A national multi centre pre-hospital ECPR stepped wedge study; design and rationale of the ON-SCENE study

BACKGROUND

The likelihood of return of spontaneous circulation with conventional advanced life support is known to have an exponential decline and therefore neurological outcome after 20 min in patients with a cardiac arrest is poor. Initiation of venoarterial ExtraCorporeal Membrane Oxygenation (ECMO) during resuscitation might improve outcomes if used in time and in a selected patient category. However, previous studies have failed to significantly reduce the time from cardiac arrest to ECMO flow to less than 60 min. We hypothesize that the initiation of Extracorporeal Cardiopulmonary Resuscitation (ECPR) by a Helicopter Emergency Medical Services System (HEMS) will reduce the low flow time and improve outcomes in refractory Out of Hospital Cardiac Arrest (OHCA) patients.

METHODS

The ON-SCENE study will use a non-randomised stepped wedge design to implement ECPR in patients with witnessed OHCA between the ages of 18-50 years old, with an initial presentation of shockable rhythm or pulseless electrical activity with a high suspicion of pulmonary embolism, lasting more than 20, but less than 45 min. Patients will be treated by the ambulance crew and HEMS with prehospital ECPR capabilities and will be compared with treatment by ambulance crew and HEMS without prehospital ECPR capabilities. The primary outcome measure will be survival at hospital discharge. The secondary outcome measure will be good neurological outcome defined as a cerebral performance categories scale score of 1 or 2 at 6 and 12 months.

DISCUSSION

The ON-SCENE study focuses on initiating ECPR at the scene of OHCA using HEMS. The current in-hospital ECPR for OHCA obstacles encompassing low survival rates in refractory arrests, extended low-flow durations during transportation, and the critical time sensitivity of initiating ECPR, which could potentially be addressed through the implementation of the HEMS system. When successful, implementing on-scene ECPR could significantly enhance survival rates and minimize neurological impairment.

TRIAL REGISTRATION

Clinicaltyrials.gov under NCT04620070, registration date 3 November 2020.

Opportunities and barriers for prehospital emergency medical services research in the Netherlands; results of a mixed-methods consensus study

INTRODUCTION

Quality improvement in prehospital emergency medical services (EMS) can only be achieved by high-quality research and critical appraisal of current practices. This study examines current opportunities and barriers in EMS research in the Netherlands.

METHODS

This mixed-methods consensus study consisted of three phases. The first phase consisted of semi-structured interviews with relevant stakeholders. Thematic analysis of qualitative data derived from these interviews was used to identify main themes, which were subsequently discussed in several online focus groups in the second phase. Output from these discussions was used to shape statements for an online Delphi consensus study among relevant stakeholders in EMS research. Consensus was met if 80% of respondents agreed or disagreed on a particular statement.

RESULTS

Forty-nine stakeholders participated in the study; qualitative thematic analysis of the interviews and focus group discussions identified four main themes: (1) data registration and data sharing, (2) laws and regulations, (3) financial aspects and funding, and (4) organization and culture. Qualitative data from the first two phases of the study were used to construct 33 statements for an online Delphi study. Consensus was reached on 21 (64%) statements. Eleven (52%) of these statements pertained to the storage and use of EMS patient data.

CONCLUSION

Barriers for prehospital EMS research in the Netherlands include issues regarding the use of patient data, privacy and legislation, funding and research culture in EMS organizations. Opportunities to increase scientific productivity in EMS research include the development of a national strategy for EMS data and the incorporation of EMS topics in research agendas of national medical professional associations.

Persistent elbow dislocation

Acute elbow dislocation is a common injury with an incidence in the general population estimated at around 5/100,000. Persistent (or static) elbow dislocation is a relatively rare problem but might occur due to inappropriate assessment or treatment of acute simple or complex elbow dislocations. Persistent elbow dislocation can be an invalidating and painful condition with a more ominous prognosis than an acute elbow dislocation with appropriate treatment. Surgical treatment of persistent elbow dislocation is a complex intervention that requires extended surgical exposure and arthrolysis in combination with circumferential ligamentous and osseous stabilization. Satisfactory results are described, but complication and reintervention rates are high. After-treatment with a dynamic external fixator is often necessary.

Intravenous lidocaine attenuates distention of the optical nerve sheath, a correlate of intracranial pressure, during endotracheal intubation

BACKGROUND

By preventing hypoxia and hypercapnia, advanced airway management can save lives among patients with traumatic brain injury. During endotracheal intubation (ETI), tracheal stimulation causes an increase in intracranial pressure (ICP), which may impair brain perfusion. It has been suggested that intravenous lidocaine might attenuate this ICP response. We hypothesized that adding lidocaine to the standard induction medication for general anesthesia might reduce the ICP response to ETI. Here, we measured the optical nerve sheath diameter (ONSD) as a correlate of ICP and evaluated the effect of intravenous lidocaine on ONSD during and after ETI in patients undergoing anesthesia.

METHODS

This double-blinded, randomized placebo-controlled trial included 60 patients with American Society of Anesthesiologists I or II physical status that were scheduled for elective surgery under general anesthesia. In addition to the standard anesthesia medication, 30 subjects received 1.5 mg/kg 1% lidocaine (0.15 mL/kg, ONSD lidocaine) and 30 received 0.15 mL/kg 0.9% NaCl (ONSD placebo). ONSDs were measured with ultrasound on the left eye, before (T0), during (T1), and 4 times after ETI (T2-5 at 5-min intervals).

RESULTS

Compared to placebo, lidocaine did not significantly affect the baseline ONSD after anesthesia induction measured at T0. During ETI, the ONSD lidocaine was significantly smaller (β=-0.24 mm P=0.022) than the ONSD placebo. At T4 and T5, the ONSD placebo increased steadily, up to 20 min after ETI, but the ONSD lidocaine tended to return to baseline levels.

CONCLUSIONS

We found that the ONSD was distended during and after ETI in anesthetized patients, and intravenous lidocaine attenuated this effect.

Proximal humerus fractures (PHFs): comparison of functional outcome 1 year after minimally invasive plate osteosynthesis (MIPO) versus open reduction internal fixation (ORIF)

PURPOSE

Osteosynthetic treatment strategies of PHFs include MIPO or ORIF techniques. The aim of this study was to compare the 1 year outcome following either technique in type B PHFs.

METHODS

This study was designed as a retrospective cohort study of patients treated at one academic Level 1 trauma center. Patients from 2009 to 2019 who required surgical treatment of a type B PHF were eligible to be included in this study. Patients with A- or C-type fractures or patients requiring arthroplasty were excluded. All patients were treated with Proximal Humerus Interlocking System (PHILOS) and stratified according the approach into Group MIPO or Group ORIF. Outcome measures include local complications that occurred during hospitalization, nonunion after 12 months, and range of motion after 1 year follow-up.

