Routine 6-weeks outpatient visit in patients treated surgically for upper extremity fractures: Is it truly necessary?

OBJECTIVES: To investigate the usefulness of the routinely planned six-week outpatient visit and x-ray in patients treated surgically for the most common upper extremity fractures including clavicle, proximal humerus, humeral shaft, olecranon, radial shaft and distal radius. METHOD: This was a retrospective cohort study of all patients treated surgically for the most common upper extremity fractures between 2019 and 2022 in a level 1 trauma center. The first outcome of interest was the incidence of abnormalities found on the x-ray made at the 6-week outpatient visit. Abnormalities were defined as all differences between the intra-operative (or direct postoperative) and 6-week x-ray. In case an abnormality was detected, the hospital records were screened to determine its clinical consequence. The clinical consequences were categorized into requiring either additional diagnostics, additional interventions, change of standard postoperative immobilization, weightbearing or allowed range of motion (ROM). The second outcome of interest was the incidence of deviations from the local standard post operative treatment and follow-up protocol based on the 6-week outpatient visit as a whole. Deviations were also categorized into either requiring additional diagnostics, additional interventions, change of standard postoperative immobilization, weightbearing or allowed range of motion. RESULTS: A total of 267 patients were included. Abnormalities on x-ray at 6 weeks postoperatively were found in only 10 (3.7%) patients of which only 4 (1.5%) had clinical implications (in three patients extra imaging was required and in one patient it was necessary to deviate from standard weightbearing/ROM limitation regime). The clinical/radiological findings during the 6-week outpatient visit led to a deviation from standard in only 8 (3.0%) patients. Notably, the majority of these patients experienced symptoms suggestive for complications. CONCLUSION: The routine 6-week outpatient visit and x-ray, after surgery for common upper extremity fractures, rarely has clinical consequences. It should be questioned whether these routine visits are necessary and whether a more selective approach should be considered. LEVEL OF EVIDENCE: Level IV; Case Series; Prognosis Study.

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.

High Percentage of Complications and Re-Operations Following Dynamic Locking Plate Fixation with the Targon® FN for Intracapsular Proximal Femoral Fractures: An Analysis of Risk Factors.

The ideal surgical treatment of femoral neck fractures remains controversial. When treating these fractures with internal fixation, many fixation constructs exist. The primary aim of this study was to evaluate the incidence and specific risk factors associated with complication and re-operation following fixation of intracapsular proximal femoral fractures using the Targon-FN system (B.Braun Melsungen AG). A secondary aim was to identify if lateral prominence of the implant relative to the lateral border of the vastus ridge was a specific risk factor for elective plate removal. Methodically, a retrospective case series was conducted of all consecutive adult patients treated at a single level 1 trauma center in Switzerland for an intracapsular proximal femoral fracture with the Targon-FN. Demographic data were collected. Patients with a follow-up of less than three months were excluded. Complications as well as plate position were recorded. Statistical analysis to identify specific risk factors for re-operation and complications was performed. In result, a total of 72 cases with intracapsular femoral neck fractures were treated with the Targon-FN locking plate system between 2010 and 2017. Thirty-four patients (47.2%) experienced one or more complications. The most common complication was mechanical irritation of the iliotibial band (ITB) (23.6%, n = 17). Complications included intraarticular screw perforation (6.9%, n = 5), avascular necrosis (5.6%, n = 4), non-union (5.6%, n = 4) among others. In total, 46 re-operations were required. Younger age, fracture displacement and time to postoperative weight bearing were identified as risk factors for re-operation. In conclusion, intracapsular femoral neck fractures treated with the Targon-FN system resulted in a high rate of post-operative complication and re-operation. Statistical analysis revealed patient age, fracture displacement, time to postoperative full weight bearing were risk factors for re-operation. The main limitation is the limited number of cases and a short follow-up of less than 12 months in a subgroup of our patients.

Reduced pre-operative skin oxygen saturation predicts revision after open reduction and internal fixation in calcaneal fractures : A reduced pre-operative oxygen saturation as measured by laser-Doppler spectrophotometry in 8 mm depth is associated with revision surgery after open reduction and internal fixation of calcaneal fractures through an extended lateral approach.

