Cause of Extensor Pollicis Longus Ruptures After Distal Radius Fracture Fixation Using a Volar Plate.

BACKGROUND: This research sought to analyze a cohort of patients with extensor pollicis longus (EPL) ruptures after volar locked plating of a distal radius fracture (DRF) to characterize the incidence of ruptures that are unlikely to be related to dorsal screw prominence. METHODS: This is a retrospective, observational, descriptive cohort study of adults with operative fixation of a closed DRF and an EPL rupture between 2002 and 2022. Eighteen patients with operative fixation using a volar plate of a closed DRF had an EPL rupture. The cohort consisted of 66% women with an average age of 57.5 years. Median follow-up was 14.5 months. RESULTS: The incidence of EPL rupture was 0.4% (18/4768). The average time from DRF and DRF fixation to EPL rupture was 3.7 and 3.4 months, respectively. Based on the operative record, in 2 of the 18 patients (11%), the rupture was directly attributable to prominent hardware; however, in 4 of the 18 patients (22%), the rupture was not related to prominent hardware, and the cause was indeterminate in 12 patients (67%). Radiologic analysis of those in the indeterminate group demonstrated that 5 of the 12 patients had screws that had a high probability of being prominent. CONCLUSIONS: The incidence of EPL rupture after volar plating of DRF is between 0% and 1% and usually occurs about 3 months after fixation. Approximately 50% of EPL ruptures are attributable to prominent dorsal screws. Although screw prominence is an important cause of EPL rupture, it is not the sole cause of rupture.

Fractures and other chest wall abnormalities after thoracotomy for esophageal cancer: A retrospective cohort study.

BACKGROUND: Chest pain following a thoracotomy for esophageal cancer is frequently reported but poorly understood. This study aimed to (1) determine the prevalence of thoracotomy-related thoracic fractures on postoperative imaging and (2) compare complications, long-term pain, and quality of life in patients with versus without these fractures. METHODS: This retrospective cohort study enrolled patients with esophageal cancer who underwent a thoracotomy between 2010 and 2020 with pre- and postoperative CTs (<1 and/or >6 months). Disease-free patients were invited for questionnaires on pain and quality of life. RESULTS: Of a total of 366 patients, thoracotomy-related rib fractures were seen in 144 (39%) and thoracic transverse process fractures in 4 (2%) patients. Patients with thoracic fractures more often developed complications (89% vs. 74%, p = 0.002), especially pneumonia (51% vs. 39%, p = 0.032). Questionnaires were completed by 77 after a median of 41 (P25 -P75 28-91) months. Long-term pain was frequently (63%) reported but was not associated with thoracic fractures (p = 0.637), and neither were quality of life scores. CONCLUSIONS: Thoracic fractures are prevalent in patients following a thoracotomy for esophageal cancer. These thoracic fractures were associated with an increased risk of postoperative complications, especially pneumonia, but an association with long-term pain or reduced quality of life was not confirmed.

A real-world study of quality of life following treatment with xylometazoline hydrochloride in individuals with common cold.

BACKGROUND: The common cold is a frequent, acute, and mild upper respiratory human disease. Nasal congestion has been considered the most bothersome symptom in the common cold, impacting quality of life (QoL). Topical decongestants containing steroids benefit QoL in allergic rhinitis, but no published research has assessed the impact of topical decongestants on QoL in the common cold. OBJECTIVE: To evaluate the effects of xylometazoline hydrochloride 0.1% (Otrivin, GSK Consumer Healthcare SARL, Switzerland) for up to 7 days on QoL in participants with nasal congestion associated with the common cold. DESIGN: This was a decentralized, longitudinal, open-label study. METHODS: The study enrolled 136 participants (⩾18 years) with early symptoms of the common cold, of which 102 were included in the modified intention-to-treat (mITT) population. Within 24 h of study product receipt, participants confirmed a 'plugged nose' and ⩾1 other common cold symptom. Primary endpoints were Wisconsin Upper Respiratory Symptom Survey-21 (WURSS-21) total score, total and individual symptom scores, and total QoL score. Secondary endpoints were additional QoL scores. Exploratory and post hoc analyses included median days to resolution for each QoL factor and analyses of five QoL categories. RESULTS: Consistent improvements in symptoms and QoL were seen in the mITT population. From day 1, improvements were seen in the 'plugged nose' symptom (p = 0.0023), WURSS-21 total QoL score, and all individual QoL scores (p < 0.0001 for all). After the last dose needed, significant improvements were seen in sleep quality (73%), vitality (76%), physical activity (71%), social activity (80%), and sensation (81%). No serious or unexpected adverse events were reported. CONCLUSION: This study is the first to demonstrate in a real-life setting that treating nasal congestion in adults with xylometazoline hydrochloride 0.1% during the common cold positively impacts QoL factors relevant to daily living [Otrivin: Quality of Life (QoL) Impact in a Real-World Setting; https://clinicaltrials.gov/study/NCT05556148].

