Concepts, utilization, and perspectives on the Dutch Nationwide Trauma registry: a position paper

Over the last decades, the Dutch trauma care have seen major improvements. To assess the performance of the Dutch trauma system, in 2007, the Dutch Nationwide Trauma Registry (DNTR) was established, which developed into rich source of information for quality assessment, quality improvement of the trauma system, and for research purposes. The DNTR is one of the most comprehensive trauma registries in the world as it includes 100% of all trauma patients admitted to the hospital through the emergency department. This inclusive trauma registry has shown its benefit over less inclusive systems; however, it comes with a high workload for high-quality data collection and thus more expenses. The comprehensive prospectively collected data in the DNTR allows multiple types of studies to be performed. Recent changes in legislation allow the DNTR to include the citizen service numbers, which enables new possibilities and eases patient follow-up. However, in order to maximally exploit the possibilities of the DNTR, further development is required, for example, regarding data quality improvement and routine incorporation of health-related quality of life questionnaires. This would improve the quality assessment and scientific output from the DNTR. Finally, the DNTR and all other (European) trauma registries should strive to ensure that the trauma registries are eligible for comparisons between countries and healthcare systems, with the goal to improve trauma patient care worldwide.

Effects of reduction technique for acute anterior shoulder dislocation without sedation or intra-articular pain management: a systematic review and meta-analysis

INTRODUCTION

Anterior shoulder dislocations are commonly seen in the emergency department for which several closed reduction techniques exist. The aim of this systematic review is to identify the most successful principle of closed reduction techniques for an acute anterior shoulder dislocation in the emergency department without the use of sedation or intra-articular lidocaine injection.

METHODS

A literature search was conducted up to 15-08-2022 in the electronic databases of PubMed, Embase and CENTRAL for randomized and observational studies comparing two or more closed reduction techniques for anterior shoulder dislocations. Included techniques were grouped based on their main operating mechanism resulting in a traction-countertraction (TCT), leverage and biomechanical reduction technique (BRT) group. The primary outcome was success rate and secondary outcomes were reduction time and endured pain scores. Meta-analyses were conducted between reduction groups and for the primary outcome a network meta-analysis was performed.

RESULTS

A total of 3118 articles were screened on title and abstract, of which 9 were included, with a total of 987 patients. Success rates were 0.80 (95% CI 0.74; 0.85), 0.81 (95% CI 0.63; 0.92) and 0.80 (95% CI 0.56; 0.93) for BRT, leverage and TCT, respectively. No differences in success rates were observed between the three separate reduction groups. In the network meta-analysis, similar yet more precise effect estimates were found. However, in a post hoc analysis the BRT group was more successful than the combined leverage and TCT group with a relative risk of 1.33 (95% CI 1.19, 1.48).

CONCLUSION

All included techniques showed good results with regard to success of reduction. The BRT might be the preferred technique for the reduction of an anterior shoulder dislocation, as patients experience the least pain and it results in the fastest reduction.

Outcomes of the resuscitative and emergency thoracotomy at a Dutch level-one trauma center: are there predictive factors for survival?

PURPOSE

To investigate the 30-day survival rate of resuscitative and emergency thoracotomies in trauma patients. Moreover, factors that positively influence 30-day survival rates were investigated.

METHODS

A retrospective study of patients (> 16 years), between 2008 and 2020, who underwent a resuscitative or emergency thoracotomy at a level-one trauma center in the Netherlands was conducted.

RESULTS

Fifty-six patients underwent a resuscitative (n = 45, 80%) or emergency (n = 11, 20%) thoracotomy. The overall 30-day survival rate was 32% (n = 18), which was 23% after blunt trauma and 72% after penetrating trauma, and which was 18% for the resuscitative thoracotomy and 91% for the emergency thoracotomy. The patients who survived had full neurologic recovery. Factors associated with survival were penetrating trauma (p < 0.001), (any) sign of life (SOL) upon presentation to the hospital (p = 0.005), Glasgow Coma Scale (GCS) of 15 (p < 0.001) and a thoracotomy in the operating room (OR) (p = 0.018). Every resuscitative thoracotomy after blunt trauma and pulseless electrical activity (PEA) or asystole in the pre-hospital phase was futile (0 survivors out of 11 patients), of those patients seven (64%) had concomitant severe neuro-trauma.

