Pediatric Trauma in The Netherlands: Incidence, Mechanism of Injury and In-Hospital Mortality.

BACKGROUND: In the Netherlands, there are no specialized or certified pediatric trauma centers, especially for severely injured children. National and regional agreements on centralization of pediatric trauma care are scarce. This study aims to describe the incidence, injury mechanism and in-hospital mortality of pediatric trauma in the Netherlands, as a prelude to the further organization of pediatric trauma care. METHODS: A retrospective cohort analysis of data from the Dutch National Trauma Registry in 2009-2018, concerning all children (0-16 years) hospitalized due to injury in the Netherlands. RESULTS: The annual number of admitted injured children increased from 8666 in 2009 to 13,367 in 2018. Domestic accidents were the most common cause of non-fatal injury (67.9%), especially in children aged 0-5 years (89.2%). Severe injury (injury severity score ≥  16) accounted for 2.5% and 74% of these patients were treated in level-1 trauma centers. In both deceased and surviving patients with severe injuries, head injuries were the most common (72.1% and 64.3%, respectively). In-hospital mortality after severe injury was 8.2%. Road-traffic accidents (RTAs) were the leading cause of death (46.5%). CONCLUSIONS: Domestic accidents are the most common cause of injury, especially in younger children, whereas RTAs are the lead cause of fatal injury. Severe pediatric trauma in the Netherlands is predominantly managed in level-1 trauma centers, where a multidisciplinary team of experts is available. Improving the numbers of severely injured patients primarily brought to level-1 trauma centers may help to further reduce mortality.

The Detrimental Impact of the COVID-19 Pandemic on Major Trauma Outcomes in the Netherlands: A Comprehensive Nationwide Study.

OBJECTIVE: To evaluate the impact of the COVID-19 pandemic on the outcome of major trauma patients in the Netherlands. SUMMARY BACKGROUND DATA: Major trauma patients highly rely on immediate access to specialized services, including ICUs, shortages caused by the impact of the COVID-19 pandemic may influence their outcome. METHODS: A multi-center observational cohort study, based on the Dutch National Trauma Registry was performed. Characteristics, resource usage, and outcome of major trauma patients (injury severity score ≥16) treated at all trauma-receiving hospitals during the first COVID-19 peak (March 23 through May 10) were compared with those treated from the same period in 2018 and 2019 (reference period). RESULTS: During the peak period, 520 major trauma patients were admitted, versus 570 on average in the pre-COVID-19 years. Significantly fewer patients were admitted to ICU facilities during the peak than during the reference period (49.6% vs 55.8%; P=0.016). Patients with less severe traumatic brain injuries in particular were less often admitted to the ICU during the peak (40.5% vs 52.5%; P=0.005). Moreover, this subgroup showed an increased mortality compared to the reference period (13.5% vs 7.7%; P=0.044). These results were confirmed using multivariable logistic regression analyses. In addition, a significant increase in observed versus predicted mortality was recorded for patients who had a priori predicted mortality of 50% to 75% (P=0.012). CONCLUSIONS: The COVID-19 peak had an adverse effect on trauma care as major trauma patients were less often admitted to ICU and specifically those with minor through moderate brain injury had higher mortality rates.

Systematic Review of the Association Between Trauma Severity and Postinjury Symptoms of Depression.

BACKGROUND: Greater symptoms of depression are associated with greater symptom intensity during recovery from musculoskeletal injury. It is not clear that more severe trauma is associated with greater symptoms of depression as one might expect. The goal of this study was to systematically review the existing evidence regarding the association of Injury Severity Score (ISS) with symptoms of depression during recovery from musculoskeletal injury. METHODS: Two independent reviewers used PubMed and Embase to identify studies that measured both ISS and symptoms of depression. Among the 17 studies satisfying inclusion criteria, 5 studies assessed the correlation of symptoms of depression and ISS on their continuum; 3 studies compared the mean of symptoms of depression for people above and below a specific ISS level; five compared mean ISS above and below a threshold level of symptoms of depression; and four compared dichotomized ISS and dichotomized depression. Four of the 17 evaluated factors associated with symptoms of depression in multivariable analysis. RESULTS: In bivariate analysis, 12 of 17 studies (71%) found no association between ISS level and symptoms of depression. Three studies found a bivariate association that did not persist in multivariable analysis. Two studies reported slight associations in bivariate analysis, but did not perform multivariable analysis. CONCLUSIONS: The knowledge that symptoms of depression are common during recovery, in combination with the finding of this review that they have little or no relationship with injury severity, directs clinicians to anticipate and address mental health during recovery from physical trauma of any severity.

