Preinjury use of antithrombotic medication (PAM) may increase bleeding risk and adverse outcomes in older trauma patients. PAM is not routinely recorded in the Dutch trauma registry, leaving its impact on outcomes unclear. This study describes PAM among older trauma patients and assesses its association with injury patterns and patient outcomes, thereby informing whether routine documentation in trauma registries would be useful. Data from trauma patients aged ≥ 65 years admitted to hospitals within the West-Netherlands trauma region in June-September 2024 were obtained from the regional trauma registry. PAM was additionally documented during this period. Poor outcome was defined as in-hospital mortality and Glasgow Outcome Scale (GOS) score ≤ 3 at hospital discharge. Associations between PAM and outcomes were analyzed using multivariable logistic regression. Of 1,112 patients, 50

Evidence on non-operative management of multiple single rib fractures remains limited, resulting in institutional treatment variation. This study compared outcomes of different pain management strategies. A retrospective cohort study at Massachusetts General Hospital (MGH, USA) and Leiden University Medical Center (LUMC, The Netherlands) included patients ≥ 18 years with ≥ 3 single rib fractures between 2018 and 2023. Exclusion criteria included flail chest, surgical fixation, severe extra-thoracic trauma, Glasgow Coma Scale < 15 after 72 h, and transfers. Primary outcomes were pain score change, discharge opioid use, and pulmonary complications. Secondary outcomes included mortality and hospital length of stay (HLOS). Subgroup analysis compared fracture side and displacement, and ICU admission. Forward stepwise logistic regression analysis identified predictors of pneumonia. 545 patients were included (109 at LUMC). LUMC patients were younger (61 vs. 68 years, p < 0.001) with fewer comorbidities but higher injury severity scores (13 vs. 10, p < 0.001). LUMC favored patient-controlled analgesia (22.9

Background: Distal radius malunion accompanied by increased dorsal angulation tends to alter wrist biomechanics, leading to a range of carpal malalignment patterns, which may affect both the radiocarpal (radiolunate) and midcarpal (capitolunate) joints. One type has radiocarpal malalignment with an aligned midcarpal joint, and the second type has midcarpal malalignment with an aligned radiocarpal joint. Previous studies have demonstrated that corrective osteotomy tends to restore normal radiocarpal and midcarpal alignment. However, we observed that radiocarpal and midcarpal malalignment persist in a subset of patients, despite appropriate correction of the malunited distal radius. The primary aim was to assess the effects of postoperative persistent carpal malalignment on functional outcomes by comparing the Patient-Rated Wrist Evaluation (PRWE) of patients with and without persistent radiocarpal or midcarpal malalignment following a corrective osteotomy of the distal radius. Methods: For this retrospective study, we screened all consecutive adult patients who had an extra-articular corrective osteotomy between January 2019 and 2024 for a distal radius malunion. Radiocarpal and midcarpal malalignment was assessed on pre- and postoperative radiographs by two researchers. The PRWE was evaluated during the standard postoperative follow-up. Results: This study showed that PRWE scores of patients with carpal malalignment did not differ from those of patients with normal carpal alignment, both preoperatively and postoperatively. Furthermore, the prevalence of all types of malalignment decreased following the corrective osteotomy, and all patients reported improved hand and wrist function, with a median improvement of 50 points on the PRWE. Conclusions: Midcarpal malalignment is common in distal radius malunions and may exist simultaneously with radiocarpal malalignment. Despite the presence of malalignment, all patients experienced improved function after the corrective osteotomy. Therefore, we conclude that persistent radial or midcarpal malalignment following a corrective osteotomy does not have an adverse effect on functional outcome. Level of evidence: Level III (Therapeutic).

