Let's Agree to Disagree on Operative Versus Nonoperative Treatment for Distal Radius Fractures in Older People: Protocol for a Prospective International Multicenter Cohort Study

BACKGROUND

Distal radius fractures are the most frequently encountered fractures in Western societies, typically affecting patients aged 50 years and older. Although this is a common injury, the best treatment for these fractures in older patients is still under debate.

OBJECTIVE

This prospective study aims to compare the outcome of operatively and nonoperatively treated distal radius fractures in the older population. Only patients with distal radius fractures for which equipoise regarding the optimal treatment exists will be included.

METHODS

This prospective international multicenter observational cohort study will be designed as a natural experiment. Natural experiments are observational studies in which treatment allocation is determined by factors outside the control of the investigators but also (largely) independent of patient characteristics. Patients aged 65 years and older with an acute distal radius fracture will be considered for inclusion. Treatment allocation (operative vs nonoperative) will be based on the local preferences of the treating hospital either in Switzerland or the Netherlands. Hence, the process governing treatment allocation resembles that of randomization. Patients will be identified after treatment has been initiated. Based on the radiographs and baseline information of the patient, an expert panel of 6 certified trauma surgeons from 2 regions will provide their treatment recommendation. Only patients for whom the experts disagree on treatment recommendations will ultimately be included in the study (ie, for whom there is a clinical equipoise). For these patients, both operative and nonoperative treatment of distal radius fractures are viable, and treatment choice is predominantly determined by personal or local preference. The primary outcome will be the Patient-Rated Wrist Evaluation score at 12 weeks. Secondary outcomes will include the Physical Activity Score for the Elderly, the EQ questionnaire, pain, the living situation, range of motion, complications, and radiological outcomes. By including outcomes such as living situation and the Physical Activity Score for the Elderly, which are not relevant for younger cohorts, valuable information to tailor treatment to the needs of the older population can be gained. According to the sample size collection, which was based on the minimal important clinical difference of the Patient-Rated Wrist Evaluation, 92 patients will have to be included, with at least 46 patients in each treatment group.

RESULTS

Enrollment began in July 2023 and is expected to continue until summer 2024. The final follow-up will be 2 years after the last patient is included.

CONCLUSIONS

Although many trials on this topic have previously been published, there remains an ongoing debate regarding the optimal treatment for distal radius fractures in older patients. This observational study, which will use a fairly new methodological study design, will provide further information on treatment outcomes for older patients with distal radius fractures for which to date equipoise exists regarding the optimal treatment.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52917.

Pre-hospital tranexamic acid administration in patients with a severe hemorrhage: an evaluation after the implementation of tranexamic acid administration in the Dutch pre-hospital protocol

PURPOSE

To evaluate the pre-hospital administration of tranexamic acid in ambulance-treated trauma patients with a severe hemorrhage after the implementation of tranexamic acid administration in the Dutch pre-hospital protocol.

METHODS

All patients with a severe hemorrhage who were treated and conveyed by EMS professionals between January 2015, and December 2017, to any trauma-receiving emergency department in the eight participating trauma regions in the Netherlands, were included. A severe hemorrhage was defined as extracranial injury with > 20% body volume blood loss, an extremity amputation above the wrist or ankle, or a grade ≥ 4 visceral organ injury. The main outcome was to determine the proportion of patients with a severe hemorrhage who received pre-hospital treatment with tranexamic acid. A Generalized Linear Model (GLM) was performed to investigate the relationship between pre-hospital tranexamic acid treatment and 24 h mortality.

RESULTS

A total of 477 patients had a severe hemorrhage, of whom 124 patients (26.0%) received tranexamic acid before arriving at the hospital. More than half (58.4%) of the untreated patients were suspected of a severe hemorrhage by EMS professionals. Patients treated with tranexamic acid had a significantly lower risk on 24 h mortality than untreated patients (OR 0.43 [95% CI 0.19-0.97]).

CONCLUSION

Approximately a quarter of the patients with a severe hemorrhage received tranexamic acid before arriving at the hospital, while a severe hemorrhage was suspected in more than half of the non-treated patients. Severely hemorrhaging patients treated with tranexamic acid before arrival at the hospital had a lower risk to die within 24 h after injury.

Effectiveness of a digital vs face-to-face preoperative assessment: A randomized, noninferiority clinical trial

STUDY OBJECTIVE

Digitalizing the preoperative assessment clinic can be a solution to keep up with the growing demand for surgery. It remains unclear if a digital preoperative assessment clinic is as safe, and effective in terms of patient health outcomes and experience compared to face-to-face consultations. This study aimed to compare quality of recovery and mental state in patients undergoing a digital preoperative assessment versus regular face-to-face consultations.

DESIGN

This was a single centre, randomized (1:1), parallel, open-label, noninferiority trial.

SETTING

The preoperative clinic and preoperative unit of an urban secondary care hospital.

PATIENTS

All adult, Dutch speaking, ASA I-IV patients with access to an online computer who required surgery.

INTERVENTIONS

Digital preoperative screening, consisting of an electronic screening questionnaire and web-based platform with personalized information and recommendations related to the procedure, or face-to-face screening, consisting of two 20-min in-hospital consultations.

MEASUREMENTS

The primary endpoint was quality of recovery, measured 48 h after surgery. The analysis followed a per-protocol principle, and only patients who underwent the intended screening were included in the analysis. The noninferiority margin was set at -6. The trial was registered at ClinicalTrials.gov, NCT05535205, during the study on 09/08/2022, before analysing results.

MAIN RESULTS

Between March 1, 2021 and 30 august 2021, 480 patients were assessed for eligibility. 400 patients were randomly assigned to the digital group (n = 200) or face-to-face group (n = 201), of which respectively 117 and 124 patients were eventually included in the primary analysis. The mean quality of recovery score of patients undergoing digital screening (158) was non-inferior to that of patients undergoing face-to-face screening (155), with a mean difference of 3·2 points and a 97.5% lower confidence limit of -2.1 points. There were no adverse events.

CONCLUSIONS

A digital preoperative screening is not inferior to face-to-face consultations in patients undergoing predominantly low to moderate risk surgery. Given its potential to reduce physician workload, reallocate healthcare resources, and lower healthcare costs, a digital preoperative screening may be a better choice for preoperative assessments.

Inter-rater reliability of the Abbreviated Injury Scale scores in patients with severe head injury shows good inter-rater agreement but variability between countries. An inter-country comparison study

INTRODUCTION

Substantial difference in mortality following severe traumatic brain injury (TBI) across international trauma centers has previously been demonstrated. This could be partly attributed to variability in the severity coding of the injuries. This study evaluated the inter-rater and intra-rater reliability of Abbreviated Injury Scale (AIS) scores of patients with severe TBI across three international level I trauma centers.

METHODS

A total 150 patients (50 per center) were randomly selected from each respective trauma registry: University Medical Center Utrecht (UMCU), the Netherlands; John Hunter Hospital (JHH), Australia; and Harborview Medical Center (HMC), the United States. Reliability between coders and trauma centers was measured with the intraclass correlation coefficient (ICC).

RESULTS

The reliability between the coders and the original trauma registry scores was 0.50, 0.50, and 0.41 in, respectively, UMCU, JHH, and HMC. The AIS coders at UMCU scored the most AIS codes of ≥ 4. Reliability within the trauma centers was substantial in UMCU (ICC = 0.62) and HMC (ICC = 0.78) and almost perfect in JHH (ICC = 0.85). Reliability between trauma centers was 0.70 between UMCU and JHH, 0.70 between JHH and HMC, and 0.59 between UMCU and HMC.

CONCLUSION

The results of this study demonstrated a substantial and almost perfect reliability of the AIS coders within the same trauma center, but variability across trauma centers. This indicates a need to improve inter-rater reliability in AIS coders and quality assessments of trauma registry data, specifically for patients with head injuries. Future research should study the effect of differences in AIS scoring on outcome predictions.

Accuracy of Prehospital Triage of Adult Patients With Traumatic Injuries Following Implementation of a Trauma Triage Intervention

Importance

Adequate prehospital triage is pivotal to enable optimal care in inclusive trauma systems and reduce avoidable mortality, lifelong disabilities, and costs. A model has been developed to improve the prehospital allocation of patients with traumatic injuries and was incorporated in an application (app) to be implemented in prehospital practice.

Objective

To evaluate the association between the implementation of a trauma triage (TT) intervention with an app and prehospital mistriage among adult trauma patients.

Design, Setting, and Participants

This population-based, prospective quality improvement study was conducted in 3 of the 11 Dutch trauma regions (27.3%), with full coverage of the corresponding emergency medical services (EMS) regions participating in this study. Participants included adult patients (age ≥16 years) with traumatic injuries who were transported by ambulance between February 1, 2015, and October 31, 2019, from the scene of injury to any emergency department in the participating trauma regions. Data were analyzed between July 2020 and June 2021.

Exposures

Implementation of the TT app and the awareness of need for adequate triage created by its implementation (ie, the TT intervention).

Main Outcomes and Measures

The primary outcome was prehospital mistriage, evaluated in terms of undertriage and overtriage. Undertriage was defined as the proportion of patients with an Injury Severity Score (ISS) of 16 or greater who were initially transported to a lower-level trauma center (designated to treat patients who are mildly and moderately injured) and overtriage as the proportion of patients with an ISS of less than 16 who were initially transported to a higher-level trauma center (designated to treat patients who are severely injured).

Results

A total of 80 738 patients were included (40 427 [50.1%] before and 40 311 [49.9%] after implementation of the intervention), with a median (IQR) age of 63.2 (40.0-79.7) years and 40 132 (49.7%) male patients. Undertriage decreased from 370 of 1163 patients (31.8%) to 267 of 995 patients (26.8%), while overtriage rates did not increase (8202 of 39 264 patients [20.9%] vs 8039 of 39 316 patients [20.4%]). The implementation of the intervention was associated with a statistically significantly reduced risk for undertriage (crude risk ratio [RR], 0.95; 95% CI, 0.92 to 0.99, P = .01; adjusted RR, 0.85; 95% CI, 0.76-0.95; P = .004), but the risk for overtriage was unchanged (crude RR, 1.00; 95% CI, 0.99-1.00; P = .13; adjusted RR, 1.01; 95% CI, 0.98-1.03; P = .49).