High risks of failure observed for A1 trochanteric femoral fractures treated with a DHS compared to the PFNA in a prospective observational cohort study.

INTRODUCTION: Both the DHS and the PFNA are common and well-studied treatment options for stable trochanteric fractures. The aim of the current study was to compare the implant failure rates of these two implants in 31A1 type trochanteric femoral fractures. MATERIALS AND METHODS: A single-centre observational cohort study was conducted in the Hip Fracture Unit of a multicentre level 1 trauma teaching hospital between December 2016 and October 2018. Patients with an AO/OTA type 31A1 fracture were included. Pathological fractures, bilateral fractures, high-energy traumas and patients younger than 18 years of age were excluded. Surgery was performed using either a DHS or PFNA. Both were used routinely for stable trochanteric fractures, and allocation was decided by the surgeon performing the operation. The primary outcome of this study was the implant failure rate in the first postoperative year. Secondary outcomes included the reoperation rate, functional recovery, pain and morphine use. RESULTS: Data were available from 126 patients treated with a DHS (n = 32, 25.4%) or PFNA (n = 95, 74.6%). Minor differences were observed in the patient characteristics including the prevalence of cognitive impairment (18.8% vs 40.2%; P = 0.028), prefracture independence in activities of daily living (87.1% vs 67.4%; P = 0.034) and prefracture mobility (independently without aides: 61.3% vs 40.4%; P = 0.033). Fractures treated with a DHS showed 25% implant failures, compared to 1.1% for fractures treated with a PFNA (P = 0.004). No differences were observed in any of the secondary outcomes. CONCLUSIONS: Significantly more implant failures were observed for the DHS compared the PFNA within 1 year after surgery. Despite the fact that this did not result in differences in revision surgery, we conclude that the PFNA, considering the minimal number of implant-related fractures is a viable implant for A1 type trochanteric fractures.

Andexanet Alfa or Prothrombin Complex Concentrate for Factor Xa Inhibitor Reversal in Acute Major Bleeding: A Systematic Review and Meta-Analysis.

OBJECTIVES: To combine evidence on andexanet alfa and prothrombin complex concentrates for factor Xa inhibitor-associated bleeding to guide clinicians on reversal strategies. DATA SOURCES: Embase, Pubmed, Web of Science, and the Cochrane Library. STUDY SELECTION: Observational studies and randomized clinical trials studying hemostatic effectiveness of andexanet alfa or prothrombin complex concentrate for acute reversal of factor Xa inhibitor-associated hemorrhage. DATA EXTRACTION: Two independent reviewers extracted the data from the studies. Visualization and comparison of hemostatic effectiveness using Sarode et al or International Society of Thrombosis and Hemostasis Scientific and Standardization Committee criteria at 12 and 24 hours, (venous) thrombotic event rates, and inhospital mortality were performed by constructing Forest plots. Exploratory analysis using a logistic mixed model analysis was performed to identify factors associated with effectiveness and venous thromboembolic event. DATA SYNTHESIS: A total of 21 studies were included (andexanet: 438 patients; prothrombin complex concentrate: 1,278 patients). The (weighted) mean effectiveness for andexanet alfa was 82% at 12 hours and 71% at 24 hours. The (weighted) mean effectiveness for prothrombin complex concentrate was 88% at 12 hours and 76% at 24 hours. The mean 30-day symptomatic venous thromboembolic event rates were 5.0% for andexanet alfa and 1.9% for prothrombin complex concentrate. The mean 30-day total thrombotic event rates for andexanet alfa and prothrombin complex concentrate were 10.7% and 3.1%, respectively. Mean inhospital mortality was 23.3% for andexanet versus 15.8% for prothrombin complex concentrate. Exploratory analysis controlling for potential confounders did not demonstrate significant differences between both reversal agents. CONCLUSIONS: Currently, available evidence does not unequivocally support the clinical effectiveness of andexanet alfa or prothrombin complex concentrate to reverse factor Xa inhibitor-associated acute major bleeding, nor does it permit conventional meta-analysis of potential superiority. Neither reversal agent was significantly associated with increased effectiveness or a higher rate of venous thromboembolic event. These results underscore the importance of randomized controlled trials comparing the two reversal agents and may provide guidance in designing institutional guidelines.

