The mode of delivery after operative fixation of pelvic ring fractures-a retrospective observational study.

PURPOSE: The purpose of this study is to investigate whether retained hardware after surgical treatment for a pelvic fracture prior to pregnancy affects the choice of delivery method. The study aims to provide insights into the rates of vaginal delivery and caesarean sections, understanding whether the mode of delivery was influenced by patient preference or the recommendations of obstetricians or surgeons, and examining the rate of complications during delivery and postpartum. METHODS: All women of childbearing age who underwent surgical fixation for a pelvic ring fracture between 1994 and 2021 were identified. A questionnaire was sent about their possible pregnancies and deliveries. Of the included patients, surgical data were collected and the fracture patterns were retrospectively classified. Follow-up was a minimum of 36 months. RESULTS: A total of 168 women with a pelvic fracture were identified, of whom 13 had a pregnancy after surgical stabilization. Eleven women had combined anterior and posterior fracture patterns and two had isolated sacral fractures. Four women underwent combined anterior and posterior fixation, the others either anterior or posterior fixation. Seven women had a total of 11 vaginal deliveries, and 6 women had 6 caesarean sections. The decision for vaginal delivery was often the wish of the mother (n = 4, 57%) while the decision to opt for caesarean section was made by the surgeon or obstetrician (n = 5, 83%). One woman in the vaginal delivery group suffered a postpartum complication possibly related to her retained pelvic hardware. CONCLUSION: Women with retained hardware after pelvic ring fixation can have successful vaginal deliveries. Complications during labor or postpartum are rare. The rate of primary caesarean sections is high (46%) and is probably influenced by physician bias. Future research should focus on tools that can predict labor outcomes in this specific population, and larger multicenter studies are needed. LEVEL OF EVIDENCE: Level III.

The effect of ATLS/PHTLS spinal motion restriction protocol on the incidence of spinal cord injury, a nationwide database study.

PURPOSE: To study trends in incidence and outcome of patients with traumatic spinal cord injury (TSCI) in the Netherlands before, during and after implementation of the Advanced Trauma Life Support (ATLS®) and Pre-Hospital Trauma Life Support (PHTLS®)- Spinal Motion Restriction(SMR) protocol. METHODS: In an observational database we studied national hospital admission and emergency department databases to analyse incidence rates and outcome of traumatic spinal cord injury and spinal fractures in the emergency department and in admittances in The Netherlands between 1986 and 2021. RESULTS: A significant increase of 39% in TSCI in admitted patients with spinal fractures over the past 35 years (p < 0.001). This increase was especially prevalent in cervical spinal fractures (132%), while thoracic and lumbosacral spinal fractures showed a decrease in accompanied TSCI (64% and 88% respectively). The overall increase in spinal fractures was not significant. The duration of hospital admission decreased for spinal fractures without TSCI and with TSCI (66% and 56% respectively). CONCLUSION: Since implementation of the SMR-protocol was aiming to limit TSCI in patients who suffered a spinal fracture, the increase in TSCI is an unexpected finding. Exact explanation for this increase is unclear and the contribution of the SMR-protocol is not fully understood due to confounders in the used datasets. Either way, the scientific evidence supporting this costly time- and labor-intensive SMR-protocol remains debated, along with evidence contradicting it. Therefore it stresses the need for clear, evidencebased reasoning for spinal immobilization according to ATLS, as this is currently lacking.

The Value of Routine Radiography in the Nonoperative Treatment of Metatarsal Fractures: A Retrospective Cohort Study.

Although widely used in follow-up treatment protocols, the added value of routine radiographs to clinical decision-making in nonoperative treatment of patients with metatarsal fractures is unclear. This retrospective cohort study aimed to determine whether routine follow-up radiographs contributed to changes in treatment strategies in nonoperative treatment of patients with a metatarsal fracture. Adult (aged ≥ 18 years) patients who received nonoperative follow-up treatment for a metatarsal fracture between May first, 2020 and May second, 2022 were included. All relevant data were extracted from patient records. Radiographs without a documented clinical indication were classified as routine. Outcomes included changes in treatment strategies based on routine radiographs during follow-up treatment and secondarily, changes in treatment strategy based on clinically indicated radiographs. A total of 168 patients were included, with 135 single and 33 multiple metatarsal fractures. During follow-up, 223 radiographs were performed, of which 154 (69%) were routine and 69 (31%) were on clinical indication. Of routine radiographs, 9 (6%) led to a change in treatment which only included additional imaging. No switch to operative treatment or prolonging of immobilization was observed based on routine radiographs. Of clinically indicated radiographs, 16 (23%) led to a change of treatment, including prolonged immobilization (n = 2), additional follow-up appointments (n = 1) and additional imaging (n = 12). Our results show routinely performed radiographs seldom affect treatment strategies in nonoperative treatment of metatarsal fractures, indicating minimal added value to clinical decision-making. Omitting routine radiographs from treatment protocols may contribute to the reduction of unnecessary healthcare resource utilization in clinical practice.

