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Willinge GJA, Boulidam D, Salentijn DA, Twigt BA, Goslings JC, van Veen RN. The Value of Routine Radiography in the Nonoperative Treatment of Metatarsal Fractures: A Retrospective Cohort Study. J Foot Ankle Surg 2024:S1067-2516(24)00151-0. [PMID: 39033847 DOI: 10.1053/j.jfas.2024.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 06/23/2024] [Accepted: 07/13/2024] [Indexed: 07/23/2024]
Abstract
Although widely used in follow-up treatment protocols, the added value of routine radiographs to clinical decision-making in nonoperative treatment of patients with metatarsal fractures is unclear. This retrospective cohort study aimed to determine whether routine follow-up radiographs contributed to changes in treatment strategies in nonoperative treatment of patients with a metatarsal fracture. Adult (aged ≥ 18 years) patients who received nonoperative follow-up treatment for a metatarsal fracture between May first, 2020 and May second, 2022 were included. All relevant data were extracted from patient records. Radiographs without a documented clinical indication were classified as routine. Outcomes included changes in treatment strategies based on routine radiographs during follow-up treatment and secondarily, changes in treatment strategy based on clinically indicated radiographs. A total of 168 patients were included, with 135 single and 33 multiple metatarsal fractures. During follow-up, 223 radiographs were performed, of which 154 (69%) were routine and 69 (31%) were on clinical indication. Of routine radiographs, 9 (6%) led to a change in treatment which only included additional imaging. No switch to operative treatment or prolonging of immobilization was observed based on routine radiographs. Of clinically indicated radiographs, 16 (23%) led to a change of treatment, including prolonged immobilization (n = 2), additional follow-up appointments (n = 1) and additional imaging (n = 12). Our results show routinely performed radiographs seldom affect treatment strategies in nonoperative treatment of metatarsal fractures, indicating minimal added value to clinical decision-making. Omitting routine radiographs from treatment protocols may contribute to the reduction of unnecessary healthcare resource utilization in clinical practice.
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Affiliation(s)
- Gijs J A Willinge
- Department of Trauma Surgery, OLVG Hospital, Amsterdam, AE, Amsterdam, The Netherlands.
| | - Dries Boulidam
- Department of Trauma Surgery, OLVG Hospital, Amsterdam, AE, Amsterdam, The Netherlands
| | - Dorien A Salentijn
- Department of Trauma Surgery, OLVG Hospital, Amsterdam, AE, Amsterdam, The Netherlands
| | - Bas A Twigt
- Department of Trauma Surgery, OLVG Hospital, Amsterdam, AE, Amsterdam, The Netherlands
| | - J Carel Goslings
- Department of Trauma Surgery, OLVG Hospital, Amsterdam, AE, Amsterdam, The Netherlands
| | - Ruben N van Veen
- Department of Trauma Surgery, OLVG Hospital, Amsterdam, AE, Amsterdam, The Netherlands
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Al Salman A, Fatehi A, Crijns TJ, Ring D, Doornberg JN. Surgeon preferences are associated with utilization of telehealth in fracture care. Eur J Trauma Emerg Surg 2023; 49:261-272. [PMID: 35882636 PMCID: PMC9323880 DOI: 10.1007/s00068-022-02065-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 06/30/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND The SARS-CoV-2 (COVID-19) pandemic has the potential to evoke lasting changes in the delivery of care, and the utilization of telehealth. We sought associations between surgeon personal factors and greater use of telehealth to treat fractures relative to in-person care. METHODS Seventy-five fracture surgeons participated in a survey-based experiment. All surgeons were asked about their preferences regarding remote compared to in-person communication. Participants rated the following items on slider scales: their degree of introversion, the importance of a hands-on/physical exam and surgeon preferences regarding telehealth. We identified factors associated with the use of, and comfort with, telehealth. RESULTS The use of telehealth during the pandemic was associated with comfort evaluating wounds via telehealth. A greater proportion of remote visits was associated with comfort evaluating wounds and confidence teaching exercises via telehealth. There was consensus that telehealth did not alter utilization rates of radiographs or offer of discretionary surgery. The use of absorbable sutures to limit in-person visits was associated with a preference for working from home and greater comfort with evaluating wounds remotely. The use of 2- and 6-week post-operative telehealth visits and plans to use telehealth after the pandemic (52%) were associated with greater comfort in evaluating wounds through telehealth and greater confidence with video instruction of exercises. CONCLUSIONS The finding that personal factors are associated with utilization of telehealth helps target strategies for increased use of telehealth and other technologies as the pandemic wanes. Given that telehealth adds convenience for people with ambulatory difficulties or in remote areas, such efforts are warranted. LEVEL OF EVIDENCE Not applicable.
