Indications for surgical fixation of low-energy pelvic ring fractures in elderly: a systematic review.

INTRODUCTION: There are no generally accepted criteria for when and how to fixate osteoporotic pelvic ring fractures in elderly. This systemic review aims to summarize the currently available literature regarding the indications and methods for surgical fixation of fragility fractures of the pelvic ring in elderly patients after low-energy trauma. MATERIALS AND METHODS: The Pubmed and Embase databases were searched using the key words pelvic fractures, geriatric, fragility, osteoporosis, and surgical fixation, and their synonyms. Extracted data including the indication, method of operative fixation, and post-operative outcomes (pain levels, mobility, complications and mortality) were analyzed using descriptive statistics. The studies were too heterogeneous to perform a meta-analysis. RESULTS: Eleven cohort studies (3 comparative and 8 noncomparative) were included. The methodological quality was poor to moderate; the studies were heterogeneous regarding study design and reported outcomes. In all included studies operative treatment for all fracture types was preceded by a period of conservative treatment comprising physiotherapy-guided full weight-bearing. Time to surgery differed widely. For posterior ring fixation, the majority of the included studies used minimally invasive surgery with trans-iliosacral screws. Five studies described a form of additional fixation of the anterior pelvic ring but did not report the indications. CONCLUSIONS: Fixation of low-energy pelvic ring fractures in elderly is commonly performed after a period of conservative treatment, with persistent pain as the most frequent indication for fixation. Fracture classification based on stability seems to be of secondary importance. Timing for surgical fixation of the pelvic ring fracture in elderly patients remains diverse. Large well-designed comparative prospective studies and randomized controlled trials are needed to provide clearly substantiated guidelines.

Managing patient expectations about recovery after a distal radius fracture based on patient reported outcomes.

INTRODUCTION: PROMs are increasingly used by clinicians to evaluate recovery after distal radius fractures, but can also be used as benchmark data to help patients managing their expectations about recovery after DRF. PURPOSE OF THE STUDY: The study aimed to determine the general course of patient-reported functional recovery and complaints during 1 year after a DRF, depending on fracture type and age. The study aimed to determine the general course of patient-reported functional recovery and complaints during one year after a DRF, depending on fracture type and age. METHODS: Retrospectively analyzed PROMs of 326 patients with DRF from a prospective cohort at baseline and at 6, 12, 26 and 52 weeks included PRWHE questionnaire for measuring functional outcome, VAS for pain during movement, and items of the DASH for measuring complaints (tingling, weakness, stiffness) and limitations in work and daily activities. The effect of age and fracture type on outcomes were assessed using repeated measures analysis. RESULTS: PRWHE scores after one year were on average 5.4 points higher compared to the patients' pre-fracture scores. Patients with type B DRF had significantly better function and less pain than those with types A or C at every time point. After six months, more than 80% of the patients reported mild or no pain. Tingling, weakness or stiffness were reported by 55-60% of the overall cohort after six weeks, while 10-15% had persisting complaints at one year. Older patients reported worse function and more pain, complaints and limitations. CONCLUSIONS: Functional recovery after a DRF is predictable in time with functional outcome scores after one-year follow-up that are similar to pre-fracture values. Some outcomes after DRF differ between age and fracture type groups.

Rates and risk factors of complications associated with operative treatment of pelvic fractures.

PURPOSE: Post-operative complications following fixation of pelvic fractures can lead to mortality and increased morbidity. Available literature regarding complications is heterogeneous and knowledge on risk factors is limited. This study aims to identify the most common post-operative complications and their possible risk factors following pelvic fracture surgery. METHODS: A retrospective cohort study was performed in two level-1 trauma centers in the Netherlands between January 2015 and January 2021. Included patients were all adult patients (≥ 18 years) with an operatively treated pelvic fracture (pelvic ring and/or acetabular fractures). Post-operative complications included surgical site infections (SSI), material-related complications, neurological complications, malunion/non-union and performed reoperations. A forward stepwise multivariable logistic regression analysis was used to identify any risk factors associated with these complications. RESULTS: Complications occurred in 55 (24%) of the 233 included patients. SSI's were most common, occurring in 34 (15%) patients. Duration of surgery (odds ratio 1.01 per minute, 95% confidence interval 1.00-1.01) and obesity (odds ratio 1.10 per BMI point, 95% confidence interval 1.29-7.52) were independent risk factors for development of SSI. Less common post-operative complications were material-related complications (8%) and neurological damage (5%). CONCLUSION: Limiting operation time by using less invasive and less time-consuming surgical approaches may reduce the risk of SSI. More awareness and post-operative screening for early signs of SSI is mandatory, especially in obese patients. Future research should include large prospective patient cohorts to determine risk factors for other post-operative complications associated with pelvic fracture surgery.