Aims and background: Distal tibiofibular syndesmosis injuries often require stabilization to prevent osteoarthritis (OA) and functional impairment. Malreduction rates up to 52% have been reported after fluoroscopy-guided fibula–tibia (fib–tib) positioning screw placement, and malreduction is associated with poor outcomes, including chronic pain, instability, and posttraumatic arthritis. Traditional two-dimensional (2D) fluoroscopy often fails to detect subtle malreductions, contributing to these suboptimal results. In contrast, intraoperative three-dimensional (3D) imaging modalities, such as computed tomography (CT) or cone-beam CT, are increasingly utilized to improve detection of malalignment during surgery. This study evaluates if intraoperative 3D imaging in syndesmotic reconstruction using fib–tib positioning screws improves detection of malreduction and assesses how often 3D imaging leads to intraoperative revision of reduction. Materials and methods: This retrospective case series includes all patients (n = 22) who underwent syndesmotic reconstruction by fib–tib positioning screws using intraoperative 3D imaging (by O-arm or motorized 3D C-arm) at our trauma center between 2022 and 2024. All 3D reconstructions were performed after reductions and temporary fixation appeared satisfactory on fluoroscopy. Reduction of the fibula in the notch was subjectively assessed by the operating surgeon. The primary outcome was the frequency and nature of immediate intraoperative revisions following 3D imaging. Early complications were noted. Results: About 22 patients (mean age 40) were included: 9 with proximal fibular fractures (AO type 44-C3), 11 with 44-C1 or 44-C2 fractures, 1 with a 44-B3 fracture, and 1 with an isolated posterior malleolar fracture. In 14 cases, two syndesmotic screws were used; in eight cases, only one was used. Although fluoroscopic findings appeared satisfactory, intraoperative 3D imaging prompted revision of syndesmotic reduction in nine cases (41%). Complications occurred in three cases: (1) deep venous thrombosis, (2) infection after an open fracture, and (3) secondary dislocation due to screw failure. Conclusion: Syndesmotic malreductions after trans-syndesmotic fib–tib screw stabilization are common and often missed on standard fluoroscopy. Intraoperative 3D imaging or postoperative CT is recommended to detect and address these malreductions in all syndesmotic injuries. Level of evidence: Level IV.

Background:Radiology reports on radiographic findings during follow-up (FU) after extremity fractures are generally not yet available when the patient is seen by the treating orthopedic trauma surgeon and may therefore be redundant. The aim of this study was to explore the inter-observer agreement on the reported findings of the FU radiograph between orthopedic trauma surgeons and radiologists. Method:This retrospective cohort study included all FU radiographs of adult patients with an extremity fracture, treated in a Dutch university hospital between January 2022 and July 2023. The radiologist's and orthopedic trauma surgeon's assessments of unacceptable alignment, delayed/non-union and abnormalities associated with osteosynthesis material (OSM) on the FU radiographs were collected from the medical files. Fracture healing was considered normal in the absence of these findings. The interobserver agreement of the radiographic parameters between surgeon and radiologist was determined using Cohens' Kappa (κ). Additionally, incidental findings and their clinical relevance were explored. Results:953 FU radiographs of 569 patients were included. The interobserver agreement was close to perfect for normal fracture healing (κ = 0.82, 95 % CI 0.77-0.88) and delayed/non-union (κ = 0.94, 95 % CI 0.89-0.99). The inter-observer agreement was substantial for unacceptable alignment of the fracture (κ = 0.80, 95 % CI 0.72-0.88) and abnormalities associated with the OSM (κ = 0.77, 95 % CI 0.65-0.89). Twenty-one incidental findings were diagnosed in the FU by the radiologist of which two were also independently described by the surgeon. Three of the findings that were missed or not described by the surgeon could have clinical significance, however the missing of these findings did not lead complications or additional hospital visits. These included two missed rib fractures and one osteochondral defect, which led to prolonged immobilization due to pain. Conclusion:Radiographic reports in the FU of extremity fractures have limited additional value for clinical care and probably lacks cost-effectiveness or efficiency.