Anterior locking plate fixation versus cast immobilization for acceptably reduced extra- articular distal radial fractures: long-term follow-up of a randomized controlled trial.

This study reports the long-term results of a randomized controlled trial comparing anterior locking plate fixation with cast immobilization for extra-articular distal radial fractures. After 5.3 years of follow-up, no clinically relevant functional differences were found.

Posterolateral or Direct Lateral Surgical Approach for Hemiarthroplasty After a Hip Fracture: A Randomized Clinical Trial Alongside a Natural Experiment.

Importance: Hip fractures in older adults are serious injuries that result in disability, higher rates of illness and death, and a substantial strain on health care resources. High-quality evidence to improve hip fracture care regarding the surgical approach of hemiarthroplasty is lacking. Objective: To compare 6-month outcomes of the posterolateral approach (PLA) and direct lateral approach (DLA) for hemiarthroplasty in patients with acute femoral neck fracture. Design, Setting, and Participants: This multicenter, randomized clinical trial (RCT) comparing DLA and PLA was performed alongside a natural experiment (NE) at 14 centers in the Netherlands. Patients aged 18 years or older with an acute femoral neck fracture were included, with or without dementia. Secondary surgery of the hip, pathological fractures, or patients with multitrauma were excluded. Recruitment took place between February 2018 and January 2022. Treatment allocation was random or pseudorandom based on geographical location and surgeon preference. Statistical analysis was performed from July 2022 to September 2022. Exposure: Hemiarthroplasty using PLA or DLA. Main Outcome and Measures: The primary outcome was health-related quality of life 6 months after surgery, quantified with the EuroQol Group 5-Dimension questionnaire (EQ-5D-5L). Secondary outcomes included dislocations, fear of falling and falls, activities of daily living, pain, and reoperations. To improve generalizability, a novel technique was used for data fusion of the RCT and NE. Results: A total of 843 patients (542 [64.3%] female; mean [SD] age, 82.2 [7.5] years) participated, with 555 patients in the RCT (283 patients in the DLA group; 272 patients in the PLA group) and 288 patients in the NE (172 patients in the DLA group; 116 patients in the PLA group). In the RCT, mean EQ-5D-5L utility scores at 6 months were 0.50 (95% CI, 0.45-0.55) after DLA and 0.49 (95% CI, 0.44-0.54) after PLA, with 77% completeness. The between-group difference (-0.04 [95% CI, -0.11 to 0.04]) was not statistically significant nor clinically meaningful. Most secondary outcomes were comparable between groups, but PLA was associated with more dislocations than DLA (RCT: 15 of 272 patients [5.5%] in PLA vs 1 of 283 patients [0.4%] in DLA; NE: 6 of 113 patients [5.3%]) in PLA vs 2 of 175 patients [1.1%] in DLA). Data fusion resulted in an effect size of 0.00 (95% CI, -0.04 to 0.05) for the EQ-5D-5L and an odds ratio of 12.31 (95% CI, 2.77 to 54.70) for experiencing a dislocation after PLA. Conclusions and Relevance: This combined RCT and NE found that among patients treated with a cemented hemiarthroplasty after an acute femoral neck fracture, PLA was not associated with a better quality of life than DLA. Rates of dislocation and reoperation were higher after PLA. Randomized and pseudorandomized data yielded similar outcomes, which suggests a strengthening of these findings. Trial Registration: ClinicalTrials.gov Identifier: NCT04438226.

Efficiency of a virtual fracture care protocol in non-operative treatment of adult patients with a distal radial fracture.