Conclusions and Relevance

In this quality improvement study, implementation of the TT intervention was associated with improvements in rates of undertriage. Further research is needed to assess whether these findings are generalizable to other trauma systems.

Evaluating the influence of alcohol intoxication on the pre-hospital identification of severe head injury: a multi-center, cohort study

OBJECTIVE

To determine the influence of intoxication on the pre-hospital recognition of severely head-injured patients by Emergency Medical Services (EMS) professionals and to investigate the relationship between suspected alcohol intoxication and severe head injury.

METHODS

This multi-center, retrospective, cohort study included trauma patients, aged ≥ 16 years, transported by an ambulance of the Regional Ambulance Facility Utrecht to any emergency department in the participating trauma regions.

RESULTS

Between January 1, 2015 and December 31, 2017, 19,206 patients were included, of whom 1167 (6.0%) were suspected to have a severe head injury in the field, and 623 (3.2%) were diagnosed with such an injury at the hospital. These injuries were less frequently recognized in patients with a GCS ≥ 13 than in patients with a GCS < 13 (25.0% vs. 76.2%). Patients suspected to be intoxicated had a higher chance to suffer from severe head injury (OR 1.42, 95%-CI 1.22-1.65) and were recognized slightly more often (45.3% vs. 40.2%).

CONCLUSION

Severe head injuries are difficult to recognize in the field, especially in patients without a decreased GCS. Suspicion of alcohol intoxication did not seem to influence pre-hospital injury recognition, as it possibly makes a severe head injury harder to recognize and simultaneously raises caution for a severe injury.

Long-term follow-up of patients treated with pyrocarbon disc implant for thumb carpometacarpal osteoarthritis: the effect of disc position on outcomes measures

Pyrocarbon disc interposition arthroplasty is an effective treatment for thumb base osteoarthritis. However, as with all implant techniques, the disc can (sub)luxate over time. The relationship between disc position, the experienced pain, and the necessity for revision surgery is not known. This study evaluated the effect of radiographic pyrocarbon disc position on the Michigan Hand Questionnaire (MHQ) outcome measurement. In addition, the correlation between disc position and other factors, including pain intensity, thumb strength, and occupation, was assessed. In this retrospective study, we included 136 patients (161 thumbs) with a mean follow-up of 6.7 years (range 3.3-11). Radiographs were scored on disc position and classified as 'well aligned' (Grade 1) up to 'luxated' (Grade 4). A database used for outcome measures included MHQ scores, pain intensity, satisfaction, thumb strength, range of motion, occupation, and hand dominance. In bivariate analyses, we assessed any association between disc position and outcome measurements. Eighty of the 136 implants (59%) were well-positioned (not displaced), 41% were (slightly) displaced (grade 2-3). No relationship existed between the degree of disc displacement and MHQ scores. Manual labor occupation was the only factor that correlated with more severe disc displacement. We could not detect any association between disc position and other outcome variables including pain intensity, thumb strength, or hand dominance. In conclusion, our study suggests that radiographic disc displacement has little clinical consequences. Future studies must assess if there is a causality between heavy mechanical stress to the CMC1 joint and luxation of the pyrocarbon disc over time.Level of evidence: IV Therapeutic-Retrospective case series.

Dutch Multidisciplinary Guideline on Dupuytren Disease

Purpose

To provide a comprehensive, evidence-based overview of the treatment for Dupuytren disease, specifically needle techniques, radiotherapy, primary conservative therapy, surgery, lipofilling, operative arthrolysis, salvage techniques, and the postoperative protocol and to make clinical recommendations for health care practitioners and patients.

Methods

Comprehensive multidisciplinary guideline process funded by the Quality Foundation of the Dutch Federation of Medical Specialists. This process included a development, commentary, and authorization phase. Patients participated in every phase. Multiple databases and existing guidelines up to August 2020 were searched. Studies on Dupuytren disease were considered eligible. Specific eligibility criteria were described per module. To appraise the certainty of the evidence, reviewers extracted data, assessed the risk of bias, and used the Grading of Recommendations Assessment, Development and Evaluation method, where applicable. Important considerations were as follows: patient values and preferences, costs, acceptability of other stakeholders, and feasibility of implementation. Recommendations were made based on the evidence from the literature and the considerations. The primary and secondary outcome measures were defined per module based on the input of patients obtained in collaboration with the Netherlands Patient Federation and health care providers from different professions.

Results

The following 8 specific modules were completed for Dupuytren disease: (1) needle techniques, (2) radiotherapy, (3) primary conservative therapy, (4) surgery, (5) lipofilling, (6) operative arthrolysis, (7) salvage techniques, and (8) the postoperative protocol.

Conclusions

Our Dutch multidisciplinary guideline on Dupuytren disease provides 8 modules developed according to the standards of the Dutch Federation of Medical Specialists. Evidence-based recommendations for clinical practice are provided for needle techniques, radiotherapy, primary conservative therapy, surgery, lipofilling, operative arthrolysis, salvage techniques, and the postoperative protocol. This guideline can assist health care providers and patients in clinical practice.

Type of study/level of evidence

Systematic review/I-II.

Impact of the COVID-19 pandemic on surgical care in the Netherlands

BACKGROUND

The COVID-19 pandemic caused disruption of regular healthcare leading to reduced hospital attendances, repurposing of surgical facilities, and cancellation of cancer screening programmes. This study aimed to determine the impact of COVID-19 on surgical care in the Netherlands.

METHODS

A nationwide study was conducted in collaboration with the Dutch Institute for Clinical Auditing. Eight surgical audits were expanded with items regarding alterations in scheduling and treatment plans. Data on procedures performed in 2020 were compared with those from a historical cohort (2018-2019). Endpoints included total numbers of procedures performed and altered treatment plans. Secondary endpoints included complication, readmission, and mortality rates.

RESULTS

Some 12 154 procedures were performed in participating hospitals in 2020, representing a decrease of 13.6 per cent compared with 2018-2019. The largest reduction (29.2 per cent) was for non-cancer procedures during the first COVID-19 wave. Surgical treatment was postponed for 9.6 per cent of patients. Alterations in surgical treatment plans were observed in 1.7 per cent. Time from diagnosis to surgery decreased (to 28 days in 2020, from 34 days in 2019 and 36 days in 2018; P < 0.001). For cancer-related procedures, duration of hospital stay decreased (5 versus 6 days; P < 0.001). Audit-specific complications, readmission, and mortality rates were unchanged, but ICU admissions decreased (16.5 versus 16.8 per cent; P < 0.001).

CONCLUSION

The reduction in the number of surgical operations was greatest for those without cancer. Where surgery was undertaken, it appeared to be delivered safely, with similar complication and mortality rates, fewer admissions to ICU, and a shorter hospital stay.

Impact of Comorbidities on the Cause of Death by Necrotizing Soft Tissue Infections

Background: The aim of this study was to identify the cause of death in patients with necrotizing soft tissue infections (NSTIs) stratified by patient's pre-existing comorbidities (American Society of Anesthesiologists [ASA] classification 3/4 vs. ASA 1/2). Differences in clinical presentation, mortality rate, and factors associated with mortality between those two comorbidity groups were investigated. Patients and Methods: A retrospective multicenter study of patients with NSTIs between 2010 and 2020 was conducted. The primary outcome was the cause of death within the first 30 days. Furthermore, factors associated with mortality were identified. All analysis were stratified by severity of comorbidities (ASA 1/2 or ASA 3/4). Results: Of the 187 patients, 39 patients (21%) died within 30 days. American Society of Anesthesiologists 1/2 patients (overall mortality rate, 11%) died more often as direct result of the infection compared with ASA 3/4 patients (overall mortality rate, 33%) (ASA 1/2 group: 92% vs. ASA 3/4 group: 48%; p = 0.013). American Society of Anesthesiologists 3/4 patients died more often due to withdrawal of life-sustaining therapies based on assumed poor outcome after severe critical illness (ASA 1/2 group: 52% vs. ASA 3/4 group: 8%; p = 0.013). Conclusions: Mortality rates of patients with NSTIs varied from 11% in previously healthy patients to 33% in patients with multiple or severe comorbidities. The predominant cause of mortality was overwhelming infection and associated sepsis in healthy patients whereas in patients with multiple or severe pre-existing medical disease, death most often occurred after treatment limitations based on patient's wishes and prognosis.

Evaluating pre-hospital triage and decision-making in patients who died within 30 days post-trauma: A multi-site, multi-center, cohort study

INTRODUCTION

Evaluating pre-hospital triage and decision-making in patients who died post-trauma is crucial to decrease undertriage and improve future patients' chances of survival. A study that has adequately investigated this is currently lacking. The aim of this study was therefore to evaluate pre-hospital triage and decision-making in patients who died within 30 days post-trauma.

MATERIALS AND METHODS

A multi-site, multi-center, cohort study was conducted. Trauma patients who were transported from the scene of injury to a trauma center by ambulance and died within 30 days post-trauma, were included. The main outcome was undertriage, defined as erroneously transporting a severely injured patient (Injury Severity Score ≥ 16) to a lower-level trauma center.

RESULTS

Between January 2015 and December 2017, 2116 patients were included, of whom 765 (36.2%) were severely injured. A total of 103 of these patients (13.5%) were undertriaged. Undertriaged patients were often elderly with a severe head and/or thoracic injury as a result of a minor fall (< 2 m). A majority of the undertriaged patients were triaged without assistance of a specialized physician (100 [97.1%]), did not meet field triage criteria for level-I trauma care (81 [78.6%]), and could have been transported to the nearest level-I trauma center within 45 min (93 [90.3%]).

CONCLUSION

Approximately 14% of the severely injured patients who died within 30 days were undertriaged and could have benefited from treatment at a level-I trauma center (i.e., specialized trauma care). Improvement of pre-hospital triage is needed to potentially increase future patients' chances of survival.

Low profile dual plating for mid-shaft clavicle fractures: a meta-analysis and systematic review of observational studies

INTRODUCTION

Low profile dual plate fixation using two mini fragment plates (< 2.7 mm thickness) is a relatively new technique and alternative to single plating for treating midshaft clavicle fractures. To date, no meta-analysis has been performed comparing these two techniques. Therefore, a systematic review and meta-analysis of observational studies and randomized clinical trials was performed comparing single plating to low profile dual plating for midshaft clavicle fractures.