Severely injured patients may suffer from acute disease-related or injury-related malnutrition involving a marked inflammatory response. This study investigated the prevalence and incidence of malnutrition and its relation with complications in severely injured patients admitted to the intensive care unit (ICU). This observational prospective cohort study included severely injured patients (Injury Severity Score ≥ 16), admitted to the ICU of five level-1 trauma centers in the Netherlands and United States. Malnutrition was defined as a Subjective Global Assessment score ≤ 5. Complications included systemic-, surgery-, and fracture-related complications, pneumonia, urinary tract infection, deep venous thrombosis, and pulmonary embolism. In-ICU and in-hospital mortality were recorded separately. The complication rate was compared between patients who had or developed malnutrition and patients who remained well-nourished, using multivariable logistic regression analysis. Of 100 included patients, twelve (12

Peri-operative cardiopulmonary collapse (CPC) poses an increased risk of in-hospital mortality, especially in frail patients. Bone Cement Implantation Syndrome (BCIS) is CPC following, cemented, arthroplasty, characterized by hypoxia and/or hypotension. The main objective of this study was to evaluate the association between cemented hemiarthroplasty and CPC, in patients with a femoral neck fracture (FNF) and increased pre-operative risk, and identify other risk factors for cardiopulmonary collapse. This retrospective cohort study included patients with a FNF treated with a cemented or uncemented hemiarthroplasty, aged ≥ 80 years, with ASA score ≥ 3 and ≥ 1 cardiac or pulmonal comorbidity. CPC was defined as hypoxia/hypotension grade ≥ 2 according to Donaldson’s criteria. Multivariable logistic regression analysis was used to adjust for confounding in the relation between cemented hemiarthroplasty and CPC, and to identify other risk factors for CPC in patients with a cemented hemiarthroplasty. The incidence of CPC was 51.1

Background: According to the nationally imposed standard of care in the Netherlands, severely injured patients should be brought to a Level-1 trauma center for primary treatment. If not, they are considered to be under- triaged. This study aimed to determine the incidence of undertriage among severely injured geriatric patients and to evaluate the relation between hospital-undertriage and patient outcomes in elderly. Methods: This retrospective cohort study used anonymized data from the regional trauma registry of 1,431 patients aged >70 years with an Injury Severity Score >16 that were admitted to hospitals within the Trauma Region West-Netherlands between 2015 and 2022. Poor patient outcome was defined as in-hospital mortality or as a Glasgow Outcome Scale (GOS) score <= 3 at hospital discharge. The association between hospital level and poor outcomes was analyzed using multivariable logistic regression analysis with adjustment for confounders after multiple imputation of missing values. Results: Seventeen percent of the severely injured geriatric patients were primarily transported to a Level-2/3 hospital. Female patients, older patients, and patients that had suffered a low-energy fall were most likely to be undertriaged. The adjusted odds ratio's for in-hospital mortality and GOS score <= 3 in Level-1 versus Level-2/3 hospitals were 1.26 (95 % confidence interval, 0.83-1.93; p = 0.28) and 0.81 (95 % confidence interval, 0.57-1.15; p = 0.24), respectively. Conclusion: Undertriaged severely injured geriatric patients did not have a higher risk for poor outcomes. Level- 2/3 hospitals seem to present a safe alternative for the treatment of these patients.

Trauma systems are vital components of healthcare infrastructure, addressing the significant burden of severe injuries across Europe. Effective trauma systems improve patient outcomes and reduce mortality by providing timely, specialised care. However, significant disparities remain between countries, with only a few well-structured and maintained systems currently operating in Europe. Developing trauma systems requires collaboration among healthcare providers, emergency services, and government agencies. Standardised protocols for triage, transport, and treatment are essential, supported by robust infrastructure, public education, and injury prevention initiatives. Trauma systems comprise four core components: • Injury Prevention. • Pre-Hospital Care. • Facility Care. • Post-Hospital Care/Rehabilitation. These components rely on key elements such as leadership, professional resources, education, quality improvement, and funding. Political commitment, geographical considerations, and the efforts of dedicated clinicians are crucial for ensuring system success. Trauma systems across Europe are evolving under diverse healthcare structures. Over recent decades, dedicated clinicians, often with support from national medical societies, have initiated and sustained these systems. Typically, trauma hospitals, or trauma centres (TCs), are categorised into two or three levels, with the highest being ‘Level I TC’ or ‘Major TC,’ capable of managing the most complex cases. This chapter outlines general requirements for these categories, leaving individual nations to tailor standards to their healthcare systems.

