Mark R. de Vries

More than half of hip fracture patients do not regain mobility in the first postoperative year

Aim:  To measure functional recovery and determine risk factors for failure to return to the prefracture level of mobility of hip fracture patients 1 year postoperatively.

Complications of Syndesmotic Screw Removal

Background: Currently, the metallic syndesmotic screw is the gold standard in the treatment of syndesmotic disruption. Whether or not this screw needs to be removed remains debatable. The aim of the current study was to determine the complications which occur following routine removal of the syndesmotic screw following operative treatment of unstable ankle fractures. Methods: This was a retrospective study with consecutive cases in a Level-2 Trauma center. All patients with routine removal of a syndesmotic screw, following the treatment of an unstable ankle fracture, between January 1, 2004 and November 30, 2010 were included. Complications recorded were: 1) minor or major wound infection following removal of the syndesmotic screw, 2) recurrent syndesmotic diastasis, and 3) unnecessary removal of a broken screw, not recognized during preoperative planning prior to surgery. Results: A total of 76 patients were included. A wound infection occurred in 9.2% (N=7) of which 2.6% (N=2) were deep infections requiring reoperation. Recurrent syndesmotic diastasis was found in 6.6% (N=5) of patients, and in 6.6% (N=5) screws were broken at the time of implant removal. In the group with recurrent diastasis the screws were removed significantly earlier compared with the group without recurrent diastasis (Mann- Whitney U-test; p= 0.011) and the group with screw breakage had their screws significantly longer in place compared with the group without breakage (p = 0.038). Conclusion: A total of 22.4% complications occurred upon routine removal of the syndesmotic screw. Removal might therefore be considered only in selected cases with complaints, after a minimum of eight to twelve weeks and using antibiotic prophylaxis during removal. Level of Evidence: IV, Retrospective Case Study

Delirium risk screening and haloperidol prophylaxis program in hip fracture patients is a helpful tool in identifying high-risk patients, but does not reduce the incidence of delirium

BackgroundDelirium in patients with hip fractures lead to higher morbidity and mortality. Prevention in high-risk patients by prescribing low dose haloperidol is currently under investigation.MethodsThis prospective cohort surveillance assessed hip fracture patients for risk of developing a delirium with the Risk Model for Delirium (RD) score. High-risk patients (score ≥ 5 points) were treated with a prophylactic low-dose of haloperidol according to hospital protocol. Primary outcome was delirium incidence. Secondary outcomes were differences between high- and low-risk patients in delirium, length of stay (LOS), return to pre-fracture living situation and mortality. Logistic regression analysis was performed with age, ASA-classification, known dementia, having a partner, type of fracture, institutional residence and psychotropic drug use as possible confounders.Results445 hip fracture patients aged 65 years and older were admitted from January 2008 to December 2009. The RD-score was completed in 378 patients, 173 (45.8%) high-risk patients were treated with prophylactic medication. Sensitivity was 71.6%, specificity 63.8% and the negative predictive value (NPV) of a score < 5 was 85.9%.Delirium incidence (27.0%) was not significantly different compared to 2007 (27.8%) 2006 (23.9%) and 2005 (29.0%) prior to implementation of the RD- protocol.Logistic regression analysis showed that high-risk patients did have a significant higher delirium incidence (42.2% vs. 14.1%, OR 4.1, CI 2.43-7.02). They were more likely to be residing at an alternative living situation after 3 months (62.3% vs. 17.0%, OR 6.57, CI 3.23-13.37) and less likely to be discharged from hospital before 10 days (34.9% vs. 55.9%, OR 1.63, CI 1.03-2.59). Significant independent risk factors for a delirium were a RD-score ≥ 5 (OR 4.13, CI 2.43-7.02), male gender (OR 1.93, CI 0.99-1.07) and age (OR 1.03, CI 0.99-1.07).ConclusionsIntroducing the delirium prevention protocol did not reduce delirium incidence.The RD-score did identify patients with a high risk to develop a delirium. This high-risk group had a longer LOS and returned to pre-fracture living situation less often.The NPV of a score < 5 was high, as it should be for a screening instrument. Concluding, the RD-score is a useful tool to identify patients with poorer outcome.

Outcome in hip fracture patients related to anemia at admission and allogeneic blood transfusion: an analysis of 1262 surgically treated patients