METHODS

PubMed/Medline/Embase/CENTRAL/CINAHL were searched for both randomized clinical trials (RCT) and observational studies comparing both treatments. Effect estimates were pooled across studies using random effects models. The primary outcome is overall complication rate and re-intervention rate. Secondary outcomes include healing, operation duration and functional scores.

RESULTS

Low profile dual plating has favourable outcomes regarding overall complication rate (8.1% vs. 22.5%, OR 0.3, 95% CI 0.2-0.7, I² = 16%, p = 0.007) and re-intervention rate (6.1% vs. 16.1%, OR 0.3, 95% CI 0.1-0.9, I² = 25%, p = 0.02). The largest contributing factor behind these differences was the high incidence of implant related complaints in the single plating group (4.7% vs. 11.6%, OR 0.4, 95% CI 0.2-0.9, I² = 0%, p = 0.02). The use of low profile dual plating does not have a detrimental effect on healing with union being attained in 99% compared to 97.4% in the single plating group (OR 1.8, 95% CI 0.3-10.7, I = 0%, p = 0.5). Data on operating time and functional results is limited.

CONCLUSION

This meta-analysis shows that dual plating low profile plates for midshaft clavicle fractures is a safe procedure attaining the same union rates seen in patients treated with single plating. In addition, it seems to have a lower overall complication and re-intervention rate, mostly driven by the lower incidence of implant related complaints. Low profile dual plating, however, is a fairly new technique and should be further explored in respect to more differentiated endpoints to test whether these first findings are valid.

LEVEL OF EVIDENCE

III.

The impact of prehospital time intervals on mortality in moderately and severely injured patients

BACKGROUND

Modern trauma systems and emergency medical services aim to reduce prehospital time intervals to achieve optimal outcomes. However, current literature remains inconclusive on the relationship between time to definitive treatment and mortality. The aim of this study was to investigate the association between prehospital time and mortality.

METHODS

All moderately and severely injured trauma patients (i.e., patients with an Injury Severity Score of 9 or greater) who were transported from the scene of injury to a trauma center by ground ambulances of the participating emergency medical services between 2015 and 2017 were included. Exposures of interest were total prehospital time, on-scene time, and transport time. Outcomes were 24-hour and 30-day mortality. Generalized linear models including inverse probability weights for several potential confounders were constructed. A generalized additive model was constructed to enable visual inspection of the association.

RESULTS

We included 22,525 moderately and severely injured patients. Twenty-four-hour and 30-day mortality were 1.3% and 7.3%, respectively. On-scene time per minute was significantly associated with 24-hour (relative risk [RR], 1.029; 95% confidence interval, 1.018-1.040) and 30-day mortality (RR, 1.013; 1.008-1.017). We found that this association was also present in patients with severe injuries, traumatic brain injury, severe abdominal injury, and stab or gunshot wound. An on-scene time of 20 minutes or longer demonstrated a strong association with 24-hour (RR, 1.797; 1.406-2.296) and 30-day mortality (RR, 1.298; 1.180-1.428). Total prehospital (24-hour: RR, 0.998; 0.990-1.007; 30-day: RR, 1.000, 0.997-1.004) and transport (24-hour: RR, 0.996; 0.982-1.010; 30-day: RR, 0.995; 0.989-1.001) time were not associated with mortality.

CONCLUSION

A prolonged on-scene time is associated with mortality in moderately and severely injured patients, which suggests that a reduced on-scene time may be favorable for these patients. In addition, transport time was found not to be associated with mortality.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; level III.

Let’s Agree to Disagree on Operative versus Nonoperative (LADON) treatment for proximal humerus fractures: Study protocol for an international multicenter prospective cohort study

Background

The proximal humerus fracture is a common injury, but the optimal management is much debated. The decision for operative or nonoperative treatment is strongly influenced by patient specific factors, regional and cultural differences and the preference of the patient and treating surgeon. The aim of this study is to compare operative and nonoperative treatment of proximal humerus fractures for those patients for whom there is disagreement about optimal management.

Methods and analysis

This protocol describes an international multicenter prospective cohort study, in which all patients of 18 years and older presenting within three weeks after injury with a radiographically diagnosed displaced proximal humerus fracture can be included. Based on patient characteristics and radiographic images several clinical experts advise on the preferred treatment option. In case of disagreement among the experts, the patient can be included in the study. The actual treatment that will be delivered is at the discretion of the treating physician. The primary outcome is the QuickDash score at 12 months. Propensity score matching will be used to control for potential confounding of the relation between treatment modality and QuickDash scores.

Discussion

The LADON study is an international multicenter prospective cohort study with a relatively new methodological study design. This study is a “natural experiment” meaning patients receive standard local treatment and surgeons perform standard local procedures, therefore high participation rates of patients and surgeons are expected. Patients are only included after expert panel evaluation, when there is proven disagreement between experts, which makes this a unique study design. Through this inclusion process, we create two comparable groups whom received different treatments and where expert disagree about the already initiated treatment. Since we are zooming in on this particular patient group, confounding will be largely mitigated. Internationally the treatment of proximal humerus fractures are still much debated and differs much per country and hospital. This observational study with a natural experiment design will create insight into which treatment modality is to be preferred for patients in whom there is disagreement about the optimal treatment strategy.

Trial registration

Registered in Netherlands trial register NL9357 and Swiss trial register CH 2020–00961; https://clinicaltrials.gov/.

Effect of Tendon Strip (FCR vs APL) on Outcome of CMC Thumb Joint Arthroplasty With Pyrocarbon Disk Interposition

BACKGROUND

Pyrocarbon disk interposition for carpometacarpal (CMC) thumb joint osteoarthritis can be performed with a flexor carpi radialis (FCR) or abductor pollicis longus (APL) tendon strip. With the FCR technique, a ligament reconstruction is performed in addition to disk fixation, whereas with the APL technique the disk is simply secured in place. Our aim is to compare long-term postoperative outcomes between both techniques.

METHODS

In this observational study, we included 106 patients in 2 centers operated on between 2006 and 2011. We assigned patients to the FCR group or the APL group based on the respective tendon strip used. As a primary outcome, we analyzed postoperative key pinch. In addition, we analyzed postoperative tip pinch and tripod pinch, grip strength, range of motion, thumb height maintenance, and patient-reported outcome measures (PROMs).

RESULTS

The analysis showed clinically important stronger key pinch for the APL group (β = 1.28 kg). Tip pinch and grip strength showed higher outcome for the FCR group (β = 1.22 kg and 5.14 kg, respectively). Palmar abduction was in favor of the FCR group and opposition in favor of the APL group, but these were interpreted as not clinically relevant. Radiological thumb height maintenance and PROMs showed no clinical difference.

CONCLUSIONS

Pyrocarbon disk interposition arthroplasty for CMC thumb joint osteoarthritis can be secured with an APL or FCR tendon strip. At long-term follow-up, use of an APL tendon strip results in significantly higher key pinch and better opposition. Tip pinch, grip strength, and palmar abduction were better after use of the FCR tendon strip. The choice of the tendon strip can be based on outcomes considered most important for the individual patient.

An economic evaluation of triage tools for patients with suspected severe injuries in England

BACKGROUND

Many health care systems triage injured patients to major trauma centres (MTCs) or local hospitals by using triage tools and paramedic judgement. Triage tools are typically assessed by whether patients with an Injury Severity Score (ISS) ≥ 16 go to an MTC and whether patients with an ISS < 16 are sent to their local hospital. There is a trade-off between sensitivity and specificity of triage tools, with the optimal balance being unknown. We conducted an economic evaluation of major trauma triage tools to identify which tool would be considered cost-effective by UK decision makers.

METHODS

A patient-level, probabilistic, mathematical model of a UK major trauma system was developed. Patients with an ISS ≥ 16 who were only treated at local hospitals had worse outcomes compared to being treated in an MTC. Nine empirically derived triage tools, from a previous study, were examined so we assessed triage tools with realistic trade-offs between triage tool sensitivity and specificity. Lifetime costs, lifetime quality adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) were calculated for each tool and compared to maximum acceptable ICERs (MAICERs) in England.

RESULTS

Four tools had ICERs within the normal range of MAICERs used by English decision makers (£20,000 to £30,000 per QALY gained). A low sensitivity (28.4%) and high specificity (88.6%) would be cost-effective at the lower end of this range while higher sensitivity (87.5%) and lower specificity (62.8%) was cost-effective towards the upper end of this range. These results were sensitive to the cost of MTC admissions and whether MTCs had a benefit for patients with an ISS between 9 and 15.

CONCLUSIONS

The cost-effective triage tool depends on the English decision maker's MAICER for this health problem. In the usual range of MAICERs, cost-effective prehospital trauma triage involves clinically suboptimal sensitivity, with a proportion of seriously injured patients (at least 10%) being initially transported to local hospitals. High sensitivity trauma triage requires development of more accurate decision rules; research to establish if patients with an ISS between 9 and 15 benefit from MTCs; or, inefficient use of health care resources to manage patients with less serious injuries at MTCs.

The impact of operative time on the outcomes of necrotizing soft tissue infections: a multicenter cohort study

Background

The primary aim of this study was to identify if there is an association between the operative time of the initial debridement for necrotizing soft tissue infections (NSTIs) and the mortality corrected for disease severity.

Methods

A retrospective multicenter study was conducted of all patients with NSTIs undergoing surgical debridement. The primary outcome was the 30-day mortality. The secondary outcomes were days until death, length of intensive care unit (ICU) stay, length of hospital stay, number of surgeries within first 30 days, amputations and days until definitive wound closure.

Results

A total of 160 patients underwent surgery for NSTIs and were eligible for inclusion. Twenty-two patients (14%) died within 30 days and 21 patients (13%) underwent an amputation. The median operative time of the initial debridement was 59 min (IQR 35–90). In a multivariable analyses, corrected for sepsis just prior to the initial surgery, estimated total body surface (TBSA) area affected and the American Society for Anesthesiologists (ASA) classification, a prolonged operative time (per 20 min) was associated with a prolonged ICU (β 1.43, 95% CI 0.46–2.40; p = 0.004) and hospital stay (β 3.25, 95% CI 0.23–6.27; p = 0.035), but not with 30-day mortality. Operative times were significantly prolonged in case of NSTIs of the trunk (p = 0.044), in case of greater estimated TBSA affected (p = 0.006) or if frozen sections and/or Gram stains were assessed intra-operatively (p < 0.001).

