Radiological outcomes following surgical fixation with wires versus moulded cast for patients with a dorsally displaced fracture of the distal radius: a radiographic analysis from the DRAFFT2 trial.

Aims: The primary aim of this study was to report the radiological outcomes of patients with a dorsally displaced distal radius fracture who were randomized to a moulded cast or surgical fixation with wires following manipulation and closed reduction of their fracture. The secondary aim was to correlate radiological outcomes with patient-reported outcome measures (PROMs) in the year following injury. Methods: Participants were recruited as part of DRAFFT2, a UK multicentre clinical trial. Participants were aged 16 years or over with a dorsally displaced distal radius fracture, and were eligible for the trial if they needed a manipulation of their fracture, as recommended by their treating surgeon. Participants were randomly allocated on a 1:1 ratio to moulded cast or Kirschner wires after manipulation of the fracture in the operating theatre. Standard posteroanterior and lateral radiographs were performed in the radiology department of participating centres at the time of the patient's initial assessment in the emergency department and six weeks postoperatively. Intraoperative fluoroscopic images taken at the time of fracture reduction were also assessed. Results: Patients treated with surgical fixation with wires had less dorsal angulation of the radius versus those treated in a moulded cast at six weeks after manipulation of the fracture; the mean difference of -4.13° was statistically significant (95% confidence interval 5.82 to -2.45). There was no evidence of a difference in radial shortening. However, there was no correlation between these radiological measurements and PROMs at any timepoint in the 12 months post-injury. Conclusion: For patients with a dorsally displaced distal radius fracture treated with a closed manipulation, surgical fixation with wires leads to less dorsal angulation on radiographs at six weeks compared with patients treated in a moulded plaster cast alone. However, the difference in dorsal angulation was small and did not correlate with patient-reported pain and function.

Levelling up: prioritisation of global health.

Trauma has been described as "The forgotten pandemic" (Rossiter in Int Orthop 46:3-11, 2022  https://doi.org/10.1007/s00264-021055213-z ) or "The hidden pandemic" (Graham SM, Laubscher M, Lalloo DG, Harrison WJ, Maqungo S in The Surg, 20, 231-236. https://doi.org/10.1016/j.surg.2021.04.005 , 2022). If you add all deaths and disability from all contagious disease including: HIV, TB, malaria and COVID-19 these do not come close to the numbers affected annually from trauma/injury (Rossiter in Int Orthop 46:3-11, 2022; Annual deaths from the WHO Global Health Observatory (25); in: Preventing Injuries and Violence: A Guide for Ministries of Health, WHO, Geneva, 26). Prior to the present pandemic contagious disease received approximately 35% of global healthcare spending, whilst trauma received just 1% (Wesson et al. in Health Policy Plan 29:795-808, 2014). The global healthcare spending on contagious disease in the last two years has doubled and that of trauma has proportionately decreased, highlighting the significant issue of prioritisation of healthcare globally. Trauma is the greatest cause of mortality and morbidity in the 5 to 30 age group (Wesson et al. in Health Policy Plan 29:795-808, 2014). Most of the world lives in a country where the majority of the population are under the age of 35, the working population, who are disproportionately affected by trauma. Investment into trauma/injury could dramatically improve the GDP of that country and the situation of the population ( https://www.thinkglobalhealth.org/article/golden-hour-critical-time-between-life-and-death ). It is also estimated that 5 billion people globally lack "Available Accessible Acceptable & Quality" (the AAAQ framework) Surgical Obstetric Trauma & Anaesthetic (SOTA) (Meara JG et al. in Lancet, 386(9993):569-624. https://doi.org/10.1016/S0140-6736(15)60160-X , 2015). Access to this care is an agreed human right (Price R, Makasa E, Hollands M in World J Surg, 39(9):2115-25. https://doi.org/10.1007/s00268-015-3153-y . PMID: 26239773, 2015). It forms part of the 17 Millennium Sustainable Development Goals from the United Nations to be achieved within 20 years ( https://sdgs.un.org/goals#goals ). By 2014, it was recognised that AAAQ SOTA care was not going to be achieved within the next 5 years and so the G4 Alliance was born with the aim of achieving this by 2030 ( https://www.theg4alliance.org ).

"Trauma-the forgotten pandemic?"

Global annual deaths from Trauma are greater than any other single cause in the global working population, and, more than all contagious diseases added together including COVID-19. The number of people injured, either temporarily or permanently, is greater than any other medical condition. This problem affects Low and Middle Income Countries (LMICs) disproportionately. The numbers are so great as to cause "zone out" and present a human rights issue. This is a particular issue as Trauma presently receives less than 1% of global healthcare funding. This article will highlight and discuss many of the issues and raise some uncomfortable arguments showing that improvement is needed, necessary and achievable.

Mechanical prophylaxis, early mobilisation and risk stratification: as effective as drugs for low risk patients undergoing primary joint replacement. Results in 13,384 patients.

