Nonoperative treatment of multiple rib fractures, the results to beat: International multicenter prospective cohort study among 845 patients.

BACKGROUND: Optimal treatment (i.e. nonoperative or operative) for patients with multiple rib fractures remains debated. Studies that compare treatments are rationalized by the alleged poor outcomes of nonoperative treatment. METHODS: The aim of this prospective international multicenter cohort study (between January 2018 and March 2021) with one-year follow-up, was to report contemporary outcomes of nonoperatively treated patients with multiple rib fractures. Including 845 patients with three or more rib fractures. Primary outcome was in-hospital mortality. Secondary outcomes included hospital length of stay (HLOS), (pulmonary) complications, and quality of life. RESULTS: Mean age was 57.7 ± 17.0 years, median Injury Severity Score was 17 (13-22) and the median number of rib fractures was 6 (4-8). In-hospital mortality rate was 1.5% (n = 13), 112 (13.3%) patients had pneumonia and four (0.5%) patients developed a symptomatic non-union. The median HLOS was 7 (4-13) days, and median intensive care unit length of stay was 2 (1-5) days. Mean EQ-5D-5L index value was 0.83 ± 0.18 one year after trauma. Polytrauma patients had a median HLOS of 10 (6-18) days, a pneumonia rate of 17.6% (n = 77) and mortality rate of 1.7% (n = 7). Elderly patients (≥65 years) had a median HLOS of 9 (5-15) days, a pneumonia rate of 19.7% (n = 57) and mortality rate of 4.1% (n = 12). CONCLUSIONS: Overall, nonoperative treatment of patients with multiple rib fractures shows low mortality and morbidity rate and good quality of life after one year. Future studies evaluating the benefit of operative stabilisation should use contemporary outcomes to establish the therapeutic margin of rib fixation. LEVEL OF EVIDENCE: Level III, Therapeutic/Care Management.

[Distal radius fracture-tactic and approach]. / Distale Radiusfrakturen ­ Taktik und Zugangswahl.

OBJECTIVE: The aim of surgical treatment is fracture healing with restored alignment, rotation, and joint surface. Stable fixation allows for functional postoperative aftercare. INDICATIONS: Displaced intra- and extra-articular fractures which either could not be adequately reduced or in which a secondary displacement is to expected due to instability criteria. The following factors are considered instability criteria: age > 60 years, female, initial dorsal displacement > 20°, dorsal comminution, radial shortening > 5 mm, palmar displacement. CONTRAINDICATIONS: The only absolute contraindication is if the patient is deemed unfit for surgery due to concerns regarding anesthesia. Old age is a relative contraindication, as it is currently debated whether older patients benefit from the operation. SURGICAL TECHNIQUE: The surgical technique is guided by the fracture pattern. Palmar plating is most commonly performed. If the joint surface needs to be visualized, a dorsal approach (in combination with another approach or alone) or arthroscopically assisted fixation should be chosen. POSTOPERATIVE MANAGEMENT: In general, a functional postoperative regime can be carried out after plate fixation with mobilization without weightbearing. Short-term splinting can provide pain relief. Concomitant ligamentous injuries and fixations, which are not stable enough for functional aftercare (such as k­wires) require a longer period of immobilization. RESULTS: Provided the fracture is reduced correctly, osteosynthesis improves functional outcome. The complication rate ranges between 9 and 15% with the most common complication being tendon irritation/rupture and plate removal. Whether surgical treatment holds the same benefits for patients > 65 years as for younger patients is currently under debate.

In patients with combined clavicle and multiple rib fractures, does fracture fixation of the clavicle improve clinical outcomes? A multicenter prospective cohort study of 232 patients.

