Pieta Krijnen

Purpose: This study compares the syndesmosis congruity and functional outcomes after syndesmotic reconstruction by open reduction and internal fixation (ORIF) of posterior malleolar fractures (PMFs) sized > 5% versus no fixation in type C ankle fractures. Methods: This multicenter prospective cohort study compared ORIF of PMFs (FIX) with no fixation (NO-FIX). Both groups underwent fibular and medial malleolus fixation according to AO principles, with trans-syndesmotic stabilization screws in case of instability. The primary outcome was syndesmotic alignment assessed on post-operative bilateral CT scans. The main secondary outcome measures were patient-reported functional outcome up to 1 year assessed with AAOS and OMAS questionnaires, and complications. Results: 26 patients (17 FIX, 9 NO-FIX) were included, with a median PMF size of 20%. Syndesmotic stabilization with fib-tib screws was used in 6% of FIX vs 44% of NO-FIX ( p = 0.03). Anatomical reduction (primary outcome) was achieved in 85% (FIX) versus 29% (NO-FIX, p = 0.02). AAOS and OMAS scores during follow-up were superior in FIX (linear mixed models, p < 0.01). The complication rate was higher in NO-FIX (55% vs. 0%, p  < 0.001). Conclusion: in this study, ORIF of the PMF resulted in a higher rate of anatomically reduced syndesmosis, lesser need for syndesmotic stabilization screws, better functional outcome and fewer complications compared to no fixation. Fixation of PMFs in suprasyndesmotic fibula fractures with PMFs > 5% may be valuable, but more studies are needed to confirm this hypothesis due to study limitations.

Background: Distal radial fractures (DRFs) and malleolar fractures (MFs) represent almost one-third of Dutch emergency room fractures. The WARRIOR trials showed that routine follow-up radiographs obtained >2 weeks post-injury were unnecessary in most cases and safe to omit. This study evaluated 2 strategies to reduce such imaging: dissemination of WARRIOR evidence and a tailored de-implementation strategy. Methods: This multicenter retrospective observational study included adults with a DRF (OTA/AO 23A to 23C) or MF (Lauge-Hansen SA 2, SE 2 to 4, PE 1 to 4, or PA 1 to 3) treated at 5 hospitals in the West Netherlands region. Centers 1 and 2 (Level I) were participants in the WARRIOR trials; Centers 3 to 5 (Level II) were not. Exclusion criteria were open, pathological, high-energy, or SA 1 fractures. Three cohorts were compared: historical controls (n = 846; at Centers 1 and 2), after dissemination (n = 337; at Centers 1 to 5), and after de-implementation (n = 314; at Centers 1 to 5). The mean age was 55 years, and 67% were female. The de-implementation strategy included educational sessions, performance feedback, and updated guidelines. The primary outcome was the number of routine follow-up radiographs per patient; secondary outcomes were the number of treatment-phase radiographs, the total number of radiographs, and the proportion of patients without routine follow-up imaging. Operative and nonoperative fractures were analyzed jointly. Results: In Centers 1 and 2, the mean number of routine radiographs per patient decreased by 1.41 (95% confidence interval, 1.10 to 1.72) after dissemination and by a further 0.26 (0.07 to 0.46) after de-implementation for MFs, and decreased by 0.71 (0.49 to 0.94) after dissemination but by only a nonsignificant further 0.09 (−0.08 to 0.26) after de-implementation for DRFs. The probability of no routine follow-up imaging increased by 44.2% (37.1% to 51.3%) after dissemination and by a further 13.2% (3.6% to 22.8%) after de-implementation for MFs, and increased by 41.9% (36.5% to 47.3%) after dissemination but changed by a nonsignificant −3.0% (−10.2% to 4.2%) after de-implementation for DRFs. In Centers 3 to 5, the mean number of routine radiographs per patient decreased after active de-implementation by 0.38 (0.18 to 0.57) for MFs, and by 0.30 (0.16 to 0.43) for DRFs, compared with the number after dissemination. The probability of no routine follow-up imaging increased after de-implementation by 11.4% (4.8% to 18.0%) for MFs, and by 21.9% (13.8% to 30.1%) for DRFs, compared with the rate after dissemination. Conclusions: Both research dissemination and a tailored de-implementation strategy substantially reduced routine follow-up radiographs for DRFs and MFs, supporting their use to decrease low-value radiographs in trauma care. Level of Evidence: Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Purpose: 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. Methods: 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. Results: Of 1,112 patients, 50% used antithrombotic medication, most commonly platelet aggregation inhibitors (47%) or direct oral anticoagulants (37%). Users were older, more often male, had more comorbidities, and more frequently sustained low-energy falls and minor head injuries. PAM was not associated with higher ISS (median 9 in both groups, p = 0.80), more intracranial hemorrhages (74% vs. 71%, p = 0.85), increased mortality (adjusted odds ratio [OR], 0.79; 95% Confidence Interval [CI], 0.41–1.53), or poor GOS at discharge (OR, 1.06; 95% CI, 0.79–1.43). Conclusion: PAM is common among older trauma patients. In this exploratory study, PAM did not seem to be associated with more severe injuries or poorer short-term outcomes. To evaluate the in-depth and long-term effects structured documentation of PAM in trauma registries is advocated.

