What Is the Patient-reported Outcome and Complication Incidence After Operative Versus Nonoperative Treatment of Minimally Displaced Tibial Plateau Fractures?

BACKGROUND: Much controversy remains about whether minimally displaced tibial plateau fractures should be treated operatively or nonoperatively. It is generally accepted that gaps and stepoffs up to 2 mm can be tolerated, but this assumption is based on older studies using plain radiographs instead of CT to assess the degree of initial fracture displacement. Knowledge regarding the relationship between the degree of fracture displacement and expected functional outcome is crucial for patient counseling and shared decision-making, specifically in terms of whether to perform surgery. QUESTIONS/PURPOSES: (1) Is operative treatment associated with improved patient-reported outcomes compared with nonoperative treatment in minimally displaced tibial plateau fractures (fractures with up to 4 mm of displacement)? (2) What is the difference in the risk of complications after operative versus nonoperative treatment in minimally displaced tibial plateau fractures? METHODS: A multicenter, cross-sectional study was performed in patients treated for tibial plateau fractures between 2003 and 2019 at six hospitals. Between January 2003 and December 2019, a total of 2241 patients were treated for tibial plateau fractures at six different trauma centers. During that time, the general indication for open reduction and internal fixation (ORIF) was intra-articular displacement of > 2 mm. Patients treated with ORIF and those treated nonoperatively were potentially eligible; 0.2% (4) were excluded because they were treated with amputation because of severe soft tissue damage, whereas 4% (89) were excluded because of coexisting conditions that complicated outcome measurement including Parkinson disease, cerebrovascular accident, or paralysis (conditions causing an inability to walk). A further 2.7% (60) were excluded because their address was unknown, and 1.4% (31) were excluded because they spoke a language other than Dutch. Based on that, 1328 patients were potentially eligible for analysis in the operative group and 729 were potentially eligible in the nonoperative group. At least 1 year after injury, all patients were approached and asked to complete the Knee injury and Osteoarthritis Outcome Scale (KOOS) questionnaire. A total of 813 operatively treated patients (response percentage: 61%) and 345 nonoperatively treated patients (response percentage: 47%) responded to the questionnaire. Patient characteristics including age, gender, BMI, smoking, and diabetes were retrieved from electronic patient records, and imaging data were shared with the initiating center. Displacement (gap and stepoff) was measured for all participating patients, and all patients with minimally displaced fractures (gap or stepoff ≤ 4 mm) were included, leaving 195 and 300 in the operative and nonoperative groups, respectively, for analysis here. Multivariate linear regression was performed to assess the association of treatment choice (nonoperative or operative) with patient-reported outcomes in minimally displaced fractures. In the multivariate analysis, we accounted for nine potential confounders (age, gender, BMI, smoking, diabetes, gap, stepoff, AO/OTA classification, and number of involved segments). In addition, differences in complications after operative and nonoperative treatment were assessed. The minimum clinically important differences for the five subscales of the KOOS are 11 for symptoms, 17 for pain, 18 for activities of daily living, 13 for sports, and 16 for quality of life. RESULTS: After controlling for potentially confounding variables such as age, gender, BMI, and AO/OTA classification, we found that operative treatment was not associated with an improvement in patient-reported outcomes. Operative treatment resulted in poorer KOOS in terms of pain (-4.7 points; p = 0.03), sports (-7.6 points; p = 0.04), and quality of life (-7.8 points; p = 0.01) compared with nonoperative treatment, but those differences were small enough that they were likely not clinically important. Patients treated operatively had more complications (4% [7 of 195] versus 0% [0 of 300]; p = 0.01) and reoperations (39% [76 of 195] versus 6% [18 of 300]; p < 0.001) than patients treated nonoperatively. After operative treatment, most reoperations (36% [70 of 195]) consisted of elective removal of osteosynthesis material. CONCLUSION: No differences in patient-reported outcomes were observed at midterm follow-up between patients treated surgically and those treated nonsurgically for tibial plateau fractures with displacement up to 4 mm. Therefore, nonoperative treatment should be the preferred treatment option in minimally displaced fractures. Patients who opt for nonoperative treatment should be told that complications are rare, and only 6% of patients might undergo surgery by midterm follow-up. Patients who opt for surgery of a minimally displaced tibial plateau fracture should be told that complications may occur in up to 4% of patients, and 39% of patients may undergo a secondary intervention (most of which are elective implant removal). LEVEL OF EVIDENCE: Level III, therapeutic study.

