Direct discharge for children with a greenstick or torus fracture of the wrist is a non-inferior satisfactory solution to traditional treatment.

PURPOSE: Direct Discharge protocols (DD) can alleviate strain on healthcare systems by reducing routine outpatient follow-up. These protocols include low-complex musculoskeletal injuries, such as isolated greenstick fractures or torus fractures of the wrist in children. While there is consensus on the effectiveness of DD, there is a lack of injury-specific powered studies. This study compares treatment satisfaction between DD and traditional treatment in children with a greenstick fracture or torus fractures of the wrist. METHODS: Children with isolated torus or greenstick fractures of the distal radius or ulna were eligible for inclusion before (pre-DD cohort) and after (DD cohort) the implementation of DD in four hospitals. Traditionally, patients receive a (soft) cast and minimally one routine outpatient follow-up appointment. With DD, patients are discharged directly from the ED after receiving a brace and information, summarized in a smartphone app and a helpline for questions during recovery. The primary outcome was patient or proxy treatment satisfaction (0 to 10), and a power analysis was performed to assess non-inferiority. Secondary outcomes included complications, functional outcomes measured in Patient-Reported Outcomes Measurement Information System Upper Extremity (PROMIS UE), primary healthcare utilisation, and secondary healthcare utilisation (follow-up appointments and imaging). RESULTS: In total, 274 consecutive children were included to analyse the primary endpoint. Of these, 160 (58%) were male with a median age of 11 years (IQR 8 to 12). Pre-DD and DD treatment satisfaction did not vary statistically significantly for greenstick fractures (p = 0.09) and torus fractures (p = 0.93). No complications were observed. PROMIS UE showed no statistically significant differences before and after implementation of direct discharge protocol for torus (p = 0.99) or greenstick (p = 0.45) fractures. Secondary healthcare utilisation regarding follow-up was significantly lower in the DD-torus cohort compared to the pre-DD torus cohort, with a mean difference (MD) of - 1.00 follow-up appointments (95% Confidence Interval (CI) - 0.92 to - 1.13). Similar results were found in the pre DD-greenstick cohort compared to the pre-DD-greenstick cohort (MD): - 1.17 follow-up appointments, 95% CI - 1.09 to - 1.26). CONCLUSION: Direct Discharge is non-inferior to traditional treatment in terms of treatment satisfaction for paediatric patients with greenstick or torus fractures of the wrist compared to children treated with rigid immobilisation and routine follow-up. Furthermore, the results demonstrate no complications, comparable functional outcomes, and a statistically significant reduction of secondary healthcare utilisation, making DD a good solution to cope with strained resources for children with an isolated greenstick fracture or torus fracture of the wrist.

The goals of care in acute setting for geriatric patients in case of a hip fracture.

PURPOSE: For geriatric hip fracture patients, the decision between surgery and palliative, non-operative management is made through shared decision making (SDM). For this conversation, a physician must be familiar with the patient's goals of care (GOC). These are predominantly unknown for hip fracture patients and challenging to assess in acute setting. The objective was to explore these GOC of geriatric patients in case of a hip fracture. METHODS: An expert panel gathered possible outcomes after a hip fracture, which were transformed into statements where participants indicated their relative importance on a 100-point scoring scale during interviews. These GOC were ranked using medians and deemed important if the median score was 90 or above. Patients were aged 70 years or older with a hip contusion due to similarities with the hip fracture population. Three cohorts based on frailty criteria and the diagnosis of dementia were made. RESULTS: Preserving cognitive function, being with family and being with partner scored in all groups among the most important GOC. Both non-frail and frail geriatric patients scored return to pre-fracture mobility and maintaining independence among the most important GOC, where proxies of patients with a diagnosis of dementia scored not experiencing pain as the most important GOC. CONCLUSION: All groups scored preserving cognitive function, being with family and being with partner among the most important GOC. The most important GOC should be discussed when a patient is presented with a hip fracture. Since patients preferences vary, a patient-centered assessment of the GOC remains essential.

Cast versus removable orthosis for the management of stable type B ankle fractures: a systematic review and meta-analysis.