Direct Oral Anticoagulants Are a Potential Alternative to Low-Molecular-Weight Heparin for Thromboprophylaxis in Trauma Patients Sustaining Lower Extremity Fractures.

BACKGROUND: Trauma patients are at a significant risk of venous thromboembolism (VTE), with lower extremity fractures (LEF) being independent risk factors. Use of direct oral anticoagusants (DOACs) for VTE prophylaxis is effective in elective orthopedic surgery, but currently not approved for trauma patients. The primary objective of this study was to compare the effectiveness and safety of thromboprophylaxis of DOACs with low-molecular-weight heparin (LMWH) in trauma patients sustaining LEF. MATERIALS AND METHODS: We included adult trauma patients admitted to trauma quality improvement program participating trauma centers (between 2013 and 2016), who sustained LEF and were started on DOACs or LMWH for thromboprophylaxis after admission. Propensity score matching was performed to compare symptomatic VTE and bleeding control interventions between the groups. RESULTS: Of 1,009,922 patients in trauma quality improvement program, 167,640 met inclusion criteria (165,009 received LMWH and 2631 received DOACs). After propensity score matching, 2280 predominantly elderly (median age: 67 y) isolated femur fracture patients (median ISS: 10) were included in each group (4560 patients in total). Symptomatic VTE occurred in 1.4% of patients in both matched groups (P = 0.992). Bleeding control interventions occurred less often in the DOAC group, albeit statistically insignificant (5.8% versus 6.0%, P = 0.772). CONCLUSIONS: This study found similar rates of VTE and bleeding control measures for thromboprophylaxis with DOACs or LMWH in matched trauma patients with LEF. Further prospective research is warranted to consolidate the safety of DOAC thromboprophylaxis in trauma patients with LEF. Favorable oral administration and likely increased adherence could benefit this high-risk population.

Thromboprophylaxis after Knee Arthroscopy and Lower-Leg Casting.

BACKGROUND: The use of thromboprophylaxis to prevent clinically apparent venous thromboembolism after knee arthroscopy or casting of the lower leg is disputed. We compared the incidence of symptomatic venous thromboembolism after these procedures between patients who received anticoagulant therapy and those who received no anticoagulant therapy. METHODS: We conducted two parallel, pragmatic, multicenter, randomized, controlled, open-label trials with blinded outcome evaluation: the POT-KAST trial, which included patients undergoing knee arthroscopy, and the POT-CAST trial, which included patients treated with casting of the lower leg. Patients were assigned to receive either a prophylactic dose of low-molecular-weight heparin (for the 8 days after arthroscopy in the POT-KAST trial or during the full period of immobilization due to casting in the POT-CAST trial) or no anticoagulant therapy. The primary outcomes were the cumulative incidences of symptomatic venous thromboembolism and major bleeding within 3 months after the procedure. RESULTS: In the POT-KAST trial, 1543 patients underwent randomization, of whom 1451 were included in the intention-to-treat population. Venous thromboembolism occurred in 5 of the 731 patients (0.7%) in the treatment group and in 3 of the 720 patients (0.4%) in the control group (relative risk, 1.6; 95% confidence interval [CI], 0.4 to 6.8; absolute difference in risk, 0.3 percentage points; 95% CI, -0.6 to 1.2). Major bleeding occurred in 1 patient (0.1%) in the treatment group and in 1 (0.1%) in the control group (absolute difference in risk, 0 percentage points; 95% CI, -0.6 to 0.7). In the POT-CAST trial, 1519 patients underwent randomization, of whom 1435 were included in the intention-to-treat population. Venous thromboembolism occurred in 10 of the 719 patients (1.4%) in the treatment group and in 13 of the 716 patients (1.8%) in the control group (relative risk, 0.8; 95% CI, 0.3 to 1.7; absolute difference in risk, -0.4 percentage points; 95% CI, -1.8 to 1.0). No major bleeding events occurred. In both trials, the most common adverse event was infection. CONCLUSIONS: The results of our trials showed that prophylaxis with low-molecular-weight heparin for the 8 days after knee arthroscopy or during the full period of immobilization due to casting was not effective for the prevention of symptomatic venous thromboembolism. (Funded by the Netherlands Organization for Health Research and Development; POT-KAST and POT-CAST ClinicalTrials.gov numbers, NCT01542723 and NCT01542762 , respectively.).

