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Peuker F, Hoepelman RJ, Beeres FJP, Balogh ZJ, Beks RB, Sweet AAR, IJpma FFA, Lansink KWW, van Wageningen B, Tromp TN, Minervini F, van Veelen NM, Hoogendoorn JM, de Jong MB, van Baal MCPM, Leenen LPH, Groenwold RHH, Houwert RM. Nonoperative treatment of multiple rib fractures, the results to beat: International multicenter prospective cohort study among 845 patients. J Trauma Acute Care Surg 2024; 96:769-776. [PMID: 37934655 DOI: 10.1097/ta.0000000000004183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
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 1-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 nonunion. The median HLOS was 7 days (4-13 days), and median intensive care unit length of stay was 2 days (1-5 days). Mean 5-Level Quality of Life Questionnaire index value was 0.83 ± 0.18 1 year after trauma. Polytrauma patients had a median HLOS of 10 days (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 days (5-15 days), a pneumonia rate of 19.7% (n = 57) and mortality rate of 4.1% (n = 12). CONCLUSION Overall, nonoperative treatment of patients with multiple rib fractures shows low mortality and morbidity rate and good quality of life after 1 year. Future studies evaluating the benefit of operative stabilization should use contemporary outcomes to establish the therapeutic margin of rib fixation. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Affiliation(s)
- Felix Peuker
- From the Department of Trauma Surgery (F.P., R.J.H., A.A.R.S., M.B.J., M.B., L.P.H.L., R.M.H.), University Medical Center Utrecht, Utrecht, The Netherlands; Department of Orthopedic and Trauma Surgery (F.P., F.J.P.B., N.M.V.), Cantonal Hospital Lucerne, Lucerne, Switzerland; Department of Traumatology (Z.J.B.), John Hunter Hospital & University of Newcastle, Newcastle, New South Wales, Australia; Department of Trauma Surgery (F.F.A.I.), University Medical Center Groningen, Groningen; Department of Trauma Surgery (K.W.W.L.), Elisabeth TweeSteden Hospital, Tilburg; Department of Trauma Surgery (B.W., T.N.T.), Radboud University Medical Center, Nijmegen, The Netherlands; Department of Thoracic Surgery (F.M.), Cantonal Hospital Lucerne, Lucerne, Switzerland; Department of Trauma Surgery (J.M.H.), Haaglanden Medical Center, The Hague; Department of Clinical Epidemiology (R.H.H.G.), and Department of Biomedical Data Sciences (R.H.H.G.), Leiden University Medical Center, Leiden, The Netherlands
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van Veelen NM, van de Wall BJM, Hoepelman RJ, IJpma FFA, Link BC, Babst R, Groenwold RHH, van der Velde D, Diwersi N, van Heijl M, Houwert RM, Beeres FJP. Let's Agree to Disagree on Operative Versus Nonoperative Treatment for Distal Radius Fractures in Older People: Protocol for a Prospective International Multicenter Cohort Study. JMIR Res Protoc 2024; 13:e52917. [PMID: 38349719 PMCID: PMC10900084 DOI: 10.2196/52917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 12/11/2023] [Accepted: 12/11/2023] [Indexed: 03/01/2024] Open
Abstract
BACKGROUND Distal radius fractures are the most frequently encountered fractures in Western societies, typically affecting patients aged 50 years and older. Although this is a common injury, the best treatment for these fractures in older patients is still under debate. OBJECTIVE This prospective study aims to compare the outcome of operatively and nonoperatively treated distal radius fractures in the older population. Only patients with distal radius fractures for which equipoise regarding the optimal treatment exists will be included. METHODS This prospective international multicenter observational cohort study will be designed as a natural experiment. Natural experiments are observational studies in which treatment allocation is determined by factors outside the control of the investigators but also (largely) independent of patient characteristics. Patients aged 65 years and older with an acute distal radius fracture will be considered for inclusion. Treatment allocation (operative vs nonoperative) will be based on the local preferences of the treating hospital either in Switzerland or the Netherlands. Hence, the process governing treatment allocation resembles that of randomization. Patients will be identified after treatment has been initiated. Based on the radiographs and baseline information of the patient, an expert panel of 6 certified trauma surgeons from 2 regions will provide their treatment recommendation. Only patients for whom the experts disagree on treatment recommendations will ultimately be included in the study (ie, for whom there is a clinical equipoise). For these patients, both operative and nonoperative treatment of distal radius fractures are viable, and treatment choice is predominantly determined by personal or local preference. The primary outcome will be the Patient-Rated Wrist Evaluation score at 12 weeks. Secondary outcomes will include the Physical Activity Score for the Elderly, the EQ questionnaire, pain, the living situation, range of motion, complications, and radiological outcomes. By including outcomes such as living situation and the Physical Activity Score for the Elderly, which are not relevant for younger cohorts, valuable information