CONCLUSION

This study found a 30-day survival rate of 32% for resuscitative and emergency thoracotomies, all with good neurological recovery. Factors associated with survival were related to the trauma mechanism, the thoracotomy indication and response to resuscitation prior to thoracotomy (for instance, if resuscitation enables enough time for safe transport to the operating room, survival chances increase). Resuscitative thoracotomies after blunt trauma in combination with loss of SOL before arrival at the emergency room were in all cases futile, interestingly in nearly all cases due to concomitant neuro-trauma.

[Trials, observational research and the real world]

The treatment effect found in a randomized trial does not always correspond to the effect of the treatment in daily practice. To estimate the applicability of the results of a trial, a comparison can be made with the results of observational research. In this commentary we discuss such a comparison between the results of the TIME trial and the analysis of the observational DUCA database. Both compared open and minimally invasive oesophageal resection, yet results were strikingly different. We discuss nine possible explanations for the differences found in the effects of the two treatments.

Epidemiology of Traumatic Spinal Cord Injury in the Netherlands: Emergency Medical Service, Hospital, and Functional Outcomes

Background

Evaluating treatment of traumatic spinal cord injuries (TSCIs) from the prehospital phase until postrehabilitation is crucial to improve outcomes of future TSCI patients.

Objective

To describe the flow of patients with TSCI through the prehospital, hospital, and rehabilitation settings and to relate treatment outcomes to emergency medical services (EMS) transport locations and surgery timing.

Method

Consecutive TSCI admissions to a level I trauma center (L1TC) in the Netherlands between 2015 and 2018 were retrospectively identified. Corresponding EMS, hospital, and rehabilitation records were assessed.

Results

A total of 151 patients were included. Their median age was 58 (IQR 37-72) years, with the majority being male (68%) and suffering from cervical spine injuries (75%). In total, 66.2% of the patients with TSCI symptoms were transported directly to an L1TC, and 30.5% were secondarily transferred in from a lower level trauma center. Most injuries were due to falls (63.0%) and traffic accidents (31.1%), mainly bicycle-related. Most patients showed stable vital signs in the ambulance and the emergency department. After hospital discharge, 71 (47.0%) patients were admitted to a rehabilitation hospital, and 34 (22.5%) patients went home. The 30-day mortality rate was 13%. Patients receiving acute surgery (<12 hours) compared to subacute surgery (>12h, <2 weeks) showed no significance in functional independence scores after rehabilitation treatment.

Conclusion

A surge in age and bicycle-injuries in TSCI patients was observed. A substantial number of patients with TSCI were undertriaged. Acute surgery (<12 hours) showed comparable outcomes results in subacute surgery (>12h, <2 weeks) patients.

Getting it right first time: The importance of a structured tissue sampling protocol for diagnosing fracture-related infections

INTRODUCTION

Fracture-related infection (FRI) is an important complication following surgical fracture management. Key to successful treatment is an accurate diagnosis. To this end, microbiological identification remains the gold standard. Although a structured approach towards sampling specimens for microbiology seems logical, there is no consensus on a culture protocol for FRI. The aim of this study is to evaluate the effect of a structured microbiology sampling protocol for fracture-related infections compared to ad-hoc culture sampling.

METHODS

We conducted a pre-/post-implementation cohort study that compared the effects of implementation of a structured FRI sampling protocol. The protocol included strict criteria for sampling and interpretation of tissue cultures for microbiology. All intraoperative samples from suspected or confirmed FRI were compared for culture results. Adherence to the protocol was described for the post-implementation cohort.

RESULTS

In total 101 patients were included, 49 pre-implementation and 52 post-implementation. From these patients 175 intraoperative culture sets were obtained, 96 and 79 pre- and post-implementation respectively. Cultures from the pre-implementation cohort showed significantly more antibiotic use during culture sampling (P =  0.002). The post-implementation cohort showed a tendency more positive culture sets (69% vs. 63%), with a significant difference in open wounds (86% vs. 67%, P =  0.034). In all post-implementation culture sets causative pathogens were cultured more than once per set, in contrast to pre-implementation. Despite stricter tissue sampling and culture interpretation criteria, the number of polymicrobial infections was similar in both cohorts, approximately 29% of all culture sets and 44% of all positive culture sets. Significantly more polymicrobial cultures were found in early infections in the post-implementation cohort (P =  0.048). This indicates a better yield in the new protocol.

CONCLUSION

A standardised protocol for intraoperative sampling for bacterial identification in FRI is superior than an ad-hoc approach. It has a positive effect on both surgeon and microbiologist by increasing awareness about the problem at hand. This resulted in more microbiologically confirmed infections and more certainty when identifying causative pathogens.

