Evaluating the influence of alcohol intoxication on the pre-hospital identification of severe head injury: a multi-center, cohort study.

OBJECTIVE: To determine the influence of intoxication on the pre-hospital recognition of severely head-injured patients by Emergency Medical Services (EMS) professionals and to investigate the relationship between suspected alcohol intoxication and severe head injury. METHODS: This multi-center, retrospective, cohort study included trauma patients, aged ≥ 16 years, transported by an ambulance of the Regional Ambulance Facility Utrecht to any emergency department in the participating trauma regions. RESULTS: Between January 1, 2015 and December 31, 2017, 19,206 patients were included, of whom 1167 (6.0%) were suspected to have a severe head injury in the field, and 623 (3.2%) were diagnosed with such an injury at the hospital. These injuries were less frequently recognized in patients with a GCS ≥ 13 than in patients with a GCS < 13 (25.0% vs. 76.2%). Patients suspected to be intoxicated had a higher chance to suffer from severe head injury (OR 1.42, 95%-CI 1.22-1.65) and were recognized slightly more often (45.3% vs. 40.2%). CONCLUSION: Severe head injuries are difficult to recognize in the field, especially in patients without a decreased GCS. Suspicion of alcohol intoxication did not seem to influence pre-hospital injury recognition, as it possibly makes a severe head injury harder to recognize and simultaneously raises caution for a severe injury.

Impact of the COVID-19 pandemic on surgical care in the Netherlands.

BACKGROUND: The COVID-19 pandemic caused disruption of regular healthcare leading to reduced hospital attendances, repurposing of surgical facilities, and cancellation of cancer screening programmes. This study aimed to determine the impact of COVID-19 on surgical care in the Netherlands. METHODS: A nationwide study was conducted in collaboration with the Dutch Institute for Clinical Auditing. Eight surgical audits were expanded with items regarding alterations in scheduling and treatment plans. Data on procedures performed in 2020 were compared with those from a historical cohort (2018-2019). Endpoints included total numbers of procedures performed and altered treatment plans. Secondary endpoints included complication, readmission, and mortality rates. RESULTS: Some 12 154 procedures were performed in participating hospitals in 2020, representing a decrease of 13.6 per cent compared with 2018-2019. The largest reduction (29.2 per cent) was for non-cancer procedures during the first COVID-19 wave. Surgical treatment was postponed for 9.6 per cent of patients. Alterations in surgical treatment plans were observed in 1.7 per cent. Time from diagnosis to surgery decreased (to 28 days in 2020, from 34 days in 2019 and 36 days in 2018; P < 0.001). For cancer-related procedures, duration of hospital stay decreased (5 versus 6 days; P < 0.001). Audit-specific complications, readmission, and mortality rates were unchanged, but ICU admissions decreased (16.5 versus 16.8 per cent; P < 0.001). CONCLUSION: The reduction in the number of surgical operations was greatest for those without cancer. Where surgery was undertaken, it appeared to be delivered safely, with similar complication and mortality rates, fewer admissions to ICU, and a shorter hospital stay.

COVID-19 has had a significant impact on healthcare worldwide. Hospital visits were reduced, operating facilities were used for COVID-19 care, and cancer screening programmes were cancelled. This study describes the impact of the COVID-19 pandemic on Dutch surgical healthcare in 2020. Patterns of care in terms of changed or delayed treatment are described for patients who had surgery in 2020, compared with those who had surgery in 2018­2019. The study found that mainly non-cancer surgical treatments were cancelled during months with high COVID-19 rates. Outcomes for patients undergoing surgery were similar but with fewer ICU admissions and shorter hospital stay. These data provide no insight into the burden endured by patients who had postponed or cancelled operations.

The impact of operative time on the outcomes of necrotizing soft tissue infections: a multicenter cohort study.