PURPOSE: To assess which pre-operative parameters correlate with wound revisions after an extended lateral approach to the calcaneus. METHODS: Pre-operative laser-Doppler spectrophotometry was applied in patients undergoing open reduction and internal fixation. The number of wound revisions was recorded during pos-toperative follow-up. Spearman rho analysis was used to identify factors associated with wound revision and receiver operator characteristics curves were calculated for the identified factors. RESULTS: Thirty-four patients (29 men, 5 women; 37 calcanei) with a mean patient age of 43 ± 14 years were analyzed. The minimal oxygen saturation value at the five measurement locations as well as the minimal value for flow correlated negatively with wound revisions (p value = 0.025 and 0.038, respectively). The area under the curve for the pre-operative minimal value of oxygen saturation was 0.841 (95%CI 0.64-1.00, p = 0.028), indicating a good accuracy as a test to predict wound revision. CONCLUSION: A pre-operative oxygen saturation of at least 20.5% across five measurement points along the anticipated incision identified all patients not needing a wound revision (negative predictive value 100%). On the other hand, patients with at least one measurement below 20.5% were at risk for wound revision surgery (sensitivity 100%, specificity 48.5%). ClinicalTrials.gov NCT01264146.

Trochanteric Femur Fractures: Application of Skeletal Traction during Surgery Does Not Alter Soft-Tissue Microcirculation.

Background and Objectives: Wound infections provoked by alterations in microcirculation are major complications in the treatment of trochanteric femur fractures. Surgical fracture fixation on a traction table is the gold standard for treatment, but the effect on tissue microcirculation is unknown. Microcirculation could be impaired by the pull on the soft-tissue or by a release of vasoactive factors. We hypothesized that intraoperative traction impairs soft-tissue microcirculation. Materials and Methods: In 22 patients (14 women, eight men), average age 78 years (range 36-96 ± 14), with trochanteric femur fractures, non-invasive laser-Doppler spectrophotometry was used to assess oxygen saturation, hemoglobin content, and blood flow in the skin and subcutaneous tissue before and after application of traction. Measurements were recorded in nine locations around the greater trochanter at a depth of 2, 8, and 15 mm before and after fracture reduction by traction. Results: No differences were found in any depth with traction compared to without (oxygen saturation: p = 0.751, p = 0.308, and p = 0.955, haemoglobin content: p = 0.651, p = 0.928, and p = 0.926, blood flow: p = 0.829, p = 0.866, and p = 0.411). Conclusion: In this pilot study, the application of traction does not affect skin and subcutaneous microcirculation in the surgery of proximal femur fractures.

Arthroscopy versus mini-arthrotomy approach for matrix-induced autologous chondrocyte implantation in the knee: a systematic review.

BACKGROUND: Matrix-induced autologous chondrocyte implantation (mACI) can be performed in a full arthroscopic or mini-open fashion. A systematic review was conducted to investigate whether arthroscopy provides better surgical outcomes compared with the mini-open approach for mACI in the knee at midterm follow-up. METHODS: This systematic review was conducted following the PRISMA guidelines. The literature search was performed in May 2021. All the prospective studies reporting outcomes after mACI chondral defects of the knee were accessed. Only studies that clearly stated the surgical approach (arthroscopic or mini-open) were included. Only studies reporting a follow-up longer than 12 months were eligible. Studies reporting data from combined surgeries were not eligible, nor were those combining mACI with less committed cells (e.g., mesenchymal stem cells). RESULTS: Sixteen studies were included, and 770 patients were retrieved: 421 in the arthroscopy group, 349 in the mini-open. The mean follow-up was 44.3 (12-60) months. No difference between the two groups was found in terms of mean duration of symptoms, age, body mass index (BMI), gender, defect size (P > 0.1). No difference was found in terms of Tegner Score (P = 0.3), Lysholm Score (P = 0.2), and International Knee Documentation Committee (IKDC) Score (P = 0.1). No difference was found in the rate of failures (P = 0.2) and revisions (P = 0.06). CONCLUSION: Arthroscopy and mini-arthrotomy approaches for mACI in knee achieve similar outcomes at midterm follow-up. LEVEL OF EVIDENCE: II, systematic review of prospective studies.

