Predictors of mortality over time in geriatric patients with hip fracture.

Objectives: The aim of this study was to determine the variations in effect for predictors of mortality over time and risk of in-hospital complications in geriatric patients with a hip fracture. Many studies have investigated risk factors of short-term and long-term mortality separately. In current literature, little is known about the variations in effect of risk factors over time and no comparison with the general population is made. Methods: All patients with a hip fracture aged 70 years or older admitted to our hospital between January 1, 2016, and May 1, 2018, were included in this retrospective study. Patients who had undergone total hip arthroplasty (THA) were not included. The primary outcome was mortality after 1 year. Secondary outcomes were mortality after 30 days, 90 days, 2 years, and complications. Kaplan-Meier (KM) curves for risk factors were generated to visualize survival over time. Data were compared with data extracted from the national health records. Results: A total of 685 geriatric patients with hip fractures were included with a 1-year mortality of 27%. The adjusted odds ratios (AOR) found differed over time. Five risk factors for mortality were investigated in this study using KM curves: age, prefracture living situation, dementia, sex, and ASA classification. Conclusions: Over time, the variation of 5 risk factors for mortality were visualized in geriatric patients with a hip fracture: age, prefracture living situation, dementia, sex, and ASA classification. An elevated risk of mortality was discovered compared with the general population. The variation in effect observed in risk factors plays a vital role in prognosis. This insight will help guide accurate medical decision-making for a tailored treatment plan for geriatric patients with a hip fracture.

Pediatric diaphragmatic hernia induced by a rib osteochondroma.

Diaphragmatic hernia in children is uncommon, especially when not congenital. We present a case of an 11-year old boy with a diaphragmatic hernia caused by a rib osteochondroma. The osteochondroma was surgically removed and the laceration in the diaphragm was repaired. This case shows the importance of being familiar with acquired diaphragmatic hernia in children, to recognize and prevent possible complications in an early stage.

Definitions of hospital-acquired pneumonia in trauma research: a systematic review.

PURPOSE: What are reported definitions of HAP in trauma patient research? METHODS: A systematic review was performed using the PubMed/MEDLINE database. We included all English, Dutch, and German original research papers in adult trauma patients reporting diagnostic criteria for hospital-acquired pneumonia diagnosis. The risk of bias was assessed using the MINORS criteria. RESULTS: Forty-six out of 5749 non-duplicate studies were included. Forty-seven unique criteria were reported and divided into five categories: clinical, laboratory, microbiological, radiologic, and miscellaneous. Eighteen studies used 33 unique guideline criteria; 28 studies used 36 unique non-guideline criteria. CONCLUSION: Clinical criteria for diagnosing HAP-both guideline and non-guideline-are widespread with no clear consensus, leading to restrictions in adequately comparing the available literature on HAP in trauma patients. Studies should at least report how a diagnosis was made, but preferably, they would use pre-defined guideline criteria for pneumonia diagnosis in a research setting. Ideally, one internationally accepted set of criteria is used to diagnose hospital-acquired pneumonia. LEVEL OF EVIDENCE: Level III.

Bevacizumab as treatment option for recurrent respiratory papillomatosis: a systematic review.

PURPOSE: To this day, there is no cure for recurrent respiratory papillomatosis (RRP). Multiple surgical procedures are performed to achieve symptom relief and prevention of airway obstruction. A promising drug for RRP is the vascular endothelial growth factor (VEGF) binding antibody bevacizumab. This chemotherapeutic agent has an angiogenesis-inhibiting effect which inhibits tumor growth. The objective of this review was to investigate the efficacy of bevacizumab as treatment option for RRP, and to explore the difference of its effects between intralesional and systemic treatment. METHODS: A systematic search was conducted in Cochrane, PubMed, and Embase. Articles were included if bevacizumab treatment was given intralesionally and/or systemically. The methodological quality of the studies was assessed using the CAse REport (CARE) guidelines. RESULTS: Of 585 unique articles screened by title and abstract, 15 studies were included, yielding a total of 64 patients. In 95% of the patients treated with systemic bevacizumab, the post-bevacizumab surgical interval was considerably prolonged. More than half of them did not need any surgical intervention during mean follow-up of 21.6 months. Treatment with intralesional bevacizumab showed a lower efficacy: in 62% of the patients, the post-bevacizumab surgical interval (mean, 1.8 months follow-up) was extended when compared to the interval before the treatment. CONCLUSION: Systemically and intralesionally administered bevacizumab are effective treatment options for severe RRP. A systemic administration might be the treatment of first choice. Further prospective research with long term follow-up is advocated to elucidate this important topic.