Transparency in hip fracture recovery over institutional boundaries: The transmural monitoring pathway.

OBJECTIVES: To develop a transmural pathway for healthcare professionals across institutions to monitor the recovery of hip fracture patients. The secondary objectives were to evaluate the pathway's feasibility and initial outcomes. DESIGN: Prospective cohort study. METHOD: Stakeholders of the hospital and geriatric rehabilitation institutions implemented a transmural monitoring pathway in which different geriatric health domains were monitored during three phases: The in-hospital, inpatient rehabilitation, and outpatient follow-up phase. The outcomes for the first 291 patients and the feasibility of the pathway were evaluated. If the outcomes of the clinimetrics significantly improved over time, progress in functional recovery was assumed. Feasibility was assessed according to the rate of adherence to the clinimetric tests. RESULTS: During the in-hospital phase, patients showed a decline in functional level (the Katz index of independence in Activities of Daily Living (Katz-ADL) pre-fracture vs. discharge: 0 (0-2) vs. 4 (4-5), P < 0.001). Patients, in which 78.6% (n = 140) had cognitive impairment and 41.2% had malnutrition, showed the most progress (Katz-ADL 2 (1-3)) during the inpatient rehabilitation phase. In the outpatient follow-up phase, recovery remained ongoing, but most patients had not returned to their pre-fracture functional levels (Katz-ADL 1 (1-3)). The pathway feasibility during the first phase was excellent (>85%), whereas room for improvement existed during other phases (<85%). CONCLUSION: The transmural monitoring pathway provides insight into the entire recovery process for all involved healthcare professionals. Patients showed the most progress during the rehabilitation phase. The pathway feasibility was excellent during the in-hospital phase, but improvements could be made during other phases.

Foot posture and patellar tendon pain among adult volleyball players.

OBJECTIVE: We hypothesized that individuals with a normal foot posture would be less likely to experience patellar tendon pain and pathology than those with a pronated or supinated foot. DESIGN: Observational study. SETTING: Field-based study among competing athletes. PARTICIPANTS: Volleyball players competing in the Victorian State League, Australia. ASSESSMENT OF RISK FACTORS: Patellar tendinopathy (PT) is common in sports involving running and jumping and can severely limit athletes' ability to compete. Several studies have investigated potential etiological factors for the development of PT, but little is known about the association between PT and foot posture. MAIN OUTCOME MEASURES: Static foot posture index (FPI), patellar tendon pain during single-leg decline squatting, and gray scale ultrasound imaging were measured in 78 recreational to elite volleyball players (48 men and 30 women). RESULTS: Men with patellar tendon pain were more likely to have a normal foot posture and men without pain were more likely to be pronated according to the FPI (P < 0.05). Women showed no association between FPI and pain or imaging (P > 0.05). CONCLUSIONS: Men with a normal foot posture were more likely to have PT compared to men with a pronated foot type.

Missed injuries in trauma patients: the value of a diagnostic thoracotomy or thoracoscopy during surgical stabilisation of rib fractures.

