Robert Haverlag

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).

Surgery versus conservative treatment in patients with type A distal radius fractures, a randomized controlled trial

BackgroundFractures of the distal radius are common and account for an estimated 17% of all fractures diagnosed. Two-thirds of these fractures are displaced and require reduction. Although distal radius fractures, especially extra-articular fractures, are considered to be relatively harmless, inadequate treatment may result in impaired function of the wrist. Initial treatment according to Dutch guidelines consists of closed reduction and plaster immobilisation. If fracture redisplacement occurs, surgical treatment is recommended. Recently, the use of volar locking plates has become more popular. The aim of this study is to compare the functional outcome following surgical reduction and fixation with a volar locking plate with the functional outcome following closed reduction and plaster immobilisation in patients with displaced extra-articular distal radius fractures.DesignThis single blinded randomised controlled trial will randomise between open reduction and internal fixation with a volar locking plate (intervention group) and closed reduction followed by plaster immobilisation (control group). The study population will consist of all consecutive adult patients who are diagnosed with a displaced extra-articular distal radius fracture, which has been adequately reduced at the Emergency Department. The primary outcome (functional outcome) will be assessed by means of the Disability Arm Shoulder Hand Score (DASH). Secondary outcomes comprise the Patient-Rated Wrist Evaluation score (PRWE), quality of life, pain, range of motion, radiological parameters, complications and cross-overs. Since the treatment allocated involves a surgical procedure, randomisation status will not be blinded. However, the researcher assessing the outcome at one year will be unaware of the treatment allocation. In total, 90 patients will be included and this trial will require an estimated time of two years to complete and will be conducted in the Academic Medical Centre Amsterdam and its partners of the regional trauma care network.DicussionIdeally, patients would be randomised before any kind of treatment has been commenced. However, we deem it not patient-friendly to approach possible participants before adequate reduction has been obtained.Trial registrationThis study is registered at the Netherlands Trial Register (NTR3113) and was granted permission by the Medical Ethical Review Committee of the Academic Medical Centre on 01-10-2012.

Trauma surgery by general surgeons: Still an option for proximal femoral fractures?

INTRODUCTION Surgery for proximal femoral fractures in the Netherlands is performed by trauma surgeons, general surgeons and orthopaedic surgeons. The aim of this study was to assess whether there is a difference in outcome for patients with proximal femoral fractures operated by trauma surgeons versus general surgeons. Secondly, the relation between hospital and surgeon volume and postoperative complications was explored. METHODS Patients of 18 years and older were included if operated for a proximal femoral fracture by a trauma surgeon or a general surgeon in two academic, eight teaching and two non-teaching hospitals in the Netherlands from January 2010 until December 2013. The combined endpoint was defined as reoperation or surgical site infection. Multivariate analysis was used to adjust for patient and fracture characteristics and hospital and surgeon volume. Categories for hospital volume were>170/year (high volume), 96-170/year (medium volume) and <96/year (low volume). RESULTS In 4552 included patients 2382 (52.3%) had surgery by a trauma surgeon. Postoperative complications occurred in 276 (11.6%) patients operated by a trauma surgeon and in 258 (11.9%) operated by a general surgeon (p=0.751). When considering confounders in a multivariate analysis, surgery by trauma surgeons was associated with less postoperative complications (OR 0.746; 95%CI 0.580-0.958; p=0.022). Surgery in high volume hospitals was also associated with less complications (OR 0.997; 95%CI 0.995-0.999; p=0.012). Surgeon volume was not associated with complications (OR 1.008; 95%CI 0.997-1.018; p=0.175). CONCLUSION Surgery by trauma surgeons and high hospital volume are associated with less reoperations and surgical site infections for patients with proximal femoral fractures.

Classification systems for distal radius fractures: Does the reliability improve using additional computed tomography?