Conservative vs. operative treatment for humeral shaft fractures: a meta-analysis and systematic review of randomized clinical trials and observational studies.

BACKGROUND: This meta-analysis aimed to compare conservative vs. operative treatment for humeral shaft fractures in terms of the nonunion rate, reintervention rate, permanent radial nerve palsy rate, and functional outcomes. Secondarily, effect estimates from observational studies were compared with estimates of randomized clinical trials (RCTs). METHODS: The PubMed/Medline, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases were searched for both RCTs and observational studies comparing conservative with operative treatment for humeral shaft fractures. RESULTS: A total of 2 RCTs (150 patients) and 10 observational studies (1262 patients) were included. The pooled nonunion rate of all studies was higher in patients treated conservatively (15.3%) vs. operatively (6.4%) (risk difference, 8%; odds ratio [OR], 2.9; 95% confidence interval [CI], 1.8-4.5; I2 = 0%). The reintervention rate was also higher for conservative treatment (14.3%) than for operative treatment (8.9%) (risk difference, 6%; OR, 1.9; 95% CI, 1.1-3.5; I2 = 30%). The higher reintervention rate was predominantly attributable to the higher nonunion rate in patients treated conservatively. The permanent radial nerve palsy rate was equal in both groups (OR, 0.6; 95% CI, 0.2-1.9; I2 = 18%). There appeared to be no difference in mean time to union and mean Disabilities of the Arm, Shoulder and Hand scores between the treatment groups. No difference was found between effect estimates form observational studies and RCTs. CONCLUSION: This systematic review shows that satisfactory results can be achieved with both conservative and operative management; however, operative treatment reduces the risk of nonunion compared with conservative treatment, with comparable reintervention rates (for indications other than nonunion). Furthermore, operative treatment results in a similar permanent radial nerve palsy rate, despite its inherent additional surgery-related risks. No difference in mean time-to-union and short-term functional results was detected.

Long-term Outcome of Surgery Versus Conservative Management for Recurrent and Ongoing Complaints After an Episode of Diverticulitis: 5-year Follow-up Results of a Multicenter Randomized Controlled Trial (DIRECT-Trial).

OBJECTIVE: The aim of this study was to establish whether surgical or conservative treatment leads to a higher quality of life (QoL) in patients with recurring diverticulitis and/or ongoing complaints. SUMMARY OF BACKGROUND DATA: The 6 months' results of the DIRECT trial, a randomized trial comparing elective sigmoidectomy with conservative management in patients with recurring diverticulitis (>2 episodes within 2 years) and/or ongoing complaints (>3 months) after an episode of diverticulitis, demonstrated a significantly higher QoL after elective sigmoidectomy. The aim of the present study was to evaluate QoL at 5-year follow-up. METHODS: From January 2010 to June 2014, 109 patients were randomized to either elective sigmoidectomy (N = 53) or conservative management (N = 56). In the present study, the primary outcome was QoL measured by the Gastrointestinal Quality of Life Index (GIQLI) at 5-year follow-up. Secondary outcome measures were SF-36 score, Visual Analogue Score (VAS) pain score, EuroQol-5D-3L (EQ-5D-3L) score, morbidity, mortality, perioperative complications, and long-term operative outcome. RESULTS: At 5-year follow-up, mean GIQLI score was significantly higher in the operative group [118.2 (SD 21.0)] than the conservative group [108.5 (SD 20.0)] with a mean difference of 9.7 (95% confidence interval 1.7-17.7). All secondary QoL outcome measures showed significantly better results in the operative group, with a higher SF-36 physical (P = 0.030) and mental score (P = 0.010), higher EQ5D score (P = 0.016), and a lower VAS pain score (P = 0.011). Twenty-six (46%) patients in the conservative group ultimately required surgery due to severe ongoing complaints. Of the operatively treated patients, 8 (11%) patients had anastomotic leakage and reinterventions were required in 11 (15%) patients. CONCLUSION: Consistent with the short-term results of the DIRECT trial, elective sigmoidectomy resulted in a significantly increased QoL at 5-year follow-up compared with conservative management in patients with recurring diverticulitis and/or ongoing complaints. Surgeons should counsel these patients for elective sigmoidectomy weighing superior QoL, less pain, and lower risk of new recurrences against the complication risk of surgery.