Economic evaluation of endometrial scratching before the second IVF/ICSI treatment: a cost-effectiveness analysis of a randomized controlled trial (SCRaTCH trial).

STUDY QUESTION: Is a single endometrial scratch prior to the second fresh IVF/ICSI treatment cost-effective compared to no scratch, when evaluated over a 12-month follow-up period? SUMMARY ANSWER: The incremental cost-effectiveness ratio (ICER) for an endometrial scratch was €6524 per additional live birth, but due to uncertainty regarding the increase in live birth rate this has to be interpreted with caution. WHAT IS KNOWN ALREADY: Endometrial scratching is thought to improve the chances of success in couples with previously failed embryo implantation in IVF/ICSI treatment. It has been widely implemented in daily practice, despite the lack of conclusive evidence of its effectiveness and without investigating whether scratching allows for a cost-effective method to reduce the number of IVF/ICSI cycles needed to achieve a live birth. STUDY DESIGN, SIZE, DURATION: This economic evaluation is based on a multicentre randomized controlled trial carried out in the Netherlands (SCRaTCH trial) that compared a single scratch prior to the second IVF/ICSI treatment with no scratch in couples with a failed full first IVF/ICSI cycle. Follow-up was 12 months after randomization.Economic evaluation was performed from a healthcare and societal perspective by taking both direct medical costs and lost productivity costs into account. It was performed for the primary outcome of biochemical pregnancy leading to live birth after 12 months of follow-up as well as the secondary outcome of live birth after the second fresh IVF/ICSI treatment (i.e. the first after randomization). To allow for worldwide interpretation of the data, cost level scenario analysis and sensitivity analysis was performed. PARTICIPANTS/MATERIALS, SETTING, METHODS: From January 2016 until July 2018, 933 women with a failed first IVF/ICSI cycle were included in the trial. Data on treatment and pregnancy were recorded up until 12 months after randomization, and the resulting live birth outcomes (even if after 12 months) were also recorded.Total costs were calculated for the second fresh IVF/ICSI treatment and for the full 12 month period for each participant. We included costs of all treatments, medication, complications and lost productivity costs. Cost-effectiveness analysis was carried out by calculating ICERs for scratch compared to control. Bootstrap resampling was used to estimate the uncertainty around cost and effect differences and ICERs. In the sensitivity and scenario analyses, various unit costs for a single scratch were introduced, amongst them, unit costs as they apply for the United Kingdom (UK). MAIN RESULTS AND THE ROLE OF CHANCE: More live births occurred in the scratch group, but this also came with increased costs over a 12-month period. The estimated chance of a live birth after 12 months of follow-up was 44.1% in the scratch group compared to 39.3% in the control group (risk difference 4.8%, 95% CI -1.6% to +11.2%). The mean costs were on average €283 (95% CI: -€299 to €810) higher in the scratch group so that the point average ICER was €5846 per additional live birth. The ICER estimate was surrounded with a high level of uncertainty, as indicated by the fact that the cost-effectiveness acceptability curve (CEAC) showed that there is an 80% chance that endometrial scratching is cost-effective if society is willing to pay ∼€17 500 for each additional live birth. LIMITATIONS, REASONS FOR CAUTION: There was a high uncertainty surrounding the effects, mainly in the clinical effect, i.e. the difference in the chance of live birth, which meant that a single straightforward conclusion could not be ascertained as for now. WIDER IMPLICATIONS OF THE FINDINGS: This is the first formal cost-effectiveness analysis of endometrial scratching in women undergoing IVF/ICSI treatment. The results presented in this manuscript cannot provide a clear-cut expenditure for one additional birth, but they do allow for estimating costs per additional live birth in different scenarios once the clinical effectiveness of scratching is known. As the SCRaTCH trial was the only trial with a follow-up of 12 months, it allows for the most complete estimation of costs to date. STUDY FUNDING/COMPETING INTEREST(S): This study was funded by ZonMW, the Dutch organization for funding healthcare research. A.E.P.C., F.J.M.B., E.R.G. and C.B. L. reported having received fees or grants during, but outside of, this trial. TRIAL REGISTRATION NUMBER: Netherlands Trial Register (NL5193/NTR 5342).