Conclusions

Prolonged initial surgery did not result in a higher mortality rate, possible because of a short duration of surgery in most studied patients. However, a prolonged operative time was associated with a prolonged ICU and hospital stay, regardless of the estimated TBSA affected, presence of sepsis prior to surgery and the ASA classification. As such, keeping operative times as limited as possible might be beneficial for NSTI patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-021-01456-0.

Patient Perceived Involvement in Their Treatment is Influenced by Factors Other Than Independently Rated Clinician Communication Effectiveness

We analyzed (1) the correspondence of patient and clinician perceived patient involvement in decision making and ratings made by independent observer's independent ratings, as well as (2), factors associated with patient-perceived involvement, among patients seeking hand specialty care. During 63 visits, the patient, their hand specialist, and 2 independent observers each rated patient involvement in decision making using the 9-item shared decision-making questionnaire for patients and clinicians, and the 5-item observing patient involvement scale (OPTION-5). We also measured health literacy (Newest Vital Sign), patient and visit characteristics (gender, age, race, years of education, occupation, marital status, and family present). There was no correlation (ρ = 0.17; P = .17) between patient (median 42, IQR 36-44.5) and clinician (38, IQR 35-43) ratings of patient involvement in decision making. Independently rated patient involvement correlated moderately with a specialist (ρ = 0.35, P <.01), but not patient (ρ = 0.22, P = .08) ratings. The finding that patient perception of their involvement in decision making has little or no relationship to independently rated clinician communication effectiveness and effort, suggests that other aspects of the encounter-such as empathy and trust-may merit investigation as mediators of the patient agency.

Epidemiology of paediatric moderate and severe traumatic brain injury in the Netherlands

INTRODUCTION

Traumatic brain injury (TBI) is the main cause of death in children around the world. The last Dutch epidemiological study described the incidence over 10 years ago. Mechanism of injury seems to change with the age of the child, therefore it is important to appreciate different age groups. To be able to lower the impact of childhood TBI, an understanding of current incidence, mechanism of injury and outcome is necessary.

METHODS

A nationwide retrospective cohort study was conducted. The Dutch National Trauma Database was used to identify all patients 18 years and younger who were admitted to a Dutch hospital with moderate-severe TBI (Abbreviated Injury Score≥3) in the Netherlands, from January 2015 until December 2017. Subanalyses were done for different age groups.

RESULTS

In total, 1413 patients were included, of whom 5% died. The incidence rate of moderate-severe TBI was 14/100,000 person years. Median age was 10.4 years. Largest age group was patients <5 years, incidence rate was highest in patients ≥16 years. Falls were more common than road traffic accidents (RTA), but RTAs occurred far more frequently amongst children over 10. RTAs predominantly consisted of bicycle accidents. Mortality rates increased from youngest to oldest age groups, as did the chances of a Glasgow Outcome Scale score of 3.

CONCLUSION

Paediatric moderate-severe TBI represents a significant problem in the Netherlands. Falls are the most common mechanism of injury amongst younger children and RTAs amongst older children. Unique for the Netherlands is the vast amount of bicycle accident related injuries.

Incidence, causes and consequences of moderate and severe traumatic brain injury as determined by Abbreviated Injury Score in the Netherlands

Traumatic brain injury (TBI) is a leading cause of death and disability. Epidemiology seems to be changing. TBIs are increasingly caused by falls amongst elderly, whilst we see less polytrauma due to road traffic accidents (RTA). Data on epidemiology is essential to target prevention strategies. A nationwide retrospective cohort study was conducted. The Dutch National Trauma Database was used to identify all patients over 17 years old who were admitted to a hospital with moderate and severe TBI (AIS ≥ 3) in the Netherlands from January 2015 until December 2017. Subgroup analyses were done for the elderly and polytrauma patients. 12,295 patients were included in this study. The incidence of moderate and severe TBI was 30/100.000 person-years, 13% of whom died. Median age was 65 years and falls were the most common trauma mechanism, followed by RTAs. Amongst elderly, RTAs consisted mostly of bicycle accidents. Mortality rates were higher for elderly (18%) and polytrauma patients (24%). In this national database more elderly patients who most often sustained the injury due to a fall or an RTA were seen. Bicycle accidents were very frequent, suggesting prevention could be an important aspect in order to decrease morbidity and mortality.

Evaluating the effect of driving distance to the nearest higher level trauma centre on undertriage: a cohort study

BACKGROUND

It is of great importance that emergency medical services professionals transport trauma patients in need of specialised care to higher level trauma centres to achieve optimal patient outcomes. Possibly, undertriage is more likely to occur in patients with a longer distance to the nearest higher level trauma centre. This study aims to determine the association between driving distance and undertriage.

METHOD

This prospective cohort study was conducted from January 2015 to December 2017. All trauma patients in need of specialised care that were transported to a trauma centre by emergency medical services professionals from eight ambulance regions in the Netherlands were included. Patients with critical resource use or an Injury Severity Score ≥16 were defined as in need of specialised care. Driving distance was calculated between the scene of injury and the nearest higher level trauma centre. Undertriage was defined as transporting a patient in need of specialised care to a lower level trauma centre. Generalised linear models adjusting for confounders were constructed to determine the association between driving distance to the nearest higher level trauma centre per 1 and 10 km and undertriage. A sensitivity analysis was conducted with a generalised linear model including inverse probability weights.

RESULTS

6101 patients, of which 4404 patients with critical resource use and 3760 patients with an Injury Severity Score ≥16, were included. The adjusted generalised linear model demonstrated a significant association between a 1 km (OR 1.04; 95% CI 1.04 to 1.05) and 10 kilometre (OR 1.50; 95% CI 1.42 to 1.58) increase in driving distance and undertriage in patients with critical resource use. Also in patients with an Injury Severity Score ≥16, a significant association between driving distance (1 km (OR 1.06; 95% CI 1.06 to 1.07), 10 km (OR 1.83; 95% CI 1.71 to 1.95)) and undertriage was observed.

CONCLUSION

Patients in need of specialised care are less likely to be transported to the appropriate trauma centre with increasing driving distance. Our results suggest that emergency medical services professionals incorporate driving distance into their decision making regarding transport destinations, although distance is not included in the triage protocol.

Missed Empathic Opportunities During Hand Surgery Office Visits

Background: Empathy (conveyance of an understanding of a patient's situation, perspective, and feelings) deepens the therapeutic alliance and leads to better health outcomes. We studied the frequency and nature of empathic opportunities and physician responses in patients visiting a hand surgeon. We also sought patient characteristics associated with the number of patient-initiated-clues and missed opportunities by surgeons. Methods: For this prospective cohort study, we enrolled 83 new, adult patients visiting 1 of 3 hand surgeons during a period of 4 months. All visits were audio-recorded, and empathic opportunities (patient-initiated emotional or social clues) and physician responses were categorized using the model of Levenson et al. Before the visit, patients completed the Newest Vital Sign health literacy test; 3 Patient-Reported Outcomes Measurement Information System-based questionnaires: Upper-Extremity function, Pain Interference, and Depression questionnaires; and a sociodemographic survey. Results: Empathic opportunities were present in 70% of hand surgery office visits. Surgeons responded empathically to about half of the opportunities. Patients with limited health literacy and greater symptoms of depression (small correlation; r = -0.29) were less likely to receive a positive response. Response to an empathic opportunity did not affect visit duration. Conclusions: Hand surgeons often miss empathic opportunities. Future research might address the influence of training physicians to address empathic opportunities on trust, adherence, satisfaction, and outcomes.

In-house versus on-call trauma surgeon coverage: A systematic review and meta-analysis

BACKGROUND

A rapid trauma response is essential to provide optimal care for severely injured patients. However, it is currently unclear if the presence of an in-house trauma surgeon affects this response during call and influences outcomes. This study compares in-hospital mortality and process-related outcomes of trauma patients treated by a 24/7 in-house versus an on-call trauma surgeon.

METHODS

PubMed/Medline, Embase, and CENTRAL databases were searched on the first of November 2020. All studies comparing patients treated by a 24/7 in-house versus an on-call trauma surgeon were considered eligible for inclusion. A meta-analysis of mortality rates including all severely injured patients (i.e., Injury Severity Score of ≥16) was performed. Random-effect models were used to pool mortality rates, reported as risk ratios. The main outcome measure was in-hospital mortality. Process-related outcomes were chosen as secondary outcome measures.

RESULTS

In total, 16 observational studies, combining 64,337 trauma patients, were included. The meta-analysis included 8 studies, comprising 7,490 severely injured patients. A significant reduction in mortality rate was found in patients treated in the 24/7 in-house trauma surgeon group compared with patients treated in the on-call trauma surgeon group (risk ratio, 0.86; 95% confidence interval, 0.78-0.95; p = 0.002; I2 = 0%). In 10 of 16 studies, at least 1 process-related outcome improved after the in-house trauma surgeon policy was implemented.

CONCLUSION

A 24/7 in-house trauma surgeon policy is associated with reduced mortality rates for severely injured patients treated at level I trauma centers. In addition, presence of an in-house trauma surgeon during call may improve process-related outcomes. This review recommends implementation of a 24/7 in-house attending trauma surgeon at level I trauma centers. However, the final decision on attendance policy might depend on center and region-specific conditions.

LEVEL OF EVIDENCE

Systematic review/meta-analysis, level III.

Clinician Factors Rather Than Patient Factors Affect Discussion of Treatment Options

BACKGROUND

Shared decision-making aims to combine what matters most to a patient with clinician expertise to develop a personalized health strategy. It is a dialogue between patient and clinician in which preferences are expressed, misconceptions reoriented, and available options are considered. To improve patient involvement, it would help to know more about specific barriers and facilitators of patient-clinician communication. Health literacy, the ability to obtain, process, and understand health information, may affect patient participation in decision-making. If the patient is quiet, deferential, and asks few questions, the clinician may assume a more paternalistic style. A patient with greater agency and engagement could be the catalyst for shared decisions.

QUESTIONS/PURPOSES

We assessed (1) whether effective clinician communication and effort is related to patient health literacy, and (2) if there are other factors associated with effective clinician communication and effort.

