Identifying and addressing mentorship gaps in European trauma and emergency surgical training. Results from the Young European Society of Trauma and Emergency Surgery (yESTES) mentorship survey.

PURPOSE: European training pathways for surgeons dedicated to treating severely injured and critically ill surgical patients lack a standardized approach and are significantly influenced by diverse organizational and cultural backgrounds. This variation extends into the realm of mentorship, a vital component for the holistic development of surgeons beyond mere technical proficiency. Currently, a comprehensive understanding of the mentorship landscape within the European trauma care (visceral or skeletal) and emergency general surgery (EGS) communities is lacking. This study aims to identify within the current mentorship environment prevalent practices, discern existing gaps, and propose structured interventions to enhance mentorship quality and accessibility led by the European Society for Trauma and Emergency Surgery (ESTES). METHODS: Utilizing a structured survey conceived and promoted by the Young section of the European Society of Trauma and Emergency Surgery (yESTES), we collected and analyzed responses from 123 ESTES members (both surgeons in practice and in training) across 20 European countries. The survey focused on mentorship experiences, challenges faced by early-career and female surgeons, the integration of non-technical skills (NTS) in mentorship, and the perceived role of surgical societies in facilitating mentorship. RESULTS: Findings highlighted a substantial mentorship experience gap, with 74% of respondents engaging in mostly informal mentorship, predominantly centered on surgical training. Notably, mentorship among early-career surgeons and trainees was less reported, uncovering a significant early-career gap. Female surgeons, representing a minority within respondents, reported a disproportionately poorer access to mentorship. Moreover, while respondents recognized the importance of NTS, these were inadequately addressed in current mentorship practices. The current mentorship input of surgical societies, like ESTES, is viewed as insufficient, with a call for structured programs and initiatives such as traveling fellowships and remote mentoring. CONCLUSIONS: Our survey underscores critical gaps in the current mentorship landscape for trauma and EGS in Europe, particularly for early-career and female surgeons. A clear need exists for more formalized, inclusive mentorship programs that adequately cover both technical and non-technical skills. ESTES could play a pivotal role in addressing these gaps through structured interventions, fostering a more supportive, inclusive, and well-rounded surgical community.

Fat-soluble vitamins as biomarkers of nutritional status and their relation with complications in polytrauma patients.

BACKGROUND AND AIMS: This exploratory observational prospective study aimed to evaluate fat-soluble vitamin plasma levels during hospital admission and its relation with the development of malnutrition and complications in polytrauma patients, considering the protocolized multivitamin supplementation during intensive care unit (ICU) admission. METHODS: In 49 well-nourished polytrauma (injury severity score ≥ 16) patients admitted to the ICU of two level-1 trauma centers, vitamin A, D, and E levels were assessed weekly during hospital stay. All patients received multivitamin supplementation during ICU stay. Linear mixed-effect models were used to assess a trend in vitamin levels over time during hospital stay. Mixed-effects logistic regression analysis was performed to relate vitamin concentrations with malnutrition, defined as a subjective global assessment score ≤5, and complications. RESULTS: Vitamin A levels increased 0.17 µmol/L per week (95% confidence interval 0.12-0.22, p < 0.001), vitamin D levels increased 1.49 nmol/L per week (95% confidence interval 0.64-2.33, p < 0.01), vitamin E levels increased 1.17 µmol/L per week (95% confidence interval 0.61-1.73, p < 0.001) during hospital stay (29 ± 17 days). Vitamin levels were not related to malnutrition or complications during hospital stay. CONCLUSION: Vitamin A, D, and E levels increased due to supplementation during hospital admission. Plasma levels of vitamins A, D, and E do not seem to be useful as biomarkers for the nutritional status of polytrauma patients during hospital stay. No correlation with complications could be demonstrated.

The correlation of CT-derived muscle density, skeletal muscle index, and visceral adipose tissue with nutritional status in severely injured patients.

