Does preoperative hemodynamic preconditioning improve morbidity and mortality after traumatic hip fracture in geriatric patients? A retrospective cohort study.

INTRODUCTION: Dehydration is a major problem in the older population with traumatic hip fractures (THF). A preoperative hemodynamic preconditioning (PHP) protocol may help in achieving hemodynamic stability to ensure adequate perfusion and oxygenation using only clinical parameters to assess cardiovascular performance. MATERIALS AND METHODS: A single-centre retrospective study in geriatric trauma patients was conducted in a Level 1 Trauma Centre in Switzerland. Patients over the age of 70 with THFs and with Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality (P-POSSUM) scores ≥ 5% who underwent surgical treatment between February 2015 and October 2017 were included. It was hypothesized that patients whose hemodynamic stability was optimised before surgery would have fewer complications and reduced mortality postoperatively. Primary outcomes were complications and mortality. Secondary outcomes were hospital length of stay (HLOS) and place of discharge. RESULTS: 100 patients were included in the PHP group and 79 patients were included in the non-PHP group. The median age was 86.5 (82-90) in the PHP group and 86 (82-90) in the non-PHP group. Patients who had been treated according to the PHP protocol showed a significant reduction in mortality at 30 days (p = 0.02). The PHP group showed an 8.1 and 3.5% reduced mortality at 90 days and at 1 year, respectively. The PHP group showed an 11.7% reduction of patients with complicated courses. No significant differences were seen in HLOS and discharge disposition. CONCLUSIONS: The PHP group showed a significant reduction in short-term mortality, a reduction in long-term mortality, and a reduction in the number of patients with complicated courses. The PHP protocol is a safe, strictly regulated, non-invasive fluid resuscitation protocol for the optimization of geriatric patients with a THF that requires minimal effort. LEVEL OF EVIDENCE: Level III, therapeutic.

Simple Wound Irrigation in the Postoperative Treatment for Surgically Drained Spontaneous Soft Tissue Abscesses: A Prospective, Randomized Controlled Trial.

BACKGROUND: Soft tissue abscesses are among the most frequently encountered medical problems treated by different surgeons. Standard therapy remains incision and drainage with sterile saline irrigation during postoperative wound healing period. Aim of this prospective randomized controlled trial was to compare sterile irrigation versus nonsterile irrigation. STUDY DESIGN: A single center randomized controlled trial was performed to investigate postoperative wound irrigation. The control group used sterile irrigation, and the intervention group used nonsterile irrigation. Primary endpoints were reinfection and reintervention rates, assessed during follow-up controls for up to 2 years. Secondary endpoints were the duration of wound healing, inability to work, pain and quality of life. RESULTS: Between 04/2016 and 05/2017, 118 patients were randomized into two groups, with 61 allocated to the control- and 57 to the intervention group. Reinfection occurred in a total of 4 cases (6.6%) in the sterile protocol and 4 (7%) in the nonsterile protocol. Quality of life and pain values were comparable during the wound healing period, and patients treated according to the nonsterile irrigation protocol used significantly fewer wound care service teams. Despite equal wound persistence rates, a substantially shorter amount of time off from work was reported in the nonsterile protocol group (p value 0.086). CONCLUSION: This prospective, randomized trial indicates that a nonsterile irrigation protocol for patients operated on for soft tissue abscesses is not inferior to the standard sterile protocol. Moreover, a nonsterile irrigation protocol leads to a shorter period of inability to work with comparable pain and quality of life scores during the wound healing period.

Inter- and intra-observer variability of the AO/OTA classification for sternal fractures: a validation study.

