Fractures and other chest wall abnormalities after thoracotomy for esophageal cancer: A retrospective cohort study.

BACKGROUND: Chest pain following a thoracotomy for esophageal cancer is frequently reported but poorly understood. This study aimed to (1) determine the prevalence of thoracotomy-related thoracic fractures on postoperative imaging and (2) compare complications, long-term pain, and quality of life in patients with versus without these fractures. METHODS: This retrospective cohort study enrolled patients with esophageal cancer who underwent a thoracotomy between 2010 and 2020 with pre- and postoperative CTs (<1 and/or >6 months). Disease-free patients were invited for questionnaires on pain and quality of life. RESULTS: Of a total of 366 patients, thoracotomy-related rib fractures were seen in 144 (39%) and thoracic transverse process fractures in 4 (2%) patients. Patients with thoracic fractures more often developed complications (89% vs. 74%, p = 0.002), especially pneumonia (51% vs. 39%, p = 0.032). Questionnaires were completed by 77 after a median of 41 (P25 -P75 28-91) months. Long-term pain was frequently (63%) reported but was not associated with thoracic fractures (p = 0.637), and neither were quality of life scores. CONCLUSIONS: Thoracic fractures are prevalent in patients following a thoracotomy for esophageal cancer. These thoracic fractures were associated with an increased risk of postoperative complications, especially pneumonia, but an association with long-term pain or reduced quality of life was not confirmed.

In Vitro Elution of Gentamicin from CERAMENT® G Has an Antimicrobial Effect on Bacteria With Various Levels of Gentamicin Resistance Found in Fracture-related Infection.

BACKGROUND: Fracture-related infection is a serious complication after trauma. CERAMENT® G combines dead-space management with local release of gentamicin in a single-stage procedure. Bacterial resistance against antibiotics is increasing. The local effect of CERAMENT® G on bacteria resistant to systemically administered gentamicin is unknown. QUESTIONS/PURPOSES: (1) What is the in vitro elution pattern of gentamicin from CERAMENT® G using a full washout model? (2) What is the in vitro antimicrobial activity (zone of inhibition) of CERAMENT® G against bacterial isolates found in fracture-related infection with different susceptibility levels toward gentamicin? METHODS: Elution of gentamicin from CERAMENT® G was determined in vitro over a period of 2 months. Elution experiments were performed in fivefold, with gentamicin being sampled in threefold at 19 different timepoints within 2 months. Antimicrobial activity was determined using the four most-frequently cultured bacterial species found in fracture-related infection: Staphylococcus aureus, Staphylococcus epidermidis, Pseudomonas aeruginosa, and Enterobacter cloacae . For each of the species, four different isolates with a different susceptibility to gentamicin were used. According to the European Committee on Antimicrobial Susceptibility Testing, the susceptibility of each isolate was classified into four different groups: fully susceptible (minimum inhibitory concentration 0.064 to 4 mg/L), minimally resistant (minimum inhibitory concentration 4 to 16 mg/L), moderately resistant (minimum inhibitory concentration 8 to 96 mg/L), and highly resistant (minimum inhibitory concentration 24 to 1024 mg/L), depending on each organism. The antimicrobial activity of CERAMENT® G was determined according to the European Committee on Antimicrobial Susceptibility Testing disk protocol. The experiment was performed in fivefold for each isolate. The zone of inhibition was compared between each bacterial isolate and within each of the four separate species. Nonlinear regression statistics were calculated between the zone of interest and logarithmic minimum inhibitory concentration for each bacterial species. RESULTS: After 24 hours, 95% of all available gentamicin was eluted, and gentamicin was still detectable after 2 months. CERAMENT® G showed antimicrobial activity against all bacterial species; only S taphylococcus aureus (with a minimum inhibitory concentration > 1024 mg/L) was not susceptible. The zone of interest of the different bacterial isolates was correlated with the logarithmic minimum inhibitory concentration. CONCLUSION: CERAMENT® G offers a bone substitute capable of releasing high levels of gentamicin within a short period of time. This study shows that CERAMENT® G has antimicrobial activity against bacterial isolates that are resistant to gentamicin when systemically administered. This finding raises the question of whether European Committee on Antimicrobial Susceptibility Testing cutoff points for systemic application are useful for the use of local CERAMENT® G. Standardized experiments to determine local antibiotic antimicrobial activity in fracture-related infection treatment are needed to form guidelines for the use of local antibiotics and ultimately improve fracture-related infection treatment. CLINICAL RELEVANCE: Local concentrations of gentamicin with CERAMENT® G are much higher than when systemically administered. It seems effective against certain bacterial strains that are not affected by systemically reachable concentrations of gentamicin. CERAMENT® G might still be effective when bacteria that are resistant to systemically administered concentrations of gentamicin are occulated from patients with fracture-related infection.