Background and purpose — The reliability of conventional radiography when classifying distal radius fractures (DRF) is fair to moderate. We investigated whether reliability increases when additional computed tomography scans (CT) are used. Patients and methods — In this prospective study, we performed pre- and postreduction posterior–anterior and lateral radiographs of 51 patients presenting with a displaced DRF. The case was included when there was a (questionable) indication for surgical treatment and an additional CT was conducted within 5 days. 4 observers assessed the cases using the Frykman, Fernández, Universal, and AO classification systems. The first 2 assessments were performed using conventional radiography alone; the following 2 assessments were performed with an additional CT. We used the intraclass correlation coefficient (ICC) to evaluate reliability. The CT was used as a reference standard to determine the accuracy. Results — The intraobserver ICC for conventional radiography alone versus radiography and an additional CT was: Frykman 0.57 vs. 0.51; Fernández 0.53 vs. 0.66; Universal 0.57 vs. 0.64; AO 0.59 vs. 0.71. The interobserver ICC was: Frykman: 0.45 vs. 0.28; Fernández: 0.38 vs. 0.44; Universal: 0.32 vs. 0.43; AO: 0.46 vs. 0.40. Interpretation — The intraobserver reliability of the classification systems was fair but improved when an additional CT was used, except for the Frykman classification. The interobserver reliability ranged from poor to fair and did not improve when using an additional CT. Additional CT scanning has implications for the accuracy of scoring the fracture types, especially for simple fracture types.

Coverage of Exposed Bone of the Lateral Malleolus With a Proximally Based Lateral Malleolar Perforator Flap

The treatment of soft tissue defects of the ankle, combined with an implant-related infection, remains a challenge. The present case report illustrates the use of a pedicled perforator flap for soft tissue reconstruction to cover a postoperative defect at the lateral malleolus after an ankle fracture.

Complete Avulsion of the Pectoralis Major Tendon: a Case Report

Rupture of the pectoralis major muscle is a rare injury, usually occurring during sports activities or after direct trauma. This article describes the clinical presentation, diagnostic tools and treatment of a patient with a complete avulsion of the pectoralis major tendon.

Tromboseprofylaxe bij traumapatiënten: number and costs needed to treat

Inleiding. Bij 6 tot 60% van de traumapatienten komen (a)symptomatische veneuze trombo-embolieen (VTE) voor. Preventie van VTE is dan ook een belangrijk onderdeel van de behandeling van alle traumapatienten. Als ‘gouden standaard’ gelden de laagmoleculaire heparinen (LMWH). De laatste jaren is er meer wetenschappelijk bewijs gekomen voor het nut van tromboseprofylaxe bij traumapatienten. Er is bewijs voor het feit dat ook asymptomatische diepe veneuze trombose vaak een voorstadium is van symptomatische VTE. De vraag is echter hoe groot het number needed to treat (NNT) is om een geval van VTE te voorkomen en wat de kosten daarvan zijn. Het doel van dit artikel was het onderzoeken van het sterkste bewijs voor tromboseprofylaxe per categorie traumapatienten en het beschrijven van het NNT en de geassocieerde kosten. Methoden. Op basis van de beste beschikbare klinische onderzoeken werd het NNT berekend per categorie traumapatienten. Voor de kostenanalyse werd gebruikgemaakt van de kosten per standaarddosering volgens het Farmacotherapeutisch Kompas. Om de kosten voor prikinstructie te dekken, werd € 5,- bij de medicatiekosten opgeteld. Op basis van wat bekend is over het natuurlijk beloop van asymptomatische trombose, werd geschat dat circa 50% van de trombi symptomatisch wordt. Resultaten. Bij letsels van de onderste extremiteit behandeld met immobilisatie geeft LMWH een absolute reductie in VTE van 7,5% (NNT = 13). Bij zes weken profylaxe bedragen de kosten € 927,68. De geschatte absolute reductie in symptomatische VTE is 4% (NNT = 25). Bij zes weken profylaxe bedragen de kosten € 1784,-. Bij patienten met een heupfractuur geeft fondaparinux een absolute reductie in asymptomatische VTE van 33,6% (NNT = 3). Bij vier weken profylaxe bedragen de kosten € 603,-. De geschatte absolute reductie in symptomatische trombose is 16,5% (NNT = 6). De kosten bij vier weken profylaxe bedragen €1206,-. Bij polytraumapatienten bleek LMWH beter en goedkoper te zijn dan ongefractioneerde heparine. Er zijn geen placebogecontroleerde tromboseprofylaxestudies bij neurotraumapatienten en patienten met brandwonden bekend. Conclusie. Bij de meeste categorieen traumapatienten is er solide bewijs voor tromboseprofylaxe, en ook bij poly- en neurotraumapatienten lijkt er een trend te bestaan voor het uitbreiden van de indicaties. De NNT’s liggen tussen 3 en 25 en de kosten voor het voorkomen van een VTE bedragen tussen € 603,- en € 1784,-.