INTRODUCTION: Recently, a new classification system for sternal fractures has been published in the Journal of Orthopedic trauma by the Arbeitsgemeinschaft für Osteosynthesefragen (AO) foundation and the Orthopaedic Trauma Association (OTA). The aim of this study was to evaluate inter- and intra-observer variability of the AO/OTA classification for sternal fractures. MATERIALS AND METHODS: Twenty multidetector computed tomography (CT) scans of patients with sternal fractures were classified independently by six senior and six junior orthopedic trauma surgeons of two level-1 trauma centers. Assessment was done on two occasions with an interval of 6 weeks. The kappa value was calculated to determine variability. RESULTS: The inter-observer variability of the AO/OTA classification for sternal fractures showed fair-to-moderate agreement (kappa = 0.364). There was no significant difference between junior and senior surgeons. Analyses of the separate components of the classification demonstrated that agreement was lowest for classifying fracture type within the sternal body (kappa = 0.319) followed by manubrium (kappa = 0.525). The intra-observer variability showed moderate agreement with a mean kappa of 0.414. CONCLUSION: The inter- and intra-observer variability of the AO/OTA classification for sternal fractures shows fair-to-moderate agreement. The overall performance of the classification might be improved with minor modifications. LEVEL OF EVIDENCE: Diagnostic cross-sectional study (level I).

Results of plate fixation for humerus fractures in a large single-center cohort.

INTRODUCTION: This study aims to describe the results of plate fixation in one of the largest single-center cohorts that employs plate fixation as the golden standard. Additionally, risk factors related to a negative outcome were identified. MATERIALS AND METHODS: This was a retrospective cohort study of all patients treated for a humeral shaft fracture in a level-one trauma center between January 2010 and December 2017 with a mean follow-up of 1 year. RESULTS: Plate fixation was performed in 102 patients with a humeral shaft fracture. The mean age was 50 (SD 20) years with 54.9% (n = 56) being male. Forty-eight percent (n = 48) had an AO type-A, 34.3% (n = 35) type-B, and 18.7% (n = 19) type-C fracture. Deep surgical site infections and non-union occurred in 1% (n = 1) and 3.9% (n = 4) of patients, respectively. Revision of the implant was performed in 15.7% (n = 16) mainly due to implant-related complaints. Only one patient developed radial nerve palsy after surgery. The median duration to radiological fracture healing and full-weight bearing was 18 (range 7-65) weeks and 14 (range 6-56) weeks, respectively. Risk factors for negative outcome included higher age, osteoporosis, open and higher AO class fractures, performing surgery during out-office hours, and the use of LCP 3.5-mm plate and an anterolateral approach. CONCLUSION: Plate fixation for humeral shaft fractures has low risks of complications. It should be emphasized that the complications can be further minimized with a greater surgical expertise and by refraining from performing a surgery during out-office hours.

The implementation of a Geriatric Fracture Centre for hip fractures to reduce mortality and morbidity: an observational study.

INTRODUCTION: The aim of this study was to evaluate the effect of an orthogeriatric treatment model on elderly patients with traumatic hip fractures (THF). The Geriatric Fracture Centre (GFC) is a multidisciplinary care pathway with attention for possible age-related diseases, discharge management and out-of-hospital treatment. MATERIALS AND METHODS: A prospective cohort study with a historical cohort group was conducted at a level I trauma centre in Switzerland. Patients over the age of 70 years with THFs who underwent surgical treatment at GFC in 2013 and 2016 were included. Primary outcomes were mortality and complications. Secondary outcomes were hospital length of stay (HLOS), time to surgery and place of discharge. RESULTS: A total of 322 patients were included in this study. In 2016, mortality showed a reduction of 2.9% at 30 days (p = 0.42) and 3.4% at 90 days (p = 0.42) and 0.1% at 1 year (p = 0.98). The number of patients with a complicated course showed a decrease of 2.2% in 2016 (p = 0.69). A significant increase in the diagnosis of delirium by 11.2% was seen in 2016 (p < 0.001). The median HLOS was significantly reduced by 2 days (p < 0.001). An increase of 21.1% was seen in patients who were sent to rehabilitation in 2016 (p < 0.001). Day-time surgery increased by 10.2% (p = 0.04). CONCLUSION: The implementation of the GFC leads to improved processes and outcomes for geriatric patients with THFs. Increased awareness and recognition led to an increase in the diagnosis of complications that would otherwise remain untreated. Expanding these efforts might lead to more significant effects and an increase in the reduction of morbidity and mortality in the future.

[Definitions and explanations on the topic of fracture reduction]. / Definitionen und Erklärungen zum Thema Frakturreposition.

