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.

A retrospective chart analysis with 5-year follow-up of early care for geriatric hip fracture patients: why we should continue talking about hip fractures.

BACKGROUND: Timing of surgery remains a topic of debate for hip fracture treatment in the geriatric patient population. The quality indicator "early surgery" was implemented in 2014 at the Department of Trauma Surgery of the University Hospitals Leuven to enhance timely operative treatment. In this follow-up study, we aim to evaluate the performance of this quality indicator, the clinical outcomes, and room for improvement. METHODS: The charts of 1190 patients surgically treated for an acute hip fracture were reviewed between June 2017 and May 2022 at the University Hospitals Leuven. Primary endpoints were adherence to early surgery, defined as surgery within the next calendar day, and the evaluation of the reasons for deviating from this protocol. Secondary endpoints were length of stay (LOS); intensive care unit (ICU) admission and length of ICU stay; mortality after 30 days, 60 days, 90 days, and 6 months; and 90-day readmission rate. Pearson's Chi-square test and Mann-Whitney U test were used for data analysis. RESULTS: One thousand eighty-four (91.1%) patients received early surgery versus 106 (8.9%) patients who received delayed surgery. The main reasons for surgical delay were the use of anticoagulants (33%), a general health condition not allowing safe surgery and/or existing comorbidities requiring workup prior to surgery (26.4%), and logistical reasons (17.9%). Patient delay and transfer from other hospitals were responsible for respectively 8.5% and 6.6% of delayed surgery. Early surgery resulted in a significantly shorter LOS and ICU stay (12 [8-25] vs. 18 [10-36] and 3 [2-6] vs. 7 [3-13] days, early vs. delayed surgery, respectively). No significant reduction was observed in ICU admission, mortality, and readmission rate. CONCLUSION: We have been able to maintain the early surgery hip fracture protocol in approximately 90% of the patients. Comorbidities and anticoagulant use were responsible for delayed surgery in the majority of the patients. Correct implementation of the existing protocol on anticoagulant use could lead to a one-third decrease in the number of delayed surgeries. Subsequently, since the LOS and ICU stay in the delayed surgery group were significantly longer, a further increase of early surgery will lower the current economic burden.

Tibial plateau fracture morphology based on injury force mechanism is predictive for patient-reported outcome and conversion to total knee arthroplasty.

PURPOSES: The aim of this study was to assess the relationship between injury mechanism-based fracture patterns and patient-reported outcome as well as conversion rate to total knee arthroplasty (TKA) at follow-up. METHODS: A multicenter cross-sectional study was performed including 1039 patients treated for a tibial plateau fracture between 2003 and 2019. At a mean follow-up of 5.8 ± 3.7 years, patients completed the Knee injury and Osteoarthritis Outcome Score (KOOS) questionnaire. For all patients, the injury force mechanism was defined based on CT images. Analysis of variance (ANOVA) was used to assess the relationship between different injury mechanisms and functional recovery. Cox regression was performed to assess the association with an increased risk on conversion to TKA. RESULTS: A total of 378 (36%) patients suffered valgus-flexion, 305 (29%) valgus-extension, 122 (12%) valgus-hyperextension, 110 (11%) varus-flexion, 58 (6%) varus-hyperextension, and 66 (6%) varus-extension injuries. ANOVA showed significant different KOOS values between injury fracture patterns in all subscales (P < 0.01). Varus-flexion injuries had the lowest average KOOS scores (symptoms 65; pain 67; ADL 72; sport 35; QoL 48). Varus-flexion mechanism was associated with an increased risk on a TKA (HR 1.8; P = 0.03) whereas valgus-extension mechanism was associated with a reduced risk on a TKA (HR 0.5; P = 0.012) as compared to all other mechanisms. CONCLUSION: Tibial plateau fracture patterns based on injury force mechanisms are associated with clinical outcome. Varus-flexion injuries have a worse prognosis in terms of patient-reported outcome and conversion rate to TKA at follow-up. Valgus-extension injuries have least risk on conversion to TKA.

Pediatric proximal tibial fractures: How does the trauma mechanism guide the operative strategy?

