Pieta Krijnen

Surgical treatment of Neer type-II fractures of the distal clavicle: a meta-analysis.

Background and purpose Type-II distal clavicle fractures according to the Neer classification are generally operated because of the high non-union rate after non-operative treatment. Several surgical techniques have been developed in order to reduce the non-union rate and improve functional outcome. This meta-analysis overviews the available surgical techniques for type-II distal clavicular fractures. Methods We searched the literature systematically. No comparative studies were found. 21 studies (8 prospective and 13 retrospective cohort studies) were selected for the meta-analysis. Data were pooled for 5 surgical outcome measures: function, time to union, time to implant removal, major complications, and minor complications. Results The 21 studies selected included 350 patients with a distal clavicular fracture. Union was achieved in 98% of the patients. Functional outcome was similar between the treatment modalities. Hook-plate fixation was associated with an 11-fold increased risk of major complications compared to intramedullary fixation and a 24-fold increased risk compared to suture anchoring. Interpretation If surgical treatment of a distal clavicle fracture is considered, a fixation procedure with a low risk of complications and a high union rate such as plate fixation or intramedullary fixation should be used. The hook-plate fixation had an increased risk of implant-related complications.

Nonsilver treatment vs. silver sulfadiazine in treatment of partial-thickness burn wounds in children: A systematic review and meta-analysis

The evidence for application of silver‐containing dressings and topicals in the treatment of partial‐thickness burns in pediatric patients is largely based on clinical trials involving adult patients despite the important differences between the skin of children and adults. A systematic review and meta‐analysis was performed of all randomized controlled trials comparing nonsilver treatment with silver‐containing dressings and silver topical agents in children with partial‐thickness burns in the acute stage. Endpoints were wound healing, grafting, infection, pain, number of dressing changes, length of hospital stay, and scarring. Seven randomized controlled trials were included involving 473 participants. All trials used silver sulfadiazine as control in comparison with five different nonsilver treatments. Most trials were of moderate quality with high risk of bias. Use of nonsilver treatment led to shorter wound healing time (weighted mean difference: −3.43 days, 95% confidence interval: −4.78, −2.07), less dressing changes (weighted mean difference: −19.89 dressing changes, 95% confidence interval: −38.12, −1.66), and shorter length of hospital stay (weighted mean difference: −2.07 days, 95% confidence interval: −2.63, −1.50) compared with silver sulfadiazine treatment, but no difference in the incidence of wound infection or grafting was found. In conclusion, nonsilver treatment may be preferred over silver sulfadiazine, but high‐quality randomized controlled trials are needed to validly confirm the effectiveness of silver containing preparations, in particular silver‐containing dressings, above nonsilver treatments.

Displaced midshaft fractures of the clavicle: non-operative treatment versus plate fixation (Sleutel-TRIAL). A multicentre randomised controlled trial

BackgroundThe traditional view that the vast majority of midshaft clavicular fractures heal with good functional outcomes following non-operative treatment may be no longer valid for all midshaft clavicular fractures. Recent studies have presented a relatively high incidence of non-union and identified speciic limitations of the shoulder function in subgroups of patients with these injuries.AimA prospective, multicentre randomised controlled trial (RCT) will be conducted in 21 hospitals in the Netherlands, comparing fracture consolidation and shoulder function after either non-operative treatment with a sling or a plate fixation.Methods/designA total of 350 patients will be included, between 18 and 60 years of age, with a dislocated midshaft clavicular fracture. The primary outcome is the incidence of non-union, which will be determined with standardised X-rays (Antero-Posterior and 30 degrees caudocephalad view). Secondary outcome will be the functional outcome, measured using the Constant Score. Strength of the shoulder muscles will be measured with a handheld dynamometer (MicroFET2). Furthermore, the health-related Quality of Life score (ShortForm-36) and the Disabilities of Arm, Shoulder and Hand (DASH) Outcome Measure will be monitored as subjective parameters. Data on complications, bone union, cosmetic aspects and use of painkillers will be collected with follow-up questionnaires. The follow-up time will be two years. All patients will be monitored at regular intervals over the subsequent twelve months (two and six weeks, three months and one year). After two years an interview by telephone and a written survey will be performed to evaluate the two-year functional and mechanical outcomes. All data will be analysed on an intention-to-treat basis, using univariate and multivariate analyses.DiscussionThis trial will provide level-1 evidence for the comparison of consolidation and functional outcome between two standardised treatment options for dislocated midshaft clavicular fractures. The gathered data may support the development of a clinical guideline for treatment of clavicular fractures.Trial registrationNetherlands National Trial Register NTR2399