The process of reduction is a key step for successful fracture treatment. The goal of fracture reduction is the realignment of the displaced fractured fragments caused by muscle tension or impaction back into the original anatomic relationship. The reduction process includes not only the application of force at or remote from the fracture site to reverse the deforming forces but also the preoperative planning where to apply these forces and by what means. Furthermore, consideration should be preoperatively given on how to position the patient and the C­arm and how to temporarily maintain reduction for intraoperative x­ray control of the axis, rotation and lengths before definitive fixation.

Criminal victimization and psychotic experiences: cross-sectional associations in 35 low- and middle-income countries.

OBJECTIVE: Criminal victimization has been associated with elevated risk for psychotic symptoms in the United Kingdom, but has not been studied in low- and middle-income countries (LMICs). Understanding whether crime exposure may play a role in the social etiology of psychosis could help guide prevention and intervention efforts. METHOD: We tested the hypothesis that criminal victimization would be associated with elevated odds of psychotic experiences in 35 LMICs (N = 146 999) using cross-sectional data from the World Health Organization World Health Survey. Multivariable logistic regression analyses were used to test for associations between criminal victimization and psychotic experiences. RESULTS: Victimization was associated with greater odds of psychotic experiences, OR (95% CI) = 1.72 (1.50-1.98), and was significantly more strongly associated with psychotic experiences in non-urban, OR (95% CI) = 1.93 (1.60-2.33), compared to urban settings, OR (95% CI) = 1.48 (1.21-1.81). The association between victimization and psychosis did not change across countries with varying aggregated levels of criminal victimization. CONCLUSIONS: In the largest ever study of victimization and psychosis, the association between criminal victimization and psychosis appears to generalize across a range of LMICs and, therefore, across nations with a broad range of crime rates, degree of urban development, average per capita income, and racial/ethnic make-up.

[Treatment of an osteo-fascio-cutaneous defect of the femur with a serial connected flow-through free-flap]. / Therapie eines osteo-fascio-cutanen Femurdefektes mit in Reihe geschalteter Durchflusslappenplastik.

Covering large osteo-fascio-cutaneous defects after debridement often calls for elaborate soft tissue reconstruction. Large tissue loss or structural damage that requires distinct repair is rarely coverable by a single conventional flap. Here, we report the case of serial flap coverage using sequentially connected fibular and latissimus dorsi free flaps.

Disease characteristics, treatment patterns, and outcomes of follicular lymphoma in patients 40 years of age and younger: an analysis from the National Lymphocare Study†.

BACKGROUND: Follicular lymphoma (FL) is the most common indolent non-Hodgkin lymphoma, with median age at diagnosis in the seventh decade. FL in young adults (YAs), defined as diagnosis at ≤40 years, is uncommon. No standard approaches exist guiding the treatment of YA FL, and little is known about their disease characteristics and outcomes. To gain further insights into YA FL, we analyzed the National LymphoCare Study (NLCS) to describe characteristics, initial treatments, and outcomes in this population versus patients aged >40 years. PATIENTS AND METHODS: Using the NLCS database, we stratified FL patients by age: 18-40 (YA), 41-60, 61-70, 71-80, and >80 years. Survival probability was estimated using Kaplan-Meier methodology. We examined associations between age and survival using hazard ratios and 95% confidence intervals (CIs) from multivariable Cox models. RESULTS: Of 2652 eligible FL patients in the NLCS, 164 (6%) were YAs. Of YA patients, 69% had advanced disease, 80% had low-grade histology, and 50% had good-risk disease according to the Follicular Lymphoma International Prognostic Index (FLIPI). Nineteen percent underwent observation, 12% received rituximab monotherapy, and 46% received chemoimmunotherapy [in 59% of these: R-CHOP (rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone)]. With a median follow-up of 8 years, overall survival (OS) at 2, 5, and 8 years was 98% (95% CI 93-99), 94% (95% CI 89-97), and 90% (95% CI 83-94), respectively. Median progression-free survival (PFS) was 7.3 years (95% CI 5.6-not reached). CONCLUSIONS: In one of the largest cohorts of YA FL patients treated in the rituximab era, disease characteristics and outcomes were similar to patients aged 41-60 years, with favorable OS and PFS in YAs. Longer-term outcomes and YA-specific survivorship concerns should be considered when defining management. These data may not support the need for more aggressive therapies in YA FL. CLINICAL TRIAL NUMBER: Roche/Genentech ML01377 (U2963n).