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.

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.

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.

Postoperative headache after surgical treatment of cerebellopontine angle tumors: a systematic review.

PURPOSE: Postoperative headache (POH) is a complication that occurs after surgical resection of cerebellopontine angle (CPA) tumors. The two most common surgical approaches are the translabyrinthine (TL), and retrosigmoid (RS) approach. The objective of this systematic review was to investigate whether POH occurs more frequently after RS compared to TL approaches. METHODS: A systematic search was conducted in Cochrane, Pubmed and Embase. Studies were included if POH after CPA tumor removal was reported and both surgical approaches were compared. The methodological quality of the studies was assessed using the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool. RESULTS: In total, 3,942 unique articles were screened by title and abstract. After the initial screening process 63 articles were screened for relevance to the inquiry, of which seven studies were included. Three studies found no significant difference between both surgical approaches (p = 0.871, p = 0.120, p = 0.592). Three other studies found a lower rate of POH in the TL group compared to the RS group (p = 0.019, p < 0.001, p < 0.001). Another study showed a significantly lower POH rate in the TL group after one and six months (p = 0.006), but not after 1 year (p = 0.6). CONCLUSION: The results of this systematic review show some evidence of a lower rate of POH in favor of the TL approach versus the RS approach for CPA tumor resection. Prospective research studies are needed to further investigate this finding.

Development and Internal Validation of a Prediction Model for In-Hospital Mortality in Geriatric Patients With a Hip Fracture.

OBJECTIVE: To develop and validate a prediction model for in-hospital mortality in patients with hip fracture 85 years of age or older undergoing surgery. DESIGN: A multicenter prospective cohort study. SETTING: Six Dutch trauma centers, level 2 and 3. PARTICIPANTS: Patients with hip fracture 85 years of age or older undergoing surgery. INTERVENTION: Hip fracture surgery. MAIN OUTCOME MEASUREMENTS: In-hospital mortality. RESULTS: The development cohort consisted of 1014 patients. In-hospital mortality was 4%. Age, male sex, American Society of Anesthesiologists classification, and hemoglobin levels at presentation were independent predictors of in-hospital mortality. The bootstrap adjusted performance showed good discrimination with a c-statistic of 0.77. CONCLUSION: Age, male sex, higher American Society of Anesthesiologists classification, and lower hemoglobin levels at presentation are robust independent predictors of in-hospital mortality in patients with geriatric hip fracture and were incorporated in a simple prediction model with good accuracy and no lack of fit. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

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.

Intratympanic Treatment in Menière's Disease, Efficacy of Aminoglycosides Versus Corticosteroids in Comparison Studies: A Systematic Review.

OBJECTIVE: To compare the functional outcomes and complications of intratympanic gentamicin (ITG) versus intratympanic corticosteroids (ITC) in Menière's disease. DATA SOURCES: An electronic search was conducted in the Cochrane Library, PubMed, and Embase databases on February 3, 2019. Articles written in English, Dutch, German, French, or Turkish language were included. STUDY SELECTION: Study inclusion criteria were: 1) patients diagnosed with definite Menière's disease according to the criteria of the American Academy of Otolaryngology-Head and Neck Surgery, 2) treated with ITG or ITC in a comparison study, and 3) reported subjective and objective outcomes concerning Menière's disease. DATA EXTRACTION: The quality of eligible studies was assessed according to an adjusted version of the Cochrane Risk of Bias tool. The extracted data were study characteristics (study design, publication year, and number of relevant patients), patient's characteristics (sex and age), disease characteristics (uni or bilateral and duration of Menière's disease), treatment protocol, and different therapeutic outcomes (vertigo, tinnitus, aural fullness, and hearing loss). DATA SYNTHESIS: A total of eight articles were included for data extraction and analysis. For subjective outcomes, ITG was slightly favored compared to intratympanic corticosteroids. This was significant only in three studies (p < 0.05). For objective outcomes and complications, no significant differences were seen. CONCLUSIONS: The result of this systematic review shows some benefit of ITG over ITC for subjective outcomes and no difference regarding objective outcomes or complication rate. However, this superiority of ITG is rather weak. Both interventions can be effectively and safely used in controlling Menière's disease in acute situations.

Treatment of a Scientifically Neglected Ankle Injury: The Isolated Medial Malleolar Fracture. A Systematic Review.

