Maturation of trauma systems in Europe.

PURPOSE: To provide an overview of trauma system maturation in Europe. METHODS: Maturation was assessed using a self-evaluation survey on prehospital care, facility-based trauma care, education/training, and quality assurance (scoring range 3-9 for each topic), and key infrastructure elements (scoring range 7-14) that was sent to 117 surgeons involved in trauma, orthopedics, and emergency surgery, from 24 European countries. Average scores per topic were summed to create a total score on a scale from 19 to 50 per country. Scores were compared between countries and between geographical regions, and correlations between scores on different sections were assessed. RESULTS: The response rate was 95%. On the scale ranging from 19 to 50, the mean (SD, range) European trauma system maturity score was 38.5 (5.6, 28.2-48.0). Prehospital care had the highest mean score of 8.2 (0.5, 6.9-9.0); quality assurance scored the lowest 5.9 (1.7, 3.2-8.5). Facility-based trauma care was valued 6.9 (1.4, 4.1-9.0), education and training 7.0 (1.2, 5.2-9.0), and key infrastructure elements 10.3 (1.6, 7.6-13.5). All aspects of trauma care maturation were strongly correlated (r > 0.6) except prehospital care. End scores of Northern countries scored significantly better than Southern countries (p = 0.03). CONCLUSION: The level of development of trauma care systems in Europe varies greatly. Substantial improvements in trauma systems in several European countries are still to be made, especially regarding quality assurance and key infrastructure elements, such as implementation of a lead agency to oversee the trauma system, and funding for growth, innovation and research.

Pediatric Trauma in The Netherlands: Incidence, Mechanism of Injury and In-Hospital Mortality.

BACKGROUND: In the Netherlands, there are no specialized or certified pediatric trauma centers, especially for severely injured children. National and regional agreements on centralization of pediatric trauma care are scarce. This study aims to describe the incidence, injury mechanism and in-hospital mortality of pediatric trauma in the Netherlands, as a prelude to the further organization of pediatric trauma care. METHODS: A retrospective cohort analysis of data from the Dutch National Trauma Registry in 2009-2018, concerning all children (0-16 years) hospitalized due to injury in the Netherlands. RESULTS: The annual number of admitted injured children increased from 8666 in 2009 to 13,367 in 2018. Domestic accidents were the most common cause of non-fatal injury (67.9%), especially in children aged 0-5 years (89.2%). Severe injury (injury severity score ≥  16) accounted for 2.5% and 74% of these patients were treated in level-1 trauma centers. In both deceased and surviving patients with severe injuries, head injuries were the most common (72.1% and 64.3%, respectively). In-hospital mortality after severe injury was 8.2%. Road-traffic accidents (RTAs) were the leading cause of death (46.5%). CONCLUSIONS: Domestic accidents are the most common cause of injury, especially in younger children, whereas RTAs are the lead cause of fatal injury. Severe pediatric trauma in the Netherlands is predominantly managed in level-1 trauma centers, where a multidisciplinary team of experts is available. Improving the numbers of severely injured patients primarily brought to level-1 trauma centers may help to further reduce mortality.

Is hospital volume related to quality of hip fracture care? Analysis of 43,538 patients and 68 hospitals from the Dutch Hip Fracture Audit.