RESULTS

This study included 149 (75.3%) patients in Group ORIF, and 49 (24.7%) in Group MIPO. The fracture morphology and concomitant injuries were comparable amongst these groups. When compared with Group MIPO, Group ORIF had a 2.6 (95% CI 0.6-11.7) higher risk of suffering from local complications. The rate of postoperative nerve lesions was comparable (OR 0.9, 95% CI 0.1-9.7) as was the rate of soft tissue complications (OR 2.0, 95% CI 0.2-17.2). The risk for nonunion was 4.5 times higher (95% 1.1-19.5) in Group ORIF when compared with Group MIPO. Group MIPO had a higher chance of flexion above 90° (OR 8.2, 95% CI 2.5-27.7).

CONCLUSION

This study provides indications that patients following surgical treatment of PHFs in MIPO technique might have favourable outcome. Large-scale and high-quality studies are warranted to confirm these results.

Severe isolated injuries have a high impact on resource use and mortality: a Dutch nationwide observational study

PURPOSE

The Berlin poly-trauma definition (BPD) has proven to be a valuable way of identifying patients with at least a 20% risk of mortality, by combining anatomical injury characteristics with the presence of physiological risk factors (PRFs). Severe isolated injuries (SII) are excluded from the BPD. This study describes the characteristics, resource use and outcomes of patients with SII according to their injured body region, and compares them with those included in the BPD.

METHODS

Data were extracted from the Dutch National Trauma Registry between 2015 and 2019. SII patients were defined as those with an injury with an Abbreviated Injury Scale (AIS) score ≥ 4 in one body region, with at most minor additional injuries (AIS ≤ 2). We performed an SII subgroup analysis per AIS region of injury. Multivariable linear and logistic regression models were used to calculate odds ratios (ORs) for SII subgroup patient outcomes, and resource needs.

RESULTS

A total of 10.344 SII patients were included; 47.8% were ICU admitted, and the overall mortality was 19.5%. The adjusted risk of death was highest for external (2.5, CI 1.9-3.2) and for head SII (2.0, CI 1.7-2.2). Patients with SII to the abdomen (2.3, CI 1.9-2.8) and thorax (1.8, CI 1.6-2.0) had a significantly higher risk of ICU admission. The highest adjusted risk of disability was recorded for spine injuries (10.3, CI 8.3-12.8). The presence of ≥ 1 PRFs was associated with higher mortality rates compared to their poly-trauma counterparts, displaying rates of at least 15% for thoracic, 17% for spine, 22% for head and 49% for external SII.

CONCLUSION

A severe isolated injury is a high-risk entity and should be recognized and treated as such. The addition of PRFs to the isolated anatomical injury criteria contributes to the identification of patients with SII at risk of worse outcomes.

The impact of video laryngoscopy on the first-pass success rate of prehospital endotracheal intubation in The Netherlands: a retrospective observational study

Purpose

The first-pass success rate for endotracheal intubation (ETI) depends on provider experience and exposure. We hypothesize that video laryngoscopy (VL) improves first-pass and overall ETI success rates in low and intermediate experienced airway providers and prevents from unrecognized oesophageal intubations in prehospital settings.

Methods

In this study 3632 patients were included. In all cases, an ambulance nurse, HEMS nurse, or HEMS physician performed prehospital ETI using direct Laryngoscopy (DL) or VL.

Results

First-pass ETI success rates for ambulance nurses with DL were 45.5% (391/859) and with VL 64.8% (125/193). For HEMS nurses first-pass success rates were 57.6% (34/59) and 77.2% (125/162) respectively. For HEMS physicians these successes were 85.9% (790/920) and 86.9% (1251/1439). The overall success rate for ambulance nurses with DL was 58.4% (502/859) and 77.2% (149/193) with VL. HEMS nurses successes were 72.9% (43/59) and 87.0% (141/162), respectively. HEMS physician successes were 98.7% (908/920) and 99.0% (1425/1439), respectively. The incidence of unrecognized intubations in the oesophagus before HEMS arrival in traumatic circulatory arrest (TCA) was 30.6% with DL and 37.5% with VL. In medical cardiac arrest cases the incidence was 20% with DL and 0% with VL.

Conclusion

First-pass and overall ETI success rates for ambulance and HEMS nurses are better with VL. The used device does not affect success rates of HEMS physicians. VL resulted in less unrecognized oesophageal intubations in medical cardiac arrests. In TCA cases VL resulted in more oesophageal intubations when performed by ambulance nurses before HEMS arrival.

The Detrimental Impact of the COVID-19 Pandemic on Major Trauma Outcomes in the Netherlands: A Comprehensive Nationwide Study

OBJECTIVE

To evaluate the impact of the COVID-19 pandemic on the outcome of major trauma patients in the Netherlands.

SUMMARY BACKGROUND DATA

Major trauma patients highly rely on immediate access to specialized services, including ICUs, shortages caused by the impact of the COVID-19 pandemic may influence their outcome.

METHODS

A multi-center observational cohort study, based on the Dutch National Trauma Registry was performed. Characteristics, resource usage, and outcome of major trauma patients (injury severity score ≥16) treated at all trauma-receiving hospitals during the first COVID-19 peak (March 23 through May 10) were compared with those treated from the same period in 2018 and 2019 (reference period).

RESULTS

During the peak period, 520 major trauma patients were admitted, versus 570 on average in the pre-COVID-19 years. Significantly fewer patients were admitted to ICU facilities during the peak than during the reference period (49.6% vs 55.8%; P=0.016). Patients with less severe traumatic brain injuries in particular were less often admitted to the ICU during the peak (40.5% vs 52.5%; P=0.005). Moreover, this subgroup showed an increased mortality compared to the reference period (13.5% vs 7.7%; P=0.044). These results were confirmed using multivariable logistic regression analyses. In addition, a significant increase in observed versus predicted mortality was recorded for patients who had a priori predicted mortality of 50% to 75% (P=0.012).

CONCLUSIONS

The COVID-19 peak had an adverse effect on trauma care as major trauma patients were less often admitted to ICU and specifically those with minor through moderate brain injury had higher mortality rates.

Health-related quality of life and return to work 1 year after major trauma from a network perspective

Introduction

Major trauma often results in long-term disabilities. The aim of this study was to assess health-related quality of life, cognition, and return to work 1 year after major trauma from a trauma network perspective.