BACKGROUND: The primary aim of this study was to identify if there is an association between the operative time of the initial debridement for necrotizing soft tissue infections (NSTIs) and the mortality corrected for disease severity. METHODS: A retrospective multicenter study was conducted of all patients with NSTIs undergoing surgical debridement. The primary outcome was the 30-day mortality. The secondary outcomes were days until death, length of intensive care unit (ICU) stay, length of hospital stay, number of surgeries within first 30 days, amputations and days until definitive wound closure. RESULTS: A total of 160 patients underwent surgery for NSTIs and were eligible for inclusion. Twenty-two patients (14%) died within 30 days and 21 patients (13%) underwent an amputation. The median operative time of the initial debridement was 59 min (IQR 35-90). In a multivariable analyses, corrected for sepsis just prior to the initial surgery, estimated total body surface (TBSA) area affected and the American Society for Anesthesiologists (ASA) classification, a prolonged operative time (per 20 min) was associated with a prolonged ICU (ß 1.43, 95% CI 0.46-2.40; p = 0.004) and hospital stay (ß 3.25, 95% CI 0.23-6.27; p = 0.035), but not with 30-day mortality. Operative times were significantly prolonged in case of NSTIs of the trunk (p = 0.044), in case of greater estimated TBSA affected (p = 0.006) or if frozen sections and/or Gram stains were assessed intra-operatively (p < 0.001). CONCLUSIONS: Prolonged initial surgery did not result in a higher mortality rate, possible because of a short duration of surgery in most studied patients. However, a prolonged operative time was associated with a prolonged ICU and hospital stay, regardless of the estimated TBSA affected, presence of sepsis prior to surgery and the ASA classification. As such, keeping operative times as limited as possible might be beneficial for NSTI patients.

Evaluating the effect of driving distance to the nearest higher level trauma centre on undertriage: a cohort study.

BACKGROUND: It is of great importance that emergency medical services professionals transport trauma patients in need of specialised care to higher level trauma centres to achieve optimal patient outcomes. Possibly, undertriage is more likely to occur in patients with a longer distance to the nearest higher level trauma centre. This study aims to determine the association between driving distance and undertriage. METHOD: This prospective cohort study was conducted from January 2015 to December 2017. All trauma patients in need of specialised care that were transported to a trauma centre by emergency medical services professionals from eight ambulance regions in the Netherlands were included. Patients with critical resource use or an Injury Severity Score ≥16 were defined as in need of specialised care. Driving distance was calculated between the scene of injury and the nearest higher level trauma centre. Undertriage was defined as transporting a patient in need of specialised care to a lower level trauma centre. Generalised linear models adjusting for confounders were constructed to determine the association between driving distance to the nearest higher level trauma centre per 1 and 10 km and undertriage. A sensitivity analysis was conducted with a generalised linear model including inverse probability weights. RESULTS: 6101 patients, of which 4404 patients with critical resource use and 3760 patients with an Injury Severity Score ≥16, were included. The adjusted generalised linear model demonstrated a significant association between a 1 km (OR 1.04; 95% CI 1.04 to 1.05) and 10 kilometre (OR 1.50; 95% CI 1.42 to 1.58) increase in driving distance and undertriage in patients with critical resource use. Also in patients with an Injury Severity Score ≥16, a significant association between driving distance (1 km (OR 1.06; 95% CI 1.06 to 1.07), 10 km (OR 1.83; 95% CI 1.71 to 1.95)) and undertriage was observed. CONCLUSION: Patients in need of specialised care are less likely to be transported to the appropriate trauma centre with increasing driving distance. Our results suggest that emergency medical services professionals incorporate driving distance into their decision making regarding transport destinations, although distance is not included in the triage protocol.

An economic evaluation of triage tools for patients with suspected severe injuries in England.

BACKGROUND: Many health care systems triage injured patients to major trauma centres (MTCs) or local hospitals by using triage tools and paramedic judgement. Triage tools are typically assessed by whether patients with an Injury Severity Score (ISS) ≥ 16 go to an MTC and whether patients with an ISS < 16 are sent to their local hospital. There is a trade-off between sensitivity and specificity of triage tools, with the optimal balance being unknown. We conducted an economic evaluation of major trauma triage tools to identify which tool would be considered cost-effective by UK decision makers. METHODS: A patient-level, probabilistic, mathematical model of a UK major trauma system was developed. Patients with an ISS ≥ 16 who were only treated at local hospitals had worse outcomes compared to being treated in an MTC. Nine empirically derived triage tools, from a previous study, were examined so we assessed triage tools with realistic trade-offs between triage tool sensitivity and specificity. Lifetime costs, lifetime quality adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) were calculated for each tool and compared to maximum acceptable ICERs (MAICERs) in England. RESULTS: Four tools had ICERs within the normal range of MAICERs used by English decision makers (£20,000 to £30,000 per QALY gained). A low sensitivity (28.4%) and high specificity (88.6%) would be cost-effective at the lower end of this range while higher sensitivity (87.5%) and lower specificity (62.8%) was cost-effective towards the upper end of this range. These results were sensitive to the cost of MTC admissions and whether MTCs had a benefit for patients with an ISS between 9 and 15. CONCLUSIONS: The cost-effective triage tool depends on the English decision maker's MAICER for this health problem. In the usual range of MAICERs, cost-effective prehospital trauma triage involves clinically suboptimal sensitivity, with a proportion of seriously injured patients (at least 10%) being initially transported to local hospitals. High sensitivity trauma triage requires development of more accurate decision rules; research to establish if patients with an ISS between 9 and 15 benefit from MTCs; or, inefficient use of health care resources to manage patients with less serious injuries at MTCs.