Rib Fixation for Multiple Rib Fractures: Healthcare Professionals Perceived Barriers and Facilitators to Clinical Implementation.

BACKGROUND: Surgical stabilization of rib fractures (SSRF) is associated with improved respiratory symptoms and shorter intensive care admission in patients with flail chest. For multiple rib fractures, the benefit of SSRF remains a topic of debate. This study investigated barriers and facilitators of healthcare professionals to SSRF as treatment for multiple traumatic rib fractures. METHODS: Dutch healthcare professionals were asked to complete an adapted version of the Measurement Instrument for Determinants of Innovations questionnaire to identify barriers and facilitators of SSRF. If ≥ 20% of participants responded negatively, the item was considered a barrier, and if ≥ 80% responded positively, the item was considered a facilitator. RESULTS: Sixty-one healthcare professionals participated; 32 surgeons, 19 non-surgical physicians, and 10 residents. The median experience was 10 years (P25-P75 4-12). Sixteen barriers and two facilitators for SSRF in multiple rib fractures were identified. Barriers included lack of knowledge, experience, evidence on (cost-)effectiveness, and the implication of more operations and higher medical costs. Facilitators were the assumption that SSRF alleviates respiratory problems and the feeling that surgeons are supported by colleagues for SSRF. Non-surgeons and residents reported more and several different barriers than surgeons (surgeons: 14; non-surgical physicians: 20; residents: 21; p < 0.001). CONCLUSION: For adequate implementation of SSRF in patients with multiple rib fractures, implementation strategies should address the identified barriers. Especially, improved clinical experience and scientific knowledge of healthcare professionals, and high-level evidence on the (cost-) effectiveness of SSRF potentially increase its use and acceptance.

Short-term and long-term increased mortality in elderly patients with burn injury: a national longitudinal cohort study.

BACKGROUND: The population of elderly patients with burn injuries is growing. Insight into long-term mortality rates of elderly after burn injury and predictors affecting outcome is limited. This study aimed to provide this information. METHODS: A multicentre observational retrospective cohort study was conducted in all three Dutch burn centres. Patients aged ≥65 years, admitted with burn injuries between 2009 and 2018, were included. Data were retrieved from electronic patient records and the Dutch Burn Repository R3. Mortality rates and standardized mortality ratios (SMRs) were calculated. Multivariable logistic regression was used to assess predictors for in-hospital mortality and mortality after discharge at 1 year and five-year. Survival analysis was used to assess predictors of five-year mortality. RESULTS: In total, 682/771 admitted patients were discharged. One-year and five-year mortality rates were 8.1 and 23.4%. The SMRs were 1.9(95%CI 1.5-2.5) and 1.4(95%CI 1.2-1.6), respectively. The SMRs were highest in patients aged 75-80 years at 1 year (SMRs 2.7, 95%CI 1.82-3.87) and five-year in patients aged 65-74 years (SMRs 10.1, 95%CI 7.7-13.0). Independent predictors for mortality at 1 year after discharge were higher age (OR 1.1, 95%CI 1.0-1.1), severe comorbidity, (ASA-score ≥ 3) (OR 4.8, 95%CI 2.3-9.7), and a non-home discharge location (OR 2.0, 95%CI 1.1-3.8). The relative risk of dying up to five-year was increased by age (HR 1.1, 95%CI 1.0-1.1), severe comorbidity (HR 2.3, 95%CI 1.6-3.5), and non-home discharge location (HR 2.1, 95%CI 1.4-3.2). CONCLUSION: Long-term mortality until five-year after burn injury was higher than the age and sex-matched general Dutch population, and predicted by higher age, severe comorbidity, and a non-home discharge destination. Next to pre-injury characteristics, potential long-lasting systemic consequences on biological mechanisms following burn injuries probably play a role in increased mortality. Decreased health status makes patients more prone to burn injuries, leading to early death.