This study aimed to determine the effects of virtual fracture care (VFC) on secondary healthcare utilization in non-operative treatment of adult patients with a distal radial fracture. A retrospective cohort study was performed, including those who received non-operative treatment without VFC (pre-VFC) and with VFC (VFC). Outcomes included secondary healthcare utilization, calculated treatment costs, emergency department (ED) reattendances and complication rates. In total, 88 pre-VFC and 99 VFC patients were included. Pre-VFC patients had more follow-up appointments, with a median of 4 (IQR: 3) versus a median of 4 (IQR: 1) in VFC patients. In addition, 3% of follow-up appointments for pre-VFC patients were performed remotely compared to 18% for VFC patients. Complications and ED reattendances were comparable between groups. In this study, non-operative treatment of adult patients with a distal radial fracture through VFC reduced secondary healthcare utilization, with similar reported complication and ED reattendance rates compared with treatment without VFC.Level of evidence: III.

Nonoperatively Treated Proximal Humerus Fractures: Randomized Trial of Immediate Versus Delayed Initiation of Exercises.

Objectives: There is debate about when to start exercises in the nonoperative treatment of a proximal humerus fracture. This randomized trial compared immediate and one-month delayed shoulder exercises in the nonoperative treatment of fractures of the proximal humerus. Methods: Twenty-six patients with a fracture of the proximal humerus who chose nonoperative treatment were randomized to start pendulum exercises within a few days and 24 were randomized to delayed exercises and started with active self-assisted stretching 1 month after fracture. Three and six months after the injury, patients completed the Disabilities of the Arm Shoulder and Hand questionnaire to measure capability, a measure of pain intensity, and had motion measurements. Results: There was no significant difference in forward flexion (primary outcome) six months after injury between patients that started motion exercises immediately compared to 1 month after injury (p = 0.85). There was no difference in any motion measurement, pain intensity, upper extremity specific disability (DASH score) three or six months after injury. Conclusion: Delaying exercises for a month does not affect recovery from nonoperative treatment of a fracture of the proximal humerus. People can choose whether to start exercises immediately or wait until they feel comfortable.

Rehabilitation after Distal Radius Fractures: Opportunities for Improvement.

Background Exercises are frequently prescribed to regain function; yet there is no consensus on a standardized protocol, and adherence is low. Smart technology innovations, such as mobile applications, may be useful to provide home-based patient support in rehabilitation after distal radius fractures. Purposes Our purpose was to establish the potential of digital innovations for support and monitoring of patients and treatment adherence in rehabilitation programs, and additionally, to compare the current practice among physiotherapists to the various wrist exercise regimens and their effectiveness as described in the literature. Methods Standard practice, including the use of support tools for treatment adherence, was evaluated using a nationwide survey. Then, scientific databases were searched using "distal radius fracture" and "physiotherapy" or "exercise therapy," and related search terms, up until 23 March 2023. Results of the survey and literature review were compared. Results The survey was completed by 92 therapists. Nonstandardized support tools were used by 81.6% of respondents; 53.2% used some form of technology, including taking photos on the patients' smartphone for home reference. In the literature review, 23 studies were included, of which five described an exercise protocol. Treatment adherence was not reported in any of the included studies. Two studies described the use of smart technology or support tools. Conclusions There is no consensus on a standardized exercise protocol for rehabilitation after distal radius fractures, neither from a systematic literature search nor from a nationwide survey. Smart technology may facilitate monitoring of patients and exercise adherence, hereby supporting self-efficacy and improving adherence and outcomes.

Procedural sedation and analgesia versus nerve blocks for reduction of fractures and dislocations in the emergency department: A systematic review and meta-analysis.

