Cement augmentation for proximal humerus fractures: a meta-analysis of randomized trials and observational studies.

INTRODUCTION: It is unclear if elderly patients treated with plate osteosynthesis for proximal humerus fractures benefit from cement augmentation. This meta-analysis aims to compare cement augmentation to no augmentation regarding healing, complications, and functional results. METHODS: PubMed, Embase, and Cochrane Central Register of Controlled Trials were searched for randomized clinical trials and observational studies. Effect estimates were pooled across studies using random effects models. The primary outcome is overall complication rate. Stratified analyses were performed for types of complication (implant-related or systemic). Secondary outcomes include re-interventions, hospital stay, operation time, functional scores, and general quality of life. RESULTS: Five observational studies and one randomized controlled trial with a total of 541 patients were included. The overall complication rate was significantly lower in the augmented group (15.6% versus 25.4%, OR 0.54 (95%CI 0.33-0.87)). This was caused by a reduction of implant-related complications (10.4% vs. 19.9%, OR 0.49 (95%CI 0.28, 0.88)). No difference in humeral head necrosis was found. Data on re-intervention, hospital stay, and operation time was limited but did not show significant differences. No impact on functional scores and general quality of life was detected. CONCLUSION: This meta-analysis shows that cement augmentation may reduce overall complications, mainly by preventing implant-related complications. No difference was detected regarding need for re-intervention, functional scores, general quality of life, and hospital stay. This is the first meta-analysis on this topic. It remains to be seen whether conclusions will hold when more and better-quality data becomes available.

Let's Agree to Disagree on Operative Versus Nonoperative Treatment for Distal Radius Fractures in Older People: Protocol for a Prospective International Multicenter Cohort Study.

BACKGROUND: Distal radius fractures are the most frequently encountered fractures in Western societies, typically affecting patients aged 50 years and older. Although this is a common injury, the best treatment for these fractures in older patients is still under debate. OBJECTIVE: This prospective study aims to compare the outcome of operatively and nonoperatively treated distal radius fractures in the older population. Only patients with distal radius fractures for which equipoise regarding the optimal treatment exists will be included. METHODS: This prospective international multicenter observational cohort study will be designed as a natural experiment. Natural experiments are observational studies in which treatment allocation is determined by factors outside the control of the investigators but also (largely) independent of patient characteristics. Patients aged 65 years and older with an acute distal radius fracture will be considered for inclusion. Treatment allocation (operative vs nonoperative) will be based on the local preferences of the treating hospital either in Switzerland or the Netherlands. Hence, the process governing treatment allocation resembles that of randomization. Patients will be identified after treatment has been initiated. Based on the radiographs and baseline information of the patient, an expert panel of 6 certified trauma surgeons from 2 regions will provide their treatment recommendation. Only patients for whom the experts disagree on treatment recommendations will ultimately be included in the study (ie, for whom there is a clinical equipoise). For these patients, both operative and nonoperative treatment of distal radius fractures are viable, and treatment choice is predominantly determined by personal or local preference. The primary outcome will be the Patient-Rated Wrist Evaluation score at 12 weeks. Secondary outcomes will include the Physical Activity Score for the Elderly, the EQ questionnaire, pain, the living situation, range of motion, complications, and radiological outcomes. By including outcomes such as living situation and the Physical Activity Score for the Elderly, which are not relevant for younger cohorts, valuable information to tailor treatment to the needs of the older population can be gained. According to the sample size collection, which was based on the minimal important clinical difference of the Patient-Rated Wrist Evaluation, 92 patients will have to be included, with at least 46 patients in each treatment group. RESULTS: Enrollment began in July 2023 and is expected to continue until summer 2024. The final follow-up will be 2 years after the last patient is included. CONCLUSIONS: Although many trials on this topic have previously been published, there remains an ongoing debate regarding the optimal treatment for distal radius fractures in older patients. This observational study, which will use a fairly new methodological study design, will provide further information on treatment outcomes for older patients with distal radius fractures for which to date equipoise exists regarding the optimal treatment. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/52917.

Digitally enhanced hands-on surgical training (DEHST) enhances the performance during freehand nail distal interlocking.