Surgical management of bifocal femoral fractures: a systematic review and pooled analysis of treatment with a single implant versus double implants.

INTRODUCTION: Fractures of the proximal femur accompanied by a fracture of the femoral shaft are relatively rare, with a reported prevalence between 1 and 12%. Multiple surgical options are available, consisting of treatment with a single implant or with double implants. Controversy exists about the optimal management. A systematic review and pooled analysis were performed to assess the most reliable treatment for bifocal femoral fractures of the femur. MATERIALS AND METHODS: A literature search was conducted on July 15, 2022. Selected studies were screened on title and abstract by two researchers independently, and full texts were read by both authors. Emphasis was put on adverse events such as postoperative infection, healing complications, malalignment, and functional outcome using either a single implant or double implants. RESULTS: For the proximal femoral fractures, no significant difference could be confirmed for avascular necrosis of the femoral neck (5.1% for single implant and 3.8% for double implants), nonunion (6.4% for single implant and 7.8% for double implants), or varus malalignment (6.6% for single implant and 10.9% for double implants). This study also suggests that the number of implants is irrelevant for complications of the femoral shaft regarding the rates of postoperative infection and healing complications. Pooled rates of bone healing complications were 1.6-2.7-fold higher when patients were treated with a single implant, but statistical significance could not be confirmed. For hardware failure, revision surgery, leg length discrepancy, and functional outcome, no difference between the two groups was found either. CONCLUSIONS: The pooled proportions of all postoperative complications had overlapping confidence intervals; thus, no inference about a statistically significant difference on the number of implants used for treating ipsilateral fractures of the femur can be made. Both treatment groups showed a similar functional outcome at the last moment of follow-up, with more than 75% of the patients reporting a good outcome.

Humeral shaft fracture: systematic review of non-operative and operative treatment.

INTRODUCTION: Humeral shaft fractures can be treated non-operatively or operatively. The optimal management is subject to debate. The aim was to compare non-operative and operative treatment of a humeral shaft fracture in terms of fracture healing, complications, and functional outcome. METHODS: Databases of Embase, Medline ALL, Web-of-Science Core Collection, and the Cochrane Central Register of Controlled Trials (CENTRAL) were systematically searched for publications reporting clinical and functional outcomes of humeral shaft fractures after non-operative treatment with a functional brace or operative treatment by intramedullary nailing (IMN; antegrade or retrograde) or plate osteosynthesis (open plating or minimally invasive). A pooled analysis of the results was performed using MedCalc. RESULTS: A total of 173 studies, describing 11,868 patients, were included. The fracture healing rate for the non-operative group was 89% (95% confidence interval (CI) 84-92%), 94% (95% CI 92-95%) for the IMN group and 96% (95% CI 95-97%) for the plating group. The rate of secondary radial nerve palsies was 1% in patients treated non-operatively, 3% in the IMN, and 6% in the plating group. Intraoperative complications and implant failures occurred more frequently in the IMN group than in the plating group. The DASH score was the lowest (7/100; 95% CI 1-13) in the minimally invasive plate osteosynthesis group. The Constant-Murley and UCLA shoulder score were the highest [93/100 (95% CI 92-95) and 33/35 (95% CI 32-33), respectively] in the plating group. CONCLUSION: This study suggests that even though all treatment modalities result in satisfactory outcomes, operative treatment is associated with the most favorable results. Disregarding secondary radial nerve palsy, specifically plate osteosynthesis seems to result in the highest fracture healing rates, least complications, and best functional outcomes compared with the other treatment modalities.