Impact of xylometazoline hydrochloride 0.1% on quality of life in people with blocked nose associated with the common coldThe common cold is a widespread, mild respiratory illness for which a hallmark symptom is a blocked or stuffy nose, which makes breathing and sleeping difficult. This study focused on how a nasal spray called Otrivin (containing xylometazoline hydrochloride 0.1%) impacts the quality of life (QoL) of people suffering from nasal congestion due to the common cold.Participants answered a questionnaire called the Wisconsin Upper Respiratory Symptom Survey-21 (WURSS-21), which helped understand how people experience respiratory symptoms and how different aspects of QoL were impacted. Participants also responded to eight additional QoL questions not covered in the WURSS-21.The results showed that from the first day of using the nasal spray, participants experienced significant relief from the blocked nose symptom and reported an overall improvement in their QoL and well-being, such as in sleep quality, energy levels, senses, and physical and social activities.In conclusion, this real-world study demonstrated that using xylometazoline hydrochloride 0.1% nasal spray during the common cold can significantly improve nasal congestion and various aspects of a person's daily life. These findings provide valuable evidence for using this nasal spray to relieve symptoms and enhance the overall well-being of individuals with the common cold.

Validity of the ACS NSQIP surgical risk calculator as a tool to predict postoperative outcomes in subacute orthopedic trauma diagnoses.

Purpose: This retrospective study aimed to validate the ACS NSQIP Surgical Risk Calculator (SCR) to predict 30-day postoperative outcomes in patients with one of the following subacute orthopedic trauma diagnoses; multiple rib fractures, pelvic ring/acetabular fracture, or unilateral femoral fracture. Methods: Data of patients with these diagnoses treated between January 1, 2015 and September 19, 2020 were extracted from the patients' medical files. Diagnostic performance, discrimination, calibration, and accuracy of the ACS NSQIP SRC to predict specific outcomes developing within 30 days after surgery was determined. Results: The total cohort of the three diagnoses consisted of 435 patients. ACS NSQIP SRC underestimated the risk for serious complications, especially in patients with multiple rib fractures (8.3% predicted vs 17.2% observed) or pelvic ring/acetabular fracture (6.1% vs 19.8%). Underestimation was more pronounced for the composite outcome 'any complication'. Sensitivity ranged from 16.7% to 100% and specificity from 41.1% to 97.1%. Specificity exceeded sensitivity for pelvic ring/acetabular and femoral fractures. Discrimination was good for predicting death (femoral fracture), fair for readmission (femoral fracture), serious complication (multiple rib fractures), and any complication (multiple rib fractures), but poor in all other outcomes and diagnoses. Calibration and accuracy were adequate for all three diagnoses (p-value for Hosmer-Lemeshow test >0.05 and Brier scores <0.25). Conclusion: Performance of the ACS NSQIP SRC in the studied cohort was variable for all three diagnoses. Although it underestimated the risk of most outcomes, calibration and accuracy seemed generally adequate. For most outcomes, adequate diagnostic performance and discrimination could not be confirmed.

Radiographic rib fracture nonunion and association with fracture classification in adults with multiple rib fractures without flail segment: A multicenter prospective cohort study.