Clinician Factors Rather Than Patient Factors Affect Discussion of Treatment Options.

BACKGROUND: Shared decision-making aims to combine what matters most to a patient with clinician expertise to develop a personalized health strategy. It is a dialogue between patient and clinician in which preferences are expressed, misconceptions reoriented, and available options are considered. To improve patient involvement, it would help to know more about specific barriers and facilitators of patient-clinician communication. Health literacy, the ability to obtain, process, and understand health information, may affect patient participation in decision-making. If the patient is quiet, deferential, and asks few questions, the clinician may assume a more paternalistic style. A patient with greater agency and engagement could be the catalyst for shared decisions. QUESTIONS/PURPOSES: We assessed (1) whether effective clinician communication and effort is related to patient health literacy, and (2) if there are other factors associated with effective clinician communication and effort. METHODS: We combined a prospective, cross-sectional cohort of 86 audio-recorded visits of adult patients seeking specialist hand care for a new problem at an urban community hospital in the Netherlands with a cohort of 72 audio-recorded hand surgery visits from a tertiary hospital in the United States collected for a prior study. The American cohort represents a secondary use of data from a set of patients from a separate study using audio-recorded visits and administering similar questionnaires that assessed different endpoints. In both cohorts, adult patients seeking specialist hand care for a new problem were screened. In total, 165 patients were initially screened, of which 96% (158) participated. Eight percent (13) of visits were excluded since the final diagnosis remained unclear, 8% (12) since it was not the first consultation for the current problem, 5% (8) in which only one treatment option was available, and < 1% (1) since there was a language barrier. A total of 123 patients were analyzed, 68 from the Netherlands and 55 from the United States. The Newest Vital Sign (NVS) health literacy test, validated in both English and Dutch, measures the ability to use health information and is based on a nutrition label from an ice cream container. It was used to assess patient health literacy on a scale ranging from 0 (low) to 6 (high). The 5-item Observing Patient Involvement (OPTION5) instrument is commonly used to assess the quality of patient-clinician discussion of options. Scores may be influenced by clinician effort to involve patients in decision-making as well as patient engagement and agency. Each item is scored from 0 (no effort) to 4 (maximum effort), with a total maximum score of 20. Two independent raters reached agreement (kappa value 0.8; strong agreement), after which all recordings were scored by one investigator. Visit duration and patient questions were assessed using the audio recordings. Patients had a median (interquartile range) age of 54 (38 to 66) years, 50% were men, 89% were white, 66% had a nontraumatic diagnosis, median (IRQ) years of education was 16 (12 to 18) years, and median (IQR) health literacy score was 5 (2 to 6). Median (IQR) visit duration was 9 (7 to 12) minutes. Cohorts did not differ in important ways. The number of visits per clinician ranged from 14 to 29, and the mean overall communication effectiveness and effort score for the visits was low (8.5 ± 4.2 points of 20 points). A multivariate linear regression model was used to assess factors associated with communication effectiveness and effort. RESULTS: There was no correlation between health literacy and clinician communication effectiveness and effort (r = 0.087 [95% CI -0.09 to 0.26]; p = 0.34), nor was there a difference in means (SD) when categorizing health literacy as inadequate (7.8 ± 3.8 points) and adequate (8.9 ± 4.5 points; mean difference 1.0 [95% CI -2.6 to 0.54]; p = 0.20). After controlling for potential confounding variables such as gender, patient questions, and health literacy, we found that longer visit duration (per 1 minute increase: r2 = 0.31 [95% CI -0.14 to 0.48]; p < 0.001), clinician 3 (compared with clinician 1: OR 33 [95% CI 4.8 to 229]; p < 0.001) and clinician 5 (compared with clinician 1: OR 11 [95% CI 1.5 to 80]; p = < 0.02) were independently associated with more effective communication and effort, whereas clinician 6 was associated with less effective communication and effort (compared with clinician 1: OR 0.08 [95% CI 0.01 to 0.75]; p = 0.03). Clinicians' communication strategies (the clinician variable on its own) accounted for 29% of the variation in communication effectiveness and effort, longer visit duration accounted for 11%, and the full model accounted for 47% of the variation (p < 0.001). CONCLUSION: The finding that the overall low mean communication effectiveness and effort differed between clinicians and was not influenced by patient factors including health literacy suggests clinicians may benefit from training that moves them away from a teaching or lecturing style where patients receive rote directives regarding their health. Clinicians can learn to adapt their communication to specific patient values and needs using a guiding rather than directing communication style (motivational interviewing).Level of Evidence Level II, prognostic study.