PURPOSE: Pediatric proximal tibial fractures (PTF) are rare but potentially debilitating. So far, no system for guiding surgical treatment based on injury-force mechanism has been documented, while adult tibial plateau fractures have benefited greatly from such an approach. This study reviews the diagnosis and treatment experience at a tertiary trauma center and introduces the reduction-traction method. METHODS: Pediatric patients (0-17 years old) diagnosed with PTF were identified in the hospital database from 2017 to 2021. Their injury mechanism, injury location, treatment type, and treatment outcomes were recorded. Images were reviewed to establish an injury-force classification according to Mubarak et al., 2009. When appropriate, patients were treated using a "reduction-traction" approach. RESULTS: Twenty-nine patients were identified, and followed-up for a mean of 6.8 months. The most common cause of injury was falling from height < 2 m, often from a trampoline. The tibial plateau and proximal tibial metaphysis were most commonly involved. Thirteen patients were treated non-operatively, 10 with open reduction and internal fixation, and six with arthroscopic surgery. A bimodal distribution according to age was noted in the injury mechanism, injury site, and treatment type. No adverse outcomes were recorded, and all patients resumed sports activities. The "reduction-traction" technique produced favorable outcomes in three patients. CONCLUSIONS: Pediatric PTF has a bimodal distribution with high risk before three years and after 15 years. The injury-force classification can supplement the Salter-Harris classification in guiding surgical treatment. The "reduction-traction" approach in children differs from adults, and results in good outcomes.

Surgical treatment options for chronic instability of the peroneal tendons: a systematic review and proportional meta-analysis.

INTRODUCTION: Several surgical techniques for chronic instability of the peroneal tendons have been reported. Yet, the most optimal technique has not been clarified. This study aims to perform a systematic review and meta-analysis of all existing evidence and compare all published surgical techniques in both the athletic as the nonathletic population. MATERIALS AND METHODS: A systematic review and a proportional meta-analysis, with a random-effects model, were carried out according to the PRISMA guidelines, using the keywords "chronic luxation" OR "instability" AND "peroneal tendon" AND "treatment" OR "treatment protocol". Four surgical techniques were compared in patients with chronic peroneal instability, comprising superior peroneal retinaculum (SPR) repair or replacement, groove deepening procedures (primarily with additional SPR operations), rerouting procedures, and bony procedures (respectively group S, G, R and B). Outcomes of interest include the pre- and postoperative American orthopedic foot and ankle society hindfoot score, return to sports, postoperative redislocation and complications. Pooled estimates of the last two outcomes were obtained. RESULTS: For the systematic review, 31 studies were eligible. Of these, 25 papers met the criteria for inclusion in the meta-analysis. All techniques demonstrated a clinical improvement postoperatively. Group B, however, demonstrated overall more unsatisfactory results, and higher complication rates were observed for both group R and group B. The latter was established by the proportional meta-analysis as well [95% confidence interval group S: (0.01-0.10); group G: (0.02-0.10); group R: (0.13-0.57); group B: (0.24-0.40)]. Concerning surgical efficacy (= no postoperative redislocation), no significant difference was statistically observed. Finally, considerable differences in study quality were identified. CONCLUSION: Surgical treatment results in excellent clinical and functional outcomes in patients with chronic peroneal instability. More inferior results were demonstrated for rerouting and bony procedures. However, no high-quality studies are available and future randomized controlled trials are necessary to advocate for the most advantageous approach.

Functional Outcome After Nonoperative Management of Tibial Plateau Fractures in Skeletally Mature Patients: What Sizes of Gaps and Stepoffs Can be Accepted?