to tailor treatment to the needs of the older population can be gained. According to the sample size collection, which was based on the minimal important clinical difference of the Patient-Rated Wrist Evaluation, 92 patients will have to be included, with at least 46 patients in each treatment group. RESULTS Enrollment began in July 2023 and is expected to continue until summer 2024. The final follow-up will be 2 years after the last patient is included. CONCLUSIONS Although many trials on this topic have previously been published, there remains an ongoing debate regarding the optimal treatment for distal radius fractures in older patients. This observational study, which will use a fairly new methodological study design, will provide further information on treatment outcomes for older patients with distal radius fractures for which to date equipoise exists regarding the optimal treatment. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/52917.
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Affiliation(s)
- Nicole Maria van Veelen
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Luzern, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Luzern, Switzerland
| | - Bryan J M van de Wall
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Luzern, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Luzern, Switzerland
| | - Ruben J Hoepelman
- Department of Trauma Surgery, Universitair Medisch Centrum Utrecht, Utrecht, Netherlands
| | - Frank F A IJpma
- Department of Trauma Surgery, Universitair Medisch Centrum Groningen, Groningen, Netherlands
| | - Björn-Christian Link
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Luzern, Switzerland
| | - Reto Babst
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Luzern, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Luzern, Switzerland
| | - Rolf H H Groenwold
- Department of Clinical Epidemiology, Universitair Medisch Centrum Leiden, Leiden, Netherlands
| | | | - Nadine Diwersi
- Department of General and Trauma Surgery, Kantonsspital Obwalden, Sarnen, Switzerland
| | - Mark van Heijl
- Department of Surgery, Diakonessenhuis Utrecht, Utrecht, Netherlands
| | - R Marijn Houwert
- Department of Trauma Surgery, Universitair Medisch Centrum Utrecht, Utrecht, Netherlands
| | - Frank J P Beeres
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Luzern, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Luzern, Switzerland
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van de Wall BJM, Hoepelman RJ, Michelitsch C, Diwersi N, Sommer C, Babst R, Beeres FJP. Minimally invasive plate osteosynthesis (MIPO) for scapular fractures. Oper Orthop Traumatol 2023; 35:390-396. [PMID: 37594566 DOI: 10.1007/s00064-023-00819-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 02/02/2023] [Accepted: 02/08/2023] [Indexed: 08/19/2023]
Abstract
OBJECTIVE Presentation of a minimally invasive surgical approach for the treatment of scapular fractures and the clinical outcome using this technique. INDICATIONS Displaced extra-articular fractures of the scapula body and glenoid neck (AO 14B and 14F) and simple intra-articular fractures of the glenoid. CONTRAINDICATIONS Complex intra-articular fractures and isolated fractures of the coracoid base. SURGICAL TECHNIQUE Make a straight or slightly curved incision along the lateral margin of the scapula leaving the deltoid fascia intact. Identify the interval between the teres minor muscle and infraspinatus to visualize the lateral column, whilst retracting the deltoid to visualize the glenoid neck. Reduce and align the fracture using direct and indirect reduction tools. A second window on the medial border of the scapula can be made to aid reduction and/or to augment stability. Small (2.0-2.7 mm) plates in a 90° configuration on the lateral border and, if required, on the medial border are used. Intra-operative imaging confirms adequate reduction and extra-articular screw placement. POSTOPERATIVE MANAGEMENT Direct postoperative free functional nonweight-bearing rehabilitation limited to 90° abduction for the first 6 weeks. Sling for comfort. Free range of motion and permissive weight-bearing after 6 weeks. RESULTS We collected data from 35 patients treated with minimally invasive plate osteosynthesis (MIPO) between 2011 and 2021. Average age was 53 ± 15.1 years (range 21-71 years); 17 had a type B and 18 a type F fracture according the AO classification. All patients suffered concomitant injuries of which thoracic (n = 33) and upper extremity (n = 25) injuries were most common. Double plating of the lateral border (n = 30) was most commonly performed as described in the surgical technique section. One patient underwent an additional osteosynthesis 3 months after initial surgery due to pain and lack of radiological signs of healing of a fracture extension into the spine of the scapula. In the same patient, the plate on the spine of scapula was later removed due to plate irritation. In 2 patients postoperative images showed a screw protruding into the glenohumeral joint requiring revision surgery. After standardisation of intra-operative imaging following these two cases, intra-articular screw placement did not occur anymore. No patient suffered from iatrogenic nerve injury and none developed a wound infection.