Background: Procedural sedation and analgesia (PSA) and peripheral nerve blocks (NBs) are techniques to manage pain and facilitate reduction of dislocated joints or fractures. However, it is unclear if either approach provides any distinct advantage in the emergency department (ED). The aim of this systematic review is to compare these 2 techniques on pain scores, adverse events, patient satisfaction, and length of stay (LOS) in the ED. Methods: We performed an electronic search of MEDLINE, EMBASE, and the Cochrane Library, and references were hand-searched. Randomized controlled trials (RCTs) comparing PSA with NBs for orthopedic reductions in the ED were included. Outcomes of interest included pain scores, adverse events, patient satisfaction, and LOS in the ED. A total of 2 reviewers independently screened abstracts and extracted data into a standardized form. The Cochrane risk-of-bias tool was used to evaluate study quality. The Grading of Recommendation Assessment Development and Evaluation approach was used to assess the certainty and strength of the evidence. Data on pain scores were pooled using a random-effects model and are reported as standardized mean differences (SMDs) with 95% confidence intervals (CIs). Results: A total of 6 RCTs (n = 256) were included in a qualitative review, and 4 RCTs (n = 101) were included in the meta-analysis. There was no significant difference in pain scores between the PSA and NB groups (P = 0.47; SMD, 0.45; 95% CI, -0.78 to 1.69; I2 = 0.94). There were less adverse events in the NB group (0%-3.3%) compared with the PSA group (0%-20%; n = 256). LOS times were consistently shorter in the NB group (n = 215). Patient satisfaction was comparable in both groups (n = 196). Conclusion: Based on the available evidence, NBs performed by emergency physicians are as effective as PSA in managing pain during orthopedic reductions in the ED. NBs are associated with fewer adverse events and shorter LOS in the ED. The quality of evidence is low.

Tranexamic acid in hip hemiarthroplasty surgery: a systematic review and meta-analysis.

PURPOSE: Anemia is one of the most common complications after hip fracture surgery. Tranexamic acid (TXA) has been considered effective in preventing anemia in total hip arthroplasty, but its role in hemiarthroplasty is debated. The aim of this systematic review was to investigate the efficacy and safety of perioperative TXA for hip hemiarthroplasty. METHODS: A systematic literature search was performed to identify studies comparing adult patients who underwent hemiarthroplasty for a hip fracture with and without perioperative TXA. The primary outcome was transfusion rate. Secondary outcomes included postoperative hemoglobin, length of hospital stay, adverse events (i.e., deep venous thromboses and pulmonary embolism), and 30-day mortality. RESULTS: In total, 13 articles were included, comprising 54,843 patients of whom 14.1% received perioperative TXA. TXA was applied intravenous in ten studies, topical in two studies, one study investigated both. Pooled results showed a significant reduction in transfusion rate (pooled RR: 0.48, 95% CI 0.40-0.58, p < 0.01). Postoperative hemoglobin and length of stay were investigated in nine studies, pooled results showed significant improvement of both outcomes for patients that received TXA. Eleven studies investigated thromboembolic events, and there was no statistical difference in deep venous thromboses (pooled RR: 0.67, 95% CI 0.18-2.56, p = 0.56) or pulmonary embolism (pooled RR: 1.10, 95% CI 0.45-2.68, p = 0.83) among the two groups. There was a significant reduction in 30-day mortality for patients that received TXA. CONCLUSION: TXA can be considered effective and safe for patients undergoing hip hemiarthroplasty, with a reduction in transfusion rate and increase in postoperative hemoglobin, without increasing adverse events. Optimal timing, dosage, and type of administration of TXA remain unclear.

Kinesiotaping for Acute Pain Due to Uncomplicated Traumatic Injury of the Shoulder or Chest Wall.

INTRODUCTION: Traumatic injuries of the shoulder or chest wall are commonly treated in the Emergency Department (ED). A complementary treatment is kinesiotaping, an elastic tape often used to treat musculoskeletal dysfunction and pain. However, the added pain-reducing effect of kinesiotape in comparison to standard conservative treatment is unknown. The aim of this study was to determine the effect of kinesiotaping on pain relief compared to standard treatment with pain medication and immobilization in patients with uncomplicated traumatic injury of the shoulder or chest wall in the ED. METHOD: A pilot randomized controlled trial (RCT) was conducted in the ED of a teaching hospital in the Netherlands from January 2021 until the end of March 2021. Patients diagnosed with uncomplicated isolated rib fractures, rib contusions, clavicle fracture, disruption of the AC joint and fracture of the proximal humerus were assigned to two treatment groups. The control group received the standard treatment with oral analgesics (acetaminophen q6h 1000 mg and NSAID (according to prescription) and if shoulder injury also a sling. The intervention group received kinesiotaping in addition to the same standard treatment. Pain intensity was measured with 0-10 Numeric Rating Scale (NRS) just before treatment (T1) and after 15 min (T2). On day 4 both groups were assessed with NRS in a follow up phone call (T3). RESULTS: A total of 251 patients presented with traumatic injury of the shoulder or chest wall in the study period, 85 patients were approached to participate and 2 of them were excluded. The remaining 83 were randomly allocated to kinesiotaping (n = 40) or control group (n = 43), 57 of them completed the study and had sufficient data for complete analysis In both groups, pain intensity after 15 min and 4 days significantly reduced compared with baseline. Regarding the reduction of pain intensity on day 4, kinesiotaping was significantly superior compared to the control group with a difference in pain reduction of 2.45 compared with 0.88 in control group (p = 0.018). CONCLUSION: Compared to standard treatment alone, kinesiotaping combined with standard care appears to be more effective in terms of acute pain reduction in patients with uncomplicated traumatic injury of the shoulder or chest wall. Further research is recommended.