METHODS

We combined a prospective, cross-sectional cohort of 86 audio-recorded visits of adult patients seeking specialist hand care for a new problem at an urban community hospital in the Netherlands with a cohort of 72 audio-recorded hand surgery visits from a tertiary hospital in the United States collected for a prior study. The American cohort represents a secondary use of data from a set of patients from a separate study using audio-recorded visits and administering similar questionnaires that assessed different endpoints. In both cohorts, adult patients seeking specialist hand care for a new problem were screened. In total, 165 patients were initially screened, of which 96% (158) participated. Eight percent (13) of visits were excluded since the final diagnosis remained unclear, 8% (12) since it was not the first consultation for the current problem, 5% (8) in which only one treatment option was available, and < 1% (1) since there was a language barrier. A total of 123 patients were analyzed, 68 from the Netherlands and 55 from the United States. The Newest Vital Sign (NVS) health literacy test, validated in both English and Dutch, measures the ability to use health information and is based on a nutrition label from an ice cream container. It was used to assess patient health literacy on a scale ranging from 0 (low) to 6 (high). The 5-item Observing Patient Involvement (OPTION5) instrument is commonly used to assess the quality of patient-clinician discussion of options. Scores may be influenced by clinician effort to involve patients in decision-making as well as patient engagement and agency. Each item is scored from 0 (no effort) to 4 (maximum effort), with a total maximum score of 20. Two independent raters reached agreement (kappa value 0.8; strong agreement), after which all recordings were scored by one investigator. Visit duration and patient questions were assessed using the audio recordings. Patients had a median (interquartile range) age of 54 (38 to 66) years, 50% were men, 89% were white, 66% had a nontraumatic diagnosis, median (IRQ) years of education was 16 (12 to 18) years, and median (IQR) health literacy score was 5 (2 to 6). Median (IQR) visit duration was 9 (7 to 12) minutes. Cohorts did not differ in important ways. The number of visits per clinician ranged from 14 to 29, and the mean overall communication effectiveness and effort score for the visits was low (8.5 ± 4.2 points of 20 points). A multivariate linear regression model was used to assess factors associated with communication effectiveness and effort.

RESULTS

There was no correlation between health literacy and clinician communication effectiveness and effort (r = 0.087 [95% CI -0.09 to 0.26]; p = 0.34), nor was there a difference in means (SD) when categorizing health literacy as inadequate (7.8 ± 3.8 points) and adequate (8.9 ± 4.5 points; mean difference 1.0 [95% CI -2.6 to 0.54]; p = 0.20). After controlling for potential confounding variables such as gender, patient questions, and health literacy, we found that longer visit duration (per 1 minute increase: r2 = 0.31 [95% CI -0.14 to 0.48]; p < 0.001), clinician 3 (compared with clinician 1: OR 33 [95% CI 4.8 to 229]; p < 0.001) and clinician 5 (compared with clinician 1: OR 11 [95% CI 1.5 to 80]; p = < 0.02) were independently associated with more effective communication and effort, whereas clinician 6 was associated with less effective communication and effort (compared with clinician 1: OR 0.08 [95% CI 0.01 to 0.75]; p = 0.03). Clinicians' communication strategies (the clinician variable on its own) accounted for 29% of the variation in communication effectiveness and effort, longer visit duration accounted for 11%, and the full model accounted for 47% of the variation (p < 0.001).

CONCLUSION

The finding that the overall low mean communication effectiveness and effort differed between clinicians and was not influenced by patient factors including health literacy suggests clinicians may benefit from training that moves them away from a teaching or lecturing style where patients receive rote directives regarding their health. Clinicians can learn to adapt their communication to specific patient values and needs using a guiding rather than directing communication style (motivational interviewing).Level of Evidence Level II, prognostic study.

Priority accuracy by dispatch centers and Emergency Medical Services professionals in trauma patients: a cohort study

Purpose

Priority-setting by dispatch centers and Emergency Medical Services professionals has a major impact on pre-hospital triage and times of trauma patients. Patients requiring specialized care benefit from expedited transport to higher-level trauma centers, while transportation of these patients to lower-level trauma centers is associated with higher mortality rates. This study aims to evaluate the accuracy of priority-setting by dispatch centers and Emergency Medical Services professionals.

Methods

This observational study included trauma patients transported from the scene of injury to a trauma center. Priority-setting was evaluated in terms of the proportion of patients requiring specialized trauma care assigned with the highest priority (i.e., sensitivity), undertriage, and overtriage. Patients in need of specialized care were defined by a composite resource-based endpoint. An Injury Severity Score ≥ 16 served as a secondary reference standard.

Results

Between January 2015 and December 2017, records of 114,459 trauma patients were collected, of which 3327 (2.9%) patients were in need of specialized care according to the primary reference standard. Dispatch centers and Emergency Medical Services professionals assigned 83.8% and 74.5% of these patients with the highest priority, respectively. Undertriage rates ranged between 22.7 and 65.5% in the different prioritization subgroups. There were differences between dispatch and transport priorities in 17.7% of the patients.

Conclusion

The majority of patients that required specialized care were assigned with the highest priority by the dispatch centers and Emergency Medical Services professionals. Highly accurate priority criteria could improve the quality of pre-hospital triage.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-021-01685-1.

Medium to Long-Term Follow-Up After Pyrocarbon Disc Interposition Arthroplasty for Treatment of CMC Thumb Joint Arthritis

PURPOSE

Pyrocarbon disc interposition arthroplasty has been designed for the surgical treatment of Eaton-Glickel grade II/III carpometacarpal thumb joint arthritis. This study presents the results of this technique with a minimum 5-year follow up.

METHODS

We assessed 4 questionnaires for patient-reported outcome measurements in a cross-sectional study: the Patient-Rated Wrist and Hand Evaluation, Disabilities of Arm, Shoulder, and Hand questionnaire, Michigan Hand Questionnaire, and questions about satisfaction at the 5-year follow up. We evaluated grip and pinch strength, range of motion, and the radiological position of the disc. Finally, a Kaplan-Meier survival analysis was performed.

RESULTS

A total of 164 thumbs (in 137 patients) were available for follow-up varying from 5 to 12 years. Median Patient-Rated Wrist and Hand Evaluation, Disabilities of Arm, Shoulder, and Hand, and Michigan Hand Questionnaire scores were 17, 18, and 76, respectively. The satisfaction score was 9 (Likert scale of 1-10). Grip and pinch strength reached nearly 100% compared with the contralateral hand. Range of motion resulted in a Kapandji score of 10. Thumb height showed a marginal loss and the Kaplan-Meier survival curve showed a survival rate of 91%.

CONCLUSIONS

Our study suggests that pyrocarbon disc interposition arthroplasty is a reliable and feasible treatment for carpometacarpal thumb joint arthritis at medium-term follow-up. It was associated with a high level of patient satisfaction; it maintained thumb height and the implant survived in 91% of patients. Strength and range of motion were comparable to the contralateral hand after a minimum follow-up of 5 years.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Delayed Extension Block Pinning in 27 Patients With Mallet Fracture

Background: Untreated bony mallet fingers can cause an array of problems; therefore, adequate treatment is essential. The primary aim of this study was to determine the patient-reported functional outcome of delayed surgical intervention of bony mallet fingers. The secondary aim was to determine the complication rate of delayed surgical intervention. Methods: In this single-center retrospective cohort study, all consecutive patients treated between 2010 and 2016 at our level 2 regional teaching hospital were included. Inclusion criterion was a bony mallet finger injury (excluding the thumb), presenting >21 days after injury, treated with extension block pinning. Indications for surgery were >2 mm fragment displacement or volar subluxation of the distal interphalangeal joint. Six to 82 months postoperatively, patients completed the Patient-Rated Wrist and Hand Evaluation (PRWHE) by phone. Complications were extracted by chart review. Results: Twenty-seven patients were included, and all completed the PRWHE. Median time to surgery was 35 days (interquartile range [IQR] = 29-42; range = 22-61). Reasons for delay in surgical treatment were patient/physician delay in 24 cases and failed conservative treatment in 3 cases. The median PRWHE score was 0 (IQR = 0-5; range = 0-22.5). After retrospective assessment of the outpatient charts, no early symptoms of malunion or nonunion were found. One patient had a loss of Kirschner-wire fixation, which was corrected. Three patients had an infection that required antibiotic treatment. Conclusions: Delayed surgical management of bony mallet fingers demonstrated adequate functional outcome with minimal complications when compared with prior literature.

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.

Arthroscopic debridement does not enhance surgical treatment of intra-articular distal radius fractures: a randomized controlled trial

The aim of this study was to determine the difference in functional outcomes after open reduction and internal fixation (ORIF) with and without arthroscopic debridement in adults with displaced intra-articular distal radius fractures. In this multicentre trial, 50 patients were randomized between ORIF with or without arthroscopic debridement. The primary outcome measure was the Patient-Rated Wrist Evaluation (PRWE) score. Secondary outcome measures were Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, pain scores, range of wrist motion, grip strength, and complications. Median PRWE was worse for the intervention group at 3 months and was equal for both groups at 12 months. The secondary outcome measures did not show consistent patterns of differences at different time-points of follow-up. We conclude that patients treated with additional arthroscopy to remove intra-articular hematoma and debris did not have better outcomes than those treated with ORIF alone. We therefore do not recommend arthroscopy for removal of hematoma and debris when surgically fixing distal radius fractures. Level of evidence: I.

Mindfulness in Patients with Upper-Extremity Conditions: A Summary of Existing Literature

Mindfulness implies entering a mental state of awareness which allows for the reframing of an experience, and functionality has shown to be influenced by mindset. The aim of this systematic review was to assess effects of mindfulness in patients with upper-extremity conditions. PubMed, Embase, Cochrane, and CINAHL databases were searched on June 19, 2019, for studies investigating mindfulness in patients with upper-extremity conditions. Two validated instruments for methodologic assessment were used to assess study quality. Studies that reported pain, psychological, or functional outcome measures were included. One randomized controlled trials and three observational studies were included, which together included 335 patients that completed final follow-up. The weighted average age was 52.4 years and 48% of the patients were male. Evaluation of the outcome measures used was immediately after the mindfulness intervention or assessment in all studies. Mindfulness appeared to be positively associated with less pain (though below the minimal clinically important difference), increased mood, and better function. Mindfulness is associated with increased mood and possibly better functionality in adults with a large range of upper-extremity conditions when measured or used as an intervention. Future researcher should expand the subject as only four studies were included in this review. This is a Level IV study.