Medium to Long-Term Follow-Up After Pyrocarbon Disc Interposition Arthroplasty for Treatment of CMC Thumb Joint Arthritis.

PURPOSE: Pyrocarbon disc interposition arthroplasty has been designed for the surgical treatment of Eaton-Glickel grade II/III carpometacarpal thumb joint arthritis. This study presents the results of this technique with a minimum 5-year follow up. METHODS: We assessed 4 questionnaires for patient-reported outcome measurements in a cross-sectional study: the Patient-Rated Wrist and Hand Evaluation, Disabilities of Arm, Shoulder, and Hand questionnaire, Michigan Hand Questionnaire, and questions about satisfaction at the 5-year follow up. We evaluated grip and pinch strength, range of motion, and the radiological position of the disc. Finally, a Kaplan-Meier survival analysis was performed. RESULTS: A total of 164 thumbs (in 137 patients) were available for follow-up varying from 5 to 12 years. Median Patient-Rated Wrist and Hand Evaluation, Disabilities of Arm, Shoulder, and Hand, and Michigan Hand Questionnaire scores were 17, 18, and 76, respectively. The satisfaction score was 9 (Likert scale of 1-10). Grip and pinch strength reached nearly 100% compared with the contralateral hand. Range of motion resulted in a Kapandji score of 10. Thumb height showed a marginal loss and the Kaplan-Meier survival curve showed a survival rate of 91%. CONCLUSIONS: Our study suggests that pyrocarbon disc interposition arthroplasty is a reliable and feasible treatment for carpometacarpal thumb joint arthritis at medium-term follow-up. It was associated with a high level of patient satisfaction; it maintained thumb height and the implant survived in 91% of patients. Strength and range of motion were comparable to the contralateral hand after a minimum follow-up of 5 years. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Patient-Reported Outcomes and Complications After Surgical Fixation of 143 Proximal Phalanx Fractures.

PURPOSE: Multiple methods exist to surgically fix unstable phalangeal fractures. Whereas these methods have different rates of complications or reoperation, it is not known whether these differences lead to changes in patient reported outcome. We compared patient-reported outcomes measures and complications of Kirschner wire (K-wire), lag-screw and plate fixation of proximal phalanx fractures (excluding the thumb). METHODS: From 2010 to 2015, 159 patients with 159 proximal phalanx fractures were identified in 2 level 2 trauma centers and fixed with K-wires (44% of patients), lag-screws (26%), or plates (30%). Disabilities of the Arm, Shoulder, and Hand (DASH), and Patient-Rated Wrist/Hand Evaluation (PRWHE) and complications were assessed. In addition, subjective outcomes were assessed. Follow-up was achieved for 143 fractures (90%) and average time to follow-up was 3.4 years. RESULTS: Mean DASH and PRWHE scores were 5.0 and 8.2, respectively. No differences in functional outcomes were found between fixation methods, although unplanned reoperation was more common in the plate fixation group (9 patients; 21%) than in the K-wire and lag-screw fixation groups (3 patients and 1 patient; 4.8 and 2.7%, respectively). We also found that K-wire fixation was associated with better aesthetic outcome than open reduction internal fixation. CONCLUSIONS: Overall patient-reported outcomes measure scores were similar across fixation methods, and unplanned reoperation was more prevalent after plate fixation. In addition, we found that regardless of fracture pattern, percutaneous fixation with K-wires was often sufficient and associated with better aesthetic outcome than open reduction and internal fixation. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Treatment of a Scientifically Neglected Ankle Injury: The Isolated Medial Malleolar Fracture. A Systematic Review.