This study investigated the prevalence of high nutritional risk (modified Nutrition Risk in Critically Ill (mNUTRIC) score ≥ 5) and its relation with malnutrition and other adverse in-hospital outcomes in severely injured patients (Injury Severity Score ≥ 16), admitted to the ICU. We hypothesized that high nutritional risk is associated with an increased risk of developing malnutrition (primary hypothesis) and of complications and mortality (secondary hypotheses) in adults with severe injuries compared to those with low nutrition risk. In this observational prospective study, 100 severely injured patients admitted to the ICU of five Level-1 trauma centers in the US and the Netherlands between 2018–2022 were included. During ICU and hospital stay, malnutrition rates (Subjective Global Assessment score ≤ 5), complication rates (systemic complications, pneumonia, urinary tract infection, venous thromboembolism), and mortality of severely injured patients with high versus low nutritional risk were compared. A cause-specific Cox regression model was fitted to analyze whether high nutritional risk was related to developing malnutrition. Eighteen percent of patients had high nutritional risk (95

Traumatic injuries are a leading cause of global morbidity and mortality, with 40 million people permanently injured and nearly 6 million deaths every year. Approximately 90% of trauma-related deaths occur in low- and middle-income countries, and 50% of trauma-related deaths are believed to be preventable. Although effective trauma systems encompassing prehospital, hospital, and rehabilitative care are critical for improving outcomes, global documentation remains limited. This study provides a comparative analysis of trauma care systems across 8 countries-the United States, Canada, Brazil, Belgium, the Netherlands, Australia, Japan, and South Africa-spanning 5 continents. Each country's analysis includes demographic context, system organization (including prehospital, hospital, and posthospital care), clinical and systemic outcomes, and future directions. Trauma systems across countries vary significantly in the structure and regulation of trauma care, injury patterns, national data collection, and accessibility, reflecting diverse demographics and healthcare infrastructures. National trauma registries are well established in countries like the Netherlands, Japan, and Canada but are in early development stages in Brazil, South Africa, and Belgium. In some countries, such as the Netherlands and Canada, trauma from traffic collisions and falls dominates, whereas others, such as Brazil and South Africa, have higher rates of violence-related injuries like homicides. Accessibility in remote areas remains a challenge in countries with large landmasses such as Canada and Australia, where rural populations often face limited or delayed trauma care. Other countries, such as the United States and South Africa, face different challenges linked to disparities in quality of and access to care between public and private systems. Although centralization of trauma care, standardization of national trauma care systems, and investment in workforce and infrastructure are universal goals for improving outcomes, solutions tailored to each country are required to optimize trauma systems globally.

This systematic review aims to summarize the currently available literature regarding the association of plasma metabolites and vitamins with the nutritional status in adult hospitalized patients. A systematic literature search was performed in PubMed and EMBASE, and all studies comparing metabolite or vitamin levels in malnourished versus well-nourished hospitalized patients were included. Twenty-three studies were eligible for inclusion, representing 3803 hospitalized patients. Several metabolites involved in the metabolism of methionine, purine, glutathione, carnitine, phenylalanine, and tryptophan, as well as some vitamins, seem to be associated with malnutrition in hospitalized patients. These compounds can potentially be used to assess nutritional status.