Operative vs Nonoperative Treatment of Distal Radius Fractures in Adults: A Systematic Review and Meta-analysis

IMPORTANCE

No consensus has been reached to date regarding the optimal treatment for distal radius fractures. The international rate of operative treatment has been increasing, despite higher costs and limited functional outcome evidence to support this shift.

OBJECTIVES

To compare functional, clinical, and radiologic outcomes after operative vs nonoperative treatment of distal radius fractures in adults.

DATA SOURCES

The PubMed/MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases were searched from inception to June 15, 2019, for studies comparing operative vs nonoperative treatment of distal radius fractures.

STUDY SELECTION

Randomized clinical trials (RCTs) and observational studies reporting on the following: acute distal radius fracture with operative treatment (internal or external fixation) vs nonoperative treatment (cast immobilization, splinting, or bracing); patients 18 years or older; and functional outcome. Studies in a language other than English or reporting treatment for refracture were excluded.

DATA EXTRACTION AND SYNTHESIS

Data extraction was performed independently by 2 reviewers. Effect estimates were pooled using random-effects models and presented as risk ratios (RRs) or mean differences (MDs) with 95% CIs. Data were analyzed in September 2019.

MAIN OUTCOMES AND MEASURES

The primary outcome measures included medium-term functional outcome measured with the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) and the overall complication rate after operative and nonoperative treatment.

RESULTS

A total of 23 unique studies were included, consisting of 8 RCTs and 15 observational studies, that described 2254 unique patients. Among the studies that presented sex data, 1769 patients were women [80.6%]. Overall weighted mean age was 67 [range, 22-90] years). The RCTs included 656 patients (29.1%); observational studies, 1598 patients (70.9%). The overall pooled effect estimates the showed a significant improvement in medium-term (≤1 year) DASH score after operative treatment compared with nonoperative treatment (MD, -5.22 [95% CI, -8.87 to -1.57]; P = .005; I2 = 84%). No difference in complication rate was observed (RR, 1.03 [95% CI, 0.69-1.55]; P = .87; I2 = 62%). A significant improvement in grip strength was noted after operative treatment, measured in kilograms (MD, 2.73 [95% CI, 0.15-5.32]; P = .04; I2 = 79%) and as a percentage of the unaffected side (MD, 8.21 [95% CI, 2.26-14.15]; P = .007; I2 = 76%). No improvement in medium-term DASH score was found in the subgroup of studies that only included patients 60 years or older (MD, -0.98 [95% CI, -3.52 to 1.57]; P = .45; I2 = 34%]), compared with a larger improvement in medium-term DASH score after operative treatment in the other studies that included patients 18 years or older (MD, -7.50 [95% CI, -12.40 to -2.60]; P = .003; I2 = 77%); the difference between these subgroups was statically significant (test for subgroup differences, P = .02).

CONCLUSIONS AND RELEVANCE

This meta-analysis suggests that operative treatment of distal radius fractures improves the medium-term DASH score and grip strength compared with nonoperative treatment in adults, with no difference in overall complication rate. The findings suggest that operative treatment might be more effective and have a greater effect on the health and well-being of younger, nonelderly patients.

Development and Validation of a Prediction Model for Prehospital Triage of Trauma Patients

Importance

Prehospital trauma triage protocols are used worldwide to get the right patient to the right hospital and thereby improve the chance of survival and avert lifelong disabilities. The American College of Surgeons Committee on Trauma set target levels for undertriage rates of less than 5%. None of the existing triage protocols has been able to achieve this target in isolation.

Objective

To develop and validate a new prehospital trauma triage protocol to improve current triage rates.

Design, Setting, and Participants

In this multicenter cohort study, all patients with trauma who were 16 years and older and transported to a trauma center in 2 different regions of the Netherlands were included in the analysis. Data were collected from January 1, 2012, through June 30, 2014, in the Central Netherlands region for the design data cohort and from January 1 through December 31, 2015, in the Brabant region for the validation cohort. Data were analyzed from May 3, 2017, through July 19, 2018.

Main Outcomes and Measures

A new prediction model was developed in the Central Netherlands region based on prehospital predictors associated with severe injury. Severe injury was defined as an Injury Severity Score greater than 15. A full-model strategy with penalized maximum likelihood estimation was used to construct a model with 8 predictors that were chosen based on clinical reasoning. Accuracy of the developed prediction model was assessed in terms of discrimination and calibration. The model was externally validated in the Brabant region.

Results

Using data from 4950 patients with trauma from the Central Netherlands region for the design data set (58.3% male; mean [SD] age, 47 [21] years) and 6859 patients for the validation Brabant region (52.2% male; mean [SD] age, 51 [22] years), the following 8 significant predictors were selected for the prediction model: age; systolic blood pressure; Glasgow Coma Scale score; mechanism criteria; penetrating injury to the head, thorax, or abdomen; signs and/or symptoms of head or neck injury; expected injury in the Abbreviated Injury Scale thorax region; and expected injury in 2 or more Abbreviated Injury Scale regions. The prediction model showed a C statistic of 0.823 (95% CI, 0.813-0.832) and good calibration. The cutoff point with a minimum specificity of 50.0% (95% CI, 49.3%-50.7%) led to a sensitivity of 88.8% (95% CI, 87.5%-90.0%). External validation showed a C statistic of 0.831 (95% CI, 0.814-0.848) and adequate calibration.

Conclusions and Relevance

The new prehospital trauma triage prediction model may lower undertriage rates to approximately 10% with an overtriage rate of 50%. The next step should be to implement this prediction model with the use of a mobile app for emergency medical services professionals.

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.

Arthrodesis of the Carpometacarpal Thumb Joint for Osteoarthritis; Long-Term Results Using Patient-Reported Outcome Measurements

Background  Results following carpometacarpal (CMC) arthrodesis of the thumb for osteoarthritis vary widely in literature. Data on long-term patient-reported outcome measurements (PROMs) after thumb CMC joint arthrodesis for osteoarthritis are scarce. Purpose  We report the long-term outcomes of PROMs (function, pain, and satisfaction) after arthrodesis of the thumb CMC joint. We evaluated the correlation of function and pain with patient satisfaction. Methods  Long-term PROMs after thumb CMC arthrodesis for osteoarthritis were evaluated using a retrospective cohort (1996-2015). Three different PROM questionnaires (Disabilities of the Arm, Shoulder, and Hand Questionnaire, Dutch Language version [DASH-DLV], the Patient-Related Wrist and Hand Questionnaire Dutch Language version [PRWHE-DLV], and a questionnaire concerning satisfaction) were sent to all patients. Results  Twenty-five arthrodeses (21 patients) were available for long-term follow-up. The median follow-up time was 10.8 years (interquartile range [IQR]: 9.7-13.0). The median DASH score was 29.2 (IQR: 14.4-38.3), median PRWHE score was 25.0 (IQR: 12.5-44.3). The median satisfaction after the operation and satisfaction with outcome of the operation was 10 for both (on a Likert's scale with 1 worse and 10 excellent satisfaction). There was a statistically significant correlation between the PRWHE total score and PRWHE pain score and satisfaction with surgery and satisfaction with the result. There was no correlation between PRWHE function score and satisfaction or DASH and satisfaction. Results after hardware removal showed no significant differences compared with patients without hardware removal. Conclusion  Patients who underwent arthrodesis for thumb CMC osteoarthritis showed high satisfaction at long-term follow-up, despite moderate results as measured using the DASH and PRWHE. The PRWHE total and PRWHE pain scores correlated significantly with satisfaction with surgery and satisfaction with the result, respectively, whereas no correlation was observed with the PRWHE function score or DASH and satisfaction. This therapeutic study reflects level of evidence IV.

Accuracy of Prehospital Triage in Selecting Severely Injured Trauma Patients

Importance

A major component of trauma care is adequate prehospital triage. To optimize the prehospital triage system, it is essential to gain insight in the quality of prehospital triage of the entire trauma system.

Objective

To prospectively evaluate the quality of the field triage system to identify severely injured adult trauma patients.

Design, Setting, and Participants

Prehospital and hospital data of all adult trauma patients during 2012 to 2014 transported with the highest priority by emergency medical services professionals to 10 hospitals in Central Netherlands were prospectively collected. Prehospital data collected by the emergency medical services professionals were matched to hospital data collected in the trauma registry. An Injury Severity Score of 16 or more was used to determine severe injury.

Main Outcomes and Measures

The quality and diagnostic accuracy of the field triage protocol and compliance of emergency medical services professionals to the protocol.

Results

A total of 4950 trauma patients were evaluated of which 436 (8.8%) patients were severely injured. The undertriage rate based on actual destination facility was 21.6% (95% CI, 18.0-25.7) with an overtriage rate of 30.6% (95% CI, 29.3-32.0). Analysis of the protocol itself, regardless of destination facility, resulted in an undertriage of 63.8% (95% CI, 59.2-68.1) and overtriage of 7.4% (95% CI, 6.7-8.2). The compliance to the field triage trauma protocol was 73% for patients with a level 1 indication.

Conclusions and Relevance

More than 20% of the patients with severe injuries were not transported to a level I trauma center. These patients are at risk for preventable morbidity and mortality. This finding indicates the need for improvement of the prehospital triage protocol.

