The value of chest radiography after chest tube removal in nonventilated trauma patients: A post hoc analysis of a multicenter prospective cohort study.

BACKGROUND: Chest tubes are commonly placed in trauma care to treat life-threatening intrathoracic injuries by evacuating blood or air from the pleural cavity. Currently, it is common practice to routinely obtain chest radiographs between 1 to 8 hours after chest tube removal, while the necessity of it has been questioned. This study describes the "ins-and-outs" of chest tubes and evaluates the value of routine postremoval chest radiography in nonventilated trauma patients. METHODS: A post hoc analysis of a multicenter observational prospective cohort study was performed in blunt chest trauma patients admitted with multiple rib fractures to two level 1 trauma centers between January 2018 and March 2021 and treated with one or more chest tubes. Exclusion criteria were mechanical ventilation during chest tube removal, missing reports of postremoval chest radiography, transfer to another hospital, or mortality before chest tube removal. Descriptive analyses were performed to calculate the number of findings on postremoval chest radiographs and reinterventions. RESULTS: A total of 207 patients were included for analysis of whom 14 underwent bilateral chest tube placement, resulting in 221 chest tube removals investigated in this study. The mean ± SD age was 58 ± 17 years, 71% were male, 73% had American Society of Anesthesiologists scores of 1 or 2, and the median Injury Severity Score was 19 (interquartile range, 14-29). In 68 of 221 chest tube removals (31%), postremoval chest radiography showed increased or recurrent intrathoracic pathology (i.e., 13% pneumothorax, 18% pleural fluid, and 8% atelectasis). Only two (3%) of these patients underwent a same-day reintervention based on these findings, of whom one had signs or symptoms of recurrent pathology and one was asymptomatic. CONCLUSION: It seems safe to omit routine use of postremoval chest radiography in nonventilated blunt chest trauma patients and to selectively use imaging in those patients presenting with clinical signs or symptoms after chest tube removal. LEVEL OF EVIDENCE: Diagnostic Tests/Criteria; Level IV.

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

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

Quality of life and clinical outcomes of operatively treated patients with flail chest injuries: A multicentre prospective cohort study.

Introduction: Most studies about rib fractures focus on mortality and morbidity. Literature is scarce on long term and quality of life (QoL) outcomes. Therefore, we report QoL and long-term outcomes after rib fixation in flail chest patients. Methods: A prospective cohort study of clinical flail chest patients admitted to six level 1 trauma centres in the Netherlands and Switzerland between January 2018 and March 2021. Outcomes included in-hospital outcomes and long-term outcomes, such as QoL measurements 12 months after hospitalization using the EuroQoL five dimensions (EQ-5D) questionnaire. Results: Sixty-one operatively treated flail chest patients were included. Median hospital length of stay was 15 days and intensive care length of stay was 8 days. Sixteen (26%) patients developed pneumonia and two (3%) died. One year after hospitalization the mean EQ5D score was 0.78. Complication rates were low and included hemothorax (6%) pleural effusion (5%) and two revisions of the implant (3%). Implant related irritation was commonly reported by patients (n = 15, 25%). Conclusions: Rib fixation for flail chest injuries can be considered a safe procedure and with low mortality rates. Future studies should focus on quality of life rather than solely short-term outcomes.Trial registration: Registered in the Netherlands Trial Register NTR6833 on 13/11/2017 and the Swiss Ethics Committees Registration Number 2019-00668.

The association of radiologic body composition parameters with clinical outcomes in level-1 trauma patients.

