The societal costs of femoral neck fracture patients treated with internal fixation.

SUMMARY: The study rationale was to provide a detailed overview of the costs for femoral neck fracture treatment with internal fixation in the Netherlands. Mean total costs per patient at 2-years follow-up were 19,425. Costs were higher for older, less healthy patients. Results are comparable to internationally published costs. INTRODUCTION: The aim of this study was to provide a detailed overview of the cost and healthcare consumption of patients treated for a hip fracture with internal fixation. A secondary aim was to compare costs of patients who underwent a revision surgery with patients who did not. METHODS: The study was performed alongside the Dutch sample of an international randomized controlled trial, concerning femoral neck fracture patients treated with internal fixation. Patient characteristics and healthcare consumption were collected. Total follow-up was 2 years. A societal perspective was adopted. Costs included hospital costs during primary stay and follow-up, and costs related to rehabilitation and changes in living situation. Costs were compared between non-revision surgery patients, implant removal patients, and revision arthroplasty patients. RESULTS: A total of 248 patients were included (mean age 71 years). Mean total costs per patient at 2-years follow-up were 19,425. In the non-revision surgery patients total costs were 17,405 (N = 137), in the implant removal patients 10,066 (N = 38), and in the revision arthroplasty patients 26,733 (N = 67). The main contributing costs were related to the primary surgery, admission days, physical therapy, and revision surgeries. CONCLUSIONS: The main determinant was the costs of admission to a rehabilitation center/nursing home. Costs were specifically high in elderly with comorbidity, who were less independent pre-fracture, and have a longer admission to the hospital and/or a nursing home. Costs were also higher in revision surgery patients. The 2-years follow-up costs in our study were comparable to published costs in other Western societies.

Radiological work-up after mass casualty incidents: are ATLS guidelines applicable?

OBJECTIVES: In mass casualty incidents (MCI) a large number of patients need to be evaluated and treated fast. Well-designed radiological guidelines can save lives. The purpose of this study was to evaluate the Advanced Trauma Life Support (ATLS) radiological guidelines in the MCI of an aeroplane crash. METHODS: Medical data of all 126 survivors of an aeroplane crash were analysed. Data included type and body region of the radiological studies performed on the survivors, Abbreviated Injury Score (AIS) and Injury Severity Score (ISS) codes and trauma care level of the hospitals. RESULTS: Ninety patients (72 %) underwent one or more imaging studies: in total 297 radiographs, 148 CTs and 18 ultrasounds were performed. Only 18 % received diagnostic imaging of all four body regions as recommended by ATLS. Compliance with ATLS was highest (73.3 %) in severely injured victims (ISS ≥16); this group underwent two thirds of the (near) total body CTs, all performed in level I trauma centres. CONCLUSION: Overall compliance with ATLS radiological guidelines was low, although high in severely injured patients. Level I trauma centres frequently used (near) total body CT. Deviation from ATLS guidelines in radiological work-up in less severely injured patients can be safe and did not result in delayed diagnosis of serious injury. KEY POINTS: • Radiological imaging protocols can assist the management of mass casualty incidents needs. • Advanced Trauma Life Support (ATLS) radiological guidelines have been developed. • But radiological guidelines have not frequently been applied in aeroplane crashes. • Aircraft accidents are of high energy so ATLS guidelines should be applied. • Following mass casualty incidents total body CT seems appropriate within ATLS protocols.

Subtalar dislocation: two cases requiring surgery and a literature review of the last 25 years.

BACKGROUND: Subtalar dislocations are uncommon, representing ~1% of all traumatic dislocations. We present two cases of closed medial subtalar dislocation and a systematic literature review of the last 25 years. METHODS: We performed an Embase, Medline, Pubmed and Cochrane search of the literature written in English between January 1988 and December 2012. Keywords used were subtalar, peritalar, subastragalar, luxatio pedis sub talo, dislocation and dislocations. All articles presenting original patient data were included. All available data regarding gender, age, direction, affected side, open or closed injury, accompanying fractures, reduction, time of immobilization and outcomes were collected in a database. RESULTS: Seventy-six articles were included with a total of 528 reported cases. Males (318/419 = 76%) and the right foot (122/200 = 61%) were affected more often than females and the left foot. Average age was 33.8 years (range 19 months-86 years). Cause of injury was a traffic accident in 43.7% (157/359), a fall in 32.9% (118/359), sports injuries in 13.9% (50/359), sprain injuries in 5.3% (19/359) and other causes in 4.2% (15/359). The direction of the dislocation was medial in 71.5 % (352/492), lateral in 26.0% (128/492), posterior in 1.6% (8/492) and anterior in 0.8% (4/492). Open dislocation was reported in 22.5% (67/298). In 61.4% (216/352) an additional osseous injury was diagnosed. Closed reduction was unsuccessful in 14.0% (51/364) requiring immediate open reduction. Overall outcomes in the literature were good in 52.3% (172/329), fair in 25.2% (83/329) and poor in 22.5% (74/329). LEVEL OF CLINICAL EVIDENCE: 4.