PURPOSE: Freehand distal interlocking of intramedullary nails remains a challenging task. Recently, a new training device for digitally enhanced hands-on surgical training (DEHST) was introduced, potentially improving surgical skills needed for distal interlocking. AIM: To evaluate whether training with DEHST enhances the performance of novices (first-year residents without surgical experience in freehand distal nail interlocking). METHODS: Twenty novices were randomly assigned to two groups and performed distal interlocking of a tibia nail in mock operation under operation-room-like conditions. Participants in Group 1 were trained with DEHST (five distal interlocking attempts, 1 h of training), while those in Group 2 did not receive training. Time, number of X-rays shots, hole roundness in the X-rays projection and hit rates were compared between the groups. RESULTS: Time to complete the task [414.7 s (range 290-615)] and X-rays exposure [17.8 µGcm2 (range 9.8-26.4)] were significantly lower in Group 1 compared to Group 2 [623.4 s (range 339-1215), p = 0.041 and 32.6 µGcm2 (range 16.1-55.3), p = 0.003]. Hole projections were significantly rounder in Group 1 [95.0% (range 91.1-98.0) vs. 80.8% (range 70.1-88.9), p < 0.001]. In Group 1, 90% of the participants achieved successful completion of the task in contrast to a 60% success rate in Group 2. This difference was not statistically significant (p = 0.121). CONCLUSIONS: In a mock-operational setting, training with DEHST significantly enhanced the performance of novices without surgical experience in distal interlocking of intramedullary nails and hence carries potential to improve safety and efficacy of this important and demanding surgical task to steepen the learning curve without endangering patients. LEVEL OF EVIDENCE: II.

New generation of superior single plating vs. low-profile dual minifragment plating in diaphyseal clavicle fractures: a biomechanical comparative study.

BACKGROUND: Recently, a new generation of superior clavicle plates was developed featuring the variable-angle locking technology for enhanced screw positioning and a less prominent and optimized plate-to-bone fit design. On the other hand, minifragment plates in dual plating mode have demonstrated promising clinical results. The aim of the current study was to compare the biomechanical competence of single superior plating using the new-generation plate vs. dual plating using low-profile minifragment plates. METHODS: Sixteen paired human cadaveric clavicles were pairwise assigned to 2 groups for instrumentation with either a superior 2.7-mm variable-angle locking compression plate (group 1), or with one 2.5-mm anterior combined with one 2.0-mm superior matrix mandible plate (group 2). An unstable clavicle shaft fracture (AO/OTA 15.2C) was simulated by means of a 5-mm osteotomy gap. Specimens were cyclically tested to failure under craniocaudal cantilever bending, superimposed with bidirectional torsion around the shaft axis, and monitored via motion tracking. RESULTS: Initial construct stiffness was significantly higher in group 2 (9.28 ± 4.40 N/mm) compared to group 1 (3.68 ± 1.08 N/mm), P = .003. The amplitudes of interfragmentary motions in terms of axial and shear displacement, fracture gap opening and torsion, over the course of 12,500 cycles were significantly higher in group 1 compared to group 2, P ≤ .038. Cycles to 2 mm shear displacement were significantly lower in group 1 (22,792 ± 4346) compared to group 2 (27,437 ± 1877), P = .047. CONCLUSION: From a biomechanical perspective, low-profile 2.5/2.0-mm dual plates could be considered as a useful alternative for diaphyseal clavicle fracture fixation, especially in less common unstable fracture configurations.

Is augmented femoral lateral plating with helically shaped medial plates biomechanically advantageous over straight medial plates?

Dual plating of comminuted distal femoral fractures allows for early patient mobilization. An additional helically shaped medial plate avoids the medial vital structures of the thigh. The aim of this study is to investigate the biomechanical competence of an augmented lateral locking compression plate distal femur (LCP-DF) using an additional straight versus a helically shaped medial LCP of the same length. Ten pairs of human cadaveric femora were instrumented with a lateral anatomical 15-hole LCP-DF. Following, they were pairwise instrumented with either an additional medial straight 14-hole LCP (group 1) or a 90°-helical shape LCP (group 2). All specimens were biomechanically tested under quasi-static and progressively increasing combined cyclic axial and torsional loading until failure. Initial interfragmentary axial displacement and flexion under static compression were significantly smaller in group 1 (0.11 ± 0.12 mm and 0.21 ± 0.10°) versus group 2 (0.31 ± 0.14 mm and 0.68 ± 0.16°), p ≤ 0.007. Initial varus deformation under static compression remained not significantly different between group 1 (0.57 ± 0.23°) and group 2 (0.75 ± 0.34°), p = 0.085. Flexion movements during dynamic loading were significantly bigger in group 2 (2.51 ± 0.54°) versus group 1 (1.63 ± 1.28°), p = 0.015; however, no significant differences were observed in terms of varus, internal rotation, and axial and shear displacements between the groups, p ≥ 0.204. Cycles to failure and load at failure were higher in group 2 (25,172 ± 6376 and 3017 ± 638 N) compared to group 1 (22,277 ± 4576 and 2728 ± 458 N) with no significant differences between them, p = 0.195. From a biomechanical perspective, helical double plating may be considered a useful alternative to straight double plating, demonstrating ameliorated damping capacities during flexion deformation and safer application as the medial neurovascular structures of the thigh are avoided.