PURPOSE: The present study aims to assess whether CT-derived muscle mass, muscle density, and visceral fat mass are associated with in-hospital complications and clinical outcome in level-1 trauma patients. METHODS: A retrospective cohort study was conducted on adult patients admitted to the University Medical Center Utrecht following a trauma between January 1 and December 31, 2017. Trauma patients aged 16 years or older without severe neurological injuries, who underwent a CT that included the abdomen within 7 days of admission, were included. An artificial intelligence (AI) algorithm was used to retrieve muscle areas to calculate the psoas muscle index and to retrieve psoas muscle radiation attenuation and visceral fat (VF) area from axial CT images. Multivariable logistic and linear regression analyses were performed to assess associations between body composition parameters and outcomes. RESULTS: A total of 404 patients were included for analysis. The median age was 49 years (interquartile range [IQR] 30-64), and 66.6% were male. Severe comorbidities (ASA 3-4) were seen in 10.9%, and the median ISS was 9 (IQR 5-14). Psoas muscle index was not independently associated with complications, but it was associated with ICU admission (odds ratio [OR] 0.79, 95% confidence interval [CI] 0.65-0.95), and an unfavorable Glasgow Outcome Scale (GOS) score at discharge (OR 0.62, 95% CI 0.45-0.85). Psoas muscle radiation attenuation was independently associated with the development of any complication (OR 0.60, 95% CI 0.42-0.85), pneumonia (OR 0.63, 95% CI 0.41-0.96), and delirium (OR 0.49, 95% CI 0.28-0.87). VF was associated with developing a delirium (OR 1.95, 95% CI 1.12-3.41). CONCLUSION: In level-1 trauma patients without severe neurological injuries, automatically derived body composition parameters are able to independently predict an increased risk of specific complications and other poor outcomes.

Rib fractures in the elderly population: a systematic review.

BACKGROUND: Multiple rib fractures are associated with significant morbidity and mortality, especially in elderly patients. There is growing interest in surgical stabilization in this subgroup of patients. This systematic review compares conservative treatment to surgical fixation in elderly patients (older than 60 years) with multiple rib fractures. The primary outcome is mortality. Secondary outcomes include hospital and intensive care length of stay (HLOS and ILOS), duration of mechanical ventilation (DMV) and pneumonia rates. METHODS: Multiple databases were searched for comparative studies reporting on conservative versus operative treatment for rib fractures in patients older than 60 years. Both observational studies and randomised clinical trials were considered. RESULTS: Five observational studies (n = 2583) were included. Mortality was lower in operatively treated patients compared to conservative treatment (4% vs. 8%). Pneumonia rate and DMV were similar (5/6% and 5.8/6.5 days) for either treatment modality. Overall ILOS and HLOS of stay were longer in operatively treated patients (6.5 ILOS and 12.7 HLOS vs. 2.7 ILOS and 6.5 ILOS). There were only minimal reports on perioperative complications. Notably, the median number of rib fractures (8.4 vs. 5) and the percentage of flail chest were higher in operatively treated patients (47% vs. 39%). CONCLUSION: It remains unknown to what extent conservative and operative treatment contribute individually to reducing morbidity and mortality in the elderly with multiple rib fractures. To date, the quality of evidence is rather low, thus well-performed comparative observational studies or randomised controlled trials considering all confounders are needed to determine whether operative treatment can improve a patient's outcome.

Cardiovascular parameters on computed tomography are independently associated with in-hospital complications and outcomes in level-1 trauma patients.

BACKGROUND: In-hospital complications after trauma may result in prolonged stays, higher costs, and adverse functional outcomes. Among reported risk factors for complications are pre-existing cardiopulmonary comorbidities. Objective and quick evaluation of cardiovascular risk would be beneficial for risk assessment in trauma patients. Studies in non-trauma patients suggested an independent association between cardiovascular abnormalities visible on routine computed tomography (CT) imaging and outcomes. However, whether this applies to trauma patients is unknown. PURPOSE: To assess the association between cardiopulmonary abnormalities visible on routine CT images and the development of in-hospital complications in patients in a level-1 trauma center. METHODS: All trauma patients aged 16 years or older with CT imaging of the abdomen, thorax, or spine and admitted to the UMC Utrecht in 2017 were included. Patients with an active infection upon admission or severe neurological trauma were excluded. Routine trauma CT images were analyzed for visible abnormalities: pulmonary emphysema, coronary artery calcifications, and abdominal aorta calcification severity. Drug-treated complications were scored. The discharge condition was measured on the Glasgow Outcome Scale. RESULTS: In total, 433 patients (median age 50 years, 67% male, 89% ASA 1-2) were analyzed. Median Injury Severity Score and Glasgow Coma Scale score were 9 and 15, respectively. Seventy-six patients suffered from at least one complication, mostly pneumonia (n = 39, 9%) or delirium (n = 19, 4%). Left main coronary artery calcification was independently associated with the development of any complication (OR 3.9, 95% CI 1.7-8.9). An increasing number of calcified coronary arteries showed a trend toward an association with complications (p = 0.07) and was significantly associated with an adverse discharge condition (p = 0.02). Pulmonary emphysema and aortic calcifications were not associated with complications. CONCLUSION: Coronary artery calcification, visible on routine CT imaging, is independently associated with in-hospital complications and an adverse discharge condition in level-1 trauma patients. The findings of this study may help to identify trauma patients quickly and objectively at risk for complications in an early stage without performing additional diagnostics or interventions.