PURPOSE: Evidence for a hospital volume-outcome relationship in hip fracture surgery is inconclusive. This study aimed to analyze the association between hospital volume as a continuous parameter and several processes and outcomes of hip fracture care. METHODS: Adult patients registered in the nationwide Dutch Hip Fracture Audit (DHFA) between 2018 and 2020 were included. The association between annual hospital volume and turnaround times (time on the emergency ward, surgery < 48 h and length of stay), orthogeriatric co-treatment and case-mix adjusted in-hospital and 30 days mortality was evaluated with generalized linear mixed models with random effects for hospital and treatment year. We used a fifth-degree polynomial to allow for nonlinear effects of hospital volume. P-values were adjusted for multiple comparisons using the Bonferoni method. RESULTS: In total, 43,258 patients from 68 hospitals were included. The median annual hospital volume was 202 patients [range 1-546]. Baseline characteristics did not differ with hospital volume. Provision of orthogeriatric co-treatment improved with higher volumes but decreased at > 367 patients per year (p < 0.01). Hospital volume was not significantly associated with mortality outcomes. No evident clinical relation between hospital volume and turnaround times was found. CONCLUSION: This is the first study analyzing the effect of hospital volume on hip fracture care, treating volume as a continuous parameter. Mortality and turnaround times showed no clinically relevant association with hospital volume. The provision of orthogeriatric co-treatment, however, increased with increasing volumes up to 367 patients per year, but decreased above this threshold. Future research on the effect of volume on complications and functional outcomes is indicated.

The relation between surgical approaches for pelvic ring and acetabular fractures and postoperative complications: a systematic review.

INTRODUCTION: Although many articles report complications after pelvic ring and acetabular fracture surgery, a general overview of complication rates and potential risk factors is lacking. The current review provides a comprehensive summary of the complications after pelvic ring and acetabular fracture surgery in relation to the surgical approach. MATERIAL AND METHODS: Pubmed and Embase databases were systematically searched using the key words: pelvic fracture, acetabular fracture, fixation, surgical approaches, complications, and their synonyms. Extracted data included patient and fracture characteristics, surgical approaches, and post-operative complications; surgical site infections (SSI), implant-related complications, malunion and non-union. Study data were summarized using descriptive statistics. RESULTS: Twenty-two studies (twenty-one retrospective cohort studies, of which three comparative, and one randomized controlled trial) were included in this review. The overall complication rates reported for the included surgical approaches were: 17% for the (Modified) Stoppa approach, 11% for percutaneous fixation, 5% for the Kocher-Langenbeck approach, 7% for the ilioinguinal approach and 31% for external fixation. The most frequent complications were SSI (22%) and neurological (31%) complications, which were most often reported in patients treated with an external fixator. Re-operation rates were comparable for the surgical approaches (4-8%). Two studies reported on risk factors and identified concomitant traumatic injuries, prolonged ICU stay and high body mass index as risk factors for SSI. CONCLUSION: External fixation of pelvic fractures is associated with highest complications rates including SSI's and neurological complications. Although post-operative complications are frequently reported after pelvic fracture surgery, more studies are needed that identify potential risk factors. These will assist the surgeon in (pre)operative decision making and development of preventive strategies.

Variation in posterior fragment fixation in the Netherlands: a nationwide study.

PURPOSE: The treatment of the posterior fragment in trimalleolar fractures differs from hospital to hospital in the Netherlands. A nationwide survey was performed to evaluate the fixation criteria and practice variation. METHODS: An online cross-sectional survey amongst (orthopaedic) trauma surgeons was performed in the Netherlands. It consisted of three sections: a general section, a section showing preoperative images of six cases and a section with postoperative images of nine cases. RESULTS: A total of 151 surgeons completed the online survey. 45% of the respondents indicated that they fixated the posterior fragment if smaller than 25% of the intra-articular surface. 48% preferred an open posterior approach to fixate the posterior fragment. There was good consensus in treatment for the two cases with Bartonicek type 4 fractures (operative treatment in 73 and 72% respectively). Little consensus was found for Bartonicek type 2 and 3 fractures (88% opted for operative treatment in one case, but 89% for conservative treatment in the second case). Reoperation was mostly considered in cases with a step-off of more than 1 mm (by 33-38% of the respondents). There was great variation in the choice of treatment if only the size of the posterior fragment was considered. Other fixation criteria such as postoperative step-off or instability after fixation of the lateral and medial malleoli are taken into account. In cases where fixation was needed, a percutaneous approach and an open posterolateral approach were equally preferred. CONCLUSIONS: There is much variation in treatment of the posterior malleolar fracture amongst orthopaedic and trauma surgeons in the Netherlands. The percutaneous approach and open posterolateral approach to fixate the posterior malleolar fracture seem to be equally used in the Netherlands. Still, there is no uniformity in treatment of posterior malleolar fracture, especially for Bartonicek 2 and Bartonicek 3 fractures. Reoperation is considered by less than half of the surgeons in case of postoperative persistent step-off of more than 1 mm.