BACKGROUND: Clavicle and rib fractures are often sustained concomitantly. The combination of injuries may result in decreased stability of the chest wall, making these patients prone to (respiratory) complications and prolonged hospitalization. This study aimed to assess whether adding chest wall stability by performing clavicle fixation improves clinical outcomes in patients with concurrent clavicle and rib fractures. METHODS: A prospective multicenter study was performed including all adult patients admitted between January 2018 and March 2021 with concurrent ipsilateral clavicle and rib fractures. Patients treated operatively versus nonoperatively for their clavicle fracture were matched using propensity score matching. The primary outcome was hospital length of stay (HLOS). Secondary outcomes were intensive care unit length of stay, duration of mechanical ventilation, pain, complications, and quality of life at 6 weeks and 12 months of follow-up. RESULTS: In total, 232 patients with concomitant ipsilateral clavicle and rib fractures were included. Fifty-two patients (22%) underwent operative treatment of which 39 could be adequately matched to 39 nonoperatively treated patients. No association was observed between clavicle plate fixation and HLOS (mean difference, 2.3 days; 95% confidence interval, -2.1 to 6.8; p = 0.301) or any secondary endpoint. Eight of the 180 nonoperatively treated patients (4%) had a symptomatic nonunion, for which 5 underwent secondary clavicle fixation. CONCLUSION: We found no evidence that, in patients with combined clavicle and multiple rib fractures, plate fixation of the clavicle reduces HLOS, pain, or (pulmonary) complications, nor that it improves quality of life. STUDY TYPE: Therapeutic/Care Management; Level III.

Quality of life and clinical outcomes of operatively treated patients with flail chest injuries: A multicentre prospective cohort study.

Introduction: Most studies about rib fractures focus on mortality and morbidity. Literature is scarce on long term and quality of life (QoL) outcomes. Therefore, we report QoL and long-term outcomes after rib fixation in flail chest patients. Methods: A prospective cohort study of clinical flail chest patients admitted to six level 1 trauma centres in the Netherlands and Switzerland between January 2018 and March 2021. Outcomes included in-hospital outcomes and long-term outcomes, such as QoL measurements 12 months after hospitalization using the EuroQoL five dimensions (EQ-5D) questionnaire. Results: Sixty-one operatively treated flail chest patients were included. Median hospital length of stay was 15 days and intensive care length of stay was 8 days. Sixteen (26%) patients developed pneumonia and two (3%) died. One year after hospitalization the mean EQ5D score was 0.78. Complication rates were low and included hemothorax (6%) pleural effusion (5%) and two revisions of the implant (3%). Implant related irritation was commonly reported by patients (n = 15, 25%). Conclusions: Rib fixation for flail chest injuries can be considered a safe procedure and with low mortality rates. Future studies should focus on quality of life rather than solely short-term outcomes.Trial registration: Registered in the Netherlands Trial Register NTR6833 on 13/11/2017 and the Swiss Ethics Committees Registration Number 2019-00668.

Validation of the modified AO sternum classification system.

INTRODUCTION: The Arbeitsgemeinschaft für Osteosynthesefragen (AO) foundation along with the Orthopaedic. Trauma Association (OTA) introduced a new classification for sternal fractures in 2018 aiming to provide greater uniformity and clinical utility for the surgical community. A previous validation study identified some critical issues such as the differentiation between type A and B fractures and localization of the fracture either in the manubrium or in the body. Due to the moderate agreement in inter- and intra-observer variability, some modifications were proposed in order to improve the performance of the classification. The aim of this study was to re-assess the inter- and intra-observer variability after adding modifications to the classification. Our hypothesis was that a significative improvement of inter- and intra-observer variability could be achieved. MATERIAL AND METHODS: Twenty computed tomography (CT) scans of patients with sternal fractures were analyzed by six. Junior and six senior surgeons independently. Two assessments were performed with an interval of 6 weeks. The kappa (K) value was calculated in order to assess inter- and intra-observer variability. RESULTS: The overall mean kappa value for inter-observer variability improved from 0.364 to 0.468 (p < 0.001). Inter-observer variability mean for location was 0.573 (SD 0.221) and for type was 0.441 (SD: 0.181). Intra-observer variability showed a mean of 0.703 (SD: 0.153) with a statistic significant improvement when compared to the previous study (mean 0.414, SD: 0.256, p < 0.001). CONCLUSIONS: By modifying the AO/OTA classification of sternal fractures, the inter- and intra-observer variability improved and now shows moderate to substantial agreement.

Non-operative vs. operative treatment for multiple rib fractures after blunt thoracic trauma: a multicenter prospective cohort study.