BACKGROUND: This study explored if computerized tomography-derived body composition parameters (CT-BCPs) are related to malnutrition in severely injured patients admitted to the Intensive Care Unit (ICU). METHODS: This prospective cohort study included severely injured (Injury Severity Score ≥ 16) patients, admitted to the ICU of three level-1 trauma centers between 2018 and 2022. Abdominal CT scans were retrospectively analyzed to assess the CT-BCPs: muscle density (MD), skeletal muscle index (SMI), and visceral adipose tissue (VAT). The Subjective Global Assessment was used to diagnose malnutrition at ICU admission and on day 5 of admission, and the modified Nutrition Risk in Critically ill at admission was used to assess the nutritional risk. RESULTS: Seven (11%) of the 65 analyzed patients had malnutrition at ICU admission, increasing to 23 patients (35%) on day 5. Thirteen (20%) patients had high nutritional risk. CT-BCPs were not related to malnutrition at ICU admission and on day 5. Patients with high nutritional risk at admission had lower MD (median (IQR) 32.1 HU (25.8-43.3) vs. 46.9 HU (37.7-53.3); p < 0.01) and higher VAT (median 166.5 cm2 (80.6-342.6) vs. 92.0 cm2 (40.6-148.2); p = 0.01) than patients with low nutritional risk. CONCLUSION: CT-BCPs do not seem related to malnutrition, but low MD and high VAT may be associated with high nutritional risk. These findings may prove beneficial for clinical practice, as they suggest that CT-derived parameters may provide valuable information on nutritional risk in severely injured patients, in addition to conventional nutritional assessment and screening tools. LEVEL OF EVIDENCE: Level III, Prognostic/Epidemiological.

Reverse Shoulder Arthroplasty versus Non-Operative Treatment of Three-Part and Four-Part Proximal Humerus Fractures in the Elderly Patient: A Pooled Analysis and Systematic Review.

Background: The treatment of complex proximal humerus fractures in elderly patients is not yet fully elucidated. Of all treatment options, reverse shoulder arthroplasty (RSA) and non-operative treatment (NOT) appear to provide the best results. Evidence to guide the choice between the two is sparse. Therefore, this review provides an overview of the available evidence on RSA versus NOT. Methods: Studies comparing complex proximal humerus fractures in patients aged >65 years treated either with RSA or NOT were included for systematic review and direct comparison via pooled analysis of patient-rated outcome and range of motion. Indirect comparison of case series and non-comparative studies on either treatment was performed separately. Results: Three comparative studies including 77 patients treated with RSA and 81 treated non-operatively were analysed. The RSA group scored better for both the Constant-Murley score (mean difference 6 points) and DASH score (mean difference 8 points). No differences were detected in ASES, PENN score, pain scores, or range of motion between treatment groups. The most common complications for RSA were infection (3%), nerve injury (2%), and dislocation (2%). Reoperation was required in 5%. In the NOT group, common complications included malunion (42%), osteonecrosis (25%), and non-union (3%); no reoperation was required. Patient satisfaction was equal in both groups. Conclusions: The functional outcomes and range of motion after RSA seemed satisfactory and potentially superior to NOT in elderly patients. Patient satisfaction was comparable despite a high malunion and osteonecrosis rate in the non-operative treatment group, which did not require re-interventions.

Two big bones, one big decision: When to fix bilateral femur fractures.

PURPOSE: For polytrauma patients with bilateral femoral shaft fractures (BFSF), there is currently no consensus on the optimal timing of surgery. This study assesses the impact of early (≤ 24 h) versus delayed (>24 h) definitive fixation on clinical outcomes, especially focusing on concomitant versus staged repair. We hypothesized that early definitive fixation leads to lower mortality and morbidity rates. METHODS: The 2017-2020 Trauma Quality Improvement Program was used to identify patients aged ≥16 years with BFSF who underwent definitive fixation. Early definitive fixation (EDF) was defined as fixation of both femoral shaft fractures within 24 h, delayed definitive fixation (DDF) as fixation of both fractures after 24 h, and early staged fixation (ESF) as fixation of one femur within 24 h and the other femur after 24 h. Propensity score matching and multilevel mixed effects regression models were used to compare groups. RESULTS: 1,118 patients were included, of which 62.8% underwent EDF. Following propensity score matching, 279 balanced pairs were formed. EDF was associated with decreased overall morbidity (12.9% vs 22.6%, p = 0.003), lower rate of deep venous thrombosis (2.2% vs 6.5%, p = 0.012), a shorter ICU LOS (5 vs 7 days, p < 0.001) and a shorter hospital LOS (10 vs 15 days, p < 0.001). When compared to DDF, early staged fixation (ESF) was associated with lower rates of ventilator acquired pneumonia (0.0% vs 4.9%, p = 0.007), but a longer ICU LOS (8 vs 6 days, p = 0.004). Using regression analysis, every 24-hour delay to definitive fixation increased the odds of developing complications by 1.05, postoperative LOS by 10 h and total hospital LOS by 27 h. CONCLUSION: Early definitive fixation (≤ 24 h) is preferred over delayed definitive fixation (>24 h) for patients with bilateral femur shaft fractures when accounting for age, sex, injury characteristics, additional fractures and interventions, and hospital level. Although mortality does not differ, overall morbidity and deep venous thrombosis rates, and length of hospital and intensive care unit stay are significantly lower. When early definitive fixation is not possible, early staged repair seems preferable over delayed definitive fixation.