Systematic Review of the Association Between Trauma Severity and Postinjury Symptoms of Depression.

BACKGROUND: Greater symptoms of depression are associated with greater symptom intensity during recovery from musculoskeletal injury. It is not clear that more severe trauma is associated with greater symptoms of depression as one might expect. The goal of this study was to systematically review the existing evidence regarding the association of Injury Severity Score (ISS) with symptoms of depression during recovery from musculoskeletal injury. METHODS: Two independent reviewers used PubMed and Embase to identify studies that measured both ISS and symptoms of depression. Among the 17 studies satisfying inclusion criteria, 5 studies assessed the correlation of symptoms of depression and ISS on their continuum; 3 studies compared the mean of symptoms of depression for people above and below a specific ISS level; five compared mean ISS above and below a threshold level of symptoms of depression; and four compared dichotomized ISS and dichotomized depression. Four of the 17 evaluated factors associated with symptoms of depression in multivariable analysis. RESULTS: In bivariate analysis, 12 of 17 studies (71%) found no association between ISS level and symptoms of depression. Three studies found a bivariate association that did not persist in multivariable analysis. Two studies reported slight associations in bivariate analysis, but did not perform multivariable analysis. CONCLUSIONS: The knowledge that symptoms of depression are common during recovery, in combination with the finding of this review that they have little or no relationship with injury severity, directs clinicians to anticipate and address mental health during recovery from physical trauma of any severity.

Serum sclerostin levels in osteoporotic fracture patients.

PURPOSE: Sclerostin inhibits bone formation and stimulates bone resorption. Previous studies found a positive association between bone density and serum sclerostin, but literature on sclerostin levels in osteoporotic fracture patients is scarce. The aim of the present study was to compare the serum sclerostin levels in osteoporotic and non-osteoporotic fracture patients and to assess the correlation of the sclerostin levels with bone mineral density and vitamin D status. METHODS: In this cross-sectional study, we included patients over 50 years, with an extremity fracture after low-energy trauma treated between 2012 and 2018, with biobank samples and available bone density measurements by Dual X-ray Absorption. Osteoporosis was diagnosed according the World Health Organisation criteria. Vitamin D deficiency was defined as a 25(OH)D concentration < 30 nmol/L. After defrosting biobank samples, serum sclerostin was measured using the human SOST (sclerostin) enzyme-linked immunosorbent assay kit. We prespecified a subgroup analysis including only female patients. RESULTS: 179 patients were included of whom 139(78%) were female. In 46 patients (25.7%), osteoporosis was diagnosed. Bone mineral density was positively associated with sclerostin levels (r = 0.17, p = 0.026) and patients with osteoporosis had a significantly lower serum sclerostin compared to non-osteoporotic fracture patients (mean 41.9 pmol/L vs 48.1 pmol/L; p = 0.03). This difference remained significant after correction for potential confounders. Similar results were found in the subgroup of female patients. No association between serum sclerostin and vitamin D deficiency was found. CONCLUSION: Osteoporotic fracture patients had lower levels of sclerostin than non-osteoporotic fracture patients. Future research should focus on the use of sclerostin as biomarker for osteoporosis in fracture patients.

Agreement on fixation of pediatric supracondylar humerus fractures.