Background This study explored if computerized tomography-derived body composition parameters (CT-BCPs) are related to malnutrition in severely injured (“polytrauma”) patients admitted to the Intensive Care Unit (ICU). Methods This prospective cohort study included polytrauma (Injury Severity Score ≥ 16) patients, admitted to the ICU of three level-1 trauma centers between 2018–2022. Abdominal CT scans were retrospectively analyzed to assess the CT-BCPs: muscle density (MD), skeletal muscle index (SMI), and visceral adipose tissue (VAT). The Subjective Global Assessment was used to diagnose malnutrition at ICU admission and on day 5 of admission, and the modified Nutrition Risk in Critically ill at admission was used to assess the nutritional risk. Results Seven (11%) of the 65 analyzed patients had malnutrition at ICU admission, increasing to 23 patients (35%) on day 5. Thirteen (20%) patients had high nutritional risk. CT-BCPs were not related to malnutrition at ICU admission and on day 5. Patients with high nutritional risk at admission had lower MD (median (IQR) 32.1 HU (25.8–43.3) vs 46.9 HU (37.7–53.3); p < 0.01) and higher VAT (median 166.5 cm2 (80.6–342.6) vs 92.0 cm2 (40.6–148.2); p = 0.01) than patients with low nutritional risk. Conclusion CT-BCPs do not seem related to malnutrition, but low MD and high VAT may be associated with high nutritional risk. These findings may prove beneficial for clinical practice, as they suggest that CT-derived parameters may provide valuable information on nutritional risk in polytrauma patients, in addition to conventional nutritional assessment and screening tools.

Background: This study aimed to identify plasma lipoproteins and small metabolites associated with high risk of malnutrition during intensive care unit (ICU) stay in patients with severe injuries. Methods: This observational prospective exploratory study was conducted at two level-1 trauma centers in the Netherlands. Adult patients (aged ≥18 years) who were admitted to the ICU for more than 48 h between July 2018 and April 2022 owing to severe injuries (polytrauma, as defined by Injury Severity Scores of ≥16) caused by blunt trauma were eligible for inclusion. Partial least squares discriminant analysis was used to analyze the relationship of 112 lipoprotein-related components and 23 small metabolites with the risk of malnutrition (modified Nutrition Risk in Critically Ill score). Malnutrition was diagnosed based on Subjective Global Assessment scores. The relationship of lipoprotein properties and small metabolite concentrations with malnutrition (during ICU admission) was evaluated using mixed effects logistic regression. Results: Overall, 51 patients were included. Lower (very) low-density lipoprotein ([V]LDL) (free) cholesterol and phospholipid levels, low particle number, and higher levels of LDL triglycerides were associated with a higher risk of malnutrition (variable importance in projection [VIP] value >1.5). Low levels of most (V)LDL and intermediate-density lipoprotein subfractions and high levels of high-density lipoprotein Apo-A1 were associated with the diagnosis of malnutrition (VIP value >1.5). Increased levels of dimethyl sulfone, trimethylamine N-oxide, creatinine, N, N-dimethylglycine, and pyruvic acid and decreased levels of creatine, methionine, and acetoacetic acid were also indicative of malnutrition (VIP value >1.5). Overall, 14 lipoproteins and 1 small metabolite were significantly associated with a high risk of malnutrition during ICU admission (P <0.05); however, the association did not persist after correcting the false discovery rate (P=0.35 for all). Conclusion: Increased triglyceride in several lipoprotein subfractions and decreased levels of other lipoprotein subfraction lipids and several small metabolites (involved in the homocysteine cycle, ketone body formation, and muscle metabolism) may be indicative of malnutrition risk. Following validation in larger cohorts, these indicators may guide institution of preventive nutritional measures in patients admitted to the ICU with severe injuries.

Purpose For polytrauma patients with bilateral femoral shaft fractures (BFSF), there is currently no consensus on the optimal timing of surgery. This study assesses the impact of early (≤ 24 hours) versus delayed (>24 hours) definitive fixation on clinical outcomes, especially focusing on concomitant versus staged repair. We hypothesized that early definitive fixation leads to lower mortality and morbidity rates. Methods The 2017-2020 Trauma Quality Improvement Program was used to identify patients aged ≥16 years with BFSF who underwent definitive fixation. Early definitive fixation (EDF) was defined as fixation of both femoral shaft fractures within 24 hours, delayed definitive fixation (DDF) as fixation of both fractures after 24 hours, and early staged fixation (ESF) as fixation of one femur within 24 hours and the other femur after 24 hours. Propensity score matching and multilevel mixed effects regression models were used to compare groups. Results 1,118 patients were included, of which 62.8% underwent EDF. Following propensity score matching, 279 balanced pairs were formed. EDF was associated with decreased overall morbidity (12.9% vs 22.6%, p=0.003), lower rate of deep venous thrombosis (2.2% vs 6.5%, p=0.012), a shorter ICU LOS (5 vs 7 days, p<0.001) and a shorter hospital LOS (10 vs 15 days, p<0.001). When compared to DDF, early staged fixation (ESF) was associated with lower rates of ventilator acquired pneumonia (0.0% vs 4.9%, p=0.007), but a longer ICU LOS (8 vs 6 days, p=0.004). Using regression analysis, every 24-hour delay to definitive fixation increased the odds of developing complications by 1.05, postoperative LOS by 10 hours and total hospital LOS by 27 hours. Conclusion Early definitive fixation (≤ 24 hours) is preferred over delayed definitive fixation (>24 hours) for patients with bilateral femur shaft fractures when accounting for age, sex, injury characteristics, additional fractures and interventions, and hospital level. Although mortality does not differ, overall morbidity and deep venous thrombosis rates, and length of hospital and intensive care unit stay are significantly lower. When early definitive fixation is not possible, early staged repair seems preferable over delayed definitive fixation.