Quantification of Trauma Center Access Using Geographical Information System-Based Technology.

OBJECTIVES: There is no generally accepted methodology to assess trauma system access. The goal of this study is to determine the influence of the number and geographical distribution of trauma centers (TCs) on transport times (TT) using geographic information system (GIS)-technology. METHODS: Using ArcGIS-PRO, we calculated differences in TT and population coverage in 7 scenarios with 1, 2, or 3 TCs during rush (R) and low-traffic (L) hours in a densely populated region with 3 TCs in the Netherlands. RESULTS: In all 7 scenarios, the population that could reach the nearest TC within <45 minutes varied between 96% and 99%. In the 3-TC scenario, roughly 57% of the population could reach the nearest TC <15 minutes both during R and L. The hypothetical geographically well-spread 2-TC scenario showed similar results as the 3-TC scenario. In the 1-TC scenarios, the population reaching the nearest TC <15 minutes decreased to between 19% and 32% in R and L. In the 3-TC scenario, the average TT increased by about 1.5 minutes to almost 21 minutes during R and 19 minutes during L. Similar results were seen in the scenarios with 2 geographically well-spread TCs. In the 1-TC scenarios and the less well-spread 2-TC scenario, the average TT increased by 5 to 8 minutes (L) and 7 to 9 minutes (R) compared to the 3-TC scenario. CONCLUSIONS: This study shows that a GIS-based model offers a quantifiable and objective method to evaluate trauma system access under different potential trauma system configurations. Transport time from accident to TC would remain acceptable, around 20 minutes, if the current 3-TC situation would be changed to a geographically well-spread 2-center scenario.

Injury Pattern and Injury Severity of In-Hospital Deceased Road Traffic Accident Victims in The Netherlands: Dutch Road Traffic Accidents Fatalities.

BACKGROUND: Further reduction in road traffic accident (RTA) fatalities is a key priority in the European Union. Since data on injury patterns related to mortality in RTAs are scarce, the aim of this study was to analyze injury patterns and injury severity of in-hospital RTA fatalities in the Netherlands. METHODS: All in-hospital deceased RTA victims in the Netherlands during the period 2015-2016 were analyzed. Data were obtained from the National Trauma Registry. Injury patterns, injury severity, accident and patient characteristics of road user groups were compared. RESULTS: A total of 497 deceased RTA victims were analyzed, of which most were bicyclists. All analyzed motorcyclists had an ISS ≥ 16. Head trauma was most frequent in pedestrians (73.7%) and bicyclists (71.3%). Thorax trauma was most frequent in motorcyclists and motorists (60.9% and 65.8%, respectively). RTA victims younger than 25 years were more severely injured (median ISS 38, interquartile range [IQR] 29-46) compared to RTA victims aged over 75 years (median ISS 25, IQR 13-30). More than 10% of the severely injured (ISS ≥ 16) RTA victims was not transported to a level I trauma center. The majority of this group was older than 75 years. CONCLUSIONS: Further prevention of head trauma is needed to reduce RTA fatalities, especially in bicyclists. Also, undertriage of severe trauma in elderly RTA victims is obvious and should be addressed in the early phases of trauma care, especially during prehospital triage and initial care at admission.

Flaminal® versus Flamazine® in the treatment of partial thickness burns: A randomized controlled trial on clinical effectiveness and scar quality (FLAM study).

