European Journal of Trauma and Emergency Surgery最新文献

Introduction: The minimal clinically important difference (MCID), patient-acceptable symptom state (PASS), and substantial clinical benefit (SCB) are designed to prioritise clinically significant outcomes that demonstrate true clinical benefit rather than relying solely on statistical significance. These instruments aid clinicians in understanding the patient's perspective, allowing healthcare professionals to set treatment goals that align with patients' desires and expectations. This systematic review analysed tools to estimate the clinical relevance of the most commonly used PROMs to assess patients following surgical knee ligament reconstruction.

Methods: This study was conducted according to the 2020 PRISMA statement. In January 2024, the following databases were accessed: PubMed, Web of Science, and Embase. No time constraint was set for the search. All the clinical studies investigating tools to assess the clinical relevance of PROMs in knee ligament surgery were accessed. Only studies which evaluated the MCID, PASS, and SCB were eligible. The PROMs of interest were: International Knee Document Committee (IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS) and its related subscales activity of day living (ADL), pain, quality of life (QoL), sport and recreational, and symptoms (Roos et al. in J Orthop Sports Phys Ther 28:88-96, 1998), Lysholm knee scoring scale, Short Form 12 (SF-12) and its related mental and physical component subscales, Tegner Activity Scale.

Results: Seven non-RCT investigations, three with a prospective and four with a retrospective study design, were selected for inclusion in the present review, including 1,414 patients. The overall risk of bias was low to moderate in 71.4% (5 of 7) and serious in 28.6% (2 of 7) of the studies assessed in the present investigation, indicating a broadly acceptable methodological quality. The IKDC reported an MCID of 13.8/100, the KOOS 8.0/100, the Lysholm 9.9/100, and the Tegner Activity Scale 0.5/10.

Conclusion: This systematic review demonstrated that more dependable scientific data, appropriate study methodology, and adequate reporting of MCID, SCB, and PASS in surgical knee ligament reconstruction is necessary. The IKDC score, the Lysholm score, and the Tegner activity scale were the only instruments with multiple studies reporting values. Level of evidence Level IV, systematic review and meta-analysis.

Purpose: Tranexamic acid is widely accepted for hip fractures but there is no agreement about dose or application method and the use is still off label for hip fractures. The aim of our study was to find the best application method of tranexamic acid in patients with femoral neck fractures comparing total blood loss, hemoglobin and transfusion rate.

Methods: A retrospective single centre cohort study (level I trauma centre) with 2008 patients treated operatively for a proximal femur fracture between January 2016 and January 2022 was performed. 1 g of tranexamic acid was applied in 314 cases (systemic, topic or combined application) if patients consented. Patient data, surgical procedure, complications, and mortality were assessed. Haemoglobin levels, blood loss and transfusion rates were compared amongst application methods.

Results: For 884 femoral neck fractures treated with arthroplasty blood loss was significantly reduced by tranexamic acid which 314 had received in total (1151.0 ml vs 738.28 ml; p < 0.001). 151 patients received 1 g of tranexamic acid systemically which reduced blood loss from 1151 to 943.25 ml. Combined application of 1 g i.v. and 1 g topically reduced blood loss even further to 869.79 ml and topical application achieved the lowest total blood loss at 391.59 ml (average reduction of 759.41 ml compared to without tranexamic acid), p < 0.001. Transfusion rate and amount of RBC units transfused were the lowest for topical use and showed the highest hemoglobin levels postoperatively. Complication rates did not differ for adverse vascular events.

Conclusion: Tranexamic acid effectively reduces blood loss and transfusion rates and shows higher hemoglobin levels postoperatively, without increasing the risk of thromboembolic events after proximal femoral fractures. Single topic application of 1 g for arthroplasty treatment of femoral neck fractures has better results for blood loss reduction than single i.v. or combined application.

Background: Traumatic brain injury (TBI) is considered a major cause of death globally, resulting from trauma. Decompressive craniectomy (DC) may improve functional outcomes in patients with TBI and its associated complications. This study was designed to determine safety and efficacy of DC in improving clinical outcomes in TBI patients compared to standard therapy.

Methods: A systematic search was conducted across six electronic databases to identify relevant randomized controlled trials (RCTs) examining decompressive craniotomy (DC) and traumatic brain injury (TBI) from database inception until March 2021. The pooled risk ratio was estimated for categorical outcomes, while the pooled standardized mean difference with a 95% confidence interval was calculated for continuous outcomes. Statistical analysis software, including RevMan 5.4 and STATA version 17, was employed to perform this meta-analysis. The protocol for this study is registered with the OSF registry, ensuring transparency and reproducibility.