BACKGROUND: Rib fracture nonunion is a probable cause of chronic pain following chest trauma, although its prevalence remains unknown. The aims of this study were to determine rib fracture nonunion prevalence following nonoperative management and to determine if presence of nonunion was associated with the number of rib fractures, or the rib fracture classification of anatomical location, type, and displacement. METHODS: This multicenter prospective cohort study included trauma patients with three or more fractured ribs but without a flail segment, who participated in the nonoperative management group of the FixCon trial between January 2019 and June 2022. The number and classification of rib fractures were assessed on trauma chest CT. Chest CTs conducted six months post-trauma were evaluated for the presence of nonunion. Radiological characteristics of nonunions were compared with normally healed rib fractures using the Mann-Whitney U, χ2 test, and Fisher's exact test as appropriate. A generalized linear model adjusted for multiple observations per patient when assessing the associations between nonunion and fracture characteristics. RESULTS: A total of 68 patients were included with 561 post-traumatic fractures in 429 ribs. Chest CT after six months revealed nonunions in 67 (12 %) rib fractures in 29 (43 %) patients with a median of 2 (P25-P75 1-3) nonunions per patient. Nonunion was most commonly observed in ribs seven to 10 (20-23 %, p < 0.001, adjusted p = 0.006). Nonunion occurred in 14 (5 %) undisplaced, 22 (19 %) offset, and 20 (23 %) displaced rib fractures (p < 0.001). No statistically significant association between rib fracture type and nonunion was found. CONCLUSIONS: Forty-three percent of patients with multiple rib fractures had radiographic nonunion six months after trauma. Fractures in ribs seven to 10 and dislocated fractures had an increased risk of rib fracture nonunion.

Domestic pigs are susceptible to experimental infection with non-human primate-derived Reston virus without the need for adaptation.

Domestic pigs are a critical component of the food supply and one of the most commonly raised production animals. Pork consumption has driven the intensification of pig production expanding into environments conducive to increased emergence and spread of infectious diseases, including the spillover of pathogens into human populations. One of these emerging viruses, Reston virus (RESTV), is an enigma among the Orthoebolavirus genus in that its lack of human pathogenicity is in stark contrast to the high virulence associated with most other ebolaviruses. RESTV is, however, associated with outbreaks of highly lethal hemorrhagic disease in non-human primates (NHP), as well as poorly understood clinical manifestations of mixed virulence and lethality in naturally and experimentally infected domestic pigs. Our results show it is possible for RESTV derived from an NHP to infect domestic pigs resulting in a spectrum of disease, from asymptomatic to severe respiratory distress. Further, we report on the first experimental transmission of RESTV between infected pigs and a co-housed, naïve animal, as well as the first report of the successful use of group oral fluids for the detection of RESTV RNA and virus-specific IgA antibodies.

Rib fractures and other injuries after cardiopulmonary resuscitation for non-traumatic cardiac arrest: a systematic review and meta-analysis.

PURPOSE: This study aims to ascertain the prevalence of rib fractures and other injuries resulting from CPR and to compare manual with mechanically assisted CPR. An additional aim was to summarize the literature on surgical treatment for rib fractures following CPR. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Embase, Medline Ovid, Cochrane Central, Web of Science, and Google Scholar. REVIEW METHODS: The databases were searched to identify studies reporting on CPR-related injuries in patients who underwent chest compressions for a non-traumatic cardiopulmonary arrest. Subgroup analysis was conducted to compare the prevalence of CPR-related injuries in manual versus mechanically assisted chest compressions. Studies reporting on surgery for CPR-related rib fractures were also reviewed and summarized. RESULTS: Seventy-four studies reporting CPR-related injuries were included encompassing a total of 16,629 patients. Any CPR-related injury was documented in 60% (95% confidence interval [95% CI] 49-71) patients. Rib fractures emerged as the most common injury, with a pooled prevalence of 55% (95% CI 48-62). Mechanically assisted CPR, when compared to manual CPR, was associated with a higher risk ratio for CPR-related injuries of 1.36 (95% CI 1.17-1.59). Eight studies provided information on surgical stabilization of CPR-related rib fractures. The primary indication for surgery was the inability to wean from mechanical ventilation in the presence of multiple rib fractures. CONCLUSION: Rib fractures and other injuries frequently occur in patients who undergo CPR after a non-traumatic cardiopulmonary arrest, especially when mechanical CPR is administered. Surgical stabilization of CPR-related rib fractures remains relatively uncommon. LEVEL OF EVIDENCE: Level III, systematic review and meta-analysis.

Evolution of Pulmonary Contusions in Patients With Severe Rib Fractures: Cause for Concern?