Treatment with ddAVP improves platelet-based coagulation in a rat model of traumatic hemorrhagic shock.

Objectives: Trauma-induced hemorrhagic shock is characterized by increased endothelial permeability and coagulopathy. Vasopressin analog ddAVP (desmopressin) acts by reorganizing and redistributing adhesive and tight junction molecules, enhancing endothelial barrier function. Furthermore, ddAVP increases von Willebrand factor (vWF) plasma levels and thereby potentially enhances platelet-based coagulation. The objective of this study was to assess whether the use of ddAVP results in improvement of both endothelial barrier function and platelet-based coagulation, thereby improving shock reversal and reduce organ failure in a rat model of trauma and transfusion. Methods: Blood products were prepared from syngeneic rat blood according to blood bank standards. Polytrauma was induced in Sprague Dawley rats by a fractured femur and crush injury to the intestines and liver. The rats were hemorrhaged until a mean arterial pressure of 40 mm Hg and transfused with RBCs, fresh frozen plasmas and platelets in a 1:1:1 ratio, and randomized to receive a single dose of ddAVP (n=7 per group). Blood samples were taken up to 6 hours after trauma to assess biochemistry, markers of endothelial injury and coagulation status by rotational thromboelastometry (ROTEM). Organ damage was assessed by histopathology. Results: Rats receiving ddAVP showed significantly better shock reversal compared with controls. Also, coagulation parameters remained stable in the ddAVP treated group, whereas rats in the control group showed deterioration of coagulation parameters, including decreased clot strength and decreased platelet functioning (89% (IQR 82% to 92%) of baseline values). Platelet count and vWF antigen levels at exsanguination did not differ between groups. ddAVP did not reduce markers of endothelial dysfunction nor markers of organ injury. Conclusions: The use of ddAVP in a rat trauma-transfusion model improved shock parameters and ROTEM parameters of clot formation. However, this did not abrogate the amount of organ failure. Level of evidence: Level III.

Healthcare utilization and satisfaction with treatment before and after direct discharge from the Emergency Department of simple stable musculoskeletal injuries in the Netherlands.

PURPOSE: To evaluate healthcare utilization and satisfaction with treatment before and after implementing direct discharge (DD) from the Emergency Department (ED) of patients with simple, stable musculoskeletal injuries. METHODS: Patients with simple, stable musculoskeletal injuries were included in two Dutch hospitals, both level-2 trauma centers: OLVG and Sint Antonius (SA), before (pre-DD-cohort) and after implementing DD (DD-cohort). With DD, no routine follow-up appointments are scheduled after the ED visit, supported by information leaflets, a smartphone application and a telephone helpline. Outcomes included: secondary healthcare utilization (follow-up appointments and X-ray/CT/MRI); satisfaction with treatment (scale 1-10); primary healthcare utilization (general practitioner (GP) or physiotherapist visited, yes/no). Linear regression was used to compare secondary healthcare utilization for all patients and per injury subgroup. Satisfaction and primary healthcare utilization were analyzed descriptively. RESULTS: A total of 2033 (OLVG = 1686; SA = 347) and 1616 (OLVG = 1396; SA = 220) patients were included in the pre-DD-cohort and DD-cohort, respectively. After DD, the mean number of follow-up appointments per patient reduced by 1.06 (1.13-0.99; p < 0.001) in OLVG and 1.07 (1.02-0.93; p < 0.001) in SA. Follow-up appointments reduced significantly for all injury subgroups. Mean number of follow-up X-rays per patient reduced by 0.17 in OLVG (p < 0.001) and 0.18 in SA (p < 0.001). Numbers of CT/MRI scans were low and comparable. In OLVG, mean satisfaction with treatment was 8.1 (pre-DD-cohort) versus 7.95 (DD-cohort), versus 7.75 in SA (DD-cohort only). In OLVG, 23.6% of pre-DD-cohort patients visited their GP, versus 26.1% in the DD-cohort, versus 13.3% in SA (DD-cohort only). Physiotherapist use was comparable. CONCLUSION: This study performed in a large population and additional hospital confirms earlier pilot results, i.e., that DD has the potential to effectively reduce healthcare utilization, while maintaining high levels of satisfaction. LEVEL OF EVIDENCE: II.

