Dislocation of total hip replacement in patients with fractures of the femoral neck: A prospective cohort study of 713 consecutive hips

Background Total hip replacement is increasingly used in active, relatively healthy elderly patients with fractures of the femoral neck. Dislocation of the prosthesis is a severe complication, and there is still controversy regarding the optimal surgical approach and its influence on stability. We analyzed factors influencing the stability of the total hip replacement, paying special attention to the surgical approach

Dislocation of hip arthroplasty in patients with femoral neck fractures

Treatment of displaced fractures of the femoral neck with a hemiarthroplasty (HA) or a total hip arthroplasty (THA) today constitutes standard procedures with a good and predictable outcome with regard to the need for revision surgery, hip function and the health-related quality of life (HRQoL). However, dislocation of the prosthesis remains a substantial clinical problem in this patient group and the dislocation rate is considerably higher than what can be expected following a THA in patients with osteoarthritis. There are several reported risk factors for prosthetic dislocations of which the influence of the surgical approach in patients with femoral neck fractures is still controversial. Moreover, little is known about the effect of the dislocation on the patients HRQoL. In order to prevent dislocation of the hip arthroplasty information on the direction of the dislocation is important for accurate implant positioning and for optimising the postoperative regimens. However, specific studies regarding this topic are missing for patients with fractures of the femoral neck. In Study I, a prospective cohort study on 739 hips treated with HA due to a femoral neck fracture, factors influencing the risk of prosthetic dislocation were analysed. In a 2 10 year follow-up the posterolateral approach was associated with a significantly increased risk for dislocation of the prosthesis compared to the anterolateral approach. The patients age, gender, the indication for surgery, the surgeon s experience or the type of HA did not affect the dislocation rate. In Study II, another prospective cohort study with a 1 11 year follow-up of 713 hips treated with THA due to a femoral neck fracture, factors influencing the risk of prosthetic dislocation were analysed. Compared to the anterolateral approach, the posterolateral approach was associated with a significantly increased risk for dislocation of the prosthesis. The patients age, gender, the indication for surgery, the surgeon s experience or the size of the femoral head did not affect the dislocation rate. In Study III, a multicentre prospective cohort study on 319 patients treated with a primary HA or THA due to a femoral neck fracture, dislocation of the prosthesis had a significant negative effect on the HRQoL during the first year after the surgery. A recurrent dislocation of the arthroplasty seems to result in a persistent deterioration in the HRQoL, while patients with a single dislocation appear to experience only a temporary deterioration. In Study IV a study on 74 patients with a primary dislocation of an HA or a THA within one year after surgery due to a femoral neck fracture, the surgical approach significantly influenced the direction of dislocation in patients treated with HA, while no such correlation was found after THA. This suggests that the surgical approach is only one of several factors affecting the direction of dislocation after THA. Our results imply that the position of the acetabular component might be one important factor. The major conclusions of this thesis are that a prosthesis dislocation has a negative influence on the health-related quality of life and, in order to reduce the overall dislocation rate after both HA and THA in patients with femoral neck fractures, an anterolateral surgical approach should be used instead of a posterolateral one

Pipkin fractures : epidemiology and outcome.

PURPOSE: To describe the epidemiology of Pipkin fractures including detailed fracture classification and outcome for joint preservation and death. METHODS: We extracted data on all Pipkin fractures in the Swedish Fracture Register from 2013 to 2020 in patients ≥ 18 years. The cohort was cross-matched with the Swedish Hip Arthroplasty Register to obtain data on primary or secondary treatment with arthroplasty. We analysed data on age, sex, injury mechanism, fracture classification, treatment including secondary operative treatment with arthroplasty and mortality. Primary outcome was joint preservation. RESULTS: In total 47 Pipkin fractures with a median age of 48 years were included. 74% of the fractures were in males. The median follow-up time was 3.5 years. The most common primary treatment was internal fixation (45%), followed by primary arthroplasty (28%), and excision of fragment (15%). Three of the 34 patients with primary non arthroplasty treatment received secondary treatment with arthroplasty. Two patients died within 30 days, and no further deaths occurred up to 1 year after injury. CONCLUSION: Three of four fractures occurred in males and more than half of the fractures were due to high energetic injuries. Half of the patients received internal fixation (predominantly younger patients) and 28% were treated with primary arthroplasty (predominantly older patients). The revision rate was low, and after secondary treatment with arthroplasty two thirds of the patients still had a preserved joint

Early versus late surgical treatment of pelvic and acetabular fractures a five-year follow-up of 419 patients