Helical Plating Compared with Straight Plating and Nailing for Treatment of Proximal Third Humeral Shaft Fractures-A Biomechanical Study.

Background and Objectives: The surgical treatment of proximal humeral shaft fractures usually considers application of either long straight plates or intramedullary nails. By being able to spare the rotator cuff and avoid the radial nerve distally, the implementation of helical plates might overcome the downsides of common fixation methods. The aims of the current study were (1) to explore the biomechanical competence of different plate designs and (2) to compare their performance versus the alternative treatment option of using intramedullary nails. Materials and Methods: Twenty-four artificial humeri were assigned to the following four groups for simulation of an unstable proximal humeral shaft fracture and instrumentation: Group 1 (Straight-PHILOS), Group 2 (MULTILOC-Nail), Group 3 (45°-Helical-PHILOS), and Group 4 (90°-Helical-PHILOS). All specimens underwent non-destructive, quasi-static biomechanical testing under loading in axial compression, torsion in internal/external rotation, and pure bending in four directions, accompanied by motion tracking. Results: Axial stiffness/displacement in Group 2 was significantly higher/smaller than in all other groups (p ≤ 0.010). Torsional displacement in Group 2 was significantly bigger than in all other groups (p ≤ 0.017). Significantly smaller coronal plane displacement was identified in Group 2 versus all other groups (p < 0.001) and in Group 4 versus Group 1 (p = 0.022). Significantly bigger sagittal plane displacement was detected in Group 4 versus all other groups (p ≤ 0.024) and in Group 1 versus Group 2 (p < 0.001). Conclusions: Intramedullary nails demonstrated higher axial stiffness and smaller axial interfragmentary movements compared with all investigated plate designs. However, they were associated with bigger torsional movements at the fracture site. Although 90°-helical plates revealed bigger interfragmentary movements in the sagittal plane, they demonstrated improved resistance against displacements in the coronal plane when compared with straight lateral plates. In addition, 45°-helical plates manifested similar biomechanical competence to straight plates and may be considered a valid alternative to the latter from a biomechanical standpoint.

Nonoperative treatment of multiple rib fractures, the results to beat: International multicenter prospective cohort study among 845 patients.

BACKGROUND: Optimal treatment (i.e. nonoperative or operative) for patients with multiple rib fractures remains debated. Studies that compare treatments are rationalized by the alleged poor outcomes of nonoperative treatment. METHODS: The aim of this prospective international multicenter cohort study (between January 2018 and March 2021) with one-year follow-up, was to report contemporary outcomes of nonoperatively treated patients with multiple rib fractures. Including 845 patients with three or more rib fractures. Primary outcome was in-hospital mortality. Secondary outcomes included hospital length of stay (HLOS), (pulmonary) complications, and quality of life. RESULTS: Mean age was 57.7 ± 17.0 years, median Injury Severity Score was 17 (13-22) and the median number of rib fractures was 6 (4-8). In-hospital mortality rate was 1.5% (n = 13), 112 (13.3%) patients had pneumonia and four (0.5%) patients developed a symptomatic non-union. The median HLOS was 7 (4-13) days, and median intensive care unit length of stay was 2 (1-5) days. Mean EQ-5D-5L index value was 0.83 ± 0.18 one year after trauma. Polytrauma patients had a median HLOS of 10 (6-18) days, a pneumonia rate of 17.6% (n = 77) and mortality rate of 1.7% (n = 7). Elderly patients (≥65 years) had a median HLOS of 9 (5-15) days, a pneumonia rate of 19.7% (n = 57) and mortality rate of 4.1% (n = 12). CONCLUSIONS: Overall, nonoperative treatment of patients with multiple rib fractures shows low mortality and morbidity rate and good quality of life after one year. Future studies evaluating the benefit of operative stabilisation should use contemporary outcomes to establish the therapeutic margin of rib fixation. LEVEL OF EVIDENCE: Level III, Therapeutic/Care Management.