Validity and reliability of a wearable-controlled serious game and goniometer for telemonitoring of wrist fracture rehabilitation.

PURPOSE: To determine the validity of wrist range of motion (ROM) measurements by the wearable-controlled ReValidate! wrist-rehabilitation game, which simultaneously acts as a digital goniometer. Furthermore, to establish the reliability of the game by contrasting ROM measurements to those found by medical experts using a universal goniometer. METHODS: As the universal goniometer is considered the reference standard, inter-rater reliability between surgeons was first determined. Internal validity of the game ROM measurements was determined in a test-retest setting with healthy volunteers. The reliability of the game was tested in 34 patients with a restricted range of motion, in whom the ROM was measured by experts as well as digitally. Intraclass-correlation coefficients (ICCs) were determined and outcomes were analyzed using Bland-Altman plots. RESULTS: Inter-rater reliability between experts using a universal goniometer was poor, with ICCs of 0.002, 0.160 and 0.520. Internal validity testing of the game found ICCs of - 0.693, 0.376 and 0.863, thus ranging from poor to good. Reliability testing of the game compared to medical expert measurements, found that mean differences were small for the flexion-extension arc and the radial deviation-ulnar deviation arc. CONCLUSION: The ReValidate! game is a reliable home-monitoring device digitally measuring ROM in the wrist. Interestingly, the test-retest reliability of the serious game was found to be considerably higher than the inter-rater reliability of the reference standard, being healthcare professionals using a universal goniometer. TRIAL REGISTRATION NUMBER: (internal hospital registration only) MEC-AMC W17_003 #17.015.

Functional outcome of routine versus on-demand removal of the syndesmotic screw: a multicentre randomized controlled trial.

AIMS: The aim of this study was to investigate whether on-demand removal (ODR) is noninferior to routine removal (RR) of syndesmotic screws regarding functional outcome. METHODS: Adult patients (aged above 17 years) with traumatic syndesmotic injury, surgically treated within 14 days of trauma using one or two syndesmotic screws, were eligible (n = 490) for inclusion in this randomized controlled noninferiority trial. A total of 197 patients were randomized for either ODR (retaining the syndesmotic screw unless there were complaints warranting removal) or RR (screw removed at eight to 12 weeks after syndesmotic fixation), of whom 152 completed the study. The primary outcome was functional outcome at 12 months after screw placement, measured by the Olerud-Molander Ankle Score (OMAS). RESULTS: There were 152 patients included in final analysis (RR = 73; ODR = 79). Of these, 59.2% were male (n = 90), and the mean age was 46.9 years (SD 14.6). Median OMAS at 12 months after syndesmotic fixation was 85 (interquartile range (IQR) 60 to 95) for RR and 80 (IQR 65 to 100) for ODR. The noninferiority test indicated that the observed effect size was significantly within the equivalent bounds of -10 and 10 scale points (p < 0.001) for both the intention-to-treat and per-protocol, meaning that ODR was not inferior to RR. There were significantly more complications in the RR group (12/73) than in the ODR group (1/79) (p = 0.007). CONCLUSION: ODR of the syndesmotic screw is not inferior to routine removal when it comes to functional outcome. Combined with the high complication rate of screw removal, this offers a strong argument to adopt on demand removal as standard practice of care after syndesmotic screw fixation. Cite this article: Bone Joint J 2021;103-B(11):1709-1716.

Cost-effectiveness of direct discharge from the emergency department of patients with simple stable injuries in the Netherlands.