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Affiliation(s)
- B J M van de Wall
- Klinik für Orthopädie und Unfallchirurgie, Luzerner Kantonsspital, Spitalstrasse, 6000, Luzern, Switzerland
- University of Luzern, Luzern, Switzerland
| | - R J Hoepelman
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - C Michelitsch
- Unfallchirurgie, Kantonsspital Graubünden, Chur, Switzerland
| | - N Diwersi
- Klinik für Chirurgie, Kantonsspital Obwalden, Sarnen, Switzerland
| | - C Sommer
- Unfallchirurgie, Kantonsspital Graubünden, Chur, Switzerland
| | - R Babst
- Klinik für Orthopädie und Unfallchirurgie, Luzerner Kantonsspital, Spitalstrasse, 6000, Luzern, Switzerland
- University of Luzern, Luzern, Switzerland
| | - F J P Beeres
- Klinik für Orthopädie und Unfallchirurgie, Luzerner Kantonsspital, Spitalstrasse, 6000, Luzern, Switzerland.
- University of Luzern, Luzern, Switzerland.
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Hoepelman RJ, Kik CC, Beeres FJP, Zwart DLM, Groenwold RHH, Houwert RM. [Treatment of traumatic rib fractures]. Ned Tijdschr Geneeskd 2023; 167:D7434. [PMID: 37742123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 09/25/2023]
Abstract
Patients with rib fractures are a heterogenous group of patients who are treated by general practitioners as well as by specialized trauma surgeons. We present three patients with rib fractures with different degrees of thoracic trauma and therefore treatments differ significantly. The cornerstone in the treatment of rib fractures remains attaining adequate analgesia and breathing exercises. The last decade, there has been an increase in the utilization of rib fixation, however, precise indications remain unknown. It has proven effective in patients with flail chest on mechanical ventilation in whom it decrease intensive care and hospital length and reduces mortality. In case of prolonged (> 3 months) pain, dyspnea or a clicking sensation one could think of a nonunion of the rib fracture. Rib fixation can relieve these complaints in about 60% of the patients, however due to a high implant irritation rate and secondary operation to remove the osteosynthesis is common.
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Affiliation(s)
| | | | | | - Dorien L M Zwart
- UMC Utrecht, Julius Centrum voor Gezondheidswetenschappen en Eerstelijnsgeneeskunde, Utrecht
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Hoepelman RJ, van der Linde RA, Beeres FJ, Beks RB, Sweet AA, Lansink KW, van Wageningen B, Tromp TN, Minervini F, Link BC, van Veelen NM, Hoogendoorn JM, de Jong MB, van Baal MC, Leenen LP, Groenwold RH, Houwert RM, IJpma FF. 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. J Trauma Acute Care Surg 2023; 95:249-255. [PMID: 37165478 PMCID: PMC10389406 DOI: 10.1097/ta.0000000000004001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/15/2023] [Accepted: 03/29/2023] [Indexed: 05/12/2023]
Abstract
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.