INTRODUCTION: The progression of pulmonary contusions remains poorly understood. This study aimed to measure the radiographic change in pulmonary contusions over time and evaluate the association of the radiographic change with clinical outcomes and surgical stabilization of rib fractures (SSRF). METHODS: This retrospective cohort study included adults admitted with three or more displaced rib fractures or flail segment on trauma CT and when a chest CT was repeated within one week after trauma. Radiographic severity of pulmonary contusions was assessed using the Blunt Pulmonary Contusion Score (BPC18). Logistic regression was performed to evaluate the relation between SSRF and worsening contusions on repeat CT, adjusted for potential confounders. RESULTS: Of 231 patients, 56 (24%) had a repeat CT scan. Of these, 55 (98%) had pulmonary contusion on the first CT scan with a median BPC18 score of 5 (P25-P75 3-7). Repeat CTs showed an overall decrease of the median BPC18 score to 4 (P25-P75 2-6, P = .02), but demonstrated a worsening of the pulmonary contusion in 16 patients (29%). All repeat CTs conducted within 12 hours post-injury demonstrated increasing BPC18. Radiographic worsening of pulmonary contusions was not associated with SSRF, nor with worse respiratory outcomes or intensive care length of stay, compared to patients with radiographically stable or improving contusions. DISCUSSION: In patients with severe rib fracture patterns who undergo repeat imaging, pulmonary contusions are prevalent and become radiographically worse within at least the first 12 hours after injury. No association between radiographic worsening and clinical outcomes was found.

An initiative to assess and improve the resources and patient care processes used among Chest Wall Injury Society collaborative centers study (CWIS-CC2).

BACKGROUND: Over the last two decades, the acute management of rib fractures has changed significantly. In 2021, the Chest Wall injury Society (CWIS) began recognizing centers that epitomize their mission as CWIS Collaborative Centers. The primary aim of this study was to determine the resources, surgical expertise, access to care, and institutional support that are present among centers. METHODS: A survey was performed including all CWIS Collaborative Centers evaluating the resources available at their hospital for the treatment of patients with chest wall injury. Data about each chest wall injury center care process, availability of resources, institutional support, research support, and educational offerings were recorded. RESULTS: Data were collected from 20 trauma centers resulting in an 80% response rate. These trauma centers were made up of 5 international and 15 US-based trauma centers. Eighty percent (16 of 20) have dedicated care team members for the evaluation and management of rib fractures. Twenty-five percent (5 of 20) have a dedicated rib fracture service with a separate call schedule. Staffing for chest wall injury clinics consists of a multidisciplinary team: with attending surgeons in all clinics, 80% (8 of 10) with advanced practice providers and 70% (7 of 10) with care coordinators. Forty percent (8 of 20) of centers have dedicated rib fracture research support, and 35% (7 of 20) have surgical stabilization of rib fracture (SSRF)-related grants. Forty percent (8 of 20) of centers have marketing support, and 30% (8 of 20) have a web page support to bring awareness to their center. At these trauma centers, a median of 4 (1-9) surgeons perform SSRFs. In the majority of trauma centers, the trauma surgeons perform SSRF. CONCLUSION: Considerable similarities and differences exist within these CWIS collaborative centers. These differences in resources are hypothesis generating in determining the optimal chest wall injury center. These findings may generate several patient care and team process questions to optimize patient care, patient experience, provider satisfaction, research productivity, education, and outreach. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.

Safety and Performance of Narhinel 0.9% Sodium Chloride Monodose and Otrisal 0.74% Sodium Chloride Monodose Nasal Saline Solutions and Nasal Aspirators in Real-World Settings: Postmarket Clinical Follow-up Study Results.