BACKGROUND: Gap and stepoff measurements provide information about fracture displacement and are used for clinical decision-making when choosing either operative or nonoperative management of tibial plateau fractures. However, there is no consensus about the maximum size of gaps and stepoffs on CT images and their relation to functional outcome in skeletally mature patients with tibial plateau fractures who were treated without surgery. Because this is important for patient counseling regarding treatment and prognosis, it is critical to identify the limits of gaps and stepoffs that are well tolerated. QUESTIONS/PURPOSES: (1) In patients treated nonoperatively for tibial plateau fractures, what is the association between initial fracture displacement, as measured by gaps and stepoffs at the articular surface on a CT image, and functional outcome? (2) What is the survivorship of the native joint, free from conversion to a total knee prosthesis, among patients with tibial plateau fractures who were treated without surgery? METHODS: A multicenter cross-sectional study was performed in all patients who were treated nonoperatively for a tibial plateau fracture between 2003 and 2018 in four trauma centers. All patients had a diagnostic CT scan, and a gap and/or stepoff more than 2 mm was an indication for recommending surgery. Some patients with gaps and/or stepoffs exceeding 2 mm might not have had surgery based on shared decision-making. Between 2003 and 2018, 530 patients were treated nonoperatively for tibial plateau fractures, of which 45 had died at follow-up, 30 were younger than 18 years at the time of injury, and 10 had isolated tibial eminence avulsions, leaving 445 patients for follow-up analysis. All patients were asked to complete the validated Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire consisting of five subscales: symptoms, pain, activities of daily living (ADL), function in sports and recreation, and knee-related quality of life (QOL). The score for each subscale ranged from 0 to 100, with higher scores indicating better function. A total of 46% (203 of 445) of patients participated at a mean follow-up of 6 ± 3 years since injury. All knee radiographs and CT images were reassessed, fractures were classified, and gap and stepoff measurements were taken. Nonresponders did not differ much from responders in terms of age (53 ± 16 years versus 54 ± 20 years; p = 0.89), gender (70% [142 of 203] women versus 59% [142 of 242] women; p = 0.01), fracture classifications (Schatzker types and three-column concept), gaps (2.1 ± 1.3 mm versus 1.7 ± 1.6 mm; p = 0.02), and stepoffs (2.1 ± 2.2 mm versus 1.9 ± 1.7 mm; p = 0.13). In our study population, the mean gap was 2.1 ± 1.3 mm and stepoff was 2.1 ± 2.2 mm. The participating patients divided into groups with increasing fracture displacement based on gap and/or stepoff (< 2 mm, 2 to 4 mm, or > 4 mm), as measured on CT images. ANOVA was used to assess whether an increase in the initial fracture displacement was associated with poorer functional outcome. We estimated the survivorship of the knee free from conversion to total knee prosthesis at a mean follow-up of 5 years using a Kaplan-Meier survivorship estimator. RESULTS: KOOS scores in patients with a less than 2 mm, 2 to 4 mm, or greater than 4 mm gap did not differ (symptoms: 83 versus 83 versus 82; p = 0.98, pain: 85 versus 83 versus 86; p = 0.69, ADL: 87 versus 84 versus 89; p = 0.44, sport: 65 versus 64 versus 66; p = 0.95, QOL: 70 versus 71 versus 74; p = 0.85). The KOOS scores in patients with a less than 2 mm, 2 to 4 mm, or greater than 4 mm stepoff did not differ (symptoms: 84 versus 83 versus 77; p = 0.32, pain: 85 versus 85 versus 81; p = 0.66, ADL: 86 versus 87 versus 82; p = 0.54, sport: 65 versus 68 versus 56; p = 0.43, QOL: 71 versus 73 versus 61; p = 0.19). Survivorship of the knee free from conversion to total knee prosthesis at mean follow-up of 5 years was 97% (95% CI 94% to 99%). CONCLUSION: Patients with minimally displaced tibial plateau fractures who opt for nonoperative fracture treatment should be told that fracture gaps or stepoffs up to 4 mm, as measured on CT images, could result in good functional outcome. Therefore, the arbitrary 2-mm limit of gaps and stepoffs for tibial plateau fractures could be revisited. The survivorship of the native knee free from conversion to a total knee prosthesis was high. Large prospective cohort studies with high response rates are needed to learn more about the relationship between the degree of fracture displacement and functional recovery after tibial plateau fractures. LEVEL OF EVIDENCE: Level III, prognostic study.

Fracture-related infection of the patella: Treatment options and outcome.

BACKGROUND: Fracture-related infection (FRI) after the operative management of patella fractures is a serious complication that can result in prolonged hospitalization, multiple revision procedures and permanent functional impairment. Till today, treatment modalities and outcome of FRI of the patella are not well described. Therefore, the main objective of this retrospective cohort study was to evaluate treatment options, functional outcome and healthcare costs related to FRI of the patella. METHODS: This study evaluated 111 consecutive patients that were surgically treated for patella fractures, at the department of trauma surgery of the University Hospitals Leuven (Belgium), between January 2015 and April 2020. Patients were excluded if they (1) were younger than 18 years at the time of injury or (2) died during follow up. The minimal follow-up for all patients was 18 months. RESULTS: During the 5-year study period, 107 patients with 108 patella fractures were included. A total of 10 patients were diagnosed with an FRI (9.3%). Four of these were treated with a DAIR approach and three patients underwent implant removal or exchange. Finally, three patients were treated with total patellectomy. Out of the 10 patients, two were diagnosed with a recurrence of infection. Overall, we observed substantial lower scores for all Knee Injury and Osteoarthritis Outcome Score subscales in the FRI group, compared to a reference population. Moreover, our study shows that direct hospital-related healthcare costs of FRI of the patella were nine times higher compared to non-FRI cases. CONCLUSIONS: FRI of the patella is a challenging complication and recurrence of infection not uncommon. Although multiple treatment modalities exist, a multidisciplinary patient-specific approach is crucial. An early or delayed onset infection can be managed with a DAIR approach, but only when the construct is stable and the soft tissue coverage adequate. In patients with an FRI, implant removal is preferred when the fracture has healed. A total patellectomy can be used as a salvage procedure in complex cases with acceptable functional results. Overall, FRI of the patella leads to both a negative impact on the functional status of the patient and a ninefold increase in total healthcare costs.