Isolated medial malleolar fractures are frequently encountered injuries. Literature regarding their treatment, though, is scarce and contradicting. The aim of this systematic review is to compare surgical and conservative treatment of isolated medial malleolar fractures considering complication rates and functional outcomes. PubMed, Embase, Cochrane, and CINAHL were searched for this review. Articles from 1980 or later, written in English, French, German, or Dutch, reporting any outcome of 10 or more isolated medial malleolar fractures in skeletally mature patients were included. Study quality was assessed using the Methodological Index for Non Randomized Studies (MINORS) instrument. Eighteen studies were included involving 2566 isolated medial malleolar fractures, which showed a mean (± SD) MINORS score of 8 ± 2. Mean nonunion rate was 1.7% after surgical treatment and 3.5% after conservative treatment. Overall, comparable functional outcomes were found after both treatment methods. Only 2 of the included studies reported the exact amount of fracture displacement. One study-comparing surgical and conservative treatment-showed similar functional outcomes for 1- and 2-mm displaced isolated medial malleolar fractures, and the other, a nonunion rate of 3.5% and a good mean functional outcome in 57 conservatively treated isolated medial malleolar fractures with a mean displacement of 3.8 mm. The available evidence is scarce and of low quality but suggests that conservative treatment of isolated medial malleolar fractures displaced ≤2 mm is safe. No study exists that compares surgical and conservative treatment in isolated medial malleolar fractures displaced >2 mm. Therefore, further research is needed. Until then, the eventual choice of treatment for isolated medial malleolar fractures displaced >2 mm, might be mainly dependent on the patients' characteristics and demands.

Excellent functional recovery after Kirschner-wire extension blocking technique for displaced closed bony mallet finger injuries; results of 36 cases.

Bony mallet finger injuries comprise 30% of all mallet injuries. Operative treatment of bony mallet fingers injuries still remains controversial. The aim of this study was to describe the k-wire extension blocking technique and the functional results using the PRWHE questionnaire. A single center retrospective observational cohort of 36 patients was defined between January 2010 and December 2015. Inclusion criteria for this study were acute fractures with 1) persistent displacement of more than 3 mm in extension splint, 2) palmar subluxation of the distal phalanx or 3) fracture fragments consisting of more than one third of the joint surface. According to the PRWHE questionnaire, excellent results were observed with a mean follow up period of 32 months of all patients. Two patients developed a clinically relevant superficial wound infection and one patient developed a nail deformity. In conclusion, the k-wire extension blocking technique is safe and results in excellent mid-term functional outcome.

Surgical treatment of Neer type II and type V lateral clavicular fractures: comparison of hook plate versus superior plate with lateral extension: a retrospective cohort study.

PURPOSE: Different fixation methods are used for treatment of unstable lateral clavicle fractures (LCF). Definitive consensus and guidelines for the surgical fixation of LCF have not been established. The aim of this study was to compare patient-reported functional outcome after open reduction and internal fixation with the clavicle hook plate (CHP) and the superior clavicle plate with lateral extension (SCPLE). METHODS: A dual-center retrospective cohort study was performed. All patients operatively treated for unstable Neer type II and type V LCF between 2011 and 2016, with the CHP (n = 23) or SCPLE (n = 53), were eligible for inclusion. The primary outcome was the QuickDASH score. Secondary outcomes were the numerical rating scale (NRS) pain score, complications, and implant removal. RESULTS: A total of 67 patients (88%) were available for the final follow-up. There was a significant difference in bicortical lateral fragment size, 15 mm (± 4, range 6-21) in the CPH group compared to 20 mm (± 8, range 8-43) in the SCPLE group (p ≤ 0.001). There was no significant difference in median QuickDASH score (CHP; 0.00 [IQR 0.0-0.0], SCPLE; 0.00 [IQR 0.0-4.5]; p = 0.073) or other functional outcome scores (NRS at rest; p = 0.373, NRS during activity; p = 0.559). There was no significant difference in median QuickDASH score or other functional outcome scores between Neer type II and type V fractures. There was no significant difference in complication rate, CHP 11% and SCPLE 8% (relative risk 1.26; [95% CI 0.25-6.33; p = 0.777]). The implant removal rate was 100% in the CHP group compared to 42% in the SCPLE group (relative risk 2.40; [95% CI 1.72-3.35; p ≤ 0.001]). CONCLUSION: Both the CHP and SCPLE are effective fixation methods for the treatment of unstable LCF, resulting in excellent patient-reported functional outcome and similar complication rates. SCPLE fixation is an effective fixation method for the treatment of both Neer type II and type V LCF. The SCPLE has a lower implant removal rate. Therefore, if technically feasible, we recommend SCPLE fixation for the treatment of unstable LCF.

Effectiveness of prehospital trauma triage systems in selecting severely injured patients: Is comparative analysis possible?