BACKGROUND: Patients with multiple rib fractures without a clinical flail chest are increasingly being treated with rib fixation; however, high-quality evidence to support this development is lacking. METHODS: We conducted a prospective multicenter observational study comparing rib fixation to non-operative treatment in all patients aged 18 years and older with computed tomography confirmed multiple rib fractures without a clinical flail chest. Three centers performed rib fixation as standard of care. For adequate comparison, the other three centers performed only non-operative treatment. As such clinical equipoise formed the basis for the comparison in this study. Patients were matched using propensity score matching. RESULTS: In total 927 patients with multiple rib fractures were included. In the three hospitals that performed rib fixation, 80 (14%) out of 591 patients underwent rib fixation. From the nonoperative centers, on average 71 patients were adequately matched to 71 rib fixation patients after propensity score matching. Rib fixation was associated with an increase in hospital length of stay (HLOS) of 4.9 days (95%CI 0.8-9.1, p = 0.02) and a decrease in quality of life (QoL) measured by the EQ5D questionnaire at 1 year of 0.1 (95% CI - 0.2-0.0, p = 0.035) compared to non-operative treatment. A subgroup analysis of patients who received operative care within 72 h showed a similar decrease in QoL. Up to 22 patients (28%) who underwent surgery experienced implant-related irritation. CONCLUSIONS: We found no benefits and only detrimental effects associated with rib fixation. Based on these results, we do not recommend rib fixation as the standard of care for patients with multiple rib fractures. TRIAL REGISTRATION: Registered in the Netherlands Trial Register NTR6833 on 13/11/2017.

[Augmentation in the treatment of proximal humeral and femoral fractures]. / Augmentation bei der Versorgung proximaler Humerus- und Femurfrakturen.

BACKGROUND: Proximal humeral and trochanteric femoral fractures in older patients are typically caused by low-energy trauma and are therefore often associated with osteoporosis. The treatment of such fragility fractures can be difficult as implant purchase is reduced in osteoporotic bone. By augmenting the fixation with cement the contact surface between implant and bone can be increased, which improves the stability of the osteosynthesis. OBJECTIVE: This article describes the operative technique for the augmentation of trochanteric femoral fractures treated with the Trochanteric Fixation Nail-Advanced (TFNA, DePuy Synthes, Oberdorf BL, Switzerland) and proximal humeral fractures stabilized with a PHILOS plate (DePuy Synthes). Furthermore, the evidence for the augmentation of these two fracture types is elucidated. RESULTS: Biomechanical studies could show an improved stability of the osteosynthesis after successful augmentation for both fracture types. The current evidence also indicates a clinical reduction of fixation failure. Whether the augmentation has an influence on the functional result could so far not yet clearly be proven. CONCLUSION: Augmentation seems to be a safe and valuable addition to available treatment options especially for patients with fragility fractures.

MIPO vs. intra-medullary nailing for extra-articular distal tibia fractures and the efficacy of intra-operative alignment control: a retrospective cohort of 135 patients.

INTRODUCTION: Definitive treatment of distal extra-articular fractures of the tibia is challenging and both minimal invasive plate osteosynthesis (MIPO) and intramedullary nailing (IMN) are considered to be feasible surgical modalities with their own implant-specific merits and demerits. This retrospective study was designed to compare MIPO versus IMN in terms of fracture healing, complications, functional and radiological outcomes and to assess the efficacy of intra-operative alignment control to reduce the rate of malalignment after definitive fixation of distal extra-articular fractures of the tibia. MATERIALS AND METHODS: All consecutive adult patients with extra-articular distal meta- or diaphyseal tibia fractures that were treated between January 2012 and September 2019 either with MIPO or IMN were included. Outcome measures included fracture healing, complications (infection, malalignment, subsequent surgeries), functional and radiological outcomes. Intra-operative alignment control encompassed bilateral draping of the lower extremities. RESULTS: A total of 135 patients were included out of which 72 patients (53%) were treated with MIPO and 63 patients (47%) underwent IMN. There was a significantly higher incidence of non-union for fractures treated with IMN (13 (22%) vs. 4 (6%), p = 0.04). There was no significant difference between both groups in terms of rotational malalignment (3% vs. 10%) and angular malalignment (4% vs. 5%). A significantly higher rate of infection was found after MIPO after correction of significant differences in baseline characteristics. No differences were found in subsequent surgeries or functional outcomes. CONCLUSION: Both MIPO and IMN are reliable surgical techniques. IMN is associated with higher rates of non-union, whereas MIPO results in a higher risk for infection. The incidence of malalignment was surprisingly low endorsing the utility of the intra-operative alignment control.