Tibial plateau fractures in Belgium: epidemiology, financial burden and costs curbing strategies.

PURPOSE: We describe the incidence of tibial plateau fractures and the evolution of its management and financial burden in Belgium, perform a similar audit at University Hospitals Leuven, and define strategies to curb the increasing cost. METHODS: National data on tibial plateau fractures were collected from the NIHDI and compared to our performance. Several clinical parameters, such as age, sex, treatment modality and length-of-stay, were included. The total healthcare costs are considered as the sum of hospitalization costs and ambulatory care costs. RESULTS: Between 2006 and 2018, a total number of 35,226 tibial plateau fractures were diagnosed in Belgium and 861 at our center. The incidence increased 41% over time (mean 25/100,000 persons per year). The mean rate of surgery in Belgium was 37% and slightly decreased over time, due to a larger increase of non-operatively treated tibial plateau fractures. The rate of surgery at the UHL was 49%. Surprisingly, the average cost per patient was equal for operatively and non-operatively treated patients in Belgium, and driven by the length-of stay. CONCLUSION: Since length-of-stay is the main driver of the total healthcare costs of tibial plateau fractures, guidelines on appropriate length-of-stay can help to decrease variability and curb the total healthcare costs, particularly of the non-operatively treated patients. Our performance was in line with this. LEVEL OF EVIDENCE: Level IV.

Posterior tibial plateau fracture treatment with the new WAVE posterior proximal tibia plate: feasibility and first results.

INTRODUCTION: Operative management of posterior tibial plateau fractures (PTPF) remains challenging. The treatment goal is to restore the alignment and articular congruence, and providing sufficient stability which allows early mobilization. The purpose of this study was to assess the feasibility and safety of the newly developed WAVE posterior proximal tibia plate. METHODS: Between Oct 2017 and Jun 2020, 30 adult patients with a tibial plateau fracture and posterior involvement were selected for treatment with a WAVE posterior proximal tibia plate. Patient reported outcome was assessed using the Knee injury and Osteoarthritis Outcome Score (KOOS) at time of injury (pre-injury) and at 1-year follow-up. Radiological outcome was evaluated with CT-imaging. RESULTS: Twenty-eight patients were eligible for treatment with the new implant (3 'one-column', 10 'two column' and 15 'three-column' fractures), whereas in 2 patients anatomical fit was insufficient. KOOS results showed fair outcome scores at 1 year, with a large negative impact compared to pre-injury levels; however, a trend towards better results compared to a previous PTPF reference cohort. Radiological follow-up showed insufficient posterolateral buttress in two cases and residual articular step-off (> 2 mm) in seven patients, of which five were classified as three column fractures. CONCLUSION: Management of PTPF using the WAVE posterior proximal tibia plate is feasible and safe with satisfactory clinical and radiological results after 1 year. Nevertheless, there is a learning curve regarding optimal implant positioning to achieve the maximum benefit of the implant.

Does 3D-assisted surgery of tibial plateau fractures improve surgical and patient outcome? A systematic review of 1074 patients.