Background and Aims: This exploratory observational prospective study aimed to evaluate fat-soluble vitamin plasma levels during hospital admission and its relation with the development of malnutrition and complications in polytrauma patients, considering the protocolized multivitamin supplementation during intensive care unit (ICU) admission. Methods: In 49 well-nourished polytrauma (injury severity score >= 16) patients admitted to the ICU of two level-1 trauma centers, vitamin A, D, and E levels were assessed weekly during hospital stay. All patients received multivitamin supplementation during ICU stay. Linear mixed-effect models were used to assess a trend in vitamin levels over time during hospital stay. Mixed-effects logistic regression analysis was performed to relate vitamin concentrations with malnutrition, defined as a subjective global assessment score <= 5, and complications. Results: Vitamin A levels increased 0.17 mu mol/L per week (95% confidence interval 0.12-0.22, p < 0.001), vitamin D levels increased 1.49 nmol/L per week (95% confidence interval 0.64-2.33, p < 0.01), vitamin E levels increased 1.17 mu mol/L per week (95% confidence interval 0.61-1.73, p < 0.001) during hospital stay (29 +/- 17 days). Vitamin levels were not related to malnutrition or complications during hospital stay. Conclusion::::::::::::::::: Vitamin A, D, and E levels increased due to supplementation during hospital admission. Plasma levels of vitamins A, D, and E do not seem to be useful as biomarkers for the nutritional status of polytrauma patients during hospital stay. No correlation with complications could be demonstrated.

This study aimed to investigate the long-term outcomes of patients with a femoral neck fracture (FNF), treated with the Dynamic Locking Blade Plate (DLBP). Retrospective analysis of prospectively collected data of a multicentre cohort of patients with FNFs was conducted, regarding the long-term incidence of revision surgery after DLBP. Implant failure was evaluated using Kaplan-Meier and Cox regression analysis. Secondary outcomes were the indication for revision surgery, complications, time to revision surgery, rate of elective removal of the implant, potential predictors for revision surgery and mortality. Median follow-up of 389 included patients was 98 months; 20.6