Methods

All major trauma patients in 2016 (Injury Severity Score > 15, n = 536) were selected from trauma region Southwest Netherlands. Eligible patients (n = 365) were sent questionnaires with the EQ-5D-5L and questions on cognition, level of education, comorbidities, and resumption of paid work 1 year after trauma.

Results

A 50% (n = 182) response rate was obtained. EQ-US and EQ-VAS scored a median (IQR) of 0.81 (0.62–0.89) and 70 (60–80), respectively. Limitations were prevalent in all health dimensions of the EQ-5D-5L; 90 (50%) responders reported problems with mobility, 36 (20%) responders reported problems with self-care, 108 (61%) responders reported problems during daily activities, 129 (73%) responders reported pain or discomfort, 70 (39%) responders reported problems with anxiety or depression, and 102 (61%) of the patients reported problems with cognition. Return to work rate was 68% (37% full, 31% partial). A median (IQR) EQ-US of 0.89 (0.82–1.00) and EQ-VAS of 80 (70–90) were scored for fully working responders; 0.77 (0.66–0.85, p < 0.001) and 70 (62–80, p = 0.001) for partial working respondents; and 0.49 (0.23–0.69, p < 0.001) and 55 (40–72, p < 0.001) for unemployed respondents.

Conclusion

The majority experience problems in all health domains of the EQ-5D-5L and cognition. Return to work status was associated with all health domains of the EQ-5D-5L and cognition.

Dutch trauma system performance: Are injured patients treated at the right place?

BACKGROUND

The goal of trauma systems is to match patient care needs to the capabilities of the receiving centre. Severely injured patients have shown better outcomes if treated in a major trauma centre (MTC). We aimed to evaluate patient distribution in the Dutch trauma system. Furthermore, we sought to identify factors associated with the undertriage and transport of severely injured patients (Injury Severity Score (ISS) >15) to the MTC by emergency medical services (EMS).

METHODS

Data on all acute trauma admissions in the Netherlands (2015-2016) were extracted from the Dutch national trauma registry. An ambulance driving time model was applied to calculate MTC transport times and transport times of ISS >15 patients to the closest MTC and non-MTC. A multivariable logistic regression analysis was performed to identify factors associated with ISS >15 patients' EMS undertriage to an MTC.

RESULTS

Of the annual average of 78,123 acute trauma admissions, 4.9% had an ISS >15. The nonseverely injured patients were predominantly treated at non-MTCs (79.2%), and 65.4% of patients with an ISS >15 received primary MTC care. This rate varied across the eleven Dutch trauma networks (36.8%-88.4%) and was correlated with the transport times to an MTC (Pearson correlation -0.753, p=0.007). The trauma networks also differed in the rates of secondary transfers of ISS >15 patients to MTC hospitals (7.8% - 59.3%) and definitive MTC care (43.6% - 93.2%). Factors associated with EMS undertriage of ISS >15 patients to the MTC were female sex, older age, severe thoracic and abdominal injury, and longer additional EMS transport times.

CONCLUSIONS

Approximately one-third of all severely injured patients in the Netherlands are not initially treated at an MTC. Special attention needs to be directed to identifying patient groups with a high risk of undertriage. Furthermore, resources to overcome longer transport times to an MTC, including the availability of ambulance and helicopter services, may improve direct MTC care and result in a decrease in the variation of the undertriage of severely injured patients to MTCs among the Dutch trauma networks. Furthermore, attention needs to be directed to improving primary triage guidelines and instituting uniform interfacility transfer agreements.

Ambulance deceleration causes increased intra cranial pressure in supine position: a prospective observational prove of principle study

BACKGROUND

Ambulance drivers in the Netherlands are trained to drive as fluent as possible when transporting a head injured patient to the hospital. Acceleration and deceleration have the potential to create pressure changes in the head that may worsen outcome. Although the idea of fluid shift during braking causing intra cranial pressure (ICP) to rise is widely accepted, it lacks any scientific evidence. In this study we evaluated the effects of driving and deceleration during ambulance transportation on the intra cranial pressure in supine position and 30° upright position.

METHODS

Participants were placed on the ambulance gurney in supine position. During driving and braking the optical nerve sheath diameter (ONSD) was measured with ultrasound. Because cerebro spinal fluid percolates in the optical nerve sheath when ICP rises, the diameter of this sheath will distend if ICP rises during braking of the ambulance. The same measurements were taken with the headrest in 30° upright position.

RESULTS

Mean ONSD in 20 subjects in supine position increased from 4.80 (IQR 4.80-5.00) mm during normal transportation to 6.00 (IQR 5.75-6.40) mm (p < 0.001) during braking. ONSD's increased in all subjects in supine position. After raising the headrest of the gurney 30° mean ONSD increased from 4.80 (IQR 4.67-5.02) mm during normal transportation to 4.90 (IQR 4.80-5.02) mm (p = 0.022) during braking. In 15 subjects (75%) there was no change in ONSD at all.

CONCLUSIONS

ONSD and thereby ICP increases during deceleration of a transporting vehicle in participants in supine position. Raising the headrest of the gurney to 30 degrees reduces the effect of breaking on ICP.

Evaluation of the Berlin polytrauma definition: A Dutch nationwide observational study

BACKGROUND

The Berlin polytrauma definition (BPD) was established to identify multiple injury patients with a high risk of mortality. The definition includes injuries with an Abbreviated Injury Scale score of ≥3 in ≥2 body regions (2AIS ≥3) combined with the presence of ≥1 physiological risk factors (PRFs). The PRFs are based on age, Glasgow Coma Scale, hypotension, acidosis, and coagulopathy at specific cutoff values. This study evaluates and compares the BPD with two other multiple injury definitions used to identify patients with high resource utilization and mortality risk, using data from the Dutch National Trauma Register (DNTR).

METHODS

The evaluation was performed based on 2015 to 2018 DNTR data. First, patient characteristics for 2AIS ≥3, Injury Severity Score (ISS) of ≥16, and BPD patients were compared. Second, the PRFs prevalence and odds ratios of mortality for 2AIS ≥3 patients were compared with those from the Deutsche Gesellschaft für Unfallchirurgie Trauma Register. Subsequently, the association between PRF and mortality was assessed for 2AIS ≥3-DNTR patients and compared with those with an ISS of ≥16.

RESULTS

The DNTR recorded 300,649 acute trauma admissions. A total of 15,711 patients sustained an ISS of ≥16, and 6,263 patients had suffered a 2AIS ≥3 injury. All individual PRFs were associated with a mortality of >30% in 2AIS ≥3-DNTR patients. The increase in PRFs was associated with a significant increase in mortality for both 2AIS ≥3 and ISS ≥16 patients. A total of 4,264 patients met the BPDs criteria. Overall mortality (27.2%), intensive care unit admission (71.2%), and length of stay were the highest for the BPD group.