PURPOSE: The aim of this systematic review was to provide an overview of current applications of 3D technologies in surgical management of tibial plateau fractures and to assess whether 3D-assisted surgery results in improved clinical outcome as compared to surgery based on conventional imaging modalities. METHODS: A literature search was performed in Pubmed and Embase for articles reporting on the use of 3D techniques in operative management of tibial plateau fractures. This systematic review was performed in concordance with the PRISMA-guidelines. Methodological quality and risk of bias was assessed according to the guidelines of the McMaster Critical Appraisal. Differences in terms of operation time, blood loss, fluoroscopy frequency, intra-operative revision rates and patient-reported outcomes between 3D-assisted and conventional surgery were assessed. Data were pooled using the inverse variance weighting method in RevMan. RESULTS: Twenty articles evaluating 948 patients treated with 3D-assisted surgery and 126 patients with conventional surgery were included. Five different concepts of 3D-assisted surgery were identified: '3D virtual visualization', '3D printed hand-held fracture models', 'Pre-contouring of osteosynthesis plates', '3D printed surgical guides', and 'Intra-operative 3D imaging'. 3D-assisted surgery resulted in reduced operation time (104.7 vs. 126.4 min; P < 0.01), less blood loss (241 ml vs. 306 ml; P < 0.01), decreased frequency of fluoroscopy (5.8 vs. 9.1 times; P < 0.01). No differences in functional outcome was found (Hospital for Special Surgery Knee-Rating Scale: 88.6 vs. 82.8; P = 0.23). CONCLUSIONS: Five concepts of 3D-assisted surgical management of tibial plateau fractures emerged over the last decade. These include 3D virtual fracture visualization, 3D-printed hand-held fracture models for surgical planning, 3D-printed models for pre-contouring of osteosynthesis plates, 3D-printed surgical guides, and intra-operative 3D imaging. 3D-assisted surgery may have a positive effect on operation time, blood loss, and fluoroscopy frequency.

Accelerated Rehabilitation in Non-operative Management of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-analysis.

The optimal treatment and rehabilitation strategy for Achilles tendon ruptures is still under debate. There is a paradigm shift toward early mobilization and weightbearing. We examined the treatment effect of accelerated functional rehabilitation in nonoperative management of acute Achilles tendon ruptures. A systematic search of PubMed, EMBASE, and Web of Science databases for articles comparing accelerated versus delayed rehabilitation in the nonoperative management of acute Achilles tendon rupture was performed. Outcomes of interest were Achilles tendon rupture score (ATRS) (standardized patient-reported instrument related to symptoms and physical activity after treatment of an acute Achilles tendon rupture), rerupture rate, strength, range of motion, return to work, and sports. A total of 2001 articles were identified using our search strategy. We included 6 randomized controlled trials of interest. Although the concept of accelerated rehabilitation has gained popularity in recent years, no statistically significant differences could be revealed in any of the outcomes of interest. We performed a meta-analysis on the following outcomes: ATRS (mean difference -0.93 95% confidence interval [CI] -6.01 to 4.14), Rerupture rate (odds ratio [OR] 0.97, 95% CI: 0.46-2.03), Return to sports (OR 1.31, 95% CI 0.76-2.25), Return to work (mean difference 5.24, 95% CI to -12.04 to 22.51). The treatment effect of accelerated rehabilitation in nonoperatively treated patients seems to be small. However, we recommend accelerated rehabilitation for all conservatively treated patients, because it is a safe option and no detrimental effects have been described in the literature. Furthermore, many patients prefer this type of rehabilitation to avoid the practical disadvantages of prolonged immobilization.

Healthcare utilization and related cost of midshaft clavicle fracture treatment in Belgium.

INTRODUCTION: The debate regarding the economic impact and cost effectiveness of surgical midshaft clavicle fracture treatment is ongoing. Variations exist between healthcare systems in terms of financing, provider payment mechanism and the role of the government in all of this. Therefore, the primary aim of our study was to describe the in-hospital-related healthcare costs associated with midshaft clavicle fracture treatment in Belgium. The secondary aim was to define those clinical variables that drive the costs related to surgically treated clavicle fractures and define strategies that could reduce these costs. PATIENTS AND METHODS: A total of 345 patients with a midshaft clavicle fracture were included in the study. We selected 17 clinical variables and 5 cost categories were defined. Three multivariate linear models were built to determine which parameters drive the costs. RESULTS: The median total healthcare cost for non-operatively treated patients was €367 and the median total cost for operatively treated patients was €3296. The length-of-stay was the most important variable that predicted the total cost. The clinical variables Number of fracture fragments, Delayed Stage Surgery, Revision Surgery and Infection most influenced the length-of-stay. DISCUSSION: In conclusion, the initial healthcare utilization cost of operatively treated midshaft clavicle fractures is larger than that of non-operatively treated fractures. The length-of-stay is the most important parameter that drives the cost and is predominantly influenced by patients' age, fracture complexity and complications requiring a surgical re-intervention. LEVEL OF EVIDENCE: III.