Treatment of a Scientifically Neglected Ankle Injury: The Isolated Medial Malleolar Fracture. A Systematic Review

Isolated medial malleolar fractures are frequently encountered injuries. Literature regarding their treatment, though, is scarce and contradicting. The aim of this systematic review is to compare surgical and conservative treatment of isolated medial malleolar fractures considering complication rates and functional outcomes. PubMed, Embase, Cochrane, and CINAHL were searched for this review. Articles from 1980 or later, written in English, French, German, or Dutch, reporting any outcome of 10 or more isolated medial malleolar fractures in skeletally mature patients were included. Study quality was assessed using the Methodological Index for Non Randomized Studies (MINORS) instrument. Eighteen studies were included involving 2566 isolated medial malleolar fractures, which showed a mean (± SD) MINORS score of 8 ± 2. Mean nonunion rate was 1.7% after surgical treatment and 3.5% after conservative treatment. Overall, comparable functional outcomes were found after both treatment methods. Only 2 of the included studies reported the exact amount of fracture displacement. One study-comparing surgical and conservative treatment-showed similar functional outcomes for 1- and 2-mm displaced isolated medial malleolar fractures, and the other, a nonunion rate of 3.5% and a good mean functional outcome in 57 conservatively treated isolated medial malleolar fractures with a mean displacement of 3.8 mm. The available evidence is scarce and of low quality but suggests that conservative treatment of isolated medial malleolar fractures displaced ≤2 mm is safe. No study exists that compares surgical and conservative treatment in isolated medial malleolar fractures displaced >2 mm. Therefore, further research is needed. Until then, the eventual choice of treatment for isolated medial malleolar fractures displaced >2 mm, might be mainly dependent on the patients' characteristics and demands.

Bipolar clavicular fractures and treatment options

Introduction

Fractures of the clavicle are common injuries, accounting 2.6–4% of all fractures in adults. Of these fractures, 21–28% are lateral clavicle fractures and 2–3% are medial clavicle fractures. Bipolar clavicle fractures are defined as a lateral and medial fracture and are uncommon. There is no consensus on the treatment of these fractures. The aim of this study is to provide a treatment on bipolar clavicle fractures based on the current literature.

Methods

The electronic databases PubMed, the Cochrane library and EMBASE were searched up on September 25th, 2017. Two reviewers (KR and TG) independently screened titles and abstracts for their relevance. Studies designed to evaluate the outcomes of conservative and/or operative treatment of segmental bipolar clavicle fractures in adults (> 16 years) were included. Editorials and commentaries were excluded, as well as synthetic, cadaveric and animal studies. Primary outcomes considered were pain reduction and shoulder function. Secondary outcomes considered are complications.

Results

Ten studies reporting results from ten patients were included for the review. In most patients, if treated operatively, surgical treatment with the use of double plating was performed. Only in elderly patients conservative treatment was adopted. All included patients were pain free and had a full range of motion after 3–6 months. Only two case reports provided a DASH score, while in eight studies no functional outcome score was measured.

Conclusion

A missed bipolar fracture can complicate the clinical progress. Surgical management of these fractures may be necessary; however, the treatment of choice depends on the age of the patient, daily activities and comorbidity.

Electronic supplementary material

The online version of this article (10.1007/s00068-019-01191-5) contains supplementary material, which is available to authorized users.

Excellent functional recovery after Kirschner-wire extension blocking technique for displaced closed bony mallet finger injuries; results of 36 cases

Bony mallet finger injuries comprise 30% of all mallet injuries. Operative treatment of bony mallet fingers injuries still remains controversial. The aim of this study was to describe the k-wire extension blocking technique and the functional results using the PRWHE questionnaire. A single center retrospective observational cohort of 36 patients was defined between January 2010 and December 2015. Inclusion criteria for this study were acute fractures with 1) persistent displacement of more than 3 mm in extension splint, 2) palmar subluxation of the distal phalanx or 3) fracture fragments consisting of more than one third of the joint surface. According to the PRWHE questionnaire, excellent results were observed with a mean follow up period of 32 months of all patients. Two patients developed a clinically relevant superficial wound infection and one patient developed a nail deformity. In conclusion, the k-wire extension blocking technique is safe and results in excellent mid-term functional outcome.

Identification of thoracic injuries by emergency medical services providers among trauma patients

INTRODUCTION

Severe thoracic injuries are time sensitive and adequate triage to a facility with a high-level of trauma care is crucial. The emergency medical services (EMS) providers are required to identify patients with a severe thoracic injury to transport the patient to the right hospital. However, identifying these patients on-scene is difficult. The accuracy of prehospital assessment of potential thoracic injury by EMS providers of the ground ambulances is unknown. Therefore, the aim of this study is to evaluate the diagnostic accuracy of the assessment of the EMS provider in the identification of a thoracic injury and determine predictors of a severe thoracic injury.

METHODS

In this multicentre cohort study, all trauma patients aged 16 and over, transported with a ground erence standard. Prehospital variables were analysed using logistic regression to explore prehospital ambulance to a trauma centre, were evaluated. The diagnostic value of EMS provider judgment was determined using the Abbreviated Injury Scale (AIS) of ≥ 1 in the thoracic region as ref predictors of a severe thoracic injury (AIS ≥ 3).

RESULTS

In total 2766 patients were included, of whom 465 (16.8%) sustained a thoracic injury and 210 (7.6%) a severe thoracic injury. The EMS providers' judgment had a sensitivity of 54.8% and a specificity of 92.6% for the identification of a thoracic injury. Significant independent prehospital predictors were: age, oxygen saturation, Glasgow Coma Scale, fall > 2 m, and suspicion of inhalation trauma or a thoracic injury by the EMS provider.

CONCLUSION

EMS providers could identify little over half of the patients with a thoracic injury. A supplementary triage protocol to identify patients with a thoracic injury could improve prehospital triage of these patients. In this supplementary protocol, age, vital signs, and mechanism criteria could be included.

Clavicle fractures in adults; current concepts

BACKGROUND

For decades, clavicle fractures have been treated conservatively. In the last 20 years, however, non-union rates after conservative treatment appear higher than previously reported and more evidence regarding operative treatment has become available. This has led to a paradigm shift towards an increase in operative treatment. The aim of this review is to present the current concepts and available evidence regarding clavicle fracture treatment.

METHODS

Conservative and operative treatment options together with their indications for medial, shaft and lateral clavicle fractures are discussed. For all three anatomical locations, a treatment algorithm is proposed.

CONCLUSION

In general, non-displaced fractures are treated conservatively. Operative treatment has to be discussed with patients with displaced clavicle fractures, especially in the young and active patient.

Surgical treatment of Neer type II and type V lateral clavicular fractures: comparison of hook plate versus superior plate with lateral extension: a retrospective cohort study

Purpose

Different fixation methods are used for treatment of unstable lateral clavicle fractures (LCF). Definitive consensus and guidelines for the surgical fixation of LCF have not been established. The aim of this study was to compare patient-reported functional outcome after open reduction and internal fixation with the clavicle hook plate (CHP) and the superior clavicle plate with lateral extension (SCPLE).

Methods

A dual-center retrospective cohort study was performed. All patients operatively treated for unstable Neer type II and type V LCF between 2011 and 2016, with the CHP (n = 23) or SCPLE (n = 53), were eligible for inclusion. The primary outcome was the QuickDASH score. Secondary outcomes were the numerical rating scale (NRS) pain score, complications, and implant removal.

Results

A total of 67 patients (88%) were available for the final follow-up. There was a significant difference in bicortical lateral fragment size, 15 mm (± 4, range 6–21) in the CPH group compared to 20 mm (± 8, range 8–43) in the SCPLE group (p ≤ 0.001). There was no significant difference in median QuickDASH score (CHP; 0.00 [IQR 0.0–0.0], SCPLE; 0.00 [IQR 0.0–4.5]; p = 0.073) or other functional outcome scores (NRS at rest; p = 0.373, NRS during activity; p = 0.559). There was no significant difference in median QuickDASH score or other functional outcome scores between Neer type II and type V fractures. There was no significant difference in complication rate, CHP 11% and SCPLE 8% (relative risk 1.26; [95% CI 0.25–6.33; p = 0.777]). The implant removal rate was 100% in the CHP group compared to 42% in the SCPLE group (relative risk 2.40; [95% CI 1.72–3.35; p ≤ 0.001]).

Conclusion

Both the CHP and SCPLE are effective fixation methods for the treatment of unstable LCF, resulting in excellent patient-reported functional outcome and similar complication rates. SCPLE fixation is an effective fixation method for the treatment of both Neer type II and type V LCF. The SCPLE has a lower implant removal rate. Therefore, if technically feasible, we recommend SCPLE fixation for the treatment of unstable LCF.

Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis

OBJECTIVES

To compare re-rupture rate, complication rate, and functional outcome after operative versus nonoperative treatment of Achilles tendon ruptures; to compare re-rupture rate after early and late full weight bearing; to evaluate re-rupture rate after functional rehabilitation with early range of motion; and to compare effect estimates from randomised controlled trials and observational studies.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed/Medline, Embase, CENTRAL, and CINAHL databases were last searched on 25 April 2018 for studies comparing operative versus nonoperative treatment of Achilles tendon ruptures.

STUDY SELECTION CRITERIA

Randomised controlled trials and observational studies reporting on comparison of operative versus nonoperative treatment of acute Achilles tendon ruptures.

DATA EXTRACTION

Data extraction was performed independently in pairs, by four reviewers, with the use of a predefined data extraction file. Outcomes were pooled using random effects models and presented as risk difference, risk ratio, or mean difference, with 95% confidence interval.

RESULTS

29 studies were included-10 randomised controlled trials and 19 observational studies. The 10 trials included 944 (6%) patients, and the 19 observational studies included 14 918 (94%) patients. A significant reduction in re-ruptures was seen after operative treatment (2.3%) compared with nonoperative treatment (3.9%) (risk difference 1.6%; risk ratio 0.43, 95% confidence interval 0.31 to 0.60; P<0.001; I²=22%). Operative treatment resulted in a significantly higher complication rate than nonoperative treatment (4.9% v 1.6%; risk difference 3.3%; risk ratio 2.76, 1.84 to 4.13; P<0.001; I²=45%). The main difference in complication rate was attributable to the incidence of infection (2.8%) in the operative group. A similar reduction in re-rupture rate in favour of operative treatment was seen after both early and late full weight bearing. No significant difference in re-rupture rate was seen between operative and nonoperative treatment in studies that used accelerated functional rehabilitation with early range of motion (risk ratio 0.60, 0.26 to 1.37; P=0.23; I²=0%). No difference in effect estimates was seen between randomised controlled trials and observational studies.

CONCLUSIONS

This meta-analysis shows that operative treatment of Achilles tendon ruptures reduces the risk of re-rupture compared with nonoperative treatment. However, re-rupture rates are low and differences between treatment groups are small (risk difference 1.6%). Operative treatment results in a higher risk of other complications (risk difference 3.3%). The final decision on the management of acute Achilles tendon ruptures should be based on patient specific factors and shared decision making. This review emphasises the potential benefits of adding high quality observational studies in meta-analyses for the evaluation of objective outcome measures after surgical treatment.