Abstract Background Surgical treatment of pelvic and acetabular fractures is an advanced intervention with a high risk of subsequent complications. These patients are often polytrauma patients with multiple injuries in several organ systems. The optimal timing for the definitive surgery of these fractures has been debated. The primary aim of this study was to investigate the influence of timing of definitive surgery on the rate of unplanned reoperations. Secondary aims included its influence on the occurrence of adverse events and mortality. Methods All patients from 18 years with a surgically treated pelvic or acetabular fracture operated at the Karolinska University Hospital in Sweden during 2010 to 2019 were identified and included. Data was collected through review of medical records and radiographs. Logistic regression analysis was performed to evaluate factors associated with unplanned reoperations and other adverse events. Results A total of 419 patients with definitive surgical treatment within 1 month of a pelvic (n = 191, 46%) or an acetabular (n = 228, 54%) fracture were included. The majority of the patients were males (n = 298, 71%) and the mean (SD, range) age was 53.3 (19, 18–94) years. A total of 194 (46%) patients had their surgery within 72 h (early surgery group), and 225 (54%) later than 72 h (late surgery group) after the injury. 95 patients (23%) had an unplanned reoperation. There was no difference in the reoperation rate between early (n = 44, 23%) and late (n = 51, 23%) surgery group (p = 1.0). A total of 148 patients (35%) had any kind of adverse event not requiring reoperation. The rate was 32% (n = 62) in the early, and 38% (n = 86) in the late surgery group (p = 0.2). When adjusting for relevant factors in regression analyses, no associations were found that increased the risk for reoperation or other adverse events. The 30-day mortality was 2.1% (n = 4) for the early and 2.2% (n = 5) for the late surgery group (p = 1.0). The 1-year mortality was 4.1% (n = 8) for the early and 7.6% (n = 17) for the late surgery group (p = 0.2). Conclusions Early (within 72 h) definitive surgery of patients with pelvic or acetabular fractures seems safe with regard to risk for reoperation, other adverse events and mortality

Epidemiology, treatment and mortality of trochanteric and subtrochanteric hip fractures: data from the Swedish fracture register

Abstract Background Hip fractures are a major worldwide public health problem and includes two main types of fractures: the intracapsular (cervical) and the extracapsular (trochanteric and subtrochanteric) fractures. The aim of this study on patients with trochanteric and subtrochanteric hip fractures was to describe the epidemiology, treatment and outcome in terms of mortality within the context of a large register study. Methods A descriptive epidemiological register study including patients registered in the national Swedish Fracture Register from January 2014 to December 2016. Inclusion criteria were all primary surgically treated traumatic non-pathological trochanteric and subtrochanteric femoral fractures in patients aged 18 years and above. Individual patient data (age, gender, injury location, injury cause, fracture type, treatment and timing of surgery) were retrieved from the register database. Mortality data was obtained via linkage to the Swedish Death Register. Results A total of 10,548 consecutive patients were identified and included in the study. The mean (±SD) age for all patients was 82 ± 11 years and the majority of the patients were females (69%). Most of the fractures were caused by a fall at the same level (83%) at the patients’ accommodation (75%). Fractures were classified using the AO/OTA classification as 31-A1 in 29%, as 31-A2 in 49% and as 31-A3 in 22% of the cases. The most commonly used implant was a short antegrade intramedullary nail (42%), followed by a plate with sliding hip screw (37%). With increasing fracture complexity, the proportion of intramedullary nails was increasing, and also the use of long versus short nails. The majority of the patients were operated within 36 h (90%). There was a higher mortality at 30 days and 1 year for males, and for all those who were delayed to surgery > 36 h. Conclusion Safety measures to prevent fall at elderly patient’s accommodation might be a way to reduce the number of trochanteric and subtrochanteric hip fractures. Surgery as soon as possible without delay should be considered to reduce the mortality rate. The selection of surgical methods depends on the fracture complexity

Is fast reversal and early surgery (within 24 h) in patients on warfarin medication with trochanteric hip fractures safe? A case-control study

Abstract Background Hip fracture patients in general are elderly and they often have comorbidities that may necessitate anticoagulation treatment, such as warfarin. It has been emphasized that these patients benefit from surgery without delay to avoid complications and reduce mortality. This creates a challenge for patients on warfarin and especially for those with trochanteric or subtrochanteric hip fractures treated with intramedullary nailing, as this is associated with increased bleeding compared to other types of hip fractures and surgical methods. The aim of the study was to evaluate if early surgery (within 24 h) of trochanteric or subtrochanteric hip fractures using intramedullary nailing is safe in patients on warfarin treatment after fast reversal of the warfarin effect. Methods A retrospective case-control study including 198 patients: 99 warfarin patients and 99 patients without anticoagulants as a 1:1 ratio control group matched for age, gender and surgical implant. All patients were operated within 24 h with a cephalomedullary nail due to a trochanteric or subtrochanteric hip fracture. All patients on warfarin were reversed if necessary to INR ≤ 1.5 before surgery using vitamin K and/or four-factor prothrombin complex concentrate (PCC). Per- and postoperative data, transfusion rates, adverse events and mortality was compared. Results There were no significant differences in the calculated blood-loss, in-house adverse events or mortality (in-house, 30-day or 1-year) between the groups. There were no significant differences in the pre- or peroperative transfusions rates, but there was an increased rate of postoperative transfusions in the control group (p = 0.02). Conclusion We found that surgical treatment with intramedullary nailing within 24 h of patients with trochanteric or subtrochanteric hip fractures on warfarin medication after reversing its effect to INR ≤ 1.5 using vitamin K and/or PCC is safe