Ulnar styloid process nonunion and outcome in patients with a distal radius fracture: a meta-analysis of comparative clinical trials.

PURPOSE There is no consensus on the relation between ulnar styloid process nonunion and outcome in patients with distal radius fractures. The aim of this study was to analyze whether patient-reported outcome is influenced by the nonunion of the accompanying ulnar styloid fracture in distal radius fracture patients. METHODS A meta-analysis of published studies comparing outcomes after distal radius fractures with a united versus a non-united ulnar styloid process was performed. In addition, if provided by the authors, the raw data of these studies were pooled and analysed as one study. The outcome measures of the analyses included patient-reported outcome, functional outcome, grip-strength, pain, and distal radioulnar joint (DRUJ) instability. RESULTS Data from six comparative studies were included, concerning 365 patients with a distal radius fracture. One hundred and thirty-five patients with an ulnar styloid union were compared with 230 patients with a nonunion of the ulnar styloid. No significant differences were found between groups regarding any outcome measure. CONCLUSION Based on this meta-analysis, there is no relation between the nonunion of the ulnar styloid process and function in patients with a distal radius fracture.

Epidemiology of clinically relevant bacterial pathogens in a burn center in the Netherlands between 2005 and 2011.

The aim of this study was to analyze the epidemiology in the bacteriological profile and susceptibility of clinically relevant bacterial pathogens in a burn center in the Netherlands over a 7-year period. The swab results of 693 patients of the period 2005 to 2008 and 539 patients of the period 2009 to 2011 were studied for change of microorganisms and antibiotic resistance. Definitions according to the Working Party on Infection Prevention were used as a tool for assessing the scale of the resistance problem at a local level. Between the studied periods only small changes were found in the bacteriological profile. Staphylococcus aureus showed a slight increase of prevalence in inventory swabs during the second period. In both inventory and wound swabs, S. aureus is the most frequently isolated clinically relevant bacterial pathogen. Resistance for ciprofloxacin in Escherichia coli increased from 3% in 2005 to 2008 to 7% in 2009 to 2011 (P = .028). Resistance for cefotaxim in E. coli increased from 4% in 2005 to 2008 to 14% in 2009 to 2011, although this decrease was not statistically significant (P = .24). The prevalence of highly resistant microorganisms (HRMOs) remained low in both time periods, 4.9% in 2005 to 2008 and 7.4% in 2009 to 2011 (P = .063). The Netherlands is considered a low-prevalence country for antimicrobial resistance, and the occurrence of HRMOs in our center is relatively rare. A large percentage of HRMO isolates were extended spectrum &bgr;-lactamase producers, indicating the rapid increase in the production of this resistance mechanism in recent years. The transmission of HRMOs in our center is controlled effectively, using well-established transmission-based precautions.

Posttraumatic midshaft clavicular shortening does not result in relevant functional outcome changes.