BACKGROUND: Pediatric supracondylar humerus fractures (pSCHFs) may be challenging injuries to treat because of the potential residual deformity. There is debate regarding the technical aspects of adequate closed reduction and crossed Kirschner wire (K-wire) fixation. PURPOSE: Do surgeons have an agreement on the aspects of the fixation of pSCHFs? METHODS: Radiographs of 20 patients from a cohort of 154 patients with pSCHFs treated with closed reduction and crossed K-wire fixation were selected. Forty-four surgeons viewed the postoperative radiographs and diagnosed the presence or absence of technical flaws and made a recommendation for or against reoperation. An expert panel of three orthopedic and trauma surgeons provided a reference standard for technical factors. Furthermore, final outcome 2 years after trauma was assessed. RESULTS: There was limited agreement on potential technical flaws (ICC 0.15-0.28), radiographic measures of alignment (ICC for anterior humeral line and Baumann angle of 0.37 and 0.23 respectively), the quality of postoperative reduction, position of the elbow in cast, and recommendation for repeat surgery (ICCs between 0.23 and 0.40). Sensitivity and specificity for these questions ranged from 0.59 to 0.90. There was no correlation between the voted quality of postoperative reduction and loss of reduction or final function. CONCLUSIONS: Surgeons have limited agreement on the quality of postoperative results in pSCHFs and the indication for reoperation. Reviewing postoperative radiographs may present a good learning opportunity and could help improve skills, but it is not a validated method for quality control and has to be seen in light of clinical outcome.

Treatment and outcomes of anticoagulated geriatric trauma patients with traumatic intracranial hemorrhage after falls.

INTRODUCTION: Emergency physicians and trauma surgeons are increasingly confronted with pre-injury direct oral anticoagulants (DOACs). The objective of this study was to assess if pre-injury DOACs, compared to vitamin K antagonists (VKA), or no oral anticoagulants is independently associated with differences in treatment, mortality and inpatient rehabilitation requirement. METHODS: We performed a review of the prospectively maintained institutional trauma registry at an urban academic level 1 trauma center. We included all geriatric patients (aged ≥ 65 years) with tICH after a fall, admitted between January 2011 and December 2018. Multivariable logistic regression analysis controlling for demographics, comorbidities, vital signs, and tICH types were performed to identify the association between pre-injury anticoagulants and reversal agent use, neurosurgical interventions, inhospital mortality, 3-day mortality, and discharge to inpatient rehabilitation. RESULTS: A total of 1453 tICH patients were included (52 DOAC, 376 VKA, 1025 control). DOAC use was independently associated with lower odds of receiving specific reversal agents [odds ratio (OR) 0.28, 95% confidence interval (CI) 0.15-0.54] than VKA patients. DOAC use was independently associated with requiring neurosurgical intervention (OR 3.14, 95% CI 1.36-7.28). VKA use, but not DOAC use, was independently associated with inhospital mortality, or discharge to hospice care (OR 1.62, 95% CI 1.15-2.27) compared to controls. VKA use was independently associated with higher odds of discharge to inpatient rehabilitation (OR 1.41, 95% CI 1.06-1.87) compared to controls. CONCLUSION: Despite the higher neurosurgical intervention rates, patients with pre-injury DOAC use were associated with comparable rates of mortality and discharge to inpatient rehabilitation as patients without anticoagulation exposure. Future research should focus on risk assessment and stratification of DOAC-exposed trauma patients.

The impact of regionalized trauma care on the distribution of severely injured patients in the Netherlands.

BACKGROUND: Twenty years ago, an inclusive trauma system was implemented in the Netherlands. The goal of this study was to evaluate the impact of structured trauma care on the concentration of severely injured patients over time. METHODS: All severely injured patients (Injury Severity Score [ISS] ≥ 16) documented in the Dutch Trauma Registry (DTR) in the calendar period 2008-2018 were included for analysis. We compared severely injured patients, with and without severe neurotrauma, directly brought to trauma centers (TC) and non-trauma centers (NTC). The proportion of patients being directly transported to a trauma center was determined, as was the total Abbreviated Injury Score (AIS), and ISS. RESULTS: The documented number of severely injured patients increased from 2350 in 2008 to 4694 in 2018. During this period, on average, 70% of these patients were directly admitted to a TC (range 63-74%). Patients without severe neurotrauma had a lower chance of being brought to a TC compared to those with severe neurotrauma. Patients directly presented to a TC were more severely injured, reflected by a higher total AIS and ISS, than those directly transported to a NTC. CONCLUSION: Since the introduction of a well-organized trauma system in the Netherlands, trauma care has become progressively centralized, with more severely injured patients being directly presented to a TC. However, still 30% of these patients is initially brought to a NTC. Future research should focus on improving pre-hospital triage to facilitate swift transfer of the right patient to the right hospital.