INTRODUCTION: In an optimal trauma system, prehospital trauma triage ensures transport of the right patient to the right hospital. Incorrect triage results in undertriage and overtriage. The aim of this systematic review is to evaluate and compare prehospital trauma triage system quality worldwide and determine effectiveness in terms of undertriage and overtriage for trauma patients. METHODS: A systematic search of Pubmed/MEDLINE, Embase, and Cochrane Library databases was performed, using "trauma", "trauma center," or "trauma system", combined with "triage", "undertriage," or "overtriage", as search terms. All studies describing ground transport and actual destination hospital of patients with and without severe injuries, using prehospital triage, published before November 2017, were eligible for inclusion. To assess the quality of these studies, a critical appraisal tool was developed. RESULTS: A total of 33 articles were included. The percentage of undertriage ranged from 1% to 68%; overtriage from 5% to 99%. Older age and increased geographical distance were associated with undertriage. Mortality was lower for severely injured patients transferred to a higher-level trauma center. The majority of the included studies were of poor methodological quality. The studies of good quality showed poor performance of the triage protocol, but additional value of EMS provider judgment in the identification of severely injured patients. CONCLUSION: In most of the evaluated trauma systems, a substantial part of the severely injured patients is not transported to the appropriate level trauma center. Future research should come up with new innovative ways to improve the quality of prehospital triage in trauma patients.

Operative versus nonoperative treatment of proximal humeral fractures: a systematic review, meta-analysis, and comparison of observational studies and randomized controlled trials.

BACKGROUND: There is no consensus on the choice of treatment for displaced proximal humeral fractures in older patients (aged > 65 years). The aims of this systematic review and meta-analysis were (1) to compare operative with nonoperative management of displaced proximal humeral fractures and (2) to compare effect estimates obtained from randomized controlled trials (RCTs) and observational studies. METHODS: The databases of MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) were searched on September 5, 2017, for studies comparing operative versus nonoperative treatment of proximal humeral fractures; both RCTs and observational studies were included. The criteria of the Methodological Index for Non-Randomized Studies, a validated instrument for methodologic quality assessment, were used to assess study quality. The primary outcome measure was physical function as measured by the absolute Constant-Murley score after operative or nonoperative treatment. Secondary outcome measures were major reinterventions, nonunion, and avascular necrosis. RESULTS: We included 22 studies, comprising 7 RCTs and 15 observational studies, resulting in 1743 patients in total: 910 treated operatively and 833 nonoperatively. The average age was 68.3 years, and 75% of patients were women. There was no difference in functional outcome between operative and nonoperative treatment, with a mean difference of -0.87 (95% confidence interval, -5.13 to 3.38; P = .69; I2 = 69%). Major reinterventions occurred more often in the operative group. Pooled effects of RCTs were similar to pooled effects of observational studies for all outcome measures. CONCLUSIONS: We recommend nonoperative treatment for the average elderly patient (aged > 65 years) with a displaced proximal humeral fracture. Pooled effects of observational studies were similar to those of RCTs, and including observational studies led to more generalizable conclusions.

Intramedullary nailing of displaced midshaft clavicle fractures using a TEN with end cap: issues encountered.

The purpose of this study was to describe our experience with a possible solution for implant- related irritation after intramedullary nailing of displaced midshaft clavicle fractures: the end cap. Ten patients with a displaced midshaft clavicle fracture were treated with intramedullary nailing and an end cap in 2013. Patients were followed in the outpatient clinic until fracture union. In 2015 patients were contacted again. Prospectively collected data included shoulder function and complications. The median follow-up time was 28.5 months (between 27 and 30 months). No patients were lost to follow- up. QuickDASH scores were 18.2, 9.1 and 2.3 after 6 weeks, 3 month and latest follow-up respectively. Nine patients (90%) had some type of implant-related complication. In three of these patients implant removal was required before union. One implant failure occurred which required major revision surgery using plate fixation. In conclusion, because in 70% of the patients the implant-related irritation was directly caused by the end cap, we believe end caps should not be used after intramedullary nailing for displaced midshaft clavicle fractures.

High Irritation and Removal Rates After Plate or Nail Fixation in Patients With Displaced Midshaft Clavicle Fractures.