Polytrauma and High-energy Injury Mechanisms are Associated with Worse Patient-reported Outcomes After Distal Radius Fractures

BACKGROUND

Patient-reported outcomes (PROs) are increasingly relevant when evaluating the treatment of orthopaedic injuries. Little is known about how PROs may vary in the setting of polytrauma or secondary to high-energy injury mechanisms, even for common injuries such as distal radius fractures.

QUESTIONS/PURPOSES

(1) Are polytrauma and high-energy injury mechanisms associated with poorer long-term PROs (EuroQol Five Dimension Three Levels [EQ-5D-3L] and QuickDASH scores) after distal radius fractures? (2) What are the median EQ-5D-3L, EQ-VAS [EuroQol VAS], and QuickDASH scores for distal radius fractures in patients with polytrauma, high-energy monotrauma and low-energy monotrauma METHODS: This was a retrospective study with followup by questionnaire. Patients treated both surgically and conservatively for distal radius fractures at a single Level 1 trauma center between 2008 and 2015 were approached to complete questionnaires on health-related quality of life (HRQoL) (the EQ-5D-3L and the EQ-VAS) and wrist function (the QuickDASH). Patients were grouped according to those with polytrauma (Injury Severity Score [ISS] ≥ 16), high-energy trauma (ISS < 16), and low-energy trauma based on the ISS score and injury mechanism. Initially, 409 patients were identified, of whom 345 met the inclusion criteria for followup. Two hundred sixty-five patients responded (response rate, 77% for all patients; 75% for polytrauma patients; 76% for high-energy monotrauma; 78% for low-energy monotrauma (p = 0.799 for difference between the groups). There were no major differences in baseline characteristics between respondents and nonrespondents. The association between polytrauma and high-energy injury mechanisms and PROs was assessed using forward stepwise regression modeling after performing simple bivariate linear regression analyses to identify associations between individual factors and PROs. Median outcome scores were calculated and presented.

RESULTS

Polytrauma (intraarticular: β -0.11; 95% confidence interval [CI], -0.21 to -0.02]; p = 0.015) was associated with lower HRQoL and poorer wrist function (extraarticular: β 11.9; 95% CI, 0.4-23.4; p = 0.043; intraarticular: β 8.2; 95% CI, 2.1-14.3; p = 0.009). High-energy was associated with worse QuickDASH scores as well (extraarticular: β 9.5; 95% CI, 0.8-18.3; p = 0.033; intraarticular: β 11.8; 95% CI, 5.7-17.8; p < 0.001). For polytrauma, high-energy trauma, and low-energy trauma, the respective median EQ-5D-3L outcome scores were 0.84 (range, -0.33 to 1.00), 0.85 (range, 0.17-1.00), and 1.00 (range, 0.174-1.00). The VAS scores were 79 (range, 30-100), 80 (range, 50-100), and 80 (range, 40-100), and the QuickDASH scores were 7 (range, 0- 82), 11 (range, 0-73), and 5 (range, 0-66), respectively.

CONCLUSIONS

High-energy injury mechanisms and worse HRQoL scores were independently associated with slightly inferior wrist function after wrist fractures. Along with relatively well-known demographic and injury characteristics (gender and articular involvement), factors related to injury context (polytrauma, high-energy trauma) may account for differences in patient-reported wrist function after distal radius fractures. This information may be used to counsel patients who suffer a wrist fracture from polytrauma or high-energy trauma and to put their outcomes in context. Future research should prospectively explore whether our findings can be used to help providers to set better expectations on expected recovery.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Long-term follow-up after MIPO Philos plating for proximal humerus fractures

INTRODUCTION

Minimally invasive plate osteosynthesis (MIPO) has been described as a suitable technique for the treatment of proximal humerus fractures, but long-term functional results have never been reported. The aim of this study was to describe the long-term functional outcome and implant-related irritation after MIPO for proximal humerus fractures.

METHODS

A long-term prospective cohort analysis was performed on all patients treated for a proximal humerus fracture using MIPO with a Philos plate (Synthes, Switzerland) between December 2007 and October 2010. The primary outcome was the QuickDASH score. Secondary outcome measures were the subjective shoulder value (SSV), implant related irritation and implant removal.