Arterial angioembolisation versus pre-peritoneal pelvic packing in haemodynamically unstable patients with complex pelvic fractures: a meta-analysis.

INTRODUCTION: Angioembolisation (AE) and/or pre-peritoneal pelvic packing (PPP) may be necessary for patients with complex pelvic fractures who are haemodynamically unstable. However, it remains unclear whether AE or PPP should be performed as an initial intervention and ongoing debates exist. This meta-analysis aimed to compare AE versus PPP in haemodynamically unstable patients with acute pelvic fractures. The primary outcomes of interest were to compare in-hospital mortality rate and number of blood units transfused. Secondary outcomes included evaluating differences in the time from diagnosis to treatment, as well as the length of stay in the intensive care unit (ICU) and hospital. METHODS: All clinically relevant studies comparing AE versus PPP in patients with complex pelvic fractures and haemodynamic instability were accessed. The 2020 PRISMA guidelines were followed. In September 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar and Embase, without constraint. RESULTS: Data from 320 patients were collected (AE: 174; PPP: 146). The mean age on admission was 47.4 ± 7.2 years. The mean Injury Severity Score (ISS) on admission was 43.5 + 5.4 points. Baseline comparability was observed in ISS (P = 0.5, Table 3) and mean age (P = 0.7, Table 3). No difference was reported in mortality rate (P = 0.2) or rate of blood units transfused (P = 0.3). AE had a longer mean time to the procedure of 44.6 min compared to PPP (P = 0.04). The mean length of ICU and hospital stay were similar in both groups. CONCLUSION: Despite the longer mean time from admission to the procedure, no significant differences were found between AE and PPP in terms of in-hospital mortality, blood units transfused, or length of ICU, and hospital stay. These findings should be interpreted considering the limitations of the present study. High-quality comparative research is strongly warranted. LEVEL OF EVIDENCE: Level IV, meta-analysis.

Maturation of trauma systems in Europe.

PURPOSE: To provide an overview of trauma system maturation in Europe. METHODS: Maturation was assessed using a self-evaluation survey on prehospital care, facility-based trauma care, education/training, and quality assurance (scoring range 3-9 for each topic), and key infrastructure elements (scoring range 7-14) that was sent to 117 surgeons involved in trauma, orthopedics, and emergency surgery, from 24 European countries. Average scores per topic were summed to create a total score on a scale from 19 to 50 per country. Scores were compared between countries and between geographical regions, and correlations between scores on different sections were assessed. RESULTS: The response rate was 95%. On the scale ranging from 19 to 50, the mean (SD, range) European trauma system maturity score was 38.5 (5.6, 28.2-48.0). Prehospital care had the highest mean score of 8.2 (0.5, 6.9-9.0); quality assurance scored the lowest 5.9 (1.7, 3.2-8.5). Facility-based trauma care was valued 6.9 (1.4, 4.1-9.0), education and training 7.0 (1.2, 5.2-9.0), and key infrastructure elements 10.3 (1.6, 7.6-13.5). All aspects of trauma care maturation were strongly correlated (r > 0.6) except prehospital care. End scores of Northern countries scored significantly better than Southern countries (p = 0.03). CONCLUSION: The level of development of trauma care systems in Europe varies greatly. Substantial improvements in trauma systems in several European countries are still to be made, especially regarding quality assurance and key infrastructure elements, such as implementation of a lead agency to oversee the trauma system, and funding for growth, innovation and research.

Clockwise torque results in higher reoperation rates in left-sided femur fractures.

