In patients with combined clavicle and multiple rib fractures, does fracture fixation of the clavicle improve clinical outcomes? A multicenter prospective cohort study of 232 patients.

BACKGROUND: Clavicle and rib fractures are often sustained concomitantly. The combination of injuries may result in decreased stability of the chest wall, making these patients prone to (respiratory) complications and prolonged hospitalization. This study aimed to assess whether adding chest wall stability by performing clavicle fixation improves clinical outcomes in patients with concurrent clavicle and rib fractures. METHODS: A prospective multicenter study was performed including all adult patients admitted between January 2018 and March 2021 with concurrent ipsilateral clavicle and rib fractures. Patients treated operatively versus nonoperatively for their clavicle fracture were matched using propensity score matching. The primary outcome was hospital length of stay (HLOS). Secondary outcomes were intensive care unit length of stay, duration of mechanical ventilation, pain, complications, and quality of life at 6 weeks and 12 months of follow-up. RESULTS: In total, 232 patients with concomitant ipsilateral clavicle and rib fractures were included. Fifty-two patients (22%) underwent operative treatment of which 39 could be adequately matched to 39 nonoperatively treated patients. No association was observed between clavicle plate fixation and HLOS (mean difference, 2.3 days; 95% confidence interval, -2.1 to 6.8; p = 0.301) or any secondary endpoint. Eight of the 180 nonoperatively treated patients (4%) had a symptomatic nonunion, for which 5 underwent secondary clavicle fixation. CONCLUSION: We found no evidence that, in patients with combined clavicle and multiple rib fractures, plate fixation of the clavicle reduces HLOS, pain, or (pulmonary) complications, nor that it improves quality of life. STUDY TYPE: Therapeutic/Care Management; Level III.

What are the long-term patient-reported and clinical outcomes after lateral clavicle fractures? A cross-sectional study of 619 patients.

BACKGROUND: Lateral clavicle fractures account for 17% of all clavicle fractures and large studies comparing nonoperative and operative treatment are lacking. Therefore, patients cannot be properly informed about different treatment options and prognosis. We assessed long-term patient-reported and clinical outcomes in patients with lateral clavicle fractures. METHODS: A multicenter cross-sectional study was performed in patients treated for lateral clavicle fractures between 2007 and 2016. Primary outcome included patient-reported outcome measures (PROMs) (DASH, EQ-5D, return to work, sports, cosmetics and satisfaction). Questionnaires were sent to 619 eligible patients, of which 353 (57%) responded after a mean follow-up of 7.4 ± 2.8 years. Secondary outcome included adverse events and secondary interventions. Outcomes after nonoperative vs. operative treatment (stratified by nondisplaced vs. displaced fractures) were compared using Student t tests and linear regression analysis. RESULTS: Nondisplaced lateral clavicle fractures were treated nonoperatively and resulted in excellent PROMs. Six patients (3%) developed a nonunion. For displaced lateral clavicle fractures, no differences were found between nonoperative and operative treatment with regard to DASH score (7.8 ± 12.5 vs 5.4 ± 8.6), EQ-5D (0.91 ± 0.13 vs 0.91 ± 0.09), pain (0.9 ± 1.7 vs. 0.8 ± 1.6), patient satisfaction (90.1 ± 25.5 vs. 86.3 ± 20.4), return to work (96.4% vs. 100%) and sports (61.4% vs. 62.3%). The absolute risk of nonunion in patients with a displaced fracture was higher after nonoperative than operative treatment (20.2% vs. 2.9%; p = 0.002), with six patients needing treatment to avoid one nonunion. CONCLUSIONS: Nondisplaced lateral clavicle fractures should be treated nonoperatively and result in good functional outcomes and high union rates. For displaced fractures, neither nonoperative nor operative treatment seems superior. Patients opting for nonoperative treatment should be informed that nonunion occurs in 20% of patients, but only half of these need additional operative treatment. Patients who opt for surgery should be told that nonunion occurs in only 3%; however, most patients (56%) will require secondary intervention for elective implant removal. Regardless of the type of treatment, no differences in functional outcome and PROMs should be expected at long-term follow-up.

Up to 10-year follow-up after EVAR with the Endurant stent graft system: a single-center experience.