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Affiliation(s)
- Aresh Al Salman
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Health Discovery Building, MC Z0800, 1701 Trinity St., Austin, TX, 78712, USA
- Department of Orthopaedic Surgery, Universitair Medisch Centrum Groningen, Rijksuniversiteit Groningen at Groningen, Groningen, The Netherlands
| | - Amirreza Fatehi
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Health Discovery Building, MC Z0800, 1701 Trinity St., Austin, TX, 78712, USA
| | - Tom J Crijns
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Health Discovery Building, MC Z0800, 1701 Trinity St., Austin, TX, 78712, USA
- Department of Orthopaedic Surgery, Universitair Medisch Centrum Groningen, Rijksuniversiteit Groningen at Groningen, Groningen, The Netherlands
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Health Discovery Building, MC Z0800, 1701 Trinity St., Austin, TX, 78712, USA.
| | - Job N Doornberg
- Department of Orthopaedic Surgery, Universitair Medisch Centrum Groningen, Rijksuniversiteit Groningen at Groningen, Groningen, The Netherlands
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Haas Y, Stimmer H, Biberthaler P. [Postoperative imaging of the musculoskeletal system : Clinical aspects]. RADIOLOGIE (HEIDELBERG, GERMANY) 2022; 62:817-824. [PMID: 35796756 DOI: 10.1007/s00117-022-01039-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/10/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Postoperative imaging in trauma surgery is an essential part of documenting optimal osteosynthetic care. A precise and goal-oriented analysis with a justifiable indication is essential. The clinical information has a great impact on the quality of imaging. An objective evaluation and structured reporting complete the postoperative imaging procedure. MATERIALS AND METHODS Conventional x‑rays in two planes is the standard of postoperative imaging in musculoskeletal surgery. In specific anatomic structures, additional images may be necessary. The postoperative x‑ray is the simplest way to visualize a successful osteosynthesis and combines the most important points of postoperative management. Computed tomography (CT) is mostly used in emergencies, but also in the postoperative management of some elective procedures, including patients with surgery of the spine, hip or to the proximal long bones of the extremities. Furthermore, CT is useful in postoperative imaging of complicated ankle fractures. Magnetic resonance imaging (MRI) plays a modest role in postoperative imaging and is mostly used in musculoskeletal cancer surgery. Ultrasound rather plays a subordinated role in postoperative management, but it is increasingly becoming established as a tool for postoperative quality control. The great advantage is dynamic visualization in real time. CONCLUSION Postoperative imaging remains challenging, but can detect most issues regarding osteosynthesis, which can be then be treated or monitored. Various imaging modalities are available to make reliable statements on osteosynthetic material, bone and soft tissue.
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Affiliation(s)
- Y Haas
- Klinik und Poliklinik für Unfallchirurgie, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, München, Deutschland.
