Wound infection following implant removal of foot, ankle, lower leg or patella; a protocol for a multicenter randomized controlled trial investigating the (cost-)effectiveness of 2 g of prophylactic cefazolin compared to placebo (WIFI-2 trial).

BACKGROUND: Elective implant removal (IR) after fracture fixation is one of the most common procedures within (orthopedic) trauma surgery. The rate of surgical site infections (SSIs) in this procedure is quite high, especially below the level of the knee. Antibiotic prophylaxis is not routinely prescribed, even though it has proved to lower SSI rates in other (orthopedic) trauma surgical procedures. The primary objective is to study the effectiveness of a single intravenous dose of 2 g of cefazolin on SSIs after IR following fixation of foot, ankle and/or lower leg fractures. METHODS: This is a multicenter, double-blind placebo controlled trial with a superiority design, including adult patients undergoing elective implant removal after fixation of a fracture of foot, ankle, lower leg or patella. Exclusion criteria are: an active infection, current antibiotic treatment, or a medical condition contraindicating prophylaxis with cefazolin including allergy. Patients are randomized to receive a single preoperative intravenous dose of either 2 g of cefazolin or a placebo (NaCl). The primary analysis will be an intention-to-treat comparison of the proportion of patients with a SSI at 90 days after IR in both groups. DISCUSSION: If 2 g of prophylactic cefazolin proves to be both effective and cost-effective in preventing SSI, this would have implications for current guidelines. Combined with the high infection rate of IR which previous studies have shown, it would be sufficiently substantiated for guidelines to suggest protocolled use of prophylactic antibiotics in IR of foot, ankle, lower leg or patella. Trial registration Nederlands Trial Register (NTR): NL8284, registered on 9th of January 2020, https://www.trialregister.nl/trial/8284.

Normative data for the Patient-Rated Wrist Evaluation questionnaire.

STUDY DESIGN: Cross-sectional study. INTRODUCTION: The Patient-Rated Wrist Evaluation (PRWE) questionnaire is used to evaluate functional outcomes after treatment of wrist and hand injuries and nontraumatic conditions. Since patients commonly present with an injury, it is impossible to assess preinjury physical functioning. Therefore, it is important to be aware of the population-based normative data. PURPOSE OF THE STUDY: The aim of this study was to determine the normative data for the PRWE questionnaire. Secondary, we aimed to determine if there were factors influencing these normative data. METHODS: Visitors and employees of 4 hospitals were requested to participate. Excluded were all participants who were scheduled for surgery or were in treatment or after treatment for an injury of the wrist or hand within 1 year after trauma. All participants were asked to complete the PRWE questionnaire and were asked for their age, sex, history of wrist or hand fracture or surgery, daily activities, and the type of employment. The socioeconomic status was determined based on the zip code. RESULTS: The median PRWE score was 0 (interquartile range: 0-8.5) and the mean score 7.7 (standard deviation: 15.0). Women had significantly higher scores compared to men, and younger individuals had significantly lower scores. Participants with a history of wrist or hand fracture or surgery, and participants who were unfit for work had significantly higher scores. Socioeconomic status was not correlated with the PRWE score. DISCUSSION: The purpose was to provide an representative overview of the normative data for the normal population. We did not want to present the data of an unnatural healthy population, which is not representative of the normal population. Deleting patients with chronic wrist or hand complaints, would have resulted in normative values which are not representable for the normal, average population. CONCLUSION: Low scores are observed for the PRWE in the general population. These scores are age and sex dependent and are higher in individuals with a history of wrist or hand fracture or surgery or who are unfit for work.

Health care consumption and costs due to foot and ankle injuries in the Netherlands, 1986-2010.

BACKGROUND: Foot and ankle injuries account for a large proportion of Emergency Department attendance. The aim of this study was to assess population-based trends in attendances due to foot and ankle injuries in the Netherlands since 1986, and to provide a detailed analysis of health care costs in these patients. METHODS: Age- and gender-standardized emergency attendance rates and incidence rates for hospital admission were calculated for each year of the study. Injury cases and hospital length of stay were extracted from the National Injury Surveillance System (non-hospitalized patients) and the National Medical Registration (hospitalized patients). Data were grouped into osseous and ligamentous injuries for foot and ankle separately. An incidence-based cost model was applied to calculate associated direct health care costs. RESULTS: Since 1986 the overall emergency attendance rate decreased from 858 to 640 per 100,000 person years. In non-admitted patients (90% of cases), ligamentous injuries approximately halved, whereas osseous injuries increased by 28% (foot) and 25% (ankle). The incidence rate for hospital admission increased by 35%, mainly due to an almost doubling of osseous injuries. Attendance rates showed a peak in adolescents and adults until ~45 years of age in males and (less pronounced) in females. The total number of hospital days decreased to 58,708 days in 2010. Hospital length of stay (HLOS) increased with age and was highest for osseous injuries. HLOS was unaffected by gender, apart for longer stay in elderly females with an osseous ankle injury. Health care costs per case were highest for osseous injuries of the ankle (€ 3,461). Costs were higher for females and increased with age to € 6,023 in elderly males and € 10,949 in elderly females. Main cost determinants were in-hospital care (56% of total costs), rehabilitation/nursing care (15%), and physical therapy (12%). CONCLUSIONS: Since 1986, the emergency attendance rate of foot and ankle injuries in the Netherlands decreased by 25%. Throughout the years, the attendance rate of (relatively simple) ligamentous injuries strongly reduced, whereas osseous injuries nearly doubled. Attendance rates and health care costs were gender- and age-related. Main cost determinants were in-hospital care, rehabilitation/nursing care, and physical therapy.

Hemi-Castaing ligamentoplasty for the treatment of chronic lateral ankle instability: a retrospective assessment of outcome.

PURPOSE: In the treatment of chronic ankle instability, most non-anatomical reconstructions use the peroneus brevis tendon. This, however, sacrifices the natural ankle stabilising properties of the peroneus brevis muscle. The aim of this study was to evaluate the functional outcome of patients treated with a hemi-Castaing procedure, which uses only half the peroneus brevis tendon. METHODS: We performed a retrospective cohort study of patients who underwent hemi-Castaing ligamentoplasty for chronic lateral ankle instability between 1993 and 2010, with a minimum of one year follow-up. Patients were sent a postal questionnaire comprising five validated outcome measures: Olerud-Molander Ankle Score (OMAS), Karlsson Ankle Functional Score (KAFS), Tegner Activity Level Score (pre-injury, prior to surgery, at follow-up), visual analog scale on pain (VAS) and the Short Form 36 (SF-36). RESULTS: Twenty patients completed the questionnaire on functional outcome. The OMAS showed good to excellent outcome in 80% and the KAFS in 65%, the Tegner Score improved from surgery but did not reach pre-injury levels, the VAS on pain was 1 of 10 and the SF-36 returned to normal compared with the average population. CONCLUSIONS: Even though most patients were satisfied with the results, outcome at long-term follow-up was less favourable compared with the literature on anatomical reconstructions. In accordance with the literature, we therefore conclude that the initial surgical treatment of chronic lateral ankle instability should be an anatomical repair with augmentation (i.e. the Broström-Gould technique) and the non-anatomical repair should be reserved for unsuccessful cases after anatomical repair or in cases where no adequate ligament remnants are available for reconstruction.