Bone material strength index as measured by in vivo impact microindentation is normal in subjects with high-energy trauma fractures.

Bone material properties were assessed using impact microindentation in patients with high-energy trauma fractures. Compared to patients with low-energy trauma fractures, bone material strength index was significantly higher in patients with high-energy trauma fractures, and did not differ between patients with osteopenia and those with osteoporosis within each trauma group. INTRODUCTION: Impact microindentation (IMI) is a technique to assess tissue-level properties of bone at the tibia. Bone material strength index (BMSi), measured by IMI, is decreased in patients with low-energy trauma fractures, independently of areal bone mineral density (aBMD), but there is no information about BMSi in patients with high-energy trauma fractures. In the present study, we evaluated tissue-level properties of bone with IMI in patients with high-energy trauma fractures. METHODS: BMSi was measured 3.0 months (IQR 2.0-5.8) after the fracture in 40 patients with high-energy trauma and 40 age- and gender-matched controls with low-energy trauma fractures using the OsteoProbe® device. RESULTS: Mean age of high- and low-energy trauma patients was 57.7 ± 9.1 and 57.2 ± 7.7 years, respectively (p = 0.78). Fracture types were comparable in high- vs low-energy trauma patients. Lumbar spine (LS)-aBMD, but not femoral neck (FN)-aBMD, was higher in high- than in low-energy trauma patients (LS 0.96 ± 0.13 vs 0.89 ± 0.13 g/cm2, p = 0.02; FN 0.75 ± 0.09 vs 0.72 ± 0.09 g/cm2, p = 0.09). BMSi was significantly higher in high- than in low-energy trauma patients (84.4 ± 5.0 vs 78.0 ± 4.6, p = 0.001), also after adjusting for aBMD (p = 0.003). In addition, BMSi did not differ between patients with osteopenia and those with osteoporosis within each trauma group. CONCLUSION: Our data demonstrate that BMSi and LS-aBMD, but not FN-aBMD, are significantly higher in high-energy trauma patients compared to matched controls with similar fractures from low-energy trauma. Further studies of non-osteoporotic patients with high-energy trauma fracture with measurements of BMSi are warranted to determine whether IMI might help in identifying those with reduced bone strength.

The value of radiologic diagnostics in evaluating deltoid integrity in isolated type B ankle fractures: a systematic review of the literature.

INTRODUCTION: Excluding deep deltoid ligament (DDL) rupture in isolated type B ankle fractures is crucial in the decision-making process for surgical or conservative treatment. There is no consensus about the most accurate radiologic diagnostic test to determine medial injury. The aim of this study is to systematically review the literature concerning radiologic diagnostics that evaluate medial injury in adult patients with isolated type B ankle fractures. METHODS: The electronic databases PubMed, Embase, Web of Science, COCHRANE Library, and Emcare were searched to identify studies published from January 1990 to December 2020 concerning sensitivity and specificity of diagnostic tests that evaluate medial injury in patients with an isolated type B ankle fracture. For inclusion, comparison to a reference test was required to provide results in terms of sensitivity, specificity, and preferably positive predictive value and negative predictive value RESULTS: This review included 8 studies. Ultrasound showed the highest sensitivity of 100% and a specificity between 90 and 100% for detecting DDL rupture. Gravity stress radiographs showed a sensitivity of 71-100% and a specificity between 88 and 92%. The mortise, external rotation stress test, and MRI had lower sensitivity and specificity values, between 65 and 88%. CONCLUSION: The most accurate and available methods for diagnosing deltoid integrity seem to be the ultrasound and the GS radiograph. Further research is needed to confirm the results of this review.

Fibular displacement does not predict instability in type B ankle fractures.

INTRODUCTION: Despite the wide prevalence of ankle fractures, no consensus exists on the most accurate radiologic diagnostic tool to indicate medial ligament injury in isolated type B distal fibular fractures. The aim of this study was to evaluate the value of the fibular fracture displacement in predicting medial clear space widening on the gravity stress radiographs, as a parameter of fracture instability. METHODS: This retrospective cohort study included 192 patients with an isolated type B fibular fracture, for which a regular mortise and gravity stress radiograph were made in our hospital between January 2014 and December 2019. On the regular mortise and lateral radiographs, the medial clear space (MCS), superior clear space (SCS), anteroposterior and lateral fibular displacement were measured. On the gravity stress radiograph, the MCS and SCS were measured. Instability was defined as MCS ≥ SCS + 3.0 mm on the gravity stress radiograph. A receiver operating characteristic (ROC) curve was constructed to evaluate the predictive value of the fibular displacement. RESULTS: Of the 192 included patients, 55 (29%) patients had instable ankle fractures. In predicting instability, fibular displacement demonstrated an area under the curve (AUC) of 0.68 (95% confidence interval 0.60-0.77) and a correlation coefficient of 0.41 with MCS. CONCLUSION: Fibular displacement on regular mortise view is a poor predictor of instability in type B fibular fractures. It should not be advised to use the fracture displacement as parameter for medial injury and thus for operative treatment.