Poor sporting abilities after tibial plateau fractures involving the posterior column: how can we do better?

PURPOSE: Tibial plateau fractures with the involvement of the posterior column are an important prognostic factor towards poor functional outcome. We aimed to assess the sporting abilities postoperatively with special emphasis on the type of sports and sport-specific movements, as well as time needed to resume sports, restricting factors in sports engagement, and patient satisfaction. We aimed to provide prognostic information on return to sports. METHODS: Demographic, clinical and radiological variables were retrospectively collected from 82 multicentric patients between 2014 and 2016. Prospectively, sporting abilities before and after surgery were determined using questionnaires at a mean follow-up of 33 months postoperatively. RESULTS: Involvement in sports significantly decreased, with only 68.4% of patients resuming sports (p < 0.001). The mean time needed to partially or fully resume sports was 6-9 and 9-12 months, respectively. The ability to resume at the pre-injury level of effort and performance was 22% and 12%, respectively. Restricting factors were pain (66%), fear of re-injury (37%), limited range of motion (26%), and instability (21%). The majority (59%) of patients were unsatisfied with their physical abilities. Significantly worse outcomes were observed in patients playing high-impact sports, experiencing knee pain during physical activity, suffering from extension/valgus or flexion/varus trauma. CONCLUSIONS: Tibial plateau fractures with the involvement of the posterior column significantly hamper the patients' sporting abilities, leaving the majority of patients unsatisfied. Preoperative counseling about prognosis, setting realistic expectations, optimizing rehabilitation and pain management postoperatively, and advising low-impact sports might improve engagement in physical activities and emotional impact on patients. LEVEL OF EVIDENCE: 3.

Intramedullary tissue cultures from the Reamer-Irrigator-Aspirator system for diagnosing fracture-related infection.

Fracture-related infection (FRI) is a serious complication following musculoskeletal trauma. Accurate diagnosis and appropriate treatment depend on retrieving adequate deep tissue biopsies for bacterial culture. The aim of this cohort study was to compare intraoperative tissue cultures obtained by the Reamer-Irrigator-Aspirator system (RIA)-system against standard tissue cultures obtained during the same surgical procedure. All patients had long bone fractures of the lower limbs and were assigned to the FRI or Control group based on the FRI consensus definition. The FRI group consisted of 24 patients with confirmed FRI and the Control group consisted of 21 patients with aseptic nonunion or chronic pain (in the absence of other suggestive/confirmatory criteria). Standard tissue cultures and cultures harvested by the RIA-system showed similar results. In the FRI group, standard tissue cultures and RIA cultures revealed relevant pathogens in 67% and 71% of patients, respectively. Furthermore, in four FRI patients, cultures obtained by the RIA-system revealed additional relevant pathogens that were not found by standard tissue culturing, which contributed to the optimization of the treatment plan. In the Control group, there were no false-positive RIA culture results. As a proof-of-concept, this cohort study showed that the RIA-system could have a role in the diagnosis of FRI as an adjunct to standard tissue cultures. Since scientific evidence on the added value of the RIA-system in the management of FRI is currently limited, further research on this topic is required before its routine application in clinical practice.

Functional outcome and general health status after plate osteosynthesis of posterior malleolus fractures - The quest for eligibility.

INTRODUCTION: The necessity for reduction and fixation of posterior malleolus fractures remains under debate. Therefore, we assessed the functional outcome and quality after plate osteosynthesis of the posterior malleolus, identified the main drivers of outcome and aimed to determine which patient and fracture type are eligible for plate osteosynthesis of the posterior malleolus. MATERIALS AND METHODS: A prospective patient cohort of 50 patients with an ankle fracture including the posterior malleolus underwent plate osteosynthesis via a posterior approach, and was compared to a retrospective patient cohort of 85 consecutive patients who did not. Twenty-five demographic, operative and postoperative characteristics were assessed. Outcome was recorded using questionnaires: AOFAS, EQ-5D, EQ-5D-VAS, EQ-5D-TTO, sensory nerve-associated complications, and flexion deficit of the hallux. RESULTS: Direct reduction and plate osteosynthesis of posterior malleolus fractures was inferior to non-operative treatment. Subanalysis of trimalleolar fractures revealed that the outcome of plate osteosynthesis was equal. Both fracture type and plate osteosynthesis were independent drivers of the outcome; Haraguchi type 3 posterior malleolus fractures were associated with the best functional outcome and quality of life scores. Comorbidity, age, postoperative complications and reintervention largely determined the outcome. Up to 30% of the patients reported (temporarily) flexion deficit of the hallux and 38% numbness at the lateral side of the foot. CONCLUSIONS: There is no indication for routine plate osteosynthesis of all posterior malleolus fractures. Careful patient selection, less invasive surgery and modified postoperative rehabilitation seem mandatory to improve the outcome and prevent adverse effects.