BACKGROUND: Approximately one-third of musculoskeletal injuries are simple stable injuries (SSIs). Direct discharge (DD) from the emergency department (ED) of patients with SSIs reduces healthcare utilization, without compromising patient outcome and experience, when compared with "traditional" care with routine follow-up. This study aimed to determine the cost-effectiveness of DD compared with traditional care from a societal perspective. METHODS: Societal costs, including healthcare, work absenteeism, and travel costs, were calculated for patients with an SSI, 6 months before (pre-DD cohort) and after implementation of DD (DD cohort). The pre-DD cohort was treated according to local protocols. The DD cohort was treated using orthoses, discharge leaflet, smartphone application, and telephone helpline, without scheduling routine follow-up. Effect measures included generic health-related quality of life (HR-QoL; EuroQol Five-Dimensional Questionnaire); disease-specific HR-QoL (functional outcome, different validated questionnaires, converted to 0-100 scale); treatment satisfaction (Visual Analog Scale (VAS), 1-10); and pain (VAS, 1-10). All data were assessed using a 3-month postinjury survey and electronic patient records. Incremental cost-effectiveness ratios were calculated and uncertainty was assessed using bootstrapping techniques. RESULTS: Before DD, 144 of 348 participants completed the survey versus 153 of 371 patients thereafter. There were no statistically significant differences between the pre-DD cohort and the DD cohort for generic HR-QoL (0.03; 95% CI -0.01 to 0.08), disease-specific HR-QoL (4.4; 95% CI -1.1 to 9.9), pain (0.08; 95% CI -0.37 to 0.52) and treatment satisfaction (-0.16; 95% CI -0.53 to 0.21). Total societal costs were lowest in the DD cohort (-€822; 95% CI -€1719 to -€67), including healthcare costs (-€168; 95% CI -€205 to -€131) and absenteeism costs (-€645; 95% CI -€1535 to €100). The probability of DD being cost-effective was 0.98 at a willingness-to-pay of €0 for all effect measures, remaining high with increasing willingness-to-pay for generic HR-QoL, disease-specific HR-QoL, and pain, and decreasing with increasing willingness-to-pay for treatment satisfaction. DISCUSSION: DD from the ED of patients with SSI seems cost-effective from a societal perspective. Future studies should test generalizability in other healthcare systems and strengthen findings in larger injury-specific cohorts. LEVEL OF EVIDENCE: II.

Optimizing orthopedic trauma care delivery during the COVID-19 pandemic. A closed-loop audit of implementing a virtual fracture clinic and fast-track pathway in a Dutch level 2 trauma center.

BACKGROUND: Guidelines concerning outpatient management of patients during the coronavirus pandemic required minimized face-to-face follow-up and increased remote care. In response, we established a virtual fracture clinic (VFC) review for emergency department (ED) patients with musculoskeletal injuries, meaning patients are reviewed 'virtually' the next workday by a multidisciplinary team, instead of routine referral for face-to-face fracture clinic review. Patients wait at home and are contacted afterwards to discuss treatment. Based on VFC review, patients with minor injuries are discharged, while for other patients an extensive treatment plan is documented using injury-specific care pathways. Additionally, we established an ED orthopedic trauma fast-track to reduce waiting time. This study aimed to evaluate the extent to which our workflow supported adherence to national coronavirus-related guidelines and effects on ED waiting time. METHODS: A closed-loop audit was performed during two 4-week periods using predefined standards: (1) all eligible ED orthopedic trauma patients are referred for VFC review; (2) reached afterwards; and follow-up is (3) patient initiated, or (4) performed remotely, whenever possible. Total ED waiting time, time to review, time for review, and time after review were assessed during both audit periods and compared with previous measurements. RESULTS: During both audits, the majority of eligible ED patients were referred for VFC review (1st: n=162 (88.0%); 2nd: n=302 (98.4%)), and reached afterwards (1st: 98.1%; 2nd: 99.0%). Of all referred patients, 17.9% and 13.6% were discharged 'virtually' during first and second audits, respectively, while 45.0% and 41.1% of scheduled follow-up appointments were remote. Median total ED waiting time was reduced (1st: -36 minutes (p<0.001); 2nd: -33 minutes (p<0.001)). During the second audit, median ED time to review was reduced by -13 minutes (p<0.001), as well as time for review: -10 minutes (p=0.019). DISCUSSION: In line with national guidelines, our VFC review allowed time-effective review and triage of the majority of ED orthopedic trauma patients, supporting patient-initiated and remote follow-up, whenever possible. ED waiting time was reduced after implementing the VFC review and orthopedic trauma fast-track. LEVEL OF EVIDENCE: IV.

Platelet-to-red blood cell ratio and mortality in bleeding trauma patients: A systematic review and meta-analysis.