[Treatment of traumatic rib fractures]. / Behandeling van traumatische ribfracturen.

Patients with rib fractures are a heterogenous group of patients who are treated by general practitioners as well as by specialized trauma surgeons. We present three patients with rib fractures with different degrees of thoracic trauma and therefore treatments differ significantly. The cornerstone in the treatment of rib fractures remains attaining adequate analgesia and breathing exercises. The last decade, there has been an increase in the utilization of rib fixation, however, precise indications remain unknown. It has proven effective in patients with flail chest on mechanical ventilation in whom it decrease intensive care and hospital length and reduces mortality. In case of prolonged (> 3 months) pain, dyspnea or a clicking sensation one could think of a nonunion of the rib fracture. Rib fixation can relieve these complaints in about 60% of the patients, however due to a high implant irritation rate and secondary operation to remove the osteosynthesis is common.

A natural experiment study: Low-profile double plating versus single plating techniques in midshaft clavicle fractures-Study protocol.

BACKGROUND: Single plate osteosynthesis is commonly employed when performing surgical stabilization of midshaft clavicle fractures. In recent years, a smaller structural low-profile double plating technique has been described as a possible solution for the high removal rates associated with single plating. A previous meta-analysis has demonstrated that low-profile double plating attains the same healing rates as single plating without a higher chance of fracture-related infections. This meta-analysis, however, was based on relatively small studies. Therefore, a multicentre prospective natural experiment was designed using natural variation in treatment regimens and geographical location of the trauma as treatment allocation mechanism to compare both treatments on a larger scale. This manuscript describes its protocol. MATERIAL & METHODS: Patients (≥16 years) with primary midshaft clavicle fractures that are eligible for operative treatment will be included. Treatment allocation will be determined by the geographical location of the accident and local hospital providing treatment. In two centres, single plating is the treatment of choice for these patients. In two others, low-profile double plating has become the standard treatment. For the low-profile double plating group, one superiorly positioned VariAx 2.0mm and one anterior VariAx 2.4mm or 2.7mm plate will be used. For the single plating group, the standard locally available implant will be used. A total of 336 patients will be included. The primary outcome of interest is re-intervention. Secondary outcomes include complications, operative time, length of incision, functional scores (DASH, EQ-5D-DL, VAS-Pain/Satisfaction) and cost-effectiveness. DISCUSSION: This study will determine whether low-profile double plating has significant clinical and cost-effective benefits over single plating techniques in midshaft clavicle fractures. The study will also give insight in the performance of a natural experiment study design for orthopedic trauma research. TRIAL REGISTRATION: This study has been registered on ClincialTrials.gov, identifier NCT05579873.

[Distal radius fracture-tactic and approach]. / Distale Radiusfrakturen ­ Taktik und Zugangswahl.

OBJECTIVE: The aim of surgical treatment is fracture healing with restored alignment, rotation, and joint surface. Stable fixation allows for functional postoperative aftercare. INDICATIONS: Displaced intra- and extra-articular fractures which either could not be adequately reduced or in which a secondary displacement is to expected due to instability criteria. The following factors are considered instability criteria: age > 60 years, female, initial dorsal displacement > 20°, dorsal comminution, radial shortening > 5 mm, palmar displacement. CONTRAINDICATIONS: The only absolute contraindication is if the patient is deemed unfit for surgery due to concerns regarding anesthesia. Old age is a relative contraindication, as it is currently debated whether older patients benefit from the operation. SURGICAL TECHNIQUE: The surgical technique is guided by the fracture pattern. Palmar plating is most commonly performed. If the joint surface needs to be visualized, a dorsal approach (in combination with another approach or alone) or arthroscopically assisted fixation should be chosen. POSTOPERATIVE MANAGEMENT: In general, a functional postoperative regime can be carried out after plate fixation with mobilization without weightbearing. Short-term splinting can provide pain relief. Concomitant ligamentous injuries and fixations, which are not stable enough for functional aftercare (such as k­wires) require a longer period of immobilization. RESULTS: Provided the fracture is reduced correctly, osteosynthesis improves functional outcome. The complication rate ranges between 9 and 15% with the most common complication being tendon irritation/rupture and plate removal. Whether surgical treatment holds the same benefits for patients > 65 years as for younger patients is currently under debate.