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Hoepelman RJ, Driessen MLS, de Jongh MAC, Houwert RM, Marzi I, Lecky F, Lefering R, van de Wall BJM, Beeres FJP, Dijkgraaf MGW, Groenwold RHH, Leenen LPH. Concepts, utilization, and perspectives on the Dutch Nationwide Trauma registry: a position paper. Eur J Trauma Emerg Surg 2023; 49:1619-1626. [PMID: 36624221 PMCID: PMC10449938 DOI: 10.1007/s00068-022-02206-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 12/17/2022] [Indexed: 01/11/2023]
Abstract
Over the last decades, the Dutch trauma care have seen major improvements. To assess the performance of the Dutch trauma system, in 2007, the Dutch Nationwide Trauma Registry (DNTR) was established, which developed into rich source of information for quality assessment, quality improvement of the trauma system, and for research purposes. The DNTR is one of the most comprehensive trauma registries in the world as it includes 100% of all trauma patients admitted to the hospital through the emergency department. This inclusive trauma registry has shown its benefit over less inclusive systems; however, it comes with a high workload for high-quality data collection and thus more expenses. The comprehensive prospectively collected data in the DNTR allows multiple types of studies to be performed. Recent changes in legislation allow the DNTR to include the citizen service numbers, which enables new possibilities and eases patient follow-up. However, in order to maximally exploit the possibilities of the DNTR, further development is required, for example, regarding data quality improvement and routine incorporation of health-related quality of life questionnaires. This would improve the quality assessment and scientific output from the DNTR. Finally, the DNTR and all other (European) trauma registries should strive to ensure that the trauma registries are eligible for comparisons between countries and healthcare systems, with the goal to improve trauma patient care worldwide.
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Affiliation(s)
- R J Hoepelman
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, The Netherlands.
| | - M L S Driessen
- Dutch Network for Emergency Care (LNAZ), Utrecht, The Netherlands
| | - M A C de Jongh
- Brabant Trauma Registry, Network Emergency Care Brabant, Tilburg, The Netherlands
| | - R M Houwert
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| | - I Marzi
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - F Lecky
- The Trauma Audit and Research Network, The University of Manchester, Salford Royal-Northern Care Alliance NHS Foundation Trust, Salford, UK
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - R Lefering
- Faculty of Health, IFOM-Institute for Research in Operative Medicine, University Witten/Herdecke, Cologne, Germany
| | - B J M van de Wall
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - F J P Beeres
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - M G W Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Methodology, Amsterdam Public Health, Amsterdam, The Netherlands
| | - R H H Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - L P H Leenen
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, The Netherlands
- Dutch Network for Emergency Care (LNAZ), Utrecht, The Netherlands
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Hoepelman RJ, Minervini F, Beeres FJP, van Wageningen B, IJpma FF, van Veelen NM, Lansink KWW, Hoogendoorn JM, van Baal MCP, Groenwold RHH, Houwert RM. Quality of life and clinical outcomes of operatively treated patients with flail chest injuries: A multicentre prospective cohort study. Front Surg 2023; 10:1156489. [PMID: 37009603 PMCID: PMC10050428 DOI: 10.3389/fsurg.2023.1156489] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/27/2023] [Indexed: 03/17/2023] Open
Abstract
IntroductionMost 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.MethodsA 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.ResultsSixty-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%).ConclusionsRib 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
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Affiliation(s)
- Ruben J. Hoepelman
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Fabrizio Minervini
- Department of Thoracic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
- Correspondence: Fabrizio Minervini
| | - Frank J. P. Beeres
- Department of Orthopedics and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Bas van Wageningen
- Department of Trauma Surgery, Radboud University Medical Center Utrecht, Nijmegen, Netherlands
| | - Frank F. IJpma
- Department of Trauma Surgery, University Medical Center Groningen, Groningen, Netherlands
| | - Nicole M. van Veelen
- Department of Orthopedics and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Koen W. W. Lansink
- Department of Trauma Surgery, Elisabeth-Tweesteden Hospital, Tilburg, Netherlands
| | | | - Mark. C. P. van Baal
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Rolf H. H. Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
| | - Roderick M. Houwert
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, Netherlands