Limited value of the column concept in the operative management of posterior column tibial plateau fractures.

INTRODUCTION: The three-column concept has been proposed as tool in surgical decision-making for treating tibial plateau fractures. Recent studies have underscored the negative effect of posterior column tibial plateau fractures on clinical outcome. The purpose of this study was to assess the value of the three-column concept and posterior plating in posterior column fractures. We hypothesized that treating patients according to the three-column concept improves functional outcome. METHODS: 111 consecutive tibial plateau fractures, treated between January 2009 and December 2016, with at least a posterior column fracture were included. Relevant demographic and treatment variables were studied. Applied treatment was retrospectively evaluated according to the three-column concept. Patient reported outcome was assessed using the Knee injury and Osteoarthritis Outcome Score (KOOS). RESULTS: Median follow-up was 43.1 months (IQR 29.0-63.3) with a response rate of 80.2%. Outcome scores were markedly lower compared to the general population. 22.5% patients were treated according to the three-column concept and 27% was treated with posterior plating. Predominantly combined fractures of posterior and lateral columns were treated without fixation of the posterior column. Neither treatment according to the three-column concept and/or with posterior plating was found to significantly influence outcome. CONCLUSIONS: The outcome of posterior column fractures was equal, regardless of whether these fractures were treated or not. This indicates that the three-column concept seems insufficient and gives rise to further debate on surgical strategies of posterior column fractures. The implementation of trauma mechanism-based fracture morphology in the three-column concept might be important to consummate the three-column concept as guiding tool. LEVEL OF EVIDENCE: 3.

Regional anaesthesia for surgical repair of proximal humerus fractures: a systematic review and critical appraisal.

INTRODUCTION: Regional anaesthesia (RA) is often used in shoulder surgery because it provides adequate postoperative analgesia and may enhance the patient outcome. RA reduces overall opioid consumption and is frequently used in enhanced recovery programs to decrease hospital stay. However, there is very limited literature confirming these advantages in the surgical repair of proximal humerus fractures. This paper reviews the current literature on the use of RA in pain management after surgical repair of these fractures and evaluates the effect of RA on the functional outcome, length of stay in hospital, and health care expenditure. MATERIALS AND METHODS: The PubMed, Embase, Web of Science, and Cochrane Library databases were searched up to March 1, 2018. Studies investigating the use of RA in the management of proximal humerus fractures were included. RESULTS: Eleven studies (containing 1872 patients) were eligible for inclusion. The analgesic effect of RA was investigated in eight studies that confirmed its pain-relieving ability. Two studies measured functionality and length of hospitalization and suggested that RA improved function and shortened the stay in hospital. Nine papers mentioned side effects associated with RA while three articles claim that RA decreases the incidence of adverse events associated with general anaesthesia. CONCLUSIONS: This systematic review suggests that RA is a good option for postoperative analgesia in patients undergoing surgical repair of a proximal humerus fracture and is associated with fewer adverse events, a shorter recovery time, and a better functional outcome than those achieved by general anaesthesia alone. However, given the limited amount of data available, conclusions need to be made with caution and prospective studies are needed in the future.

Standardization of torsional CT measurements of the lower limbs with threshold values for corrective osteotomy.

