Roderick M. Houwert

Weight-Bearing and Mobilization in the Postoperative Care of Ankle Fractures: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Cohort Studies

Purpose To determine the effectiveness and safety of interventions used for rehabilitation after open reduction and internal fixation of ankle fractures. Methods A systematic review and meta-analysis was performed using both randomized trials and cohort studies. The effect of mobilization, weight-bearing, and unprotected weight-bearing as tolerated on postoperative recovery was compared using the Olerud Molander score, return to work/daily activities, and the rate of complications. Results A total of 25 articles were included. Ankle exercises resulted in earlier return to work and/or daily activities compared to immobilization (mean difference (MD) -20.76 days; 95% confidence interval (CI) -40.02 to -1.50). There was no difference in the rate of complications between exercises and immobilization (risk ratio (RR) 1.22; 95% CI 0.60 to 2.45) or between early and late weight-bearing (RR 1.26; 95%CI 0.56 to 2.85). Interpretation Results of this meta-analysis show that following ankle surgery, 1) active exercises accelerate return to work and daily activities compared to immobilization, 2) early weight-bearing tends to accelerate return to work and daily activities compared to late weight-bearing. Active exercises in combination with immediate weight-bearing may be a safe option.

Plate fixation or intramedullary fixation for midshaft clavicle fractures: a systematic review and meta-analysis of randomized controlled trials and observational studies.

BACKGROUND The last decade has shown a shift toward operative treatment of a subset of midshaft clavicle fractures. However, it is unclear whether there are differences between plate fixation and intramedullary fixation regarding complications and functional outcome. The aim of this systematic review and meta-analysis was to compare plate fixation and intramedullary fixation for midshaft clavicle fractures. METHODS The Medline, Embase, and Cochrane databases were searched for both randomized controlled trials and observational studies. The methodologic quality of all included studies was assessed using the Methodological Index for Non-Randomized Studies. RESULTS Twenty studies were included. Ten of the 20 included studies used a fracture classification. Seven of these studies reported exclusion of patients with comminuted fractures. No difference in the total re-intervention rate was found (odds ratio [OR], 1.21; 95% confidence interval [CI], 0.71 to 2.04). Major re-interventions occurred more often after plate fixation (OR, 1.88; 95% CI, 1.02 to 3.46). The mean implant removal rates were 38% after plate fixation and 73% after intramedullary fixation. Re-fracture after implant removal occurred more often after plate fixation (OR, 3.42; 95% CI, 1.12 to 10.42). The Constant-Murley scores showed no differences at both short term (mean difference, -1.18; 95% CI, -13.41 to 11.05) and long term (mean difference, 0.15; 95% CI, -1.57 to 1.87). No differences were observed regarding nonunion (OR, 1.50; 95% CI, 0.82 to 2.75). The rate of infections showed no differences when outlier studies were excluded (OR, 1.54; 95% CI, 0.88 to 2.69). CONCLUSION Major re-intervention and re-fracture after implant removal occurred more frequently after plate fixation of non-comminuted, displaced midshaft clavicle fractures. No differences in terms of function and nonunion between plate fixation and intramedullary fixation were observed.

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.

Surgical Versus Nonsurgical Treatment for Midshaft Clavicle Fractures in Patients Aged 16 Years and Older: A Systematic Review, Meta-analysis, and Comparison of Randomized Controlled Trials and Observational Studies