Incidence and treatment of hand and wrist injuries in Dutch emergency departments.

PURPOSE: The purpose of this study was to describe the epidemiology, treatment and costs of hand and wrist injuries presenting to the Dutch ED. With increasing medical costs and crowding of emergency departments (ED), a more detailed description of emergency department attendance of hand and wrist injuries and their treatment may help to facilitate more adequate allocation of health care services. METHODS: The Dutch Injury Surveillance System obtained a total of 160,250 hand and wrist injuries. Patient characteristics, incidence rates, type of injury, treatment, and costs were described. RESULTS: The incidence of hand and wrist injuries in the Netherlands in 2016 was 11 per 1000 in males and 8 per 1000 in females. This is about 25% of all injuries presented at the ED. Of all hand injuries, only 3% was directly admitted to the hospital or received emergency surgery. Thirty percent did not need further treatment in the hospital. CONCLUSION: The current data suggest that a substantial proportion of the hand and wrist injuries needed no subsequent specialized treatment. Although the severity of the injury could not be deduced from our data, the data suggest a ground for a more extensive role of primary health care (general) practitioners in the primary triage and treatment of hand and wrist injuries. This may reduce health care cost and help decongest the ED departments. Prospective studies are needed to confirm these preliminary conclusions. LEVEL OF EVIDENCE: III.

Variation in treatment of hip fractures and guideline adherence amongst surgeons with different training backgrounds in the Netherlands.

BACKGROUND AND PURPOSE: Two medical specialties, general surgery and orthopaedic surgery, with different training programs but matching trauma certification requirements, provide hip fracture surgery in the Netherlands. This study analyses treatment preferences and guideline adherence of Dutch surgeons with different surgical backgrounds. PATIENTS AND METHODS: All hip fracture patients registered in the Dutch Hip Fracture Audit in 2018 and 2019 were included in this retrospective study. Four types of surgeons were distinguished: trauma-certified general surgeons (ST+), non-trauma certified general surgeons (ST-), trauma-certified orthopaedic surgeons (OT+) and non-trauma certified orthopaedic surgeons (OT-). Differences in patient characteristics, and practice variation in treatment choices and guideline adherence per fracture type were analysed using descriptive statistics. RESULTS: 28,656 patients were included; 16,367 (57.1%) treated by ST+, 1,371 (4.8%) by ST-, 4,692 (16.4%) by OT+ and 6,226 (21.7%) by OT-. Few clinically relevant differences in patient characteristics and hospital processes were found between all surgeon groups. Displaced FNF were the most commonly treated fracture type for all types of surgeons. Both OT+ and OT- operated mostly (displaced) FNFs, while the fracture types treated by ST+ and ST- were more heterogeneous. For all fracture types, the orthopaedic surgeons performed THA and HA more often than general surgeons, while general surgeons more often placed SHS and IMN for specific fracture types. Guideline adherence was on average 68.4% and differed significantly per surgeon type (68.7% by ST+, 65.2% by ST-, 74.4% by OT+ and 63.6% by OT- (p<0.01)), as well as per fracture type: >90% treatment according to the guideline for trochanteric AO-31A2 and A3 fractures, 18.8% for AO-31A1 fractures and 51.7% guideline adherence for undisplaced FNF. Guideline adherence for displaced FNF varied depending on patient characteristics. DISCUSSION: In the Netherlands, different surgical specialists treat different types of hip fractures and have different preferences concerning implants for hip fracture surgery in comparable patients. Guideline adherence of trauma- and non-trauma certified orthopaedics and general surgeons differs significantly. Reduction of practice variation should be strived for in order to improve hip fracture care.