PURPOSE: Effects of clockwise torque rotation onto proximal femoral fracture fixation have been subject of ongoing debate: fixated right-sided trochanteric fractures seem more rotationally stable than left-sided fractures in the biomechanical setting, but this theoretical advantage has not been demonstrated in the clinical setting to date. The purpose of this study was to identify a difference in early reoperation rate between patients undergoing surgery for left- versus right-sided proximal femur fractures using cephalomedullary nailing (CMN). MATERIALS AND METHODS: The American College of Surgeons National Surgical Quality Improvement Program was queried from 2016-2019 to identify patients aged 50 years and older undergoing CMN for a proximal femoral fracture. The primary outcome was any unplanned reoperation within 30 days following surgery. The difference was calculated using a Chi-square test, and observed power calculated using post-hoc power analysis. RESULTS: In total, of 20,122 patients undergoing CMN for proximal femoral fracture management, 1.8% (n=371) had to undergo an unplanned reoperation within 30 days after surgery. Overall, 208 (2.0%) were left-sided and 163 (1.7%) right-sided fractures (p=0.052, risk ratio [RR] 1.22, 95% confidence interval [CI] 1.00-1.50), odds ratio [OR] 1.23 (95%CI 1.00-1.51), power 49.2% (α=0.05). CONCLUSION: This study shows a higher risk of reoperation for left-sided compared to right-sided proximal femur fractures after CMN in a large sample size. Although results may be underpowered and statistically insignificant, this finding might substantiate the hypothesis that clockwise rotation during implant insertion and (postoperative) weightbearing may lead to higher reoperation rates. LEVEL OF EVIDENCE: Therapeutic level II.

Pediatric Trauma in The Netherlands: Incidence, Mechanism of Injury and In-Hospital Mortality.

BACKGROUND: In the Netherlands, there are no specialized or certified pediatric trauma centers, especially for severely injured children. National and regional agreements on centralization of pediatric trauma care are scarce. This study aims to describe the incidence, injury mechanism and in-hospital mortality of pediatric trauma in the Netherlands, as a prelude to the further organization of pediatric trauma care. METHODS: A retrospective cohort analysis of data from the Dutch National Trauma Registry in 2009-2018, concerning all children (0-16 years) hospitalized due to injury in the Netherlands. RESULTS: The annual number of admitted injured children increased from 8666 in 2009 to 13,367 in 2018. Domestic accidents were the most common cause of non-fatal injury (67.9%), especially in children aged 0-5 years (89.2%). Severe injury (injury severity score ≥  16) accounted for 2.5% and 74% of these patients were treated in level-1 trauma centers. In both deceased and surviving patients with severe injuries, head injuries were the most common (72.1% and 64.3%, respectively). In-hospital mortality after severe injury was 8.2%. Road-traffic accidents (RTAs) were the leading cause of death (46.5%). CONCLUSIONS: Domestic accidents are the most common cause of injury, especially in younger children, whereas RTAs are the lead cause of fatal injury. Severe pediatric trauma in the Netherlands is predominantly managed in level-1 trauma centers, where a multidisciplinary team of experts is available. Improving the numbers of severely injured patients primarily brought to level-1 trauma centers may help to further reduce mortality.

Is hospital volume related to quality of hip fracture care? Analysis of 43,538 patients and 68 hospitals from the Dutch Hip Fracture Audit.

PURPOSE: Evidence for a hospital volume-outcome relationship in hip fracture surgery is inconclusive. This study aimed to analyze the association between hospital volume as a continuous parameter and several processes and outcomes of hip fracture care. METHODS: Adult patients registered in the nationwide Dutch Hip Fracture Audit (DHFA) between 2018 and 2020 were included. The association between annual hospital volume and turnaround times (time on the emergency ward, surgery < 48 h and length of stay), orthogeriatric co-treatment and case-mix adjusted in-hospital and 30 days mortality was evaluated with generalized linear mixed models with random effects for hospital and treatment year. We used a fifth-degree polynomial to allow for nonlinear effects of hospital volume. P-values were adjusted for multiple comparisons using the Bonferoni method. RESULTS: In total, 43,258 patients from 68 hospitals were included. The median annual hospital volume was 202 patients [range 1-546]. Baseline characteristics did not differ with hospital volume. Provision of orthogeriatric co-treatment improved with higher volumes but decreased at > 367 patients per year (p < 0.01). Hospital volume was not significantly associated with mortality outcomes. No evident clinical relation between hospital volume and turnaround times was found. CONCLUSION: This is the first study analyzing the effect of hospital volume on hip fracture care, treating volume as a continuous parameter. Mortality and turnaround times showed no clinically relevant association with hospital volume. The provision of orthogeriatric co-treatment, however, increased with increasing volumes up to 367 patients per year, but decreased above this threshold. Future research on the effect of volume on complications and functional outcomes is indicated.