CONCLUSION

This study confirms that the BPD identifies high-risk patients in a population-based registry. The addition of PRFs to the anatomical injury scores improves the identification of severely injured patients with a high risk of mortality. Compared with the ISS ≥16 and 2AIS ≥3 multiple injury definitions, the BPD showed to improve the accuracy of capturing patients with a high medical resource need and mortality rate.

LEVEL OF EVIDENCE

Epidemiological study, level III.

The impact of the Trauma Triage App on pre-hospital trauma triage: design and protocol of the stepped-wedge, cluster-randomized TESLA trial

BACKGROUND

Field triage of trauma patients is crucial to get the right patient to the right hospital within a particular time frame. Minimization of undertriage, overtriage, and interhospital transfer rates could substantially reduce mortality rates, life-long disabilities, and costs. Identification of patients in need of specialized trauma care is predominantly based on the judgment of Emergency Medical Services professionals and a pre-hospital triage protocol. The Trauma Triage App is a smartphone application that includes a prediction model to aid Emergency Medical Services professionals in the identification of patients in need of specialized trauma care. The aim of this trial is to assess the impact of this new digital approach to field triage on the primary endpoint undertriage.

METHODS

The Trauma triage using Supervised Learning Algorithms (TESLA) trial is a stepped-wedge cluster-randomized controlled trial with eight clusters defined as Emergency Medical Services regions. These clusters are an integral part of five inclusive trauma regions. Injured patients, evaluated on-scene by an Emergency Medical Services professional, suspected of moderate to severe injuries, will be assessed for eligibility. This unidirectional crossover trial will start with a baseline period in which the default pre-hospital triage protocol is used, after which all clusters gradually implement the Trauma Triage App as an add-on to the existing triage protocol. The primary endpoint is undertriage on patient and cluster level and is defined as the transportation of a severely injured patient (Injury Severity Score ≥ 16) to a lower-level trauma center. Secondary endpoints include overtriage, hospital resource use, and a cost-utility analysis.

DISCUSSION

The TESLA trial will assess the impact of the Trauma Triage App in clinical practice. This novel approach to field triage will give new and previously undiscovered insights into several isolated components of the diagnostic strategy to get the right trauma patient to the right hospital. The stepped-wedge design allows for within and between cluster comparisons.

TRIAL REGISTRATION

Netherlands Trial Register, NTR7243. Registered 30 May 2018, https://www.trialregister.nl/trial/7038.

Effect of the Dutch Hip Fracture Audit implementation on mortality, length of hospital stay and time until surgery in elderly hip fracture patients; a multi-center cohort study

BACKGROUND

In 2040 the estimated number of people with a hip fracture in the Netherlands will be about 24,000. The medical care for this group of patients is complicated and challenging. Multidisciplinary approaches aim to improve clinical outcome. Quality indicators that gain insight in the treatment and outcome of hip fracture patients may help to optimize and monitor the standard of medical care. The Dutch Hip Fracture Audit (DHFA) is a new multidisciplinary quality indicator that is implemented in the Dutch hospitals in 2017.

AIM

The aim of this study was to determine the effect of the implementation of the DHFA on 30-day mortality, length of hospital stay and time until surgery in elderly with a hip fracture in the Netherlands.

METHODS

A multicenter retrospective comparative cohort study was conducted and data were extracted from the Dutch Nationwide Trauma Registration (LTR). Included were patients aged 60 years and older with a hip fracture (femoral neck and trochanteric) and admitted in one of the ten participating hospitals registered in 2015 and 2017. Data from 2015, before implementation of DHFA, were compared with data from 2017, when the DHFA was implemented. The primary outcome was 30-day mortality; secondary outcomes were length of hospital stay and time until surgery. Multivariable regression models were used to compare outcomes between groups.

RESULTS

3808 patients were included, 1839 in the 2015 cohort and 1969 in the 2017 cohort. 29% was male; mean age 82 years. The multilevel analysis showed a positive non-significant difference between groups on the primary outcome30-day mortality (OR adjusted 1.23, 95%CI 0.93 - 1.63). The secondary outcomes length of hospital stay (adjusted effect estimates -0.002, 95%CI -0.03 - 0.03) and time until surgery (adjusted effect estimates 0.292, 95%CI -2.68 - 3.26) showed no differences between groups.

CONCLUSIONS

Implementation of the DHFA quality indicator does have a positive non-significant trend on 30-day mortality, but showed no impact on length of hospital stay and time until surgery. More research on relevant quality indicators seems therefore mandatory.

The volume-outcome relationship among severely injured patients admitted to English major trauma centres: a registry study

BACKGROUND

Many countries have centralized and dedicated trauma centres with high volumes of trauma patients. However, the volume-outcome relationship in severely injured patients (Injury Severity Score (ISS) > 15) remains unclear. The aim of this study was to determine the association between hospital volume and outcomes in Major Trauma Centres (MTCs).

METHODS

A retrospective observational cohort study was conducted using the Trauma Audit and Research Network (TARN) consisting of all English Major Trauma Centres (MTCs). Severely injured patients (ISS > 15) admitted to a MTC between 2013 and 2016 were included. The effect of hospital volume on outcome was analysed with random effects logistic regression models with a random intercept for centre and was tested for nonlinearity. Primary outcome was in-hospital mortality.

RESULTS

A total of 47,157 severely injured patients from 28 MTCs were included in this study. Hospital volume varied from 69 to 781 severely injured patients per year. There were small between-centre differences in mortality after adjusting for important demographic and injury severity characteristics (adjusted 95% odds ratio range: 0.99-1.01). Hospital volume was found to be linear and not associated with in-hospital mortality (adjusted odds ratio (aOR) 1.02 per 10 patients, 95% confidence interval (CI) 0.68-1.54, p = 0.92).

CONCLUSIONS

Despite the large variation in volume of the included MTCs, no relationship between hospital volume and outcome of severely injured patients was found. These results suggest that centres with similar structure and processes of care can achieve comparable outcomes in severely injured patients despite the number of severely injured patients they treat.

Accuracy of pre-hospital trauma triage and field triage decision rules in children (P2-T2 study): an observational study

BACKGROUND

Adequate pre-hospital trauma triage is crucial to enable optimal care in inclusive trauma systems. Transport of children in need of specialised trauma care to lower-level trauma centres is associated with adverse patient outcomes. We aimed to evaluate the diagnostic accuracy of paediatric field triage based on patient destination and triage tools.