Equivalence of DOACS and LMWH for thromboprophylaxis after hip fracture surgery: Systematic review and meta-analysis.

BACKGROUND: Patients with hip fractures (HF) have an increased risk of venous thromboembolism (VTE). In elective orthopedic surgery direct oral anticoagulants (DOACs) have proven to be similarly or more effective compared to low molecular weight heparin (LMWH), but DOACs are not yet approved for thromboprophylaxis in trauma patients with HF. The aim of this study was to systematically review the literature comparing the effectiveness of DOACs and LMWH for thromboprophylaxis in trauma patients with surgically treated HF. MATERIALS AND METHODS: We searched PubMed, the Cochrane Library, Web of Science, and Embase. The primary outcome was the incidence of VTE (symptomatic and asymptomatic combined). Secondary outcomes were symptomatic VTE; a symptomatic VTE, symptomatic deep venous thrombosis (DVT); symptomatic pulmonary embolism (PE); major, clinically relevant non-major (CRNM), and minor bleeding. Meta-analysis was performed to compare the odds of VTE and secondary outcomes between DOACs and LMWH. RESULTS: The search resulted in 738 titles. Five studies matched inclusion criteria. In total, 4748 hip fracture patients were analyzed (DOACs: 2276 patients, LMWH: 2472 patients). The pooled odds ratio for the risk of VTE for DOAC use was 0.52 (95% confidence interval 0.25-1.11, p = 0.09) compared to LMWH. No statistically significant differences between DOAC and LMWH were found for asymptomatic VTE, symptomatic DVT, PE, major or CRNM bleeding, and minor bleeding. CONCLUSIONS: Meta-analysis of the literature suggests that DOACs are associated with equivalent effectiveness and safety compared to LMWH.

Andexanet Alfa or Prothrombin Complex Concentrate for Factor Xa Inhibitor Reversal in Acute Major Bleeding: A Systematic Review and Meta-Analysis.

OBJECTIVES: To combine evidence on andexanet alfa and prothrombin complex concentrates for factor Xa inhibitor-associated bleeding to guide clinicians on reversal strategies. DATA SOURCES: Embase, Pubmed, Web of Science, and the Cochrane Library. STUDY SELECTION: Observational studies and randomized clinical trials studying hemostatic effectiveness of andexanet alfa or prothrombin complex concentrate for acute reversal of factor Xa inhibitor-associated hemorrhage. DATA EXTRACTION: Two independent reviewers extracted the data from the studies. Visualization and comparison of hemostatic effectiveness using Sarode et al or International Society of Thrombosis and Hemostasis Scientific and Standardization Committee criteria at 12 and 24 hours, (venous) thrombotic event rates, and inhospital mortality were performed by constructing Forest plots. Exploratory analysis using a logistic mixed model analysis was performed to identify factors associated with effectiveness and venous thromboembolic event. DATA SYNTHESIS: A total of 21 studies were included (andexanet: 438 patients; prothrombin complex concentrate: 1,278 patients). The (weighted) mean effectiveness for andexanet alfa was 82% at 12 hours and 71% at 24 hours. The (weighted) mean effectiveness for prothrombin complex concentrate was 88% at 12 hours and 76% at 24 hours. The mean 30-day symptomatic venous thromboembolic event rates were 5.0% for andexanet alfa and 1.9% for prothrombin complex concentrate. The mean 30-day total thrombotic event rates for andexanet alfa and prothrombin complex concentrate were 10.7% and 3.1%, respectively. Mean inhospital mortality was 23.3% for andexanet versus 15.8% for prothrombin complex concentrate. Exploratory analysis controlling for potential confounders did not demonstrate significant differences between both reversal agents. CONCLUSIONS: Currently, available evidence does not unequivocally support the clinical effectiveness of andexanet alfa or prothrombin complex concentrate to reverse factor Xa inhibitor-associated acute major bleeding, nor does it permit conventional meta-analysis of potential superiority. Neither reversal agent was significantly associated with increased effectiveness or a higher rate of venous thromboembolic event. These results underscore the importance of randomized controlled trials comparing the two reversal agents and may provide guidance in designing institutional guidelines.