PURPOSE:European training pathways for surgeons dedicated to treating severely injured and critically ill surgical patients lack a standardized approach and are significantly influenced by diverse organizational and cultural backgrounds. This variation extends into the realm of mentorship, a vital component for the holistic development of surgeons beyond mere technical proficiency. Currently, a comprehensive understanding of the mentorship landscape within the European trauma care (visceral or skeletal) and emergency general surgery (EGS) communities is lacking. This study aims to identify within the current mentorship environment prevalent practices, discern existing gaps, and propose structured interventions to enhance mentorship quality and accessibility led by the European Society for Trauma and Emergency Surgery (ESTES). METHODS:Utilizing a structured survey conceived and promoted by the Young section of the European Society of Trauma and Emergency Surgery (yESTES), we collected and analyzed responses from 123 ESTES members (both surgeons in practice and in training) across 20 European countries. The survey focused on mentorship experiences, challenges faced by early-career and female surgeons, the integration of non-technical skills (NTS) in mentorship, and the perceived role of surgical societies in facilitating mentorship. RESULTS:Findings highlighted a substantial mentorship experience gap, with 74% of respondents engaging in mostly informal mentorship, predominantly centered on surgical training. Notably, mentorship among early-career surgeons and trainees was less reported, uncovering a significant early-career gap. Female surgeons, representing a minority within respondents, reported a disproportionately poorer access to mentorship. Moreover, while respondents recognized the importance of NTS, these were inadequately addressed in current mentorship practices. The current mentorship input of surgical societies, like ESTES, is viewed as insufficient, with a call for structured programs and initiatives such as traveling fellowships and remote mentoring. CONCLUSIONS:Our survey underscores critical gaps in the current mentorship landscape for trauma and EGS in Europe, particularly for early-career and female surgeons. A clear need exists for more formalized, inclusive mentorship programs that adequately cover both technical and non-technical skills. ESTES could play a pivotal role in addressing these gaps through structured interventions, fostering a more supportive, inclusive, and well-rounded surgical community.

Background: The treatment of complex proximal humerus fractures in elderly patients is not yet fully elucidated. Of all treatment options, reverse shoulder arthroplasty (RSA) and non-operative treatment (NOT) appear to provide the best results. Evidence to guide the choice between the two is sparse. Therefore, this review provides an overview of the available evidence on RSA versus NOT. Methods: Studies comparing complex proximal humerus fractures in patients aged >65 years treated either with RSA or NOT were included for systematic review and direct comparison via pooled analysis of patient-rated outcome and range of motion. Indirect comparison of case series and non-comparative studies on either treatment was performed separately. Results: Three comparative studies including 77 patients treated with RSA and 81 treated non-operatively were analysed. The RSA group scored better for both the Constant–Murley score (mean difference 6 points) and DASH score (mean difference 8 points). No differences were detected in ASES, PENN score, pain scores, or range of motion between treatment groups. The most common complications for RSA were infection (3%), nerve injury (2%), and dislocation (2%). Reoperation was required in 5%. In the NOT group, common complications included malunion (42%), osteonecrosis (25%), and non-union (3%); no reoperation was required. Patient satisfaction was equal in both groups. Conclusions: The functional outcomes and range of motion after RSA seemed satisfactory and potentially superior to NOT in elderly patients. Patient satisfaction was comparable despite a high malunion and osteonecrosis rate in the non-operative treatment group, which did not require re-interventions.

Purpose: Effects of clockwise torque rotation onto proximal femoral fracture fixation have been subject of ongoing debate: fixated right-sided trochanteric fractures seem more rotationally stable than left-sided fractures in the biomechanical setting, but this theoretical advantage has not been demonstrated in the clinical setting to date. The purpose of this study was to identify a difference in early reoperation rate between patients undergoing surgery for left-versus right-sided proximal femur fractures using cephalomedullary nailing (CMN). Materials and methods: The American College of Surgeons National Surgical Quality Improvement Program was queried from 2016-2019 to identify patients aged 50 years and older undergoing CMN for a proximal femoral fracture. The primary outcome was any unplanned reoperation within 30 days following surgery. The difference was calculated using a Chi-square test, and observed power calculated using post-hoc power analysis. Results: In total, of 20,122 patients undergoing CMN for proximal femoral fracture management, 1.8% (n=371) had to undergo an unplanned reoperation within 30 days after surgery. Overall, 208 (2.0%) were left-sided and 163 (1.7%) right-sided fractures (p=0.052, risk ratio [RR] 1.22, 95% confidence interval [CI] 1.00-1.50), odds ratio [OR] 1.23 (95%CI 1.00-1.51), power 49.2% (& alpha;=0.05). Conclusion: This study shows a higher risk of reoperation for left-sided compared to right-sided proximal femur fractures after CMN in a large sample size. Although results may be underpowered and statistically insignificant, this finding might substantiate the hypothesis that clockwise rotation during implant insertion and (post-operative) weightbearing may lead to higher reoperation rates. Level of evidence: Therapeutic level II.