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Objectives: The aim of this study was to determine the variations in effect for predictors of mortality over time and risk of in-hospital complications in geriatric patients with a hip fracture. Many studies have investigated risk factors of short-term and long-term mortality separately. In current literature, little is known about the variations in effect of risk factors over time and no comparison with the general population is made., Methods: All patients with a hip fracture aged 70 years or older admitted to our hospital between January 1, 2016, and May 1, 2018, were included in this retrospective study. Patients who had undergone total hip arthroplasty (THA) were not included. The primary outcome was mortality after 1 year. Secondary outcomes were mortality after 30 days, 90 days, 2 years, and complications. Kaplan-Meier (KM) curves for risk factors were generated to visualize survival over time. Data were compared with data extracted from the national health records., Results: A total of 685 geriatric patients with hip fractures were included with a 1-year mortality of 27%. The adjusted odds ratios (AOR) found differed over time. Five risk factors for mortality were investigated in this study using KM curves: age, prefracture living situation, dementia, sex, and ASA classification., Conclusions: Over time, the variation of 5 risk factors for mortality were visualized in geriatric patients with a hip fracture: age, prefracture living situation, dementia, sex, and ASA classification. An elevated risk of mortality was discovered compared with the general population. The variation in effect observed in risk factors plays a vital role in prognosis. This insight will help guide accurate medical decision-making for a tailored treatment plan for geriatric patients with a hip fracture., Competing Interests: The authors declare no conflict of interest, (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

Background: In current literature, the benefit of postoperative physiotherapy versus postoperative instructions by treating specialist only remains unclear. The aim of this review is to systematically assess existing literature regarding the functional outcome of postoperative physiotherapy compared to postoperative instructions by treating specialist only in the rehabilitation of patients with an ankle fracture. The secondary aim is to determine if there is a difference in ankle range of motion, strength, pain, complications, quality of life, and patient's satisfaction between these 2 rehabilitation methods., Methods: For this review, the PubMed/MEDLINE, PEDro, Embase, Cochrane, and CINAHL databases were searched for studies that compared postoperative rehabilitation groups., Results: The electronic data search detected 20 579 articles. After exclusion, 5 studies with a total of 552 patients were included. Overall, no significant benefit in functional outcome of postoperative physiotherapy was seen compared to the instructions-only group. One study even found a significant benefit in favor of the instructions-only group. An exemption for beneficial effect of the use of physiotherapy could be made for younger patients, as 2 studies described younger age as a factor for better outcomes (functional outcome and ankle range of motion) in the postoperative physiotherapy group. Patients' satisfaction, described by one study, was found to be significantly higher in the physiotherapy group ( P  = .047). All other secondary aims showed no significant difference., Conclusion: Because of the limited number of studies and the heterogeneity among studies, a valid conclusion about the general effect of physiotherapy cannot be formed. However, we identified limited evidence suggesting a possible benefit of physiotherapy in younger patients with an ankle fracture in functional outcome and ankle range of motion., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. ICMJE forms for all authors are available online., (© The Author(s) 2023.)

Objective: The objective of this study was to explore the experiences from the period after the choice was made for palliative, non-operative management for geriatric patients with a hip fracture, to the most important factors in the process, as reported by a proxy., Design: Semistructured interviews were conducted between 1 August 2020 and 1 April 2021 to investigate by-proxy reported patient experiences of non-operative management after hip fracture. Interviews followed a topic guide, recorded and transcribed per word. Thematic analysis was used to identify themes in the data., Setting and Participants: Patients were retrospectively identified from the electronic patient record. Relatives (proxies) of the patients who underwent palliative, non-operative management were contacted and were asked to participate in a semistructured interview and were named participants. The participants were proxies of the patients since patients were expected to be deceased during the timing of the interview., Results: A total of 26 patients were considered eligible for inclusion in this study. The median age of the patients was 88 years (IQR 83-94). The 90-day mortality rate was 92.3%, with a median palliative care period of 11 days (IQR 4-26). A total of 19 participants were subjected to the interview. After thematic analysis, four recurring themes were identified: (1) the decision-making process, (2) pain experience, (3) patient-relative interaction and (4) the active dying., Conclusions: With the introduction of shared decision-making in an acute setting for geriatric patients with hip fracture, proxies reported palliative, non-operative management as an acceptable and adequate option for patients with high risk of adverse outcomes after surgery. The emerged themes in palliative care for patients with hip fracture show great similarity with severe end-stage disease palliative care, with pain identified as the most important factor influencing comfort of the patient and their environment after hip fracture. Future research should focus on further improving targeted analgesia for these patients focusing on acute pain caused by the fracture., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