[Proximal humerus fractures; conservative or surgical treatment?]

There is an increasing incidence of proximal humerus fractures. Patients with proximal humerus fractures have traditionally been treated conservatively. During the past decades, however, various new osteosynthetic and prosthetic implants have been developed for the shoulder and surgical treatment of proximal humerus fractures has increased. However, recent literature in which conservative and surgical treatment of proximal humerus fractures is compared has shown no difference in functional outcome. The trend towards more frequent surgical treatment is thus not based on scientific evidence. In this article, we present the current state of affairs and attempt to give a nuanced picture of who will not, but also who might profit from surgical treatment of a proximal humerus fracture.

Development and validation of a novel prediction model to identify patients in need of specialized trauma care during field triage: design and rationale of the GOAT study

BACKGROUND

Adequate field triage of trauma patients is crucial to transport patients to the right hospital. Mistriage and subsequent interhospital transfers should be minimized to reduce avoidable mortality, life-long disabilities, and costs. Availability of a prehospital triage tool may help to identify patients in need of specialized trauma care and to determine the optimal transportation destination.

METHODS

The GOAT (Gradient Boosted Trauma Triage) study is a prospective, multi-site, cross-sectional diagnostic study. Patients transported by at least five ground Emergency Medical Services to any receiving hospital within the Netherlands are eligible for inclusion. The reference standards for the need of specialized trauma care are an Injury Severity Score ≥ 16 and early critical resource use, which will both be assessed by trauma registrars after the final diagnosis is made. Variable selection will be based on ease of use in practice and clinical expertise. A gradient boosting decision tree algorithm will be used to develop the prediction model. Model accuracy will be assessed in terms of discrimination (c-statistic) and calibration (intercept, slope, and plot) on individual participant's data from each participating cluster (i.e., Emergency Medical Service) through internal-external cross-validation. A reference model will be externally validated on each cluster as well. The resulting model statistics will be investigated, compared, and summarized through an individual participant's data meta-analysis.

DISCUSSION

The GOAT study protocol describes the development of a new prediction model for identifying patients in need of specialized trauma care. The aim is to attain acceptable undertriage rates and to minimize mortality rates and life-long disabilities.

Intramedullary nailing of displaced midshaft clavicle fractures using a TEN with end cap: issues encountered

The purpose of this study was to describe our experience with a possible solution for implant- related irritation after intramedullary nailing of displaced midshaft clavicle fractures: the end cap. Ten patients with a displaced midshaft clavicle fracture were treated with intramedullary nailing and an end cap in 2013. Patients were followed in the outpatient clinic until fracture union. In 2015 patients were contacted again. Prospectively collected data included shoulder function and complications. The median follow-up time was 28.5 months (between 27 and 30 months). No patients were lost to follow- up. QuickDASH scores were 18.2, 9.1 and 2.3 after 6 weeks, 3 month and latest follow-up respectively. Nine patients (90%) had some type of implant-related complication. In three of these patients implant removal was required before union. One implant failure occurred which required major revision surgery using plate fixation. In conclusion, because in 70% of the patients the implant-related irritation was directly caused by the end cap, we believe end caps should not be used after intramedullary nailing for displaced midshaft clavicle fractures.

Weight-bearing or non-weight-bearing after surgical treatment of ankle fractures: a multicenter randomized controlled trial

Purpose

The goal of this study was to assess if unprotected weight-bearing as tolerated is superior to protected weight-bearing and unprotected non-weight-bearing in terms of functional outcome and complications after surgical fixation of Lauge-Hansen supination external rotation stage 2–4 ankle fractures.

Methods

A multicentered randomized controlled trial was conducted in patients ranging from 18 to 65 years of age without severe comorbidities. Patients were randomized to unprotected non-weight-bearing, protected weight-bearing, and unprotected weight-bearing as tolerated. The primary endpoint of the study was the Olerud Molander Ankle Score (OMAS) 12 weeks after randomization. The secondary endpoints were health-related quality of life using the SF-36v2, time to return to work, time to return to sports, and the number of complications.

Results

The trial was terminated early as advised by the Data and Safety Monitoring Board after interim analysis. A total of 115 patients were randomized. The O’Brien–Fleming threshold for statistical significance for this interim analysis was 0.008 at 12 weeks. The OMAS was higher in the unprotected weight-bearing group after 6 weeks c(61.2 ± 19.0) compared to the protected weight-bearing (51.8 ± 20.4) and unprotected non-weight-bearing groups (45.8 ± 22.4) (p = 0.011). All other follow-up time points did not show significant differences between the groups. Unprotected weight-bearing showed a significant earlier return to work (p = 0.028) and earlier return to sports (p = 0.005). There were no differences in the quality of life scores or number of complications.

Conclusions

Unprotected weight-bearing and mobilization as tolerated as postoperative care regimen improved short-term functional outcomes and led to earlier return to work and sports, yet did not result in an increase of complications.

Electronic supplementary material

The online version of this article (10.1007/s00068-018-1016-6) contains supplementary material, which is available to authorized users.

Operative versus nonoperative treatment of proximal humeral fractures: a systematic review, meta-analysis, and comparison of observational studies and randomized controlled trials

BACKGROUND

There is no consensus on the choice of treatment for displaced proximal humeral fractures in older patients (aged > 65 years). The aims of this systematic review and meta-analysis were (1) to compare operative with nonoperative management of displaced proximal humeral fractures and (2) to compare effect estimates obtained from randomized controlled trials (RCTs) and observational studies.

METHODS

The databases of MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) were searched on September 5, 2017, for studies comparing operative versus nonoperative treatment of proximal humeral fractures; both RCTs and observational studies were included. The criteria of the Methodological Index for Non-Randomized Studies, a validated instrument for methodologic quality assessment, were used to assess study quality. The primary outcome measure was physical function as measured by the absolute Constant-Murley score after operative or nonoperative treatment. Secondary outcome measures were major reinterventions, nonunion, and avascular necrosis.

RESULTS

We included 22 studies, comprising 7 RCTs and 15 observational studies, resulting in 1743 patients in total: 910 treated operatively and 833 nonoperatively. The average age was 68.3 years, and 75% of patients were women. There was no difference in functional outcome between operative and nonoperative treatment, with a mean difference of -0.87 (95% confidence interval, -5.13 to 3.38; P = .69; I² = 69%). Major reinterventions occurred more often in the operative group. Pooled effects of RCTs were similar to pooled effects of observational studies for all outcome measures.

CONCLUSIONS

We recommend nonoperative treatment for the average elderly patient (aged > 65 years) with a displaced proximal humeral fracture. Pooled effects of observational studies were similar to those of RCTs, and including observational studies led to more generalizable conclusions.

Compliance to prehospital trauma triage protocols worldwide: A systematic review

BACKGROUND

Emergency medical services (EMS) providers must determine the injury severity on-scene, using a prehospital trauma triage protocol, and decide on the most appropriate hospital destination for the patient. Many severely injured patients are not transported to higher-level trauma centres. An accurate triage protocol is the base of prehospital trauma triage; however, ultimately the quality is dependent on the destination decision by the EMS provider. The aim of this systematic review is to describe compliance to triage protocols and evaluate compliance to the different categories of triage protocols.

METHODS

An extensive search of MEDLINE/Pubmed, Embase, CINAHL and Cochrane library was performed to identify all studies, published before May 2018, describing compliance to triage protocols in a trauma system. The search terms were a combination of synonyms for 'compliance,' 'trauma,' and 'triage'.

RESULTS

After selection, 11 articles were included. The studies showed a variety in compliance rates, ranging from 21% to 93% for triage protocols, and 41% to 94% for the different categories. The compliance rate was highest for the criterion: penetrating injury. The category of the protocol with the lowest compliance rate was: vital signs. Compliance rates were lower for elderly patients, compared to adults under the age of 55. The methodological quality of most studies was poor. One study with good methodological quality showed that the triage protocol identified only a minority of severely injured patients, but many of whom were transported to higher-level trauma centres.

CONCLUSIONS

The compliance rate ranged from 21% to 94%. Prehospital trauma triage effectiveness could be increased with an accurate triage protocol and improved compliance rates. EMS provider judgment could lower the undertriage rate, especially for severely injured patients meeting none of the criteria. Future research should focus on the improvement of triage protocols and the compliance rate.

Modified Stoppa approach for operative treatment of acetabular fractures: 10-year experience and mid-term follow-up

INTRODUCTION

The (modified) Stoppa approach for acetabular fracture surgery has gained significant popularity and early results have been encouraging but clinical outcome at extensive follow-up is scarce. The purpose of this study is to provide an update on our experience with this approach for operative treatment of acetabular fractures and to assess clinical outcome at mid-term follow-up.

METHODS

In this retrospective study, all patients treated operatively for an acetabular fracture using the Stoppa approach over a 10-year period were included. Surgery details were reviewed and patients were contacted and requested to return for follow-up. Primary outcome was native hip survivorship, secondary outcome measures included; functional outcome (Merle d'Aubiginé, Harris hip) scores, health-related quality of life (short-form 36) and radiographic outcome (heterotopic ossification, hip osteoarthritis).

RESULTS

Forty-five patients received operative fixation for 47 acetabular fractures using the Stoppa approach. Complications requiring surgical intervention were found in one patient (with a vascular lesion) intra-operatively and 3 patients (with wound infections (2) and diffuse bleeding (1)) post-operatively. Follow-up was 83% and 29/39 (74%) native hips survived at mean 59 months (SD 49) postoperatively. Excellent-good functional scores were found in 88% (Merle d'Aubiginé) and 76% (Harris hip) of patients who had retained their native hip. Most (6/8) short-form 36 indices in these patients were comparable to population norms. Of 29 native hips with radiographic follow-up (mean 59 months (SD 49), 4 (86%) had no-minimal radiographic abnormalities.

CONCLUSION

This study confirms that the Stoppa approach is a safe and effective technique for acetabular fracture fixation. Moreover, at mid-term follow-up, this approach is associated with satisfactory results in terms of hip survivorship as well as functional and radiographic outcome. As such, our findings reinforce the notion that this less invasive technique presents a valuable alternative to the ilioinguinal approach for the surgical treatment of acetabular fractures.