The Submental Nasal Appearance Scale for the Assessment of Repaired Unilateral Complete Cleft Lip: A Validation Study.

OBJECTIVE: To reassess reliability and validity of the Submental Nasal Appearance Scale (SNAS) compared to the preliminary pilot study, for assessment of patient photographs with repaired unilateral cleft lip and palate (UCLP). When utilizing the SNAS, 3 nasal features (1. nasal outline; 2. alar base position; 3. nostril axis) must be graded according to symmetry between the cleft and noncleft side using a 5-point scale with reference photographs for each feature. The mean score calculated from the graded features reflects the overall degree of nasal symmetry, which is considered an important goal when repairing UCLP. DESIGN: Fifty patient photographs were selected and cropped, displaying the submental view. Six raters assessed these photographs using the SNAS and a separate 5-point scale to assess the overall submental appearance. Interrater reliability was determined for both methods and correlation was calculated between these as an indication of construct validity. SETTING: Amsterdam UMC, location VUmc, Amsterdam, The Netherlands. PATIENTS: Six- to 9-year-old patients with repaired UCLP. RESULTS: Interrater reliability of 0.73 and 0.48 was found for the SNAS and overall appearance assessment, respectively, while in the pilot study values of 0.79 and 0.69 were found. Correlation of 0.59 and 0.74 was found in the current and pilot study, respectively, between the SNAS and overall appearance assessment. CONCLUSIONS: The SNAS is a reliable tool to assess nasal symmetry from the submental perspective. Reliability of the SNAS is higher compared to grading overall appearance, but validity of the SNAS was less well supported.

Reduction of routine use of radiography in patients with ankle fractures leads to lower costs and has no impact on clinical outcome: an economic evaluation.

BACKGROUND: To evaluate the cost-effectiveness of a reduction in the number of routine radiographs in the follow-up of patients with ankle fractures. METHODS: We performed an economic evaluation alongside the multicentre, randomised WARRIOR trial. Participants were randomised to a reduced imaging follow-up protocol (i.e. radiographs at week 6 and 12 follow-up obtained on clinical indication) or usual care (i.e. routine radiography at weeks 6 and 12). The Olerud & Molander Ankle Score (OMAS) was used to assess ankle function and the EQ-5D-3L was used to estimate Quality-Adjusted Life Years (QALYs). Costs and resource use were assessed using self-reported questionnaires and medical records, and analysed from a societal perspective. Multiple imputation was used for missing data, and data were analysed using seemingly unrelated regression analysis and bootstrapping. RESULTS: In total, 246 patients had data available for analysis (reduced imaging = 118; usual care = 128). Fewer radiographs were obtained in the reduced imaging group (median = 4) compared with the usual-care group (median = 5). Functional outcome was comparable in both groups. The difference in QALYs was - 0.008 (95% CI:-0.06 to 0.04) and the difference in OMAS was 0.73 (95% CI:-5.29 to 6.76). Imaging costs were lower in the reduced imaging group (-€48; 95% CI:- €72 to -€25). All other cost categories did not statistically differ between the groups. The probability of the reduced imaging protocol being cost-effectiveness was 0.45 at a wiliness-to-pay of €20,000 per QALY. CONCLUSIONS: Reducing the number of routine follow-up radiographs has a low probability of being cost-effective compared with usual care. Functional outcome, health-related quality of life and societal costs were comparable in both groups, whereas imaging costs were marginally lower in the reduced imaging group. Given this, adherence to a reduced imaging follow-up protocol for those with routine ankle fractures can be followed without sacrificing quality of care, and may result in reduced costs. TRIAL REGISTRATION: The trial was registered on 26-05-2014 in the Netherlands Trial Registry, with reference number NL4477 ( www.trialregister.nl/trial/4477 ).