Nonunion of traumatic rib fractures: a suitable indication for surgery?

PURPOSE: Nonunion of traumatic rib fractures is a clinical/radiological diagnosis caused by an alteration of bone healing reparative process. Since it is a painful condition, nonunion has a significative impact on patient's morbidity and quality of life. The aim of this study was to evaluate the outcomes after surgical stabilization of ribs affected by nonunion after traumatic fractures. METHODS: We conducted a retrospective cohort analysis of all patients who were treated with surgical stabilization of nonunion after traumatic rib fractures. We analyzed demographic data as well as clinical and patient-reported outcomes. RESULTS: Nineteen patients were identified and included in this analysis. Median age was 49 years (range 25-69 years). Mean length of stay was 5.4 days. No in-hospital mortality was observed. After a median follow-up of 46.94 months (range 0-103), 16 (84.2%) patients were completely asymptomatic, while 3 (15.8%) were still suffering from pain after surgery. CONCLUSIONS: Surgical stabilization in patients affected by rib nonunion can be safely performed with few complications, good clinical outcomes and satisfactory quality of life.

Is there a need for standardized postoperative X-rays after operative treatment of clavicular fractures?

PURPOSE: In most hospitals, acquiring postoperative X-rays after operative treatment of a fracture is the standard. Its value, however, after operative treatment for clavicular fractures is questionable. The aim of this study was to evaluate how often there is a change in treatment plan due to the postoperative X-ray after operative treatment of clavicular fractures when intra-operative images were acquired. METHODS: This was a retrospective cohort study performed in a level I trauma center. All consecutive patients treated surgically for clavicular fractures between 2014 and 2018 were included. The primary outcome was any deviation from the standard postoperative protocol resulting from the routine postoperative X-ray taken within the first 72 h after surgery. Secondary outcomes included all other complications and re-interventions performed during follow-up of patients with at least 6-month follow-up. RESULTS: In total, 241 patients were included in the study with a mean age of 42 years (SD 17). Only one patient had an abnormality on postoperative X-ray necessitating additional CT-scanning. No additional re-interventions or deviations from standard postoperative protocol were required. For secondary analyses, 187 patients were available. Seven patients had a late implant associated infection: one was detected at the time of implant removal and six during revision for non-union. Six patients had aseptic complications: four with non-union and two with implant failure. One-hundred and seven patients had an implant removal due to irritation after consolidation. CONCLUSION: Routinely performing postoperative X-rays after osteosynthesis for clavicular fractures seems unnecessary. Refraining from performing unnecessary radiographs will decrease exposure to radiation and likely have a beneficial effect on costs, length of hospital stay as well as healthcare consumption. This study was performed in a single center; therefore, it remains to be seen whether the findings are reproducible in another setting.

The radiographic relationship between the cortical overlap view (COV) and the tip of the greater trochanter.

For proximal femoral nailing, choosing the proper entry point with the aid of C-arm imaging is crucial. Therefore, obtaining accurate radiological views that facilitate sound identification of the tip of the greater trochanter (GT) is of utmost importance. The aim of this study was to define a radiological view characterised by reproducible radiographic landmarks which will allow the reliable identification of the tip of the GT in the anteroposterior view. Anatomical and radiographic features of 16 cadaveric femurs were analysed. The cortical overlap view (COV), characterised by the radiological overlap of the density line of the piriform fossa and the intertrochanteric crest, was identified. It marks the rotation of the proximal femur at which the GT can be accurately identified and used to determine the desired entry point for a proximal femoral nail. Trainees and fully qualified orthopedic trauma surgeons were asked to identify the correct COV in radiological imaging series. Mean internal rotation of the femur to achieve a COV was 17.5° (range 12.8°-21.8°). In the COV the tip of the GT is the highest visible point and the mean distance from the cortical overlap line to the tip of the GT is 4.45 mm. Intra- and inter-rater reliability was high with ICC(2,k) = 0.932 and ICC(2,k) = 0.987 respectively. Trainees achieved higher rates of correct COV identification than specialists. There was no significant correlation between the internal rotation of the femur to achieve the COV and femoral antetorsion. In conclusion, the COV is a highly reproducible radiological view that is characterised by radiographic landmarks easy to recognise. It allows for accurate identification of the tip of the GT, which can be used by the surgeon as a reference to determine the desired entry point for an intramedullary nail.

