Plate Fixation Compared with Nonoperative Treatment for Displaced Midshaft Clavicular Fractures: A Multicenter Randomized Controlled Trial.

BACKGROUND: The use of operative treatment for clavicular fractures is increasing, despite varying results in previous studies. The aim of this study was to compare plate fixation and nonoperative treatment for displaced midshaft clavicular fractures with respect to nonunion, adverse events, and shoulder function. METHODS: In this multicenter, prospective, randomized controlled trial, patients between 18 and 60 years old with a displaced midshaft clavicular fracture were randomized between nonoperative treatment and open reduction with internal plate fixation. The primary outcome was evidence of nonunion at 1 year. Other outcomes were secondary operations, arm function as measured with the Constant shoulder score and Disabilities of the Arm, Shoulder and Hand (DASH) score, pain, cosmetic results, and general health status. Outcomes were recorded at 6 weeks, 3 months, and 1 year following trauma. RESULTS: One hundred and sixty patients were randomized. The rate of nonunion was significantly higher in the nonoperatively treated group than in the operatively treated group (23.1% compared with 2.4%; p < 0.0001), as was the rate of nonunion for which secondary plate fixation was performed (12.9% compared with 1.2%; p = 0.006). The rate of secondary operations was 27.4% in the operatively treated group (16.7% for elective plate removal) and 17.1% in the nonoperatively treated group (p = 0.18). Nineteen percent of the patients in the operatively treated group had persistent loss of sensation around the scar. No difference was found between the groups with respect to the Constant and DASH scores at all time points. CONCLUSIONS: For patients with a diaphyseal fracture of the clavicle displaced at least 1 shaft width, plate fixation improves the chances that the bone will heal; however, the rate of patients who need a second operation is considerable. In addition, the procedure does not improve shoulder function or general symptoms, and it does not decrease limitations compared with nonoperative treatment in a sling. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Implementing a clinical pathway for hip fractures; effects on hospital length of stay and complication rates in five hundred and twenty six patients.

PURPOSE: Modern management of the elderly with a hip fracture is complex and costly. The aim of this study was to compare the treatment-related hospital length of stay (HLOS) before and after implementing a clinical pathway for patients undergoing hip fracture surgery. METHODS: This was a retrospective, before-and-after study. The first period ranged from June 21, 2008 to November 1, 2009 (N = 212), and the second was from January 7, 2010 to July 7, 2011 (N = 314). The electronic hospital system and patients records were reviewed for demographics, HLOS, mortality, complications and readmissions. RESULTS: In the first period 53 % had a femoral neck fracture, of which 57 % were treated with hemiarthroplasty. In the second period this was 46 % and 71 %. Pertrochanteric fractures were treated with a Gamma nail in 85 % in the first period, and in 92 % in the second period. The median HLOS decreased from nine to six days (p < 0.001). For the hemiarthroplasty group HLOS decreased from nine to seven days (p < 0.001); for internal fixation there was no significant difference (five versus six days, p = 0.557) and after Gamma nailing it decreased from ten to six days (p < 0.001). For mortality no statistically significant difference was found (6 % versus 5 %, p = 0.698). Complications decreased for the Gamma nail group (44 % versus 31 %, p = 0.049). Readmissions for the total group were not different (16 % versus 17 %, p = 0.720). CONCLUSIONS: Implementing a clinical pathway for hip fractures is a safe way to reduce the HLOS and it improves the quality of care.

Displaced midshaft fractures of the clavicle: non-operative treatment versus plate fixation (Sleutel-TRIAL). A multicentre randomised controlled trial.

BACKGROUND: The traditional view that the vast majority of midshaft clavicular fractures heal with good functional outcomes following non-operative treatment may be no longer valid for all midshaft clavicular fractures. Recent studies have presented a relatively high incidence of non-union and identified speciic limitations of the shoulder function in subgroups of patients with these injuries. AIM: A prospective, multicentre randomised controlled trial (RCT) will be conducted in 21 hospitals in the Netherlands, comparing fracture consolidation and shoulder function after either non-operative treatment with a sling or a plate fixation. METHODS/DESIGN: A total of 350 patients will be included, between 18 and 60 years of age, with a dislocated midshaft clavicular fracture. The primary outcome is the incidence of non-union, which will be determined with standardised X-rays (Antero-Posterior and 30 degrees caudocephalad view). Secondary outcome will be the functional outcome, measured using the Constant Score. Strength of the shoulder muscles will be measured with a handheld dynamometer (MicroFET2). Furthermore, the health-related Quality of Life score (ShortForm-36) and the Disabilities of Arm, Shoulder and Hand (DASH) Outcome Measure will be monitored as subjective parameters. Data on complications, bone union, cosmetic aspects and use of painkillers will be collected with follow-up questionnaires. The follow-up time will be two years. All patients will be monitored at regular intervals over the subsequent twelve months (two and six weeks, three months and one year). After two years an interview by telephone and a written survey will be performed to evaluate the two-year functional and mechanical outcomes. All data will be analysed on an intention-to-treat basis, using univariate and multivariate analyses. DISCUSSION: This trial will provide level-1 evidence for the comparison of consolidation and functional outcome between two standardised treatment options for dislocated midshaft clavicular fractures. The gathered data may support the development of a clinical guideline for treatment of clavicular fractures. TRIAL REGISTRATION: Netherlands National Trial Register NTR2399.

Surgical anatomy for subfascial endoscopic perforating vein surgery of laterally located perforating veins.

OBJECTIVES: Endoscopic ligation of perforating veins is useful in treatment of perforating vein incompetence. Over the last few years the topic of interest has been the medial side of the lower leg; however, laterally located venous ulcers (10% of all) are of equal importance. Our poor results with lateral subfascial endoscopic perforating vein surgery (SEPS) procedures led us to study the anatomy of the perforating veins in the lateral leg. The presence of persistent insufficient perforating veins in our patients suggests that our procedure failed because of misinterpreted perforator anatomy. METHODS AND RESULTS: Anatomic dissection was performed in 16 cadavers in two stages, subcutaneously and subfascially. Perforating veins were classified relative to the short saphenous vein and intermuscular septa, with coordinates. Three hundred fifty-one perforating veins were found, for an average of 21.9 perforating veins per leg. The results showed that there is alignment of the perforating veins according to the septa between the anterior and peroneal compartment and between the peroneal compartment and the superficial dorsal compartment. Most of the perforating veins did not correlate with the short saphenous vein. CONCLUSION: Poor clinical results of lateral SEPS procedures might be improved after adjustment of the procedure for new anatomic information, which shows alignment of perforating veins along the intermuscular septa, obligating full septa dissection on the lateral side.