Non-operative vs. operative treatment for multiple rib fractures after blunt thoracic trauma: a multicenter prospective cohort study.

BACKGROUND: Patients with multiple rib fractures without a clinical flail chest are increasingly being treated with rib fixation; however, high-quality evidence to support this development is lacking. METHODS: We conducted a prospective multicenter observational study comparing rib fixation to non-operative treatment in all patients aged 18 years and older with computed tomography confirmed multiple rib fractures without a clinical flail chest. Three centers performed rib fixation as standard of care. For adequate comparison, the other three centers performed only non-operative treatment. As such clinical equipoise formed the basis for the comparison in this study. Patients were matched using propensity score matching. RESULTS: In total 927 patients with multiple rib fractures were included. In the three hospitals that performed rib fixation, 80 (14%) out of 591 patients underwent rib fixation. From the nonoperative centers, on average 71 patients were adequately matched to 71 rib fixation patients after propensity score matching. Rib fixation was associated with an increase in hospital length of stay (HLOS) of 4.9 days (95%CI 0.8-9.1, p = 0.02) and a decrease in quality of life (QoL) measured by the EQ5D questionnaire at 1 year of 0.1 (95% CI - 0.2-0.0, p = 0.035) compared to non-operative treatment. A subgroup analysis of patients who received operative care within 72 h showed a similar decrease in QoL. Up to 22 patients (28%) who underwent surgery experienced implant-related irritation. CONCLUSIONS: We found no benefits and only detrimental effects associated with rib fixation. Based on these results, we do not recommend rib fixation as the standard of care for patients with multiple rib fractures. TRIAL REGISTRATION: Registered in the Netherlands Trial Register NTR6833 on 13/11/2017.

Epidemiology of combined clavicle and rib fractures: a systematic review.

PURPOSE: The aim of this systematic review was to provide an overview of the incidence of combined clavicle and rib fractures and the association between these two injuries. METHODS: A systematic literature search was performed in the MEDLINE, EMBASE, and CENTRAL databases on the 14th of August 2020. Outcome measures were incidence, hospital length of stay (HLOS), intensive care unit admission and length of stay (ILOS), duration of mechanical ventilation (DMV), mortality, chest tube duration, Constant-Murley score, union and complications. RESULTS: Seven studies with a total of 71,572 patients were included, comprising five studies on epidemiology and two studies on treatment. Among blunt chest trauma patients, 18.6% had concomitant clavicle and rib fractures. The incidence of rib fractures in polytrauma patients with clavicle fractures was 56-60.6% versus 29% in patients without clavicle fractures. Vice versa, 14-18.8% of patients with multiple rib fractures had concomitant clavicle fractures compared to 7.1% in patients without multiple rib fractures. One study reported no complications after fixation of both injuries. Another study on treatment, reported shorter ILOS and less complications among operatively versus conservatively treated patients (5.4 ± 1.5 versus 21 ± 13.6 days). CONCLUSION: Clavicle fractures and rib fractures are closely related in polytrauma patients and almost a fifth of all blunt chest trauma patients sustain both injuries. Definitive conclusions could not be drawn on treatment of the combined injury. Future research should further investigate indications and benefits of operative treatment of this injury.