| | - H Stimmer
- Institut für Radiologische und interventionelle Diagnostik, Klinikum rechts der Isar, München, Deutschland
| | - P Biberthaler
- Klinik und Poliklinik für Unfallchirurgie, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, München, Deutschland
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Oehme F, Kremo V, van Veelen N, Mühlhäusser J, Brunner J, Peek J, van de Wall BJM, Link BC, Knobe M, Babst R, Beeres FJP. Routine x-rays after the osteosynthesis of distal radius and ankle fractures—a prospective randomized controlled trial on the necessity of routine imaging. DEUTSCHES ÄRZTEBLATT INTERNATIONAL 2022; 119:279-284. [PMID: 35140009 PMCID: PMC9437839 DOI: 10.3238/arztebl.m2022.0099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 01/17/2021] [Accepted: 01/03/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The utility of routine x-rays after the osteosynthesis of distal radius fractures and ankle fractures is questionable. We performed a trial to determine whether such x-rays are justified in patients who have undergone standardized imaging with C-arm fluoroscopy during surgery. METHODS Patients requiring surgery for a distal radius fracture or an ankle fracture were candidates for inclusion in this prospective, randomized, controlled, non-blinded trial. Standardized intraoperative images were obtained with C-arm fluoroscopy and stored at the end of the operation. The next day, patients in the control group underwent imaging with a standard postoperative x-ray, while those in the intervention group did not. The primary endpoint was a change in the treatment plan, defined as additional imaging or a second operation. The secondary endpoints included the range of motion, pain as rated on the Visual Analog Scale, and a functional outcome analysis (PRWE/FAOS). RESULTS 316 patients were included in the trial (163 in the control group, 153 in the intervention group), of whom 202 (64%) had radius fractures and 114 (36%) had ankle fractures. The treatment plan changed in twelve patients (3.8%; four in the control group and eight in the intervention group), seven of whom (2.2%; three in the control group and four in the intervention group) underwent a second operation. The frequency of changes in the treatment plan and of reoperations was comparable in the two groups (p = 0.36). On follow-up at six weeks and one year, the results with respect to functional outcomes and pain were comparable. CONCLUSION In this trial, routine postoperative x-rays after the osteosynthesis of distal radial fractures and ankle fractures did not improve the care of patients who had undergone standardized intraoperative imaging.
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Bérubé M, Moore L, Tardif PA, Berry G, Belzile É, Lesieur M, Paquet J. Low-value injury care in the adult orthopaedic trauma population: A systematic review. Int J Clin Pract 2021; 75:e15009. [PMID: 34816530 DOI: 10.1111/ijcp.15009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 11/19/2021] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES Fifteen potentially low value practices in adult orthopaedic trauma care were previously identified in a scoping review. The aim of this study was to synthesise the evidence on these practices. METHODS We searched four databases for systematic reviews, randomised controlled trials (RCTs), cohort studies and case series that assessed the effectiveness of selected practices. Methodological quality was evaluated using the Measurement Tool to Assess Systematic Reviews version 2 (AMSTAR-2) for systematic reviews and the Critical Appraisal Checklist for Case Series. We evaluated risk of bias with the Cochrane revised tool for RCTs and the risk of bias in non-randomised studies of interventions tool for observational studies. We summarised findings with measures of frequency and association for primary outcomes. RESULTS Of the 30,670 records screened, 70 studies were retained. We identified high-level evidence of lack of effectiveness or harm for routine initial imaging of ankle injury, orthosis for A0-A3 thoracolumbar burst fracture in patients <60 years of age, cast or splint immobilisation for suspected scaphoid fracture negative on MRI or confirmed fifth metacarpal neck fracture, and routine follow-up imaging for distal radius and ankles fractures. However, evidence was mostly based on studies of low methodological quality or high risk of bias. CONCLUSION In this review, we identified clinical practices in orthopaedic injury care which are not supported by current evidence and whose use may be questioned. In future research, we should measure their frequency, assess practice variations and evaluate root causes to identify practices that could be targeted for de-implementation.
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Affiliation(s)
- Mélanie Bérubé
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), Québec City, Québec, Canada
- Faculty of Nursing, Université Laval, Québec City, Québec, Canada
| | - Lynne Moore
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), Québec City, Québec, Canada
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Québec City, Québec, Canada
| | - Pierre-Alexandre Tardif
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), Québec City, Québec, Canada
| | - Gregory Berry
- Division of Orthopaedic Surgery, McGill University Health Center, Montréal, Québec, Canada
| | - Étienne Belzile
- Division of Orthopaedic Surgery, CHU de Québec-Université Laval, Québec City, Québec, Canada
| | - Martin Lesieur
- Division of Orthopaedic Surgery, CHU de Québec-Université Laval, Québec City, Québec, Canada
| | - Jérôme Paquet
- Division of Neurosurgery, CHU de Québec-Université Laval, Québec City, Québec, Canada
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