Isolated medial malleolar fractures are frequently encountered injuries. Literature regarding their treatment, though, is scarce and contradicting. The aim of this systematic review is to compare surgical and conservative treatment of isolated medial malleolar fractures considering complication rates and functional outcomes. PubMed, Embase, Cochrane, and CINAHL were searched for this review. Articles from 1980 or later, written in English, French, German, or Dutch, reporting any outcome of 10 or more isolated medial malleolar fractures in skeletally mature patients were included. Study quality was assessed using the Methodological Index for Non Randomized Studies (MINORS) instrument. Eighteen studies were included involving 2566 isolated medial malleolar fractures, which showed a mean (± SD) MINORS score of 8 ± 2. Mean nonunion rate was 1.7% after surgical treatment and 3.5% after conservative treatment. Overall, comparable functional outcomes were found after both treatment methods. Only 2 of the included studies reported the exact amount of fracture displacement. One study-comparing surgical and conservative treatment-showed similar functional outcomes for 1- and 2-mm displaced isolated medial malleolar fractures, and the other, a nonunion rate of 3.5% and a good mean functional outcome in 57 conservatively treated isolated medial malleolar fractures with a mean displacement of 3.8 mm. The available evidence is scarce and of low quality but suggests that conservative treatment of isolated medial malleolar fractures displaced ≤2 mm is safe. No study exists that compares surgical and conservative treatment in isolated medial malleolar fractures displaced >2 mm. Therefore, further research is needed. Until then, the eventual choice of treatment for isolated medial malleolar fractures displaced >2 mm, might be mainly dependent on the patients' characteristics and demands.

Exhaustion of the immune system by Group A Streptococcus necrotizing fasciitis: the occurrence of late secondary infections in a retrospective study.

BACKGROUND: Necrotizing fasciitis is a potentially lethal condition for which early and adequate treatment with surgical debridement and broad-spectrum intravenous antibiotics are essential for survival. It is hypothesized that Group A Streptococcus (GAS) necrotizing fasciitis causes exhaustion of the immune system, making these patients more susceptible for late secondary infections. METHODS: A retrospective study was conducted of all patients with necrotizing fasciitis between 2002 and 2016. Patients with necrotizing fasciitis based on macroscopic findings, positive Gram staining, culture or fresh frozen section of fascia biopsies were included. Patients with necrotizing fasciitis were divided into two groups based on the presence of GAS. Of both groups, clinical course, outcome and occurrence of late secondary infections were analyzed. For the occurrence of secondary infections, pneumonia was chosen as reference for late secondary infections. RESULTS: Eighty-one patients with necrotizing fasciitis were included of which 38 (47%) had GAS necrotizing fasciitis and 43 (53%) had non-GAS necrotizing fasciitis. Patients with GAS necrotizing fasciitis were younger (50 vs. 61 years, p=0.023) and more often classified as ASA I (45% vs. 14%, p=0.002) compared with patients with non-GAS necrotizing fasciitis. In-hospital mortality rate for necrotizing fasciitis was 32%. Patients with comorbidities were more likely to die of necrotizing fasciitis compared with patients without comorbidities (OR 7.41, 95% CI 1.58 to 34.63). Twelve patients (39%) with GAS necrotizing fasciitis developed pneumonia compared with four patients (13%) with non-GAS necrotizing fasciitis (p=0.017; OR 4.42, 95% CI 1.124 to 15.79). Median time from diagnosis to development of pneumonia in patients with GAS necrotizing fasciitis was 10 days (IQR 9). CONCLUSION: Patients with GAS necrotizing fasciitis have an increased risk to develop late secondary infections during initial treatment for necrotizing fasciitis compared with patients with necrotizing fasciitis without involvement of GAS. This suggests exhaustion of the immune system after severe GAS infection. LEVEL OF EVIDENCE: III.

Brodie's Abscess: A Systematic Review of Reported Cases.