METHODS

We did a multisite observational study (P2-T2) of all children (aged <16 years) transported with high priority by ambulance from the scene of injury to any emergency department in seven of 11 inclusive trauma regions in the Netherlands. Diagnostic accuracy based on the initial transport destination was evaluated in terms of undertriage rate (ie, the proportion of patients in need of specialised trauma care who were initially transported to a lower-level paediatric or adult trauma centre) and overtriage rate (ie, the proportion of patients not requiring specialised trauma care who were transported to a level-I [highest level] paediatric trauma centre). The Dutch National Protocol of Ambulance Services and Field Triage Decision Scheme triage protocols were externally validated using data from this cohort against an anatomical (Injury Severity Score [ISS] ≥16) and a resource-based reference standard.

FINDINGS

Between Jan 1, 2015, and Dec 31, 2017, 12 915 children (median age 10·3 years, IQR 4·2-13·6) were transported to the emergency department with injuries. 4091 (31·7%) patients were admitted to hospital, of whom 129 (3·2%) patients had an ISS of 16 or greater and 227 (5·5%) patients used critical resources within a limited timeframe. Ten patients died within 24 h of arrival at the emergency department. Based on the primary reference standard (ISS ≥16), the undertriage rate was 16·3% (95% CI 10·8-23·7) and the overtriage rate was 21·2% (20·5-22·0). The National Protocol of Ambulance Services had a sensitivity of 53·5% (95% CI 43·9-62·9) and a specificity of 94·0% (93·4-94·6), and the Field Triage Decision Scheme had a sensitivity of 64·5% (54·1-74·1) and a specificity of 84·3% (83·1-85·5).

INTERPRETATION

Too many children in need of specialised care were transported to lower-level paediatric or adult trauma centres, which is associated with increased mortality and morbidity. Current protocols cannot accurately discriminate between patients at low and high risk, and highly sensitive and child-specific triage tools need to be developed to ensure the right patient is transported to the right hospital.

FUNDING

The Netherlands Organisation for Health Research and Development, Innovation Fund Health Insurers.

Differences in Characteristics and Outcome of Patients with Penetrating Injuries in the USA and the Netherlands: A Multi-institutional Comparison

INTRODUCTION

The incidence and nature of penetrating injuries differ between countries. The aim of this study was to analyze characteristics and clinical outcomes of patients with penetrating injuries treated at urban Level-1 trauma centers in the USA (USTC) and the Netherlands (NLTC).

METHODS

In this retrospective cohort study, 1331 adult patients (470 from five NLTC and 861 from three USTC) with truncal penetrating injuries admitted between July 2011 and December 2014 were included. In-hospital mortality was the primary outcome. Outcome comparisons were adjusted for differences in population characteristics in multivariable analyses.

RESULTS

In USTC, gunshot wound injuries (36.1 vs. 17.4%, p < 0.001) and assaults were more frequent (91.2 vs. 77.7%, p < 0.001). ISS was higher in USTC, but the Revised Trauma Score (RTS) was comparable. In-hospital mortality was similar (5.0 vs. 3.6% in NLTC, p = 0.25). The adjusted odds ratio for mortality in USTC compared to NLTC was 0.95 (95% confidence interval 0.35-2.54). Hospital stay length of stay was shorter in USTC (difference 0.17 days, 95% CI -0.29 to -0.05, p = 0.005), ICU admission rate was comparable (OR 0.96, 95% CI 0.71-1.31, p = 0.80), and ICU length of stay was longer in USTC (difference of 0.39 days, 95% CI 0.18-0.60, p < 0.0001). More USTC patients were discharged to home (86.9 vs. 80.6%, p < 0.001). Readmission rates were similar (5.6 vs. 3.8%, p = 0.17).

CONCLUSION

Despite the higher incidence of penetrating trauma, particularly firearm-related injuries, and higher hospital volumes in the USTC compared to the NLTC, the in-hospital mortality was similar. In this study, outcome of care was not significantly influenced by differences in incidence of firearm-related injuries.

Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomised controlled trial

BACKGROUND

Published work suggests a survival benefit for patients with trauma who undergo total-body CT scanning during the initial trauma assessment; however, level 1 evidence is absent. We aimed to assess the effect of total-body CT scanning compared with the standard work-up on in-hospital mortality in patients with trauma.

METHODS

We undertook an international, multicentre, randomised controlled trial at four hospitals in the Netherlands and one in Switzerland. Patients aged 18 years or older with trauma with compromised vital parameters, clinical suspicion of life-threatening injuries, or severe injury were randomly assigned (1:1) by ALEA randomisation to immediate total-body CT scanning or to a standard work-up with conventional imaging supplemented with selective CT scanning. Neither doctors nor patients were masked to treatment allocation. The primary endpoint was in-hospital mortality, analysed in the intention-to-treat population and in subgroups of patients with polytrauma and those with traumatic brain injury. The χ(2) test was used to assess differences in mortality. This trial is registered with ClinicalTrials.gov, number NCT01523626.

FINDINGS

Between April 22, 2011, and Jan 1, 2014, 5475 patients were assessed for eligibility, 1403 of whom were randomly assigned: 702 to immediate total-body CT scanning and 701 to the standard work-up. 541 patients in the immediate total-body CT scanning group and 542 in the standard work-up group were included in the primary analysis. In-hospital mortality did not differ between groups (total-body CT 86 [16%] of 541 vs standard work-up 85 [16%] of 542; p=0.92). In-hospital mortality also did not differ between groups in subgroup analyses in patients with polytrauma (total-body CT 81 [22%] of 362 vs standard work-up 82 [25%] of 331; p=0.46) and traumatic brain injury (68 [38%] of 178 vs 66 [44%] of 151; p=0.31). Three serious adverse events were reported in patients in the total-body CT group (1%), one in the standard work-up group (<1%), and one in a patient who was excluded after random allocation. All five patients died.

INTERPRETATION

Diagnosing patients with an immediate total-body CT scan does not reduce in-hospital mortality compared with the standard radiological work-up. Because of the increased radiation dose, future research should focus on the selection of patients who will benefit from immediate total-body CT.

FUNDING

ZonMw, the Netherlands Organisation for Health Research and Development.

A randomized controlled trial of nonoperative treatment versus open reduction and internal fixation for stable, displaced, partial articular fractures of the radial head: the RAMBO trial

Background

The choice between operative or nonoperative treatment is questioned for partial articular fractures of the radial head that have at least 2 millimeters of articular step-off on at least one radiograph (defined as displaced), but less than 2 millimeter of gap between the fragments (defined as stable) and that are not associated with an elbow dislocation, interosseous ligament injury, or other fractures. These kinds of fractures are often classified as Mason type-2 fractures. Retrospective comparative studies suggest that operative treatment might be better than nonoperative treatment, but the long-term results of nonoperative treatment are very good. Most experts agree that problems like reduced range of motion, painful crepitation, nonunion or bony ankylosis are infrequent with both nonoperative and operative treatment of an isolated displaced partial articular fracture of the radial head, but determining which patients will have problems is difficult. A prospective, randomized comparison would help minimize bias and determine the balance between operative and nonoperative risks and benefits.