The influence of lower-leg injury and knee arthroscopy on natural anticoagulants and fibrinolysis.

BACKGROUND: Patients with lower-leg injuries and those undergoing knee arthroscopy are at increased risk of developing venous thromboembolism. The mechanism is unknown, including the influence of lower-leg injury and knee arthroscopy on natural anticoagulant factors and fibrinolysis. OBJECTIVES: To study the effect of lower-leg injury and knee arthroscopy on plasma levels of anticoagulant and fibrinolytic factors. METHODS: We applied the following 2 designs to investigate this effect: a cross-sectional study for lower-leg trauma and a before-and-after study for knee arthroscopy. Plasma samples of POT-CAST- and POT-KAST-randomized clinical trial participants (collected shortly after lower-leg trauma or before or after arthroscopy) were analyzed for clot lysis time and levels of antithrombin, tissue factor pathway inhibitor, protein C, free protein S, plasminogen, tissue plasminogen activator, plasminogen activator inhibitor 1, antiplasmin, thrombin activatable fibrinolysis inhibitor, plasmin-antiplasmin, and D-dimer. For the effect of lower-leg injury, samples of 289 patients were compared with preoperative samples of 293 arthroscopy patients, acting as controls using linear regression and adjusting for age, sex, body mass index, comorbidities, and diurnal variation. For the effect of knee arthroscopy, mean changes were calculated for 277 patients using linear mixed models adjusted for diurnal variation. Parameters other than CLT and D-dimer were measured in smaller subsets. RESULTS: In lower-leg injury patients, most parameters were stable, whereas D-dimer increased. After arthroscopy, most parameters decreased (especially clot lysis time, D-dimer, plasminogen, and anticoagulant factors), whereas tissue plasminogen activator and thrombin activatable fibrinolysis inhibitor slightly increased. CONCLUSION: In contrast to lower-leg injury, knee arthroscopy was associated with decreased natural anticoagulant factor levels. Neither lower-leg injury nor knee arthroscopy affected in vivo fibrinolysis.

Variation in posterior fragment fixation in the Netherlands: a nationwide study.

PURPOSE: The treatment of the posterior fragment in trimalleolar fractures differs from hospital to hospital in the Netherlands. A nationwide survey was performed to evaluate the fixation criteria and practice variation. METHODS: An online cross-sectional survey amongst (orthopaedic) trauma surgeons was performed in the Netherlands. It consisted of three sections: a general section, a section showing preoperative images of six cases and a section with postoperative images of nine cases. RESULTS: A total of 151 surgeons completed the online survey. 45% of the respondents indicated that they fixated the posterior fragment if smaller than 25% of the intra-articular surface. 48% preferred an open posterior approach to fixate the posterior fragment. There was good consensus in treatment for the two cases with Bartonicek type 4 fractures (operative treatment in 73 and 72% respectively). Little consensus was found for Bartonicek type 2 and 3 fractures (88% opted for operative treatment in one case, but 89% for conservative treatment in the second case). Reoperation was mostly considered in cases with a step-off of more than 1 mm (by 33-38% of the respondents). There was great variation in the choice of treatment if only the size of the posterior fragment was considered. Other fixation criteria such as postoperative step-off or instability after fixation of the lateral and medial malleoli are taken into account. In cases where fixation was needed, a percutaneous approach and an open posterolateral approach were equally preferred. CONCLUSIONS: There is much variation in treatment of the posterior malleolar fracture amongst orthopaedic and trauma surgeons in the Netherlands. The percutaneous approach and open posterolateral approach to fixate the posterior malleolar fracture seem to be equally used in the Netherlands. Still, there is no uniformity in treatment of posterior malleolar fracture, especially for Bartonicek 2 and Bartonicek 3 fractures. Reoperation is considered by less than half of the surgeons in case of postoperative persistent step-off of more than 1 mm.