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

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

Activities of daily living in lower limb amputees with a bone-anchored prosthesis: a retrospective case series with 24 months' follow-up.

BACKGROUND AND PURPOSE: Little is known about the activities of daily living (ADL) of patients with a bone-anchored prosthesis (BAP). We aimed to objectively measure ADL without and with BAP during standard care of follow-up. Our secondary aim was to measure mobility and walking ability. PATIENTS AND METHODS: Patients aged 18-99 years who underwent surgery for transfemoral or transtibial BAP between September 11, 2017, and February 11, 2021, were eligible for inclusion in this retrospective case series of patients with socket prosthesis. ADL was measured with a continuous recording activity monitor (hours [h]) before surgery, and at 6, 12, and 24 months with BAP. Mobility and walking ability were assessed by the Timed Up and Go test (TUG) (seconds [s]) and 6 Minute Walk Test (6MWT) (meters [m]), respectively. RESULTS: 48 of the 57 eligible patients provided informed consent and were included. Their age was 59 (1st quartile to 3rd quartile 51-63) years. Total daily activity before BAP was 1.6 h (0.82-2.1) and increased to 2.1 h (1.4-2.5) at 6, 2.0 h (1.5-2.7) at 12, and 2.7 h (2.0-3.3) at 24 months with BAP. Daily walking increased from 1.3 h (0.79-1.9) before BAP to 1.8 h (1.6-2.3) at 6, to 1.7 h (1.2-2.4) at 12, and 2.0 h (1.6-2.6) at 24 months. Median TUG decreased from 12 s (9.1-14) before BAP to 8.9 s (7.7-10) at 24 months. Mean 6MWT increased from 272 m (SD 92) before BAP to 348 m (SD 68) at 24 months. CONCLUSION: Objective measurements on ADL positively changed in patients with BAP. This effect was also seen in mobility and walking ability at 24 months.

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

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

The impact of upper-extremity injuries on polytrauma patients at a level 1 trauma center.

BACKGROUND: Upper-extremity injuries often lead to long-term problems in function and quality of life in patients. However, not much is known about the effects in polytrauma patients. This study aimed to describe the upper-extremity injuries in polytrauma patients and to compare self-reported disability and quality of life in polytrauma patients with vs. without upper-extremity injuries. METHODS: We performed a retrospective cohort study of adult patients with an Injury Severity Score ≥ 16 admitted to Erasmus MC between January 1, 2007, and December 31, 2016. Patients were asked to complete the Disabilities of the Arm, Shoulder and Hand, Short Form 36, and EuroQol-5D questionnaires. Details on injuries, treatment, and clinical outcome were collected from the national trauma registry and medical files. Characteristics and self-reported outcomes of polytrauma patients with vs. without upper-extremity injuries were compared. RESULTS: In a cohort of 3469 trauma patients, 1246 (36.5%) had upper-extremity injuries. Of these, 278 (22.0%) had severe injuries (Abbreviated Injury Scale score ≥ 3). Upper-extremity injuries were associated with a longer hospitalization (median, 12 days vs. 8 days; P < .001), longer intensive care unit stay (median, 5 days vs. 4 days; P = .005), and lower mortality rate (14.6% vs. 23.9%, P < .001). Among the 598 patients who completed the questionnaires, no differences in the physical component summary score (47 vs. 48, P = .181) and mental component summary score (54 vs. 53, P = .315) of the Short Form 36 questionnaire, as well as the utility score (0.82 vs. 0.85, P = .101) and visual analog scale score (80 vs. 80, P = .963) of the EuroQol-5D questionnaire, were found. However, patients with upper-extremity injuries showed a minor increase in disability in the Disabilities of the Arm, Shoulder and Hand score (9.2 vs. 4.2, P = .023). CONCLUSION: Upper-extremity injuries in polytrauma patients are associated with a longer hospitalization, longer intensive care unit stay, and reduced mortality rate, as well as a minor increase in long-term disability.

Fracture-related outcome study for operatively treated tibia shaft fractures (F.R.O.S.T.): registry rationale and design.