Long-term quality of life and functional outcome after rib fracture fixation.

PURPOSE: The primary aim of this study was to assess the long-term quality of life and functional outcome after rib fracture fixation for patients with multiple rib fractures or flail chest. Secondarily, this study sought to identify risk factors associated with the quality of life. METHODS: A retrospective cohort study with a follow-up by questionnaire was performed at a level-1 trauma center in Switzerland. All adult patients with three or more rib fractures treated with rib fixation between 2010 and 2018 were eligible for inclusion. All outcomes were independently assessed for patients with multiple rib fractures and patients with a flail chest. The outcome measures were quality of life, level of dyspnea, return to work, implant irritation, and implant removal after a minimum of 12 months of follow-up. Quality of life was assessed using the EuroQol five-dimensional five-level questionnaire (EQ-5D-5L) and level of dyspnea was determined with the modified Medical Research Council dyspnea (mMRC) scale. RESULTS: The survey was completed by 74 out of 102 patients (73%) at a median follow-up of 26 months (IQR 15-37). The median EQ-5D utility index score was 0.91 (0.89-1.0), which was equivalent to the reference population (0.902, p = 0.523). The vast majority of patients experienced 'no problems' or 'slight problems' in any of the EQ-5D-5L dimensions. The complication rate associated with rib fracture fixation was low, implant-related irritation was the most common long-term sequela and occurred in 31% of patients. In multivariable regression analyses, total length of stay on the intensive care unit (ICU-LOS) was independently associated with a worse quality of life. CONCLUSIONS: Patients who underwent rib fracture fixation for multiple rib fractures or flail chest after severe chest trauma experienced a good quality of life at least 1 year after surgery. A longer ICU-LOS was independently associated with impaired quality of life. In addition, there were no significant differences in the long-term quality of life and functional outcome between patients with multiple rib fractures and a flail chest. Implant-related irritation was the most important long-term sequela and occurred in one-third of patients.

Epidemiology and outcome of rib fractures: a nationwide study in the Netherlands.

PURPOSE: Rib fractures following thoracic trauma are frequently encountered injuries and associated with a significant morbidity and mortality. The aim of this study was to provide current data on the epidemiology, in-hospital outcomes and 30-day mortality of rib fractures, and to evaluate these results for different subgroups. METHODS: A nationwide retrospective cohort study was performed with the use of the Dutch Trauma Registry which covers 99% of the acutely admitted Dutch trauma population. All patients aged 18 years and older admitted to the hospital between January 2015 and December 2017 with one or more rib fractures were included. Incidence rates were calculated using demographic data from the Dutch Population Register. Subgroup analyses were performed for flail chest, polytrauma, primary thoracic trauma, and elderly patients. RESULTS: A total of 14,850 patients were admitted between 2015 and 2017 with one or more rib fractures, which was 6.0% of all trauma patients. Of these, 573 (3.9%) patients had a flail chest, 4438 (29.9%) were polytrauma patients, 9273 (63.4%) were patients with primary thoracic trauma, and 6663 (44.9%) were elderly patients. The incidence rate of patients with rib fractures for the entire cohort was 29 per 100.000 person-years. The overall 30-day mortality was 6.9% (n = 1208) with higher rates observed in flail chest (11.9%), polytrauma (14.8%), and elderly patients (11.7%). The median hospital length of stay was 6 days (IQR, 3-11) and 37.3% were admitted to the intensive care unit (ICU). CONCLUSIONS: Rib fractures are a relevant and frequently occurring problem among the trauma population. Subgroup analyses showed that there is a substantial heterogeneity among patients with rib fractures with considerable differences regarding the epidemiology, in-hospital outcomes, and 30-day mortality.

Postoperative Complications of Minimally Invasive Intramedullary Nail Fixation Versus Plate Fixation for Distal Fibular Fractures in Elderly Patients: A Retrospective Double Cohort Study in a Geriatric Trauma Unit in the Netherlands.