Results: A total of 656 studies were screened, and five RCTs involving 665 subjects (334 in the DC group and 331 in the control group) were included in this meta-analysis. Our meta-analysis revealed a non-significant trend towards a higher rate of favorable clinical outcomes in subjects who underwent DC compared to those in the medical treatment (MT) group (risk ratio (RR) 1.20, 95% confidence interval (CI) 0.70 to 2.08, P = 0.50). In contrast, the mortality rate was significantly lower in patients treated with DC compared to those receiving MT alone (RR 0.58, 95% CI 0.47 to 0.73, P < 0.001). Additionally, intracranial pressure (ICP) levels were significantly lower in subjects who underwent DC compared to those receiving MT alone (standardized mean difference (SMD): - 0.87, 95% CI - 1.58 to - 0.16, P = 0.02). Furthermore, there was a statistically significant reduction in the duration of stay in the DC group compared to the MT alone group (SMD: - 1.18, 95% CI - 1.49 to - 0.86, P < 0.001).

Conclusion: This study presents evidence suggesting that DC is linked to a lower mortality rate, decreased ICP, and shorter hospital stays among patients with moderate to severe TBI. However, it did not show a significant impact on improving favorable clinical outcomes.

Purpose: If surgery is indicated for elderly patients suffering a proximal humerus fracture, reverse fracture arthroplasty became the preferred type of treatment due to its good and reliable outcomes over the last decade. Surgeons could choose from a wide range of implants and up to now there was no evaluation, if a change of the manufacturer affects patients` outcome.

Methods: The last 100 patients before and the first 100 after manufacturer change in reverse fracture arthroplasty were evaluated at a level one trauma center, all treated by only 3 senior shoulder surgeons. Clinical as well as radiographic outcome parameters were assessed, perioperative up to 24 months after surgery.

Results: Mean age in both groups was nearly 80 years with comparable distribution of gender and comorbidities. A trend to shorter duration of surgery was observed after the change, mainly according to an uncemented fixation of the stem. During follow-up no significant differences, beneficial as well as negative, could be observed regarding clinical and radiographic outcome.

Conclusion: A manufacturer change on the fly is possible without negative consequences for patients` outcome. Expertise of the whole OR-team as well as standardized training with the new implant seems to be a more important factor than a specific type of implant.

Purpose: In polytrauma patients, injuries involving the extremities are frequently seen. Treatment concepts vary from early definitive care to temporary fixation and delayed definite stabilization. This analysis therefor aims to illuminate the impact of timing for operative stabilization of extremity fractures on outcome factors in adult polytrauma patients.

Methods: We searched PubMed and Cochrane CENTRAL to identify studies from inception of each database to 14 September 2022. We included systematic reviews and RCTs comparing immediate versus delayed operative fracture stabilization and early definite care versus primary external fixation in adult polytrauma patients.

Results: Five randomized controlled trials were included, with a total of 335 patients. The analysis found no statistically significant difference in overall mortality or improvement in ICU admission between early (< 24 h) and late fracture stabilization. Comparing femoral nailing and external fixation, findings showed that femoral nailing reduce ICU length of stay and duration of invasive mechanical ventilation.

Conclusion: The results indicate that immediate surgical treatment by nailing is superior to delayed treatment or a staged surgical approach in stable polytrauma patients with long-bone fractures. As there is a lack of clear evidence regarding the optimal timing for definitive operative stabilization of extremity fractures in polytrauma patients, further high-quality studies are essential to enhance the certainty of evidence and provide more conclusive treatment algorithms.

Background: Hip fractures represent a serious public health problem with a high burden of mortality, morbidity, and resource use. Co-management has proven to enhance the clinical outcomes of hip fracture patients hospitalized in various settings.

Aim: This study aims to evaluate whether the previously observed benefits of co-management can be achieved when such a program is implemented in a rural-based district hospital.

Methods: A prospective, single-center observational study was conducted on hip fracture patients hospitalized for hip fracture. Patients were either co-managed by an internal medicine specialist with part-time dedication or not co-managed. The study was conducted in a rural hospital located in Galicia, Northwestern Spain, which serves a population of 45,000.

Results: A total of 207 patients were included in the study, of whom 97 received co-management. The majority of the patients who were co-managed were female (69.1%) and had a median age of 88 years (interquartile range 83-92). The study showed a high burden of comorbidity with a median Charlson index of 6 points, along with high prevalence rates of dementia (46%), functional disability (50%), and chronic anticoagulant therapy (25%). Despite no differences in age, sex, or preadmission cognitive or functional status, the study found lower 30-day postdischarge mortality in co-managed patients (9.3%) compared with the 110 controls (20.0%, p = 0.049). The prevalence of osteoporosis treatment, both calcium/vitamin D (87.8% vs. 60.7%, p < 0.001) and bisphosphonates/denosumab/teriparatide (42.4% vs. 15.7%, p < 0.001), was higher in the co-managed patients at 30 days after discharge. No differences were observed between the two groups in terms of in-hospital mortality and length of stay.

Conclusions: The implementation of internal medicine co-management for hip fracture patients resulted in enhanced outcomes, particularly in the reduction of mortality within 30 days of discharge as well as in the prevalence of osteoporosis treatment.