RESULTS

Seventy-nine out of 97 patients (81%) with a mean age of 59 years were available for follow-up. The mean follow-up was 8.3 years (SD 0.8). The mean QuickDASH score was 5.6 (SD 14). The mean SSV was 92 (SD 11). Forty out of 79 patients (50.6%) had implant removal, and of those, 27/40 (67.5%) were due to implant-related irritation. On average, the implant was removed after 1.2 years (SD 0.5). In bivariate analysis, there was an association between the AO classification and the QuickDASH (p = 0.008).

CONCLUSION

Treatment of proximal humerus fractures using MIPO with Philos through a deltoid split approach showed promising results. A good function can be assumed due to the excellent scores of patient oriented questionnaires. However, about one-third of the patients will have a second operation for implant removal due to implant-related irritation.

Antegrade intramedullary Kirschner-wire fixation of displaced metacarpal shaft fractures

PURPOSE

The objective of this study was to analyze complications and patient-related functional outcome after antegrade intramedullary Kirschner-wire fixation of metacarpal shaft fractures.

METHODS

All consecutive patients treated from January 2010 until December 2015 were retrospectively analyzed using patient logs and radiographic images. Indications for operative fixation were angulation > 40°, shortening > 2 mm, or rotational deficit. Complications were registered from the patient logs. Functional outcome was assessed with the Patient-rated wrist/hand evaluation (PRWHE) and Disabilities of the Arm, Shoulder, and Hand score (DASH) questionnaire both ranging from 1 to 100 after a minimum follow-up of 6 months.

RESULTS

During the study period, 34 fractures of 27 patients could be included. Mean outpatient follow-up was 11 weeks (range 4-24 weeks). The mean interval for functional assessment was 30 months (range 8-62 months) and 19 patients (70%) responded to the questionnaires. During outpatient follow-up, all fractures proceeded to union with no signs of secondary fracture dislocation or implant migration. One re-fracture after a new adequate trauma was seen and one patient underwent tenolysis due to persistent pain and impaired function. In 26 cases (81%), the K-wires were removed of which 23 (68%) were planned removals. Functional outcome was excellent with mean PRWHE and DASH scores of 7 and 5 points, respectively.

CONCLUSIONS

If surgical treatment for metacarpal shaft fractures is considered, we recommend antegrade intramedullary K-wire fixation. This technique results in low complication rates and excellent functional outcome.

Increased reduction in exsanguination rates leaves brain injury as the only major cause of death in blunt trauma

INTRODUCTION

Central nervous system (CNS) related injuries and exsanguination have been the most common causes of death in trauma for decades. Despite improvements in haemorrhage control in recent years exsanguination is still a major cause of death. We conducted a prospective database study to investigate the current incidence of haemorrhage related mortality.

MATERIALS AND METHODS

A prospective database study of all trauma patients admitted to an urban major trauma centre between January 2007 and December 2016 was conducted. All in-hospital trauma deaths were included. Cause of death was reviewed by a panel of trauma surgeons. Patients who were dead on arrival were excluded. Trends in demographics and outcome were analysed per year. Further, 2 time periods (2007-2012 and 2013-2016) were selected representing periods before and after implementation of haemostatic resuscitation and damage control procedures in our hospital to analyse cause of death into detail.

RESULTS

11,553 trauma patients were admitted, 596 patients (5.2%) died. Mean age of deceased patients was 61 years and 61% were male. Mechanism of injury (MOI) was blunt in 98% of cases. Mean ISS was 28 with head injury the most predominant injury (mean AIS head 3.4). There was no statistically significant difference in sex and MOI over time. Even though deceased patients were older in 2016 compared to 2007 (67 vs. 46 years, p < 0.001), mortality was lower in later years (p = 0.02). CNS related injury was the main cause of death in the whole decade; 58% of patients died of CNS in 2007-2012 compared to 76% of patients in 2013-2016 (p = 0.001). In 2007-2012 9% died of exsanguination compared to 3% in 2013-2016 (p = 0.001).

DISCUSSION

In this cohort in a major trauma centre death by exsanguination has decreased to 3% of trauma deaths. The proportion of traumatic brain injury has increased over time and has become the most common cause of death in blunt trauma. Besides on-going prevention of brain injury future studies should focus on treatment strategies preventing secondary damage of the brain once the injury has occurred.