Conservative or operative therapy in patients with a fragility fracture of the pelvis: study protocol for a prospective, randomized controlled trial.

BACKGROUND: The incidence of fragility fractures of the pelvis is rising. Whereas the treatment for FFP type I, III, and IV is clear, the optimal treatment for FFP type II remains a topic of discussion. Traditionally these fractures have been treated conservatively. However, there is a shift toward early surgical stabilization with percutaneous screw fixation to reduce pain and promote mobility in an already frail patient population. High-quality evidence, however, is lacking. Therefore, a randomized clinical trial was designed to compare conservative management to early percutaneous screw fixation in patients with type II fragility fractures. METHODS: This is a monocenter randomized controlled trial. All patients with a FFP type II are screened for inclusion. After obtaining informed consent, patients are randomized between conservative management and surgical stabilization. Conservative management consists of early mobilization under guidance of physiotherapy and analgesics. Patients randomized for surgical treatment are operated on within 72 h using percutaneous screw fixation. The primary endpoint is mobility measured by the DEMMI score. Secondary endpoints are other dimensions of mobility, pain levels, quality of life, mortality, and morbidity. The total follow-up is 1 year. The required sample size is 68. DISCUSSION: The present study aims to give certainty on the potential benefit of surgical treatment. Current literature on this topic remains unclear. According to the volume of FFP at the study hospital, we assume that the number of patients needed for this study is gathered within 2 years. TRIAL REGISTRATION: ClinicalTrials.gov NCT04744350. Registered on February 8, 2021.

Examination of the follicular lymphoma international prognostic index (FLIPI) in the National LymphoCare study (NLCS): a prospective US patient cohort treated predominantly in community practices.

BACKGROUND: Because follicular lymphoma (FL) patients have heterogeneous outcomes, the FL international prognostic index (FLIPI) was developed to risk-stratify patients and to predict survival. However, limited data exist regarding the role of FLIPI in the era of routine first-line rituximab (R) and R-chemotherapy regimens and in the setting of community oncology practices. PATIENTS AND METHODS: We evaluated the outcome data from the National LymphoCare Study (NLCS), a prospective, observational cohort study, which collects data on patients with FL in the United States (US) community practices. RESULTS: Among 1068 male and 1124 female patients with FLIPI data, most were treated in US community practices (79%); 35% were FLIPI good risk, 30% intermediate risk, and 35% poor risk. FLIPI risk groups were significant predictors of overall survival (OS) and progression-free survival (PFS) for patients who undergo watchful waiting (WW), and those who receive non-R-containing regimens, R-alone, and R-chemotherapy combinations. CONCLUSIONS: In the setting of contemporary practice with routine R use, stratifying patients into good, intermediate, and poor FLIPI risk groups predicts distinct outcomes in terms of OS and PFS. FLIPI remains an important prognostic index in the R era and should be used in clinical practices to support discussions about prognosis.

Rituximab Chimeric Anti-CD20 Monoclonal Antibody Therapy for Relapsed Indolent Lymphoma: Half of Patients Respond to a Four-Dose Treatment Program.

PURPOSE: The CD20 antigen is expressed on more than 90% of B-cell lymphomas. It is appealing for targeted therapy, because it does not shed or modulate. A chimeric monoclonal antibody more effectively mediates host effector functions and is itself less immunogenic than are murine antibodies. PATIENTS AND METHODS: This was a multiinstitutional trial of the chimeric anti-CD20 antibody, IDEC-C2B8. Patients with relapsed low grade or follicular lymphoma received an outpatient treatment course of IDEC-C2B8 375 mg/m2 intravenously weekly for four doses. RESULTS: From 31 centers, 166 patients were entered. Of this intent-to-treat group, 48% responded. With a median follow-up duration of 11.8 months, the projected median time to progression for responders is 13.0 months. Serum antibody levels were sustained longer after the fourth infusion than after the first, and were higher in responders and in patients with lower tumor burden. The majority of adverse events occurred during the first infusion and were grade 1 or 2; fever and chills were the most common events. Only 12% of patients had grade 3 and 3% grade 4 toxicities. A human antichimeric antibody was detected in only one patient. CONCLUSION: The response rate of 48% with IDEC-C2B8 is comparable to results with single-agent cytotoxic chemotherapy. Toxicity was mild. Attention needs to be paid to the rate of antibody infusion, with titration according to toxicity. Further investigation of this agent is warranted, including its use in conjunction with standard chemotherapy.