BACKGROUND: In traumatic bleeding, transfusion practice has shifted toward higher doses of platelets and plasma transfusion. The aim of this systematic review was to investigate whether a higher platelet-to-red blood cell (RBC) transfusion ratio improves mortality without worsening organ failure when compared with a lower ratio of platelet-to-RBC. METHODS: Pubmed, Medline, and Embase were screened for randomized controlled trials (RCTs) in bleeding trauma patients (age ≥16 years) receiving platelet transfusion between 1946 until October 2020. High platelet:RBC ratio was defined as being the highest ratio within an included study. Primary outcome was 24 hour mortality. Secondary outcomes were 30-day mortality, thromboembolic events, organ failure, and correction of coagulopathy. RESULTS: In total five RCTs (n = 1757 patients) were included. A high platelet:RBC compared with a low platelet:RBC ratio significantly improved 24 hour mortality (odds ratio [OR] 0.69 [0.53-0.89]) and 30- day mortality (OR 0.78 [0.63-0.98]). There was no difference between platelet:RBC ratio groups in thromboembolic events and organ failure. Correction of coagulopathy was reported in five studies, in which platelet dose had no impact on trauma-induced coagulopathy. CONCLUSIONS: In traumatic bleeding, a high platelet:RBC improves mortality as compared to low platelet:RBC ratio. The high platelet:RBC ratio does not influence thromboembolic or organ failure event rates.

Supporting the medial hinge in proximal humerus fractures with an intramedullary plate.

Proximal humerus fractures are common and approximately 20% of displaced fractures may benefit from surgery. A lack of medial support is found to be a predictor of failure after surgical fixation of proximal humerus fractures. The optimal technique for restoring the medial hinge is unclear. We describe two cases of patients with a dislocated 4-part humerus fracture treated with a locking plate and an additional small intramedullary plate to support the medial hinge. This technique is simple and allows for an enhanced stability of the medial hinge during and after surgery.

Direct discharge from the emergency department of simple stable injuries: a propensity score-adjusted non-inferiority trial.

BACKGROUND: Recent studies suggest a large proportion of musculoskeletal injuries are simple stable injuries (SSIs). The aim of this study was to evaluate whether direct discharge (DD) from the emergency department (ED) of SSIs is non-inferior to 'traditional care' regarding treatment satisfaction and functional outcome, and to compare other patient-reported outcomes (PROMs), patient-reported experiences (PREMs), resource utilization, and adverse outcomes before and after DD. METHODS: This trial compared outcomes for 11 SSIs 6 months before and after the implementation of DD protocols. Pre-DD, patients were treated according to local protocols. Post-DD, patients were discharged directly using removable orthoses, discharge leaflets, smartphone application, and telephone helpline. Participants received a 3-month postinjury PROM/PREM survey to assess treatment satisfaction (Visual Analog Scale, VAS), pain (VAS), functional outcome (four validated questionnaires), and health-related quality of life (HR-QoL; EuroQol-5D). Resource utilization included general practitioner (GP) visit (yes/no), physiotherapist visit (yes/no), return to work/school/sports (days), work/school absenteeism to visit hospital (yes/no), number of hospital visits, and follow-up X-rays. Other outcomes included missed injuries (additionally to SSI) and adverse outcomes (delayed union, non-union). Between-group differences were assessed using propensity score-adjusted regression analyses. Non-inferiority was assessed for satisfaction and functional outcome using predefined margins. RESULTS: 348 (pre-DD) and 371 (post-DD) patients participated; 144 (41.4%) and 153 (41.2%) patients completed the survey. Satisfaction and functional outcome post-DD were non-inferior to traditional care. Mean satisfaction was 8.13 pre-DD and 7.95 post-DD (mean difference: -0.16, p=0.408). Pain, HR-QoL, GP/physiotherapist visits, and return to work/school/sports were comparable before and after DD. Work absenteeism was higher pre-DD (OR 0.110, p<0.001), as well as school absenteeism (OR 0.084, p<0.001). Post-DD, the mean number of hospital visits and X-rays reduced: -1.68 (p<0.001) and -0.26 (p<0.001). Missed injuries occurred once pre-DD versus twice post-DD. There were no adverse outcomes. DISCUSSION: The results of this study confirm several SSIs can be discharged directly from the ED without compromising patient outcome/experience. Future injury-specific trials are needed to conclusively assess non-inferiority of DD. LEVEL OF EVIDENCE: II.