Although partial thickness burns are the most frequently reported burn injuries, there is no consensus on the optimal treatment. The objective of this study was to compare the clinical effectiveness and scar quality of Flaminal® Forte to silver sulfadiazine (Flamazine®) in the treatment of partial thickness burns. In this two-arm open label multicenter randomized controlled trial, adult patients with acute partial thickness burns and an affected total body surface area of less than 30% were randomized between Flaminal® Forte and Flamazine® and followed for 12 months. Dressing changes in the Flamazine® group were performed daily, and in the Flaminal® group during the first 3 days post burn and thereafter every other day until complete wound healing or surgery. Forty-one patients were randomly allocated to Flaminal® Forte and 48 patients to Flamazine®. The primary outcome was time to wound healing, which did not differ between the groups: median 18 days with Flaminal® Forte (range 8-49 days) versus 16 days with Flamazine® (range 7-48 days; p = 0.24). Regarding the secondary outcomes during hospital admission, there were no statistically significant differences between the groups concerning need for surgery, pain scores, pruritus, or pain-related and anticipatory anxiety. More patients in the Flaminal® group developed wound colonization (78% versus 32%, p < 0.001), but the treatment groups did not differ regarding the incidence of local infections and use of systemic antibiotics. In terms of scar quality, no statistically significant differences between both treatment groups were found regarding subjective scar assessment (Patient and Observer Scar Assessment Scale (POSAS)), scar melanin and pigmentation (DermaSpectrometer®), and scar elasticity and maximal extension (Cutometer®) during 12 month postburn. In conclusion, time to wound healing did not differ, but the use of Flaminal® Forte seemed favorable because less dressing changes are needed which lowers the burden of wound care.

Correction to: Differences in Characteristics and Outcome of Patients with Penetrating Injuries in the USA and the Netherlands: A Multi-institutional Comparison.

In the original article Dennis Den Hartog's name was tagged incorrectly. It is correct as reflected here.

The malnutrition in polytrauma patients (MaPP) study: Research protocol.

BACKGROUND: Polytrauma patients are at risk of considerable harm from malnutrition due to the metabolic response to trauma. However, there is little knowledge of (the risk of) malnutrition and its consequences in these patients. Recognition of sub-optimally nourished polytrauma patients and their nutritional needs is crucial to prevent complications and optimize their clinical outcomes. AIM: The primary objective is to investigate whether polytrauma patients admitted to the Intensive Care Unit (ICU) who have or develop malnutrition have a higher complication rate than patients who are and remain well nourished. Secondary objectives are to determine the prevalence of pre-existent and in-hospital acquired malnutrition in these patients, to assess the association between malnutrition and long-term outcomes, and to determine the association between serum biomarkers (albumin and pre-albumin) and malnutrition. METHODS: This international observational prospective cohort study will be performed at three Level-1 trauma centers in the United States and two Level-1 centers in the Netherlands. Adult polytrauma patients (Injury Severity Score ≥16) admitted to the ICU of one of the participating centers directly from the Emergency Department are eligible for inclusion. Nutritional status and risk of malnutrition will be assessed using the Subjective Global Assessment (SGA) scale and Nutritional Risk in Critically Ill (NUTRIC) score, respectively. Nutritional intake, biomarkers and complications will be collected daily. Patients will be followed up to one year after discharge for long-term outcomes. CONCLUSIONS: This international prospective cohort study aims to gain more insight into the effect and consequences of malnutrition in polytrauma patients admitted to the ICU.

Patient-reported outcomes after a distal radius fracture in adults: a 3-4 years follow-up.

Background and purpose - There are few reports on the outcome of distal radius fractures after 1 year. Therefore we investigated the long-term patient-reported functional outcome and health-related quality of life after a distal radius fracture in adults. Patients and methods - We reviewed 823 patients, treated either nonoperatively or operatively in 2012. After a mean follow-up of 3.8 years 285 patients (35%) completed the Patient-Rated Wrist Evaluation (PRWE) and EuroQol-5D. Results - The mean PRWE score was 11. The mean EQ-5D index value was 0.88 and the mean EQ VAS for self-rated health status was 80. Nonoperatively treated type A and type B fractures had lower PRWE scores compared with operatively treated patients, whereas the EQ-5D was similar between groups. The EQ VAS for patients aged 65 and older was statistically significantly lower than that of younger patients. Interpretation - Patients had a good overall long-term functional outcome after a distal radius fracture. Patients with fractures that were possible to treat nonoperatively had less pain and better wrist function after long-term follow-up than patients who needed surgical fixation.