Validation of the classification of surgically treated acetabular fractures in the Swedish Fracture Register

Objectives To validate the classification of surgically treated acetabular fractures in the Swedish Fracture Register (SFR) and to investigate the intra- and interrater reliability of the Judet-Letournel / AO/OTA classification systems. Methods Surgically treated acetabular fractures were randomly selected from the SFR (n = 132) and 124 fractures were classified independently by three experienced orthopedic pelvic surgeons at two different occasions. A gold standard classification was established for each case after these two sessions or, if necessary, after a discussion session. The gold standard classification was compared to the registered SFR classification to assess the validity of SFR data. Accuracy and intra- and interrater agreement were evaluated using Cohen's kappa with interpretation according to Landis and Koch. Results There was moderate agreement between the established gold standard classification and the SFR (kappa 0.43). The level of agreement differed between classification groups. The intrarater agreement was substantial to almost perfect and interrater agreement was moderate to substantial. Conclusions The accuracy of acetabular fracture classifications in the SFR was moderate and comparable to previous validation studies from the SFR on other fracture types. As the accuracy differed between fracture groups, care should be taken when analyzing data from the SFR on specific acetabular fracture groups

Distal radius fractures-Regional variation in treatment regimens.

OBJECTIVES:After recent technical innovations of fracture surgery implants, treatment traditions are changing for distal radius fractures, the most common orthopaedic injury. The aim of this study was to determine if the choice of surgical method for treatment of distal radius fractures differ between healthcare regions in Sweden. METHOD:The study was based on all (n = 22 378) adult patients who were registered with a surgical procedure due to a distal radius fracture during 2010-2013 in Sweden. Consecutive data was collected from the Swedish National Patient Registry. RESULTS:The proportions of use of surgical method varied among the 21 healthcare regions between 41% and 95% for internal fixation, between 2.3% and 44% for percutaneous fixation and between 0.6% and 19% for external fixation. Differences between regions were statistically significant in all but 6 comparisons when controlled for age and gender. Incidence rates of surgical treatment of a distal radius fracture varied between 4.2 and 9.2/10 000 person-years. CONCLUSION:We conclude that there is a large variation in operative management of distal radius fractures between Swedish healthcare regions

Patient claims in prosthetic hip infections: a comparison of nationwide incidence in Sweden and patient insurance data

Background and purpose — Patients in Sweden are insured against avoidable patient injuries. Prosthetic joint infections (PJIs) resulting from intraoperative contamination are regarded as compensable by the Swedish public insurance system. According to the Patient Injury Act, healthcare personnel must inform patients about any injury resulting from treatment and the possibility of filing a claim. To analyze any under-reporting of claims and their outcome, we investigated patients’ claims of PJI in a nationwide setting Patients and methods — The national cohort of PJI after primary total hip replacement, initially operated between 2005 and 2008, was established through cross-matching of registers and review of individual medical records. We analyzed 441 PJIs and the number of filed patients’ claims, with regards to incidence, outcome, and any national, sex-linked or socioeconomic differences. Results — We identified 329/441 (75%) patients with PJIs as non-claimants. 96% of the filed claims were accepted. 64 (57%) of claimants sustained permanent disability. 2 factors were found to statistically significantly reduce the odds of filing claims: patient’s age above 73 years and fracture as indication for surgery. There were no significant national, sex-linked, or socioeconomic differences. Interpretation — The incidence of patients’ claims of PJI is low but claims are usually accepted when filed. Healthcare personnel should increase their knowledge of the Patient Injury Act to inform patients about possibilities of eligible compensation

Volar locking plate versus external fixation for unstable dorsally displaced distal radius fractures-A 3-year cost-utility analysis.

AimTo investigate the cost-effectiveness of Volar Locking Plate (VLP) compared to External Fixation (EF) for unstable dorsally displaced distal radius fractures in a 3-year perspective.MethodsDuring 2009-2013, patients aged 50-74 years with an unstable dorsally displaced distal radius fracture were randomised to VLP or EF. Primary outcome was the incremental cost-effectiveness ratio (ICER) for VLP compared with EF. Data regarding health effects (Quality-adjusted life years, QALYs) was prospectively collected during the trial period until 3 years after surgery. Cost data was collected retrospectively for the same time period and included direct and indirect costs (production loss).ResultsOne hundred and thirteen patients (VLP n = 58, EF n = 55) had complete data until 3 years and were used in the analysis. At one year, the VLP group had a mean incremental cost of 878 euros and a gain of 0.020 QALYs compared with the EF group, rendering an ICER of 43 900 euros per QALY. At three years, the VLP group had a mean incremental cost of 1 082 euros and a negative incremental effect of -0.005 QALYs compared to the EF group, which means that VLP was dominated by EF. The probability that VLP was cost-effective compared to EF at three years, was lower than 50% independent of the willingness to pay per QALY.ConclusionThree years after distal radius fracture surgery, VLP fixation resulted in higher costs and a smaller effect in QALYs compared to EF. Our results indicate that it is uncertain if VLP is a cost-effective treatment of unstable distal radius fractures compared to EF