PURPOSE: Over the last decade Surgical Stabilisation of Rib Fractures (SSFR) gained popularity in our hospital. With increased numbers, we noted that frequently injuries were missed during primary/secondary survey and radiological imaging that were found during the surgical procedure. With this observation, the research question was formulated: What is the value of diagnostics thoracotomy or thoracoscopy during surgical stabilisation of rib fractures? METHODS: In a single-centre, retrospective study between February 2010 and December 2019, trauma patients who underwent Surgical Stabilisation of Rib Fractures (SSFR) and an inspection thoracotomy were included. All radiological injuries were compared with intraoperative findings. Missed injuries that were discovered during the surgical procedure that were not analysed during primary/secondary survey or on radiological imaging were recorded and retrospectively analysed by an independent radiologist. RESULTS: Fifty-one patients were included. Eight patients had additional injuries; all had a diaphragmatic rupture, one patient had an additional stomach laceration, and another patient had a significant lung laceration in need of surgical repair. On a CT scan there are 7 signs of predictive value for a diaphragmatic rupture. Only 13 out of the total of 56 diaphragm rupture CT signs were confirmed on the primary CT scans of the eight patients with diaphragmatic injuries; therefore, still 77% of signs could not be confirmed by initial radiological findings. CONCLUSION: With the recent shift towards surgical stabilisation of rib fractures, an inspection thoracoscopy or thoracotomy during SSFR should be considered to minimise the incidence of missed intrathoracic injuries requiring early or late surgical treatment.

A hybrid treatment modality of a subtrochanteric femoral fracture in a patient with osteoporosis due to a renal Fanconi syndrome: a case report.

A 24-year-old male with an idiopathic renal Fanconi syndrome presented to our ER after a low-energetic fall. Conventional imaging revealed a right subtrochanteric femoral fracture, severely decreased bone quality and cannulated collum femoris screws on the contralateral side. Regular plate-screw osteosynthesis or cephalomedullary implantation was deemed insufficient, due to a high iatrogenic and periprosthetic fracture probability. The decision was made to perform a plate-screw osteosynthesis combined with an intramedullary polymer bone enhancement (IlluminOss), to minimize this risk. No complications occurred perioperatively. The patient was able to walk independently two months postoperatively. This case shows that use of polymer implant as an enhancement of osteosynthesis in repair of fractures in the Fanconi syndrome is a safe and possible useful treatment method.

Shock due to Splenic Injury after Colonoscopy.

Colonoscopy is a common and increasingly performed procedure. It is used both as a diagnostic and therapeutic modality. Splenic injury after colonoscopy is a rare, yet life-threatening complication, most often caused by traction on the splenocolic ligament or excessive manipulation during the procedure. Although non-operative treatment is preferred upon splenic injury, early surgical or radiological intervention may be necessary in specific cases, for example in case of haemodynamic instability. A 71-year-old Caucasian man was referred to our emergency room due to shock after colonoscopy 2 days earlier. A computed tomography scan showed splenic rupture with active intra-abdominal, venous blood loss, and microperforation of the colon. An immediate splenectomy and colon repair were performed through laparotomy. After 6 days, the patient was discharged from hospital in good health. Although splenic rupture is a rare complication of colonoscopy, patients with abdominal pain and/or shock should be checked for complications such as splenic injury and colon perforation.

The implementation of a call-back system reduces the doctor's workload, and improves accessibility by telephone in general practice.

BACKGROUND: In a general practice in The Netherlands, the demand for direct telephone consultation with the doctor became extreme, which resulted in poorly managed consultations, and poor telephone access due to busy lines. A call-back telephone appointment system was therefore introduced: all calls are answered and, when possible, managed by the practice assistant. If the assistant feels incapable, or if the patient prefers to speak to the doctor, a telephone appointment is scheduled, at which time the doctor returns the patient's call. OBJECTIVE: Our aim was to evaluate the effects of a call-back telephone appointment system on doctors' workload and patients' telephone access to doctors. METHODS: Telephone consultation data over 10 weeks were selected before and after the introduction of the call-back telephone appointment system. The outcomes measured were: number and duration of telephone calls to doctors, the reason for each call and how often telephone lines were engaged during the specified telephone hour. RESULTS: The number of calls requiring the doctor's attention was reduced by 59% and total time spent on the telephone by the GPs was reduced by 39%. This reduction is explained by a change in the reasons for calling. Telephone accessibility improved, as busy telephone lines were no longer an issue. CONCLUSION: The call-back telephone appointment system is superior to the previously used open access telephone hour.