Intramedullary fixation using a fibular nail is a minimally invasive alternative to conventional plate fixation that provides superior biomechanical strength and allows immediate full weightbearing postoperatively. The study aim was to compare the postoperative complications of minimally invasive intramedullary fibular nail fixation to plate fixation for Lauge-Hansen supination external rotation type 4 (Weber B) fractures in patients aged 65 years or older treated in a single geriatric trauma unit in the Netherlands. A retrospective cohort study was performed including patients aged 65 years or older with a Lauge-Hansen supination external rotation type 4 (Weber B) fracture treated with either intramedullary fibular fixation or plate fixation between January 2017 and January 2019. A total number of 58 patients were included with a mean age of 73.9 years (range 65-95). The intramedullary fixation-cohort (n = 13) had a significantly higher mean age (82.5 vs 71.4 years, p = .002) and Charlson Co-morbidity Index (4.7 vs 3.6, p = .005) compared to the plate fixation-cohort (n = 45). The total number of postoperative complications was lower after intramedullary fixation (n = 2, 15%) compared to plate fixation (n = 15, 33%), although this relative difference was not significant (p = .307). All 2 complications observed after intramedullary fixation were wound infections demanding no debridement or implant removal. No implant related complications, hospital-acquired complications or mortality were observed after intramedullary fixation. Despite the higher mean age and co-morbidity status of patients treated with minimally invasive intramedullary fibular nailing, the total number of postoperative complications was lower after intramedullary fixation compared to plate fixation. This technique might be a promising alternative in selected patients.

Functional Outcomes and Quality of Life in Patients With Post-Traumatic Arthrosis Undergoing Open or Arthroscopic Talocrural Arthrodesis-A Retrospective Cohort With Prospective Follow-Up.

Fusion remains the gold standard for post-traumatic osteoarthritis after ankle fractures in many institutes. Patient-reported outcomes on long-term quality of life and functionality of talocrural arthrodesis remain relatively unknown. In literature, low patient numbers and inadequate outcome measures provide a poor foundation for patient expectation management. Additionally, the surgical approach is often omitted. This study presents a retrospective cohort of patients who underwent open or arthroscopic talocrural arthrodesis for post-traumatic arthritis between 2008 and 2019 with prospective follow-up by questionnaire. Participants completed the EuroQol 5-dimensional 3-level questionnaire (EQ-5D-3LTM), EuroQol Visual Analogue Scale (EQ-VASTM), Foot and Ankle Outcome Score Dutch Language Version (FAOS-DLV), and 4 additional questions. Thirty-five patients were included in the cohort and 32 were included for follow-up. Trauma mechanism was mainly a low fall or motor vehicle accident causing a talocrural fracture-dislocation in most cases. For open versus arthroscopic treatment respectively, patients reported a median EQ-5D-3LTM index of 0.775 and 0.775, EQ-VASTM of 80 and 88, FAOS-DLV of 57.0 and 63.9, and satisfaction of 90 and 88 out of 100 after a median of 6.0 and 6.5 years. This study is unique as it is the largest series on patient-reported outcomes in patients with post-traumatic arthrosis with validated questionnaires. In general, patients were satisfied with relatively high questionnaire scores, especially concerning pain and daily living. These functional scores are of importance when setting patient expectations regarding talocrural arthrodesis and recovery. Additionally, the subscale values may help preoperatively in weighing the intervention's advantages and disadvantages for individual patients.

Tibiotalocalcaneal Intramedullary Nailing for Unstable Geriatric Ankle Fractures.