BackgroundAnemia is more often seen in older patients. As the mean age of hip fracture patients is rising, anemia is common in this population. Allogeneic blood transfusion (ABT) and anemia have been pointed out as possible risk factors for poorer outcome in hip fracture patients.MethodsIn the timeframe 2005-2010, 1262 admissions for surgical treatment of a hip fracture in patients aged 65 years and older were recorded. Registration was prospective from 2008 on. Anemic and non-anemic patients (based on hemoglobin level at admission) were compared regarding clinical characteristics, mortality, delirium incidence, LOS, discharge to a nursing home and the 90-day readmission rate. Receiving an ABT, age, gender, ASA classification, type of fracture and anesthesia were used as possible confounders in multivariable regression analysis.ResultsThe prevalence of anemia and the rate of ABT both were 42.5%. Anemic patients were more likely to be older and men and had more often a trochanteric fracture, a higher ASA score and received more often an ABT. In univariate analysis, the 3- and 12-month mortality rate, delirium incidence and discharge to a nursing home rate were significantly worse in preoperatively anemic patients.In multivariable regression analysis, anemia at admission was a significant risk factor for discharge to a nursing home and readmission < 90 days, but not for mortality. Indication for ABT, age and ASA classification were independent risk factors for mortality at all moments, only the mortality rate for the 3-12 month interval was not influenced by ABT. An indication for an ABT was the largest negative contributor to a longer LOS (OR 2.26, 95% CI 1.73-2.94) and the second largest for delirium (OR 1.67, 95% CI 1.28-2.20).ConclusionsThis study has demonstrated that anemia at admission and postoperative anemia needing an ABT (PANT) were independent risk factors for worse outcome in hip fracture patients. In multivariable regression analysis, anemia as such had no effect on mortality, due to a rescue effect of PANT. In-hospital, 3- and 12-month mortality was negatively affected by PANT, with the main effect in the first 3 months postoperatively.

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

BackgroundElbow dislocations can be classified as simple or complex. Simple dislocations are characterized by the absence of fractures, while complex dislocations are associated with fractures. After reduction of a simple dislocation, treatment options include immobilization in a static plaster for different periods of time or so-called functional treatment. Functional treatment is characterized by early active motion within the limits of pain with or without the use of a sling or hinged brace. Theoretically, functional treatment should prevent stiffness without introducing increased joint instability. The primary aim of this randomized controlled trial is to compare early functional treatment versus plaster immobilization following simple dislocations of the elbow.Methods/DesignThe design of the study will be a multicenter randomized controlled trial of 100 patients who have sustained a simple elbow dislocation. After reduction of the dislocation, patients are randomized between a pressure bandage for 5-7 days and early functional treatment or a plaster in 90 degrees flexion, neutral position for pro-supination for a period of three weeks. In the functional group, treatment is started with early active motion within the limits of pain. Function, pain, and radiographic recovery will be evaluated at regular intervals over the subsequent 12 months. The primary outcome measure is the Quick Disabilities of the Arm, Shoulder, and Hand score. The secondary outcome measures are the Mayo Elbow Performance Index, Oxford elbow score, pain level at both sides, range of motion of the elbow joint at both sides, rate of secondary interventions and complication rates in both groups (secondary dislocation, instability, relaxation), health-related quality of life (Short-Form 36 and EuroQol-5D), radiographic appearance of the elbow joint (degenerative changes and heterotopic ossifications), costs, and cost-effectiveness.DiscussionThe successful completion of this trial will provide evidence on the effectiveness of a functional treatment for the management of simple elbow dislocations.Trial RegistrationThe trial is registered at the Netherlands Trial Register (NTR2025).

A hinged external fixator for complex elbow dislocations: A multicenter prospective cohort study

BackgroundElbow dislocations can be classified as simple or complex. Simple dislocations are characterized by the absence of fractures, while complex dislocations are associated with fractures of the radial head, olecranon, or coronoid process. The majority of patients with these complex dislocations are treated with open reduction and internal fixation (ORIF), or arthroplasty in case of a non-reconstructable radial head fracture. If the elbow joint remains unstable after fracture fixation, a hinged elbow fixator can be applied. The fixator provides stability to the elbow joint, and allows for early mobilization. The latter may be important for preventing stiffness of the joint. The aim of this study is to determine the effect of early mobilization with a hinged external elbow fixator on clinical outcome in patients with complex elbow dislocations with residual instability following fracture fixation.Methods/DesignThe design of the study will be a multicenter prospective cohort study of 30 patients who have sustained a complex elbow dislocation and are treated with a hinged elbow fixator following fracture fixation because of residual instability. Early active motion exercises within the limits of pain will be started immediately after surgery under supervision of a physical therapist. Outcome will be evaluated at regular intervals over the subsequent 12 months. The primary outcome is the Quick Disabilities of the Arm, Shoulder, and Hand score. The secondary outcome measures are the Mayo Elbow Performance Index, Oxford Elbow Score, pain level at both sides, range of motion of the elbow joint at both sides, radiographic healing of the fractures and formation of periarticular ossifications, rate of secondary interventions and complications, and health-related quality of life (Short-Form 36).DiscussionThe outcome of this study will yield quantitative data on the functional outcome in patients with a complex elbow dislocation and who are treated with ORIF and additional stabilization with a hinged elbow fixator.Trial RegistrationThe trial is registered at the Netherlands Trial Register (NTR1996).