Methods/Design

The RAMBO trial (Radial Head – Amsterdam – Amphia – Boston - Others) is an international prospective, randomized, multicenter trial. The primary objective of this study is to compare patient related outcome defined by the ‘Disabilities of Arm, Shoulder and Hand (DASH) score’ twelve months after injury between operative and nonoperative treated patients. Adult patients with partial articular fractures of the radial head that comprise at least 1/3^rd of the articular surface, have ≥ 2 millimeters of articular step-off but less than 2 millimeter of gap between the fragments will be enrolled. Secondary outcome measures will be the Mayo Elbow Performance Index (MEPI), the Oxford Elbow Score (OES), pain intensity through the ‘Numeric Rating Scale’, range of motion (flexion arc and rotational arc), radiographic appearance of the fracture (heterotopic ossification, radiocapitellar and ulnohumeral arthrosis, fracture healing, and signs of implant loosening or breakage) and adverse events (infection, nerve injury, secondary interventions) after one year.

Discussion

The successful completion of this trial will provide evidence on the best treatment for stable, displaced, partial articular fractures of the radial head.

Trial registration

The trial is registered at the Dutch Trial Register: NTR3413.

A comparative assessment of surgeons' tracking methods for surgical site infections

BACKGROUND

The incidence of surgical site infections (SSI) is considered increasingly to be an indicator of quality of care. We conducted a study in which daily inspection of the surgical incision was performed by an independent, trained team to monitor the incidence of SSI using U.S. Centers for Disease Control and Prevention (CDC) definitions, as a gold-standard measure of care. In the department of surgery, two registration systems for SSI were used routinely by the surgeon: An electronic and a plenary tracking system. The results of the independent team were compared with the outcomes provided by two registration systems for SSI, so as to evaluate the reliability of these systems as a possible alternative for indicating quality of care.

METHODS

The study was an incidence study conducted from May 2007 to January 2009 that included 1,000 adult patients scheduled to undergo open abdominal surgery in an academic teaching hospital. Surgical incisions were inspected daily to check for SSI according to definitions of health care-associated infections established by the CDC. Follow-up after discharge was done at the outpatient clinic of the hospital by telephone or letter in combination with patient diaries and reviews of patient charts, discharge letters, electronic files, and reported complications. Univariate and multivariable analyses were done to identify putative risk factors for missing registrations.

RESULTS

Of the 1,000 patients in the study, 33 were not evaluated. Surgical site infections were diagnosed in 26.8% of the 967 remaining patients, of which 18.0% were superficial incisional infections, 5.4% were deep incisional infections, and 3.4% were organ/space infections. More than 60% of SSIs were unreported in either of the department's two tracking systems for such infections. For these two systems, independent major risk factors for missing registrations were (1) the lack of occurrence of an SSI, (2) transplantation surgery, and (3) admission to non-surgical departments.

CONCLUSIONS

Most SSIs were not tracked with the department's two systems. These systems proved poor alternatives to the gold-standard method of quantifying the incidence of Surgical Site Infection SSI and, therefore, the quality of care. Both protocolized wound assessment and on-site documentation are mandatory for realistic quantification of the incidence of SSI.

Reliability of predictors for screw cutout in intertrochanteric hip fractures

BACKGROUND

Following internal fixation of intertrochanteric hip fractures, tip apex distance, fracture classification, position of the screw in the femoral head, and fracture reduction are known predictors for screw cutout, but the reliability of these measurements is unknown. We investigated the reliability of the tip apex distance measurement, the Cleveland femoral head dividing system, the three-grade classification system of Baumgaertner for fracture reduction, and the AO classification system as predictors for screw cutout.

METHODS

All patients with an intertrochanteric hip fracture who were managed with either a dynamic hip screw or a gamma nail between January 2007 and June 2010 were evaluated from our hip trauma database.

RESULTS

The tip apex distance measurement was reliable and patients with device cutout had a significantly higher tip apex distance. The agreement between observers with regard to screw position and fracture reduction was moderately reliable. After adjustment for tip apex distance and screw position, A3 fractures were at more risk of cutout compared with A1 fractures. Poor fracture reduction was significantly related with a higher incidence of cutout in univariate analysis, but not in multivariate analysis. Central-inferior and anterior-inferior positions, after adjustment for tip apex distance and screw position, were significantly protective against cutout.

CONCLUSION

To decrease probable risks of cutout, the tip apex distance needs to stay small or the screw needs to be placed central-inferiorly or anterior-inferiorly.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Rasch analysis of the Dutch version of the Oxford elbow score

BACKGROUND

The Oxford elbow score (OES) is a patient-rated, 12-item questionnaire that measures quality of life in relation to elbow disorders. This English questionnaire has been proven to be a reliable and valid instrument. Recently, the OES has been translated into Dutch and examined for its reliability, validity, and responsiveness in a group of Dutch patients with elbow pathology. The aim of this study was to analyze the Dutch version of the OES (OES-DV) in combination with Rasch analysis or the one-parameter item response theory to examine the structure of the questionnaire.

METHODS

The OES-DV was administered to 103 patients (68 female, 35 male). The mean age of the patients was 44.3 ± 14.7 (range 15-75) years. Rasch analysis was performed using the Winsteps(®) Rasch Measurement Version 3.70.1.1 and a rating scale parameterization.

RESULTS

The person separation index, which is a measure of person reliability, was excellent (2.30). All the items of the OES had a reasonable mean square infit or outfit value between 0.6 and 1.7. The threshold of items were ordered, so the categories can function as intended. Principal component analysis of the residuals partly confirmed the multidimensionality of the English version of the OES. The OES distinguished 3.4 strata, which indicates that about three ranges can be differentiated.

CONCLUSION

Rasch analysis of the OES-DV showed that the data fit to the stringent Rasch model. The multidimensionality of the English version of the OES was partly confirmed, and the four items of the function and three items of the pain domain were recognized as separate domains. The category rating scale of the OES-DV works well. The OES can distinguish 3.4 strata. This conclusion can only be applied to elbow dislocations, which were the largest group of patients studied.