BACKGROUND: Tibial shaft fractures (TSFs) are among the most common long bone injuries often resulting from high-energy trauma. To date, musculoskeletal complications such as fracture-related infection (FRI) and compromised fracture healing following fracture fixation of these injuries are still prevalent. The relatively high complication rates prove that, despite advances in modern fracture care, the management of TSFs remains a challenge even in the hands of experienced surgeons. Therefore, the Fracture-Related Outcome Study for operatively treated Tibia shaft fractures (F.R.O.S.T.) aims at creating a registry that enables data mining to gather detailed information to support future clinical decision-making regarding the management of TSF's. METHODS: This prospective, international, multicenter, observational registry for TSFs was recently developed. Recruitment started in 2019 and is planned to take 36 months, seeking to enroll a minimum of 1000 patients. The study protocol does not influence the clinical decision-making procedure, implant choice, or surgical/imaging techniques; these are being performed as per local hospital standard of care. Data collected in this registry include injury specifics, treatment details, clinical outcomes (e.g., FRI), patient-reported outcomes, and procedure- or implant-related adverse events. The minimum follow up is 12 months. DISCUSSION: Although over the past decades, multiple high-quality studies have addressed individual research questions related to the outcome of TSFs, knowledge gaps remain. The scarcity of data calls for an international high-quality, population-based registry. Creating such a database could optimize strategies intended to prevent severe musculoskeletal complications. The main purpose of the F.R.O.S.T registry is to evaluate the association between different treatment strategies and patient outcomes. It will address not only operative techniques and implant materials but also perioperative preventive measures. For the first time, data concerning systemic perioperative antibiotic prophylaxis, the influence of local antimicrobials, and timing of soft-tissue coverage will be collected at an international level and correlated with standardized outcome measures in a large prospective, multicenter, observational registry for global accessibility. TRIAL REGISTRATION: ClinicalTrials.gov : NCT03598530 .

Computer-Controlled Cooling in Operatively Treated Ankle or Hindfoot Fractures: A Retrospective Case-Control Study.

Ankle and hindfoot fractures are often associated with a considerable amount of pain and need for systemic analgesics. Cooling devices have been developed to reduce swelling, pain, analgesics need, and complications. The primary aim was to examine the effect of cooling versus no cooling on pain levels in adult patients treated operatively for an ankle or hindfoot fracture. Secondary aims were to assess the effect of cooling on (1) analgesics use, (2) patient satisfaction, (3) hospital length of stay (HLOS), (4) the rate of complications, and (5) the rate of secondary interventions. In this single center, retrospective case-control study patients who used a computer-controlled cooling device before and after surgery of an ankle or hindfoot fracture between January 1, 2015 and January 1, 2017 were included. Matched patients without using cooling served as control. Patient, injury and treatment characteristics, pain scores and analgesics use during hospital admission were extracted from patient's medical files. Pain scores in the cooling group (18 patients) did not statistically differ from the non-cooling group (17 patients). After surgery, less patients in the cooling group used paracetamol (p = .041), and nonsteroidal anti-inflammatory drugs (p = .006). Patient satisfaction of both groups was eight out of ten points. The total HLOS was 14 days (P25-P75 9.0-17.3) in the cooling group and 9 days (P25-P75 5.0-16.5) in the non-cooling group. This was mostly contributable to the difference in preoperative HLOS (8 days; P25-P75 4.8-13.0 versus 4 days; P25-P75 2.0-7.0) and time to surgery (13.5 days; P25-P75 9.3-16.3) versus 8 days; P25-P75 2.5-12.0). Complications and revision surgery did not differ. Patients with ankle or hindfoot fractures seem to benefit from computer-controlled cooling, since equal pain sensation is feasible with less analgesics postoperatively, whereas rates of complications and revision surgeries were comparable in both groups. Patients were highly satisfied with cooling.

Rasch analysis of the Disabilities of the Arm, Shoulder and Hand (DASH) instrument in patients with a humeral shaft fracture.