BACKGROUND: Tibiotalocalcaneal (TTC) intramedullary nailing has been suggested as an alternative to open reduction and internal fixation (ORIF) for the primary treatment of unstable fragility ankle fractures with a poor soft tissue envelope. This study aims to investigate the clinical efficacy of TTC intramedullary nail fixation for the primary treatment of unstable ankle fractures in frail elderly patients with poor soft tissue condition, by assessing the number of postoperative complications and the patient-reported functional outcomes. METHODS: A retrospective cohort study was performed including patients with an unstable ankle fracture treated between 2015 and 2019 with TTC stabilization using a retrograde intramedullary hindfoot nail that was inserted without joint preparation and allowing immediate weight-bearing postoperatively. The primary outcome was the total number of postoperative complications. RESULTS: A total of 10 patients were included out of 365 operatively treated ankle fractures. The mean age was 85.2 years (range 66-92) with a mean follow-up of 11.2 months (range 6-16). Fracture types included AO/OTA 44-B2 (n = 1), 44-B3 (n = 6), 44-C1 (n = 2) and 44-C3 (n = 1). Postoperative complications were observed in 4 patients (40%), including 3 nonunions, 2 implant related complications and 1 wound infection. No wound healing disorder or below-the-knee amputation was observed. Four patients (40%) deceased between post-operative 6 to 16 months due to medical conditions unrelated to surgery. The mean Foot and Ankle Outcome Score was 52.6 (range 44.2-73.8). CONCLUSION: Hindfoot nailingis a viable treatment option in selected high-risk patients with an advanced age, unstable ankle fractures with significant bone loss, poor soft tissue condition and/or severely impaired pre-injury mobility. In a frail geriatric population, hindfoot nailing may be a safe alternative fixation method with a low risk of wound complication or major amputation. However, unprepared joint may lead to symptomatic nonunion after TTC intramedullary nailing.

Fear of Falling, Recurrence of Falls, and Quality of Life in Patients with a Low Energy Fracture-Part II of an Observational Study.

Background and objective: Falls in elderly cause injury, mortality, and loss of independence, making Fear of Falling (FoF) a common health problem. FoF relates to activity restriction and increased fall risk. A voluntary intervention including fall risk assessment and prevention strategies was implemented to reduce falls in elderly patients with low energy fractures (LEF). The primary purpose of this study was to evaluate FoF and the number of subsequent falls in trauma patients one year after a LEF. The secondary aim was to examine how FoF affects patients' lives in terms of Quality of Life (QoL), mobility, and activity levels. Finally, participation in the voluntary fall prevention program (FPP) was evaluated. Materials and Methods: Observational cohort study in one Swiss trauma center. LEF patients, treated between 2012 and 2015, were analyzed one year after injury. Primary outcomes were Falls-Efficacy Score-International (FES-I) and number of subsequent falls. Secondary outcomes were EuroQoL-5-Dimensions-3-Levels (EQ5D-3L), mobility, activity levels, and participation in the FPP. Subgroup analysis was performed for different age categories. Results: 411 patients were included for analysis. Mean age was 72 ± 9.3, mean FES-I was 21.1 ± 7.7. Forty percent experienced FoF. A significant negative correlation between FoF and QoL (R = 0.64; p < 0.001) was found. High FoF correlated with lower activity levels (R= -0.288; p < 0.001). Six percent visited the FPP. Conclusions: At follow-up, 40% suffered from FoF which seems to negatively affect patients' QoL. Nevertheless, participation in the FPP was low. Simply informing patients about their susceptibility to falls and recommending participation in FPPs seems insufficient to motivate and recruit patients into FPPs. We suggest implementing repeated fall risk- and FoF screenings as standard procedures in the follow-up of LEF, especially in patients aged over 75 years.

Complications After Surgical Treatment of Geriatric Ankle Fractures.

The incidence of geriatric ankle fractures is rising and the potential for complications is high in this population. Little is known about factors associated with increased postoperative complications after surgical fixation of ankle fractures in older-age patients. The purpose of this retrospective cohort study was to assess the epidemiology and risk factors for complications after surgically treated ankle fractures in geriatric patients. All patients who were 65 years or older and had a surgically treated ankle fracture were included. Pilon fractures, patients who were initially treated conservatively or who had less than 1 month of follow-up were excluded. Postoperative complications, demographic-, fracture- and surgical data of 282 patients were recorded from two level 2 trauma centers between 2012 and 2017. A total of 87 (30.9%) patients developed a complication, of which wound related complications were most frequently reported. Superficial and deep wound infections were observed in 27 (9.6%) and 18 (6.4%) patients, respectively. Multivariate regression analysis demonstrated increased age to be an independent predictive variable for the occurrence of postoperative complications (odds ratio 1.04; 95% confidence interval 1.00-1.09), while cast immobilization for more than 2 weeks was a protective factor for the development of wound related complications (odds ratio 0.34; 95% confidence interval 0.17-0.66). In conclusion, the incidence of postoperative complications among geriatric patients after surgical treatment of ankle fractures is high and patients should be informed accordingly.