Study protocol for the DEFENDD trial: an RCT on the Dynamic Locking Blade Plate (DLBP) versus the Dynamic Hip Screw (DHS) for displaced femoral neck fractures in patients 65 years and younger.

BACKGROUND: The Dynamic Locking Blade Plate (DLBP) was recently introduced for fixation of displaced femoral neck fractures (FNF) and has been well received. Although the results of this implant in young patients are promising, the DLBP has not yet been compared to a standard device such as the Dynamic Hip Screw (DHS). The aim of this study is to compare the clinical outcome and costs of displaced FNF treated with internal fixation by means of either the DLBP or the DHS in patients up to 65 years of age. We hypothesize that the DLBP is superior compared to the DHS in terms of revision surgery rate, union rate, incidence of avascular necrosis and implant related failure. METHODS: The DEFENDD (DisplacEd Femoral Neck fractures Dlbp versus Dhs) trial is a multicentre randomized controlled trial that will include 266 patients of 18-65 years with a displaced FNF. Patients will be randomized to receive either a DLBP or a DHS with a 1:1 allocation using a random block size, stratified for centre. Clinical follow up will last 1 year and questionnaires will be obtained up to 2 years. The main outcome parameter is the incidence of revision surgery within 1 year, due to either non-union, avascular necrosis (AVN) or cut out of the implant. Secondary study parameters are the incidence of avascular necrosis, non-union, (implant related) complications, functional outcome, elective removal of the implant and health-related quality of life and costs. DISCUSSION: The outcome of the DEFENDD trial will provide high-level evidence of which implant is favourable for the treatment of femoral neck fractures in young patients (≤65 years). TRIAL REGISTRATION: Netherlands Trial Register, NL7300 Registration date 25-09-2018.

Quality indicators for hip fracture care, a systematic review.

Quality indicators are used to measure quality of care and enable benchmarking. An overview of all existing hip fracture quality indicators is lacking. The primary aim was to identify quality indicators for hip fracture care reported in literature, hip fracture audits, and guidelines. The secondary aim was to compose a set of methodologically sound quality indicators for the evaluation of hip fracture care in clinical practice. A literature search according to the PRISMA guidelines and an internet search were performed to identify hip fracture quality indicators. The indicators were subdivided into process, structure, and outcome indicators. The methodological quality of the indicators was judged using the Appraisal of Indicators through Research and Evaluation (AIRE) instrument. For structure and process indicators, the construct validity was assessed. Sixteen publications, nine audits and five guidelines were included. In total, 97 unique quality indicators were found: 9 structure, 63 process, and 25 outcome indicators. Since detailed methodological information about the indicators was lacking, the AIRE instrument could not be applied. Seven indicators correlated with an outcome measure. A set of nine quality indicators was extracted from the literature, audits, and guidelines. Many quality indicators are described and used. Not all of them correlate with outcomes of care and have been assessed methodologically. As methodological evidence is lacking, we recommend the extracted set of nine indicators to be used as the starting point for further clinical research. Future research should focus on assessing the clinimetric properties of the existing quality indicators.

The value of radiography in the follow-up of extremity fractures: a systematic review.

BACKGROUND: The added value of routine radiography in the follow-up of extremity fractures is unclear. The aim of this systematic review was to create an overview of radiography use in extremity fracture care and the consequences of these radiographs for the treatment of patients with these fractures. MATERIALS AND METHODS: Studies were included if they reported on the use of radiography in the follow-up of extremity fractures and on its influence on treatment strategy, clinical outcome, or complications. A comprehensive search of electronic databases (i.e., PubMed, Embase, and Cochrane) was performed to identify relevant studies. Methodological quality was assessed with the Newcastle-Ottawa scale for cohort studies. Level of evidence was assessed using GRADE. The search, quality appraisal, and data extraction were performed independently by two researchers. RESULTS: Eleven studies were included. All studies were retrospective cohorts. Of these, only two used a comparative design. Two of the included studies described fractures of both the upper and lower extremities, four studies concerned fractures of the lower extremity only, and five studies focused on fractures of the upper extremity. Pooling of data was not performed because of clinical heterogeneity. Eight studies reported on a change in treatment strategy related to radiography. Percentages ranged from 0 to 2.6%. The overall results indicated that radiographs in the follow-up of extremity fractures seldom alter treatment strategy, that the vast majority of follow-up radiographs are obtained without a clinical indication and that detection of a complication on a radiograph, in the absence of clinical symptoms, is unlikely. All included studies were regarded of a 'very low' level using GRADE. CONCLUSIONS: Based on current literature, the added value of routine radiography in the follow-up of extremity fractures seems limited. Results, however, should be interpreted with care, considering that available evidence is of a low level.