Differences in Characteristics and Outcome of Patients with Penetrating Injuries in the USA and the Netherlands: A Multi-institutional Comparison.

INTRODUCTION: The incidence and nature of penetrating injuries differ between countries. The aim of this study was to analyze characteristics and clinical outcomes of patients with penetrating injuries treated at urban Level-1 trauma centers in the USA (USTC) and the Netherlands (NLTC). METHODS: In this retrospective cohort study, 1331 adult patients (470 from five NLTC and 861 from three USTC) with truncal penetrating injuries admitted between July 2011 and December 2014 were included. In-hospital mortality was the primary outcome. Outcome comparisons were adjusted for differences in population characteristics in multivariable analyses. RESULTS: In USTC, gunshot wound injuries (36.1 vs. 17.4%, p < 0.001) and assaults were more frequent (91.2 vs. 77.7%, p < 0.001). ISS was higher in USTC, but the Revised Trauma Score (RTS) was comparable. In-hospital mortality was similar (5.0 vs. 3.6% in NLTC, p = 0.25). The adjusted odds ratio for mortality in USTC compared to NLTC was 0.95 (95% confidence interval 0.35-2.54). Hospital stay length of stay was shorter in USTC (difference 0.17 days, 95% CI -0.29 to -0.05, p = 0.005), ICU admission rate was comparable (OR 0.96, 95% CI 0.71-1.31, p = 0.80), and ICU length of stay was longer in USTC (difference of 0.39 days, 95% CI 0.18-0.60, p < 0.0001). More USTC patients were discharged to home (86.9 vs. 80.6%, p < 0.001). Readmission rates were similar (5.6 vs. 3.8%, p = 0.17). CONCLUSION: Despite the higher incidence of penetrating trauma, particularly firearm-related injuries, and higher hospital volumes in the USTC compared to the NLTC, the in-hospital mortality was similar. In this study, outcome of care was not significantly influenced by differences in incidence of firearm-related injuries.

Surgical Approaches and Hemiarthroplasty Outcomes for Femoral Neck Fractures: A Meta-Analysis.

BACKGROUND: The lateral approach (LA), posterior approach (PA), and anterior approach (AA) are conventional surgical access routes for hemiarthroplasty in proximal femoral fractures. This meta-analysis assesses and compares the outcomes and attempts to identify the best approach for hemiarthroplasty in the treatment of proximal femoral fractures. METHODS: An electronic search was performed from inception to October 25, 2017, for comparative studies including at least 2 of the conventional approaches. Outcomes including operation time, surgical blood loss, perioperative fractures, wound infections, dislocations, and hospital length of stay were plotted in forest plots. RESULTS: Twenty-one eligible studies were selected including 3 randomized, controlled trials, 7 prospective and 11 retrospective cohort studies. The odds ratio (OR) for dislocations was significantly higher for the PA compared with the AA (OR, 2.61; 95% confidence interval [CI], 1.26 to 5.43; P = .01) and the LA (OR, 2.90; 95% CI, 1.63 to 5.14; P = .0003). The PA had a higher risk of reoperation compared to the AA (OR, 1.25; 95% CI, 1.12 to 1.41; P < .0001). No significant differences were found concerning perioperative fractures, wound infections, and hospital length of stay. Some studies suggest a better short-term functional outcome using the AA compared to the PA. CONCLUSION: The PA for hemiarthroplasty in proximal femoral fractures poses an increased risk of dislocation and reoperation compared to the LA and AA. There are no evident advantages of the PA and its routine use for fracture-related hemiarthroplasty should be questioned.

Routine Follow-Up Radiographs for Ankle Fractures Seldom Add Value to Clinical Decision-Making: A Retrospective, Observational Study.