To investigate the applications of robot-assisted surgery and its effect on surgical outcomes in orthopaedic trauma patients., Data Sources: A search was performed in PubMed and Embase for articles in English, Dutch, German, or French, without restrictions on follow-up times, study size, or year of publication., Study Selection: Studies were included if they investigated patients undergoing robot-assisted fracture fixation surgery for orthopaedic trauma., Data Extraction: Outcomes studied were operating time, fluoroscopy time/frequency, complications, functional outcomes, intraoperative blood loss, fracture healing, and screw placement accuracy. Critical appraisal was done by using the Methodological Index for Non-Randomized Studies., Data Synthesis: Narrative review., Conclusions: A total of 3832 hits were identified with the search and 8 studies were included with a combined total of 437 included patients, 3 retrospective cohort studies, 2 prospective cohort studies, 1 cohort study not otherwise specified, 1 case series, and 1 randomized controlled trial. Four studies investigated pelvic ring fractures, 3 studies investigated femur fractures, and 1 study investigated scaphoid fractures. Seven investigated percutaneous screw fixation and 1 studied intramedullary nail fixation. One robotic system was used across all studies, the TiRobot, and all procedures were performed in China. The limited evidence suggests that that robot-assisted orthopaedic trauma surgery may reduce operating time, use of fluoroscopy, intraoperative blood loss, and improve screw placement accuracy, but the overall quality of evidence was low with a high risk of bias. Robot-assisted fracture fixation does not appear to lead to better functional outcomes for the patient. Level of evidence: III., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

Background: Tibiotalocalcaneal (TTC) intramedullary nailing has been suggested as an alternative to open reduction and internal fixation (ORIF) for the primary treatment of unstable fragility ankle fractures with a poor soft tissue envelope. This study aims to investigate the clinical efficacy of TTC intramedullary nail fixation for the primary treatment of unstable ankle fractures in frail elderly patients with poor soft tissue condition, by assessing the number of postoperative complications and the patient-reported functional outcomes., Methods: A retrospective cohort study was performed including patients with an unstable ankle fracture treated between 2015 and 2019 with TTC stabilization using a retrograde intramedullary hindfoot nail that was inserted without joint preparation and allowing immediate weight-bearing postoperatively. The primary outcome was the total number of postoperative complications., Results: A total of 10 patients were included out of 365 operatively treated ankle fractures. The mean age was 85.2 years (range 66-92) with a mean follow-up of 11.2 months (range 6-16). Fracture types included AO/OTA 44-B2 (n = 1), 44-B3 (n = 6), 44-C1 (n = 2) and 44-C3 (n = 1). Postoperative complications were observed in 4 patients (40%), including 3 nonunions, 2 implant related complications and 1 wound infection. No wound healing disorder or below-the-knee amputation was observed. Four patients (40%) deceased between post-operative 6 to 16 months due to medical conditions unrelated to surgery. The mean Foot and Ankle Outcome Score was 52.6 (range 44.2-73.8)., Conclusion: Hindfoot nailingis a viable treatment option in selected high-risk patients with an advanced age, unstable ankle fractures with significant bone loss, poor soft tissue condition and/or severely impaired pre-injury mobility. In a frail geriatric population, hindfoot nailing may be a safe alternative fixation method with a low risk of wound complication or major amputation. However, unprepared joint may lead to symptomatic nonunion after TTC intramedullary nailing., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2021.)

