Extramedullary versus intramedullary fixation of unstable trochanteric femoral fractures (AO type 31-A2): a systematic review and meta-analysis.

OBJECTIVE: The aim of this systematic review was to compare extramedullary fixation and intramedullary fixation for AO type 31-A2 trochanteric fractures in the elderly, with regard to functional outcomes, complications, surgical outcomes, and costs. METHODS: Embase, Medline, Web of Science, Cochrane Central Register of Controlled Trials, and Google Scholar were searched for randomized controlled trials (RCTs) and observational studies. Effect estimates were pooled across studies using random effects models. Results are presented as weighted risk ratio (RR) or weighted mean difference (MD) with corresponding 95% confidence interval (95% CI). RESULTS: Fourteen RCTs (2039 patients) and 13 observational studies (22,123 patients) were included. Statistically superior results in favor of intramedullary fixation were found for Harris Hip Score (MD 4.09, 95% CI 0.91-7.26, p = 0.04), Parker mobility score (MD - 0.67 95% CI - 1.2 to - 0.17, p = 0.009), lower extremity measure (MD - 4.07 95% CI - 7.4 to - 0.8, p = 0.02), time to full weight bearing (MD 1.14 weeks CI 0.92-1.35, p < 0.001), superficial infection (RR 2.06, 95% CI 1.18-3.58, p = 0.01), nonunion (RR 3.67, 95% CI 1.03-13.10, p = 0.05), fixation failure (RR 2.26, 95% CI 1.16-4.44, p = 0.02), leg shortening (MD 2.23 mm, 95% CI 0.81-3.65, p = 0.002), time to radiological bone healing (MD 2.19 months, 95% CI 0.56-3.83, p = 0.009), surgery duration (MD 11.63 min, 95% CI 2.63-20.62, p = 0.01), operative blood loss (MD 134.5 mL, 95% CI 51-218, p = 0.002), and tip-apex distance > 25 mm (RR 1.73, 95% CI 1.10-2.74, p = 0.02). No comparable cost/costs-effectiveness data were available. CONCLUSION: Current literature shows that several functional outcomes, complications, and surgical outcomes were statistically in favor of intramedullary fixation when compared with extramedullary fixation of AO/OTA 31-A2 fractures. However, as several of the differences found appear not to be clinically relevant and for many outcomes data remains sparse or heterogeneous, complete superiority of IM fixation for AO type 31-A2 fractures remains to be confirmed in a detailed cost-effectiveness analysis.

Extramedullary versus intramedullary fixation of stable trochanteric femoral fractures: a systematic review and meta-analysis.

OBJECTIVE: This systematic review and meta-analysis compared extramedullary fixation and intramedullary fixation for stable two-part trochanteric femoral fractures (AO type 31-A1) with regards to functional outcomes, complications, and surgical outcomes. METHODS: Embase, Medline, Web of Science, Cochrane Central Register of Controlled Trials, and Google Scholar were searched for randomized controlled trials (RCTs) and observational studies. Effect estimates were pooled across studies using random effects models. Results were presented as weighted risk ratio (RR) or weighted mean difference (MD) with corresponding 95% confidence interval (95% CI). RESULTS: Five RCTs (397 patients) and 14 observational studies (21,396 patients) were included. No significant differences in functional outcomes, complications, or surgical outcomes were found between extramedullary and intramedullary fixation devices, except for a difference in duration of surgery (MD 14.1 min, CI 5.76-22.33, p < 0.001) and intra-operative blood loss (MD 92.30 mL, CI 13.49-171.12, p = 0.02), favoring intramedullary fixation. CONCLUSION: Current literature shows no meaningful differences in complications, surgical, or functional outcomes between extramedullary and intramedullary fixation of stable two-part trochanteric femoral fractures. Both treatment options result in good outcomes. This study implicates that, costs should be taken into account when considering implants or comparing fixation methods in future research.

Adherence to the emergency management of severe burns referral criteria in burn patients admitted to a hospital with or without a specialized burn center.

BACKGROUND: The primary aim was to determine to what extent referral and admission of burn patients to a hospital with or without a burn center was in line with the EMSB referral criteria. METHODS: This was a retrospective, multicenter cohort study. Burn patients admitted from 2014 to 2018 to a hospital in the Southwest Netherland trauma region and Network Emergency Care Brabant were included in this study. Outcome measures were the adherence to the EMSB referral criteria. RESULTS: A total of 1790 patients were included, of whom 951 patients were primarily presented to a non-burn center. Of these patients, 666 (70.0%) were managed according to the referral criteria; 263 (27.7%) were appropriately not referred, 403 (42.4%) were appropriately referred. Twenty (2.1%) were overtransferred, and 265 (27.9%) undertransferred. In 1213 patients treated at a burn center 1119 (92.3%) met the referral criteria. Adherence was lowest for electrical (N = 4; 14.3%) and chemical burns (N = 16; 42.1%), and was highest in 'children ≥5% total body surface area (TBSA) burned' (N = 109; 83.2%). CONCLUSION: The overall adherence to the referral criteria of patients presented to a non-burn center was fairly high. However, approximately 25% was not transferred to a burn center while meeting the criteria. Most improvement for individual criteria can be achieved in patients with electrical and chemical burns.