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.

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.

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.

Diverticulitis in young versus elderly patients: a meta-analysis.

OBJECTIVE: To compare patients younger and older than 50 years with diverticulitis with regard to complications, disease recurrence and to the need for surgery. MATERIAL AND METHODS: A literature review and meta-analysis was conducted according to the PRISMA guidelines. MEDLINE, Embase and the Cochrane databases were searched for longitudinal cohort studies comparing patients younger and older than 50 years with diverticulitis. RESULTS: Eight studies were included with a total of 4.751 (male:female 1:0.66) patients younger and 18.328 (male:female 1:1.67) older than 50 years of age. The risk of developing at least one recurrent episode was significantly higher among patients younger than 50 years (pooled RR 1.73; 95% CI 1.40-2.13) with an estimated cumulative risk of 30% compared with 17.3% in older patients. The risk of requiring surgery during hospitalization for a primary episode of diverticulitis was equal in both age groups (pooled RR 0.99; 95% CI 0.74-1.32) and estimated at approximately 20%. Patients younger than 50 years more frequently required urgent surgery during hospitalization for a subsequent recurrent episode (pooled RR 1.46; 95% CI 1.29-1.66); the cumulative risk was 7.3% in younger and 4.9% in patients older than 50 years. CONCLUSION: Patients younger than 50 years only differ substantially in risk for recurrent disease from patients older than 50 years of age. Although the relative risk for requiring urgent surgery for recurrent disease was higher in younger patient, one should consider that the absolute risk difference is relatively small (7.3% vs. 4.9%).

Dietary restrictions for acute diverticulitis: evidence-based or expert opinion?

PURPOSE: Diet restrictions are usually advised as part of the conservative treatment for the acute phase of a diverticulitis episode. To date, the rationale behind diet restrictions has never been thoroughly studied. This study aims to investigate which factors influence the choice of dietary restriction at presentation. Additionally, the effect of dietary restrictions on hospitalization duration is investigated. METHODS: All patients hospitalized for Hinchey 0, Ia, or Ib diverticulitis between January 2010 and June 2011 were included. Patients were categorized according to the diet imposed by the treating physician at presentation and included nil per os, clear liquid, liquid diet, and solid foods. The relation between Hinchey classification, C-reactive protein, leucocyte count and temperature at presentation and diet choice was examined. Subsequently, the relation between diet restriction and number of days hospitalized was studied. RESULTS: Of the 256 patients included in the study 65 received nil per os, 89 clear liquid, 75 liquid diet, and 27 solid foods at presentation. Solely high temperature appeared to be related to a more restrictive diet choice at presentation. Patients who received liquid diet (HR 1.66 CI 1.19-2.33) or solid foods (HR 2.39 CI 1.52-3.78) were more likely to be discharged compared to patient who received clear liquid diet (HR 1.26 CI 1.52-3.78) or nils per os (reference group). This relation remained statistically significant after correction for disease severity, treatment and complications. CONCLUSION: Physicians appeared to prefer a more restrictive diet with increasing temperature at presentation. Notably, dietary restrictions prolong hospital stay.

Elective resection for ongoing diverticular disease significantly improves quality of life.

BACKGROUND: Although the risks of elective resection for diverticular disease are well studied, studies on subjective improvement are scarce. This study aims to investigate subjective improvement. METHODS: All patients who underwent elective resection for recurring or persisting complaints after an episode of diverticulitis were identified from an in-hospital database. Patients with at least 1 year of follow-up were sent visual analogue scales (VAS) to grade their quality of life (QoL) and the degree of discomfort caused by abdominal pain, abnormal defecation and fatigue before and after resection. RESULTS: One hundred and five patients responded to the questionnaire (response rate 76.6%). The median follow-up was 33 (15-53) months. Elective resection improved general QoL (median VAS improvement 40) and reduced discomfort caused by abdominal pain (median VAS improvement 60) in up to 89.3 and 87.5% of patients, respectively. The effects of elective resection are less profound for discomfort caused by abnormal defecation (77.1%, median VAS improvement 33) and fatigue (75.2%, median VAS improvement 30). CONCLUSION: Elective resection of the sigmoid for persisting or recurring symptoms after an episode of diverticulitis improves general QoL and discomfort caused by abdominal pain, abnormal defecation and fatigue in the vast majority of patients.