INTRODUCTION: Re-establishing anatomic rotational alignment of shaft fractures of the lower extremities remains challenging. Clinical evaluation in combination with radiological measurements is important in pre- and post-surgical assessment. Based on computed tomography (CT), a range of reference values for femoral torsion (FT) and tibial torsion (TT) have historically been reported, which require standardization to optimize the significant intra- and inter-observer variability. The aims of this study were (re-)evaluation of the reference FT and TT angles, determination of the normal intra-individual side-to-side torsional differences to aid the surgical decision-making process for reoperation, and development of a novel 3D measurement method for FT. MATERIALS AND METHODS: In this retrospective study, we included 55 patients, without any known torsional deformities of the lower extremities. Two radiologists, independently, measured the rotational profile of the femora using the Hernandez and Weiner CT methods for FT, and the tibiae using the bimalleolar method for TT. The intra-individual side-to-side difference in paired femora and paired tibiae was determined. A 3D technique for FT assessment using InSpace® was designed. RESULTS: FT and TT demographic values were lower than previously reported, with mean FT values of 5.1°-8.8° and mean TT values of 25.5°-27.7°. Maximal side-to-side differences were 12°-13° for FT and 12° for TT. The Weiner method for FT was less variable than the Hernandez method. The new 3D method was equivocal to the conventional CT measurements. CONCLUSION: The results from this study showed that the maximal side-to-side tolerance in asymptomatic normal adult lower extremities is 12°-13° for FT and 12° for TT, which could be a useful threshold for surgeons as indication for revision surgery (e.g., derotational osteotomy). We developed a new 3D CT method for FT measurement which is similar to 2D and could be used in the future for virtual 3D planning.

Corrective osteotomies using patient-specific 3D-printed guides: a critical appraisal.

INTRODUCTION: Over the last decade, the technique of 3D planning has found its way into trauma surgery. The use of this technique in corrective osteotomies for treatment of malunions provides the trauma surgeon with a powerful tool. However, this technique is not entirely straightforward. We aimed to define potential pitfalls of this technique and possible solutions to overcome these shortcomings. MATERIALS AND METHODS: Ten patients with either a uni-, bi- or triplanar malunion of the long bones were included in this study. These patients were divided into three groups: a weight-bearing group and a non-weight-bearing group, the latter was divided into the humerus group and the forearm group, subsequently. 2D correction parameters were defined and compared within every group, as well as the interpretations of 3D visualization. RESULTS: The weight-bearing group revealed an undercorrection for almost all clinical measurements of the femur and tibia, while there was adequate matching of the osteotomies and of screw entry points in all cases. In the humerus group, coronal correction angles were nearly perfect in all cases, while axial and sagittal correction rates, however, differed substantially. Screw entry points and osteotomies were all at the level as planned. The forearm group showed undercorrection in multiple planes while there were good matching entry points for the screw trajectories. DISCUSSION: Four major pitfalls were encountered using the 3D printing technique: (1) careful examination of the planned guide positioning is mandatory, since suboptimal intra-operative guide positioning is most likely the main cause of the incomplete correction; (2) the use of pre-drilled screw holes do not guarantee adequate screw positioning; (3) translation of bone fragments over the osteotomy planes in case of an oblique osteotomy is a potential hazard; (4) the depth of the osteotomy is hard to estimate, potentially leading to extensive cartilage damage.

The implementation of a clinical pathway enhancing early surgery for geriatric hip fractures: how to maintain a success story?

BACKGROUND: Timing of surgery in geriatric hip fracture treatment remains controversial. Early surgery is acknowledged as a quality indicator and NICE guidelines recommend surgery within 0-48 h from admission. In 2014 we implemented the indicator of early surgery in our institution, enhancing operative treatment within the next calendar day. We aimed to evaluate the implementation, define the room for improvement and provide strategies to maintain the quality indicator. METHODS: Clinical outcome of 744 patients (January 2011-December 2013) before early surgery was implemented, compared to 817 patients (June 2014-May 2017) after implementation of early surgery with a follow-up of 6 months. Data-analysis was done by Pearson's Chi-square test and Mann-Whitney U test. RESULTS: Early surgery was achieved in 47.6% and 85.7% in the preimplementation and postimplementation group, respectively (P < 0.001). Both 30 days and 6 months mortality were similar (6.0% vs. 5.4%, P = 0.573 and 18.7% vs. 16.9%, P = 0.355, preimplementation vs. postimplementation, respectively). Early surgery resulted in a significantly shorter total length-of-stay (14 vs. 12 days, P < 0.001, preimplementation vs. postimplementation, respectively). Early surgery did not reduce the readmission rate. CONCLUSIONS: The indicator of early surgery has been successfully implemented. Early surgery resulted in a significantly shorter LOS. No significant reduction in 30 days and 6 months mortality, and 90 days readmission was observed. To maintain early surgery, continuous engagement and monitoring is required by all shareholders involved and if necessary, adjustment of the clinical route is appropriate.