Mindfulness implies entering a mental state of awareness which allows for the reframing of an experience, and functionality has shown to be influenced by mindset. The aim of this systematic review was to assess effects of mindfulness in patients with upper-extremity conditions. PubMed, Embase, Cochrane, and CINAHL databases were searched on June 19, 2019, for studies investigating mindfulness in patients with upper-extremity conditions. Two validated instruments for methodologic assessment were used to assess study quality. Studies that reported pain, psychological, or functional outcome measures were included. One randomized controlled trials and three observational studies were included, which together included 335 patients that completed final follow-up. The weighted average age was 52.4 years and 48% of the patients were male. Evaluation of the outcome measures used was immediately after the mindfulness intervention or assessment in all studies. Mindfulness appeared to be positively associated with less pain (though below the minimal clinically important difference), increased mood, and better function. Mindfulness is associated with increased mood and possibly better functionality in adults with a large range of upper-extremity conditions when measured or used as an intervention. Future researcher should expand the subject as only four studies were included in this review. This is a Level IV study., Competing Interests: Ethical ApprovalConflict of Interest As no humans or animals were studied in this systematic review, ethical committee approval by the institutional review board was not necessary. None declared.

Introduction: An aging population in developed countries has increased the number of osteoporotic hip fractures and will continue to grow over the next decades. Previous studies have investigated the effect of integrated orthogeriatric trauma units and care model on outcomes of hip fracture patients. Although all of the models perform better than usual care, there is no conclusive evidence which care model is superior. More confirmative studies reporting the efficacy of orthogeriatric trauma units are needed. The objective of this study was to evaluate outcomes of hip fracture patients admitted to the hospital before and after implementation of an orthogeriatric trauma unit., Materials and Methods: This retrospective cohort study was conducted at a level 2 trauma center between 2016 and 2018. Patients aged 70 years or older with a hip fracture undergoing surgery were included to evaluate the implementation of an orthogeriatric trauma unit. The main outcomes were postoperative complications, patient mortality, time spent at the emergency department, time to surgery, and hospital length of stay., Results: A total of 806 patients were included. After implementation of the orthogeriatric trauma unit, there was a significant decrease in postoperative complications (42% vs. 49% in the historical cohort, p = 0.034), and turnaround time at the emergency department was reduced by 38 minutes. Additionally, there was significantly less missing data after implementation of the orthogeriatric trauma unit. After correcting for covariates, patients in the orthogeriatric trauma unit cohort had a lower chance of complications (OR 0.654, 95% CI 0.471-0.908, p = 0.011) and a lower chance of 1-year mortality (OR 0.656, 95% CI 0.450-0.957, p = 0.029)., Conclusions: This study showed that implementation of an orthogeriatric trauma unit leads to a decrease in postoperative complications, 1-year mortality, and time spent at the emergency department, while also improving the quality of data registration for clinical studies., Level of Evidence: Level III., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2020.)

Background: Although the phrase "time is fascia" is well acknowledged in the case of necrotizing soft tissue infections (NSTIs), solid evidence is lacking. The aim of this study is to review the current literature concerning the timing of surgery in relation to mortality and amputation in patients with NSTIs., Methods: A systematic search in PubMed/MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Controlled Register of Trials (CENTRAL) was performed. The primary outcomes were mortality and amputation. These outcomes were related to the following time-related variables: (1) time from onset symptoms to presentation; (2) time from onset symptoms to surgery; (3) time from presentation to surgery; (4) duration of the initial surgical procedure. For the meta-analysis, the effects were estimated using random-effects meta-analysis models., Result: A total of 109 studies, with combined 6051 NSTI patients, were included. Of these 6051 NSTI patients, 1277 patients died (21.1%). A total of 33 studies, with combined 2123 NSTI patients, were included for quantitative analysis. Mortality was significantly lower for patients with surgery within 6 h after presentation compared to when treatment was delayed more than 6 h (OR 0.43; 95% CI 0.26-0.70; 10 studies included). Surgical treatment within 6 h resulted in a 19% mortality rate compared to 32% when surgical treatment was delayed over 6 h. Also, surgery within 12 h reduced the mortality compared to surgery after 12 h from presentation (OR 0.41; 95% CI 0.27-0.61; 16 studies included). Patient delay (time from onset of symptoms to presentation or surgery) did not significantly affect the mortality in this study. None of the time-related variables assessed significantly reduced the amputation rate. Three studies reported on the duration of the first surgery. They reported a mean operating time of 78, 81, and 102 min with associated mortality rates of 4, 11.4, and 60%, respectively., Conclusion: Average mortality rates reported remained constant (around 20%) over the past 20 years. Early surgical debridement lowers the mortality rate for NSTI with almost 50%. Thus, a sense of urgency is essential in the treatment of NSTI., Competing Interests: Competing interestsThe authors declare that they have no competing interests., (© The Author(s). 2020.)