BACKGROUND: Studies comparing plate with intramedullary nail fixation of displaced midshaft clavicle fractures show faster recovery in the plate group and implant-related complications in both groups after short-term followup (6 or 12 months). Knowledge of disability, complications, and removal rates beyond the first postoperative year will help surgeons in making a decision regarding optimal implant choice. However, comparative studies with followup beyond the first year or two are scarce. QUESTIONS/PURPOSES: We asked: (1) Does plate fixation or intramedullary nail fixation for displaced midshaft clavicle fractures result in less disability? (2) Which type of fixation, plate or intramedullary, is more frequently associated with implant-related irritation and implant removal? (3) Is plate or intramedullary fixation associated with postoperative complications beyond the first postoperative year? METHODS: Between January 2011 and August 2012, patients with displaced midshaft clavicle fractures were enrolled and randomized to plate or intramedullary nail fixation. A total of 58 patients with plate and 62 patients with intramedullary nails initially were enrolled. Minimum followup was 30 months (mean, 39 months; range, 30-51 months). Two patients (3%) with plate fixation and two patients (3%) with intramedullary nails were lost to followup. The QuickDASH was obtained at final followup and compared between patients who had plate fixation and those who had intramedullary nail fixation. Postoperative complications measured include infection, implant-related irritation, implant failure, nonunion, and refracture after implant removal. Indications for implant removal included implant-related irritation, implant failure, nonunion, patient's wish, or surgeon's preference. RESULTS: Between patients with plate versus intramedullary nail fixation, there were no differences in QuickDASH scores (plate, 1.8 ± 3.6; intramedullary nail, 1.8 ± 7.2; mean difference, -0.7; 95% CI, -2.2 to 2.04; p = 0.95). The proportion of patients having implant-related irritation was not different (39 of 56 [70%] versus 41 of 62 [66%]; relative risk, 1.05; 95% CI, 0.82-1.35; p = 0.683). Intramedullary fixation was associated with a higher likelihood of implant removal (51 of 62 [82%] versus 28 of 56 [50%]; relative risk, 1.65; 95% CI, 1.24-2.19; p < 0.001). Among the removed implants more plates than intramedullary nails were removed after the 1-year followup (12 of 28 [43%] versus six of 51 [12%]; p = 0.002). There were no infections, implant breakage, nonunions, or refractures between the 1-year and final followup in either group. CONCLUSIONS: After a mean followup of 39 months, disability scores were excellent. Major complications did not occur after the 1-year followup. A frequent and bothersome problem after both surgical treatments is implant-related irritation, resulting in high rates of implant removal, after 1 year. Future research could focus on analyzing risk factors for implant irritation or removal. LEVEL OF EVIDENCE: Level II, therapeutic study.

Anteroinferior versus superior plating of clavicular fractures.

BACKGROUND: Open reduction and plate fixation has gained recognition as an effective treatment for certain types of clavicular fractures. However, 88% of cases report some implant-related problems. To determine the optimal plate position, the aim of the present study was to compare implant-related irritation and proportion of plate removal in patients with clavicular fractures undergoing plate fixation by an anteroinferior or superior approach. METHODS: Retrospectively collected data of 39 patients who underwent anteroinferior plating for displaced midshaft clavicular fractures were compared with prospectively collected data of 60 patients who were treated with superior plate fixation as part of a multicenter randomized controlled trial. Electronic medical records were reviewed for reports of complications, in particular, implant-related irritation and implant removal during follow-up. In addition, all patients were contacted in June 2014 to obtain additional information. The primary outcome parameter was implant-related irritation. RESULTS: Univariate and multivariate regression analysis showed plate position was not significantly associated with implant-related irritation. Higher rates of asymptomatic patients with the plate still in place were observed in the anteroinferior group (46% vs 22%, P = .01). Almost an equal percentage of implant removals was seen in both groups because of implant irritation (36% vs 37%, P = .938). CONCLUSIONS: The present study found the surgical approach of clavicular plating was not associated with implant-related irritation. Future studies are needed to determine whether there is an optimal approach for clavicle plating.

Anatomical distribution and treatment of paediatric hand fractures: a multi-centre study of 749 patients in the Netherlands.

LEVEL OF EVIDENCE: II.

Pre-hospital tranexamic acid administration in patients with a severe hemorrhage: an evaluation after the implementation of tranexamic acid administration in the Dutch pre-hospital protocol.

PURPOSE: To evaluate the pre-hospital administration of tranexamic acid in ambulance-treated trauma patients with a severe hemorrhage after the implementation of tranexamic acid administration in the Dutch pre-hospital protocol. METHODS: All patients with a severe hemorrhage who were treated and conveyed by EMS professionals between January 2015, and December 2017, to any trauma-receiving emergency department in the eight participating trauma regions in the Netherlands, were included. A severe hemorrhage was defined as extracranial injury with > 20% body volume blood loss, an extremity amputation above the wrist or ankle, or a grade ≥ 4 visceral organ injury. The main outcome was to determine the proportion of patients with a severe hemorrhage who received pre-hospital treatment with tranexamic acid. A Generalized Linear Model (GLM) was performed to investigate the relationship between pre-hospital tranexamic acid treatment and 24 h mortality. RESULTS: A total of 477 patients had a severe hemorrhage, of whom 124 patients (26.0%) received tranexamic acid before arriving at the hospital. More than half (58.4%) of the untreated patients were suspected of a severe hemorrhage by EMS professionals. Patients treated with tranexamic acid had a significantly lower risk on 24 h mortality than untreated patients (OR 0.43 [95% CI 0.19-0.97]). CONCLUSION: Approximately a quarter of the patients with a severe hemorrhage received tranexamic acid before arriving at the hospital, while a severe hemorrhage was suspected in more than half of the non-treated patients. Severely hemorrhaging patients treated with tranexamic acid before arrival at the hospital had a lower risk to die within 24 h after injury.