PURPOSE: There is currently no consensus on nonoperative management in adult patients after a stable type B ankle fracture. The aim of this review is to compare a removable orthosis versus a cast regarding safety and functional outcome in the NOM of stable type B ankle fractures. METHODS: A systematic review and meta-analysis were performed using randomized clinical trials and observational studies. The methodological quality of the included studies was assessed with the methodological index for non-randomized studies instrument. Nonoperative management was compared using the number of complications and functional outcome measured using the Olerud and Molander Score (OMAS) or the American Academy of Orthopaedic Surgeons Ankle Score. RESULTS: Five studies were included. Two were randomized clinical trials, and three were observational studies, including a total of 516 patients. A meta-analysis showed statistically significant higher odds of developing complications in the cast group [odds ratio (OR), 4.67 (95% confidence interval (CI) 1.52-14.35)]. Functional outcome in OMAS did not vary significantly at 6 weeks, mean difference (MD) - 6.64 (95% CI - 13.72 to + 0.45), and at 12 weeks, MD - 6.91 (95% CI - 18.73 to + 4.91). The mean difference of functional outcome in OMAS at 26 weeks or longer was significantly better in the removable orthosis group; MD - 2.63 (95% CI - 5.01 to - 0.25). CONCLUSION: Results of this systematic review and meta-analysis show that a removable orthosis is a safe alternative type of NOM, as complication numbers are significantly lower in the orthosis group. In addition, no statistically significant differences were found in terms of functional outcome between a removable orthosis and a cast at 6 and 12 weeks. The 6-week and the 26-week OMAS results show that in patients with stable type B ankle fractures, a removable orthosis is non-inferior to a cast in terms of functional outcome.

Proxy-reported experiences of palliative, non-operative management of geriatric patients after a hip fracture: a qualitative study.

OBJECTIVE: The objective of this study was to explore the experiences from the period after the choice was made for palliative, non-operative management for geriatric patients with a hip fracture, to the most important factors in the process, as reported by a proxy. DESIGN: Semistructured interviews were conducted between 1 August 2020 and 1 April 2021 to investigate by-proxy reported patient experiences of non-operative management after hip fracture. Interviews followed a topic guide, recorded and transcribed per word. Thematic analysis was used to identify themes in the data. SETTING AND PARTICIPANTS: Patients were retrospectively identified from the electronic patient record. Relatives (proxies) of the patients who underwent palliative, non-operative management were contacted and were asked to participate in a semistructured interview and were named participants. The participants were proxies of the patients since patients were expected to be deceased during the timing of the interview. RESULTS: A total of 26 patients were considered eligible for inclusion in this study. The median age of the patients was 88 years (IQR 83-94). The 90-day mortality rate was 92.3%, with a median palliative care period of 11 days (IQR 4-26). A total of 19 participants were subjected to the interview. After thematic analysis, four recurring themes were identified: (1) the decision-making process, (2) pain experience, (3) patient-relative interaction and (4) the active dying. CONCLUSIONS: With the introduction of shared decision-making in an acute setting for geriatric patients with hip fracture, proxies reported palliative, non-operative management as an acceptable and adequate option for patients with high risk of adverse outcomes after surgery. The emerged themes in palliative care for patients with hip fracture show great similarity with severe end-stage disease palliative care, with pain identified as the most important factor influencing comfort of the patient and their environment after hip fracture. Future research should focus on further improving targeted analgesia for these patients focusing on acute pain caused by the fracture.

Is the Parker Mobility Score in the older patient with a traumatic hip fracture associated with discharge disposition after surgery? A retrospective cohort study.

PURPOSE: The research questions for this study were as follows: (1) is the Parker Mobility Score (PMS) associated with discharge disposition and hospital length of stay (HLOS) of geriatric traumatic hip fracture patients? (2) Can the PMS be incorporated in a decision tree for the prediction of discharge disposition of geriatric traumatic hip fracture patients upon admittance. METHODS: A dual-center retrospective cohort study was conducted at two level II trauma centers. All patients aged 70 years and older with traumatic hip fractures undergoing surgery in 2018 and 2019 were included consecutively (n = 649). A χ2 automatic interaction detection analysis was performed to determine the association of the PMS (and other variables) with discharge disposition and HLOS and predict discharge destination. RESULTS: The decision tree for discharge disposition classified patients with an overall accuracy of 82.1% and a positive predictive value of 91% for discharge to a rehabilitation facility. The PMS had the second most significant effect on discharge disposition (χ2 = 22.409, p < 0.001) after age (χ2 = 79.094, p < 0.001). Regarding the tree analysis of HLOS, of all variables in the analysis, PMS had the most significant association with HLOS (F = 14.891, p < 0.001). Patients who were discharged home had a mean HLOS of 6.5 days (SD 8.0), whereas patients who were discharged to an institutional care facility had a mean HLOS of 9.7 days (SD 6.4; p < 0.001). CONCLUSION: This study shows that the PMS was strongly associated with discharge disposition and HLOS. The decision tree for the discharge disposition of geriatric traumatic hip fracture patients offers a practical solution to start discharge planning upon admittance which could potentially reduce HLOS. LEVEL OF EVIDENCE: Level III, diagnostic.