Trends in data quality and quality indicators 5 years after implementation of the Dutch Hip Fracture Audit.

PURPOSE: The Dutch Hip Fracture Audit (DHFA), a nationwide hip fracture registry in the Netherlands, registers hip fracture patients and aims to improve quality of care since 2016. This study shows trends in the data quality during the first 5 years of data acquisition within the DHFA, as well as trends over time for designated quality indicators (QI). METHODS: All patients registered in the DHFA between 1-1-2016 and 31-12-2020 were included. Data quality-registry case coverage and data completeness-and baseline characteristics are reported. Five QI are analysed: Time to surgery < 48 h, assessment for osteoporosis, orthogeriatric co-management, registration of functional outcomes at three months, 30-day mortality. The independent association between QI results and report year was tested using mixed-effects logistic models and in the case of 30-day mortality adjusted for casemix. RESULTS: In 2020, the case capture of the DHFA comprised 85% of the Dutch hip fracture patients, 66/68 hospitals participated. The average of missing clinical values was 7.5% in 2016 and 3.2% in 2020. The 3 months follow-up completeness was 36.2% (2016) and 46.8% (2020). The QI 'time to surgery' was consistently high, assessment for osteoporosis remained low, orthogeriatric co-management scores increased without significance, registration of functional outcomes improved significantly and 30-day mortality rates remained unchanged. CONCLUSION: The DHFA has successfully been implemented in the past five years. Trends show improvement on data quality. Analysis of several QI indicate points of attention. Future perspectives include lowering the burden of registration, whilst improving (registration of) hip fracture patients outcomes.

Nature, causes and consequences of unintended events in surgical units.

BACKGROUND: Several studies have shown that the rate of unintended harm is higher in surgical than in non-surgical care. To improve patient safety in surgery, information about the underlying causes is needed. This observational study examined the nature, causes and consequences of unintended events in surgical units, and the completeness of event reporting. METHODS: Ten surgical units in the Netherlands participated. The study period per unit was 8-14 weeks, during which healthcare providers reported unintended events. Event reports were analysed with a root cause analysis tool (PRISMA). In addition, an independent surgeon reviewed about 40 patient records of patients in each surgical unit to examine whether an unintended event had occurred. RESULTS: A total of 881 unintended events were reported and analysed, of which 33.0 per cent were categorized as medication events. Most root causes were human (72.3 per cent), followed by organizational (16.1 per cent) and technical (5.7 per cent). More than half of the events had consequences for the patient. Sixty-four unintended events were identified in a review of 320 patient records. Only one of these events was also reported by a healthcare provider. CONCLUSION: Event reporting and patient record review provide insight into diverse types of unintended events and complement each other. The information on unintended events from both sources may help target research and interventions to increase patient safety.

Factors associated with health-related quality of life, hip function, and health utility after operative management of femoral neck fractures.

Aims: The primary aim of this prognostic study was to identify baseline factors associated with physical health-related quality of life (HRQL) in patients after a femoral neck fracture. The secondary aims were to identify baseline factors associated with mental HRQL, hip function, and health utility. Patients and Methods: Patients who were enrolled in the Fixation using Alternative Implants for the Treatment of Hip Fractures (FAITH) trial completed the 12-item Short Form Health Survey (SF-12), Western Ontario and McMaster Universities Arthritis Index, and EuroQol 5-Dimension at regular intervals for 24 months. We conducted multilevel mixed models to identify factors potentially associated with HRQL. Results: The following were associated with lower physical HRQL: older age (-1.42 for every ten-year increase, 95% confidence interval (CI) -2.17 to -0.67, p < 0.001); female gender (-1.52, 95% CI -3.00 to -0.05, p = 0.04); higher body mass index (-0.69 for every five-point increase, 95% CI -1.36 to -0.02, p = 0.04); American Society of Anesthesiologists class III ( versus class I) (-3.19, 95% CI -5.73 to -0.66, p = 0.01); and sustaining a displaced fracture (-2.18, 95% CI -3.88 to -0.49, p = 0.01). Additional factors were associated with mental HRQL, hip function, and health utility. Conclusion: We identified several baseline factors associated with lower HRQL, hip function, and utility after a femoral neck fracture. These findings may be used by clinicians to inform treatment and outcomes. Cite this article: Bone Joint J 2018;100-B:361-9.