Let's Agree to Disagree on Operative Versus Nonoperative Treatment for Distal Radius Fractures in Older People: Protocol for a Prospective International Multicenter Cohort Study.

BACKGROUND: Distal radius fractures are the most frequently encountered fractures in Western societies, typically affecting patients aged 50 years and older. Although this is a common injury, the best treatment for these fractures in older patients is still under debate. OBJECTIVE: This prospective study aims to compare the outcome of operatively and nonoperatively treated distal radius fractures in the older population. Only patients with distal radius fractures for which equipoise regarding the optimal treatment exists will be included. METHODS: This prospective international multicenter observational cohort study will be designed as a natural experiment. Natural experiments are observational studies in which treatment allocation is determined by factors outside the control of the investigators but also (largely) independent of patient characteristics. Patients aged 65 years and older with an acute distal radius fracture will be considered for inclusion. Treatment allocation (operative vs nonoperative) will be based on the local preferences of the treating hospital either in Switzerland or the Netherlands. Hence, the process governing treatment allocation resembles that of randomization. Patients will be identified after treatment has been initiated. Based on the radiographs and baseline information of the patient, an expert panel of 6 certified trauma surgeons from 2 regions will provide their treatment recommendation. Only patients for whom the experts disagree on treatment recommendations will ultimately be included in the study (ie, for whom there is a clinical equipoise). For these patients, both operative and nonoperative treatment of distal radius fractures are viable, and treatment choice is predominantly determined by personal or local preference. The primary outcome will be the Patient-Rated Wrist Evaluation score at 12 weeks. Secondary outcomes will include the Physical Activity Score for the Elderly, the EQ questionnaire, pain, the living situation, range of motion, complications, and radiological outcomes. By including outcomes such as living situation and the Physical Activity Score for the Elderly, which are not relevant for younger cohorts, valuable information to tailor treatment to the needs of the older population can be gained. According to the sample size collection, which was based on the minimal important clinical difference of the Patient-Rated Wrist Evaluation, 92 patients will have to be included, with at least 46 patients in each treatment group. RESULTS: Enrollment began in July 2023 and is expected to continue until summer 2024. The final follow-up will be 2 years after the last patient is included. CONCLUSIONS: Although many trials on this topic have previously been published, there remains an ongoing debate regarding the optimal treatment for distal radius fractures in older patients. This observational study, which will use a fairly new methodological study design, will provide further information on treatment outcomes for older patients with distal radius fractures for which to date equipoise exists regarding the optimal treatment. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/52917.

Initial experiences of an enhanced recovery protocol in esophageal surgery.

BACKGROUND: A recent development in gastrointestinal surgery is the implementation of enhanced recovery after surgery (ERAS) programs. Evidence regarding the benefit of these programs in patients undergoing esophageal surgery is scarce. We investigated the feasibility and possible benefit of a perioperative ERAS program in patients undergoing esophagectomy for malignant disease. METHODS: The ERAS program was initiated in 2009. Patients who underwent esophagectomy and were treated according to the ERAS program were included. Items of ERAS included preoperative nutrition, early extubation, early removal of nasogastric tube, and early mobilization. Primary outcome parameters were hospital stay and the incidence of postoperative complications. Outcome parameters in the ERAS cohort were compared to a cohort of patients who underwent surgical resection in the year prior to the implementation of the ERAS protocol. A feasibility analysis was performed among a sample of ERAS patients to determine the number of achieved items per patient. RESULTS: Between 2008 and August 2010, 181 patients in our department underwent esophagectomy. Of these, 103 patients were included in the ERAS program (ERAS+ group) and were compared to 78 patients who had undergone an esophagectomy in 2008 (ERAS- group). Overall hospital stay was 14 days versus 15 days (ERAS+ and ERAS-, respectively; p = 0.013). There were no significant differences in the incidence of postoperative complications in either group. The percentage of achieved items varied between 42 and 93 % per item. CONCLUSIONS: The implementation of an ERAS program in esophageal surgery was feasible and resulted in a small but significant reduction in overall hospital stay, whereas overall morbidity was not affected.