Re-displacement of stable distal both-bone forearm fractures in children: A randomised controlled multicentre trial

INTRODUCTION Displaced metaphyseal both-bone fractures of the distal forearm are generally reduced and stabilised by an above-elbow cast (AEC) with or without additional pinning. The purpose of this study was to find out if re-displacement of a reduced stable metaphyseal both-bone fracture of the distal forearm in a child could be prevented by stabilisation with Kirschner wires. METHODS Consecutive children aged <16 years with a displaced metaphyseal both-bone fracture of the distal forearm (n = 128) that was stable after reduction were randomised to AEC with or without percutaneous fixation with Kirschner wires. The primary outcome was re-displacement of the fracture. RESULTS A total of 67 children were allocated to fracture reduction and AEC and 61 to reduction of the fracture, fixation with Kirschner wires and AEC. The follow-up rate was 96% with a mean follow-up of 7.1 months. Fractures treated with additional pinning showed less re-displacement (8% vs. 45%), less limitation of pronation and supination (mean limitation 6.9 (± 9.4)° vs. 14.3 (± 13.6)°) but more complications (14 vs. 1). CONCLUSIONS Pinning of apparent stable both-bone fractures of the distal forearm in children might reduce fracture re-displacement. The frequently seen complications of pinning might be reduced by a proper surgical technique.

Below-elbow cast for metaphyseal both-bone fractures of the distal forearm in children: A randomised multicentre study

INTRODUCTION Minimally displaced metaphyseal both-bone fractures of the distal forearm in children are often treated with an above-elbow cast (AEC). Treatment with a below-elbow cast (BEC) could give more comfort, but might lead to fracture displacement reducing pronation and supination. Because this has not been systematically investigated, we set up a randomised multicentre study. The purpose of this study was to find out whether BEC causes equal limitation of pronation and supination but with higher comfort level, compared with AEC. PATIENTS AND METHODS In four hospitals, consecutive children aged<16 (mean 7.1) years with a minimally displaced metaphyseal both-bone fracture of the distal forearm were randomised to 4 weeks BEC (n=35) or 4 weeks AEC (n=31). Primary outcome was limitation of pronation and supination 6 months after initial trauma. The secondary outcomes were cast comfort, limitation of flexion/extension of wrist/elbow, complications, cosmetics, complaints, and radiological assessment. RESULTS A group of 35 children received BEC and 31 children received AEC. All children attended for the final examination at a mean follow-up of 7.0 months (range 5.0-11.6 months). Limitation of pronation and supination 6 months after initial trauma showed no significant difference between the two groups [4.4° (± 5.8) for BEC and 5.8° (± 9.8) for AEC]. Children treated with BEC had significantly higher cast comfort on a visual analogue scale [5.6 (± 2.7) vs. 8.4 (± 1.4)] and needed significantly less help with dressing (8.2 days vs. 15.1 days). Six complications occurred in the BEC group and 14 in the AEC group. Other secondary outcomes were similar between the two groups. CONCLUSIONS Children with minimally displaced metaphyseal both-bone fractures of the distal forearm should be treated with a below-elbow cast.

Demographics and functional outcome of toe fractures.

Toe fractures are common; however, there are few data on demographics and functional outcome. We studied outcomes in 339 consecutive patients with toe fractures treated between January 2006 and September 2008. Two hundred and sixty-four patients, aged 16 to 75, were mailed an outcome questionnaire, and overall subjective satisfaction with the outcome of treatment was measured using a visual analog scale (VAS). Most frequently affected were the first (38%) and fifth (30%) toes, and most (75.6%) of the fractures were caused by stubbing or crush injury. More than 95% of the fractures were displaced less than 2 mm, and all of the fractures were treated conservatively. The questionnaire was returned by 141 (53%) patients with a median follow-up of 27 months. Respondents were female in 57.4% of cases and had a median age of 45 years. The median AOFAS score was 100 (P(25), P(75) = 93,100) points; the median VAS was 10 (P(25), P(75) = 8, 10) points. Univariate regression analysis revealed no statistically significant associations between outcome and the particular toe or phalanx involved, number of fractured toes, fracture type and location, articular involvement, gender, age, body mass index, smoking habits, and the presence of diabetes mellitus. Satisfaction VAS was dependent on age (P = .047) and gender (P = .049) in the multivariate analysis. The AOFAS midfoot score was not influenced by any of the covariates. This is the first epidemiological investigation using 2 outcome-scoring systems to determine function and satisfaction following treatment of toe fractures.

Foot and ankle fractures at the supination line

BACKGROUND The supination line is a fictive line along the foot and ankle, on which over twenty fracture types and approximately ten different ligamentous sprain-injuries have been identified. OBJECTIVE The current study was conducted to evaluate the incidence of different types of supination line injuries visible at the initial radiographs at the Emergency Department and to determine the type and percentage of misdiagnosed injuries. METHOD Retrospective study of consecutive patients who visited the Emergency Department, between January 1 and June 30, 2009, after sustaining an injury of the foot or ankle and had a radiograph taken within 24 h of the incident. RESULTS In the 6-month study period 1284 patients were included. In these cases the trauma mechanism was a sprain in 780 patients (60.7%). Of these patients 310 suffered from a fracture (40%). There were 36 (4.6%) false-positive cases and in 91 (11.7%) cases the initial diagnosis was false-negative. The number with a missed fracture expressed as a percentage of all patients with a fracture was 29.4% (91/310). CONCLUSION Detection of injuries along the supination line remains difficult. This study might aid in decreasing the number of misdiagnosed injuries, which is of value as these might negatively affect outcome.