Background: Emergency department utilization has increased tremendously over the past years, which is accompanied by an increased necessity for emergency medicine research to support clinical practice. Important sources of evidence are systematic reviews (SRs) and meta-analyses (MAs), but these can only be informative provided their quality is sufficiently high, which can only be assessed if reporting is adequate. The purpose of this study was to assess the quality of reporting of SRs and MAs in emergency medicine using the PRISMA statement., Methods: The top five emergency medicine related journals were selected using the 5-year impact factor of the ISI Web of Knowledge of 2015. All SRs and MAs published in these journals between 2015 and 2016 were extracted and assessed independently by two reviewers on compliance with each item of the PRISMA statement., Results: The included reviews (n = 112) reported a mean of 18 ± 4 items of the PRISMA statement adequately. Reviews mentioning PRISMA adherence did not show better reporting than review without mention of adherence (mean 18.6 (SE 0.4) vs. mean 17.8 (SE 0.5); p = 0.214). Reviews published in journals recommending or requiring adherence to a reporting guideline showed better quality of reporting than journals without such instructions (mean 19.2 (SE 0.4) vs. mean 17.2 (SE 0.5); p = 0.001)., Conclusion: There is room for improvement of the quality of reporting of SRs and MAs within the emergency medicine literature. Therefore, authors should use a reporting guideline such as the PRISMA statement. Active journal implementation, by requiring PRISMA endorsement, enhances quality of reporting.

Background: Necrotizing fasciitis is a potentially lethal condition for which early and adequate treatment with surgical debridement and broad-spectrum intravenous antibiotics are essential for survival. It is hypothesized that Group A Streptococcus (GAS) necrotizing fasciitis causes exhaustion of the immune system, making these patients more susceptible for late secondary infections., Methods: A retrospective study was conducted of all patients with necrotizing fasciitis between 2002 and 2016. Patients with necrotizing fasciitis based on macroscopic findings, positive Gram staining, culture or fresh frozen section of fascia biopsies were included. Patients with necrotizing fasciitis were divided into two groups based on the presence of GAS. Of both groups, clinical course, outcome and occurrence of late secondary infections were analyzed. For the occurrence of secondary infections, pneumonia was chosen as reference for late secondary infections., Results: Eighty-one patients with necrotizing fasciitis were included of which 38 (47%) had GAS necrotizing fasciitis and 43 (53%) had non-GAS necrotizing fasciitis. Patients with GAS necrotizing fasciitis were younger (50 vs. 61 years, p=0.023) and more often classified as ASA I (45% vs. 14%, p=0.002) compared with patients with non-GAS necrotizing fasciitis. In-hospital mortality rate for necrotizing fasciitis was 32%. Patients with comorbidities were more likely to die of necrotizing fasciitis compared with patients without comorbidities (OR 7.41, 95% CI 1.58 to 34.63). Twelve patients (39%) with GAS necrotizing fasciitis developed pneumonia compared with four patients (13%) with non-GAS necrotizing fasciitis (p=0.017; OR 4.42, 95% CI 1.124 to 15.79). Median time from diagnosis to development of pneumonia in patients with GAS necrotizing fasciitis was 10 days (IQR 9)., Conclusion: Patients with GAS necrotizing fasciitis have an increased risk to develop late secondary infections during initial treatment for necrotizing fasciitis compared with patients with necrotizing fasciitis without involvement of GAS. This suggests exhaustion of the immune system after severe GAS infection., Level of Evidence: III., Competing Interests: Competing interests: None declared