In patients with combined clavicle and multiple rib fractures, does fracture fixation of the clavicle improve clinical outcomes? A multicenter prospective cohort study of 232 patients.

BACKGROUND: Clavicle and rib fractures are often sustained concomitantly. The combination of injuries may result in decreased stability of the chest wall, making these patients prone to (respiratory) complications and prolonged hospitalization. This study aimed to assess whether adding chest wall stability by performing clavicle fixation improves clinical outcomes in patients with concurrent clavicle and rib fractures. METHODS: A prospective multicenter study was performed including all adult patients admitted between January 2018 and March 2021 with concurrent ipsilateral clavicle and rib fractures. Patients treated operatively versus nonoperatively for their clavicle fracture were matched using propensity score matching. The primary outcome was hospital length of stay (HLOS). Secondary outcomes were intensive care unit length of stay, duration of mechanical ventilation, pain, complications, and quality of life at 6 weeks and 12 months of follow-up. RESULTS: In total, 232 patients with concomitant ipsilateral clavicle and rib fractures were included. Fifty-two patients (22%) underwent operative treatment of which 39 could be adequately matched to 39 nonoperatively treated patients. No association was observed between clavicle plate fixation and HLOS (mean difference, 2.3 days; 95% confidence interval, -2.1 to 6.8; p = 0.301) or any secondary endpoint. Eight of the 180 nonoperatively treated patients (4%) had a symptomatic nonunion, for which 5 underwent secondary clavicle fixation. CONCLUSION: We found no evidence that, in patients with combined clavicle and multiple rib fractures, plate fixation of the clavicle reduces HLOS, pain, or (pulmonary) complications, nor that it improves quality of life. STUDY TYPE: Therapeutic/Care Management; Level III.

Quality of life and clinical outcomes of operatively treated patients with flail chest injuries: A multicentre prospective cohort study.

Introduction: Most studies about rib fractures focus on mortality and morbidity. Literature is scarce on long term and quality of life (QoL) outcomes. Therefore, we report QoL and long-term outcomes after rib fixation in flail chest patients. Methods: A prospective cohort study of clinical flail chest patients admitted to six level 1 trauma centres in the Netherlands and Switzerland between January 2018 and March 2021. Outcomes included in-hospital outcomes and long-term outcomes, such as QoL measurements 12 months after hospitalization using the EuroQoL five dimensions (EQ-5D) questionnaire. Results: Sixty-one operatively treated flail chest patients were included. Median hospital length of stay was 15 days and intensive care length of stay was 8 days. Sixteen (26%) patients developed pneumonia and two (3%) died. One year after hospitalization the mean EQ5D score was 0.78. Complication rates were low and included hemothorax (6%) pleural effusion (5%) and two revisions of the implant (3%). Implant related irritation was commonly reported by patients (n = 15, 25%). Conclusions: Rib fixation for flail chest injuries can be considered a safe procedure and with low mortality rates. Future studies should focus on quality of life rather than solely short-term outcomes.Trial registration: Registered in the Netherlands Trial Register NTR6833 on 13/11/2017 and the Swiss Ethics Committees Registration Number 2019-00668.

Intraoperative imaging in hip arthroplasty: a meta-analysis and systematic review of randomized controlled trials and observational studies.

BACKGROUND: Intraoperative fluoroscopy (IFC) is gaining popularity in total hip arthroplasty (THA), with the aim to achieve better component positioning and therefore eventually reduced revision rates. This meta-analysis investigated the benefit of IFC by comparing it to intraoperative assessment alone. The primary outcome was component positioning and the secondary outcomes included complications and revision rates. METHODS: PubMed, Embase and Cochrane Central Register of Controlled Trials were searched for both randomized clinical trials (RCT) and observational studies. Effect estimates for radiographic cup position, offset/leg length difference and outliers from a safe zone were pooled across studies using random effects models and presented as a weighted odds ratio (OR) with a corresponding 95% confidence interval (95% CI). RESULTS: A total of 10 observational studies involving 1,394 patients were included. No randomized trials were found. IFC showed no significant reduction in acetabular cup position (inclination and anteversion), offset, leg-length discrepancies, revision (none reported) or overall complication rates. CONCLUSION: The current meta-analysis found no differences in cup positioning, offset, leg length discrepancy, the incidence of complications or revision surgery. It should be acknowledged that the included studies were generally performed by experienced surgeons. The benefit of intraoperative fluoroscopy might become more evident at an early phase of the learning curve for this procedure. Therefore, its role has yet to be defined.