Background: Blocked or stuffy nose is a common and bothersome symptom of colds, particularly for young children who are unable to clear their noses on their own. Nasal saline solutions and nasal aspirators are designed to gently cleanse and remove blocking nasal secretions. Objective: To assess the safety and performance of 2 monodose isotonic saline solutions (Narhinel 0.9% and Otrisal 0.74% sodium chloride; GSK Consumer Healthcare SARL, a Haleon company, Nyon, Switzerland) and 2 nasal aspirators with disposable hard- and soft-nozzle refills used as a standalone or combination treatment. Methods: We conducted 2 observational, online questionnaire-based, postmarket clinical follow-up studies in Europeans who had used any of the devices ≥1 time in the past 6 months. Coprimary objectives were to confirm the safety and performance of the saline solutions (Narhinel and Otrisal, Study 1) and nasal aspirators (with hard- and soft-nozzle refills, Study 2). Safety was assessed via the proportion of patients reporting adverse events and/or device malfunctions while using the devices within the previous 6 months, and performance was assessed by satisfaction rated on a 5-point scale, with "satisfied" and "very satisfied" being the highest performance ratings. Results: A total of 1136 (Study 1) and 1237 (Study 2) questionnaires were initiated by volunteer participants. Less than 2% of participants reported adverse events for any evaluated product in the previous 6 months. Most participants were "satisfied" or "very satisfied" with the devices for their intended use, with 78% to 91% of participants in the Narhinel arm, 73%-94% in the Otrisal arm, 71% to 95% in the soft-nozzle arm, and 71% to 80% in the hard-nozzle arm giving these ratings. Conclusions: These data support the safety and performance of 2 monodose saline solutions (Narhinel and Otrisal) for nasal cleansing, nasal moisturization, and/or loosening nasal secretions, and of nasal aspirators (with hard- and soft-nozzle refills) for clearing a blocked nose and removing nasal secretions.

Can CT-based gap and step-off displacement predict outcome after nonoperative treatment of acetabular fractures?

Aims: The aim of this study was to investigate the association between fracture displacement and survivorship of the native hip joint without conversion to a total hip arthroplasty (THA), and to determine predictors for conversion to THA in patients treated nonoperatively for acetabular fractures. Methods: A multicentre cross-sectional study was performed in 170 patients who were treated nonoperatively for an acetabular fracture in three level 1 trauma centres. Using the post-injury diagnostic CT scan, the maximum gap and step-off values in the weightbearing dome were digitally measured by two trauma surgeons. Native hip survival was reported using Kaplan-Meier curves. Predictors for conversion to THA were determined using Cox regression analysis. Results: Of 170 patients, 22 (13%) subsequently received a THA. Native hip survival in patients with a step-off ≤ 2 mm, > 2 to 4 mm, or > 4 mm differed at five-year follow-up (respectively: 94% vs 70% vs 74%). Native hip survival in patients with a gap ≤ 2 mm, > 2 to 4 mm, or > 4 mm differed at five-year follow-up (respectively: 100% vs 84% vs 78%). Step-off displacement > 2 mm (> 2 to 4 mm hazard ratio (HR) 4.9, > 4 mm HR 5.6) and age > 60 years (HR 2.9) were independent predictors for conversion to THA at follow-up. Conclusion: Patients with minimally displaced acetabular fractures who opt for nonoperative fracture treatment may be informed that fracture displacement (e.g. gap and step-off) up to 2 mm, as measured on CT images, results in limited risk on conversion to THA. Step-off ≥ 2 mm and age > 60 years are predictors for conversion to THA and can be helpful in the shared decision-making process.

Surgical strategy for treating multiple symptomatic rib fracture malunions with bridging heterotopic ossifications: A case report.

Rib fractures are common and serious injuries, which can negatively impact long-term quality of life. Here we present a woman in her early twenties who was referred to our trauma surgery outpatient clinic five years after a motor vehicle collision in which she sustained upper extremity injury and multiple displaced rib fractures. The rib fractures were initially managed non-operatively. At the time of the outpatient consultation, she endured persistent severe pain located between the left scapula and the thoracic spine. The pain worsened on repetitive motion and deep respiration. A new chest CT revealed left-sided posterior rib fracture malunions of ribs 4 to 8 with heterotopic ossifications (HO) that formed an osseous bridge between these ribs. Surgical excision of the bridging HO and remodeling of the angulated rib malunions resulted in significant alleviation of symptoms, which allowed her to return to work and other activities. Given the dramatic improvement after surgery, we suggest considering surgical remodeling and excision for rib fracture malunions and associated HO that cause local mechanical symptoms.

Rib Fixation for Multiple Rib Fractures: Healthcare Professionals Perceived Barriers and Facilitators to Clinical Implementation.