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Tillmann F, Hoepelman RJ, Cagienard F, Link BC, Babst R, van de Wall BJM, Beeres FJP. Primary Closure or Secondary Wound Healing of Pin Sites After External Fixator Removal: A Single-Center Blinded Randomized Controlled Trial. J Bone Joint Surg Am 2023; 105:207-213. [PMID: 36622896 DOI: 10.2106/jbjs.22.00234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND The aim of this single-center randomized controlled trial was to compare primary wound closure using a suture with secondary wound healing of pin sites after removal of temporary external fixation. METHODS This noninferiority trial included all patients who were treated with a temporary external fixator on an upper or lower extremity at 1 institution. The primary outcome was pin-site infection. Secondary outcomes were measured at 2, 6, 12, 24, and 52 weeks and included all other complications, time to pin-site wound healing (in weeks), the most satisfactory pin site as rated by the patient, the visual analog scale (VAS) score for pain, and the Vancouver Scar Scale (VSS). The most proximal pin site was randomly allocated (1:1) to either primary closure or secondary wound healing, and the other pin sites were treated alternately. RESULTS Seventy patients, providing 241 pin sites, were included between January 1, 2019, and March 1, 2020. A total of 123 pin sites were treated with primary closure and 118, with secondary wound healing. The median age was 55 years (interquartile range, 46 to 67 years), 44% were male, and the median duration of the external fixation was 6 days (interquartile range, 4 to 8 days). There were no pin-site infections in either group. Wound healing was significantly faster in the primary closure group (median of 2 versus 6 weeks, p = 0.013). The VSS and patient satisfaction showed no differences between groups. There was 1 case of fracture-related infection not related to any pin site. CONCLUSIONS Primary closure of temporary external fixator pin sites did not result in higher infection rates compared with secondary wound healing, and pin sites healed significantly faster after primary closure. Primary closure should therefore be considered in patients treated with a temporary external fixator. LEVEL OF EVIDENCE Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Franz Tillmann
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ruben J Hoepelman
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.,Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Flavio Cagienard
- Department of Orthopaedics and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Björn-Christian Link
- Department of Orthopaedics and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Reto Babst
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.,Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Bryan J M van de Wall
- Department of Orthopaedics and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland.,Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Frank J P Beeres
- Department of Orthopaedics and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
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Hoepelman RJ, Beeres FJP, Heng M, Knobe M, Link BC, Minervini F, Babst R, Houwert RM, van de Wall BJM. Rib fractures in the elderly population: a systematic review. Arch Orthop Trauma Surg 2023; 143:887-893. [PMID: 35137253 PMCID: PMC9925562 DOI: 10.1007/s00402-022-04362-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 01/15/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Multiple rib fractures are associated with significant morbidity and mortality, especially in elderly patients. There is growing interest in surgical stabilization in this subgroup of patients. This systematic review compares conservative treatment to surgical fixation in elderly patients (older than 60 years) with multiple rib fractures. The primary outcome is mortality. Secondary outcomes include hospital and intensive care length of stay (HLOS and ILOS), duration of mechanical ventilation (DMV) and pneumonia rates. METHODS Multiple databases were searched for comparative studies reporting on conservative versus operative treatment for rib fractures in patients older than 60 years. Both observational studies and randomised clinical trials were considered. RESULTS Five observational studies (n = 2583) were included. Mortality was lower in operatively treated patients compared to conservative treatment (4% vs. 8%). Pneumonia rate and DMV were similar (5/6% and 5.8/6.5 days) for either treatment modality. Overall ILOS and HLOS of stay were longer in operatively treated patients (6.5 ILOS and 12.7 HLOS vs. 2.7 ILOS and 6.5 ILOS). There were only minimal reports on perioperative complications. Notably, the median number of rib fractures (8.4 vs. 5) and the percentage of flail chest were higher in operatively treated patients (47% vs. 39%). CONCLUSION It remains unknown to what extent conservative and operative treatment contribute individually to reducing morbidity and mortality in the elderly with multiple rib fractures. To date, the quality of evidence is rather low, thus well-performed comparative observational studies or randomised controlled trials considering all confounders are needed to determine whether operative treatment can improve a patient's outcome.