Biomechanical analysis of helical versus straight plating of proximal third humeral shaft fractures.

BACKGROUND: Proximal humeral shaft fractures are surgically challenging and plate osteosynthesis with a long straight plate is one operative treatment option in these patients although endangering the radial nerve distally. Helical plates potentially avoid the radial nerve by twisting around the humeral shaft. Aim of the study was to investigate in a human cadaveric model the biomechanical competence of helical plates versus straight lateral plates used for fixation of proximal third comminuted humeral shaft fractures. METHODS: Eight pairs of humeral cadaveric humeri were instrumented using either a long 90°-helical plate (Group1) or a straight long PHILOS plate (Group2). An unstable proximal humeral shaft fracture was simulated by means of a 5 cm osteotomy gap. All specimens were tested under quasi-static loading in axial compression, internal and external rotation, and bending in four directions. Subsequently, progressively increasing cyclic loading in internal rotation until failure was applied and interfragmentary movements were monitored by motion tracking. RESULTS: During static testing flexion/extension deformation in Group1 was significantly higher, however, varus/valgus deformation as well as shear and torsional displacement under torsional load remained statistically indifferent between both groups. During cyclic testing shear and torsional displacements were both significantly higher in Group1 compared to Group 2. However, cycles to catastrophic failure remained statistically indifferent between the groups. CONCLUSIONS: From a biomechanical perspective, although 90°-helical plating is associated with higher initial stability against varus/valgus collapse and comparable endurance under dynamic loading, it demonstrates lower resistance to flexion/extension and internal rotation with bigger shear interfragmentary displacements versus straight lateral plating and, therefore, cannot be considered as its real alternative. Alternative helical plate designs should be investigated in the future.

Outcome of functional treatment with a Lucerne Cast in patients with hand fractures: a retrospective case series.

PURPOSE: The purpose of this study was to determine the clinical outcome of patients treated with a functional Lucerne Cast (LuCa) for different types of hand fractures. Static casting has traditionally been the preferred treatment for hand fractures. However, functional casting may lead to good functional outcomes, less stiffness, and earlier return to work. METHODS: A retrospective case series of all consecutive patients with a metacarpal or proximal phalangeal fracture treated with a LuCa between 2018 and 2019 was conducted. A total of 90 patients were included. Clinical data were collected directly from the patient's medical records. Functional outcome was assessed with the Michigan Hand Outcomes Questionnaire (MHQ). RESULTS: The median MHQ score was 95 (IQR 83-100) with a median follow-up of 23 months. Complications occurred in 7 of 90 patients (8%). Functional impairment occurred in two (2%) patients. Functional impairment was defined as stiffness, persisting rotational deformity, a boutonnière or swanneck deformity. Persisting pain or CRPS occurred in six (7%) patients. CONCLUSION: The LuCa shows to be effective in the functional treatment of both metacarpal and proximal phalangeal fractures with excellent patient-reported outcomes but at a relatively high rate of persisting pain.

Primary Closure or Secondary Wound Healing of Pin Sites After External Fixator Removal: A Single-Center Blinded Randomized Controlled Trial.

BACKGROUND: The aim of this single-center randomized controlled trial was to compare primary wound closure using a suture with secondary wound healing of pin sites after removal of temporary external fixation. METHODS: This noninferiority trial included all patients who were treated with a temporary external fixator on an upper or lower extremity at 1 institution. The primary outcome was pin-site infection. Secondary outcomes were measured at 2, 6, 12, 24, and 52 weeks and included all other complications, time to pin-site wound healing (in weeks), the most satisfactory pin site as rated by the patient, the visual analog scale (VAS) score for pain, and the Vancouver Scar Scale (VSS). The most proximal pin site was randomly allocated (1:1) to either primary closure or secondary wound healing, and the other pin sites were treated alternately. RESULTS: Seventy patients, providing 241 pin sites, were included between January 1, 2019, and March 1, 2020. A total of 123 pin sites were treated with primary closure and 118, with secondary wound healing. The median age was 55 years (interquartile range, 46 to 67 years), 44% were male, and the median duration of the external fixation was 6 days (interquartile range, 4 to 8 days). There were no pin-site infections in either group. Wound healing was significantly faster in the primary closure group (median of 2 versus 6 weeks, p = 0.013). The VSS and patient satisfaction showed no differences between groups. There was 1 case of fracture-related infection not related to any pin site. CONCLUSIONS: Primary closure of temporary external fixator pin sites did not result in higher infection rates compared with secondary wound healing, and pin sites healed significantly faster after primary closure. Primary closure should therefore be considered in patients treated with a temporary external fixator. LEVEL OF EVIDENCE: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Natural experiments for orthopaedic trauma research: An introduction.