Differentiation in an inclusive trauma system: allocation of lower extremity fractures

Background

Implementation of an inclusive trauma system leads to reduced mortality rates, specifically in polytrauma patients. Field triage is essential in this mortality reduction. Triage systems are developed to identify patients with life-threatening injuries, and trauma mechanisms are important for triaging. Although complex extremity fractures are mostly non-lethal, these injuries are frequently the result of a high-energy trauma mechanism. The aim of this study is to compare injury and patient characteristics, as well as resource demands, of lower extremity fractures between a level (L)1 and level (L)2 trauma centre in a mature inclusive trauma system.

Methods

This is a retrospective cohort study. Patients with below-the-knee joint fractures diagnosed in a L1 or L2 trauma centre between July 2013 and June 2015 were included. Main outcome parameters were patient demographics, trauma mechanism, fracture pattern, and resource demands.

Results

One thousand two hundred sixty-seven patients with 1517 lower extremity fractures were included. Most patients were treated in the L2 centre (L1 = 417; L2 = 859). Complex fractures were more frequently triaged to the L1 centre. Patients in the L1 centre had more concomitant injuries to other body regions and ipsi- or contralateral lower extremity. Patients in the L1 centre were more resource demanding: more surgeries (> 1 surgery; 24.9% L1 vs 1.4% L2), higher immediate admission rates (70.1% L1 vs 37.6% L2), and longer length of stay (mean 13.4 days L1 vs 3.1 days L2).

Conclusion

The majority of patients were treated in the L2 trauma centre, whereas complex lower extremity injuries were mostly treated in the L1 centre, which placed higher demand on resources and labour per patient. This change in allocation is the next step in centralization of low-volume high complex care and high-volume low complex care.

Predicting suitability of intramedullary fixation for displaced midshaft clavicle fractures

PURPOSE

Implant-related irritation is a technique-specific complication seen in a substantial number of patients treated with intramedullary nailing for clavicle fractures. The purpose of this study was to identify predictors for developing implant-related irritation in patients with displaced midshaft clavicle fractures treated with elastic stable intramedullary nailing.

METHODS

A retrospective analysis of the surgical database in two level 2 trauma centers was performed. Patients who underwent intramedullary nailing for displaced midshaft clavicle fractures between 2005 and 2012 in the first hospital were included. Age, gender, fracture comminution and fracture location were assessed as possible predictors for developing irritation using multivariate logistic regression analysis. These predictors were externally validated using data of patients treated in another hospital.

RESULTS

Eighty-one patients were included in initial analysis. In the multivariate analysis, comminuted fractures in comparison to non-comminuted fractures (72 vs. 38%, p = 0.027) and fracture location (p < 0.001) were significantly associated with the development of implant-related irritation. In particular, lateral diaphyseal fractures caused irritation compared to fractures on the medial side of the cut-off point (88 vs. 26%). External validation of these predictors in 48 additional patients treated in another hospital showed a similar predictive value of the model and a good fit.

CONCLUSION

Comminuted and lateral diaphyseal fractures were found to be statistically significant and independent predictors for developing implant-related irritation. We, therefore, believe that intramedullary nailing might not be suitable for these types of fractures. Future studies are needed to determine whether alternative surgical techniques or implants would be more suitable for these specific types of fractures.

[Hip fracture in elderly patients; additional value of a multidisciplinary approach and concentration of care]

Management of elderly patients with a proximal femoral fracture is an increasing challenge for the Dutch healthcare system. Proximal femoral fractures in the elderly have high morbidity and mortality rates. Furthermore, healthcare costs for this group of patients are rising. Referral, operation and postoperative care demand efficient collaboration between healthcare professionals. Every step in this chain of events is crucial for optimal treatment results. Multidisciplinary orthogeriatric trauma care shows promising results. In addition, high volume care results in better outcome of geriatric trauma patients.

[Added value of observational studies in surgery: the hierarchical structure of study designs requires a more refined approach]

The randomised placebo-controlled trial (RCT) is the gold standard for the evaluation of medical interventions. Observational studies, on the other hand, usually do not get much credit. For studies investigating surgical interventions this does not always seem entirely justified. A more refined approach might be needed for the often-used hierarchical structure of research designs. Instead of a strict separation of results from RCTs and other designs, results of the different designs should rather be regarded as complementary to each other when evaluating surgical interventions in traumatology.

Clinical research on postoperative trauma care: has the position of observational studies changed?

OBJECTIVE

The postoperative care regimes of ankle fractures are studied for over 30 years and recommendations have shifted only slightly in the last decades. However, study methodology might have evolved. The aim of this study was to evaluate the changes in time in the design, quality and outcome measures of studies investigating the postoperative care of ankle fractures.