Background: There is no consensus on the choice of treatment of midshaft clavicle fractures (MCFs). Purpose: The aims of this systematic review and meta-analysis were (1) to compare fracture healing disorders and functional outcomes of surgical versus nonsurgical treatment of MCFs and (2) to compare effect estimates obtained from randomized controlled trials (RCTs) and observational studies. Study Design: Systematic review and meta-analysis. Methods: The PubMed/MEDLINE, Embase, CENTRAL, and CINAHL databases were searched for both RCTs and observational studies. Using the MINORS instrument, all included studies were assessed on their methodological quality. The primary outcome was a nonunion. Effects of surgical versus nonsurgical treatment were estimated using random-effects meta-analysis models. Results: A total of 20 studies were included, of which 8 were RCTs and 12 were observational studies including 1760 patients. Results were similar across the different study designs. A meta-analysis of 19 studies revealed that nonunions were significantly less common after surgical treatment than after nonsurgical treatment (odds ratio [OR], 0.18 [95% CI, 0.10-0.33]). The risk of malunions did not differ between surgical and nonsurgical treatment (OR, 0.38 [95% CI, 0.12-1.19]). Both the long-term Disabilities of the Arm, Shoulder and Hand (DASH) and Constant-Murley scores favored surgical treatment (DASH: mean difference [MD], −2.04 [95% CI, −3.56 to −0.52]; Constant-Murley: MD, 3.23 [95% CI, 1.52 to 4.95]). No differences were observed regarding revision surgery (OR, 0.85 [95% CI, 0.42-1.73]). Including only high-quality studies, both the number of malunions and days to return to work show significant differences in favor of surgical treatment (malunions: OR, 0.26 [95% CI, 0.07 to 0.92]; return to work: MD, −8.64 [95% CI, −16.22 to −1.05]). Conclusion: This meta-analysis of high-quality studies showed that surgical treatment of MCFs results in fewer nonunions, fewer malunions, and an accelerated return to work compared with nonsurgical treatment. A meta-analysis of surgical treatments need not be restricted to randomized trials, provided that the included observational studies are of high quality.

Isolated hip fracture care in an inclusive trauma system: A trauma system wide evaluation

INTRODUCTION Elderly patients with a hip fracture represent a large proportion of the trauma population; however, little is known about outcome differences between different levels of trauma care for these patients. The aim of this study is to analyse the outcome of trauma care in patients with a hip fracture within our inclusive trauma system. MATERIALS AND METHODS Retrospective cohort study. Data were collected from the electronic patient documentation of patients, with an isolated hip fracture (aged ≥ 60), admitted to a level I or level II trauma centre between January 2008 and December 2012. Main outcomes were time to operative treatment, complications, mortality, and secondary surgical intervention rate. RESULTS A total of 204 (level I) and 1425 (level II) patients were admitted. Significantly more ASA4 patients, by the American Society of Anesthesiologists (ASA) classification, were treated at the level I trauma centre. At the level II trauma centre, median time to surgical treatment was shorter (0 days; IQR 0-1 vs 1 day; IQR 1-2; P < 0.001), which was mainly influenced by postponement due to lack of operation room availability (14%, n = 28) and co-morbidities (13%, n = 26) present at the level I trauma centre. At the level II trauma centre, hospital stay was shorter (9 vs 11 days; P < 0.001) and the complication rate was lower (41%; n = 590 vs 53%; n = 108; P = 0.002), as was mortality (4%; n = 54 vs 7%; n = 15; P = 0.018). Secondary surgical intervention was performed less often at the level II trauma centre (6%; n = 91 vs 12%; n = 24; P = 0.005). However, no differences in secondary surgical procedures due to inadequate postoperative outcome or implant failure were observed. CONCLUSION AND RELEVANCE The clinical pathway and the large volume of patients at the level II centre resulted in earlier surgical intervention, lower overall complication and mortality rate, and a shorter length of stay. Therefore, the elderly patient with a hip fracture should ideally be treated in the large-volume level II hospital with a pre-established clinical pathway. However, complex patients requiring specific care that can only be provided at the level I trauma centre may be treated there with similar operative results.