Introduction: Brodie's abscess is a form of osteomyelitis. Since its first appearance in the medical literature in 1832, numerous cases have been described. The aim of this article is to provide the first comprehensive overview of published cases of Brodie's abscess, and to describe diagnostic methods, therapeutic consequences and outcomes. Methods: According to PRISMA guidelines a systematic review of the literature was performed. All published data in English or Dutch were considered for inclusion with no limitations on publication date. Data was extracted on demography, duration of symptoms, signs of inflammation, diagnostic imaging, causative agent, treatment and follow-up. Results: A total of 70 articles were included, reporting on a total of 407 patients, mostly young (median age 17) males (male:female ratio 2.1:1). The median duration of symptoms before diagnosis was 12 weeks (SD 26). Mostly consisting of pain (98%) and/or swelling (53%). 84% of all patients were afebrile, and less than 50% had elevated serum inflammation markers. Diagnosis was made with a combination of imaging modalities: plain X-ray in 96%, MRI (16%) and CT-scan (8%). Treatment consisted of surgery in 94% of the cases, in conjunction with long term antibiotics in 77%. Staphylococcus aureus was the pathogen most often found in the culture (67,3%). Outcome was generally reported as favorable. Recurrence was reported in 15,6% of the cases requiring further intervention. Two cases developed permanent disability. Conclusion: Brodie's abscess has an insidious onset as systemic inflammatory signs and symptoms were often not found. Treatment consisted mostly of surgery followed by antibiotics (77%) or only surgery (17%) and outcomes were generally reported as favourable.

Intramedullary Fixation Versus Plate Fixation of Distal Fibular Fractures: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Observational Studies.

Intramedullary fixation (IMF) has been described as a minimally invasive alternative to open reduction and internal fixation for operative treatment of distal fibular fractures in case of compromised soft tissue or severe comorbidities. The objective was to compare postoperative complications and functional outcomes of intramedullary versus plate fixation (PF) in distal fibular fractures. A systematic review and meta-analysis was performed. The PubMed/MEDLINE, Embase, Cochrane, and CINAHL databases were searched for both randomized controlled trials and observational studies. A total of 26 studies was included, reporting on 1710 patients with a mean age of 51.6 years. Meta-analysis was performed on 8 comparative studies, including subgroup and sensitivity analyses on all outcomes. IMF was associated with significantly fewer wound related complications (odds ratio [OR], 0.11; 95% confidence interval [CI], 0.04 to 0.25; p < .01), implant removals (OR, 0.54; 95% CI, 0.31 to 0.93; p = .03), and nonunions (OR, 0.31; 95% CI, 0.15 to 0.62; p < .01). No differences were found regarding malunion (OR, 0.45; 95% CI, 0.17 to 1.21; p = .11) and the Olerud Molander Ankle Score for long-term functional outcome (mean difference, 9.56; 95% CI, 1.24 to 20.37; p = .08). Results of this study apply to a select group of patients, in which the advantages of minimal soft tissue damage by IMF are preferable to optimal fracture reduction by PF. IMF of distal fibular fractures resulted in fewer wound-related complications, implant removals, and nonunions compared with PF. Especially in elderly patients, patients with chronic comorbidity, and patients with compromised soft tissue, IMF may be preferred over PF.

Severely injured patients benefit from in-house attending trauma surgeons.

INTRODUCTION: There is continuous drive to optimize healthcare for the most severely injured patients. Although still under debate, a possible measure is to provide 24/7 in-house (IH) coverage by trauma surgeons. The aim of this study was to compare process-related outcomes for severely injured patients before and after transition of attendance policy from an out-of-hospital (OH) on-call attending trauma surgeon to an in-house attending trauma surgeon. METHODS: Retrospective before-and-after study using prospectively gathered data in a Level 1 Trauma Center in the Netherlands. All trauma patients with an Injury Severity Score (ISS) >24 presenting to the emergency department for trauma before (2011-2012) and after (2014-2016) introduction of IH attendings were included. Primary outcome measures were the process-related outcomes Emergency Department length of stay (ED-LOS) and time to first intervention. RESULTS: After implementation of IH trauma surgeons, ED-LOS decreased (p = 0.009). Time from the ED to the intensive care unit (ICU) for patients directly transferred to the ICU was significantly shorter with more than doubling of the percentage of patients that reached the ICU within an hour. The percentage of patients undergoing emergency surgery within 30 min nearly doubled as well, with a larger amount of patients undergoing CT imaging before emergency surgery. CONCLUSIONS: Introduction of a 24/7 in-house attending trauma surgeon led to improved process-related outcomes for the most severely injured patients. There is clear benefit of continuous presence of physicians with sufficient experience in trauma care in hospitals treating large numbers of severely injured patients.

Comparison of analgesic interventions for traumatic rib fractures: a systematic review and meta-analysis.