Are the registry data reliable? An audit of a regional trauma registry in the Netherlands.

OBJECTIVE: Data in trauma registries need to be reliable when used for evaluation of injury management, trauma protocols and hospital statistics. The aim of this audit was to analyse the reliability of the data in the Trauma Centre West Netherlands (TCWN) region. DESIGN: Routinely registered trauma patients from all nine hospitals in the TCWN region were re-registered by a registrar for analysis. SETTING: Nine hospitals in the TCWN region in the Netherlands. PARTICIPANTS: A randomly selected representative trauma population sample of 350 patients and a sample of 100 polytrauma patients were re-registered and used for analysis. INTERVENTION: Re-registration of trauma patients in the Trauma Registry. MAIN OUTCOME MEASURE(S): The inter-rater agreement on Injury Severity Score (ISS), number of Abbreviated Injury Scale (AIS) codes, identical codes and survival status were analysed using Kappa's coefficient and intraclass correlation coefficients. RESULTS: The inter-rater agreement on ISS and number of AIS codes were, respectively, almost perfect (ICC = 0.81) and substantial (ICC = 0.76) in the trauma population sample, and substantial (ICC = 0.70) and fair (ICC = 0.33) in the polytrauma sample. For patients with serious injuries (AIS ≥ 2) in the population sample, the inter-rater agreement on ISS (ICC = 0.87) and number of AIS codes (ICC = 0.84) were almost perfect. CONCLUSIONS: These results confirm that the Dutch regional registry system works well and may serve as a reliable basis for prospective analysis of national and international trauma care. Particular attention should be paid to the coding of polytrauma patients as discrepancies are more likely to occur in this group.

Routine follow-up radiographs for distal radius fractures are seldom clinically substantiated.

INTRODUCTION: The value of routine radiographs during follow-up after distal radius fractures is unclear. The aim of this study was to evaluate whether routine radiographs performed during the follow-up period in patients with a distal radius fracture influenced clinical decision making. METHODS: This retrospective cohort study included patients aged ≥18 years who were treated for a distal radius fracture at four hospitals in The Netherlands in 2012. Demographic and clinical and radiographic characteristics were collected from medical records. RESULTS: 1042 patients were included. In 121 (14%) of the 841 radiographs, a clinical indication was reported. Treatment was affected by 22 (2.6%) radiographs, including 11 (1.5%) radiographs that were categorized as routine, 9 (1.2%) of which led to prolonged cast immobilization and 2 (0.2%) to surgery for conservatively treated patients. CONCLUSION: Although it is common practice to take radiographs after distal radius fractures, the study results indicate that routine radiographs seldom affect treatment. This finding should be weighed against the high health care costs associated with these fractures. We hope that the results of our study will trigger the awareness among surgeons that in the current practice, many radiographs are taken on routine without influencing clinical decision making and can probably be omitted. LEVEL OF EVIDENCE: Level III.

The value of CT compared to radiographs in the classification and treatment plan of trochanteric fractures.

INTRODUCTION: The clinical relevance of classification for trochanteric fractures is limited and little agreement exists on what type of implant should be used. It is unknown whether more advanced radio-diagnostics, such as CT, result in better agreement on the treatment. We assessed the effect of CT on agreement of classification and subsequent treatment for trochanteric fractures. MATERIALS AND METHODS: Eleven observers (five radiologists, four trauma surgeons and two orthopedic residents) assessed 30 radiographs and CTs of trochanteric fractures. Each rating included an assessment according to the AO classification and of the preferred type of implant. The inter-observer agreement of the AO classification and on the choice of implant was calculated. RESULTS: The inter-observer agreement was κ0.70 (SE 0.03) for radiographic assessment of the main groups of the AO classification and κ0.68 (SE 0.03) for CT assessment. The agreement on choice of implant was κ0.63 (SE 0.05) if the choice was made with radiographs and κ0.69 (SE 0.05) with CTs. Six out of the 13 fractures were classified differently after assessment of the CT. Most corrections in choice of implant occurred for the assessment of A3 fractures. CONCLUSIONS: This study confirmed that trochanteric fractures can be reliably classified on both radiographs and CT, according to the main groups of the AO classification. The implementation of CT for trochanteric fractures does not lead to higher agreement on fracture classification or choice of treatment. Therefore, the clinical relevance of CT for classification of trochanteric fractures seems low. For specific subgroups such as A3 fractures, CT may be of value for adequate fracture classification and subsequent treatment strategies.