Background and purpose — Shoulder function may be changed after healing of a nonoperatively treated clavicular fracture, especially in cases of clavicular shortening or mal-union. We investigated scapular orientations and functional outcome in healed clavicular fractures with and without clavicular shortening. Patients and methods — 32 participants with a healed nonoperatively treated midshaft clavicular fracture were investigated. Motions of the thorax, arm, and shoulder were recorded by standardized electromagnetic 3D motion tracking. The DASH score and Constant-Murley score were used to evaluate functional outcome. Orientation of the scapula and humerus at rest and during standardized tasks, and strength and function of the affected shoulders were compared with corresponding values for the uninjured contralateral shoulders. Results — Mean clavicular shortening was 25 mm (SD 16). Scapula protraction had increased by mean 4.4° in rest position in the affected shoulders. During abduction, slightly more protraction, slightly more lateral rotation, and slightly less backward tilt was found for the affected shoulders. For anteflexion, the scapular orientations of the affected shoulders also showed slightly increased protraction, slightly increased lateral rotation, and slightly reduced backward tilt. Scapulohumeral kinematics, maximum humerus angles, and strength were not associated with the degree of clavicular shortening. All participants had excellent performance on the Constant-Murley score and DASH score. Interpretation — Scapulohumeral kinematics in shoulders with a healed clavicular fracture differ from those in uninjured shoulders, but these changes are small, do not result in clinically relevant changes in outcome, and do not relate to the amount of clavicular shortening. These findings do not support routine operative reduction and fixation of shortened midshaft clavicular fractures based on the argument of functional outcome.

The relationship between trauma mechanism, fracture type, and treatment of midshaft clavicular fractures

Objective The debate on whether midshaft clavicular fractures should preferably be treated operatively or nonoperatively still continues. Several patient-related factors may influence this treatment decision. A retrospective study was carried out to determine the relation between fracture type and trauma mechanism, age and sex, and the influence of these factors on the choice of primary treatment. Methods Data on the trauma mechanism and treatment of 232 adult patients, who presented with a midshaft clavicular fracture in two hospitals in the Netherlands during the years 2006–2009, were collected. The extent of clavicular shortening, displacement, and fracture type on the primary radiograph were scored. Results Traffic accidents are the main cause of midshaft clavicular fractures. After correction for age, no relation was found between the trauma mechanism and the fracture type. Older age correlated with more comminuted and displaced fractures. Extensive shortening (>20 mm) was identified as the main clinical indication for primary surgery, whereas displacement and fracture classification seemed less relevant. Operative treatment was increasingly favored from 5% in 2006 to 44% in 2009, which could not be explained by an increase in more complex fractures or by age-related or trauma mechanism-related factors. Conclusion Age has a major influence on the fracture type, whereas the trauma mechanism does not. The choice for the surgical treatment of midshaft clavicular fractures is primarily determined by the amount of axial shortening of the clavicle, rather than by the overall displacement or fracture type. Over the years, the choice of treatment seems to have been increasingly influenced by the patient’s and surgeon’s preferences.

Plate Fixation Compared with Nonoperative Treatment for Displaced Midshaft Clavicular Fractures: A Multicenter Randomized Controlled Trial

Background: The use of operative treatment for clavicular fractures is increasing, despite varying results in previous studies. The aim of this study was to compare plate fixation and nonoperative treatment for displaced midshaft clavicular fractures with respect to nonunion, adverse events, and shoulder function. Methods: In this multicenter, prospective, randomized controlled trial, patients between 18 and 60 years old with a displaced midshaft clavicular fracture were randomized between nonoperative treatment and open reduction with internal plate fixation. The primary outcome was evidence of nonunion at 1 year. Other outcomes were secondary operations, arm function as measured with the Constant shoulder score and Disabilities of the Arm, Shoulder and Hand (DASH) score, pain, cosmetic results, and general health status. Outcomes were recorded at 6 weeks, 3 months, and 1 year following trauma. Results: One hundred and sixty patients were randomized. The rate of nonunion was significantly higher in the nonoperatively treated group than in the operatively treated group (23.1% compared with 2.4%; p < 0.0001), as was the rate of nonunion for which secondary plate fixation was performed (12.9% compared with 1.2%; p = 0.006). The rate of secondary operations was 27.4% in the operatively treated group (16.7% for elective plate removal) and 17.1% in the nonoperatively treated group (p = 0.18). Nineteen percent of the patients in the operatively treated group had persistent loss of sensation around the scar. No difference was found between the groups with respect to the Constant and DASH scores at all time points. Conclusions: For patients with a diaphyseal fracture of the clavicle displaced at least 1 shaft width, plate fixation improves the chances that the bone will heal; however, the rate of patients who need a second operation is considerable. In addition, the procedure does not improve shoulder function or general symptoms, and it does not decrease limitations compared with nonoperative treatment in a sling. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Polytrauma patients in the Netherlands and the USA: A bi-institutional comparison of processes and outcomes of care