Currently, the routine use of radiographs for uncomplicated ankle fractures represents good clinical practice. However, radiographs are associated with waiting time, radiation exposure, and costs. Studies have suggested that radiographs seldom alter the treatment strategy if no clinical indication for the imaging study was present. The objective of the present study was to evaluate the effect of routine radiographs on the treatment strategy during the follow-up period of ankle fractures. All patients aged ≥18 years, who had visited 1 of the participating clinics with an eligible ankle fracture in 2012 and with complete follow-up data were included. The data were retrospectively analyzed. The sociodemographic and clinical characteristics and the number of, and indications for, the radiographs taken were collected from the medical records of the participating clinics. We assessed the changes in treatment strategy according to the radiographic findings. In 528 patients with an ankle fracture, 1174 radiographs were performed during the follow-up period. Of these radiographs, 936 (79.7%) were considered routine. Of the routine radiographs taken during the follow-up period, only 11 (1.2 %) resulted in changes to the treatment strategy. Although it is common practice to take radiographs routinely during the follow-up period for ankle fractures, the results from the present study suggest that routine radiographs seldom alter the treatment strategy. This limited clinical relevance should be weighed against the health care costs and radiation exposure associated with the use of routine radiographs. For a definitive recommendation, however, the results of our study should be confirmed by a prospective trial, which we are currently conducting.

Prospective comparison of the anterior and lateral approach in hemiarthroplasty for hip fractures: a study protocol.

BACKGROUND: The Direct Anterior Approach (DAA) is an alternative approach to the currently most used Lateral Approach (LA) for hip replacement in femoral neck fracture patients. Compared to the LA, the DAA minimizes soft tissue damage. Sparing muscle tissue may facilitate early and improved postoperative mobility. It may also be associated with fewer complications, increased quality of life and lower 1-year mortality. The aim of this study is to compare postoperative complications, hip function and patient mobility after hemiarthroplasty via the anterior or lateral approach following a displaced femoral neck fracture. METHODS: 138 elderly patients with displaced femoral neck fractures will be operated using either the direct anterior approach or the lateral approach for a hemiarthroplasty in a single centre, prospective, comparative cohort study. The choice of surgical approach will depend on the expertise of the trauma surgeon on call. The primary outcome of this study will be the functionality of the hip after surgery measured using the Harris Hip Score during routine outpatient check-ups. Secondary outcomes include surgical and non-surgical complication rates, admission time, postoperative pain, rehabilitation time, performance in activities of daily living, health-related quality of life measured, cognitive function and balance. DISCUSSION: Many approaches are known for hip replacement arthroplasty in trauma patients with little consensus on the preferred method. Identifying the best approach facilitating an adequate and fast recovery could optimize patient independence and quality of life and minimize rehabilitation costs, morbidity and mortality rates. The study design will reflect daily clinical practice and aims to present an accurate depiction of clinical outcomes. TRIAL REGISTRATION: This trial entered the Dutch Trial Registry with registration number (NTR)6238 on the 24th of April 2017. http://www.trialregister.nl/trialreg/index.asp . Protocol version 2.0 16-03-2017.

Does clavicular shortening after nonoperative treatment of midshaft fractures affect shoulder function? A systematic review.

INTRODUCTION: Clavicular shortening due to non-anatomical healing of displaced clavicular fractures is believed to have a negative effect on shoulder function after recovery. The evidence for this, however, is equivocal. This review aimed to systematically evaluate the available literature to determine whether the current beliefs about clavicular shortening can be substantiated. MATERIALS AND METHODS: This systematic review was performed following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. PubMed, EMBASE, Web of Science and the Clinical Trial Registry were searched to identify all studies published in English that evaluated the association between clavicular shortening and shoulder function in patients aged ≥16 years with a nonoperatively treated, displaced midshaft clavicular fracture. Relevant data from the selected studies was extracted and summarized. Risk of bias of the included studies was assessed using the MINORS instrument. RESULTS: Six studies, of which five were retrospective, were included in this review analyzing a total of 379 patients. Due to heterogeneity in methods and reporting across studies, a pooled analysis of the results was not feasible. No clear associations were found between shortening and shoulder function scores (DASH and Constant score) or arm strength in each of the included studies. CONCLUSION: The existing evidence to date does not allow for a valid conclusion regarding the influence of shortening on shoulder function after union of nonoperatively treated midshaft clavicular fractures. Shortening alone is currently not an evidence-based indication to operate for the goal of functional improvement. Well-powered prospective comparative studies are needed to draw firm conclusions.