BACKGROUND: Surgical stabilization of rib fractures (SSRF) is associated with improved respiratory symptoms and shorter intensive care admission in patients with flail chest. For multiple rib fractures, the benefit of SSRF remains a topic of debate. This study investigated barriers and facilitators of healthcare professionals to SSRF as treatment for multiple traumatic rib fractures. METHODS: Dutch healthcare professionals were asked to complete an adapted version of the Measurement Instrument for Determinants of Innovations questionnaire to identify barriers and facilitators of SSRF. If ≥ 20% of participants responded negatively, the item was considered a barrier, and if ≥ 80% responded positively, the item was considered a facilitator. RESULTS: Sixty-one healthcare professionals participated; 32 surgeons, 19 non-surgical physicians, and 10 residents. The median experience was 10 years (P25-P75 4-12). Sixteen barriers and two facilitators for SSRF in multiple rib fractures were identified. Barriers included lack of knowledge, experience, evidence on (cost-)effectiveness, and the implication of more operations and higher medical costs. Facilitators were the assumption that SSRF alleviates respiratory problems and the feeling that surgeons are supported by colleagues for SSRF. Non-surgeons and residents reported more and several different barriers than surgeons (surgeons: 14; non-surgical physicians: 20; residents: 21; p < 0.001). CONCLUSION: For adequate implementation of SSRF in patients with multiple rib fractures, implementation strategies should address the identified barriers. Especially, improved clinical experience and scientific knowledge of healthcare professionals, and high-level evidence on the (cost-) effectiveness of SSRF potentially increase its use and acceptance.

What Surgical Technique to Perform for Isolated Ulnar Shortening Osteotomy After Distal Radius Malunion: A Systematic Review.

BACKGROUND: Unstable fractures of the distal radius fractures (DRFs) may result in malunion, usually consisting of subsequent shortening and angular deviations. Ulnar shortening osteotomy (USO) is assumed to be a simpler procedure than radial correction osteotomy, resulting in fewer complications and comparable outcomes. The aim of this study was to identify the best surgical technique to perform USO to restore distal radioulnar joint congruency after DRF malunion. METHODS: A systematic review of the literature is performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines in February 2022 to identify studies reporting outcomes and surgical technique for isolated USO. The primary outcome was complication rates. Secondary outcomes included functional, radiologic, and patient-rated outcomes. The methodological index for nonrandomized studies criteria were used to assess the quality of evidence. RESULTS: Included were 12 cohorts (185 participants). Due to substantial heterogeneity, a meta-analysis could not be performed. The overall complication rate was 33% (95% confidence interval, 16% to 51%). The most reported complication was implant irritation (22%), often requiring removal of the implant (13%). Only 3% nonunions were mentioned. Functional and patient-rated outcomes improved in most patients after USO. Quality of evidence of the papers was low to very low. Common methodological flaws were related to retrospective research. CONCLUSION: No evident differences in complication rates and functional outcomes between the surgical techniques were observed. Based on this literature, most complications are related to implant irritation. Nonunion and infection rates were rare. Therefore, a surgical technique with a buried implant might be preferred. This hypothesis requires further investigation.

Biomechanical characteristics of rib fracture fixation systems.

BACKGROUND: The primary aim of this study was to determine and compare the biomechanical properties of a fractured or intact rib after implant fixation on an embalmed thorax. METHODS: Five systems were fixated on the bilateral fractured or intact (randomly allocated) 6th to 10th rib of five post-mortem embalmed human specimens. Each rib underwent a four-point bending test to determine the bending structural stiffness (Newton per m2), load to failure (Newton), failure mode, and the relative difference in bending structural stiffness and load to failure as compared to a non-fixated intact rib. FINDINGS: As compared to a non-fixated intact rib, the relative difference in stiffness of a fixated intact rib ranged from -0.14 (standard deviation [SD], 0.10) to 0.53 (SD 0.35) and for a fixated fractured rib from -0.88 (SD 0.08) to 0.17 (SD 0.50). The most common failure mode was a new fracture at the most anterior drill hole for the plate and screw systems and a new fracture within the anterior portion of the implant for the clamping systems. INTERPRETATION: The current fixation systems differ in their design, mode of action, and biomechanical properties. Differences in biomechanical properties such as stiffness and load to failure especially apply to fractured ribs. Insight in the differences between the systems might guide more specific implant selection and increase the surgeon's awareness for localizing hardware complaints or failure.

Artificial intelligence fracture recognition on computed tomography: review of literature and recommendations.