The reliability, validity and responsiveness of the Dutch version of the Oxford elbow score

Background

The Oxford elbow score (OES) is an English questionnaire that measures the patients' subjective experience of elbow surgery. The OES comprises three domains: elbow function, pain, and social-psychological effects. This questionnaire can be completed by the patient and used as an outcome measure after elbow surgery. The aim of this study was to develop and evaluate the Dutch version of the translated OES for reliability, validity and responsiveness with respect to patients after elbow trauma and surgery.

Methods

The 12 items of the English-language OES were translated into Dutch and then back-translated; the back-translated questionnaire was then compared to the original English version. The OES Dutch version was completed by 69 patients (group A), 60 of whom had an elbow luxation, four an elbow fracture and five an epicondylitis. QuickDASH, the visual analogue pain scale (VAS) and the Mayo Elbow Performance Index (MEPI) were also completed to examine the convergent validity of the OES in group A. To calculate the test-retest reliability and responsiveness of the OES, this questionnaire was completed three times by 43 different patients (group B). An average of 52 days elapsed between therapy and the administration of the third OES (SD = 24.1).

Results

The Cronbach's α coefficients for the function, pain and social-psychological domains were 0.90, 0.87 and 0.90, respectively. The intra-class correlation coefficients for the domains were 0.87 for function, 0.89 for pain and 0.87 for social-psychological. The standardised response means for the domains were 0.69, 0.46 and 0.60, respectively, and the minimal detectable changes were 27.6, 21.7 and 24.0, respectively. The convergent validity for the function, pain and social-psychological domains, which were measured as the Spearman's correlation of the OES domains with the MEPI, were 0.68, 0.77 and 0.77, respectively. The Spearman's correlations of the OES domains with QuickDASH were -0.43, -0.44 and -0.47, respectively, and the Spearman's correlations with the VAS were -0.33, -0.38 and -0.42, respectively.

Conclusions

The Dutch OES is a reliable and valid 12-item questionnaire that can be completed within several minutes by patients with elbow injuries. This Dutch questionnaire was useful as an outcome measure in patients with elbow trauma.

Functional treatment versus plaster for simple elbow dislocations (FuncSiE): a randomized trial

BACKGROUND

Elbow dislocations can be classified as simple or complex. Simple dislocations are characterized by the absence of fractures, while complex dislocations are associated with fractures. After reduction of a simple dislocation, treatment options include immobilization in a static plaster for different periods of time or so-called functional treatment. Functional treatment is characterized by early active motion within the limits of pain with or without the use of a sling or hinged brace. Theoretically, functional treatment should prevent stiffness without introducing increased joint instability. The primary aim of this randomized controlled trial is to compare early functional treatment versus plaster immobilization following simple dislocations of the elbow.

METHODS/DESIGN

The design of the study will be a multicenter randomized controlled trial of 100 patients who have sustained a simple elbow dislocation. After reduction of the dislocation, patients are randomized between a pressure bandage for 5-7 days and early functional treatment or a plaster in 90 degrees flexion, neutral position for pro-supination for a period of three weeks. In the functional group, treatment is started with early active motion within the limits of pain. Function, pain, and radiographic recovery will be evaluated at regular intervals over the subsequent 12 months. The primary outcome measure is the Quick Disabilities of the Arm, Shoulder, and Hand score. The secondary outcome measures are the Mayo Elbow Performance Index, Oxford elbow score, pain level at both sides, range of motion of the elbow joint at both sides, rate of secondary interventions and complication rates in both groups (secondary dislocation, instability, relaxation), health-related quality of life (Short-Form 36 and EuroQol-5D), radiographic appearance of the elbow joint (degenerative changes and heterotopic ossifications), costs, and cost-effectiveness.

DISCUSSION

The successful completion of this trial will provide evidence on the effectiveness of a functional treatment for the management of simple elbow dislocations.

TRIAL REGISTRATION

The trial is registered at the Netherlands Trial Register (NTR2025).

Complex and unstable simple elbow dislocations: a review and quantitative analysis of individual patient data

Objective:

The primary objective of this review of the literature with quantitative analysis of individual patient data was to identify the results of available treatments for complex elbow dislocations and unstable simple elbow dislocations. The secondary objective was to compare the results of patients with complex elbow dislocations and unstable elbow joints after repositioning of simple elbow dislocations, which were treated with an external fixator versus without an external fixator.

Search Strategy:

Electronic databases MEDLINE, EMBASE, LILACS, and the Cochrane Central Register of Controlled Trials.

Selection Criteria:

Studies were eligible for inclusion if they included individual patient data of patients with complex elbow dislocations and unstable simple elbow dislocations.

Data Analysis:

The different outcome measures (MEPI, Broberg and Morrey, ASES, DASH, ROM, arthritis grading) are presented with mean and confidence intervals.

Main Results:

The outcome measures show an acceptable range of motion with good functional scores of the different questionnaires and a low mean arthritis score. Thus, treatment of complex elbow dislocations with ORIF led to a moderate to good result. Treatment of unstable simple elbow dislocations with repair of the collateral ligaments with or without the combination of an external fixator is also a good option.

The physician-rated (MEPI, Broberg and Morrey), patient-rated (DASH) and physician- and patient-rated (ASES) questionnaires showed good intercorrelations.

Arthritis classification by x-ray is only fairly correlated with range of motion.

Elbow dislocations are mainly on the non-dominant side.

Dislocation of the elbow: a retrospective multicentre study of 86 patients

The objective of this retrospective multicentre cohort study was to prospectively assess the long-term functional outcomes of simple and complex elbow dislocations.

We analysed the hospital and outpatient records of 86 patients between 01.03.1999 and 25.02.2009 with an elbow dislocation. After a mean follow-up of 3.3 years, all patients were re-examined at the outpatient clinic for measurement of different outcomes.

The mean range of motion was ROM 135.5°. The Mayo elbow performance index (MEPI) scored an average of 91.9 (87.5% of the patients were rated excellent or good). The average Quick disabilities of the arm, shoulder and hand (Quick- DASH) score was 9.7, the sports/music score 11.5 and work score 6.1. The Oxford function score was 75.7, Oxford pain score 75.2 and Oxford social-psychological score 73.9.

Elbow dislocation is a mild disease and generally, the outcome is excellent. Functional results might improve with early active movements.

Primary shoulder arthroplasty versus conservative treatment for comminuted proximal humeral fractures: a systematic literature review

The objective was to identify whether arthroplasty or conservative treatment is the best available treatment for three- and four-part proximal humeral fractures by analyzing the outcome measure of the Constant score. We conducted an electronic search. The systematic review included 33 studies encompassing 1096 patients with three- or four-part proximal humeral fractures that used the Constant score as outcome measure. The mean Constant score in the conservative group was 66.5 and in the arthroplasty group was 55.5. The difference could be attributed to selection bias, unreliable classification of the fractures and inter-observer differences in the assessment of the Constant score.