BACKGROUND: The Disabilities of the Arm, Shoulder and Hand (DASH) instrument was developed to assess the disability experienced by patients with any musculoskeletal condition of the upper extremity and to monitor change in symptoms and upper-limb function over time. The 30 items are scored on a 5-point rating scale. The Dutch-language version of the DASH instrument (DASH-DLV) has been examined with the classical test theory in patients with a humeral shaft fracture. This study aimed to examine the DASH-DLV with a more rigorous and extensive analysis by applying the Rasch model. METHODS: Data of 400 patients included in a multicenter, prospective study comparing operative and nonoperative treatment of adult patients with a humeral shaft fracture were used. The person-item map, item fit statistics, reliability, response category ordering, and dimensionality were examined. Raw data were converted to linear measures using the Rasch model. RESULTS: The DASH-DLV showed a good fit to the Rasch model, except for item 26 ("Tingling [pins and needles] in your arm, shoulder or hand"). The person reliability was 0.92. In general, the category functioning of the 5-point rating scale was working well. Dimensionality analysis revealed that the DASH-DLV is a unidimensional scale. Differential item functioning for sex was not detected, and only item 26 exhibited differential item functioning as a function for age. CONCLUSION: The DASH-DLV fits the stringent Rasch model in a clinical situation with a group of adult patients with a humeral shaft fracture. Adequate measurement for scientific research can be obtained to evaluate longitudinal intervention research.

Early mobilization versus plaster immobilization of simple elbow dislocations: a cost analysis of the FuncSiE multicenter randomized clinical trial.

INTRODUCTION: The primary aim was to assess and compare the total costs (direct health care costs and indirect costs due to loss of production) after early mobilization versus plaster immobilization in patients with a simple elbow dislocation. It was hypothesized that early mobilization would not lead to higher direct and indirect costs. MATERIALS AND METHODS: This study used data of a multicenter randomized clinical trial (FuncSiE trial). From August 25, 2009 until September 18, 2012, 100 adult patients with a simple elbow dislocation were recruited and randomized to early mobilization (immediate motion exercises; n = 48) or 3 weeks plaster immobilization (n = 52). Patients completed questionnaires on health-related quality of life [EuroQoL-5D (EQ-5D) and Short Form-36 (SF-36 PCS and SF-36 MCS)], health care use, and work absence. Follow-up was 1 year. Primary outcome were the total costs at 1 year. Analysis was by intention to treat. RESULTS: There were no significant differences in EQ-5D, SF-36 PCS, and SF-36 MCS between the two groups. Mean total costs per patient were €3624 in the early mobilization group versus €7072 in the plaster group (p = 0.094). Shorter work absenteeism in the early mobilization group (10 versus 18 days; p = 0.027) did not lead to significantly lower costs for loss of productivity (€1719 in the early mobilization group versus €4589; p = 0.120). CONCLUSION: From a clinical and a socio-economic point of view, early mobilization should be the treatment of choice for a simple elbow dislocation. Plaster immobilization has inferior results at almost double the cost.

General treatment principles for fracture-related infection: recommendations from an international expert group.

Fracture-related infection (FRI) remains a challenging complication that creates a heavy burden for orthopaedic trauma patients, their families and treating physicians, as well as for healthcare systems. Standardization of the diagnosis of FRI has been poor, which made the undertaking and comparison of studies difficult. Recently, a consensus definition based on diagnostic criteria for FRI was published. As a well-established diagnosis is the first step in the treatment process of FRI, such a definition should not only improve the quality of published reports but also daily clinical practice. The FRI consensus group recently developed guidelines to standardize treatment pathways and outcome measures. At the center of these recommendations was the implementation of a multidisciplinary team (MDT) approach. If such a team is not available, it is recommended to refer complex cases to specialized centers where a MDT is available and physicians are experienced with the treatment of FRI. This should lead to appropriate use of antimicrobials and standardization of surgical strategies. Furthermore, an MDT could play an important role in host optimization. Overall two main surgical concepts are considered, based on the fact that fracture fixation devices primarily target fracture consolidation and can be removed after healing, in contrast to periprosthetic joint infection were the implant is permanent. The first concept consists of implant retention and the second consists of implant removal (healed fracture) or implant exchange (unhealed fracture). In both cases, deep tissue sampling for microbiological examination is mandatory. Key aspects of the surgical management of FRI are a thorough debridement, irrigation with normal saline, fracture stability, dead space management and adequate soft tissue coverage. The use of local antimicrobials needs to be strongly considered. In case of FRI, empiric broad-spectrum antibiotic therapy should be started after tissue sampling. Thereafter, this needs to be adapted according to culture results as soon as possible. Finally, a minimum follow-up of 12 months after cessation of therapy is recommended. Standardized patient outcome measures purely focusing on FRI are currently not available but the patient-reported outcomes measurement information system (PROMIS) seems to be the preferred tool to assess the patients' short and long-term outcome. This review summarizes the current general principles which should be considered during the whole treatment process of patients with FRI based on recommendations from the FRI Consensus Group.Level of evidence: Level V.