Natural experiments are observational studies of medical treatments in which treatment allocation is determined by factors outside the control of the investigators, arguably resembling experimental randomisation. Natural experiments in the field of orthopaedic trauma research are scarce. However, they have great potential due to the process governing treatment allocation and the existence of opposing treatment strategies between hospitals or between regions as a result of local education, conviction, or cultural and socio-economic factors. Here, the possibilities and opportunities of natural experiments in the orthopaedic trauma field are discussed. Potential solutions are presented to improve the validity of natural experiments and how to assess the credibility of such studies. Above all, it is meant to spark a discussion about its role within the field of orthopaedic trauma research.

Rib fractures in the elderly population: a systematic review.

BACKGROUND: Multiple rib fractures are associated with significant morbidity and mortality, especially in elderly patients. There is growing interest in surgical stabilization in this subgroup of patients. This systematic review compares conservative treatment to surgical fixation in elderly patients (older than 60 years) with multiple rib fractures. The primary outcome is mortality. Secondary outcomes include hospital and intensive care length of stay (HLOS and ILOS), duration of mechanical ventilation (DMV) and pneumonia rates. METHODS: Multiple databases were searched for comparative studies reporting on conservative versus operative treatment for rib fractures in patients older than 60 years. Both observational studies and randomised clinical trials were considered. RESULTS: Five observational studies (n = 2583) were included. Mortality was lower in operatively treated patients compared to conservative treatment (4% vs. 8%). Pneumonia rate and DMV were similar (5/6% and 5.8/6.5 days) for either treatment modality. Overall ILOS and HLOS of stay were longer in operatively treated patients (6.5 ILOS and 12.7 HLOS vs. 2.7 ILOS and 6.5 ILOS). There were only minimal reports on perioperative complications. Notably, the median number of rib fractures (8.4 vs. 5) and the percentage of flail chest were higher in operatively treated patients (47% vs. 39%). CONCLUSION: It remains unknown to what extent conservative and operative treatment contribute individually to reducing morbidity and mortality in the elderly with multiple rib fractures. To date, the quality of evidence is rather low, thus well-performed comparative observational studies or randomised controlled trials considering all confounders are needed to determine whether operative treatment can improve a patient's outcome.

Validation of the modified AO sternum classification system.

INTRODUCTION: The Arbeitsgemeinschaft für Osteosynthesefragen (AO) foundation along with the Orthopaedic. Trauma Association (OTA) introduced a new classification for sternal fractures in 2018 aiming to provide greater uniformity and clinical utility for the surgical community. A previous validation study identified some critical issues such as the differentiation between type A and B fractures and localization of the fracture either in the manubrium or in the body. Due to the moderate agreement in inter- and intra-observer variability, some modifications were proposed in order to improve the performance of the classification. The aim of this study was to re-assess the inter- and intra-observer variability after adding modifications to the classification. Our hypothesis was that a significative improvement of inter- and intra-observer variability could be achieved. MATERIAL AND METHODS: Twenty computed tomography (CT) scans of patients with sternal fractures were analyzed by six. Junior and six senior surgeons independently. Two assessments were performed with an interval of 6 weeks. The kappa (K) value was calculated in order to assess inter- and intra-observer variability. RESULTS: The overall mean kappa value for inter-observer variability improved from 0.364 to 0.468 (p < 0.001). Inter-observer variability mean for location was 0.573 (SD 0.221) and for type was 0.441 (SD: 0.181). Intra-observer variability showed a mean of 0.703 (SD: 0.153) with a statistic significant improvement when compared to the previous study (mean 0.414, SD: 0.256, p < 0.001). CONCLUSIONS: By modifying the AO/OTA classification of sternal fractures, the inter- and intra-observer variability improved and now shows moderate to substantial agreement.