic gallstone disease necessary?

BACKGROUND: The aim of this study was to evaluate the value of preoperative liver function tests (LFTs) in patients with uncomplicated gallstone disease and scheduled for laparoscopic cholecystectomy. METHODS: All 1112 patients who underwent a laparoscopic cholecystectomy for symptomatic gallstone disease during a 6-year cohort were retrospectively reviewed. Only patients who presented with uncomplicated disease were selected. Preoperative LFTs, pre-, and postoperative endoscopic retrograde cholangio pancreaticographies (ERCPs) and postoperative complications were collected. RESULTS: A total of 697 patients were included. There were 629 (90.2%) patients with (group I) and 68 (9.8%) patients without (group II) preoperative LFTs. The incidence of ERCPs, ERCPs positive for bile duct stones, and postoperative complications were not significantly different between groups. Second, Group I patients were divided into four groups: 360 patients with normal LFTs (I-A1), 269 patients with at least one LFT > normal value (I-A2), 531 patients with all LFTs <2× normal (I-B1), and 98 patients with at least one LFT >2× normal (I-B2). More ERCPs were performed in group I-A2 (10%) than in group I-A1 (2.2%) and more in group I-B2 (18.4%) than I-B1 (3.2%), as a consequence of significantly more ERCPs performed preoperatively. No differences were detected between groups regarding ERCPs positive for bile duct stones or postoperative complications. CONCLUSIONS: Preoperative LFTs do not influence the occurrence of postoperative complications nor the total rate of ERCPs in patients undergoing cholecystectomy for uncomplicated gallstone disease. Preoperative determination of LFTs seems to cause a slight shift from post- to preoperative ERCPs without further clinical consequences.

Observation Versus Embolization in Patients with Blunt Splenic Injury After Trauma: A Propensity Score Analysis.

BACKGROUND: Non-operative management (NOM) is the standard of care in hemodynamically stable patients with blunt splenic injury after trauma. Splenic artery embolization (SAE) is reported to increase observation success rate. Studies demonstrating improved splenic salvage rates with SAE primarily compared SAE with historical controls. The aim of this study was to investigate whether SAE improves success rate compared to observation alone in contemporaneous patients with blunt splenic injury. METHODS: We included adult patients with blunt splenic injury admitted to five Level 1 Trauma Centers between January 2009 and December 2012 and selected for NOM. Successful treatment was defined as splenic salvage and no splenic re-intervention. We calculated propensity scores, expressing the probability of undergoing SAE, using multivariable logistic regression and created five strata based on the quintiles of the propensity score distribution. A weighted relative risk (RR) was calculated across strata to express the chances of success with SAE. RESULTS: Two hundred and six patients were included in the study. Treatment was successful in 180 patients: 134/146 (92 %) patients treated with observation and 48/57 (84 %) patients treated with SAE. The weighted RR for success with SAE was 1.17 (0.94-1.45); for complications, the weighted RR was 0.71 (0.41-1.22). The mean number of transfused blood products was 4.4 (SD 9.9) in the observation group versus 9.1 (SD 17.2) in the SAE group. CONCLUSIONS: After correction for confounders with propensity score stratification technique, there was no significant difference between embolization and observation alone with regard to successful treatment in patients with blunt splenic injury after trauma.

Wound Infections Following Implant removal below the knee: the effect of antibiotic prophylaxis; the WIFI-trial, a multi-centre randomized controlled trial.