Operative Fixation of Lateral Malleolus Fractures With Locking Plates vs Nonlocking Plates: A Systematic Review and Meta-analysis.

BACKGROUND: The exact benefit of locking plates over nonlocking plates in patients with lateral malleolus fractures remains unclear. The primary aim of this study was to compare the functional outcome of locking plates vs nonlocking plates in patients with a lateral malleolus fracture. The secondary aims were to compare the number of complications and hardware removals and to compare whether results differed for older patients and for patients treated with anatomical locking plates. METHODS: The PubMed/MEDLINE, Embase, Cochrane, and CINAHL databases were searched for studies comparing locking plates with nonlocking plates in patients with fixated lateral malleolus fractures. All included studies were assessed on their methodologic quality using the MINORS. Subgroup analyses were performed on older patients and patients treated with anatomical locking plates. RESULTS: A total of 11 studies were included. The meta-analysis showed that functional outcome did not differ between patients treated with locking plates and nonlocking plates (MD 2.38, 95% CI -2.71 to 7.46). No difference in both complication rate (OR 1.10, 95% CI 0.74-1.63) and the amount of hardware removals (OR 0.77, 95% CI 0.52-1.14) was found. Even after analyzing older patients and patients treated with anatomical locking plates, no benefit was shown. CONCLUSION: This meta-analysis demonstrates no clear benefit in selecting locking plates over nonlocking plates in the treatment of lateral malleolus fractures. CLINICAL RELEVANCE: Locking plates are increasingly being used in the treatment of lateral malleolus fractures. Biomechanical studies have shown an increased stability with use of locking vs nonlocking plates. This clinical review does not support a benefit of use of locking plates for these fractures.

Robot-assisted fracture fixation in orthopaedic trauma surgery: a systematic review.

To investigate the applications of robot-assisted surgery and its effect on surgical outcomes in orthopaedic trauma patients. DATA SOURCES: A search was performed in PubMed and Embase for articles in English, Dutch, German, or French, without restrictions on follow-up times, study size, or year of publication. STUDY SELECTION: Studies were included if they investigated patients undergoing robot-assisted fracture fixation surgery for orthopaedic trauma. DATA EXTRACTION: Outcomes studied were operating time, fluoroscopy time/frequency, complications, functional outcomes, intraoperative blood loss, fracture healing, and screw placement accuracy. Critical appraisal was done by using the Methodological Index for Non-Randomized Studies. DATA SYNTHESIS: Narrative review. CONCLUSIONS: A total of 3832 hits were identified with the search and 8 studies were included with a combined total of 437 included patients, 3 retrospective cohort studies, 2 prospective cohort studies, 1 cohort study not otherwise specified, 1 case series, and 1 randomized controlled trial. Four studies investigated pelvic ring fractures, 3 studies investigated femur fractures, and 1 study investigated scaphoid fractures. Seven investigated percutaneous screw fixation and 1 studied intramedullary nail fixation. One robotic system was used across all studies, the TiRobot, and all procedures were performed in China. The limited evidence suggests that that robot-assisted orthopaedic trauma surgery may reduce operating time, use of fluoroscopy, intraoperative blood loss, and improve screw placement accuracy, but the overall quality of evidence was low with a high risk of bias. Robot-assisted fracture fixation does not appear to lead to better functional outcomes for the patient.Level of evidence: III.

Predictors of 30-day mortality in orthogeriatric fracture patients aged 85 years or above admitted from the emergency department.