The dynamic locking blade plate: seven-year follow-up results of 389 patients with a femoral neck fracture.

PURPOSE: This study aimed to investigate the long-term outcomes of patients with a femoral neck fracture (FNF), treated with the Dynamic Locking Blade Plate (DLBP). METHODS: Retrospective analysis of prospectively collected data of a multicentre cohort of patients with FNFs was conducted, regarding the long-term incidence of revision surgery after DLBP. Implant failure was evaluated using Kaplan-Meier and Cox regression analysis. Secondary outcomes were the indication for revision surgery, complications, time to revision surgery, rate of elective removal of the implant, potential predictors for revision surgery and mortality. RESULTS: Median follow-up of 389 included patients was 98 months; 20.6% underwent revision surgery; 28.8% after treatment of a displaced FNF (dFNF) and 10.0% with a undisplaced FNF (uFNF). 5.7% (n = 22) of the patients had operation related complications and 32.9% (n = 128) deceased during follow-up. Median time to revision surgery was 13 (dFNF) and 18 months (uFNF). 15.7% of the DLBPs were electively removed. In the multivariate Cox regression analysis, female gender (hazard ratio 2.1, 95% CI 1.2-3.7) and a TAD > 25 mm (hazard ratio 2.9, 95% CI 1.7-5) were significant predictors for revision surgery in patients with dFNF. CONCLUSION: This study is the first long-term follow-up study on the outcome of the DLBP. The DLBP demonstrated positive long-term results in the treatment of FNF.

Clinical implications of additional posterior fractures in combined anterior-posterior pelvic ring fractures in elderly patients.

OBJECTIVES: Historically, pelvic ring fractures (PRF) are considered to occur predominantly in the anterior ring and therfore to be mechanically stable. Combined anterior and posterior (A + P) PRF are expected to be less mechanically stable and therefore to be associated with higher levels of pain and reduced mobility compared to isolated anterior fractures. The current study investigates the clinical relevance of combined A + P PRF in elderly patients. METHODS: A prospective multicentre cohort study was conducted in patients >70 years of age with anterior PRF after low-energy trauma diagnosed on conventional radiographs. All patients underwent an additional CT-scan. Patients were divided into two groups; isolated anterior or combined A + P fractures. Patients were treated conservatively with adequate analgesia for at least one week. If patients could not be mobilised after conservative treatment, surgical fixation was performed. Numerical Rating Scale (NRS) pain scores, dependence on walking aids and Activities of Daily Living scores (ADL) were measured at 2-4 weeks, and 3, 6 and 12 months after fracture. RESULTS: 102 patients (age 81.1 ± 7.6 years) were included. Isolated anterior fractures were diagnosed in 25 (24.5%) and A + P fractures in 77 (75.5%) patients. Baseline characteristics did not differ between the two groups. Most patients were successfully treated conservatively and 5 (4.9%) underwent percutaneous trans-iliac, trans-sacral screw fixation after failure of conservative treatment. At 2-4 weeks post trauma, patients with A + P fractures had similar median pain scores (3 (range 0-8) vs. 5 (0-10), p = 0.19) and ADL scores (85 (25-100) vs. 78.6 (5-100), p = 0.67), but were more dependent on walking aids (92.8% vs. 72.2%; p = 0.02) compared to patients with isolated anterior fractures. There were no significant differences at 3 months. At one year follow-up the median NRS pain and ADL scores for both fracture groups were 0 and 100, respectively. Mortality was 10.8%, and additional loss to follow-up was 17.6%. CONCLUSIONS: The vast majority of elderly patients with PRF have combined A + P fractures. The clinical implications of additional posterior pelvic ring fractures in elderly patients appears to be limited.

What makes fixation of femoral neck fractures fail? A systematic review and meta-analysis of risk factors.