INTRODUCTION: Current NICE Guidelines state that all patients undergoing total hip and knee arthroplasty should be given both mechanical and chemical prophylaxis. At our institution, a targeted thromboprophylaxis policy has been in place since October 1999. The aim of this study was to calculate our venous thromboembolism rates and compare these to published rates in the literature. METHODS: All patients are pre-operatively assessed for their VTE risk. Patients are stratified into high or low risk: all patients received mechanical thromboprophylaxis and the higher risk patients now receive chemical and mechanical thromboprophylaxis post op. Patients are reviewed at 2, 6 and 52 weeks and with annual postal questionnaires and clinical and radiological review at 5 and 10yrs. RESULTS: 13,384 primary THA and TKAs were entered into the database. The overall rate of clinically apparent DVT and overall PE rates of 0.48% and 0.42% respectively. 86.16% of our patients were low risk, of these 23.3% of patients were on Aspirin/Clopidogrel with mechanical thromboprophylaxis and 76.7% of patients had mechanical prophylaxis alone. There was no statistical difference between the DVT or PE rates in the low risk groups. CONCLUSION: Our results show that use of early mobilisation and mechanical prophylaxis within an Enhanced Recovery Programme results in comparable VTE rates to chemical prophylaxis for all, which is reflected in the literature. Our results question the need for chemical thromboprophylaxis or extended use of mechanical thromboprophylaxis in "lower risk" patients if a risk stratification policy is used in the context of modern surgical approaches.

Venous thromboembolism prophylaxis strategies for people undergoing elective total knee replacement: a systematic review and network meta-analysis.

BACKGROUND: Hospital-associated venous thromboembolism is a major patient safety concern. Provision of prophylaxis to patients admitted for elective total knee replacement surgery has been proposed as an effective strategy to reduce the incidence of venous thromboembolism. We aimed to assess the relative efficacy and safety of all available prophylaxis strategies in this setting. METHODS: We did a systematic review and Bayesian network meta-analyses of randomised controlled trials to assess the relative efficacy and safety of venous thromboembolism prophylaxis strategies and to populate an economic model that assessed the cost-effectiveness of these strategies and informed the updated National Institute for Health and Care Excellence (NICE) guideline recommendations for patients undergoing elective total knee replacement surgery. The Cochrane Library (CENTRAL), Embase, and Medline were last searched on June 19, 2017, with key terms relating to the population (venous thromboembolism and total knee replacement) and the interventions compared, including available pharmacological and mechanical interventions. Outcomes of interest were deep vein thrombosis (symptomatic and asymptomatic), pulmonary embolism, and major bleeding. Risk of bias was assessed, and relevant data extracted from the included randomised controlled trials for the network meta-analyses. Relative risks (RR; with 95% credible intervals [95% CrI]) compared to no prophylaxis, median ranks (with 95% CrI), and the probability of being the best intervention were calculated. The study was done in accordance with PRISMA guidelines. FINDINGS: 25 randomised controlled trials were included in the network meta-analyses. 23 trials (19 interventions; n=15 028) were included in the deep vein thrombosis network, 12 in the pulmonary embolism network (13 interventions; n=15 555), and 19 in the major bleeding network (11 interventions; n=19 797). Risk of bias ranged from very low to high. Rivaroxaban ranked first for prevention of deep vein thrombosis (RR 0·12 [95% CrI 0·06-0·22]). Low molecular weight heparin (LMWH; standard prophylactic dose, 28-35 days) ranked first in the pulmonary embolism network (RR 0·02 [95% CrI 0·00-3·86]) and LMWH (low prophylactic dose, 10-14 days) ranked first in the major bleeding network (odds ratio 0·08 [95% CrI 0·00-1·76]), but the results for pulmonary embolism and major bleeding are highly uncertain. INTERPRETATION: Single prophylaxis strategies are more effective in prevention of deep vein thrombosis in the elective total knee replacement population than combination strategies, with rivaroxaban being the most effective. The results of the pulmonary embolism and major bleeding meta-analyses are uncertain and no clear conclusion can be made other than what is biologically plausible (eg, that no prophylaxis and mechanical prophylaxis strategies should have the lowest risk of major bleeding). FUNDING: National Institute for Health and Care Excellence.

Cost-Utility Analysis of Venous Thromboembolism Prophylaxis Strategies for People Undergoing Elective Total Hip and Total Knee Replacement Surgeries in the English National Health Service.

Background: Major orthopedic surgery, such as elective total hip replacement (eTHR) and elective total knee replacement (eTKR), are associated with a higher risk of venous thromboembolism (VTE) than other surgical procedures. Little is known, however, about the cost-effectiveness of VTE prophylaxis strategies in people undergoing these procedures. Aim: The aim of this work was to assess the cost-effectiveness of these strategies from the English National Health Service perspective to inform NICE guideline (NG89) recommendations. Materials and Methods: Cost-utility analysis, using decision modeling, was undertaken to compare 15 VTE prophylaxis strategies for eTHR and 12 for eTKR, in addition to "no prophylaxis" strategy. The analysis complied with the NICE Reference Case. Structure and assumptions were agreed with the guideline committee. Incremental net monetary benefit (INMB) was calculated, vs. the model comparator (LMWH+ antiembolism stockings), at a threshold of £20,000/quality-adjusted life-year (QALY) gained. The model was run probabilistically. Deterministic sensitivity analyses (SAs) were undertaken to assess the robustness of the results. Results: The most cost-effective strategies were LMWH for 10 days followed by aspirin for 28 days (INMB = £530 [95% CI: -£784 to £1,103], probability of being most cost-effective = 72%) for eTHR, and foot pump (INMB = £353 [95% CI: -£101 to £665]; probability of being most cost-effective = 18%) for eTKR. There was considerable uncertainty regarding the cost-effectiveness ranking in the eTKR analysis. The results were robust to change in all SAs. Conclusions: For eTHR, LMWH (standard dose) for 10 days followed by aspirin for 28 days is the most cost-effective VTE prophylaxis strategy. For eTKR, the results are highly uncertain but foot pump appeared to be the most cost-effective strategy, followed closely by aspirin (low dose). Future research should focus on assessing cost-effectiveness of VTE prophylaxis in the eTKR population.