PURPOSE: Many studies report on outcomes of analgesic therapy for (suspected) traumatic rib fractures. However, the literature is inconclusive and diverse regarding the management of pain and its effect on pain relief and associated complications. This systematic review and meta-analysis summarizes and compares reduction of pain for the different treatment modalities and as secondary outcome mortality during hospitalization, length of mechanical ventilation, length of hospital stay, length of intensive care unit stay (ICU) and complications such as respiratory, cardiovascular, and/or analgesia-related complications, for four different types of analgesic therapy: epidural analgesia, intravenous analgesia, paravertebral blocks and intercostal blocks. METHODS: PubMed, EMBASE and CENTRAL databases were searched to identify comparative studies investigating epidural, intravenous, paravertebral and intercostal interventions for traumatic rib fractures, without restriction for study type. The search strategy included keywords and MeSH or Emtree terms relating blunt chest trauma (including rib fractures), analgesic interventions, pain management and complications. RESULTS: A total of 19 papers met our inclusion criteria and were finally included in this systematic review. Significant differences were found in favor of epidural analgesia for the reduction of pain. No significant differences were observed between epidural analgesia, intravenous analgesia, paravertebral blocks and intercostal blocks, for the secondary outcomes. CONCLUSIONS: Results of this study show that epidural analgesia provides better pain relief than the other modalities. No differences were observed for secondary endpoints like length of ICU stay, length of mechanical ventilation or pulmonary complications. However, the quality of the available evidence is low, and therefore, preclude strong recommendations.

Factors Associated With Wound- and Implant-Related Complications After Surgical Treatment of Ankle Fractures.

We have described the epidemiology of complications after surgical treatment of ankle fractures and assessed which factors are associated with the most frequent complications. We conducted a retrospective cohort study at 2 level 2 and 1 level 1 trauma center in a single trauma region in the Netherlands. The study variables were collected from the electronic medical patient records; all ankle fractures were classified using the Lauge-Hansen classification, and the complications were recorded. A total of 989 patients were included from 3 hospitals, with 173 complications in 156 patients (15.8%). The most frequent complication was wound related, occurring in 101 patients (10.2%). Implant-related complications occurred in 44 patients (4.4%). Other complications, such as cast pressure spots, posttraumatic dystrophy, nonunion, impingement, and pneumonia occurred in 28 patients (2.8%). The 2 most important complications were further analyzed for risk factors. Multivariate analysis showed the risk factors for wound-related complications were advanced age, increased American Society of Anesthesiologists classification, smoking, right side symptomatic, open fracture, and initial external fixation. Most implant-related complications were caused by malreduction (n = 22) or untreated syndesmotic injury (n = 19). Malreduction was associated with supination eversion fractures (p = .059), and untreated syndesmotic injury occurred more often with pronation external rotation fractures (p < .001). The most frequent complications after ankle fracture surgery were wound- and implant-related complications. Postoperative wound-related complications were multifactorial and dependent on a combination of trauma-, patient-, and treatment-related factors. In contrast, implant-related complications resulted from the interaction between the fracture type and subsequent surgical treatment.

Operative versus nonoperative treatment of proximal humeral fractures: a systematic review, meta-analysis, and comparison of observational studies and randomized controlled trials.

BACKGROUND: There is no consensus on the choice of treatment for displaced proximal humeral fractures in older patients (aged > 65 years). The aims of this systematic review and meta-analysis were (1) to compare operative with nonoperative management of displaced proximal humeral fractures and (2) to compare effect estimates obtained from randomized controlled trials (RCTs) and observational studies. METHODS: The databases of MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) were searched on September 5, 2017, for studies comparing operative versus nonoperative treatment of proximal humeral fractures; both RCTs and observational studies were included. The criteria of the Methodological Index for Non-Randomized Studies, a validated instrument for methodologic quality assessment, were used to assess study quality. The primary outcome measure was physical function as measured by the absolute Constant-Murley score after operative or nonoperative treatment. Secondary outcome measures were major reinterventions, nonunion, and avascular necrosis. RESULTS: We included 22 studies, comprising 7 RCTs and 15 observational studies, resulting in 1743 patients in total: 910 treated operatively and 833 nonoperatively. The average age was 68.3 years, and 75% of patients were women. There was no difference in functional outcome between operative and nonoperative treatment, with a mean difference of -0.87 (95% confidence interval, -5.13 to 3.38; P = .69; I2 = 69%). Major reinterventions occurred more often in the operative group. Pooled effects of RCTs were similar to pooled effects of observational studies for all outcome measures. CONCLUSIONS: We recommend nonoperative treatment for the average elderly patient (aged > 65 years) with a displaced proximal humeral fracture. Pooled effects of observational studies were similar to those of RCTs, and including observational studies led to more generalizable conclusions.