[An older man with a painful hip after a fall]. / Een oudere man met een pijnlijke heup na een val.

A 94-year-old man presented to the Emergency Room after falling on his right hip. This hip was painful and a fracture was suspected. The X-rays showed an abnormal structure of the right femur but no fracture. The images were typical for Paget's disease. The patient was treated with bisphosphonates.

Internal fixation for displaced fractures of the femoral neck. Does bone density affect clinical outcome?

The results of meta-analysis show a revision rate of 33% for internal fixation of displaced fractures of the femoral neck, mostly because of nonunion. Osteopenia and osteoporosis are highly prevalent in elderly patients. Bone density has been shown to correlate with the intrinsic stability of the fixation of the fracture in cadaver and retrospective studies. We aimed to confirm or refute this finding in a clinical setting. We performed a prospective, multicentre study of 111 active patients over 60 years of age with a displaced fracture of the femoral neck which was eligible for internal fixation. The bone density of the femoral neck was measured pre-operatively by dual-energy x-ray absorptiometry (DEXA). The patients were divided into two groups namely, those with osteopenia (66%, mean T-score -1.6) and those with osteoporosis (34%, mean T-score -3.0). Age (p = 0.47), gender (p = 0.67), delay to surgery (p = 0.07), the angle of the fracture (p = 0.33) and the type of implant (p = 0.48) were similar in both groups. Revision to arthroplasty was performed in 41% of osteopenic and 42% of osteoporotic patients (p = 0.87). Morbidity (p = 0.60) and mortality were similar in both groups (p = 0.65). Our findings show that the clinical outcome of internal fixation for displaced fractures of the femoral neck does not depend on bone density and that pre-operative DEXA is not useful.

[Large variation in indications for internal fixation or arthroplasty in displaced femoral neck fracture; results of a questionnaire distributed among general surgeons in 20 hospitals]. / Grote variatie in indicaties voor interne fixatie of artroplastiek bij de gedislokeerde mediale collumfractuur; enquête onder algemeen chirurgen in 20 ziekenhuizen.

OBJECTIVE: To describe the treatment protocols for displaced femoral neck fractures in all 8 university hospitals (UH) and 12 general hospitals (GH). DESIGN: Descriptive; questionnaire. METHOD: Questionnaires were distributed to general surgeons who also perform traumatology surgery. They were requested to give succinct answers to questions about local protocol for the maximum permissible time interval between hip trauma and operation, indications for internal fixation and arthroplasty, operative technique and postoperative degree of weight-bearing in patients over 60 years of age with a displaced femoral neck fracture. RESULTS: Internal fixation and arthroplasty were performed within 24 and 48 hours respectively in 95% of all hospitals. A biological upper age limit of between 65 and 80 years old was the most commonly quoted indication for internal fixation in 70% of all hospitals. In 83% of GH dementia was considered an indication for arthroplasty as opposed to 0% in UH. Poor bone quality, immobility, comminution and inadequate reduction were incidentally quoted indications for arthroplasty. Rheumatoid arthritis, arthrosis and pathological fracture were contra-indications for internal fixation in all hospitals. Operative techniques for internal fixation and arthroplasty were similar in both UH and GH. After internal fixation, full weight-bearing was recommended in all UH and partial weight-bearing in 7 (58%) of GH. Following arthroplasty all protocols prescribed full weight-bearing. CONCLUSION: The variation in indications for internal fixation or arthroplasty reflects the lack of studies that demonstrate clearly which patient can be treated optimally with which treatment modality. There were few differences in the operative techniques of internal fixation and arthroplasty between the hospitals.