Combined anterior-posterior surgery versus posterior surgery for thoracolumbar burst fractures: a systematic review of the literature

STUDY DESIGN

A systematic quantitative review of the literature.

OBJECTIVE

To compare combined anterior-posterior surgery versus posterior surgery for thoracolumbar fractures in order to identify better treatments.

SUMMARY OF BACKGROUND DATA

Axial load of the anterior and middle column of the spine can lead to a burst fracture in the vertebral body. The management of thoracolumbar burst fractures remains controversial. The goals of operative treatment are fracture reduction, fixation and decompressing the neural canal. For this, different operative methods are developed, for instance, the posterior and the combined anterior-posterior approach. Recent systematic qualitative reviews comparing these methods are lacking.

METHODS

We conducted an electronic search of MEDLINE, EMBASE, LILACS and the Cochrane Central Register for Controlled Trials.

RESULTS

Five observational comparative studies and no randomized clinical trials comparing the combined anteriorposterior approach with the posterior approach were retrieved. The total enrollment of patients in these studies was 755 patients. The results were expressed as relative risk (RR) for dichotomous outcomes and weighted mean difference (WMD) for continuous outcomes with 95% confidence intervals (CI).

CONCLUSIONS

A small significantly higher kyphotic correction and improvement of vertebral height (sagittal index) observed for the combined anterior-posterior group is cancelled out by more blood loss, longer operation time, longer hospital stay, higher costs and a possible higher intra- and postoperative complication rate requiring re-operation and the possibility of a worsened Hannover spine score. The surgeons' choices regarding the operative approach are biased: worse cases tended to undergo the combined anterior-posterior approach.

Primary Shoulder Arthroplasty Versus Conservative Treatment for Comminuted Proximal Humeral Fractures: A Systematic Literature Review

The objective was to identify whether arthroplasty or conservative treatment is the best available treatment for three- and four-part proximal humeral fractures by analyzing the outcome measure of the Constant score. We conducted an electronic search. The systematic review included 33 studies encompassing 1096 patients with three- or four-part proximal humeral fractures that used the Constant score as outcome measure. The mean Constant score in the conservative group was 66.5 and in the arthroplasty group was 55.5. The difference could be attributed to selection bias, unreliable classification of the fractures and inter-observer differences in the assessment of the Constant score.

Validity of Diagnosis of Superficial Infection of Laparotomy Wounds Using Digital Photography: Inter- and Intra-observer Agreement Among Surgeons

Abstract: Background. The use of digital photography to assess and document the wound healing process has become increasingly popular. One of the most common complications of wound healing is infection, but the validity of digital photography for the diagnosis of wound infection is unknown. We intended to measure the degree of inter and intra-observer agreement on the diagnosis of superficial wound infection using digital photography.

METHODS

In a prospective, observational clinical study, abdominal wounds were photographed daily and signs of infection were documented in a standard manner. Four surgeons independently assessed photographs of 50 wounds opened for infection within hours after photography and 50 normally healed wounds (n = 50). Wound pain scores, morning temperature, and postoperative day were noted. Surgeons recorded the presence of infection and treatment for each wound. Paired kappa (κ) values were calculated and intra-observer agreement was measured after 4-6 weeks.

RESULTS

Mean specificity with regard to infection was 97% (94%-100%) and mean sensitivity was 42% (32%-48%). Paired κ-values with regard to wound infection were: 0.54, 0.67, 0.68, 0.63, 0.58, and 0.61. Agreement on treatment was present in 76 of 100 wounds (κ values: 0.15, 0.17, 0.20, 0.72, 0.63, 0.68). Kappa values for intra-observer agreement on infection were: 0.66, 0.43, 0.74, and 0.76 for surgeons A, B, C, and D, respectively.

CONCLUSION

Inter- and intra-observer agreement on the diagnosis of superficial infection with digital photography are moderate, but specificity is high. Physical examination findings should also be reported. .

Pre-, intra-, and postoperative sonography of the abdominal wall in patients with incisional hernias repaired via a three-layered operative suture method

We illustrate the various sonographic (US) appearances of the abdominal wall following this type of repair, including partial and complete recurrences. Correlation is made with CT imaging. The three-layered anatomical reconstruction of an incisional hernia is described.

Open surgical procedures for incisional hernias

BACKGROUND

Incisional hernias occur frequently after abdominal surgery and can cause serious complications. The choice of a type of open operative repair is controversial. Determining the type of open operative repair is controversial, as the recurrence rate may be as high as 54%.

OBJECTIVES

To identify the best available open operative techniques for incisional hernias.

SEARCH STRATEGY

Electronic databases MEDLINE, EMBASE, LILACS, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched from 1990 to 2007 and trials were identified from the known trial reference lists.

SELECTION CRITERIA

Studies were eligible for inclusion if they were randomized trials comparing different techniques for open operative techniques for incisional hernias.

DATA COLLECTION AND ANALYSIS

Statistical analyses were performed using the fixed effects model. Results were expressed as relative risk for dichotomous outcomes and weighted mean difference for continuous outcomes with 95% confidence intervals.

MAIN RESULTS

Eight trials comparing different open repairs for incisional hernias were identified; one trial was excluded. The included studies enrolled 1,141 patients. The results of three trials comparing suture repair versus mesh repair were pooled. Hernia recurrence was more frequent, wound infection less frequent in the direct suture group compared to the onlay or sublay mesh groups. The recurrence rates of two trials comparing onlay and sublay positions were pooled. This comparison yielded no difference in recurrences (two studies pooled), although operation time was shorter in the onlay group (one study). No difference was found in recurrence, satisfaction with cosmetics, or infection between the onlay standard mesh and skin autograft groups, following analysis pooling the two treatment arms. However, the analysis demonstrated less pain in the skin autograft group. Other trials comparing different mesh materials or different positions of the mesh, or comparing mesh with the components separation technique are described individually. The comparison between lightweight and standard mesh showed a trend for more recurrences in the lightweight group. The comparison between onlay and intraperitoneal mesh positions resulted in non significant fewer hernia recurrences, less seroma formation and more postoperative pain in the intraperitoneal group. No differences in the recurrence rates between the components separation and the intraperitoneal mesh technique.

AUTHORS' CONCLUSIONS

There is good evidence from three trials that open mesh repair is superior to suture repair in terms of recurrences, but inferior when considering wound infection. Six trials yielded insufficient evidence as to which type of mesh or which mesh position (on- or sublay) should be used. There was also insufficient evidence to advocate the use of the components separation technique.