Is a chest radiograph indicated after chest tube removal in trauma patients? A systematic review.

PURPOSE: The aim of this systematic review was to assess the necessity of routine chest radiographs after chest tube removal in ventilated and nonventilated trauma patients. METHODS: A systematic literature search was conducted in MEDLINE, Embase, CENTRAL, and CINAHL on May 15, 2020. Quality assessment was performed using the Methodological Index for Nonrandomized Studies criteria. Primary outcome measures were abnormalities on postremoval chest radiograph (e.g., recurrence of a pneumothorax, hemothorax, pleural effusion) and reintervention after chest tube removal. Secondary outcome measures were emergence of new clinical symptoms or vital signs after chest tube removal. RESULTS: Fourteen studies were included, consisting of seven studies on nonventilated patients and seven studies on combined cohorts of ventilated and nonventilated patients, all together containing 1,855 patients. Nonventilated patients had abnormalities on postremoval chest radiograph in 10% (range across studies, 0-38%) of all chest tubes and 24% (range, 0-78%) of those underwent reintervention. In the studies that reported on clinical symptoms after chest tube removal, all patients who underwent reintervention also had symptoms of recurrent pathology. Combined cohorts of ventilated and nonventilated patients had abnormalities on postremoval chest radiograph in 20% (range, 6-49%) of all chest tubes and 45% (range, 8-63%) of those underwent reintervention. CONCLUSION: In nonventilated patients, one in ten developed recurrent pathology after chest tube removal and almost a quarter of them underwent reintervention. In two studies that reported on clinical symptoms, all reinterventions were performed in patients with symptoms of recurrent pathology. In these two studies, omission of routine postremoval chest radiograph seemed safe. However, current literature remains insufficient to draw definitive conclusions on this matter, and future studies are needed. LEVEL OF EVIDENCE: Systematic review study, level IV.

Study methodology in trauma care: towards question-based study designs.

The randomized controlled trial (RCT) in surgery may not always be ethical, feasible, or necessary to address a particular research question about the effect of a surgical intervention. If so, properly designed and conducted observational (non-randomized) studies may be valuable alternatives for an RCT and produce credible results. In this paper, we discus differences between RCTs and observational studies and differentiate between three types of comparisons of surgical interventions. We assert that results of different designs should be regarded as complementary to each other when evaluating surgical interventions. Criteria for credible observational research are presented to provide guidance for future observational research of surgical interventions. We argue that the research question that is being asked should guide the discussion about the value of a particular study design.

Global changes in mortality rates in polytrauma patients admitted to the ICU-a systematic review.

BACKGROUND: Many factors of trauma care have changed in the last decades. This review investigated the effect of these changes on global all-cause and cause-specific mortality in polytrauma patients admitted to the intensive care unit (ICU). Moreover, changes in trauma mechanism over time and differences between continents were analyzed. MAIN BODY: A systematic review of literature on all-cause mortality in polytrauma patients admitted to ICU was conducted. All-cause and cause-specific mortality rates were extracted as well as trauma mechanism of each patient. Poisson regression analysis was used to model time trends in all-cause and cause-specific mortality. Thirty studies, which reported mortality rates for 82,272 patients, were included and showed a decrease of 1.8% (95% CI 1.6-2.0%) in all-cause mortality per year since 1966. The relative contribution of brain injury-related death has increased over the years, whereas the relative contribution of death due to multiple organ dysfunction syndrome (MODS), acute respiratory distress syndrome, and sepsis decreased. MODS was the most common cause of death in North America, and brain-related death was the most common in Asia, South America, and Europe. Penetrating trauma was most often reported in North America and Asia. CONCLUSIONS: All-cause mortality in polytrauma patients admitted to the ICU has decreased over the last decades. A shift from MODS to brain-related death was observed. Geographical differences in cause-specific mortality were present, which may provide region-specific learning possibilities resulting in improvement of global trauma care.