Spinal injuries in an airplane crash: a description of incidence, morphology, and injury mechanism.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: Spinal injuries of the survivors of an airplane crash are described. On the basis of injury morphology and knowledge of the conditions of the accident, injury mechanisms are described and prevention measures are discussed. SUMMARY OF BACKGROUND DATA: The most common causes of spinal fractures are a high energy fall (incidence 21.2%-39%) and motor vehicle accidents (21.7%-33.61%). Detailed reports solely on spinal injuries, as a result of an airplane crash, are scarce in literature. METHODS: An analysis was performed on the spinal injuries of all 126 survivors of a commercial airplane (Boeing 737) crash near Amsterdam in 2009. Level of injury and fracture classification by morphology, independently performed by 4 specialists in spinal trauma, was documented. An analysis was done on the type of injuries and the suggested mechanism of injury by evaluating the crash characteristics analysis. RESULTS: Twenty-three (18.3%) of the survivors sustained a total of 27 spinal injuries. Four (17.1% of the patients with spinal injury) experienced a single cervical spine fracture. Eight (29.6%) injuries were at the thoracic spine and 15 (55.6%) at the lumbar spine level. More than half of the injuries included a burst component. CONCLUSION: A high number of spinal injuries was found after this airplane crash. The morphology of the injuries consisted of a high rate of burst-type fractures presumably caused by a mainly vertical trauma mechanism as shown by the accident analysis. LEVEL OF EVIDENCE: 4.

[Increased risk of heart and vascular diseases in fisherman from Urk]. / Vergroot risico van hart- en vaatziekten bij Urker vissers.

UNLABELLED: In order to assess physicians' preconceived ideas about unhealthy lifestyle of North Sea fishermen from Urk, the prevalence of five important risk factors for cardiovascular disease: hypertension, hypercholesterolaemia, smoking, obesity and diabetes mellitus was determined in a cross-sectional study in this population. In addition, the use of the Primetest device, a newly developed desk top analyser, was evaluated. Out of 646 people invited at the community centre at Urk, Flevoland, 384 (59%) fishermen were investigated using Primetest, which contains an electronic sphygmomanometer and colometrically determines total cholesterol and glucose levels. 87 laboratory determinations (with HDL-cholesterol and triglyceride determinations) were used when Primetest cholesterol determination proved insufficiently reliable. Male cardiovascular mortality in Urk was also compared with mortality in the Netherlands. Hypertension prevalence (last of six readings) corresponded with that of the nearby town of Lelystad, 6% and 8% respectively. The average total:HDL-cholesterol ratio was not higher than recent values from elsewhere in the Netherlands. Fifty per cent of the fishermen had a high risk (ratio greater than 4.5). Of these, 18% had hypertriglyceridaemia (greater than or equal to 2.3 mmol/l). Smoking rates were very high (58%) and 60% had moderate to severe obesity (Body Mass Index greater than or equal to 26 kg/m2). 2% had diabetes mellitus, corresponding with the prevalence in the Netherlands. Absolute and proportional male cardiovascular mortality in Urk did not differ from the Netherlands. CONCLUSION: two risk factors had a high prevalence among Urk fishermen. Blood pressure measurements and glucose determination with Primetest are simple and reliable. For technical reasons reliable cholesterol determination was not yet possible.

Delayed diagnosis of injury in survivors of the February 2009 crash of flight TK 1951.

INTRODUCTION: On 25th February 2009, a Boeing 737 crashed nearby Amsterdam, leaving 126 victims. In trauma patients, some injuries initially escape detection. The aim of this study was to evaluate the incidence of Delayed Diagnosis of Injury (DDI) and the tertiary survey on the victims of a plane crash, and the effect of ATLS(®) implementation on DDI incidence. PATIENTS AND METHODS: Data from all victims were analysed with respect to hospitalisation, DDI, tertiary survey, ISS, Glasgow Coma Score (GCS), injuries (number and type) and emergency intervention. Clinically significant injuries were separated from non-clinically significant injuries. The data were compared to a plane crash in the UK (1989), which occurred before ATLS(®) became widely practiced. RESULTS: All 126 victims of the Dutch crash were evaluated in a hospital; 66 were hospitalised with a total of 171 clinically significant injuries. Twelve (7%) clinically significant DDIs were found in 8 patients (12%). In 65% of all patients, a tertiary survey was documented. The incidence of DDI in patients with an ISS ≥ 16 (n=13) was 23%, vs. 9% in patients with ISS <16. Patients with >5 injuries had a DDI incidence of 25%, vs. 12% in patients with ≤ 5 injuries. Head injury patients had a DDI incidence of 19%, patients without head injury 10%. Fifty percent of patients who needed an emergency intervention (n=4) had a DDI; 3% of patients who did not need emergency intervention. Eighty-one survivors of the UK crash had a total of 332 injuries. DDIs were found in 30.9% of the patients. Of all injuries 9.6% was a DDI. The incidence of DDI in patients with >5 injuries was 5%, vs. 8% in those with ≤ 5 injuries. CONCLUSION: DDI in trauma still happen. In this study the incidence was 7% of the injuries in 12% of the population. In one third of the patients no tertiary survey was documented. A high ISS, head injury, more than 5 injuries and an emergency intervention were associated with DDI. The DDI incidence in our study was lower than in victims of a previous plane crash prior to ATLS implementation.