The relation between surgical approaches for pelvic ring and acetabular fractures and postoperative complications: a systematic review.

INTRODUCTION: Although many articles report complications after pelvic ring and acetabular fracture surgery, a general overview of complication rates and potential risk factors is lacking. The current review provides a comprehensive summary of the complications after pelvic ring and acetabular fracture surgery in relation to the surgical approach. MATERIAL AND METHODS: Pubmed and Embase databases were systematically searched using the key words: pelvic fracture, acetabular fracture, fixation, surgical approaches, complications, and their synonyms. Extracted data included patient and fracture characteristics, surgical approaches, and post-operative complications; surgical site infections (SSI), implant-related complications, malunion and non-union. Study data were summarized using descriptive statistics. RESULTS: Twenty-two studies (twenty-one retrospective cohort studies, of which three comparative, and one randomized controlled trial) were included in this review. The overall complication rates reported for the included surgical approaches were: 17% for the (Modified) Stoppa approach, 11% for percutaneous fixation, 5% for the Kocher-Langenbeck approach, 7% for the ilioinguinal approach and 31% for external fixation. The most frequent complications were SSI (22%) and neurological (31%) complications, which were most often reported in patients treated with an external fixator. Re-operation rates were comparable for the surgical approaches (4-8%). Two studies reported on risk factors and identified concomitant traumatic injuries, prolonged ICU stay and high body mass index as risk factors for SSI. CONCLUSION: External fixation of pelvic fractures is associated with highest complications rates including SSI's and neurological complications. Although post-operative complications are frequently reported after pelvic fracture surgery, more studies are needed that identify potential risk factors. These will assist the surgeon in (pre)operative decision making and development of preventive strategies.

Data-driven development of the nationwide hip fracture registry in the Netherlands.

Additional variables for a nationwide hip fracture registry must be carefully chosen to prevent unnecessary registry load. A registry pilot in seven hospitals resulted in recommending polypharmacy, serum hemoglobin at admittance, and questions screening for risk of delirium to be used in case-mix correction and for development of quality indicators. PURPOSE: Clinical registries help improve the quality of care but come at the cost of registration load. Datasets should therefore be as compact as possible; however, variables are usually chosen empirically. This study aims to evaluate potential variables with additional value to improve the nationwide Dutch Hip Fracture Audit (DHFA). METHODS: An expert panel selected eleven new variables for the DHFA, which were tested in a prospective cohort of all hip fracture patients treated in 2018 and 2019 in seven pilot hospitals participating in the DHFA. The association of these eleven variables with complications, mortality, and functional outcomes at 3 months was analyzed using multivariable logistic regression analysis. Based on the results, a proposal for variables to add to the dataset of the DHFA was made. RESULTS: In 4.904 analyzed patients, three tested variables had significant associations (p < 0.01) with outcomes: polypharmacy with complications (aOR 1.34), serum hemoglobin at admittance with complications (aOR 0.63) and mortality (aOR for 30-day mortality 0.78), and a set of questions screening for risk of delirium with complications in general (aOR 1.55), e.g., delirium (aOR 2.98), and decreased functional scores at three months (aOR 1.98). CONCLUSION: This study assesses potential new variables for a hip fracture registry. Based on the results of this study, we recommend polypharmacy, serum hemoglobin at admittance, and questions screening for risk of delirium to be used in case-mix correction and for the development of quality indicators. Incorporating these variables in the DHFA dataset may contribute to better and clinically relevant quality indicators.

Systematic Review of the Association Between Trauma Severity and Postinjury Symptoms of Depression.

BACKGROUND: Greater symptoms of depression are associated with greater symptom intensity during recovery from musculoskeletal injury. It is not clear that more severe trauma is associated with greater symptoms of depression as one might expect. The goal of this study was to systematically review the existing evidence regarding the association of Injury Severity Score (ISS) with symptoms of depression during recovery from musculoskeletal injury. METHODS: Two independent reviewers used PubMed and Embase to identify studies that measured both ISS and symptoms of depression. Among the 17 studies satisfying inclusion criteria, 5 studies assessed the correlation of symptoms of depression and ISS on their continuum; 3 studies compared the mean of symptoms of depression for people above and below a specific ISS level; five compared mean ISS above and below a threshold level of symptoms of depression; and four compared dichotomized ISS and dichotomized depression. Four of the 17 evaluated factors associated with symptoms of depression in multivariable analysis. RESULTS: In bivariate analysis, 12 of 17 studies (71%) found no association between ISS level and symptoms of depression. Three studies found a bivariate association that did not persist in multivariable analysis. Two studies reported slight associations in bivariate analysis, but did not perform multivariable analysis. CONCLUSIONS: The knowledge that symptoms of depression are common during recovery, in combination with the finding of this review that they have little or no relationship with injury severity, directs clinicians to anticipate and address mental health during recovery from physical trauma of any severity.