METHODS

The MEDLINE and EMBASE database were searched for both RCTs and cohort studies. The original studies were divided into decades of publication over the last 30 years. The methodological quality of the studies was assessed using the 'traditional' risk of bias assessment tool provided by The Cochrane Collaboration and the 'newer' MINORS criteria.

RESULTS

The percentage of RCTs on this subject declined from 67 to 38 % in the last decades. According to the Cochrane tool, the reported quality of RCTs has improved in the last three decades whereas the reported quality of observational studies has remained unchanged. However, when quality was evaluated with the MINORS criteria, equal improvement was observed for both RCTs and observational studies. In the 80s, 67 % of all studies used the range of motion as the primary outcome measure, which decreased to 45 % in the 90s. In the 00s, none of the studies used the range of motion as the primary outcome.

CONCLUSION

For postoperative care of ankle fractures, results of this study showed a relative decrease in the published number of RCTs. The overall quality of the published articles did not decline. In addition, a gradual shift from physician measured to patient-reported outcome variables was observed. However, it should be borne in mind that the findings are based on a small sample (n = 25).

Isolated hip fracture care in an inclusive trauma system: A trauma system wide evaluation

INTRODUCTION

Elderly patients with a hip fracture represent a large proportion of the trauma population; however, little is known about outcome differences between different levels of trauma care for these patients. The aim of this study is to analyse the outcome of trauma care in patients with a hip fracture within our inclusive trauma system.

MATERIALS AND METHODS

Retrospective cohort study. Data were collected from the electronic patient documentation of patients, with an isolated hip fracture (aged ≥ 60), admitted to a level I or level II trauma centre between January 2008 and December 2012. Main outcomes were time to operative treatment, complications, mortality, and secondary surgical intervention rate.

RESULTS

A total of 204 (level I) and 1425 (level II) patients were admitted. Significantly more ASA4 patients, by the American Society of Anesthesiologists (ASA) classification, were treated at the level I trauma centre. At the level II trauma centre, median time to surgical treatment was shorter (0 days; IQR 0-1 vs 1 day; IQR 1-2; P < 0.001), which was mainly influenced by postponement due to lack of operation room availability (14%, n = 28) and co-morbidities (13%, n = 26) present at the level I trauma centre. At the level II trauma centre, hospital stay was shorter (9 vs 11 days; P < 0.001) and the complication rate was lower (41%; n = 590 vs 53%; n = 108; P = 0.002), as was mortality (4%; n = 54 vs 7%; n = 15; P = 0.018). Secondary surgical intervention was performed less often at the level II trauma centre (6%; n = 91 vs 12%; n = 24; P = 0.005). However, no differences in secondary surgical procedures due to inadequate postoperative outcome or implant failure were observed.

CONCLUSION AND RELEVANCE

The clinical pathway and the large volume of patients at the level II centre resulted in earlier surgical intervention, lower overall complication and mortality rate, and a shorter length of stay. Therefore, the elderly patient with a hip fracture should ideally be treated in the large-volume level II hospital with a pre-established clinical pathway. However, complex patients requiring specific care that can only be provided at the level I trauma centre may be treated there with similar operative results.

Systematic review of complications after intramedullary fixation for displaced midshaft clavicle fractures

BACKGROUND

The number of displaced midshaft clavicle fractures treated surgically is increasing, and open reduction and intramedullary fixation is an emerging surgical treatment option. The study quality and scientific levels of published evidence in which possible complications of this treatment are presented vary greatly.

METHODS

We performed systematic computer-based searches of EMBASE and PubMed/MEDLINE. Studies included for review reported complications after intramedullary fixation alone or in comparison to either treatment with plate fixation and/or nonoperative treatment. The Level of Evidence rating and Quality Assessment Tool were used to assess the methodological quality of the studies. Included studies were ranked according to their levels of evidence.

RESULTS

Six articles were eligible for inclusion and final quality assessment; 3 studies were graded the highest level of evidence. Major complications like bone-healing problems and deep infections requiring implant removal were reported at a rate no higher than 7%. Reported rates for minor complications, such as wound infection and implant irritation that could be resolved without further surgery, were as high as 31%.

CONCLUSION

The noted rates for major complications requiring additional surgery were low, but implant-related problems that require additional surgery might present with high prevalence. Owing to routine implant removal, treatment with intramedullary fixation often requires an additional surgical procedure.