PURPOSE: The use of computed tomography (CT) in fractures is time consuming, challenging and suffers from poor inter-surgeon reliability. Convolutional neural networks (CNNs), a subset of artificial intelligence (AI), may overcome shortcomings and reduce clinical burdens to detect and classify fractures. The aim of this review was to summarize literature on CNNs for the detection and classification of fractures on CT scans, focusing on its accuracy and to evaluate the beneficial role in daily practice. METHODS: Literature search was performed according to the PRISMA statement, and Embase, Medline ALL, Web of Science Core Collection, Cochrane Central Register of Controlled Trials and Google Scholar databases were searched. Studies were eligible when the use of AI for the detection of fractures on CT scans was described. Quality assessment was done with a modified version of the methodologic index for nonrandomized studies (MINORS), with a seven-item checklist. Performance of AI was defined as accuracy, F1-score and area under the curve (AUC). RESULTS: Of the 1140 identified studies, 17 were included. Accuracy ranged from 69 to 99%, the F1-score ranged from 0.35 to 0.94 and the AUC, ranging from 0.77 to 0.95. Based on ten studies, CNN showed a similar or improved diagnostic accuracy in addition to clinical evaluation only. CONCLUSIONS: CNNs are applicable for the detection and classification fractures on CT scans. This can improve automated and clinician-aided diagnostics. Further research should focus on the additional value of CNN used for CT scans in daily clinics.

Rib fixation in patients with severe rib fractures and pulmonary contusions: Is it safe?

BACKGROUND: Pulmonary contusion has been considered a contraindication to surgical stabilization of rib fractures (SSRFs). This study aimed to evaluate the association between pulmonary contusion severity and outcomes after SSRF. We hypothesized that outcomes would be worse in patients who undergo SSRF compared with nonoperative management, in presence of varying severity of pulmonary contusions. METHODS: This retrospective cohort study included adults with three or more displaced rib fractures or flail segment. Patients were divided into those who underwent SSRF versus those managed nonoperatively. Severity of pulmonary contusions was assessed using the Blunt Pulmonary Contusion 18 (BPC18) score. Outcomes (pneumonia, tracheostomy, mechanical ventilation days, intensive care unit (ICU) length of stay, hospital length of stay, mortality) were retrieved from patients' medical records. Comparisons were made using Fisher's exact and Kruskal-Wallis tests, and correction for potential confounding was done with regression analyses. RESULTS: A total of 221 patients were included; SSRF was performed in 148 (67%). Demographics and chest injury patterns were similar in SSRF and nonoperatively managed patients. Surgical stabilization of rib fracture patients had less frequent head and abdominal/pelvic injuries ( p = 0.017 and p = 0.003). Higher BPC18 score was associated with worse outcomes in both groups. When adjusted for ISS, the ICU stay was shorter (adjusted ß , -2.511 [95% confidence interval, -4.87 to -0.16]) in patients with mild contusions who underwent SSRF versus nonoperative patients. In patients with moderate contusions, those who underwent SSRF had fewer ventilator days (adjusted ß , -5.19 [95% confidence interval, -10.2 to -0.17]). For severe pulmonary contusions, outcomes did not differ between SSRF and nonoperative management. CONCLUSION: In patients with severe rib fracture patterns, higher BPC18 score is associated with worse respiratory outcomes and longer ICU and hospital admission duration. The presence of pulmonary contusions is not associated with worse SSRF outcomes, and SSRF is associated with better outcomes for patients with mild to moderate pulmonary contusions. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Interobserver agreement for the Chest Wall Injury Society taxonomy of rib fractures using computed tomography images.

BACKGROUND: In 2020, a universal nomenclature for rib fractures was proposed by the international Chest Wall Injury Society taxonomy collaboration. The purpose of this study is to validate this taxonomy. We hypothesized that there would be at least moderate agreement, regardless of the observers' background. METHODS: An international group of independent observers evaluated axial, coronal, and sagittal computed tomography images on an online platform from 11 rib fractures for location (anterior, lateral, or posterior), type (simple, wedge, or complex), and displacement (undisplaced, offset, or displaced) of rib fractures. The multirater κ and Gwet's first agreement coefficient (AC1) were calculated to estimate agreement among the observers. RESULTS: A total of 90 observers participated, with 76 complete responses (84%). Strong agreement was found for the classification of fracture location ( κ = 0.83 [95% confidence interval (CI) 0.69-0.97]; AC1, 0.84 [95% CI, 0.81-0.88]), moderate for fracture type ( κ = 0.46 [95% CI, 0.32-0.59]; AC1, 0.50 [95% CI, 0.45-0.55]), and fair for rib fracture displacement ( κ = 0.38 [95% CI, 0.21-0.54], AC1, 0.38 [95% CI, 0.34-0.42]). CONCLUSION: Agreement on rib fracture location was strong and moderate for fracture type. Agreement on displacement was lower than expected. Evaluating strategies such as comprehensive education, additional imaging techniques, or further specification of the definitions will be needed to increase agreement on the classification of rib fracture type and displacement as defined by the Chest Wall Injury Society taxonomy. LEVEL OF EVIDENCE: Diagnostic Test or Criteria; Level IV.