Serum sclerostin levels in osteoporotic fracture patients.

PURPOSE: Sclerostin inhibits bone formation and stimulates bone resorption. Previous studies found a positive association between bone density and serum sclerostin, but literature on sclerostin levels in osteoporotic fracture patients is scarce. The aim of the present study was to compare the serum sclerostin levels in osteoporotic and non-osteoporotic fracture patients and to assess the correlation of the sclerostin levels with bone mineral density and vitamin D status. METHODS: In this cross-sectional study, we included patients over 50 years, with an extremity fracture after low-energy trauma treated between 2012 and 2018, with biobank samples and available bone density measurements by Dual X-ray Absorption. Osteoporosis was diagnosed according the World Health Organisation criteria. Vitamin D deficiency was defined as a 25(OH)D concentration < 30 nmol/L. After defrosting biobank samples, serum sclerostin was measured using the human SOST (sclerostin) enzyme-linked immunosorbent assay kit. We prespecified a subgroup analysis including only female patients. RESULTS: 179 patients were included of whom 139(78%) were female. In 46 patients (25.7%), osteoporosis was diagnosed. Bone mineral density was positively associated with sclerostin levels (r = 0.17, p = 0.026) and patients with osteoporosis had a significantly lower serum sclerostin compared to non-osteoporotic fracture patients (mean 41.9 pmol/L vs 48.1 pmol/L; p = 0.03). This difference remained significant after correction for potential confounders. Similar results were found in the subgroup of female patients. No association between serum sclerostin and vitamin D deficiency was found. CONCLUSION: Osteoporotic fracture patients had lower levels of sclerostin than non-osteoporotic fracture patients. Future research should focus on the use of sclerostin as biomarker for osteoporosis in fracture patients.

Lower-leg injury and knee arthroscopy have distinct effects on coagulation.

It is unknown how lower-leg injury and knee arthroscopy, both associated with venous thromboembolism (VTE), affect coagulation. To study the effect of (1) lower-leg trauma and (2) knee arthroscopy on coagulation, plasma samples of the Prevention of Thrombosis following CAST immobilization (POT-CAST, #NCT01542762) and Prevention of Thrombosis following Knee Arthroscopy (POT-KAST, #NCT01542723) trials were used, which were collected shortly after lower-leg trauma and before/after (<4 hours) knee arthroscopy. For aim 1, 1204 lower-leg injury patients were compared with preoperative samples of 1001 controls. Mean differences/ratios (if ln-retransformed because of skewedness) were adjusted for sex, age, body mass index, comorbidity, malignancy, and oral contraceptives using linear regression. For aim 2, perioperative mean changes of 715 arthroscopy patients were calculated. Plasma levels of fibrinogen, factor (F)VIII, FIX, FXI, von Willebrand Factor (VWF), and D-dimer were measured in all individuals. Parameters of underlying mechanisms (tissue factor, interleukin-6 [IL-6], myeloperoxidase DNA, cell-free DNA) were measured in random subsets. In lower-leg injury patients, coagulation parameter levels increased, especially FVIII, VWF, and D-dimer, that is, adjusted mean differences: FVIII 26.8% (95% confidence interval [CI], 23.7-29.9), FIX 13.8% (95% CI, 11.9-15.6), FXI 5.1% (95% CI, 3.3-7.0), VWF 29.8% (95% CI, 26.0-33.6), fibrinogen 32.5 mg/dL (95% CI, 25.8-39.2), and D-dimer (mean ratio) 3.3 (95% CI, 3.1-3.6). Remaining parameters were unchanged, except for increased IL-6 levels. After arthroscopy, all parameters decreased. Lower-leg trauma is associated with increased procoagulant factor levels in contrast to knee arthroscopy. This suggests that, in both situations, different pathways are involved in development of VTE.