Tibiotalocalcaneal Intramedullary Nailing for Unstable Geriatric Ankle Fractures.

BACKGROUND: Tibiotalocalcaneal (TTC) intramedullary nailing has been suggested as an alternative to open reduction and internal fixation (ORIF) for the primary treatment of unstable fragility ankle fractures with a poor soft tissue envelope. This study aims to investigate the clinical efficacy of TTC intramedullary nail fixation for the primary treatment of unstable ankle fractures in frail elderly patients with poor soft tissue condition, by assessing the number of postoperative complications and the patient-reported functional outcomes. METHODS: A retrospective cohort study was performed including patients with an unstable ankle fracture treated between 2015 and 2019 with TTC stabilization using a retrograde intramedullary hindfoot nail that was inserted without joint preparation and allowing immediate weight-bearing postoperatively. The primary outcome was the total number of postoperative complications. RESULTS: A total of 10 patients were included out of 365 operatively treated ankle fractures. The mean age was 85.2 years (range 66-92) with a mean follow-up of 11.2 months (range 6-16). Fracture types included AO/OTA 44-B2 (n = 1), 44-B3 (n = 6), 44-C1 (n = 2) and 44-C3 (n = 1). Postoperative complications were observed in 4 patients (40%), including 3 nonunions, 2 implant related complications and 1 wound infection. No wound healing disorder or below-the-knee amputation was observed. Four patients (40%) deceased between post-operative 6 to 16 months due to medical conditions unrelated to surgery. The mean Foot and Ankle Outcome Score was 52.6 (range 44.2-73.8). CONCLUSION: Hindfoot nailingis a viable treatment option in selected high-risk patients with an advanced age, unstable ankle fractures with significant bone loss, poor soft tissue condition and/or severely impaired pre-injury mobility. In a frail geriatric population, hindfoot nailing may be a safe alternative fixation method with a low risk of wound complication or major amputation. However, unprepared joint may lead to symptomatic nonunion after TTC intramedullary nailing.

Compartment syndrome of the leg after thyroid hormone withdrawal; two cases and a systematic review of the literature.

BACKGROUND: Acute compartment syndrome is a rare complication of severe hypothyroidism. If the symptoms are not recognized promptly and treatment initiated immediately, there is a high risk of permanent damage. Only few other cases of compartment syndrome due to hypothyroidism have been published and the exact pathophysiological mechanism remains unknown. CASE PRESENTATIONS: A 59 year old male developed acute compartment syndrome of his right lower leg after thyroid hormone withdrawal prior to radioiodine remnant ablation after total thyroidectomy for follicular thyroid cancer. He underwent emergency fasciotomy of all four compartments of the lower leg. The muscle tissue in the anterior and lateral compartment was necrotic and was therefore excised. The second patient was a 62 year old female with Hashimoto's thyroiditis, who developed acute compartment syndrome of both lower legs after thyroid hormone withdrawal due to non-compliance. Emergency fasciotomy of all four compartments of both legs was performed. The muscle tissue was viable in all compartments. CONCLUSION: Although compartment syndrome due to hypothyroidism is uncommon, it is a complication physicians should be aware of. The majority of reported cases are caused by an acute withdrawal of thyroid hormones and not by undetected hypothyroidism. No previous case of compartment syndrome caused by an iatrogenic hormone withdrawal in preparation for radioactive iodine has been published. However, as shown in this report, it may be beneficial to inform patients of this rare complication prior to hormone withdrawal in preparation for remnant ablation after thyroidectomy.

Compartment syndrome of the forearm caused by contrast medium extravasation: A case report and review of the literature.

Compartment syndrome is a rare but serious complication of contrast medium extravasation. To avoid permanent damage, it is important to recognize the symptoms quickly and immediately initiate treatment. We report a patient, who developed compartment syndrome of the forearm after extravasation of contrast medium and review the available literature on this subject. To our knowledge this is the first reported case of compartment syndrome of the forearm due to contrast medium application for a trauma CT in a patient that had no direct trauma to the affected limb.