Tranexamic Acid Use in Breast Surgery: A Systematic Review and Meta-Analysis.

BACKGROUND: The perioperative use of tranexamic acid (TXA) has become popular among plastic surgeons for a variety of surgical procedures. The aim of this study was to perform a systematic review and meta-analysis on the results reported in the literature regarding the effect of perioperative systemic TXA administration in breast surgery. METHODS: The PubMed, MEDLINE, Embase, CENTRAL, and CINAHL databases were searched for both randomized clinical trials and observational studies. Effect estimates were pooled across studies using random effects models and presented as weighted odds ratio with corresponding 95% confidence interval. RESULTS: A total of five studies encompassing 1139 patients undergoing mastectomy with or without immediate implant or free flap-based breast reconstruction or breast-conserving surgery with or without axillary lymph node dissection were included. Perioperative intravenous administration of TXA significantly reduced the risk for hematoma (7.3% versus 12.9%; OR, 0.43; 95% CI, 0.23 to 0.81) and seroma formation (11.5% versus 19.9%; OR, 0.57; 95% CI, 0.35 to 0.92) in comparison to the control group. In the studies measuring the postoperative drainage amount, the mean difference was 132 mL (95% CI, 220 to 44 mL). No thromboembolic event occurred in either group. The weighted surgical-site infection rate was higher in the control group (3.1% versus 1.5%). However, these data were too sparse to perform comparative meta-analysis. CONCLUSION: Evidence of this study suggests that perioperative administration of TXA significantly reduces the risk for postoperative hematoma and seroma formation in breast surgery, whereas the risk for thromboembolic events and postoperative infection is not increased.

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.

Outcomes of acute perilunate injuries-a systematic review.

PURPOSE: The objective of this systematic review was to perform epidemiological as well as clinical, radiological and patient-reported outcome analysis of surgically treated perilunate dislocations and fracture dislocations (PLDs and PLFDs) based on the so far largest pooled patient population to date. MATERIAL AND METHODS: This systematic review was written according to the updated guideline for reporting systematic reviews by the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. A comprehensive literature search of Pubmed, Embase, CENTRAL, and CINAHL databases was performed. All studies reporting on complications, radiological, functional and/or patient-reported outcomes of surgically treated acute PLDs and PLFDs with a minimum follow-up of 12 months were included. RESULTS: Twenty-six studies encompassing 550 patients with 553 operatively treated acute perilunate injuries (106 PLDs and 447 PLFDs) were included. The overall postoperative complication rate was 15.0% with secondary reduction loss representing the main contributing factor (10.1%). The overall reoperation rate was 10.4% and the incidence of salvage procedures was 2.8%. The risk for secondary reduction loss was higher for PLD than for PLFD injuries (24.2% vs. 7.0%, relative risk [RR] 3.5, 95% confidence interval [CI] 1.6-7.5). There was a higher overall complication rate for the combined dorsopalmar approach when compared to the isolated dorsal approach (17.4% vs. 8.4%, RR 0.5, 95% CI 0.2-1.0, number needed to treat [NNT] 11.2) and for open surgery versus arthroscopic surgery (17.4% vs. 4.8%, RR 0.3, 95% CI 0.1-0.9, NNT 8.0). A significant correlation was found between radiological osteoarthritis (rOA) and follow-up duration of the individual studies, while functional and patient-rated outcomes were comparable. CONCLUSIONS: Regardless of surgical technique, PLFDs appear to be less susceptible to secondary reduction loss than PLDs. Whenever possible, less invasive (e.g. arthroscopic) surgery should be performed to minimize postoperative complications. The rate of rOA is high and increases significantly with follow-up duration. Interestingly, rOA does not seem to correlate with reduced wrist function nor patient dissatisfaction and the need for salvage surgery is surprisingly rare. LEVEL OF EVIDENCE: Systematic review of level IV studies.

[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.