Introduction: Brodie's abscess is a form of osteomyelitis. Since its first appearance in the medical literature in 1832, numerous cases have been described. The aim of this article is to provide the first comprehensive overview of published cases of Brodie's abscess, and to describe diagnostic methods, therapeutic consequences and outcomes. Methods: According to PRISMA guidelines a systematic review of the literature was performed. All published data in English or Dutch were considered for inclusion with no limitations on publication date. Data was extracted on demography, duration of symptoms, signs of inflammation, diagnostic imaging, causative agent, treatment and follow-up. Results: A total of 70 articles were included, reporting on a total of 407 patients, mostly young (median age 17) males (male:female ratio 2.1:1). The median duration of symptoms before diagnosis was 12 weeks (SD 26). Mostly consisting of pain (98%) and/or swelling (53%). 84% of all patients were afebrile, and less than 50% had elevated serum inflammation markers. Diagnosis was made with a combination of imaging modalities: plain X-ray in 96%, MRI (16%) and CT-scan (8%). Treatment consisted of surgery in 94% of the cases, in conjunction with long term antibiotics in 77%. Staphylococcus aureus was the pathogen most often found in the culture (67,3%). Outcome was generally reported as favorable. Recurrence was reported in 15,6% of the cases requiring further intervention. Two cases developed permanent disability. Conclusion: Brodie's abscess has an insidious onset as systemic inflammatory signs and symptoms were often not found. Treatment consisted mostly of surgery followed by antibiotics (77%) or only surgery (17%) and outcomes were generally reported as favourable., Competing Interests: Competing Interests: The authors have declared that no competing interest exists.

Background: Implementation of an inclusive trauma system leads to reduced mortality rates, specifically in polytrauma patients. Field triage is essential in this mortality reduction. Triage systems are developed to identify patients with life-threatening injuries, and trauma mechanisms are important for triaging. Although complex extremity fractures are mostly non-lethal, these injuries are frequently the result of a high-energy trauma mechanism. The aim of this study is to compare injury and patient characteristics, as well as resource demands, of lower extremity fractures between a level (L)1 and level (L)2 trauma centre in a mature inclusive trauma system., Methods: This is a retrospective cohort study. Patients with below-the-knee joint fractures diagnosed in a L1 or L2 trauma centre between July 2013 and June 2015 were included. Main outcome parameters were patient demographics, trauma mechanism, fracture pattern, and resource demands., Results: One thousand two hundred sixty-seven patients with 1517 lower extremity fractures were included. Most patients were treated in the L2 centre (L1 = 417; L2 = 859). Complex fractures were more frequently triaged to the L1 centre. Patients in the L1 centre had more concomitant injuries to other body regions and ipsi- or contralateral lower extremity. Patients in the L1 centre were more resource demanding: more surgeries (> 1 surgery; 24.9% L1 vs 1.4% L2), higher immediate admission rates (70.1% L1 vs 37.6% L2), and longer length of stay (mean 13.4 days L1 vs 3.1 days L2)., Conclusion: The majority of patients were treated in the L2 trauma centre, whereas complex lower extremity injuries were mostly treated in the L1 centre, which placed higher demand on resources and labour per patient. This change in allocation is the next step in centralization of low-volume high complex care and high-volume low complex care., Competing Interests: Ethics approval was derived from the local IRB. A waiver for approval by our institutional review board was achieved.The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Introduction: Ankle fractures are among the most common type of fractures in the lower extremity. A posterior malleolar fracture is frequently part of a more complex ankle fracture and only in rare cases it occurs as isolated injury. Posterior malleolar fractures often occur with associated injuries, such as a Maisonneuve fracture or with bi- or trimalleolar ligamentous injuries. Knowledge about these associated injuries is essential to prevent missed diagnoses. The aim of this article is to describe the isolated posterior malleolar fracture, the possible associated injuries, the diagnostic work-up and therapeutic consequences., Presentation of Case: We present a case of a 26-year-old male patient who sustained an isolated posterior malleolar fracture with 4.5 years follow-up., Discussion: Isolated fractures of the posterior malleolus are uncommon injuries. Diagnosis, treatment and outcome can seldom be extracted from large series. However, several cases have been described in literature, which we have summarized., Conclusion: This case report and literature review shows that isolated posterior malleolar fractures might occur as part of a more complex ankle injury, in combination with a fracture of the lower leg or after high energy trauma. Physicians should be aware of these associated injuries. Diagnostic work-up should include X-rays of the knee and lower leg and a CT scan of the ankle. If diagnosed and treated properly, isolated posterior malleolar fractures have a good long-term functional outcome., (Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.)