Surgical stabilization of rib fractures versus nonoperative treatment in patients with multiple rib fractures following cardiopulmonary resuscitation: An international, retrospective matched case-control study.

BACKGROUND: The presence of six or more rib fractures or a displaced rib fracture due to cardiopulmonary resuscitation (CPR) has been associated with longer hospital and intensive care unit (ICU) length of stay (LOS). Evidence on the effect of surgical stabilization of rib fractures (SSRF) following CPR is limited. This study aimed to evaluate outcomes after SSRF versus nonoperative management in patients with multiple rib fractures after CPR. METHODS: An international, retrospective study was performed in patients who underwent SSRF or nonoperative management for multiple rib fractures following CPR between January 1, 2012, and July 31, 2020. Patients who underwent SSRF were matched to nonoperative controls by cardiac arrest location and cause, rib fracture pattern, and age. The primary outcome was ICU LOS. RESULTS: Thirty-nine operatively treated patient were matched to 66 nonoperatively managed controls with comparable CPR-related characteristics. Patients who underwent SSRF more often had displaced rib fractures (n = 28 [72%] vs. n = 31 [47%]; p = 0.015) and a higher median number of displaced ribs (2 [P 25 -P 75 , 0-3] vs. 0 [P 25 -P 75 , 0-3]; p = 0.014). Surgical stabilization of rib fractures was performed at a median of 5 days (P 25 -P 75 , 3-8 days) after CPR. In the nonoperative group, a rib fixation specialist was consulted in 14 patients (21%). The ICU LOS was longer in the SSRF group (13 days [P 25 -P 75 , 9-23 days] vs. 9 days [P 25 -P 75 , 5-15 days]; p = 0.004). Mechanical ventilator-free days, hospital LOS, thoracic complications, and mortality were similar. CONCLUSION: Despite matching, those who underwent SSRF over nonoperative management for multiple rib fractures following CPR had more severe consequential chest wall injury and a longer ICU LOS. A benefit of SSRF on in-hospital outcomes could not be demonstrated. A low consultation rate for rib fixation in the nonoperative group indicates that the consideration to perform SSRF in this population might be associated with other nonradiographic or injury-related variables. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

A prospective multicenter randomized clinical trial comparing endovenous laser ablation, using a 1470 nm diode laser in combination with a Tulip-TipTM fiber versus radiofrequency (Closure FAST™ VNUS®), in the treatment of primary varicose veins.

BACKGROUND: The treatment of chronic venous disease, has largely shifted from high ligation and stripping to endovenous thermal ablation (EVTA) techniques, because of its comparable efficacy and lack of invasiveness. This clinical trial aimed to compare the efficacy of two thermal ablation techniques, endovenous laser ablation (EVLA) 1470-nm with Tulip-TipTM fiber and radiofrequency ablation (RFA) ClosureFastTM using a non-inferiority design for occlusion rate (primary outcome). METHODS: A prospective multicenter randomized clinical trial randomized 280 patients for the treatment of great saphenous vein (GSV) reflux. Primary outcome was the GSV occlusion rate, secondary outcome factors were the possible side-effects of the treatment such as pain, ecchymosis, quality of Life (CIVIQ-20), revised Venous Clinical Severity Score (r-VCSS). One-year follow-up period. RESULTS: The total occlusion rates at one year follow-up were 96.4% and 94.5% in the EVLA and RFA groups respectively (P=0.15). Regarding secondary outcomes, such as postoperative CIVIQ-20, r-VCSS, analgesia, absenteeism, there was no significant difference between both treatment groups. CONCLUSIONS: RFA and EVLA, using a 1470 nm laser with Tulip-TipTM fiber, of the GSV results in equal occlusion rates at one year, with comparable postoperative pain and improved quality of life.