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Affiliation(s)
- Ruben J. Hoepelman
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, the Netherlands ,Department of Orthopedics and Trauma Surgery, Luzerner Kantonsspital, Spitalstrasse 16, 6000 Lucerne, Switzerland
| | - Frank J. P. Beeres
- Department of Orthopedics and Trauma Surgery, Luzerner Kantonsspital, Spitalstrasse 16, 6000 Lucerne, Switzerland ,Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Marilyn Heng
- Department of Orthopedic Surgery, Orthopedic Trauma Initiative, Harvard Medical School, Massachusetts General Hospital, Boston, MA USA
| | - Matthias Knobe
- Department of Orthopedics and Trauma Surgery, Luzerner Kantonsspital, Spitalstrasse 16, 6000 Lucerne, Switzerland
| | - Björn-Christian Link
- Department of Orthopedics and Trauma Surgery, Luzerner Kantonsspital, Spitalstrasse 16, 6000 Lucerne, Switzerland
| | - Fabrizio Minervini
- Department of Orthopedics and Trauma Surgery, Luzerner Kantonsspital, Spitalstrasse 16, 6000 Lucerne, Switzerland
| | - Reto Babst
- Department of Orthopedics and Trauma Surgery, Luzerner Kantonsspital, Spitalstrasse 16, 6000 Lucerne, Switzerland ,Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Roderick. M. Houwert
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Bryan J. M. van de Wall
- Department of Orthopedics and Trauma Surgery, Luzerner Kantonsspital, Spitalstrasse 16, 6000 Lucerne, Switzerland ,Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
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10
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Graafland M, van de Wall BJM, van Veelen NM, van Leeuwen R, Hoepelman RJ, Knobe M, Link BC, Babst R, Beeres FJP. Long-term follow-up of patients with displaced scapular fractures managed surgically and non-operatively. Injury 2022; 53:2087-2094. [PMID: 35184818 DOI: 10.1016/j.injury.2022.02.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Controversy remains on which patients with displaced scapula fractures benefit from surgery. This retrospective cohort study aims to compare and describe long-term patient-reported outcomes of patients with displaced scapula fractures treated both surgically and conservatively. METHODS This study included patients with intra- and extra-articular scapula fractures, treated between 2010 and 2020 in a Swiss level 1 trauma centre. The decision to operate was based on standardized criteria for fracture displacement. Patients with isolated Bankart lesions (Ideberg 1) and process fractures (AO type 14-A) were excluded. Primary outcomes were functional patient reported measures (DASH score) and quality of life (EQ5D score). Secondary outcomes were complications, radiological union, satisfaction with treatment, pain and range of motion. RESULTS Out of 486 cases, 74 patients had displaced scapula fractures. Forty patients were treated surgically and 34 were treated conservatively. Significantly more patients with intra-articular fractures and high-energy trauma were treated surgically. Fifty percent returned the questionnaires after a mean follow-up of 47 months (± SD 36). The mean DASH score of this group was 12 (SD 15.6), with a mean of 14.7 (SD 15.9) in the surgery group and 9.8 (SD 14.6) in the non-operative group (p = 0.7). Multivariate analysis did not show statistically significant correlating factors. No significant differences in quality of life were observed. Patients rated their treatment with a mean of 8.6/10 (SD 1.8). Among surgically treated patients, 19 underwent a deltoid sparing procedure with significant shorter time to union than those that underwent deltoid release (23 vs. 49 weeks, p<0.01). Complications occurred in 3/28 surgically treated patients and all three required a reoperation. CONCLUSION In this cohort, functional results after conservative and surgical treatment were similar, despite more complex fractures and more intra-articular fractures being treated surgically. Osteosynthesis of both intra- and extra-articular scapula fractures is safe and leads to good functional results, furthermore, new minimal invasive techniques may lead to faster bone healing and return to work and sports.