Current concepts in fractures of the distal femur.

This paper describes current treatment strategies of distal femoral fractures as well as their evidence based rationale. The treatment of distal femoral fractures has improved with the evolution of plating and nailing technologies. The commonly selected surgical approaches are outlined and surgical treatment techniques including both internal and external fixation are discussed.

Percutaneous sacroiliac screw fixation in fragility fractures of the pelvis: Comparison of two different augmentation techniques.

OBJECTIVE: Fragility fractures of the pelvis (FFP) are becoming increasingly common. Percutaneous sacroiliac screw fixation is an accepted and safe treatment method for FFP. Augmentation is an option to optimize fixation strength of the screws. This study aims to compare patient mobility and the occurrence of complications after operative treatment of FFP utilizing two different augmentation techniques. METHODS: All patients who received augmented sacroiliac screws for the treatment of FFPs between 01.01.2017 and 31.12.2018 at one of the two participating hospitals were included. The operative techniques only differed with regards to the augmentation method used. At the one hospital cannulated screws were used. Definitive screw placement followed augmentation. At the other hospital cannulated and fenestrated screws were used, permitting definitive screw placement prior to augmentation. RESULTS: In total, 59 patients were included. The NRS score for pain was significantly lower after surgery. Preoperative mobility levels could be maintained or improved in 2/3 of the patients. There were no fatal complications. Two revision surgeries were performed because of screw misplacement. There were no significant differences between the two augmentation techniques in terms of complications. CONCLUSION: Both augmentation techniques have a low complication rate and are safe methods to maintain patients' mobility level. The authors advocate early consideration of surgical treatment for patients with FFP. Augmentation can be considered a safe addition when performing percutaneous sacroiliac screw fixation.

Long-term follow-up of patients with displaced scapular fractures managed surgically and non-operatively.

INTRODUCTION: Controversy remains on which patients with displaced scapula fractures benefit from surgery. This retrospective cohort study aims to compare and describe long-term patient-reported outcomes of patients with displaced scapula fractures treated both surgically and conservatively. METHODS: This study included patients with intra- and extra-articular scapula fractures, treated between 2010 and 2020 in a Swiss level 1 trauma centre. The decision to operate was based on standardized criteria for fracture displacement. Patients with isolated Bankart lesions (Ideberg 1) and process fractures (AO type 14-A) were excluded. Primary outcomes were functional patient reported measures (DASH score) and quality of life (EQ5D score). Secondary outcomes were complications, radiological union, satisfaction with treatment, pain and range of motion. RESULTS: Out of 486 cases, 74 patients had displaced scapula fractures. Forty patients were treated surgically and 34 were treated conservatively. Significantly more patients with intra-articular fractures and high-energy trauma were treated surgically. Fifty percent returned the questionnaires after a mean follow-up of 47 months (± SD 36). The mean DASH score of this group was 12 (SD 15.6), with a mean of 14.7 (SD 15.9) in the surgery group and 9.8 (SD 14.6) in the non-operative group (p = 0.7). Multivariate analysis did not show statistically significant correlating factors. No significant differences in quality of life were observed. Patients rated their treatment with a mean of 8.6/10 (SD 1.8). Among surgically treated patients, 19 underwent a deltoid sparing procedure with significant shorter time to union than those that underwent deltoid release (23 vs. 49 weeks, p<0.01). Complications occurred in 3/28 surgically treated patients and all three required a reoperation. CONCLUSION: In this cohort, functional results after conservative and surgical treatment were similar, despite more complex fractures and more intra-articular fractures being treated surgically. Osteosynthesis of both intra- and extra-articular scapula fractures is safe and leads to good functional results, furthermore, new minimal invasive techniques may lead to faster bone healing and return to work and sports.