Textbook process as a composite quality indicator for in-hospital hip fracture care.

Individual process indicators often do not enable the benchmarking of hospitals and often lack an association with outcomes of care. The composite hip fracture process indicator, textbook process, might be a tool to detect hospital variation and is associated with better outcomes during hospital stay. PURPOSE: The aim of this study was to determine hospital variation in quality of hip fracture care using a composite process indicator (textbook process) and to evaluate at patient level whether fulfilment of the textbook process indicator was associated with better outcomes during hospital stay. METHODS: Hip fracture patients aged 70 and older operated in five hospitals between 1 January 2018 and 31 December 2018 were included. Textbook process for hip fracture care was defined as follows: (1) assessment of malnutrition (2) surgery within 24 h, (3) orthogeriatric management during admission and (4) operation by an orthopaedic trauma certified surgeon. Hospital variation analysis was done by computing an observed/expected ratio (O/E ratio) for textbook process at hospital level. The expected ratios were derived from a multivariable logistic regression analysis including all relevant case-mix variables. The association between textbook process compliance and in-hospital complications and prolonged hospital stay was determined at patient level in a multivariable logistic regression model, with correction for patient, treatment and hospital characteristics. In-hospital complications were anaemia, delirium, pneumonia, urinary tract infection, in-hospital fall, heart failure, renal insufficiency, pulmonary embolism, wound infection and pressure ulcer. RESULTS: Of the 1371 included patients, 753 (55%) received care according to textbook process. At hospital level, the textbook compliance rates ranged from 38 to 76%. At patient level, textbook process compliance was significantly associated with fewer complications (38% versus 46%) (OR 0.66, 95% CI 0.52-0.84), but not with hospital stay (median length of hospital stay was 5 days in both groups) (OR 1.01, 95% CI 0.78-1.30). CONCLUSION: The textbook process indicator for hip fracture care might be a tool to detect hospital variation. At patient level, this quality indicator is associated with fewer complications during hospital stay.

The Value of Additional Gravity Stress Radiographs for Decision Making in the Treatment of Isolated Type B Distal Fibular Fractures.

BACKGROUND: Prior to treatment decisions concerning isolated Weber type B ankle fractures, assessment of the stability of the ankle joint is mandatory. The gravity stress (GS) radiograph is a radiographic tool to determine stability. We hypothesized that this additional GS radiograph would lead to fewer operative treatments by applying the criterion of operative treatment when medial clear space (MCS) > superior clear space (SCS) + 2 mm on the GS radiograph, compared with the nonstressed mortise view criteria of advising operative treatment in case of MCS > SCS + 1 mm. METHODS: This retrospective comparative cohort study analyzed 343 patients aged between 18 and 70 years with an isolated Weber type B ankle fracture diagnosed at the emergency department between January 2014 and December 2019. The cohort was divided into 2 groups based on whether an additional GS radiograph was performed. Group I consisted of 151 patients in whom a regular mortise and lateral radiograph were performed. Group II comprised 192 patients, with an additional GS radiograph. Primary outcome was type of treatment (conservative vs operative). Secondary outcomes were patient-reported functional outcomes and pain. RESULTS: Baseline characteristics of both groups did not differ. In group I, surgery was performed in 60 patients (39.7%) compared with 108 patients (56.3%) in group II (P = .002). In the operatively treated patients, the mean MCS on regular mortise view was significantly smaller in patients in whom an additional GS radiograph was performed compared to patients without an additional GS radiograph (4.1 mm vs 5.2 mm, P < .001). Mean Olerud-Molander Ankle Score and mean visual analog scale (VAS) for pain did not differ significantly between groups I and II. CONCLUSIONS: Contrary to what was hypothesized, the introduction of an additional gravity stress radiograph, by which operative treatment was indicated if the MCS was wider than the SCS + 2 mm, did not result in reduced operative treatment of Weber type B ankle fractures when operative treatment was indicated for MCS > SCS + 1 mm on non-gravity stress radiographs. LEVEL OF EVIDENCE: Level III: retrospective comparative study.