BACKGROUND: In the Netherlands about 18,000 procedures with implant removal are performed annually following open or closed reduction and fixation of fractures, of which 30-80% concern the foot, ankle and lower leg region. For clean surgical procedures, the rate of postoperative wound infections (POWI) should be less than ~2%. However, rates of 10-12% following implant removal have been reported, specifically after foot, ankle and lower leg fractures. Currently, surgeons individually decide if antibiotics prophylaxis is given, since no guideline exists. This leads to undesirable practice variation. The aim of the study is to assess the (cost-)effectiveness of a single intravenous gift of Cefazolin prior to implant removal following surgical fixation of foot, ankle and/or lower leg fractures. METHODS: This is a double-blind randomized controlled trial in patients scheduled for implant removal following a foot, ankle or lower leg fracture. Primary outcome is a POWI within 30 days after implant removal. Secondary outcomes are quality of life, functional outcome and costs at 30 days and 6 months after implant removal. With 2 x 250 patients a decrease in POWI rate from 10% to 3.3% (expected rate in clean-contaminated elective orthopaedic trauma procedures) can be detected (Power = 80%, 2-sided alpha = 5%, including 15% lost to follow up). DISCUSSION: If administration of prophylactic antibiotics prior to implant removal reduces the infectious complication rate, this will offer a strong argument to adopt this as standard practice of care. This will consequently lead to less physical and social disabilities and health care use. A preliminary, conservative estimation suggests yearly cost savings in the Netherlands of € 3.5 million per year. TRIAL REGISTRATION: This study is registered at Clinicaltrials.gov ( NCT02225821 ) and the Netherlands Trial Register ( NTR4393 ) and was granted permission by the Medical Ethical Review Committee of the Academic Medical Centre on October 7 2014.

Operative Treatment of an Atypical Segmental Bipolar Fracture of the Clavicle.

INTRODUCTION: Clavicle fractures are very common, accounting for approximately 4% of all adult fractures. Segmental bipolar fractures involving the lateral and the medial ends of the clavicle are extremely rare, with only isolated cases reported in the literature. The injury mechanism is often unclear and the management of these fractures remains controversial. CASE PRESENTATION: Here is to report a case of a segmental bipolar fracture of the clavicle with a lateral fracture and a displaced medial fracture without dislocation of the sternoclavicular joint following a low energy fall to the outstretched hand, and discuss its management. CONCLUSIONS: Stability of the clavicle is crucial for shoulder function and care should be taken not to miss or underestimate segmental bipolar fractures even with a low energy mechanism. Authors believe that operative treatment should be taken into consideration for displaced fractures.

Routine urinalysis in patients with a blunt abdominal trauma mechanism is not valuable to detect urogenital injury.

OBJECTIVE: To investigate whether the routine performance of urinalysis in patients with a blunt trauma mechanism is still valuable. METHODS: Consecutive patients aged ≥16 years, admitted to a Dutch Level 1 trauma centre between January 2008 and August 2011, were included in this retrospective cohort study. Results of urinalysis (erythrocytes per µL) were divided into no, microscopic or macroscopic haematuria. Patients were divided into four groups based on whether a urinalysis was performed or not, with or without imaging for urogenital injury. Main outcome measures were the presence of urogenital injury and whether the findings on urine specimen and/or imaging led to clinical consequences. RESULTS: A total of 1815 patients were included. The prevalence of intra-abdominal and urogenital injuries was 13% and 8%, respectively. In 1363 patients (75%), urinalysis was performed and 1031 patients (57%) underwent imaging for urogenital injury as well. The presence of macroscopic haematuria (n=16) led to clinical consequences in 73% of the patients (11 out of 15), regardless of the findings on imaging. Microscopic haematuria on urinalysis in combination with no findings on imaging led to clinical consequences in 8 out of 212 patients (4%). Microscopic haematuria on urinalysis in patients who did not have imaging for urogenital injury did not lead to clinical consequences (0 out of 54 patients; 0%). All the 8 patients who underwent an intervention had positive findings on imaging. CONCLUSIONS: The results do not support the routine performance of urinalysis in patients admitted with a blunt trauma mechanism. Although urinalysis could be valuable in specific patient populations, we should consider omitting this investigation as a routine part of the assessment of trauma patients.

Improving performance and agreement in injury coding using the Abbreviated Injury Scale: a training course helps.

The aim of this study was to determine the influence of a dedicated training course on the ability of participants to assign correct codes and their inter-observer agreement using the Abbreviated Injury Scale (AIS98). Twelve participants followed a one-day training course in injury coding. Codes were recorded before, during and after the course. The number of correctly assigned codes and severity codes, as well as the Fleiss' kappas improved significantly during and after the course. This study emphasises the benefit of training in injury coding. Training improves the ability to assign correct codes and it reduces inter-observer variability. We advise all who are involved in injury coding to follow a dedicated training course.