PURPOSE: Orthogeriatric trauma patients are at risk for functional decline and mortality. It is important to identify high-risk patients in an early stage, to improve outcomes and make better informed treatment decisions. The aim of this study was to identify independent risk factors for 30-day mortality in patients aged 85 years or above admitted from the emergency department with a fracture. METHODS: All orthopaedic trauma patients 85 years or above admitted from the emergency department were included. After a 30-day follow-up, mortality was determined by consulting the patient records. Multivariable logistics regression analysis generated odd ratios for mortality risk factors. A subgroup analysis was performed for patients undergoing hip fracture surgery. RESULTS: The 30-day mortality in geriatric fracture patients admitted to the hospital was 12%. Risk factors for 30-day mortality were: increased age, male sex, decreased hemoglobin levels, living in an institutional care facility and a decreased BMI. For geriatric patients undergoing hip fracture surgery 30-day mortality was 11%. Independent risk factors for this group were: increased age, male sex, and a decreased BMI. CONCLUSION: Orthopaedic trauma patients aged 85 years or above who are admitted to the hospital with a fracture are at high risk for mortality. This study identified older age, male sex, and decreased BMI as predictors of 30-day mortality in admitted geriatric fracture patients and in geriatric hip fracture patients undergoing surgery.

Orthogeriatric Trauma Unit Improves Patient Outcomes in Geriatric Hip Fracture Patients.

INTRODUCTION: An aging population in developed countries has increased the number of osteoporotic hip fractures and will continue to grow over the next decades. Previous studies have investigated the effect of integrated orthogeriatric trauma units and care model on outcomes of hip fracture patients. Although all of the models perform better than usual care, there is no conclusive evidence which care model is superior. More confirmative studies reporting the efficacy of orthogeriatric trauma units are needed. The objective of this study was to evaluate outcomes of hip fracture patients admitted to the hospital before and after implementation of an orthogeriatric trauma unit. MATERIALS AND METHODS: This retrospective cohort study was conducted at a level 2 trauma center between 2016 and 2018. Patients aged 70 years or older with a hip fracture undergoing surgery were included to evaluate the implementation of an orthogeriatric trauma unit. The main outcomes were postoperative complications, patient mortality, time spent at the emergency department, time to surgery, and hospital length of stay. RESULTS: A total of 806 patients were included. After implementation of the orthogeriatric trauma unit, there was a significant decrease in postoperative complications (42% vs. 49% in the historical cohort, p = 0.034), and turnaround time at the emergency department was reduced by 38 minutes. Additionally, there was significantly less missing data after implementation of the orthogeriatric trauma unit. After correcting for covariates, patients in the orthogeriatric trauma unit cohort had a lower chance of complications (OR 0.654, 95% CI 0.471-0.908, p = 0.011) and a lower chance of 1-year mortality (OR 0.656, 95% CI 0.450-0.957, p = 0.029). CONCLUSIONS: This study showed that implementation of an orthogeriatric trauma unit leads to a decrease in postoperative complications, 1-year mortality, and time spent at the emergency department, while also improving the quality of data registration for clinical studies. LEVEL OF EVIDENCE: Level III.

Weight-bearing or non-weight-bearing after surgical treatment of ankle fractures: a multicenter randomized controlled trial.

PURPOSE: The goal of this study was to assess if unprotected weight-bearing as tolerated is superior to protected weight-bearing and unprotected non-weight-bearing in terms of functional outcome and complications after surgical fixation of Lauge-Hansen supination external rotation stage 2-4 ankle fractures. METHODS: A multicentered randomized controlled trial was conducted in patients ranging from 18 to 65 years of age without severe comorbidities. Patients were randomized to unprotected non-weight-bearing, protected weight-bearing, and unprotected weight-bearing as tolerated. The primary endpoint of the study was the Olerud Molander Ankle Score (OMAS) 12 weeks after randomization. The secondary endpoints were health-related quality of life using the SF-36v2, time to return to work, time to return to sports, and the number of complications. RESULTS: The trial was terminated early as advised by the Data and Safety Monitoring Board after interim analysis. A total of 115 patients were randomized. The O'Brien-Fleming threshold for statistical significance for this interim analysis was 0.008 at 12 weeks. The OMAS was higher in the unprotected weight-bearing group after 6 weeks c(61.2 ± 19.0) compared to the protected weight-bearing (51.8 ± 20.4) and unprotected non-weight-bearing groups (45.8 ± 22.4) (p = 0.011). All other follow-up time points did not show significant differences between the groups. Unprotected weight-bearing showed a significant earlier return to work (p = 0.028) and earlier return to sports (p = 0.005). There were no differences in the quality of life scores or number of complications. CONCLUSIONS: Unprotected weight-bearing and mobilization as tolerated as postoperative care regimen improved short-term functional outcomes and led to earlier return to work and sports, yet did not result in an increase of complications.