BACKGROUND: Endovascular aneurysm repair (EVAR) has become the preferred treatment for infrarenal abdominal aortic aneurysms (AAA) over open surgical repair. The Endurant stent graft is widely used, and large registries report low rates of aneurysm-related mortality and reinterventions at midterm follow-up. Reports of long-term follow-up are limited. The aim of this study is to report our experiences and share our results, reintervention rate and mortality at long-term follow-up after using the Endurant stent graft. METHODS: All consecutive patients treated between 2009 and 2013 with the Medtronic Endurant I and II stent graft for an infrarenal AAA in an elective setting were included. Primary outcomes were overall and aneurysm-related survival and reintervention rates. RESULTS: One hundred sixty-five consecutive patients (median age 74; IQR: 68-79) with an aneurysm diameter of 62 mm (IQR: 58-70) and neck length of 29 mm (IQR: 21-40) were electively treated with the Endurant I or II stent graft. One hundred thirty-four patients (81.2%) were treated inside IFU (instructions for use) and 31 (18.8%) outside IFU. At median follow-up of 76 months (IQR: 50-97), 60 patients (36.4%) were deceased. Kaplan-Meier estimates at 10 years follow-up of overall survival and freedom from aneurysm-related mortality were respectively 48.5% (CI: 43.7-53.3%) and 97.3% (CI: 95.7-98.9%). Freedom from reintervention was 86.0% with an CI: 83.1-88.9% at 5 years follow-up and 75.6% with a CI: 70.2-81.0% at 10 years follow-up. A total of 25 (15.2%) patients had an EVAR-related reintervention; indications were endoleak (EL) type 1A (N.=11), EL type 1B (N.=3), EL type 2 (N.=6), EL type 3 (N.=1) and limb occlusion (N.=4). We found no significant differences in outcome between the inside and outside IFU groups. At 5 years follow-up 92.6% of patients had stable or decreased diameter, and 7.4% had an increased diameter. CONCLUSIONS: This large cohort single-center study demonstrates the effectiveness and safety of the Endurant stent graft system at long-term follow-up with low reintervention rates and aneurysm-related mortality.

Can 3D-printing avoid discomfort-related implant removal in midshaft clavicle fractures? A four-year follow-up.

INTRODUCTION: Due to the variation in shape and curvature of the clavicle, plates often have to be adjusted during surgery to acquire a good fit. Poorly fitted plates can cause discomfort, eventually requiring implant removal. 3D-printed replicas of the fractured clavicle can assist in planning of the surgical approach, plate selection and, if necessary, adjustment of the plate prior to surgery. We hypothesized this method of preoperative preparation would reduce implant-related discomfort resulting in a reduced reoperation rate MATERIALS AND METHODS: In a prospective cohort study, perioperative plate handling and clavicle fixation were timed and follow-up data were collected from participants undergoing operative treatment for a midshaft clavicle fracture. The control group (n = 7) received conventional surgery with standard precontoured plates. For the intervention group (n = 7), 3D-printed replicas of the fractured clavicle and a mirrored version of the healthy contralateral clavicle were available prior to surgery for planning of the surgical approach, and for plate selection and contouring. Primary outcome was reoperation rate due to implant-related discomfort. Secondary outcomes were complications and time differences in the different surgical phases (reduction, fixation and overall operation time) RESULTS: More participants in the control group had the plate removed due to discomfort compared to the intervention group (5/7 vs. 0/6; P = 0.012). One participant was excluded from the intervention group due to a postoperative complication; an infection occurred at the implant site. No relevant time difference in surgical plate handling was found between both groups. CONCLUSIONS: Preoperative preparation using 3D-printed replicas of the clavicle fracture may reduce implant removal caused by plated-related discomfort. No relevant effect on surgery time was found. TRIAL REGISTRATION: Registered with 'toetsingonline.nl', trial number NL51269.075/14, 17-02-2015.

Plating for midshaft clavicular fractures: The impact on quality of life and functional outcome.

INTRODUCTION: Several studies report on functional outcome after operative treatment for midshaft clavicular fractures. According to the published data not much is known about the quality of life after operative treatment. The purpose of this study is to investigate long term patient reported quality of life (QoL) and functional outcome after plating for midshaft clavicular fractures. METHODS: Patients between 16 and 65 years of age, with a midshaft clavicular fracture which were treated with plate fixation between 2006 and 2014, were included. Information was extracted from hospital records and all patients were asked to participate in an online survey. Primary outcome was QoL (SF-36 and EQ-5D-5L). Secondary outcomes were complications, reoperation rate, patient- and cosmetic satisfaction, pain, and functional outcome (DASH). RESULTS: In a retrospective cohort design, 164 patients were included, 101 completed the online survey. Patients reported a good QoL and functional outcome. The mean physical- and mental SF36 score were 53.9±7.3 and 52.3±9.9 (0-100), the EQ-5D-5L score was 0.88±0.17 (-0.59 to 1.0) and the average DASH was 8.45±14.0 (0-100). Furthermore, there was a strong correlation between the functional outcome and QoL (p<0,001). Seventeen patients developed at least one complication (10%) and seventy-seven patients got a reoperation, with isolated implant removal as the leading cause of reoperation (80,5%). CONCLUSION: Patients which received operative treatment for a midshaft clavicle fracture have an excellent QoL, and a good functional outcome. Furthermore, there is a strong relationship between functional outcome and the QoL.

A Decreased Preload Due to a Loaded Stomach: A Rare Presentation of a Paraesophageal Hernia.

A hiatal hernia is a condition in which intraabdominal content herniates into the intrathoracic cavity. On rare occasions, a hiatal hernia can lead to cardiorespiratory compromise. We report a case of chest pain followed by cardiac arrest in a patient not known to have hiatal hernia, and without preliminary symptoms. The patient was suspected of having cardiac ischemia; however, angiography did not reveal any abnormalities. Chest tomography revealed a large paraesophageal hernia with compression of the right ventricle causing decreased preload and cardiac output. Gastric decompression was performed, and definitive surgical treatment took place the subsequent day. The postoperative course was uncomplicated.