BACKGROUND Modern trauma systems differ worldwide, possibly leading to disparities in outcomes. We aim to compare characteristics and outcomes of blunt polytrauma patients admitted to two Level 1 Trauma Centers in the US (USTC) and the Netherlands (NTC). METHODS For this retrospective study the records of 1367 adult blunt trauma patients with an Injury Severity Score (ISS) ≥ 16 admitted between July 1, 2011 and December 31, 2013 (640 from NTC, 727 from USTC) were analysed. RESULTS The USTC group had a higher Charlson Comorbidity Index (mean [standard deviation] 1.15 [2.2] vs. 1.73 [2.8], p<0.0001) and Injury Severity Score (median [interquartile range, IQR] 25 [17-29] vs. 21 [17-26], p<0.0001). The in-hospital mortality was similar in both centers (11% in USTC vs. 10% NTC), also after correction for baseline differences in patient population in a multivariable analysis (adjusted odds ratio 0.95, 95% confidence interval 0.61-1.48, p=0.83). USTC patients had a longer Intensive Care Unit stay (median [IQR] 4 [2-11] vs. 2 [2-7] days, p=0.006) but had a shorter hospital stay (median [IQR] 6 [3-13] vs. 8 [4-16] days, p<0.0001). USTC patients were discharged more often to a rehabilitation center (47% vs 10%) and less often to home (46% vs. 66%, p<0.0001), and had a higher readmission rate (8% vs. 4%, p=0.01). CONCLUSION Although several outcome parameters differ in two urban area trauma centers in the USA and the Netherlands, the quality of care for trauma patients, measured as survival, is equal. Other outcomes varied between both trauma centers, suggesting that differences in local policies and processes do influence the care system, but not so much the quality of care as reflected by survival.

Trauma systems around the world: A systematic overview

BACKGROUND Implementation of trauma care systems has resulted in improved patient outcomes, but international differences obviously remain. Improvement of care can only be established if we recognize and clarify these differences. The aim of the current review is to provide an overview of the recent literature on the state of trauma systems globally. METHODS The literature review over the period 2000 to 2016 was conducted following the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Prehospital care, acute hospital care and quality assurance were classified using the World Health Organization Trauma System Maturity Index in four levels from I (least mature) to IV (most mature). RESULTS The search yielded 93 articles about trauma systems in 32 countries: 23 high-income (HI), 8 middle-income (MI) countries and 1 low-income (LI) country. Trauma-related mortality was highest in the MI and LI countries. Level IV prehospital care with Advanced Life Support was established in 19 HI countries, in contrast to the MI and LI countries where this was only reported in Brazil, China, and Turkey. In 18 HI countries, a Level III/IV hospital-based trauma system was implemented, whereas in nine LI- and MI countries Level I/II trauma systems were seen, mostly lacking dedicated trauma centers and teams. A national trauma registry was implemented in 10 HI countries. CONCLUSION Despite the presence of seemingly sufficient resources and the evidence-based benefits of trauma systems, only nine of the 23 HI countries in our review have a well-defined and documented national trauma system. Although 90% of all lethal traumatic injuries occur in middle and LI countries, according to literature which our study is limited to, only few of these countries a hold formal trauma system or trauma registry. Much can be gained concerning trauma systems in these countries, but unfortunately, the economic situation of many countries may render trauma systems not at their top priority list. LEVEL OF EVIDENCE Systematic review, level III.