Tertiary survey in polytrauma patients should be an ongoing process

INTRODUCTION Due to prioritisation in the initial trauma care, non-life threatening injuries can be overlooked or temporally neglected. Polytrauma patients in particular might be at risk for delayed diagnosed injuries (DDI). Studies that solely focus on DDI in polytrauma patients are not available. Therefore the aim of this study was to analyze DDI and determine risk factors associated with DDI in polytrauma patients. METHODS In this single centre retrospective cohort study, patients were considered polytrauma when the Injury Severity Score was ≥ 16 as a result of injury in at least 2 body regions. Adult polytrauma patients admitted from 2007 until 2012 were identified. Hospital charts were reviewed to identify DDI. RESULTS 1416 polytrauma patients were analyzed of which 12% had DDI. Most DDI were found during initial hospital admission after tertiary survey (63%). Extremities were the most affected regions for all types of DDI (78%) with the highest intervention rate (35%). Most prevalent DDI were fractures of the hand (54%) and foot (38%). In 2% of all patients a DDI was found after discharge, consisting mainly of injuries other than a fracture. High energy trauma mechanism (OR 1.8, 95% CI 1.2-2.7), abdominal injury (OR 1.5, 95% CI 1.1-2.1) and extremity injuries found during initial assessment (OR 2.3, 95% CI 1.6-3.3) were independent risk factors for DDI. CONCLUSION In polytrauma patients, most DDI were found during hospital admission but after tertiary survey. This demonstrates that the tertiary survey should be an ongoing process and thus repeated daily in polytrauma patients. Most frequent DDI were extremity injuries, especially injuries of the hand and foot.

Comparison of analgesic interventions for traumatic rib fractures: a systematic review and meta-analysis

PurposeMany studies report on outcomes of analgesic therapy for (suspected) traumatic rib fractures. However, the literature is inconclusive and diverse regarding the management of pain and its effect on pain relief and associated complications. This systematic review and meta-analysis summarizes and compares reduction of pain for the different treatment modalities and as secondary outcome mortality during hospitalization, length of mechanical ventilation, length of hospital stay, length of intensive care unit stay (ICU) and complications such as respiratory, cardiovascular, and/or analgesia-related complications, for four different types of analgesic therapy: epidural analgesia, intravenous analgesia, paravertebral blocks and intercostal blocks.MethodsPubMed, EMBASE and CENTRAL databases were searched to identify comparative studies investigating epidural, intravenous, paravertebral and intercostal interventions for traumatic rib fractures, without restriction for study type. The search strategy included keywords and MeSH or Emtree terms relating blunt chest trauma (including rib fractures), analgesic interventions, pain management and complications.ResultsA total of 19 papers met our inclusion criteria and were finally included in this systematic review. Significant differences were found in favor of epidural analgesia for the reduction of pain. No significant differences were observed between epidural analgesia, intravenous analgesia, paravertebral blocks and intercostal blocks, for the secondary outcomes.ConclusionsResults of this study show that epidural analgesia provides better pain relief than the other modalities. No differences were observed for secondary endpoints like length of ICU stay, length of mechanical ventilation or pulmonary complications. However, the quality of the available evidence is low, and therefore, preclude strong recommendations.

Comparing fracture healing disorders and long-term functional outcome of polytrauma patients and patients with an isolated displaced midshaft clavicle fracture.

BACKGROUND Although clavicle fractures are a common injury in polytrauma patients, the functional outcome of displaced midshaft clavicle fractures (DMCFs) in this population is unknown. Our hypothesis was that there would be no differences in fracture healing disorders or functional outcome in polytrauma patients with a DMCF compared with patients with an isolated DMCF, regardless of the treatment modality. METHODS A retrospective cohort study of patients (treated at our level I trauma center) with a DMCF was performed and a follow-up questionnaire was administered. Polytrauma patients, defined as an Injury Severity Score ≥16, and those with an isolated clavicle fracture were compared. Fracture healing disorders (nonunion and delayed union) and delayed fixation rates were determined. Functional outcome was assessed by the Quick Disability of the Arm, Shoulder, and Hand questionnaire. RESULTS A total of 152 patients were analyzed, 71 polytrauma patients and 81 patients with an isolated DMCF. Questionnaire response of 121 patients (80%) was available (mean, 53 months; standard deviation, 22 months). No differences were found between polytrauma patients and those with an isolated DMCF with regard to nonunion (7% vs. 5%, respectively), delayed union (4% vs. 4%), and delayed fixation rate (13% vs. 13%). Polytrauma patients had an overall worse functional outcome, regardless of initial nonoperative treatment or delayed operative fixation. CONCLUSION Polytrauma patients had a similar nonunion and delayed fixation rate but had an overall worse functional outcome compared with patients with an isolated DMCF. For polytrauma patients, a wait and see approach can be advocated without the risk of decreased upper extremity function after delayed fixation.