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Affiliation(s)
- M Graafland
- Dept. of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Luzern, Switzerland; Dept. of Trauma Surgery, Maasstad Hospital, Rotterdam, the Netherlands
| | - B J M van de Wall
- Dept. of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Luzern, Switzerland; Dept. Health Science and Medicine, University of Lucerne, Switzerland
| | - N M van Veelen
- Dept. of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Luzern, Switzerland
| | - R van Leeuwen
- Dept. of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Luzern, Switzerland
| | - R J Hoepelman
- Dept. of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Luzern, Switzerland
| | - M Knobe
- Dept. of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Luzern, Switzerland
| | - B C Link
- Dept. of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Luzern, Switzerland
| | - R Babst
- Dept. of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Luzern, Switzerland; Dept. Health Science and Medicine, University of Lucerne, Switzerland
| | - F J P Beeres
- Dept. of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Luzern, Switzerland.
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11
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Hoepelman RJ, Ochen Y, Beeres FJP, Frima H, Sommer C, Michelitsch C, Babst R, Buenter IR, van der Velde D, Verleisdonk EJMM, Groenwold RHH, Houwert RM, van Heijl M. Let’s Agree to Disagree on Operative versus Nonoperative (LADON) treatment for proximal humerus fractures: Study protocol for an international multicenter prospective cohort study. PLoS One 2022; 17:e0264477. [PMID: 35213647 PMCID: PMC8880817 DOI: 10.1371/journal.pone.0264477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 02/09/2022] [Indexed: 12/01/2022] Open
Abstract
Background The proximal humerus fracture is a common injury, but the optimal management is much debated. The decision for operative or nonoperative treatment is strongly influenced by patient specific factors, regional and cultural differences and the preference of the patient and treating surgeon. The aim of this study is to compare operative and nonoperative treatment of proximal humerus fractures for those patients for whom there is disagreement about optimal management. Methods and analysis This protocol describes an international multicenter prospective cohort study, in which all patients of 18 years and older presenting within three weeks after injury with a radiographically diagnosed displaced proximal humerus fracture can be included. Based on patient characteristics and radiographic images several clinical experts advise on the preferred treatment option. In case of disagreement among the experts, the patient can be included in the study. The actual treatment that will be delivered is at the discretion of the treating physician. The primary outcome is the QuickDash score at 12 months. Propensity score matching will be used to control for potential confounding of the relation between treatment modality and QuickDash scores. Discussion The LADON study is an international multicenter prospective cohort study with a relatively new methodological study design. This study is a “natural experiment” meaning patients receive standard local treatment and surgeons perform standard local procedures, therefore high participation rates of patients and surgeons are expected. Patients are only included after expert panel evaluation, when there is proven disagreement between experts, which makes this a unique study design. Through this inclusion process, we create two comparable groups whom received different treatments and where expert disagree about the already initiated treatment. Since we are zooming in on this particular patient group, confounding will be largely mitigated. Internationally the treatment of proximal humerus fractures are still much debated and differs much per country and hospital. This observational study with a natural experiment design will create insight into which treatment modality is to be preferred for patients in whom there is disagreement about the optimal treatment strategy. Trial registration Registered in Netherlands trial register NL9357 and Swiss trial register CH 2020–00961; https://clinicaltrials.gov/.