The Influence of Radiograph Obliquity on Böhler's and Gissane's Angles in Calcanei.

In calcaneal fractures, Böhler's and Gissane's angles are considered important parameters to guide treatment strategy and provide prognostic information during follow-up visits. Therefore, lateral radiographs have to be accurate. The aim of this study was to evaluate the effect of craniocaudal and posteroanterior angular variations (i.e., simulate lower leg malposition) from the true lateral radiograph on Böhler's and Gissane's angles. In this radioanatomical study, 15 embalmed, skeletally mature, human anatomic lower limb specimens were used. Using predefined criteria, a true lateral radiograph (i.e., 0° angular variation) was obtained. Angular variations from this true lateral radiograph were made from -30° to +30° deviation in the craniocaudal and posteroanterior direction at 5° intervals. Böhler's and Gissane angles were independently assessed by 2 experienced trauma surgeons. Böhler's angle decreased with increasing caudal angular variations (maximum -4.3° deviation at -30°). With increasing of the posterior angular variations, Böhler's angle increased (maximum 5.0° deviation at +30°) from the true lateral radiograph, but all deviations were within the measurement error. The deviation of the angle of Gissane was most pronounced in the cranial direction, with the mean angle decreasing by -8.8° at +30° angular variation. Varying angular obliquity in the caudal and posteroanterior direction hardly affected Gissane's angle. Foot malpositioning during the making of a lateral radiograph has little influence on Böhler's and Gissane's angles. If used for clinical decision-making in initial treatment and during follow-up of calcaneal fractures, these parameters can reliably be obtained from any lateral radiograph.

Health care and productivity costs for isolated tibia shaft fracture admissions in The Netherlands.

The aim of this study was to provide a detailed overview of age and gender specific health care costs and costs due to lost productivity for hospital admitted patients with an isolated tibia shaft fracture in The Netherlands between 2008 and 2012. Injury cases and length of hospital stay were extracted from the National Medical Registration. Information on extramural health care and work absence were retrieved from a patient follow-up survey on health care use. Medical costs included ambulance care, in- hospital care, general practitioner care, home care, physical therapy, and rehabilitation/nursing care. An incidence-based cost model was applied to calculate direct health care costs and lost productivity in 2012. Total direct health care costs for all patients admitted with a tibia shaft fracture (n = 1,635) were €13.6 million. Costs for productivity loss were € 23.0 million. Total costs (direct health care and lost productivity) per patient were highest for men aged 40-49 years mainly due to lost productivity, and for women aged > 80 years, due to high direct medical costs.

An infrapatellar nerve block reduces knee pain in patients with chronic anterior knee pain after tibial nailing: a randomized, placebo-controlled trial in 34 patients.