Fractures and dislocations of the hand in polytrauma patients: Incidence, injury pattern and functional outcome

INTRODUCTION Injuries of the hand can cause significant functional impairment, diminished quality of life and delayed return to work. However, the incidence and functional outcome of hand injuries in polytrauma patients is currently unknown. The aim of this study was to determine the incidence, distribution and functional outcome of fractures and dislocation of the hand in polytrauma patients. METHODS A single centre retrospective cohort study was performed at a level 1 trauma centre. Polytrauma was defined as patients with an Injury Severity Score of 16 or higher. Fractures and dislocations to the hand were determined. All eligible polytrauma patients with hand injuries were included and a Quick Disability of Arm, Shoulder and Hand questionnaire (QDASH) and Patient-Rated Wrist/Hand Evaluation (PRWHE) were administered. Patients were contacted 1-6 years after trauma. RESULTS In a cohort of 2046 polytrauma patients 72 patients (3.5%) suffered a hand injury. The functional outcome scores of 52 patients (72%) were obtained. The Metacarpal (48%) and carpal (33%) bones were the most frequently affected. The median QDASH score for all patients with hand injury was 17 (IQR 0-31) and the PRWHE 14 (IQR 0-41). Patients with a concomitant upper extremity injury (p=0.002 for PRWHE, p0.006 for QDASH) and those with higher ISS scores (p=0.034 for PRWHE, QDASH not significant) had worse functional outcome scores. As an example, of the 5 patients with the worst outcome scores 3 suffered an isolated phalangeal injury, all had concomitant upper extremity injury or neurological injuries (3 plexus injuries, 1 severe brain injury). CONCLUSION The incidence of hand injuries in polytrauma patients is 3.5%, which is relatively low compared to a general trauma population. Metacarpal and carpal bones were most frequently affected. The functional extremity specific outcome scores are highly influenced by concomitant injuries (upper extremity injuries, neurological injuries and higher ISS).

Factors Associated With Wound- and Implant-Related Complications After Surgical Treatment of Ankle Fractures

Abstract We have described the epidemiology of complications after surgical treatment of ankle fractures and assessed which factors are associated with the most frequent complications. We conducted a retrospective cohort study at 2 level 2 and 1 level 1 trauma center in a single trauma region in the Netherlands. The study variables were collected from the electronic medical patient records; all ankle fractures were classified using the Lauge‐Hansen classification, and the complications were recorded. A total of 989 patients were included from 3 hospitals, with 173 complications in 156 patients (15.8%). The most frequent complication was wound related, occurring in 101 patients (10.2%). Implant‐related complications occurred in 44 patients (4.4%). Other complications, such as cast pressure spots, posttraumatic dystrophy, nonunion, impingement, and pneumonia occurred in 28 patients (2.8%). The 2 most important complications were further analyzed for risk factors. Multivariate analysis showed the risk factors for wound‐related complications were advanced age, increased American Society of Anesthesiologists classification, smoking, right side symptomatic, open fracture, and initial external fixation. Most implant‐related complications were caused by malreduction (n = 22) or untreated syndesmotic injury (n = 19). Malreduction was associated with supination eversion fractures (p = .059), and untreated syndesmotic injury occurred more often with pronation external rotation fractures (p < .001). The most frequent complications after ankle fracture surgery were wound‐ and implant‐related complications. Postoperative wound‐related complications were multifactorial and dependent on a combination of trauma‐, patient‐, and treatment‐related factors. In contrast, implant‐related complications resulted from the interaction between the fracture type and subsequent surgical treatment. &NA; Level of Clinical Evidence: 3