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Affiliation(s)
- Ruben J. Hoepelman
- Department of Trauma Surgery, UMC Utrecht, Utrecht, The Netherlands
- Department of Trauma Surgery, Diakonessenhuis Utrecht, Utrecht, The Netherlands
- * E-mail:
| | - Yassine Ochen
- Department of Trauma Surgery, UMC Utrecht, Utrecht, The Netherlands
- Department of Trauma Surgery St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - Frank J. P. Beeres
- Department of Trauma Surgery, Cantonal Hospital of Lucerne, Luzerne, Switzerland
| | - Herman Frima
- Department of Trauma Surgery, Noordwest Ziekenhuisgroep Alkmaar, Alkmaar, The Netherlands
| | - Christoph Sommer
- Department of Trauma Surgery, Kantonsspital Graubünden, Chur, Switzerland
| | | | - Reto Babst
- Department of Trauma Surgery, Cantonal Hospital of Lucerne, Luzerne, Switzerland
- Department of Health Science and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Isabelle R. Buenter
- Department of Trauma Surgery, Cantonal Hospital of Lucerne, Luzerne, Switzerland
| | - Detlef van der Velde
- Department of Trauma Surgery St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | | | - Rolf H. H. Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Mark van Heijl
- Department of Trauma Surgery, UMC Utrecht, Utrecht, The Netherlands
- Department of Trauma Surgery, Diakonessenhuis Utrecht, Utrecht, The Netherlands
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12
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Hesselink L, Hoepelman RJ, Spijkerman R, de Groot MCH, van Wessem KJP, Koenderman L, Leenen LPH, Hietbrink F. Persistent Inflammation, Immunosuppression and Catabolism Syndrome (PICS) after Polytrauma: A Rare Syndrome with Major Consequences. J Clin Med 2020; 9:jcm9010191. [PMID: 31936748 PMCID: PMC7019692 DOI: 10.3390/jcm9010191] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 12/23/2019] [Accepted: 01/07/2020] [Indexed: 02/07/2023] Open
Abstract
Nowadays, more trauma patients develop chronic critical illness (CCI), a state characterized by prolonged intensive care. Some of these CCI patients have disproportional difficulties to recover and suffer from recurrent infections, a syndrome described as the persistent inflammation, immunosuppression and catabolism syndrome (PICS). A total of 78 trauma patients with an ICU stay of ≥14 days (CCI patients) between 2007 and 2017 were retrospectively included. Within this group, PICS patients were identified through two ways: (1) their clinical course (≥3 infectious complications) and (2) by laboratory markers suggested in the literature (C-reactive protein (CRP) and lymphocytes), both in combination with evidence of increased catabolism. The incidence of PICS was 4.7 per 1000 multitrauma patients. The sensitivity and specificity of the laboratory markers was 44% and 73%, respectively. PICS patients had a longer hospital stay (median 83 vs. 40, p < 0.001) and required significantly more surgical interventions (median 13 vs. 3, p = 0.003) than other CCI patients. Thirteen PICS patients developed sepsis (72%) and 12 (67%) were readmitted at least once due to an infection. In conclusion, patients who develop PICS experience recurrent infectious complications that lead to prolonged hospitalization, many surgical procedures and frequent readmissions. Therefore, PICS forms a substantial burden on the patient and the hospital, despite its low incidence.
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Affiliation(s)
- Lillian Hesselink
- Department of Trauma Surgery, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands; (R.J.H.); (R.S.); (K.J.P.v.W.); (L.P.H.L.); (F.H.)
- Center for Translational Immunology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands;
- Correspondence: ; Tel.: +31-88-755-9882
| | - Ruben J. Hoepelman
- Department of Trauma Surgery, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands; (R.J.H.); (R.S.); (K.J.P.v.W.); (L.P.H.L.); (F.H.)
| | - Roy Spijkerman
- Department of Trauma Surgery, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands; (R.J.H.); (R.S.); (K.J.P.v.W.); (L.P.H.L.); (F.H.)
- Center for Translational Immunology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands;
| | - Mark C. H. de Groot
- Department of Clinical Chemistry and Hematology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands;
| | - Karlijn J. P. van Wessem
- Department of Trauma Surgery, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands; (R.J.H.); (R.S.); (K.J.P.v.W.); (L.P.H.L.); (F.H.)
| | - Leo Koenderman
- Center for Translational Immunology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands;
- Department of Respiratory Medicine, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Luke P. H. Leenen
- Department of Trauma Surgery, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands; (R.J.H.); (R.S.); (K.J.P.v.W.); (L.P.H.L.); (F.H.)
| | - Falco Hietbrink
- Department of Trauma Surgery, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands; (R.J.H.); (R.S.); (K.J.P.v.W.); (L.P.H.L.); (F.H.)
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