Introduction: Pancreatic trauma is rare, accounting for only 0.2% of all trauma cases, and reports on long‐term endocrine outcomes are scarce. Patients who undergo pancreatic resection may develop diabetes mellitus. Objectives: To summarize the available literature reporting the incidence of diabetes mellitus (DM) after pancreatic trauma and to evaluate potential influences on the incidence rates. Patients and Methods: We searched in PubMed and Embase for studies published between 1990 and July 2025 that enrolled patients with trauma of the pancreas and reported data on new‐onset DM. Results: Out of 906 identified records, six studies with a total of 297 patients with pancreatic trauma. The overall cumulative incidence of new‐onset DM is 5.7% (95% confidence interval [CI]: 3.4%–9.0%). DM developed in 8.2% (95% CI: 4.4%–13.6%) of patients who underwent (partial) pancreatic resection and in 2.9% (95% CI: 0.8%–7.4%) of patients treated nonoperatively. For low‐grade injuries, the incidence of DM was 5.5% (95% CI: 2.0%–11.5%) compared to 11.1% (95% CI: 4.9%–20.7%) for high‐grade injuries. The time until new‐onset diabetes mellitus was detailed in one study with 15 patients. Conclusion: Based on the available literature, the estimated overall incidence of DM after pancreatic trauma is 5.7%. High‐grade pancreatic injury seems to increase the risk of developing new‐onset DM, which is possibly influenced by their frequent surgical treatment.

Purpose: Both the Glasgow Coma Scale (GCS) and Abbreviated Injury Scale (AIS) for head injuries quantify traumatic brain injury (TBI) severity. The GCS is based on brain physiology of consciousness, whereas the AIS is an anatomical injury scoring system. This study aimed to describe the correlation of GCS with maximal AIS-Head (maxAIS) and summative AIS-Head (sumAIS) in TBI patients. Methods: Data of 4996 adult TBI patients admitted to two level 1 trauma centers in the Netherlands between 2015 and 2021 were selected from the regional trauma registry. The association of GCS with maxAIS and sumAIS was quantified using Spearman rank correlation coefficients (r _s ). Results: For 39% of the patients, the GCS was not documented in the trauma registry. These patients had less severe head injuries than the 3051 patients with documented GCS scores, who were further analyzed. Among those with severe head injuries (AIS-Head ≥ 4), 53% had a GCS score ≥ 13. The GCS showed a weak inverse relationship with both maxAIS and sumAIS (r _s -0.33 and − 0.34, respectively, both p < 0.001). Conclusions: The correlation between physiological alterations (GCS) and anatomical brain damage (AIS) in patients with TBI patients, represented by the GCS and AIS respectively, is weak. Additionally, the GCS appears to underestimate the severity of AIS coded severe TBI. Recognizing this limited correlation is important for valid TBI research.

Aims: Guidelines for treatment of posterior malleolar fragments (PMFs) in trimalleolar fractures are scarce, mainly based on retrospective studies, and show varying advice. The need for fixation of smaller (< 25%) PMFs remains particularly controversial. This study aims to evaluate the superiority of fixation of medium-sized PMFs versus no fixation of the fragment.Methods: A multicentre randomized controlled trial was conducted between January 2014 and January 2022 in two Dutch level 1 trauma centres (protocol registration: NCT02596529). Patients presenting with an AO-44-B3 fracture with a medium-sized (5% to 25%) PMF were 1:1 randomized online between open reduction and internal fixation (ORIF) (FIX) versus no fixation (NO-FIX) of the fragment. A total of 41 patients were allocated online to FIX via the posterolateral approach and 40 patients to NO-FIX. The primary outcome was functionality measured by the American Academy of Orthopaedic Surgeons (AAOS) questionnaire one year postoperatively. Secondary outcomes were osteoarthritis (OA) measured on radiographs and the Olerud and Molander ankle score, visual analogue scale pain, and EuroQol five-dimension questionnaire during follow-up. Quality of reduction was assessed by step-off on postoperative CT scan and radiograph. Complications were recorded.Results: After one-year follow-up, no difference (p = 0.141) in AAOS was found after FIX (median 90 (IQR 68 to 95)) and NO-FIX (median 93 (IQR 85 to 97)). OA (≥ grade 2) was present in four (17%) of the cases after FIX and five (20%) after NO-FIX (p = 0.763). After one year, median pain scores were 20 (IQR 5 to 40) versus 10 (IQR 5 to 25) (p = 0.032), and perceived general median health scores were 80 (IQR 60 to 89) versus 83 (IQR 71 to 90) (p = 0.596) after FIX and NO-FIX, respectively. Postoperative step-off > 1 mm on CT scan was present in 56% after FIX versus 71% after NO-FIX (p = 0.193). Complication rates were 18% versus 5% (p = 0.071) after FIX and NO-FIX, respectively.Conclusion: ORIF of medium-sized posterior fragments in AO type B trimalleolar fractures does not prompt superior functional or radiological results after one-year follow-up. Longer follow-up is needed to evaluate intermediate or long-term effects.Cite this article: Bone Joint J 2025;107-B(4):461–469.

Purpose: 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). Methods: 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. Results: Median follow-up of 389 included patients was 98 months; 20.6% underwent revision surgery; 28.8% after treatment of a displaced FNF (dFNF) and 10.0% with a undisplaced FNF (uFNF). 5.7% (n = 22) of the patients had operation related complications and 32.9% (n = 128) deceased during follow-up. Median time to revision surgery was 13 (dFNF) and 18 months (uFNF). 15.7% of the DLBPs were electively removed. In the multivariate Cox regression analysis, female gender (hazard ratio 2.1, 95% CI 1.2–3.7) and a TAD > 25 mm (hazard ratio 2.9, 95% CI 1.7-5) were significant predictors for revision surgery in patients with dFNF. Conclusion: This study is the first long-term follow-up study on the outcome of the DLBP. The DLBP demonstrated positive long-term results in the treatment of FNF.

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