INTRODUCTION: This systematic review aims to provide an overview of predictors for failure of treatment of displaced femoral neck fracture (dFNF) with internal fixation and quantify their risk of fixation failure in a meta-analysis. PATIENTS AND METHODS: PubMed, Embase, Web of Science, Cochrane Library, and EMCare were searched for original studies published from January 2000, including adult patients with an internally fixated dFNF, that reported data on predictors for fixation failure defined as revision surgery due to non-union, avascular femoral head necrosis or cut-out of implant. RevMan version 5 software was used to pool univariable Odds Ratio's (OR) for predictors of fixation failure by means of a random effects model. RESULTS: This review included 16 articles (15 articles cohort studies and one randomised trial). Twenty-four predictors for fixation failure were identified and analysed, 16 of which were evaluated in just one study. Data of 7 predictors were pooled in a meta-analysis. Female sex (OR 1.78, 95% confidence interval [CI] 1.26-2.52), smoking (OR 3.64, 95% CI 1.68-7.91), age >50 years (OR 3.64, 95% CI 1.68-7.91), inadequate fracture reduction (OR 2.28, 95% CI 1.62-3.22), fixation with cannulated screws (CS) or pins compared to fixed angle devices (OR 2.16, 95% CI 1.03-4.54) were identified as significant predictors for fixation failure. CONCLUSION: This study can help surgeons to choose the preferred treatment for patients with a dFNF and substantiate future algorithms and guidelines for treatment of FNF.

Systematic review and meta-analysis of antibiotic prophylaxis to prevent infections from chest drains in blunt and penetrating thoracic injuries.

BACKGROUND: No consensus exists as to whether antibiotic prophylaxis in tube thoracostomy as primary treatment for traumatic chest injuries reduces the incidence of surgical-site and pleural cavity infections. METHODS: A systematic literature search was performed according to PRISMA guidelines to identify randomized clinical trials on antibiotic prophylaxis in tube thoracostomy for traumatic chest injuries. Data were extracted by two reviewers using piloted forms. Mantel-Haenszel pooled odds ratios (ORs) were calculated with 95 per cent confidence intervals (c.i.). RESULTS: Eleven articles were included, encompassing 1241 chest drains in 1234 patients. Most patients (84·7 per cent) were men, and a penetrating injury mechanism was most common (856, 69·4 per cent). A favourable effect of antibiotic prophylaxis on the incidence of pulmonary infection was found, with an OR for the overall infectious complication rate of 0·24 (95 per cent c.i. 0·12 to 0·49). Patients who received antibiotic prophylaxis had an almost three times lower risk of empyema than those who did not receive antibiotic treatment (OR 0·32, 0·17 to 0·61). A subgroup analysis in patients with penetrating chest injuries showed that antibiotic prophylaxis in these patients reduced the risk of infection after tube thoracostomy (OR 0·28, 0·14 to 0·57), whereas in a relatively small blunt trauma subgroup no effect of antibiotic prophylaxis after blunt thoracic injury was found. CONCLUSION: Infectious complications are less likely to develop when antibiotic prophylaxis is administered to patients with thoracic injuries requiring chest drains after penetrating injury.

The additional value of weight-bearing and gravity stress ankle radiographs in determining stability of isolated type B ankle fractures.

GOAL: The aim of this study is to investigate whether weight-bearing and gravity stress radiographs have additional value in predicting concomitant deep deltoid ligamentous (DDL) injury in case of isolated Weber type B fibular fractures. This may help to make the clinically relevant distinction between unstable fractures and fractures that can be treated conservatively. METHODS: In this prospective cohort study, 90 patients with an isolated type B ankle fracture, without a medial or posterior fracture, and a medial clear space (MCS) < 6 mm on the regular mortise (RM) view were included. In all patients, an additional gravity stress (GS) view and an MRI scan were performed. Furthermore, in 51 patients, an additional weight-bearing (WB) radiograph was performed. The MCS and superior clear space (SCS) measurements of these radiographs were compared with MRI findings to measure sensitivity and specificity in excluding deep deltoid ligament (DDL) rupture. RESULTS: The mean MCS on the RM view was 3.32 mm (1.73-5.93) compared to 4.75 mm (2.33-10.40) on the GS view and 3.18 mm (1.93-6.9) on the WB radiograph. MRI showed a high-grade or complete deltoid ligament tear in 25 (28%) patients. Using an MCS cut-off value of ≥ SCS + 2 mm, the RM view showed 0% sensitivity and 97% specificity in diagnosing a DDL rupture. Both the GS view (with MCS ≥ SCS + 3 mm as cut-off value) and the WB radiograph (with cut-off value MCS ≥ SCS + 2 mm) showed 6% sensitivity and 100% specificity. CONCLUSION: The gravity stress and weight-bearing radiograph can accurately exclude DDL injury. They might have extra value in addition to the conventional mortise view in assessing the stability of isolated type B ankle fractures. This helps in deciding whether patients should be selected for operative or safe conservative treatment.