Background and purpose - Anterior knee pain is common after tibial nailing. Its origin is poorly understood. Injury of the infrapatellar nerve is a possible cause. In this randomized controlled trial we compared changes in knee pain after an infrapatellar nerve block with lidocaine or placebo in patients with persistent knee pain after tibial nailing. Patients and methods - Patients with chronic knee pain after tibial nailing were randomized to an infrapatellar nerve block with 5 ml 2% lidocaine or placebo (sodium chloride 0.9%), after which they performed 8 daily activities. Before and after these activities, pain was recorded using a numeric rating scale (NRS; 0-10). Primary endpoint was the change in pain during kneeling after the infrapatellar nerve block. Secondary outcomes were changes in pain after the nerve block during the other activities. Results - 34 patients (age 18-62 years) were equally randomized. A significant reduction of the NRS for kneeling pain with an infrapatellar nerve block with lidocaine was found compared with placebo (-4.5 [range -10 to -1] versus -1 [-9 to 2]; p = 0.002). There were no differences between the treatments for the NRS values for pain during other activities. Interpretation - Compared with placebo, an infrapatellar nerve block with lidocaine was more effective in reducing pain during kneeling in patients with chronic knee pain after tibial nailing. Our findings support the contention that kneeling pain after tibial nailing is a peripheral nerve-related problem.

A Physician-Based Helicopter Emergency Medical Services Was Associated With an Additional 2.5 Lives Saved per 100 Dispatches of Severely Injured Pediatric Patients.

OBJECTIVE: Physician-based helicopter emergency medical services (HEMS) provide specialist medical care to the accident scene in order to improve the survival of severely injured patients. Studies that focus on the role of physician-based HEMS in pediatric trauma are scarce. The aim of this retrospective, observational study was to determine the effect of physician-based HEMS assistance on the survival of severely injured pediatric patients. METHODS: All consecutive severely injured pediatric patients (age < 18 years and Injury Severity Score > 15) treated between October 1, 2000, and February 28, 2013, were included. The survival of patients who received medical care of physician-based HEMS was compared with the survival of patients treated by an ambulance paramedic crew (ie, emergency medical services group) only. A regression model was developed for calculating the survival benefit in the physician-based HEMS group. RESULTS: A total of 308 patients were included; 112 (36%) were primarily treated by emergency medical services, and 196 (64%) patients received additional physician-based HEMS assistance on scene. The model with the best diagnostic properties and fit contained physician-based HEMS assistance, 3 components of the Glasgow Coma Scale (eye, motor, and verbal) scored prehospitally (before intubation), ordinal values for the Injury Severity Scale, systolic blood pressure, and respiratory rate. This model predicted that 5 additional patients survived because of physician-based HEMS assistance. This corresponds with 2.5 additional lives saved per 100 physician-based HEMS dispatches for severely injured pediatric patients. CONCLUSION: The data suggest that an additional 2.5 lives might be saved per 100 physician-based HEMS dispatches for severely injured pediatric patients.

Early mobilisation versus plaster immobilisation of simple elbow dislocations: results of the FuncSiE multicentre randomised clinical trial.

BACKGROUND/AIM: To compare outcome of early mobilisation and plaster immobilisation in patients with a simple elbow dislocation. We hypothesised that early mobilisation would result in earlier functional recovery. METHODS: From August 2009 to September 2012, 100 adult patients with a simple elbow dislocation were enrolled in this multicentre randomised controlled trial. Patients were randomised to early mobilisation (n=48) or 3 weeks plaster immobilisation (n=52). Primary outcome measure was the Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) score. Secondary outcomes were the Oxford Elbow Score, Mayo Elbow Performance Index, pain, range of motion, complications and activity resumption. Patients were followed for 1 year. RESULTS: Quick-DASH scores at 1 year were 4.0 (95% CI 0.9 to 7.1) points in the early mobilisation group versus 4.2 (95% CI 1.2 to 7.2) in the plaster immobilisation group. At 6 weeks, early mobilised patients reported less disability (Quick-DASH 12 (95% CI 9 to 15) points vs 19 (95% CI 16 to 22); p<0.05) and had a larger arc of flexion and extension (121° (95% CI 115° to 127°) vs 102° (95% CI 96° to 108°); p<0.05). Patients returned to work sooner after early mobilisation (10 vs 18 days; p=0.020). Complications occurred in 12 patients; this was unrelated to treatment. No recurrent dislocations occurred. CONCLUSIONS: Early active mobilisation is a safe and effective treatment for simple elbow dislocations. Patients recovered faster and returned to work earlier without increasing the complication rate. No evidence was found supporting treatment benefit at 1 year. TRIAL REGISTRATION NUMBER: NTR 2025.