Background: The current standard of care for mild acute biliary pancreatitis (MABP) involves early laparoscopic cholecystectomy (ELC) to reduce the risk of recurrence. The MANCTRA-1 project revealed a knowledge-to-action gap and higher recurrence rates in patients admitted to medical wards, attributable to fewer ELCs being performed. The project estimated a 35% to 70% probability of narrowing this gap by 2025. This study evaluates the safety of suboptimal ELC implementation and identifies risk factors for recurrent acute biliary pancreatitis (RAP) in patients not undergoing ELC after an MABP episode.

Methods: We conducted a post-hoc analysis of the MANCTRA-1 registry, including MABP patients who did not undergo ELC during the index hospitalization, excluding those with related complications. The primary outcome was the 30-day hospital readmission rate due to RAP. We performed multivariable logistic regression to find risk factors associated with the primary outcome.

Results: Between January 2019 and December 2020, 1920, MABP patients from 150 centers were included in the study. The 30-day readmission rate due to RAP was 6%. Multivariable logistic regression found the admission to a medical ward (internal medicine or gastroenterology) (OR = 1.95, p = 0.001) and a positive COVID-19 test (OR = 3.08, p = 0.029) as independent risk factors for RAP.

Conclusion: Our analysis offers valuable insights into the management of MABP, particularly in centers where ELC cannot be fully implemented due to logistical and clinical constraints, worsened by the COVID-19 pandemic. Regardless of the admitting ward, prompt access to surgical care is crucial in reducing the risk of early recurrence, highlighting the need to implement surgical consultation pathways within MABP care bundles.

Background: Flail chest (FC) injuries are segmental osseous injuries of the thorax that typically result from high-energy blunt trauma and regularly occur in multiple trauma (MT) patients. FC injuries are associated with paradoxical chest wall movements and, thus, have a high risk of respiratory insufficiency or even death. An increasing number of studies recommend an early surgical stabilization of FC injuries, but a definite trigger that would indicate surgery has, thus far, not been identified.

Methods: Based on real-world injury computed tomography (CT) data, this study aimed to establish a finite elements (FE) model of a thorax simulating spontaneous breathing. The model is based on a 0.625 mm slice thickness CT data set. In this FE model, various FC injury patterns were implemented to examine the impact of an increasingly large flail segment on tidal volume and respiratory work. The impact of the segmental defect sizes on the outcome measures mentioned above was examined using correlation analyses.

Results: The FE model in this study reliably simulated the spontaneous breathing patterns of an actively breathing patient in an uninjured setting as a reference and showed clinically realistic movements of the flail segments for various injury settings. Correlation analysis showed a significant negative correlation between the FC size and tidal volume (R² = 0.852, p = 0.003), while absolute (R² = 0.845, p = 0.0096) and relative loss (R² = 0.844, p = 0.0096) of tidal volume concerning the intact model and the compensatory respiratory work required (R² = 0.816, p = 0.0136) were positively correlated with FC size.

Conclusion: This study presents an FE model of the thorax of a patient who presented to our clinic as an MT patient with an FC injury. The FE model fulfills physiologic active breathing patterns and simulates an FC injury's paradoxical movement, realistically depicting clinical observations. The FE model showed that the number of consecutive ribs involved in the flail segment and the length of the flail segment significantly impacted active breathing concerning tidal volumes and respiratory work. With this, we have made the first step to define a trigger for surgery.

Purpose: Distal radius fractures (DRFs) are often initially assessed by junior doctors under time constraints, with limited supervision, risking significant consequences if missed. Convolutional Neural Networks (CNNs) can aid in diagnosing fractures. This study aims to internally and externally validate an open source algorithm for the detection and localization of DRFs.

Methods: Patients from a level 1 trauma center from Adelaide, Australia that presented between 2016 and 2020 with wrist trauma were retrospectively included. Radiographs were reviewed confirming the presence or absence of a fracture, as well as annotating radius, ulna, and fracture location. An internal validation dataset from the same hospital was created. An external validation set was created with two other level 1 trauma centers, from Groningen and Rotterdam, the Netherlands. Three surgeons reviewed both sets for DRFs.

Results: The algorithm was trained on 659 radiographs. The internal validation set included 190 patients, showing an accuracy of 87% and an AUC of 0.93 for DRF detection. The external validation set consisted of 188 patients, with an accuracy and AUC were 82% and 0.88 respectively. Radial and ulnar bone segmentation on the internal validation was excellent with an AP50 of 99 and 98, but moderate for fracture segmentation with an AP50 of 29. For external validation the AP50 was 92, 89 and 25 for radius, ulna, and fracture respectively.

Conclusion: This open-source algorithm effectively detects DRFs with high accuracy and localizes them with moderate accuracy. It can assist clinicians in diagnosing suspected DRFs and is the first radiograph-based CNN externally validated on patients from multiple hospitals.