Current concepts in the treatment of intra-articular calcaneal fractures: results of a nationwide survey.

The treatment of intra-articular calcaneal fractures is controversial and randomised clinical trials are scarce. Moreover, the socio-economic cost remains unclear. The aim of this study was to estimate the incidence, treatment preferences and socio-economic cost of this complex fracture in the Netherlands. This data may aid in planning future clinical trials and support education. The method of study was of a cross-sectional survey design. A written survey was sent to one representative of both the traumatology and the orthopaedic staff in each hospital in the Netherlands. Data on incidence, treatment modalities, complications and follow-up strategies were recorded. The socio-economic cost was calculated. The average response rate was 70%. Fracture classifications, mostly by Sanders and Essex-Lopresti, were applied by 29%. Annually, 920 intra-articular calcaneal fractures (0.4% incidence rate) were treated, mainly with ORIF (46%), conservative (39%) and percutaneous (10%) treatment. The average non-weight-bearing mobilisation was 9 weeks (SD 2 weeks). An outcome score, mainly AOFAS, was documented by 7%. A secondary arthrodesis was performed in 21% of patients. The socio-economic cost was estimated to be euro21.5-30.7 million. Dutch intra-articular calcaneal fracture incidence is at least 0.4% of all fractures presenting to hospitals. Better insight into treatment modalities currently employed and costs in the Netherlands was obtained.

Effect of surgical delay on outcome in hip fracture patients: a retrospective multivariate analysis of 192 patients.

Previous studies have not demonstrated consistent results on the effect of surgical delay on outcome. This study investigated the association between the delay to surgery and the development of postoperative complications, length of hospital stay (LOS) and one-year mortality. Patients that underwent surgery for a hip fracture in a two-year period were included in a retrospective study. Uni- and multivariate regression analysis was performed in 192 hip fracture patients. There was a trend towards fewer postoperative complications (P = 0.064; multivariate regression, MR) and shorter LOS (P = 0.088; MR) in patients with a delay of less than one day to surgery. No association between surgical delay and one-year mortality was found in the population as a whole (P = 0.632; univariate regression, UR). Delay to surgery beyond one day was associated with an increased risk of infectious complications (P = 0.004; MR). In ASA I and II class patients, operation beyond one day from admission was associated with an increased risk of one-year mortality (P = 0.03; MR) and more postoperative infectious complications (P = 0.02; MR). The trends towards fewer complications and shorter LOS suggest that early surgery (within one day from admission) is beneficial for hip fracture patients who are able to undergo an operation.

Rating of internal fixation and clinical outcome in displaced femoral neck fractures: a prospective multicenter study.

The influence of precise surgical technique on the clinical outcome of internal fixation for displaced femoral neck fractures is an under-reported and potential confounding factor in randomized studies involving internal fixation as a treatment modality. Two experienced surgeons blindly rated internal fixation techniques on the perioperative radiographs of 102 patients selected for internal fixation in a prospective multicenter 2-year followup study. Overall technical, fracture reduction, and implant positioning ratings were given according to instruction. One or both raters assigned an inadequate overall rating in 25% of patients. There was a correlation with 2-year clinical internal fixation failure for overall technique and fracture reduction rating. Implant positioning did not correlate with 2-year internal fixation failure. Correlation increased if both raters agreed on inadequate technique. One inadequate rating indicated a problem could arise, whereas two inadequate ratings strengthened this problem likelihood. Adjudication of technique by independent rater(s) is useful, may have clinical implications, and should be performed routinely in future studies involving internal fixation in patients with displaced femoral neck fractures.