Open Versus Closed Operative Treatment for Tongue-Type Calcaneal Fractures: Case Series and Literature Review.

Because consensus on the optimal surgical treatment of tongue-type calcaneal fractures is lacking, this study aimed to compare outcomes and postoperative complications of open and closed surgical treatment of these fractures. For this cases series, all patients 18 years or older who underwent operative fixation of tongue-type calcaneal fractures at 2 level I trauma centers between 2004 and 2015 were considered eligible for participation. Data on explanatory and outcome variables were collected from medical records based on available follow-up. Additionally, a systematic literature review on surgical treatment of these fractures was conducted. Fifty-six patients (58 tongue-type fractures) were included. Open reduction internal fixation was performed in 33 fractures, and closed reduction internal (percutaneous) fixation was performed in 25. More wound problems and deep infections were observed with open treatment compared with the closed approach: 10 (30%) versus 3 (12%) and 4 (12%) versus 0 (0%) procedures, respectively. In contrast, revision and hardware removal predominated in patients with closed treatments: 4 (16%) versus 1 (3%) and 9 (36%) versus 8 (24%) procedures, respectively. The systematic literature review yielded 10 articles reporting on surgical treatment for tongue-type fractures, all showing relatively good outcomes and low complication rates with no definite advantage for either technique. Both open and closed techniques are suggested as accurate surgical treatment options for tongue-type calcaneal fractures. Surgical treatment should be individualized, considering both fracture and patient characteristics and the treating surgeon's expertise. We recommend attempting closed reduction internal fixation if deemed feasible, with conversion to an open procedure if satisfactory reduction or fixation is unobtainable.

Time is of the essence when treating necrotizing soft tissue infections: a systematic review and meta-analysis.

Background: Although the phrase "time is fascia" is well acknowledged in the case of necrotizing soft tissue infections (NSTIs), solid evidence is lacking. The aim of this study is to review the current literature concerning the timing of surgery in relation to mortality and amputation in patients with NSTIs. Methods: A systematic search in PubMed/MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Controlled Register of Trials (CENTRAL) was performed. The primary outcomes were mortality and amputation. These outcomes were related to the following time-related variables: (1) time from onset symptoms to presentation; (2) time from onset symptoms to surgery; (3) time from presentation to surgery; (4) duration of the initial surgical procedure. For the meta-analysis, the effects were estimated using random-effects meta-analysis models. Result: A total of 109 studies, with combined 6051 NSTI patients, were included. Of these 6051 NSTI patients, 1277 patients died (21.1%). A total of 33 studies, with combined 2123 NSTI patients, were included for quantitative analysis. Mortality was significantly lower for patients with surgery within 6 h after presentation compared to when treatment was delayed more than 6 h (OR 0.43; 95% CI 0.26-0.70; 10 studies included). Surgical treatment within 6 h resulted in a 19% mortality rate compared to 32% when surgical treatment was delayed over 6 h. Also, surgery within 12 h reduced the mortality compared to surgery after 12 h from presentation (OR 0.41; 95% CI 0.27-0.61; 16 studies included). Patient delay (time from onset of symptoms to presentation or surgery) did not significantly affect the mortality in this study. None of the time-related variables assessed significantly reduced the amputation rate. Three studies reported on the duration of the first surgery. They reported a mean operating time of 78, 81, and 102 min with associated mortality rates of 4, 11.4, and 60%, respectively. Conclusion: Average mortality rates reported remained constant (around 20%) over the past 20 years. Early surgical debridement lowers the mortality rate for NSTI with almost 50%. Thus, a sense of urgency is essential in the treatment of NSTI.