Trauma mechanism and patient reported outcome in tibial plateau fractures with posterior involvement.

INTRODUCTION: Posterior tibial plateau fractures (PTPF) have a high impact on functional outcome and the optimal treatment strategy is not well established. The goal of this study was to assess the relationship between trauma mechanism, fracture morphology and functional outcome in a large multicenter cohort and define possible strategies to improve the outcome. METHODS: An international retrospective cohort study was conducted in five level-1 trauma centers. All consecutive operatively treated PTPF were evaluated. Preoperative imaging was reviewed to determine the trauma mechanism. Patient reported outcome was scored using the Knee injury and Osteoarthritis Outcome Score (KOOS). RESULTS: A total of 145 tibial plateau fractures with posterior involvement were selected with a median follow-up of 32.2 months (IQR 24.1-43.2). Nine patients (6%) sustained an isolated posterior fracture. Seventy-two patients (49%) sustained a two-column fracture and three-column fractures were diagnosed in 64 (44%) patients. Varus trauma was associated with poorer outcome on the 'symptoms' (p = 0.004) and 'pain' subscales (p = 0.039). Delayed-staged surgery was associated with worse outcome scores for all subscales except 'pain'. In total, 27 patients (18%) were treated with posterior plate osteosynthesis without any significant difference in outcome. CONCLUSIONS: Fracture morphology, varus trauma mechanism and delayed-staged surgery (i.e. extensive soft-tissue injury) were identified as important prognostic factors on postoperative outcome in PTPF. In order to assess possible improvement of outcome, future studies with routine preoperative MRI to assess associated ligamentous injury in tibial plateau fractures (especially for varus trauma) are needed.

Plate vs. nail for extra-articular distal tibia fractures: How should we personalize surgical treatment? A meta-analysis of 1332 patients.

BACKGROUND: Treatment for distal diaphyseal or metaphyseal tibia fractures is challenging and the optimal surgical strategy remains a matter of debate. The purpose of this study was to compare plate fixation with nailing in terms of operation time, non-union, time-to-union, mal-union, infection, subsequent re-interventions and functional outcomes (quality of life scores, knee- and ankle scores). METHODS: A search was performed in PubMed/Embase/CINAHL/CENTRAL for all study designs comparing plate fixation with intramedullary nailing (IMN). Data were pooled using RevMan and presented as odds ratios (OR), risk difference (RD), weighted mean difference (WMD) or weighted standardized mean difference (WSMD) with a 95% confidence interval (95%CI). All analyzes were stratified for study design. RESULTS: A total of 15 studies with 1332 patients were analyzed, including ten RCTs (n = 873) and five observational studies (n = 459). IMN leads to a shorter time-to-union (WMD: 0.4 months, 95%CI 0.1 - 0.7), shorter time-to-full-weightbearing (WMD: 0.6 months, 95%CI 0.4 - 0.8) and shorter operation duration (WMD: 15.5 min, 95%CI 9.3 - 21.7). Plating leads to a lower risk for mal-union (RD: -10%, OR: 0.4, 95%CI 0.3 - 0.6), but higher risk for infection (RD: 8%, OR: 2.4, 95%CI 1.5 - 3.8). No differences were detected with regard to non-union (RD: 1%, OR: 0.7, 95%CI 0.3 - 1.7), subsequent re-interventions (RD: 4%, OR: 1.3, 95%CI 0.8 - 1.9) and functional outcomes (WSMD: -0.4, 95%CI -0.9 - 0.1). The effect estimates of RCTs and observational studies were equal for all outcomes except for time to union and mal-union. CONCLUSION: Satisfactory results can be obtained with both plate fixation and nailing for distal extra-articular tibia fractures. However, nailing is associated with higher rates of mal-union and anterior knee pain while plate fixation results in an increased risk of infection. This study provides a guideline towards a personalized approach and facilitates shared decision-making in surgical treatment of distal extra-articular tibia fractures. The definitive treatment should be case-based and aligned to patient-specific needs in order to minimize the risk of complications.