Accuracy and reliability of injury coding in the national Dutch Trauma Registry.

OBJECTIVE: Injury coding is well known for lack of completeness and accuracy. The objective of this study was to perform a nationwide assessment of accuracy and reliability on Abbreviated Injury Scale (AIS) coding by Dutch Trauma Registry (DTR) coders and to determine the effect on Injury Severity Score (ISS). Additionally, the coders' characteristics were surveyed. METHODS: Three fictional trauma cases were presented to all Dutch trauma coders in a nationwide survey (response rate 69%). The coders were asked to extract and code the cases' injuries according to the AIS manual (version 2005, update 2008). Reference standard was set by three highly experienced coders. Summary statistics were used to describe the registered AIS codes and ISS distribution. The primary outcome measures were accuracy of injury coding and inter-rater agreement on AIS codes. Secondary outcome measures were characteristics of coders: profession, work setting, experience in injury coding and training level in injury coding. RESULTS: The total number of different AIS codes used to describe 14 separate injuries in the three cases was 89. Mean accuracy per AIS code was 42.2% (range 2.4-92.7%). Mean accuracy on number of AIS codes was 23%. Overall inter-rater agreement per AIS code was 49.1% (range 2.4-92.7%). The number of assigned AIS codes varied between 0 and 18 per injury. Twenty-seven percentage of injuries were overlooked. ISS was correctly scored in 42.4%. In 31.7%, the AIS coding of the two more complex cases led to incorrect classification of the patient as ISS < 16 or ISS ≥ 16. Half (47%) of the coders had no (para)medical degree, 26% were working in level I trauma centers, 37% had less than 2 years of experience and 40% had no training in AIS coding. CONCLUSIONS: Accuracy of and inter-rater agreement on AIS injury scoring by DTR coders is limited. This may in part be due to the heterogeneous backgrounds and training levels of the coders. As a result of the inconsistent coding, the number of major trauma patients in the DTR may be over- or underestimated. Conclusions based on DTR data should therefore be drawn with caution.

Association between alcohol intoxication and mortality in severe traumatic brain injury in the emergency department: a retrospective cohort.

BACKGROUND: Acute alcohol intoxication is very common in patients with severe traumatic brain injury (TBI). Whether there is an independent association between alcohol intoxication and mortality is debated. This study hypothesized that alcohol intoxication is independently associated with less mortality after severe TBI (sTBI). METHODS: This retrospective observational cohort study included all patients with sTBI [head-Abbreviated Injury Score (AIS) ≥3, corresponding to serious head injury or worse] admitted from 1 January 2011 to 31 December 2016 in an academic level I trauma center. Patients were classified as with alcohol intoxication or without intoxication based on blood alcohol concentration or description of alcohol intoxication on admission. The primary endpoint was in-hospital mortality. Multivariable logistic regression analysis, including patient and injury characteristics, was used to assess independent association with alcohol intoxication. RESULTS: Of the 2865 TBI patients, 715 (25%) suffered from alcohol intoxication. They were younger (mean age 46 vs. 68 years), more often male (80 vs. 57%) and had a lower median Glasgow Coma Scale upon arrival (14 vs. 15) compared to the no-intoxication group. There was no difference in injury severity by head AIS or Rotterdam CT. Alcohol intoxication had an unadjusted association with in-hospital mortality [unadjusted odds ratio (OR) 0.51; 95% confidence interval (CI), 0.38-0.68]; however, there was no independent association after adjusting for potentially confounding patient and injury characteristics (adjusted OR 0.72; 95% CI, 0.48-1.09). CONCLUSION: In this retrospective study, there was no independent association between alcohol intoxication and higher in-hospital mortality in emergency patients with sTBI.